The scope of practice for nurses in Australia differs according to different designation in nursing practice. The practice standards for registered nurse and midwifes are laid down by the Nursing and Midwifery Board of Australia (NMBA) and the International Council of Nurses (ICN). Although the nursing profession is the largest regulated health workforce, however the scope of practice and practice boundaries are poorly misunderstood. The lack of clarity regarding the scope of practice significantly hampers nurse’s ability to respond to an emerging health care system of Australia. A nurse may understand their scope of practice by having the knowledge regarding the professional, ethical and legal significance of the scope of practice (Birks et al. 2016). The purpose of this report is to explore the risk in professional nursing practice by the analysis of case scenario related to work refusal and determine how lack of understanding about the scope of practice may disrupt the course of professional development in nursing practice.
Analysis Of Work Refusal And Scope Of Practice Through The Case Scenario
The case scenario is related to the dilemma faced by a graduate nurse working in acute care medical ward at a large metropolitan public hospital. At the commencement of shift, the nurse notices that she is being assigned to go relieving to the Intensive Care Unit (ICU) or High Dependency Unit (HDU). As the nurse has never worked in ICU at this hospital, she is nervous about this task allocation and finally she refuses this work allocation on the ground that the work in ICU will outside the scope of practice as a graduate nurse. Now the question that arises from this scenario is that whether the act of refusal was right for the nurse. Does she have the right to refuse without considering consequence of this action? Or was she right that the duty assigned to her was not within her scope of practice?
To examine the ethics of refusing work allocation by the nurse, it is necessary to analyze the scope of practice for graduate nurse. A graduate nurse is one who has completed her education but does not have registered nurse license. They obtain this after working professionally under the direct supervision of a registered nurse. The nurse was right in refusing the work allocation because it is necessary to be Registered Nurse to practice as a critical care nurse. As intensive care unit (ICU) deals with patients experiencing high-dependency life-threatening illness, adequate knowledge and judgment skill in necessary for a nurse to ensure optimal care and handle high pressure condition. The duty of critical care nurse is to check vital signs of patients, manage life support equipment, take blood samples and assist physicians during medical procedure. The newly graduate nurse may lack the experience and competence to carry out these duties efficiently (Health Times 2017). Hence, from the perspective of graduate, it is correct to refuse action to prevent harm to patients in critical care unit.
Ethics Of Work Refusal And Consequences Of Nurses Refusing Work
Considering the ethics of nurse action in refusing work, it can be said that it is relevant to the code of Ethics for Nurses in Australia. According to the code set by NMBA, nurses must be committed to uphold the fundamental right of both providers and receiver of care. They must value access to quality nursing care and promote a culture of safety in health care. In that case, the graduate nurse’s action was right as without adequate skills, the value of quality of nursing care in ICU might not be followed. Hence, according to ethical code of practice for nurses, they have the right to conscientiously refuse to participate in care on religious or moral grounds (Code of Ethics for Nurses in Australia 2017).
There is also professional risk in nursing practice if a nurse violated the professional standards of nursing practice. This professional risk is understood differently by nurse and regulatory bodies. In the case scenario, the graduate nurse may have taken the decision to refuse working in ICU to avoid professional risk in her career. This is ethically and legally safe action by the nurses. However, the question is to what extend refusal in nursing practice is appropriate. This topic is greatly argued because perception regarding professional risk differs for regulatory bodies and nurses. While the regulatory bodies encourage nurses to be professionally accountable for their practice, frontline nurses tend to avoid professional discipline when they feel they are incompetent to interpret practice standards. Fear, lack of experience and uncertainty in work procedure is the most common reason for refusal of task. In the case scenario, it might be possible for nurse to work in ICU under the supervision of registered nurse to learn the needs of critically ill patients. Hence, act of refusal might minimize their opportunity to grow in their nursing career. Therefore, it is mostly argued that professional protocols and practice standards cannot anticipate eventuality in clinical practice and hence out of fear of profession discipline nurse tend to refuse task (Beardwood and Kainer 2015).
The implication and consequence of the graduate nurse action in refusing the task is that it might lead to potential dilemma and legal issues. The nurse might be confused regarding the action of refusing. However considering that the graduate nurse has not experience with critically ill patients in ICU, she was right to assess that this was outside her scope of practice and she is not competent to deliver care in ICU. It is an ethically and legally responsible act by the nurse as it would protect her from any dilemma during practice and promote safety of patients. The graduate refused the task as she had immediate concern for the patient safety and due to her own legal accountability in providing safe care. However, before taking this decision to refuse task, nurses must consider all options and be prepared for potential disciplinary action by the employer. She might have to prepare document detailing her concern for patient safety, her experience and competency so far and the steps used by her to take the decision of refusing (Sørensen and Brahe 2014).
The concern and fear of graduate nurse in working in ICU is ethically correct for her as she has the professional liability to safe and quality care. The practice of hiring recent nursing graduate nurse in critical care has increased due to the shortage of nurse in these facilities. Earlier only experience registered nurse were hired in critical care unit. The graduate nurse action in refusing the work may have an impact on the orientation process in critical care. The immediate action by the metropolitan hospital would be to make the nurse work under registered nurse to understand the complexities in ICU patients and enhance the skills to gain confidence in practicing in critical care units. The arrangement of orientation program for graduate nurse will help to develop critical thinking skills in nurse and develop the competencies that might support them to practice in critical care setting (Elmers 2010).
A nurse may be sued for negligence if they are to found to work within the scope of practice without the skills to provide safe nursing care. It is legally binding for nurse to refuse work allocation if they are outside the scope of practice. According to the 1.3 National Competency Standards for the Registered Nurse, they have the responsibility to identify and respond to unsafe nursing practice. They can do so by clarifying groups to change or refuse care and communicating about lack of skill requirement to meets needs of particular group (National competency standards for the registered nurse 2017). Hence, the graduate nurse in the case scenario may be rightfully denying care to protect critically ill patient from any harm and she has valid reasons for refusing to work in ICU. The ultimate consequence of this action would be that the complain regarding work refusal will be presented to nursing director at the hospital and upon being summoned, the nurse will have the duty to justify the reasons for rejection of task taking support from the code of practice of nurses in Australia and NMBA standards of practice. The decision panel may then view the ethical and legal side of the nurse action to refuse work allocation (Edmonds et al. 2016). The justification of the act to refuse can also be given by analyzing all the alternative options and consulting with other team members regarding practice in ICU. The American Nurse Association also upholds that nurses have the right to reject a work based on serious harm to patients or themselves as part of their professional and ethical responsibilities. The practice of unsafe staffing is creating risk for safety and quality of patient care and this exposed large number of nurse to professional dilemma. In such situation, providing safe, competent and ethical care is not possible and nurse must exercise their right to refuse based on professional judgment of the situation (Nursingworld.org. 2017).
The scenario of the graduate nurse is an example of how delegation of assignments puts nurses in a challenging situation. Many questions arise regarding the delegation and refusal of assignment. Floating practice is also a main area of concern and nurses are likely to refuse work when they are unfamiliar with particular area (example-critical care unit). The scenario was related to nurse being asked to work outside the scope of practice. Other scenario might also arise such as nurses being asked to take more responsibility than they can handle or being asked to work for longer hours. This action may lead to physical and mental fatigue in nurses. Performing act beyond the scope of practice and working without the ability or knowledge may lead to disciplinary against the nurse. Hence, the graduate nurse saved herself from the ethical and legal issues in care. The only consequences of this action is that she will have to clearly justify her reasons for rejection with support from relevant nursing regulatory board guidelines and code of practice for nursing (Kunaviktikul et al., 2015). Therefore, nurses must always utilize their judgment skills to refuse an assignment. They might also consider alternative option to refusal such as consulting with senior nurses to accept only those parts of the work which they feel competent to perform and only assist other nurse in activities where they do not feel competent to take total responsibility.
The enquiry regarding the graduate nurse decision to refuse work in ICU might also reveal ethical challenges faced by them that make them nervous about working in this setting. For instance research into ethical challenges faced by nurse in working in critical care unit included challenges in seeking information support at the end of life service, professional liability in independent care, decision making for patients, respect and professional secrecy in service. The dilemmas regarding death process in patients and human rights dilemma takes a toll on nurse’s performance. Hence, it is a sense of liability of the health care organization to set particular competency standards and qualification requirement to practice in critical care units in hospital. This will help to reduce the dilemma faced by nurse in refusing task and it would prevent the number of task refusal due to scope of practice issue. This would promote safety of patients by hiring professionally competent nurse in practice and reduce the time involved in probation for refusal of nursing work allocations. Certain mediating factor in organization might helps nurses and health care organization to overcome ethical dilemma in professional practice such as proper communication between professional members in a team, team leadership support, professional confidence and self-esteem in work, analyzing the suitability of resources and many others (Nunes 2015).
Implication Of Nurse Action To Refuse Work Allocation
The analysis of the case scenario reveals several limitations in the health care system that put nurses at sharp end of care. Considering the fact that health care organization tend to ignore standards of care for work allocation, the immediate action for the future will to look for ways to curb this practice. Care standards fall due to resource allocation issues such as lack of appropriate policies and workforce shortage. This reflects weakness of the health care system in understanding the greater effects of the complex health care system and its work environment. The nurse accountability to understand their scope of practice and engage in refusing task based on safety and quality issues in care might bring to the forefront the error made by health care service in staffing procedure (Kennedy 2015). However, this is dependent on sound knowledge and judgment of nurses to fully understand all regulatory policies; their professional responsibility and its alignment with meeting patients need in particular scenarios. The rise in nurse’s act to refuse may expose the weakness of the organization and enquiry regarding refusal might help to improve the staffing situation in the long run.
To efficiently build a work environment that supports nurses to engage in professional standard of practice, health care organization will have to capitalize on evidence based practice so that nurse get favorable working environment and the commitment to maintain safety and quality of care. This will help to mitigate the challenges faced by nurse in providing the right care (Hughes 2008). As ICU nurses working in hospitals experience variable situation, uncertainties, they require high level of knowledge, skills and competence to take care of patients. In such situation, hospitals have the accountability to ensure that skill of nurses and their scope of practice is adequately analyzed so that events of task refusal is reduces and time spent on probation is utilized for other productive work (Shimizu et al. 2011). Therefore the analysis of the practice of work refusal by nurses suggest that appropriate agenda is necessary to change work conditions and give continuous professional development to nurses to work in their required area of specialization.
The analysis of the case scenario related to the graduate nurse act of refusing work allocation in critical care units lead to questioning the ethics of the nurse’s action to refuse and its relevance with scope of practice. The review of the NMBA standards, code of ethics for nursing in Australia and other professional liability of nurse revealed that nurses are entitled to refuse work on religious and moral grounds. The practice of refusal also occurs due to unsafe working condition or the request to work overtime. The ultimate consequence of refusal is that involved health care facility has to engage in probation process to examine the reason for rejection of task and the nurses have to prepare themselves to justify the reason for their act of refusing nursing task. Faulty staffing practice and lack of accountability of health care organization exposes nurse to ethical dilemma as conflicts between professional obligation and professional obligation occurs. The potential implication for nurse is to use ethical problem solver approach to overcome the dilemma and the future role of health organization is to promote professional, legal and ethical responsibilities in care by modifying the work environment and staffing practices.
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