can nurses refuse patient assignment

How To Refuse an Unsafe Patient Assignment as a Nurse

What is a safe nursing assignment, when should you refuse an assignment, how to refuse a patient assignment.

You walk into work, ready to spend the next 12 hours taking care of your patients and providing them with the best nursing care possible.  You look at your patient assignment and see you have one extra patient than usual, as well as only one CNA for your entire nursing unit.  Your charge nurse has a full patient assignment too, making her less available to offer help and support.  You hear machines beeping, bed alarms sounding, and patients yelling, and you stop and think to yourself “is this safe?”

Does this scenario sound familiar to you as a nurse?  

Being given an inappropriate assignment can be very overwhelming and stressful.  Your patients need you to show up and take care of them, and your nursing team needs you, and you want to help.

But where do you draw the line, and say “NO”, to a patient assignment?  What is an unsafe assignment, and can a nurse refuse an assignment?

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An appropriate nursing assignment is any patient assignment where the nurse can safely and effectively provide all the necessary care for their patients, and have the necessary tools, training, medications, knowledge, resources, and equipment to perform their nursing duties for those patients.

The definition of a safe and appropriate nursing assignment is variable, has to do with much more than patient ratios alone, and will vary by state and facility.

Per the American Nurses Association (ANA), nurses have not only a right but also an obligation to assess and determine if they can safely and appropriately provide care on any given patient assignment.  They provide this list of questions that every nurse should be asking themselves before accepting any patient assignment.

What does an inappropriate or unsafe patient assignment look like, and what are some reasons you might stop and consider refusing the assignment or asking your leader for changes to the assignment?

Too Many Patients

There are only 2 states in the US that have laws mandating nurse-to-patient ratios , California and Massachusetts.  Some states, but not all of them, have mandatory reporting requirements for staffing.  Others have staffing committees with some nurse members to assist in making staffing decisions, but still no mandated ratios.

You will learn as you gain more nursing experience how many patients are too much for you as one nurse.  This will depend on your unit’s acuity level, patient population, and the individual staffing policies at your facility.

• Inappropriate distribution of patient acuity

5 “walkie-talkie” patients are vastly different from 5 patients on high-level oxygen.  The ability to understand what constitutes high acuity will also come with more nursing experience.  You may not know or understand, what the acuity level is of a COVID patient on continuous BIPAP, until you have cared for that type of patient.

Also take into consideration how many discharges or empty rooms you have, if you have any patients on continuous drips or pain pumps, your patient’s mobility level, and if your patient is scheduled for any procedure that will warrant intense post-procedure monitoring when they return.

A particular patient’s acuity can change with each shift, which means nursing management must be in close communication with the team and get accurate patient acuity updates before making each assignment.

Inadequate knowledge or training

Are you being asked to care for a post-surgical patient on gynecology, when you normally take care of patients recovering from a stroke?  Are you being asked to care for pediatric patients when you have only ever cared for adults?  Maybe you are being asked to do something you think may be out of your scope of practice as a nurse.  This would be a reason to voice concern and ultimately refuse a particular assignment.

No Supplies or Help

Do you have all of the equipment you need to do your job?  Do you know where your code cart is, and can you safely and effectively help your patient in an emergency?  Are your medications stocked, machines in good working order, and can you get extra help if you need it?

If you don’t have all of the above, keeping your patients safe could be a challenge, and this alone would deem your assignment unsafe.

If you find yourself in any of the above situations, or others in which you feel your license and patient safety are in jeopardy,  can you refuse to take the assignment ?

The ANA upholds that “ registered nurses – based on their professional and ethical responsibilities – have the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.”  Read the full ANA position statement here.

It is not only your right as a nurse, but also your duty, to raise concern and ultimately refuse an unsafe, inappropriate assignment.  Here are some tips on how you can bring up these concerns and refuse your assignment as a nurse.

Know your rights, and be prepared to state them

It is solely your responsibility as a nurse to know your rights, as well as your responsibilities, in the state in which you practice as a nurse. Each state has its own Nurse Practice Act, which defines by law what you can, and cannot do, as a nurse.  It also contains your nursing scope of practice.   Visit the NCSBN website to quickly navigate to each state's Nurse Practice Act .

The NCSBN also provides a great decision-making tool to help explain the proper process of determining whether or not a certain activity is within the nurse’s scope.

Be prepared to refer to the Nursing Code of Ethics , and verbalize any statement of your nursing rights when communicating about your patient assignment with your leader.  By knowing your rights as a nurse, and being ready to state them, you can clearly and effectively communicate with your manager why you want to refuse an assignment when placed in an unsafe situation.

Don’t Create a Nurse-Patient Relationship

Before you decide to accept any patient assignment, you need to avoid any activity that could be considered creating a nurse-patient relationship.  There is a fine line between refusing a patient assignment, and nurse abandonment, which also varies state by state.  

For example in Arizona, the board of nursing defines patient abandonment as a nurse severing or ending the nurse-patient relationship, after creating the relationship, without giving handoff or reporting to another capable nurse to take over that patient's care.

Here are some things that may be considered for establishing a nurse-patient relationship:

Viewing the patient’s electronic medical record

Saying hi to the patient, or going into their room at all

Taking orders from a doctor regarding that patient

Administering any type of patient care such as assisting them to the bathroom, taking them a food tray, or administering them any medications.

It is critical to read up on your state’s Nurse Practice Act and get a very clear definition of what patient abandonment is in your state.  Your state’s board of nursing will have the resources needed to give you directions on the correct process of refusing an assignment in your state of licensure.

Do Your Research and Be Prepared

Nurses are always thinking ahead, preparing for what can go wrong with our patients, and ready to act in case of any emergency.  We know exactly what equipment we will need for our patients, and would never allow our patients to be without adequate IV access.

Apply this same principle to the safety of your nursing license, your patients, and your team, by doing your research on the process of refusing a patient assignment correctly.  Study your facilities policies, your nursing rights, and your state’s Nurse Practice Act.

It is your responsibility to know these things, and you don’t want to be scrambling at the very last second trying to do this research when you are being pressured at the moment to take a dangerous assignment.

Keep Everything in Writing

If you do end up voicing any sort of staffing or patient safety concerns, or ultimately refusing an assignment, always make sure you are communicating it to all of the appropriate leaders and follow your chain of command.

Send an email to all members of your leadership team to summarize the situation, and provide thorough documentation of why you are refusing an assignment, with adequate details.

Keep any paper records for yourself, just in case.

Help Find Solutions

Refusing a patient assignment will have an impact on all of the patients in the unit, the entire hospital, as well as the rest of the members of the healthcare team.  It is your right, and duty, to refuse an inappropriate assignment.  But try to be as professional and flexible as possible, keeping the ultimate goal of patient safety in mind.

Can you and your team brainstorm with your nursing leader on other ways to make everyone’s assignments safe and appropriate, such as:

Calling in a resource RN to help with patient care tasks

Re-arranging the patient assignment to re-distribute patient acuity better among all nurses

Obtaining a 1:1 sitter for all confused patients, ensuring their safety and also freeing up your extra time for your other patients?

Better assigning the patients to nurses based on their appropriate certifications, and expertise?

Ultimately you are a team, and you are there for your patients and each other.  The goal is patient safety, and if you don’t speak up and refuse to take an inappropriate assignment, your patient’s well-being and your nursing license are on the line.  

Be prepared to have these conversations, and be well-versed in your rights as a nurse.  By refusing inappropriate assignments, you are advocating for yourself, and your patients, and being a voice for positive change in healthcare.

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When an Assignment is Unsafe

Imagine that you are a new nurse, about six months out of school and working on a cardiac floor at a large teaching hospital. It is Christmas Eve and you report to your unit to work the night shift. The nursing supervisor calls and tells you to go to the oncology unit – you’ve been floated. You tell the supervisor you’ve never worked oncology. She says you are just going to help out, do general basic nursing care; the regular staff nurses will handle everything else. When you get to the unit, the charge nurse gives you a fast report on your assigned patients. Contrary to what the supervisor said, you have most of the sickest patients on the unit and it is a regular patient care assignment, including administration of chemotherapy for which you are not qualified. What do you do?

Unfortunately, many nurses – and many leaders — will answer the question with some form of “suck it up and do the best you can.” And while I know that questioning an assignment, let alone refusing it, is hard, this is exactly what you must consider doing. Think about it this way: if you were a new airplane mechanic and were assigned to work solo on a new type of engine that you haven’t seen before, knowing that the plane was due to fly over 300 passengers and crew in 2 hours, would you do it without objection? If you were an internal medicine physician and told that you, as the only doctor available, had to perform a craniotomy, would you do it?

The shortage of qualified practicing nurses is not new. Neither are nurses’ legal, professional, and ethical duties. The American Nurses Association has backed the nurse’s right to refuse an unsafe assignment since at least the 1980s. The current position statement, “Rights of Registered Nurses When Considering a Patient Assignment,” (ANA, 2009) expressly states that nurses have “the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.” (Emphasis added.)

In addition, the ANA’s Code of Ethics for Nurses (2001) spells out the RN’s accountability “for judgments made and actions taken in the course of nursing practice, irrespective of health care organizations’ policies or providers’ directives” , (Provision 4).

Nurse leaders should take note of Provision 6: “acquiescing and accepting unsafe or inappropriate practices, even if the individual does not participate in the specific practice, is equivalent to condoning unsafe practice.”

Most state/territorial nursing associations and state boards of nursing echo these statements and many states have statutes that protect nurses who point out unsafe conditions. In Texas, it is called the “safe harbor” provision and other states, although they may not use that term, have similar policies or statutory wording. Nurses and leaders must speak up when circumstances put the nurse and the patient at risk of harm. Boards of nursing will discipline nurses and leaders who knowingly allow or foster unsafe practices.

Even if you have never been in questionable situation, you should know your organization’s policies and your state’s laws and regulations regarding refusing an assignment. Objections must be in writing so check to see if your facility or state has a form and keep several blank copies in your locker or backpack.

When a potential situation arises – either at the beginning of the shift or later on if conditions deteriorate – try to identify exactly what the problem is. Are you unqualified to care for the patients assigned? Is the assignment outside the scope of your practice or your experience and knowledge level? Has the assignment changed since you accepted it – have you received new patients or has a patient’s condition deteriorated?

Put your objections or refusal in writing. State facts, include the date and time, and why you are refusing or objecting. Don’t use subjective or accusatory terms such as “short-staffing.” Sign it. Give a copy to your leader and keep a copy for yourself. Understand that sometimes you must care or continue to care for the patients because not caring is the greater harm.

If you are a leader, do not punish the nurse objecting or refusing the assignment. This is retaliation and it is barred by law and professional practice rules. Listen carefully, consider all available options, and thank the nurse for having the courage to speak up. Document carefully and use the experience to identify potential staff or policy needs and ways to respond to future such situations. The ANA position statement is an excellent resource to start.

As for the two examples at the beginning, they happened and I was the nurse. In the first situation, the supervisor told me to do the best I could, and none of my patients died that night. In the second situation, one of the attending physicians saw what was happening and went to the nursing office himself. I got some help. My head nurse, who was off that day, phoned and accused me of deliberately trying to make her look bad to senior management. This was the latest of many staffing incidents at this facility. I had the next two days off; I interviewed at another hospital where I was immediately hired. I worked my two weeks’ notice under the icy glare of my head nurse, knowing I’d done the best I could to keep my patients safe.

Remember that it could be you or a loved one in the patient room someday. Don’t hope that everything will be alright. Ask for help and help your colleagues when they are facing an unsafe assignment.

written by BJ Strickland

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BJ Strickland

Beth J. (“BJ”) Strickland is from Tennessee. She is an RN with Bachelor’s and Master’s degrees in nursing and a Master’s degree in history from Vanderbilt University. She is also a licensed attorney with her Juris Doctor degree from the University of Tennessee. She has practiced nursing since 1976 and has experience in clinical nursing, administration and teaching in several clinical areas. She has practiced law in state and federal courts in Tennessee since 1996 with an interest in healthcare risk management, employment law and medical malpractice. She retired from the U.S. Army in 2015 as a Lieutenant Colonel. This article is not legal advice. It is offered only as information about nursing topics of interest. If you have legal questions, please speak with a licensed attorney in your area. Neither the author or the website publisher are responsible for any actions a reader may take based on material in this article or on this website.

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8 thoughts on “ when an assignment is unsafe ”.

Thank you for this article. I appreciate the legal advice. Nurses are warm, compassionate and forgiving to a fault. Unfortunately, the legal system is just, not fair. When considering how to proceed in a difficult legal, ethical and professional situation, solid advice grounded in the law, which is backed by the American Nurses Association, is the best way to proceed. It is not enough to say that we want what is best for our patients; we must also do what is best for our patients. “Acqeisising and accepting unsafe or inappropriate practices is equivalent to condoning unsafe practice.” (Prov. 6, ANA, 2009)

I agree! I reference the ANA Code often with my students! Thank you for your comment.

Thank you so much for this article! I’m in the first stages of getting into nursing school and this article basically sums up my concerns and addresses them exactly! Thank you!

a Supervisor in Kindred Hospital in West Minister California has a Habit of assigning RN to a patient in 2 different departments, So when a call light is on 1 patient , you cannot see or hear your other patient, And if refuse this assignment , you are reprimanded by your superiors, The CNA rep also has no idea to battle this on going problem. please help the nurses reason legally to this unsafe patient services

You cannot be responsible for patients in 2 different locations (units, departments) at the same time UNLESS a qualified provider is covering the other patient. It is one thing to have patients on a unit and one goes to radiology. Then radiology is taking care of the patient FOR A SHORT TIME. If we’re talking about a full-shift assignment, the facility is setting itself up for a malpractice suit and likely sanctions from the licensing/accrediting body, which could result in large fines, even revocation of Medicare status. A CNA is not legally sufficient full-shift coverage for patients assigned to an RN. This is such an unsafe situation for everyone. I don’t understand why any supervisor would put him or herself, the facility, the patients, and the nurses in this situation. The supervisor can be legally held liable for failure to properly assign, supervise, delegate and so could the hospital in the event of patient injury or death. I strongly recommend contacting your state board of nursing, state nurses’ association, and the state facility licensing board to find out what their regulations are. The federal level (CMS) requires certain staffing too. I am so sorry you are going through this. If you don’t have your own malpractice/professional liability insurance, you should invest in coverage immediately because the facility will likely try to shift blame for any patient injuries or deaths to the individual nurse. Adequate coverage runs about $10-12/month and many policies include a legal representation benefit if your BON tries to discipline you. Good luck!

I work at a Children’s and Women’s hospital. I have worked NICU for 31 years. Recently our hospital has opened an adult unit as an overflow from the University hospital. Our hospital is expected to staff this unit. Nurses are being pulled from the NICU to take care of these adult patients, some of which have tracheostomies, closed head injuries, etc. My question is this. For a nurse like me who has zero adult experience can I be forced to take care of these patients? They are not providing any cross training at all.

My apologies for not answering sooner. I had a very similar question from another nurse recently where the NICU nurses were being used as “sitters” due to reduced NICU census. In your situation, it is absolutely unwise to assign you to direct patient care for any patients you do not feel qualified to care for. That is something you need to address with your risk manager AND absolutely worth a phone call to your state board of nursing for their guidance. No nurse, from a patient safety and legal liability standpoint, should ever be assigned primary care responsibility for patients that they are unqualified to care for — yes, your license says you MAY care for these patients BUT that is only AFTER you’ve had training and supervision. Yours is a specialization and you can’t be “transplanted” to another area — imagine if any of the adult care nurses were suddenly told they had to care for NICU patients without training and supervision. You have a duty to protect the patients and the general public. Your license is not a free pass for employers to use you anywhere they feel a need. Contact your BON for guidance, and if you have your own malpractice insurance (and I believe every nurse should, beyond any coverage provided by the employer) contact the carrier’s risk management service for additional perspective. In the meantime, make sure you document what you were told, who told you, what they said verbatim, when, etc. and keep a record of everything. I hope you’ll never need it but under current circumstances, you may. Good luck!

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You have the right to refuse unsafe assignments

July 11, 2019.

Unsafe Assignments

According to the American Nurses Association , Nurses have the "professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered Nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm." In short, Nurses are empowered to say "no" when management puts our patients at risk by violating safe staffing laws. Here are some articles that explain this right—and how to claim it.

Think your assignment violates the law? Follow this flow chart!

"Unfortunately, many nurses – and many leaders — will answer the question with some form of “suck it up and do the best you can.” And while I know that questioning an assignment, let alone refusing it, is hard, this is exactly what you must consider doing." —Nurse Guidance

When an Assignment is Unsafe (via Nurse Guidance) The scenarios described in this quick read might sound too familiar to Nurses that work in chronically understaffed hospitals. But fear not Nurse Guidance has you covered with great tips on what to do when it's time to say "I refuse."

California Code Regs Disciplinary Action for Nurses There are laws that protect Nurses so we can practice our profession ethically. Know the Codes!

Moral Resilience: Managing and Preventing Moral Distress and Moral Residue Moral resilience is defined by the author of this paper as “the ability and willingness to speak and take right and good action in the face of an adversity that is moral/ethical in nature.” Nurses that say no to unsafe assignments need plenty of this.

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Refusing a patient care assignment

March 16, 2020 • less than 1 minute to read

You may have to make a decision about accepting an assignment involving abnormally dangerous conditions that pose an imminent risk to your safety and health, and could potentially cause serious injury or death.

If you have already accepted the assignment your professional license may be at risk if you fail to continue that assignment, unless you have handed off the assignment and been relieved of responsibility for the patient. If you decide to refuse the assignment, you should remain at the workplace and offer to perform other work that does not pose an imminent risk to your safety and health (e.g., an assignment for which you are provided proper safety equipment and training).

A decision to refuse an assignment could result in disciplinary action taken against you by the employer. Under the collective bargaining agreement between the employer and WSNA, there must be "just cause" for any discipline. WSNA would defend you if you are subjected to unjust discipline, but resolution of any such discipline would likely be delayed and the outcome may be uncertain as a result of the current national and state emergency declarations.

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Accountabilities when refusing assignments or discontinuing nursing services

On this page.

As nurses, your primary accountability is to patients. When deciding whether to provide care in a particular situation, exercise your professional judgment and follow an ethical decision-making process.

Abandonment occurs when a nurse accepts an assignment and discontinues care, without:

• the patient requesting the discontinuation
• arranging a suitable alternative or replacement service; or
• allowing a reasonable opportunity for alternative or replacement services to be provided

Nurses may be concerned that declining work could be considered abandonment. There are many situations that can lead nurses to think about refusing assignments or discontinue care. For example, working in practice environments outside of their knowledge, skill and judgement, workload issues or even workplace strikes.

When deciding whether to refuse an assignment or discontinue nursing care, you are accountable to:

• Assess the potential for harm to yourself and your patients Consider the circumstances of the situation and your practice setting. Continue to work within your knowledge, skill and judgement and complete a point-of-care risk assessment.
• Use evidence-based sources to inform your decision-making and consider the context of the situation
• Communicate your concerns to your employer  Tell your employer that you are considering refusing an assignment or discontinuing nursing care. Discuss your concerns with your employer and consider their response. If, after doing so, you choose to refuse the assignment or discontinue care, work with your employer to develop a plan to ensure that safe patient care continues.
• Ensure your patient(s) continue to receive care  You must ensure that a suitable alternative for care is available for your patient(s) or allow reasonable time for alternate or replacement services to be arranged.
• Document your decision-making process, actions and decision

For more information, read the following resources:

• Code of Conduct
• Conflict Prevention and Management  

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Page last reviewed July 21, 2023

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Under what circumstances can a nurse LEGALLY refuse an assignment?

Nurses General Nursing

Updated: Apr 9, 2023   Published Jul 5, 2004

Hellllllo Nurse, BSN, RN

2 Articles; 3,563 Posts

For instance- a nurse is reporting to work in a hospital. She feels her pt load is too large for her to be able to provide safe care- OR- a nurse is assigned to an area where she does not feel competent, I.e., a medical surgical nurse w/ no L&D experience is assigned to L&D.

Please only answer these questions if you have the FACTS.

"I think" and "I heard" type of answers won't help.

Thank you so much.

• + Add a Comment

barefootlady, ADN, RN

2,174 Posts

You may legally refuse to care for family members. You may legally refuse to care for a patient who has threatened to harm you physically/legally. You may refuse an assignment on a floor or in an area that you are not cross-trained to work in, this may lead to punitive measures, including termination, but it is your license in the end. You may not refuse to give standard nursing care in an emergency situation, even if the situation is not familiar to you. I hope this helps.

RN4NICU, LPN, LVN

1,711 Posts

Hellllllo Nurse said: For instance- a nurse is reporting to work in a hospital. She feels her pt load is too large for her to be able to provide safe care- OR- a nurse is assigned to an area where she does not feel competent, I.e., a medical surgical nurse w/ no L&D experience is assigned to L&D. Please only answer these questions if you have the FACTS. "I think" and "I heard" type of answers won't help. Thank you so much.

This was told to me by a nurse's attorney at a legal nursing conference. I took it to be fact. You take it as you like.

The nurse can refuse the assignment for any of the above reasons LEGALLY in order to protect the patient and his/her license. However, the hospital can still fire the nurse for insubordination - LEGALLY in a right-to-work state. The nurse can sue the hospital and demand to be reinstated. Those cases are decided on a case-by-case basis. Sometimes they are won, sometimes not. The point of the situation is - jobs come and go, and you do what you have to do to protect your license.

barefootlady said: You may legally refuse to care for family members. You may legally refuse to care for a patient who has threatened to harm you physically/legally. You may refuse an assignment on a floor or in an area that you are not cross-trained to work in, this may lead to punitive measures, including termination, but it is your license in the end. You may not refuse to give standard nursing care in an emergency situation, even if the situation is not familiar to you. I hope this helps.

That is a state-by-state thing. In my state (and many others), if you are not ASSIGNED to the patient, you do not have the duty to care. This is per a nurse attorney who specializes in negligence and malpractice cases.

At what point has a nurse been "assigned" to a pt?

I have been told that it is legal for a nurse to refuse an assignment if she has not yet taken a report on an assignment. I want to know if this is true.

How will a nurse know what her assignment entails if she has not yet taken a report?

6,375 Posts

Hellllllo Nurse said: At what point has a nurse been "assigned" to a pt? I have been told that it is legal for a nurse to refuse an assignment if she has not yet taken a report on an assignment. I want to know if this is true. How will a nurse know what her assignment entails if she has not yet taken a report?

It is correct that a nurse may "legally" refuse an assignment at the beginning of the shift if she has not yet "assumed" care of the patients.

It is also correct that the facility may discipline or fire the nurse for doing so. But the State BON will not take action for patient abandonment because a nurse can not abandon patients for whom s/he has not assumed care.

So, if you report to work and are told to take an assignment of 10 patients, which you believe to be unsafe, you may refuse the assignment and protect your license but still lose your job.

So it's almost like a Catch-22 thing, huh? So you mean to say that if (for example) a nurse manager wants to "get rid of" a particular nurse, all they have to do is to create a situation (like giving the nurse 15 cases) in which the nurse MUST refuse to protect her license, but she will DEFINITELY be fired and out the nurse manager's hair who wanted her to leave in the beginning?

Also, you say that jobs come and go, but being fired has GOT to look bad on a resume when you're searching for a new job!

Thanks for your responses. I am not currently in a situation where I need to know this, but I have been in the past. I accepted an assignment that I felt was unsafe more than once. Both times I voiced my objections to my charge nurse. I explained why I felt the assignment was unsafe and why I did not think I should take it. Both times the charge nurse said nothing and walked away, leaving me alone with the pt. Nothing untoward happened, thank God, but I still look back on the situations with uneasiness and unanswered questions.

I gave my notice the day after the first situation, and the second situation happened when I was completing my notice.

Also, a friend of mine believes that she does not have the right to refuse any assignment without risking charges of pt abandonment. I do not believe this to be true and want some information to take back to her.

At the hospital where I worked several years ago, some of the nurses would come up to the floor prior to clocking in to see the assignment. The hospital was known for giving us 8 to 10 total care patients with 1 CNA for 20 + patients. This was not a LTC facility. I was a new nurse and didn't understand the way things worked. But the other nurses told me that they did this prior to clocking in so that if they didn't want the assignment, they would call off. Thinking back, I'm sure they could have been terminated if they had actually "called off" at the last minute, but they wouldn't have been reported for abandonment.

Havin' A Party!, ASN, RN

2,722 Posts

Jolie said: It is correct that a nurse may "legally" refuse an assignment at the beginning of the shift if she has not yet "assumed" care of the patients. It is also correct that the facility may discipline or fire the nurse for doing so. But the State BON will not take action for patient abandonment because a nurse can not abandon patients for whom s/he has not assumed care. So, if you report to work and are told to take an assignment of 10 patients, which you believe to be unsafe, you may refuse the assignment and protect your license but still lose your job.

This sounds correct to me.

pnurseuwm said: Like giving the nurse 15 cases.

It seems a bit exaggerated.

If the assignment is totally unrealistic, the facility will certainly encounter several prob's they'd rather not have to deal with.

As stated above, a lot of this is situational -- all depends on the specific particulars.

11,191 Posts

And unless you have a contract, an employee-at-will can be fired for any darn reason at all.

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The ethics of refusing to care for patients during the coronavirus pandemic: A Chinese perspective

Junhong zhu.

1 Nursing Studies, School of Medicine, Zhejiang University, Hangzhou China

Teresa Stone

2 Faculty of Medicine and Health Sciences, Yamaguchi University, Ube City Japan

Marcia Petrini

3 Wuhan University School of Nursing, Wuhan China

4 Chiang Mai University, Chiang Mai Thailand

As a result of the coronavirus (COVID‐19) pandemic, health professionals are faced with situations they have not previously encountered and are being forced to make difficult ethical decisions. As the first group to experience challenges of caring for patients with coronavirus, Chinese nurses endure heartbreak and face stressful moral dilemmas. In this opinion piece, we examine three related critical questions: Whether society has the right to require health professionals to risk their lives caring for patients; whether health professionals have the right to refuse to care for patients during the coronavirus pandemic; and what obligations there are to protect health professionals? Value of care, community expectations, legal obligations, professional and codes of practice may compel health professionals to put themselves at risks in emergency situations. The bioethical principles of autonomy, justice, beneficence and non‐maleficence, as well as public health ethics, guide nurses to justify their decisions as to whether they are entitled to refuse to treat COVID‐19 patients during the pandemic. We hope that the open discussion would support the international society in addressing similar ethical challenges in their respective situations during this public health crisis.

1. INTRODUCTION

As the first group to witness patients suffer and die during the pandemic, Chinese health professionals have endured heartbreak and faced impossibly stressful moral dilemmas (Thomson,  2020 ).

I am only performing my responsibility Being a lifesaver as a nurse Often, I had to stand at the front line without any protection No choice of life or death Do not have any great thoughts Please do not give me a wreath Do not give me any applause And not …, martyr, or any merit Coming over to Wuhan, not for …receiving praise Just want to go back home safely after the epidemic Even if it is just a skinny body left I want to bring myself back to my children and my parents Ask yourself: Who is willing to hold your peer's urn Making the way to home

A poem written by a nurse sent from another province to work in a field hospital in Wuhan (Rou,  2020 ). The Chinese people were deeply moved by this poem. The nurse's simple words struck a chord among many health professionals, which is worthy of reflection: Do we, as a society, have the right to require the health professionals to devote their lives to the care of patients when they may also have obligations to their own family?

Coronavirus disease (COVID‐19) caused by the virus named severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) was characterized as a pandemic by the World Health Organization (WHO) on 11 March 2020 (WHO, 2020a ). There are now over 16 million cases worldwide across 188 countries/regions and 648, 966 deaths as at 27 July (Center of Systems Science & Engineering at Johns Hopkins University, 2020 ) with numbers expected to grow. The characteristics of this public health crisis include a novel pathogen; uncertain transmission routes; deficiencies in testing for the virus; no effective treatment; a shortage of protective equipment; and the exponential speed of its spread (Livingston, Desai, & Berkwits,  2020 ; Omer, Malani, & del Rio,  2020 ). These characteristics have meant that health professionals, including nurses, face real dangers and have to confront new and difficult moral questions in a crisis situation (Thorne,  2020 ).

There is a significant element of distress and anxiety in the face of COVID‐9 among the general public as well as health professionals (Montemurro,  2020 ) with some evidence that both experience vicarious traumatization (Li et al.,  2020 ). Dealing with the unprecedented uncertainties and challenges means that health professionals are likely to confront ethical dilemmas and conflicts for which they are ill‐equipped. 'Perception, rather than reality, has been seen to control the resolution of ethical dilemmas' (Freedman,  1988 , p.20), and the perception, based on widespread coverage of the COVID‐19 pandemic, is that it is risky to take care of a patient who has COVID‐19. In this paper, we examine three interrelated questions: Whether society has the right to require health professionals to risk their lives caring for patients; whether health professionals have the right to refuse to care for patients during the coronavirus pandemic; and what obligations are there to protect health professionals? We discuss these ethical issues starting from the perspective of Chinese health professionals before situating them in a global perspective.

2. BACKGROUND

Chinese health professionals were the first to face the challenge of caring for patients with coronavirus when little was known about the nature of the virus and demand for health services outstripped their ability to respond. At the outbreak of COVID‐19, 346 health care teams consisting of 42,600 health care workers from across China went to Wuhan to support the local health care services (Beijing News,  2020 ; Rou,  2020 ). Initially, the situation in Wuhan was challenging: dead bodies could not be moved from wards on time because of lack of personnel and equipment, and patients had to wait for treatment for hours and even days in a state of panic (Thomas,  2020 ).

Faced with the kind of dilemmas posed by the coronavirus pandemic, decision‐makers and health professionals, including nurses, need to base decisions in an ethical framework according to a set of agreed values. These should balance the rights and duties of individuals, communities and populations with regard to protecting and maintaining health (Schröder‐Bäck, Duncan, Sherlaw, Brall, & Czabanowska,  2014 ). We pose a series of questions based on the experience of Chinese nurses and discuss these through the lens of ethics.

3. DOES SOCIETY HAVE THE RIGHT TO REQUIRE HEALTH PROFESSIONALS TO RISK THEIR LIVES CARING FOR PATIENTS WITH COVID‐19?

Early in the pandemic, health professionals working at the frontline caring for suspected and diagnosed patients with COVID‐19 were faced with tough ethical decisions about whose safety to prioritize—their patients and that of the whole community, or their own. To explore this, we have drawn on the concepts of duty of care and how this is shaped by community expectations and culture, codes of conduct, law and regulations, and biomedical as well as public health ethics.

3.1. Duty of care

From a professional perspective, duty of care refers to obligations to act towards others in regard to a particular standard (Royal College of Nursing (RCN), 2019 ). The Royal College of Nursing (RCN) in the UK goes on to state that there is both a legal and professional duty of care: the law imposes a duty of care where it is 'reasonably foreseeable' that the health practitioner might cause harm to patients through their actions or omissions. The professional duty of care pertains to adherence to professional codes of practice (RCN, 2019 ; Wright, Peterson, & Gifford,  2020 ). Registered nurses are required to be accountable for the safety of themselves, their patients and the public (American Nurse Association (ANA), 2015 ; Royal College of Nursing (RCN), 2020 ; Wright et al.,  2020 ).

Prioritizing which of these concerns is paramount, especially in the context of a disaster, such as a pandemic, when existing resources are overwhelmed may create dilemmas. For example, if health professionals do not have access to the required personal protective equipment they may put themselves or their patients at risk but refusal to provide care will also risk patients’ lives. That this can be a balancing act with responsibility to one party (e.g. the health service), possibly in conflict with the responsibility to clients, is acknowledged by an Australian health service (New South Wales Health, 2004 ).

3.2. Community expectations, culture and political ideology

Historically, nursing, and perhaps to a lesser extent medicine, has seen as a 'calling,' in which nurses and doctors are expected to sacrifice themselves for their patients (Freedman,  1988 ; Kao & Jager,  2018 ).

During the COVID‐19 pandemic, Chinese media and government emphasized the idea of sacrifice. The ideal of sacrificing oneself for a higher, national goal is deeply embedded in Chinese culture: 'sacrificing one's family for all, and putting the country before oneself has always been a spiritual hallmark of the Chinese nation [and is] ingrained in our genes'. (Ministry of Foreign Affairs of PRC, 2020 ).

In China, the dual effects of traditional culture, media publicity and propaganda, has bypassed questions of ethics and duty of care in emotional appeals to health professionals to 'give up family for everyone, for the country', where the risk of sacrifice is the greatest (Xu,  2020 ). The media praised the health professionals working at the front line at high risk of infection and depicted them as heroes, 'soldiers in white' (Beijing News,  2020 ). Health professionals were encouraged to have the spirit to continue to work even if they were ill: 'do not leave the front‐line while being slightly injured' (We‐yuan‐rong‐mei,  2020 ; Zi‐gong‐chen‐shi, 2020 ). A particularly pertinent example of this propaganda is a video, released by Chinese state media, of a heavily pregnant Chinese nurse treating people with coronavirus with the intent to portray her as a self‐sacrificing hero (BBC News,  2020 ). Instead, there was a backlash across China with people responding that the woman was being used as a tool and that it was 'sick' (BBC News,  2020 ).

Exhausted health professionals had mixed reactions to media accolades. As narrated in the heartfelt poem, presented at the beginning of this paper, nurses wanted to return to their homes and families and not sacrifice themselves and be praised as martyrs (Rou,  2020 ). Media depictions of health professionals as heroes are not confined to China: this has been happening across the globe as COVID‐19 affects other countries, for example in Italy people sang from their balconies and during the lockdown in the UK people gathered on their doorsteps to clap health workers. A registered nurse from a Massachusetts‐based hospital notes that 'praise and applause from hospital leadership does not alleviate the dangers nurses face' (Vaidya,  2020 ). It is also not new: during the SARS outbreak, a doctor in Taiwan stated that it was too heavy a burden to be called a hero 'I just do what I should do'. (Hsin & Macer,  2004 , p.210). Albert Camus in his classic and prescient novel 'The Plague' written in 1948 put it thus:

There's no question of heroism in all this. It's a matter of common decency. That's an idea which may make some people smile, but the only means of fighting a plague is common decency. (p. 57)

During the COVID‐19 pandemic, a head of an infection control department in China told the media: 'I require all health care workers who are communist party members to replace all those who have been working over the past days. In this critical period, there is no negotiation, and all communist party members should work at the frontline'. This demand was widely supported by Chinese local and national official media (Xinhuanet,  2020 ). Communist ideology is taught in school and is a required subject at university level. The communist ideology combines the traditional Chinese cultural message that sacrifices should be honoured if one dies for the people into the political imperative that one should eliminate all difficulties and serve the people without fear of sacrifice (Xinhuanet, 2020 ). This contrasts with the situation in the west: police and army are obliged by their service to put their lives at risk and professionals in health are relied on to follow their codes of professional conduct and ethics; vocation is drawn on as a concept to reinforce this expectation of service.

As health professionals, we should ensure there is an adequate workforce and that workforce is adequately protected without having to resort to demands to work based on political grounds. Political ideology can be an uneasy fit with medical ethics and professional judgement. While it is admirable that the communist party members act as a role model, if their own health status prohibits them from working or they lack the required clinical knowledge, they should not be working at the front line without sufficient preparation. Health professionals' autonomy and right to make their own choices should be respected.

3.3. Codes of ethics, law and regulations

Codes of ethics are based on the ethical principles derived from the broader ethical considerations and adapted to the scope of practice and role of each health professional in order to clarify roles and responsibilities to ensure ethical practice. The established nursing ethical standards provide a guide for nurses in ethical analysis and decision‐making (ANA, 2015 ). However, health professional codes of practice and ethical statements may be prescriptive (Freedman,  1988 ), for example, stating that nurses are required to care for patients regardless of diagnosis. In the context of the human immunodeficiency virus (HIV), the American Nurses Association suggested that nurses must care where the value of the care outweighs the potential risk to the nurse (Freedman,  1988 ), but the ethical code of the American Nursing Association indicates that nurses have the obligation and responsibility to take care of their own health while taking care of patients (ANA, 2015 ). In practice, it is not easy to assess the value of care and risk.

During an emergency, if Chinese nurses do not assume their professional responsibility to save lives, they could violate the first principle of the Chinese Nurses Association code of ethics, which indicates that 'Nurses' responsibilities are … to follow the nursing mission by protecting lives, relieving pain, promoting health, and preventing disease'. (Zhang,  2014 ). A provision of the Chinese Nurses’ Regulation states that nurses must participate in health care during a natural disaster, public health event and other emergencies that seriously threaten the life and health of the public (State Council of PRC,  2008 ). Accordingly, the health authority will give a warning and order correction if a nurse fails to meet the obligations mentioned above when asked to do so. In serious circumstances, the nurse's certificate for practice shall be suspended for more than six months but less than one year; it may also be subject to revocation (State Council of PRC, 2008 ).

Faced with a public health crisis, politicians, hospital leaders and the media should not expect the health professionals to be martyrs for society on moral grounds or political grounds. It is not enough to say that the health professional has a duty of care, other ethical principles apply.

There are four basic principles of biomedical ethics according to Beauchamp and Childress ( 2001 ): autonomy, justice, beneficence and non‐maleficence. Autonomy is about the protection of individual choice, rights and freedoms against the control of organizations (Thompson, Melia, Boyd, & Horsburgh, 2006 ). Justice in the context of medical ethics means that there should be fairness in medical decisions and involves fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation (Beauchamp & Childress,  2001 ). Beneficence is the principle that requires care to be provided with the intent of doing good—that all professionals have the foundational moral imperative of doing the right thing (Kinsinger,  2019 ). Non‐maleficence refers to the principle that care harms neither the patient nor others in society.

The four above‐stated ethical principles mainly guide health professionals in making their decisions to protect individual patients’ best interests in clinical medicine. However, complying with public health emergency requests a move away from a person‐centred care approach to a population health approach (Mckenna,  2020 ). Ensuring the health population often entails imposing limitations on rights and preference of individuals, which may impose burdens on health professionals. We fully agree 'the straightforward application of the principles of autonomy, beneficence, non‐malfeasance and justice in public health practice is problematic' (Upshur,  2002 , p.101). The principle of 'do no harm' should also be applied to any decisions made about deploying health professionals in dangerous situations.

One of the lessons to be drawn from the severe acute respiratory syndrome (SARS) epidemic in 2003, arguably, is for us to pay greater attention to the duty of care owed to health professionals (Singer, Benatar, & Bernstein,  2003 ). Health care professionals sacrificed time, income or health should be compensated (Upshur,  2002 ). Strategies should focus on protection and compensation, such as guarantees for health professionals' safety; adequate rest; attention to the welfare of themselves and their families; psychological support; financial compensation; and affirmation. An example of this is the initiative of the COVID‐19 working team in Chinese central government in February 2020 that included ten strategies for protecting health professionals (State Council of PRC, 2020 ). These included increasing salary, a monetary bonus, opportunities for promotion and the provision of psychological and social support for health professionals who were working with COVID‐19 patients.

Recently, the CNA Code of Ethics highlighted the duty of employers and governments to protect and support nurses during disasters, outbreaks and pandemics (Wright et al.,  2020 ). As was advocated by Hsin and Macer ( 2004 ): a well‐developed society should have sufficient space to apply humanism to everyone in any kind of situation, including a public health crisis. Then, the second question follows:

4. DO HEALTH PROFESSIONALS HAVE THE RIGHT TO REFUSE TO TAKE CARE OF PATIENTS DURING THE CORONAVIRUS PANDEMIC?

Caring for patients is a foundational value and moral commitment in nursing (Watson, 2009 ) and the same is true of other health professionals. For nurses, their ethical behaviour is theoretically grounded in the responsibility to care for the patient (Georges & Grypdonck,  2002 ) as well as a professional obligation (ANA, 2015 ). Caring for others is also a major reason people join the helping professions and a value that guides their actions. When unable to practice in a way that upholds their ethical values, they are vulnerable to moral distress (Davis,  2006 ) and we witnessed the tears of Chinese doctors and nurses who went to Wuhan to support the local medical personnel but were unable to save many of their patients.

Health professionals have a responsibility to take care of their own safety and health, and this may come into conflict with their moral duty to care (McKenna,  2020 ). If health professionals either individually or as a group refuse to take care of patients during an emergency, such as a pandemic, they are highly likely to face widespread condemnation both from the public and from other health professionals.

Health professionals across the world working at the front line of the COVID‐19 pandemic are realistically anxious about their own health and that of their family because, until the development of a vaccine for COVID‐19, health professionals face the threat of becoming infected and even dying. Health care workers in China made many sacrifices to protect their own family's welfare: many chose to stay in hotels due to the fear of transmitting the infection to their loved ones. Across the globe, nurses have also faced prejudice with laypeople concerned about them bringing infectious disease to the community and they have faced eviction and hostility (Nguyen,  2020 ).

Most nurses and health professionals will care for patients with infectious diseases, but during the SARS, MERS and Ebola viruses, a minority of nurses refused: they escaped from working at the front line, either by taking sick leave or by resigning due to fear of infection, or worries about the safety of family members (Venkat et al.,  2015 ). Although we do not have definitive evidence of this occurring in China during the coronavirus, health professionals were heard voicing their fears and considering this as an option (Liu et al.,  2020 ).

In February 2020 for a period of five days, Hong Kong's Hospital Authority Employees Alliance staged a planned protest. Some nurses called in sick to register their disapproval of the government's response to the virus (Chan,  2020 ). They also requested that the government provide adequate personal protective equipment. This resulted in a public debate with many harshly condemned the health professionals refuse to treat and care for patients with COVID‐19 and stated that they did not fulfil their humanitarian duty to save lives during an emergency (Global Times,  2020 ).

The experience of recent history shaped the nurses’ actions. In 2003, about 20% (about 1,000) of Hong Kong's health professionals were infected by the SARS virus and among those who died about one‐third were doctors and nurses (Liu,  2020b ). In Wuhan, for the first four weeks of January 2020 40 (29%) of the 138 patients with COVID‐19 who were treated in Zhongnan Hospital were health care workers infected due to insufficient equipment and strategies, or not following proper self‐protection procedures in the early stages of the epidemic. By 11 February 2020, 1,716 health care workers in China were diagnosed with COVID‐19, which was 3.8% of all cases in China, and at least six have died (Ma, 2020 ). International Council of Nurses (ICN, 2020 ) declared more than 600 nurses die from COVID‐19 worldwide and calls on all countries to record more detailed data on infections and deaths of health care workers on 6 May 2020 (Liu,  2020a ), and there is lack of updated statistics in Chinese official report yet.

The primary principle of biomedical ethics as proposed by Beauchamp and Childress ( 2001 ) is that decisions should consider the balance of beneficence, risks and costs of actions. It is arguable that authorities requiring health professionals to work at the front line with insufficient PPE may have the intent to do good to patients, but the decision is not in line with beneficence or non‐maleficence for health professionals. The government has the responsibility to develop a plan of emergency preparation for epidemics, which includes measures to protect staff. Health professionals’ safety cannot be guaranteed without adequate personal protective equipment (PPE), and they can become the source of infection themselves and endanger lives. In short, compromising the safety of health professionals in the short term with also has longer‐term ill effects on patients, the public and society.

4.1. Circumstances in which it is acceptable for health professionals to withdraw from care provisions or to refuse to provide care for patients with COVID‐19

• Clinician's health condition. For example, health professionals who may be suffering from an infectious disease that they could potentially pass on to patients and colleagues. Health professionals have an obligation to report whether they are suffering from, or potentially suffering from, an infectious disease so that they do not put themselves, their colleagues or patients at risk. It was sad knowing two Italian nurses with coronavirus kills themselves (Steinbuch,  2020 ). It is important to encourage health professionals to seek psychological counselling when they are extremely stressful.
• If a health professional has an underlying condition which weakens their immunity, then this would preclude them from working with patients diagnosed with COVID‐19 and hospital management has the responsibility to facilitate this. Sadly, many retired doctors heeded a call to return to work, despite knowing that their age put them at risk of being infected and many have died (Weaver,  2020 ).
• When the care is outside the health professional's scope of competence or training (RCN, 2020 ). Unlike other overseas countries who brought student health care workers into clinical settings before their training was complete in order to bolster the workforce, student involvement in COVID‐19 pandemic is forbidden in China. Some Chinese students have objected to this decision, as they feel ethically compelled to fulfil their duty to care for COVID‐19 patients. The restriction was largely justified during Ebola outbreaks: it aims to protect the public health by minimizing the population directly engaged with COVID‐19 at clinical front lines, and it ensures trainee well‐being as recommended by American College of Emergency Physicians, the Emergency Nurse Association and the Society for Academic Emergency Medicine (Venkat et al.,  2015 ).
• Where there is conscientious objection (RCN, 2020 ). The Australian Nursing & Midwifery Federation (ANMF, 2017 ) has made clear that 'fear, personal convenience or preference, are not sufficient basis for conscientious objection'. Fear, personal preference and convenience cannot be cited by nurses as reasons to avoid treating COVID‐19 patients. Chinese health professionals have made remarkable contributions in challenging work environments while being fully aware of the dangers of their tasks (Wen‐Xue‐City,  2020 ; Zhu,  2020 ). The same is true of their colleagues around the globe.
• Where there is physical violence (RCN, 2020 ). Regrettably, this has included, in the coronavirus pandemic, health professionals being deliberately coughed or spat on.
• Where there are health and safety hazards, for example a lack of appropriate equipment (RCN, 2020 ). For example, under the Canadian provincial and territorial occupational health and safety legislation, employers have a responsibility to provide a safe work environment. While health professionals are forced to decide between the risk of providing patient care and the need to protect their own (or their family's) health and safety, the CNA Code of Ethics highlights the reciprocal duty of employers and governments to protect and support nurses during disasters, outbreaks and pandemics (Wright et al.,  2020 ).

The refusal to care on the basis of health and safety hazards has created the majority of dilemmas health care professionals have faced in this pandemic (Medoza & Kruesi,  2020 ). Health professionals should be able to raise concerns about safety without detriment to themselves. In the turmoil of COVID‐19, whistleblowers daring to speak up and tell the truth have been targeted (Zhu,  2020 ). Tragically, three Russian doctors were reported to have mysteriously 'fallen' out of a window after raising concerns about lack of PPE and being forced to work despite a positive COVID‐19 test (CNN, 2020 ). This then leads to our third question:

5. WHAT OBLIGATIONS ARE THERE TO PROTECT HEALTH PROFESSIONALS?

Commentators on the current coronavirus crisis have frequently likened requiring health professionals to care for patients with coronavirus without adequate supplies of personal protective equipment to sending soldiers into war with no guns (Hushion,  2020 ). On 27 February 2020, the WHO Director‐General called on all countries to prioritize the protection of health professionals during the COVID‐19 outbreak (WHO, 2020b ) because across the globe clinicians and frontline workers have not been given the equipment they need to stay safe and many have died as a result.

In most countries, the law requires every employee and the employer to protect their own safety and the safety of others. Health professionals are entitled to a safe place of work as was laid out by the British Medical Association (BMA, 2020 ) and RCN ( 2020 ) which both noted that health professionals have employment rights to ensure their protection and employers must provide a safe system of work, which includes provision of appropriate PPE. The British Medical Association (BMA) concerned about the British government's inability to provide adequate protection and subsequent 'watering down' of PPE recommendations advised doctors that they should not face a disciplinary process or detriment if they are confronted with serious and imminent danger in their workplace and they refuse to work. They advised that there are limits to the risks they can be expected to face:

You are under no obligation to provide high‐risk services without appropriate safety and protection. You can refuse to treat patients if your PPE is inadequate, you are at high risk of infection and there is no other way of delivering the care. (BMA 2020, p.1)

Similarly in April 2020, the UK Royal College of Nursing (RCN) issued guidelines for nurses if they are considering refusing to treat due to a lack of adequate PPE during the pandemic (RCN, 2020 ). The guidance provides the decision route and potential legal consequences for nurses deciding whether the PPE provided is appropriate for nurses and what to do if it is not. All staff, registered or not, if they are considering refusing to treat due to lack of adequate PPE, they must be empowered by RCN and the employment law protections to speak up and promote the safest way forward (RCN, 2020 ).

Nurses in the United States are taking legal action against the New York State Department of Health because they were supplied with 'grossly inadequate and negligent protections' and were instead forced to work in 'unsafe working conditions' (Mahbubani,  2020 ). The CNA Code of Ethics highlights that nurses have a right to receive truthful and complete information so they have a clear understanding about the obligations and expectations around their role, and be able to fulfil their duty to provide care (Wright et al.,  2020 ).

On 6 April 2020, the United Nations Educational, Scientific and Cultural Organization (UNESCO), International Bioethics Committee (IBC) and World Commission on the Ethics of Scientific Knowledge and Technology (COMEST) highlight an urgent recognition all over the world that 'our right to health can be guaranteed only by our duty to health both on an individual and collective levels' (UNESCO, IBC, & COMEST, 2020 , p. 2).

6. CONCLUSION

Consideration of the COVID‐19 pandemic and its various ramifications continues and with it continued ethical dilemmas for health professionals, health service managers and decision‐makers at government level. The paper has highlighted the pandemic ethical issues relating to cultural, political and social contexts and competing values and perspectives.

We sincerely hope that this open discussion starting from a Chinese perspective will highlight the need for a collaborative global approach to the pandemic and the ethical dilemmas it raises. As the nurse so eloquently put it in her poem, we 'just want to go back home safely after the epidemic'.

ACKNOWLEDGEMENT

The authors would like to express their gratitude to Emeritus Professor Kath Melia, University of Edinburgh, Professor Xinqing Zhang, Peking Union Medical College,Associate Professor Honggu He, Singapore National University for their inspiration through insightful communication and Special Funds of the National Science Foundation of China (Grant No.72042005).

Zhu JH, Stone T, Petrini M. The ethics of refusing to care for patients during the coronavirus pandemic: A Chinese perspective . Nurs Inq .2021; 28 :e12380. 10.1111/nin.12380 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

[Correction added on 30 September 2020, after first online publication: Special funding has been added to the Acknowledgement section]

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Registered Nurses' personal rights vs. professional responsibility in caring for members of underserved and disenfranchised populations

Affiliation.

• 1 Nursing Resource Center, Barry University, Miami Shores, Florida, USA. [email protected]
• PMID: 15840068
• DOI: 10.1111/j.1365-2702.2004.01107.x

Aims: Health disparities exist and refer to the chasms in health status between the advantaged and disadvantaged. Intense multiculturalism will require different approaches and moral obligations to work with these groups and urgency exists to develop nursing caring strategies when dealing with these populations. Development of nursing curricula which identify prejudicial thinking and intolerance for marginalized groups will help to decrease fears and increase nurses' willingness to provide culturally competent health care for underserved and disenfranchised populations.

Background: Caring for members of disenfranchised groups instills fear at some level in nurses who are working with these individuals. This fear may be due, in part, to the potential harm nurses perceive the patient may cause them, or perhaps it is because they feel they could possibly be in the individual's situation at some point in their lives. Prejudice and discrimination continue to exist in society and have adversely affected the health care system and the nursing profession. Discrimination may be based on differences due to age, ability, gender, race, ethnicity, religion, sexual orientation, or any characteristics by which people differ.

Relevance to clinical practice: Registered Nurses are accountable for nursing decisions and actions regardless of personal preferences. Due to the rapidly changing healthcare system the nurse faces increasing ethical dilemmas and human rights issues. Nurses are individually accountable for caring for each patient and the right to refuse an assignment should be carefully interpreted to avoid patient abandonment. Nurses' objections can be based on moral, ethical, or religious beliefs not on personal preferences and in an emergency the nurse must provide treatment regardless of any personal objections.

Publication types

• Attitude of Health Personnel*
• Attitude to Health / ethnology
• Codes of Ethics
• Cultural Diversity*
• Education, Nursing / standards
• Health Knowledge, Attitudes, Practice
• Health Services Needs and Demand
• Models, Nursing
• Nurse's Role* / psychology
• Nurse-Patient Relations
• Nursing Theory
• Patient Advocacy / education
• Patient Advocacy / ethics
• Patient Advocacy / psychology
• Professional Competence
• Social Responsibility*
• Transcultural Nursing / education
• Transcultural Nursing / organization & administration
• Vulnerable Populations* / ethnology

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Guest Essay

Doctors Need a Better Way to Treat Patients Without Their Consent

By Sandeep Jauhar

Dr. Jauhar is a cardiologist in New York who writes frequently about medical care and public health.

Not long ago, I took care of a middle-aged man at my hospital who had severe heart failure requiring life support. When he was disconnected from machines after a few days of treatment, he began to display psychotic symptoms, including delusional thinking, tangential speech and paranoia. He had a long history of untreated schizophrenia, I learned, which had estranged him from family members and friends, with whom he had virtually no contact.

My patient demanded to leave the hospital. However, sending him home was going to be a problem. He could not take care of himself. There was little chance he would take his medications, including a blood thinner to dissolve a clot in his heart before it caused a stroke. He was even less likely to take psychiatric drugs that he did not believe he needed.

My colleagues and I didn’t know what to do, so we called the treating psychiatrist. The psychiatrist immediately declared that our patient lacked the capacity to discharge himself from the hospital. The patient could not grasp the implications of this choice, for instance, or properly weigh its risks and benefits. The psychiatrist said the patient should remain in the hospital to receive psychiatric treatment, even against his will.

The psychiatrist’s opinion made sense to me. Patients with untreated schizophrenia have a higher rate of death than those who undergo treatment. Hopefully treatment would restore my patient’s judgment to the point where he would take his medications when he went home — or even decide not to take them, but to make that risky decision in the full appreciation of the likely consequences. (If autonomy means anything, it means that patients have the right to make bad decisions, too.) Treating him, even over his objections, seemed to be in his best interests.

However, according to New York law — and the law of other states — such involuntary treatment would require a court order. As doctors, we would have to plead our case before a judge. But was a judge without medical or psychiatric expertise the best person to decide this man’s fate?

In this case and also more generally, I think the answer is no. The law ought to be changed to keep such decisions in hospitals — in the hands of doctors, medical ethicists and other relevant experts.

Doctors don’t always have to resort to the courts to treat patients without their consent. There are some notable exceptions, such as during a life-threatening emergency (if a competent patient has not previously refused such treatment) or when there is a pressing societal interest (such as requiring patients with communicable tuberculosis to take antibiotics).

But judicial review has been the cornerstone of “treatment over objection,” as it’s known, for the past four decades or so. Appellate courts in the 1980s ruled that judicial hearings in such cases are needed to safeguard patients’ rights. For example, in 1983, in Rogers v. Commissioner of Department of Mental Health, the Massachusetts Supreme Judicial Court declared that a judge could override medical judgments favoring involuntary psychiatric treatment.

The underlying motivation behind judicial review was and remains laudable: to avoid the sort of paternalistic abuses that have characterized too much of medical history. Doctors often used to withhold bad news from patients, to cite just a small example. Involuntary treatment, even with benevolent intentions, reeks of such paternalism.

But though medical practice is by no means perfect, times have changed. The sort of abuse dramatized in the 1975 movie “One Flew Over the Cuckoo’s Nest,” with its harrowing depiction of forced electroconvulsive therapy, is far less common. Doctors today are trained in shared decision-making. Safeguards are now in place to prevent such maltreatment, including multidisciplinary teams in which nurses, social workers and bioethicists have a voice.

In addition to being less necessary to prevent abuse than they once were, courts are by nature poorly suited for making decisions about treatment over objection. For one thing, they are slow: Having to go to court often results in delays, sometimes up to a week or more, which can harm patients who need care urgently.

Moreover, judges have neither the experience nor the expertise to properly evaluate psychological states, assess decision-making capacity or determine whether a proposed treatment’s benefits outweigh its risks. It is no surprise that by some estimates 95 percent or more of requests for treatment over objection are approved by judges, who invariably haven’t met the patient and must rely on information provided by the treating medical team.

A better system for determining whether a patient should be treated over his or her objection would be a hospital hearing in which a committee of doctors, ethicists and other relevant experts — all of whom would be independent of the hospital and not involved in the care of the patient — engaged in conversation with the medical team and the patient and patient’s family. Having hearings on site would expedite decisions and minimize treatment delays. The committee would make the final decision.

Of course, such a committee would have to be granted immunity from legal liability (as with judges in our current system), so that experts would be willing to serve and speak candidly. Patients’ interests could be safeguarded by requiring the committee to publish its reasoning. Periodic audits by a regulatory body could ensure that the committee’s deliberations were meeting medical and ethical standards.

In the event that the committee could not reach a consensus on the best course of action (or if there were allegations of wrongdoing), then the parties involved could appeal to a judge. But that would be the exception rather than the rule.

In the case of my patient with heart failure, the decision ultimately didn’t have to go before a judge. Multiple discussions involving the patient, the hospital ethics and palliative care teams, social workers, nurses, psychiatrists and other doctors — discussions that in many respects served the function of a formal committee of the sort I’m proposing — yielded an agreement with the patient that his interests would be best served by sending him home with hospice care.

Capacity must be judged relative to the decision being made, and it became clear over the course of hospitalization that our patient understood the terminal nature of his condition and had the capacity to choose hospice care. Forced treatment was unlikely to significantly improve his psychiatric symptoms before the natural progression of heart failure caused his death.

So he was discharged home. It was the best decision under the circumstances, one reached by expert deliberation, not legal procedure. He passed away a few weeks later without, fortunately, ever setting foot in court.

Sandeep Jauhar ( @sjauhar ) is a doctor at Northwell Health in New York and the author, most recently, of “ My Father’s Brain : Life in the Shadow of Alzheimer’s.”

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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National Nurses Week 2024: RN reflects on the state of the profession, calls for change

Monday, May 6 kicks off National Nurses Week , and it gives folks an opportunity to show their love and appreciation for the people who take care of the sick, injured and dying.

From neonatal nurses who help welcome newborns into the world to hospice nurses that provide peace and comfort to their dying patients, nurses play a crucial role in the medical industry.

According to the American Association of Colleges of Nurses, nurses make up the largest part of the healthcare workforce, are the primary health providers for patients in hospitals and give the most long-term care in the nation.

Restaurants and chains, like Chipotle and Dunkin' , are offering discounts and coupons to the medical professionals to show their appreciation for what they do. But experts are saying that it isn't enough and what nurses need right now goes beyond discounts.

New nursing home staffing regulations Nursing homes must meet minimum federal staffing levels under Biden rule

Catherine Kennedy, a registered nurse and the Vice President of National Nurses United , told USA TODAY that there needs to be systemic change on the federal level to give nurses the best chance to care for their patients.

A study published by the National Library of Medicine states that in 2021, nurses would work an average of "8.2 hours of paid overtime and 5.8 hours of unpaid overtime per week that year — making up the equivalent of more than 9000 full-time jobs."

According to a different study that analyzed a poll sent in from 29,472 registered nurses and 24,061 licensed practical nurses or licensed vocational nurses across 45 different states found that that 62% of nurses said they saw an increase in their work load during the COVID-19 pandemic.

According to those polled they felt the following at least “a few times a week” or “every day:”

• 50.8% felt "emotionally drained"
• 56.4% felt "used up"
• 49.7% felt "fatigued"
• 45.1% felt "burned out "
• 29.4% felt "at the end of their rope"

Despite being labeled as heroes during COVID-19, Kennedy said nurses were not given the support they needed to do their jobs properly.

"Nurses were in tears because they could not provide the proper care," said Kennedy. "So a lot of nurses left nursing and other states because of that."

Difference between 2020 and now

According to Kennedy, nurses have always struggled to fight for better working conditions. But, when cases of COVID surged and the world shut down in 2020 , "it got worse."

She said nurses had to fight to make sure they had the proper equipment they needed to protect themselves, and adds that that hasn't changed four years later.

Hospitals and medical institutes are using the same techniques they did at the height of the pandemic to cut costs and it comes at the expense of nurses' safety, said Kennedy.

"It is still a constant battle to make sure that nurses are protected [and] have what they need as it relates to proper [personal protective equipment.]"

She adds that it's been an "ongoing battle" just to make sure the working conditions are safe for patients and nurses.

Safe working conditions

Safe working conditions for nurses doesn't just include having enough masks to protect oneself. It means having enough nurses and aides on staff to provide the care patients need without overworking an understaffed team.

"Every day that we walk through the doors of a hospital, we wanna be able to do the things that we've been trained to do and that's to take care of our patients," said Kennedy.

But, she adds that having to fight to be properly staffed, errors in patients' admission and racial discrimination play a factor in how well nurses can do their job.

Kennedy said that it's important to allow nurses to "do what we do best and that's taking care of patients, and we can't do that if we don't have safe working conditions."

According to National Nurses United , when nurses "are forced" to focus on too many patients, patients are at a higher risk of the following:

• Preventable medical errors
• Avoidable complications
• Pressure sores
• Longer hospital stays
• Higher numbers of hospital readmissions

Nurses push for change by backing proposed staffing standards act

To avoid complications related to overwork, exhaustion and burnout, the union supports the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023, S. 1113 and H.R. 2530.

Although the act was introduced a year ago in March 2023 it is still awaiting approval.

If passed, the act will require hospitals to enforce a nurse-to-patient ratio and limit the number of patients a nurse can be assigned.

Hospitals will also have to post notices of what the nurse-to-patient ratio is in each unit, record ratios in every shift and follow a procedure that determines how the ratio is determined for each unit. It will ban other staff from performing tasks that should be done by a nurse unless they are "specifically authorized within a state's scope of practice rules."

The act also states that a nurse can refuse assignments if "it would violate minimum ratios or if they are not prepared by education or experience to fulfill the assignment without compromising the safety of a patient or jeopardizing their nurse's license."

Kennedy said that a nurse-to-patient ratio will improve work conditions and bring nurses back to their jobs.

California already has a ratio in place and Kennedy said it improves working conditions.

When Kennedy worked as a nurse before the ratio was put in place, she saw anywhere from 12 to 24 patients a day. Now, she only sees five.

According to the union, the ratio law reduced costs for hospitals, improved nurse safety and job satisfaction and reduced the following:

• Spending on temporary RNs,
• Overtime costs
• Staff turnover

"California is not an island," said Kennedy. "And so federally, we need to push the ratio law because the patients are no different in California than they are in Mississippi or Montana."