It’s a situa­tion most nurses can relate to. You’re standing up for your patients, your license, your job — and you’re overruled by a physi­cian. An admin­is­trator. A pharma­cist. What do you do?

In an odd twist, one of the most instruc­tive cases on this point inciden­tally estab­lishes a legal opinion on the 5‑second rule. As the court in question put it, when it comes to nursing practice, th[e] eyeball test, consis­tent with the five-second rule some might use to deter­mine whether to eat food… is not… a profes­sion­ally recog­nized practice.”

Much more impor­tantly, the court found that when it comes to the practice of nursing, nurses, not anyone else, own the profes­sion and its standard of care.

To wit: in a Delaware jail, two nurses were in the process of counting controlled medica­tions, when one acciden­tally spilled 10 expen­sive hepatitis C pills (i.e. Sofos­buvir) onto the ground. Consis­tent with standard practice, the nurses disposed of the spilled medica­tion in a sharps container. Insofar as the medica­tion costs approx­i­mately $1,000 a pill, the nurses also notified the pharma­cist on duty.

A jail physi­cian, in turn, eventu­ally contacted a different nurse and instructed her to retrieve the pills from the sharps container” — which that nurse did. Out of the sharps container also came syringes, lancets and testing strips.

The on-site pharma­cist gave the pills an eyeball test,” deter­mine they were good to go… and the nurse admin­is­tered them to the patient.

Many things went wrong in this situa­tion. The physi­cian never should have instructed anyone to empty out a sharps container. The nurse should not have followed that instruc­tion. The pharma­cist should not have assessed the pills as accept­able for consump­tion. The nurse should not have followed the pharmacist’s instruc­tions to admin­ister the medication.

However, as unfair as it seems, one thing went right: the courts upheld the Delaware Board of Nursing’s disci­pline of the nurse in question. Here’s why: no physi­cian, pharma­cist, or admin­is­trator is respon­sible for your license, or your practice.

Only you are.

Physi­cians do not practice nursing. Pharma­cists do not practice nursing. Admin­is­tra­tors are not respon­sible for your nursing practice. The piece of paper that you worked your tail off for, spent count­less hours studying for, paying for, shedding tears for and standing up for is yours, and only yours — and as the Delaware court found, you are respon­sible for your practice.

At the end of the day, this is a blessing and a curse. On the one hand, it’s diffi­cult to stand up for yourself in your practice in the face of a physi­cian ordering you to do one thing when it’s obvious that your practice dictates another. On the other hand, this case should empower you: the physi­cian does not control your license or your practice.

It’s an apples and oranges compar­ison. Physi­cians and other health care profes­sionals practice their art, while we practice ours. They are respon­sible for their side of the house, and us ours. Realtors and home inspec­tors both work on houses but have vastly different jobs outside of each other’s juris­dic­tion despite the overlap.

So, what can you do in these types of situa­tions? I always recom­mend that nurses use their indepen­dent profes­sional judgment to act in the best inter­ests of the patient — protecting your patient enables you to protect your license.

Ultimately, you might decide that protecting your license may be more impor­tant to you and your patients than protecting your job.

Following an inappro­priate order has the poten­tial to place the nurse in jeopardy of legal liability. As the Washington Admin­is­tra­tive Code on Standards of Nursing Conduct or Practice states, the nurse shall be respon­sible and account­able for the quality of nursing care given to clients.” By protecting the patient, you will be able to more effec­tively defend your practice and your license.

Tips for consid­er­a­tion if you disagree with an order or treat­ment plan:

  1. Prepare: Person­alize your standard response for use when inappro­priate delegation(s) arises. Dr. Jones- what you’re directing me to do does not seem to align with standard/​best practice. I’ll need to inves­ti­gate further before I proceed”. This should be done off-stage,” away from other providers and the patient.
  2. Check facts: Assess data and details; access relevant facility policies/​procedures; know best practice.
  3. Consult: Seek perspec­tive by discussing the situa­tion with a trusted colleague and/​or union repre­sen­ta­tives and stewards.
  4. Escalate: Include your supervisor/​manager/​director to protect your patients and profes­sion. This is especially impor­tant when the event is associ­ated with imminent harm.
  5. Activate resources: Contact the risk manager or safety officer and use resources to stop and resolve,” stop the line,” etc.
  6. Document: Capture what happened, what you are being asked to do, and why you are objecting. Put it in writing and ask the other individual or a witness to sign it.

Other Key Principles:

  • If an order or treat­ment plan requires a nurse to exceed scope of practice, the nurse has a legit­i­mate basis for refusal to carry out the order or treat­ment plan.
  • Avoid following orders/​treatment plans that result in non-compli­ance with facility policy/​procedure
  • Refusal to follow a physician’s order must be based on evidence and standard of care, not on a differ­ence of opinion.
  • Do not relin­quish under pressure. As a profes­sion, nurses must stay true to the purpose of safe and quality patient care. Avoid actions that are not best for the patient or the nurse’s license.

Deploy the safety technique of Stop and Resolve when orders/​treatment plans/​delegation:

  • Require practice beyond regis­tered nurse scope
  • Conflict with facility policy/​procedure expectations
  • Is inaccu­rate or erroneous
  • Is unsafe with poten­tial harm to the patient/​care provider
  • Lacks training to perform orders/​treatment plans/​delegation