Question

Nurses and Contracts

Betty A, RN, graduated from an AD program 2 years ago and is now the charge nurse on the 3 p.m. to 11 p.m. shift on the medical unit of a small rural hospital. Most of her experience for the past 2 years was in the medical unit, although she had occasionally floated to the maternity unit, emergency room (ER), and ICU. The usual staffing for her unit on her shift was an RN, an LPN, and an aide.

One Friday evening, the nursing supervisor called Betty at the beginning of her shift and stated that she needed Betty to go to the six-bed ICU to cover for 1 to 1.5 hours because the scheduled RN for the ICU had been in a minor accident on the way to work. The supervisor believed Betty was the best qualified of the nurses who were in the hospital at that time and that the medical unit was quiet enough so that the LPN could handle it while Betty was gone.

Betty quickly went to the ICU, where she received an abbreviated report on the four unit clients from the nurses who worked from 7 a.m. to 3 p.m. who were waiting to leave for the weekend. The day shift RN also mentioned that there was a client in the ER who was experiencing some chest pain and might be admitted to the ICU.

Within minutes of receiving report, the ER called and said they were admitting a 46-year-old man with an acute anterior MI to the ICU. They also relayed the fact that they had begun streptokinase therapy and the client would require very close monitoring for dysrhythmias, blood pressure changes, and bleeding.

Betty had never administered to or cared for a client receiving streptokinase and felt incompetent to care for such a client. Although the LPN working with her had worked with these types of patients, she was not permitted to administer any of the many IV medications this client required. Just as the client was being brought through the ICU doors, Betty called the nursing supervisor to let her know that she would need help with this client. The nursing supervisor said that there was no help available at this time because of call-ins and that Betty just needed to admit the client. The regular ICU RN should be in at any time.

Betty assessed the client and checked his vital signs. He was cold; diaphoretic; and a pale, grey color. His blood pressure was 88/42 mm Hg, his pulse was 52 bpm, and he was having frequent premature ventricular contractions (PVCs). The monitor technician also informed Betty that the client was in a 2:1 atrioventricular (AV) block. Betty wanted the supervisor to come to the floor and relieve her of the responsibility for the care of this client. Betty did not know the ICU protocols for dysrhythmia and did not feel competent to care for this seriously ill client. It would be at least another 45 minutes before the regular RN would arrive.

Questions for Thought

1. What are Betty’s obligations under her contract with the hospital? What are the hospital’s obligations in this situation?

2. Where do the issues of justice and fidelity fit into this situation? Are there any “fidelity conflicts” in this situation?

3. How should Betty best resolve the dilemma?

Answer 1

1. Under her contract with the hospital, Betty has obligations to do the work that she is being assigned to do. She is supposed to be flexible in her position and should be ever prepared to do the work assigned to her. She should also take initiatives to carry out the work she is being told to do. This being one side of the coin, as per the contract she should also conform to ethical principles and laws affecting her profession. At the same time, she should also fulfill and obey any lawful direction or order from superiors. Even though she is supposed to obey the orders, she does not have enough experience to deal with a critically ill ICU case with acute anterior MI with low BP, low pulse, frequent PVCs, and 2:1 AV block. The hospital has the obligation to post an experienced RN or a supervisor to take care of this patient. They can have one of the morning shift nurses to stay back for 1 to 1.5 hours to take care of this patient and pay for the extended service. Based on ethical principles, it will not be good to reject a patient in such a serious condition. It is the hospital's responsibility to arrange for an experienced RN to take care of this patient.

2. The issue of justice can be seen in providing good care, i.e., the maximum, to save this patient as well as to arrange an experienced and qualified nurse to take care of the patient. The hospital should arrange for an RN with ICU experience rather than ordering an RN without ICU experience to do the job. By doing so the hospital can do justice to the patient as well as the RN. There is no question of the fidelity of the RN or fidelity conflict as she remains faithful to the promise she made to provide competent quality care. It would have been a question of fidelity if the RN provided care without experience in dealing with a critically ill patient.

3. Betty can resolve this dilemma by asking for help from an experienced RN. She can report her lack of experience to the supervisor and the supervisor will post another RN or get the morning shift RN's services extended for one more hour and take care of the situation.