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Disagreeing with the Care Plan
Q: I work as an in-patient surgical unit nurse. Recently I cared for a patient and did not agree with the patient’s care plan. What are my accountabilities when this happens? Am I obligated to follow all patient orders?
A: All nurses, in all roles and practice settings are responsible for their actions and resulting consequences. As self-reflective and regulated health professionals, a nurse’s clinical judgment or critical thinking skills are always applied in assessing an order.
Nurses who disagree with or are concerned about implementing a care plan are responsible for following appropriate channels and conducting themselves in ways that promote respect for the profession. In situations compromising patient safety and well-being, a nurse is primarily responsible to the patient. A nurse demonstrates leadership by promoting best possible patient care and taking appropriate action in situations they have identified as unsafe.
When nurses disagree about what constitutes safe, ethical care they must assess the situation, incorporate best available evidence, consult with key stakeholders and communicate with the most responsible health care provider (for example, physician or NP) and other relevant team members. These actions are key when demonstrating nurses’ accountability to share nursing knowledge with others and in advocating on behalf of patients to promote best possible outcomes.
Resolving dilemmas caused by conflicting obligations requires thoughtful consideration of all relevant factors and using an ethical decision-making process to reach the best decision. Nurses must consider relevant CNO practice standards and guidelines and organizational policies and guidelines. Also, nurses must identify key decision-makers, understand risks associated with the questioned activity, take into account the patient’s beliefs and examine personal beliefs and values, as applicable.
When disagreeing with a patient’s care plan, guiding your decision-making these reflective questions may be helpful:
- What are my specific concerns about the patient’s care plan?
- What evidence am I applying to the situation?
- Have I consulted with other nursing colleagues, experts and other health care professionals to verify the concerns? What are the results?
- Have I discussed my concerns with relevant leadership team members?
- Have I advocated for additional support in resolving the issue?
- Am I aware of, and following, relevant organizational policies applying to the patient situation?
- Am I aware of, and following, relevant organizational policies applying to resolving disagreements?
- Have I consulted with management authority? (that is, quality and risk, professional practice leaders)
- Have I communicated my decision to not implement the care plan?
- Do I understand the risks when doing so?
- Have I documented specific concerns and steps taken to resolve the issue?
Nurses are accountable for maintaining respectful and collaborative professional relationships and demonstrating effective conflict-resolution skills. However, if unable to resolve the issue and you decide to refuse to implement any aspect of the patient’s care plan, you are accountable for communicating your decision effectively to minimize patient risks. This involves documenting concerns and specific steps taken directly relating to patient care into the patient record. Complete documentation of nursing care provided and all nursing process aspects, including assessment, planning, intervention and evaluation is required.
You may also find the practice guideline, Refusing Assignments and Discontinuing Nursing Services, helpful as a decision-making framework for nurses resolving dilemmas caused by conflicting obligations.
CNO practice standards
CNO practice guidelines