5.4 Ethical Challenges in Scope of Practice

Questioning Provider Orders

It can feel intimidating to question a provider’s order, but ethically, nurses have a responsibility to advocate for their patients’ care and safety. Although nurses may not agree with a specific order from a provider, they cannot randomly decide to not follow an order without the possibility of facing disciplinary actions by their employer. It is the nurse’s responsibility to follow the provider’s orders. However, if an order seems incorrect or unclear, the nurse needs to call the provider for clarification.

However, when there is a safety concern, the nurse has an obligation to advocate for the patient by questioning the provider’s order. For instance, one of the rights of medication administration is “right medication.” If the nurse conducts a safety check and determines that a medication is not indicated, they should question the provider’s order. If the provider insists on administering the medication, the nurse may need to move up the chain of command to speak to a provider in a higher position as well as notify the nursing supervisor of the situation. The alternative solution would be to administer the medication and risk the patient having an adverse outcome, which could create a risk to the nurse’s license. Each individual state’s Board of Nursing handles disciplinary action risking license suspension or revocation.

Cultural and Spiritual Implications

There may be situations in which nurse is presented with the dilemma of choosing a patient’s spiritual preference versus an evidence-based scientific solution. For example, patients who are Jehovah’s Witnesses do not believe in receiving blood products, yet these products may be needed in a life-threatening situation. A nurse can advocate for the patient by discussing with the provider the possibility of ordering epoetin instead of a blood product.

Although it is the duty of the nurse to present the evidence-based information to the patient so the patient can make an informed decision, it is equally important for the nurse to set aside their own personal beliefs to respect the patient’s spiritual beliefs and decisions regarding their care. This is patient-centered care at its deepest level and requires a great deal of compassion from the nurse. Autonomy is the patient’s right regardless of the evidence-based information or scientific treatment presented, and beneficence is the nurse’s duty to their patient.

Use of Opioids

The administration of opioids can create quite a dilemma. Although nurses have an ethical responsibility to manage the patient’s pain and to provide comfort, nursing clinical knowledge indicates that high dosages of opioids can lead to respiratory distress and even death. Nurses also have to exercise caution when administering medications such as opioids to a patient with known or suspected substance use disorders who may request more than actually needed. To further complicate the administration of pain medication, some nurses are hesitant to administer large doses of pain medications to terminally ill patients. However, the risk of respiratory depression is not the intent of the action (the administration) and should not be used as an excuse for withholding the analgesia. Although it is important to report respiratory depression to the physician, the administration of pain medication should be governed by the patient’s needs.

End-of-Life Decision-Making

End-of-life care and decision-making can be difficult for the nurse as well as for the patient and families. However, there is an established trust in the patient-nurse relationship, and the nurse is often looked to for guidance. It is important to set aside one’s own beliefs to compassionately respect the patient’s and family’s beliefs and desires.

When a patient chooses to not be resuscitated if their heart or breathing stops, a verbal order is not sufficient. It is imperative to discuss this subject with all patients upon admission to ensure a DNR or DNI order has been signed by the patient (or their durable power of attorney) and placed in the patient’s record. If the patient has an advance directive, it is also important to obtain a copy to be placed in the patient’s record. Additionally, it is important to discuss the patient’s wishes with the provider, which may lead to further communication with the family, especially if the family is afraid to let a loved one die with no efforts to resuscitate. Finally, compassion should also be extended to colleagues who are facing these difficult situations. Talking and listening can provide a level of needed support.

Maintaining Boundaries on Social Media

Social media and professional boundaries are challenging in today’s world. Each generation of nurses comes into the nursing profession more technologically savvy than the previous generation, often resulting in a blurred line with professional boundaries, especially with the increased use of social media. The use of social media can also create a challenge in distinguishing between one’s personal identity and professional identity. However, professional standards in the nursing profession are outlined by the ANA’s Code of Ethics for Nurses. It is important to maintain one’s integrity by adopting clearly established professional boundaries to support safe use of social media as well as to promote the future profession of nursing.