February 2020
You Asked Us

What do I do if I disagree with the patient's care plan?

Q: I work as an in-patient surgical unit nurse. Recently, I did not agree with the care plan for one of my patients. What are my accountabilities when this happens? Am I required 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 self-regulated health professionals, you should always use your clinical judgment and critical thinking skills when assessing an order.

If you disagree with or are concerned about implementing a care plan, you are responsible for following appropriate channels and conducting yourself in ways that promote respect for the profession. In situations compromising patient safety and well-being, your primary responsibility is to your patient. Remember, nurses demonstrate leadership by promoting the best possible patient care and taking appropriate action in situations they have identified as unsafe.

When you disagree about what constitutes safe, ethical care you must assess the situation, incorporate best available evidence, consult with the broader health care team and communicate with the most responsible health care provider (for example, physician or NP). Remember that you have an accountability to share your nursing knowledge with others and advocate 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. You must consider relevant CNO practice standards and guidelines and organizational policies and guidelines. Also, you 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.

To guide your decision-making when you disagree with a patient’s care plan, reflect on the following questions:

  • 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 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? (such as, 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. These accountabilities are outlined in the Code of Conduct. However, if you are 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 resolving dilemmas caused by conflicting obligations.

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Ask Practice features questions and answers about a variety of practice-related issues that nurses may face over the course of their careers. The questions come from nurses and the answers are written by our Practice Support team. Check out other Ask Practice questions, or write to us with your question.

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