NR 549 Week 6 Ethics Position Paper Example

Ethics Position Paper: A Step-Down Nurse Floated to the Intensive Care Unit Should Accept a Limited Assignment and Document the Limits, Not Refuse the Float, Argued From Provisions 3, 4, 5 and 6 of the Code

Student Name

College of Nursing, Chamberlain University

NR 549: Foundational Concepts for Professional Nursing Practice

Instructor Name

Month Day, Year

Ethics Position Paper: A Step-Down Nurse Floated to the Intensive Care Unit Should Accept a Limited Assignment and Document the Limits, Not Refuse the Float, Argued From Provisions 3, 4, 5 and 6 of the Code

Position

When a registered nurse from a cardiac step-down unit is floated to a medical intensive care unit and lacks competence for critical care, the nurse should accept the float but negotiate a limited assignment matched to the nurse's competence, and document the limits, rather than refuse the float outright.

The Case, Compressed

At 1900 on a Saturday, the house supervisor floats a step-down nurse with eight years of experience to the medical intensive care unit, which is two nurses short. The intensive care charge nurse offers two patients: one on a ventilator with a norepinephrine infusion being titrated, and one recovering from diabetic ketoacidosis on an insulin infusion. The step-down nurse has never managed a ventilated patient or titrated a vasopressor. The hospital's floating policy states that a floated nurse "will be assigned patients whose care is within the nurse's documented competencies" and that the nurse "should communicate any concerns about the assignment to the charge nurse before accepting it."

Authorities

Provision 4 places authority over nursing practice, and accountability for it, with the individual nurse (American Nurses Association, 2015). Accountability for the assignment rests with the nurse who accepts it, which means the nurse must judge whether the assignment is within competence.

Provision 5 counts keeping one's competence among the duties a nurse owes to self (American Nurses Association, 2015). Competence is specific to the care being delivered; eight years of step-down experience is not competence in ventilator management.

Provision 3 makes protecting patient safety part of the nurse's advocacy (American Nurses Association, 2015). Protection applies to the ventilated patient, who could be harmed by an unprepared nurse, and to every intensive care patient who would be left with fewer nurses if the float nurse refused.

Provision 6 asks nurses, alone and together, to shape a workplace and employment conditions that support safe care (American Nurses Association, 2015). Reporting the staffing gap and the mismatch between floating practice and policy is part of this obligation.

The employer's policy supports matching the assignment to documented competence and requires concerns to be raised before acceptance.

Professional standards also expect nurses to practice within their competence and to collaborate to deliver safe care, as set out in the standards of professional performance (American Nurses Association, 2021).

Educational standards place contributing to a culture of patient safety within the quality and safety domain (American Association of Colleges of Nursing, 2021). Speaking up about an assignment beyond one's competence, before accepting it, is part of that culture rather than a breach of teamwork.

The Argument

The float nurse has two obligations that point in different directions. Provision 4 and Provision 5 require the nurse to decline care the nurse cannot competently provide. Provision 3 requires the nurse to protect patients, and on a unit two nurses short, the patients most at risk include those who would receive no nurse at all if the float nurse left.

Refusing the float satisfies the first obligation and fails the second. Accepting the full assignment satisfies neither, since it exposes the ventilated patient to an unprepared nurse and puts the float nurse's license at risk. A limited assignment satisfies both. The float nurse can safely care for the patient recovering from ketoacidosis, since insulin infusions and glucose monitoring are within step-down competence. The float nurse can also take over tasks that free intensive care nurses, such as admissions paperwork, medication passes for stable patients, repositioning and responding to call lights. The ventilated patient is reassigned to an intensive care nurse. The float nurse documents the limits, notifies the house supervisor in writing and files a staffing report.

The Strongest Objection

An intensive care charge nurse would object as follows. "A limited assignment is a fiction on a unit this short. If I take the ventilated patient from the float nurse, I give it to one of my nurses who already has two critically ill patients, making three. That is less safe than giving it to a float nurse with eight years of acute care experience, who can at least recognize deterioration and call for help. The Code says the nurse protects the patient, and the patient is safer with a capable nurse in the room than with an overloaded specialist down the hall. Refusing the patient does not remove the patient; it moves the risk onto someone else."

This objection is serious. Its strongest point is that the risk does not disappear when the float nurse declines; it moves. The objection is right that a nurse with acute care experience can recognize many forms of deterioration.

Reply to the Objection

The reply is that recognizing deterioration is not the same as managing a ventilator and titrating a vasopressor, which are the specific tasks this patient needs. An unprepared nurse titrating norepinephrine is not a safer version of an overloaded expert; it is a different risk, harder to see and harder to rescue. The charge nurse's concern is best met not by giving the float nurse an unsafe assignment, but by redistributing tasks so that the intensive care nurse holding three patients has the float nurse's hands for everything that does not require critical care competence. Provision 6 also points beyond the shift: if floating regularly produces this choice, the float nurse and the charge nurse together have an obligation to report it, so that the next Saturday is staffed differently.

What Would Change the Position

If the float nurse had documented critical care competence, or if the hospital provided a structured cross-training program the nurse had completed, the position would change and the full assignment would be appropriate. If no redistribution were possible and the only choices were the float nurse or no nurse for the ventilated patient, the float nurse should accept, stay within tasks the nurse can perform, request immediate help for anything beyond them, and document the circumstances. The position is about the common case in which redistribution is possible, not about genuine emergencies.

The same reasoning applies to any float between specialties where competence differs, including intensive care nurses floated to pediatrics or obstetrics.

The principle is the same in each case.

References

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education.

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.).