Refusal to Implement an Order

An RN on your unit presents to your office with a client’s chart and asks to speak with you. The RN discloses that they are refusing to implement one of the physician’s orders because they believe it is an inappropriate use of medication for this client. They believe that the type and dosage of medication is unsafe and unnecessary given their knowledge of the client they have been caring for over the last several weeks. You explore this situation with them and collaborate to decide on an appropriate course of action to address the concerns raised. 

• RNs have an obligation to respectfully challenge and take action on unclear or questionable orders, decisions or actions made by other health care team members. They seek clarity and strive for safe patient outcomes (1). If resolution of the issue at the lowest level does not occur, RNs are expected to escalate their concerns up the established chain of command.
• RNs question, intervene, report and address unsafe, non-compassionate, unethical or incompetent practice or conditions that interfere with their ability to provide safe, compassionate, competent and ethical care to those to whom they are providing care, and they support those who do the same (2).
• RNs advocate for persons receiving care if they believe that the health of those persons is being compromised by factors beyond their control, including the decision-making of others (3).
• RNs foster a moral community in which ethical values and challenges can be openly discussed and supported (4).
• RNs use established communication policies and protocols when alerting employers about potential threats to patient safety and quality health outcomes (5 & 6).

I am not an RN but I manage RNs. Are there situations where I should not support RNs when they refuse to implement an order?

There may be situations where the RN does not follow accepted and established communication policies or protocols when refusing to implement an order. For example, if the RN simply does not implement the order and makes no effort to respectfully discuss this with the physician, it may put the client at risk for untoward outcomes. It could be some time before this situation is discovered and, in the meantime, the client is not receiving the prescribed medication, treatment, etc.

This situation requires the RN to professionally question and intervene in the best interest of the client but gives no opportunity for the physician to respond. As the manager, if you become aware of this type of situation, you would likely be unable to support the RN’s choice.

I just received a complaint from a family member that one of the RNs on the unit did not provide care that had been ordered by the physician over the weekend.  When I followed up with the RN, they said that they did not provide the care because the client and her family were not nice to them, so they did not want anything more to do with them. What is the best thing for me to do?

The RN has a professional and ethical responsibility to directly provide and/or coordinate care for the client. At times, nursing care is requested that conflicts with the RN’s moral beliefs and values but in keeping with professional practice, the RN is expected to provide safe, compassionate, competent and ethical care until alternative care arrangements are in place to meet the person’s needs or desires. However, this does not appear to be the case. In this situation, it would be necessary to speak with the RN to determine their level of understanding of their professional responsibilities and accountabilities and the ethical implications of their decision. It may be necessary to educate them and to determine if this is a pattern of behaviour that needs to be addressed. Each situation will be unique and will require different responses. If you need guidance about this or other professional practice situations, please contact CRNS Nursing Advisors at practiceadvice@crns.ca.

CRNS Resources

Code of Ethics for Registered Nurses (2017)

Registered Nurse Practice Standards (2019)

Registered Nurse Entry-Level Competencies (2019)