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Unqualified but Required

By Dr. Allan Barsky

As social workers, the NASW Code of Ethics suggests that social workers not only have ethical duties to their clients, but also to their colleagues and employers (e.g., Standards 1.01, 4.01, 2.02, 2.10, and 3.09). So what happens when these obligations collide? How do we determine our primary responsibility, and how do we choose the most ethical course of action when there is no ideal choice? The following case scenario is fictional, but it is based on situations shared with me by a number of different students:

Natalie is a nurse who works on an oncology unit. Although she does not have qualifications to provide chemotherapy to patients, her supervisor has asked her on a number of occasions to provide chemotherapy. The hospital does not have enough qualified nurses to provide chemotherapy, so it has provided some training to other nurses so that they can provide chemotherapy, particularly when the hospital is short-staffed (on weekends and at night). In confidence, Natalie tells you (a social work colleague at the hospital) that although she has received some chemotherapy, she does not feel qualified and she is scared that she is putting her patients at risk. When you ask Natalie why she has not refused to provide chemotherapy, she says that she is scared for her job. She says that all the nurses comply with requests to provide chemotherapy, because they are concerned that they will be fired if they do not comply. She also says the hospital has a “blacklist” that it sends to other hospitals, so that it would be impossible to get a nursing job at another hospital.

In this case, we are not going to ask what Natalie should do, but rather, what is your ethical responsibility? You have knowledge about nurses performing a procedure that they are not qualified to do – putting the patients, the nurses, and the hospital at risk. An obvious response might be to persuade the nurse to refuse to perform procedures that are outside her area of competence (just as social workers are not supposed to engage in interventions outside of their areas of competence, NASW Code, Standard 1.04(a)). Assume, however, that despite how skilled you are at trying to persuade Natalie, she refuses. Further, she tells you not to tell anyone else at the hospital, or she will be fired.

Questions that you may be asking yourself include:

  • Do I have any ethical or legal obligations to report this issue to the hospital administration or any other authorities? (see NASW Code of Ethics, s.2.10)
  • If I do report this concern to the hospital administration or any other authorities within the hospital, what are the possible – and likely – repercussions for the Natalie, and for yourself? (assume that the hospital administrators know that unqualified nurses are providing chemotherapy and that they do not want to hire additional qualified nurses because of costs)
  • If you do take your concerns to the hospital administrators and they are unresponsive (or respond negatively), what are your other options? Do you “blow the whistle” by going to the media or others outside of the hospital? If you decide to blow the whistle, it is important to know the laws that may protect your, as well as the resources that may be able to support your efforts.
  • Do you have a duty of confidentiality toward the particular nurse, who asked you not to share information, for fear of being fired? (NASW Code of Ethics, S.2.02)

Again, we can easily say that you should not stand idly by when patients are being subjected to treatment from unqualified practitioners. We are supposed to look out for the needs and interests of our patients/clients (S.1.01), as well as for other vulnerable people in society (S.6.01). Consider, do your obligations differ if you are protecting the interests of a patient you are serving, versus a concern about patients generally (even if none of your current patients is receiving chemotherapy from an unqualified nurse).

One of the first steps that I might take is to ask for help. I may not be sure about the laws governing chemotherapy, including who is competent to provide chemotherapy. I may need the help of an attorney to answer these legal questions. If I have legal questions, should I ask my own attorney, or the hospital’s?

As a social worker, I may not be aware of the actual risks of chemotherapy and why there are laws or policies requiring that oncology nurses have specific qualifications. For instance, if the risks of inappropriately administering chemotherapy were limited to some patients experiencing a small amount of additional pain or nausea, this would be different from the risk that patients will die. I may be able to ascertain some of this risk information by reading relevant research and scholarly literature. Consulting oncology experts may also be helpful. What if the risks to the patient are relatively low? What if there are different types of chemotherapy, and only certain types are high risk?

When you know that illegal or unprofessional practice is being condoned (or even supported) by administration, doing the right thing is difficult. You may want to consult people who can support you in pursuing this cause. Rather than pursuing the issue alone, are there other nurses, social workers, or staff who would be willing to work with you? Are there any unions or professional associations that may be willing to help you advocate for what is right? Are there any patient advocates or patient rights groups who could assist with this issue? Are there any attorneys or law firms that might be willing to help?

Despite all the people and organizations that might be able to help, I leave you with the following questions:

  1. Would you be willing to advocate that only qualified nurses be allowed to provide chemotherapy, even if it meant putting Natalie’s job at risk?
  2. Would you be willing to advocate that only qualified nurses be allowed to provide chemotherapy, even if it meant putting your own job at risk?

I’ve asked many questions, but provided few answers. As the social worker, what would you do in this situation, and more importantly, what is your reasoning?

Allan Barsky, JD, MSW, PhD is Professor of Social Work at Florida Atlantic University and incoming Chair of the NASW National Ethics Committee. He is the author of Ethics and Values in Social Work: An Integrated Approach for a Comprehensive Curriculum, now featuring Xtranormal videos on the instructor’s manual website.

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