Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: You are a sergeant at a field hospital. An anaesthetist uses a rapid infuser with the incorrect bore size for a deteriorating patient.  They shout saying you are incompetent.  You make an offensive comment and walk away. What are the ethical issues?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers the ethics of practising effectively with colleagues, promoting professionalism and trust and preserving patient safety. It also refers to having a duty of care to the patient and that healthcare professionals must not breach the standard of care to the patient through any potential negligence no matter how stressful the situation is.

Step 2 – ANALYSE

Patient: 2 principles of beneficence and non-maleficence apply. The patient has the right to expect that doctors and nurses contribute towards patient welfare and refrain from harming them. In addition, it obligates healthcare professionals to refrain from causing harm to patients, whether that it is intentional or unintentional or through an act or an omission. Patients also expect that healthcare professionals will work collegiality together and promote an atmosphere of teamwork, integrity and trust.  

Clinical: Who is going to give the anaesthetist the correct bore size for the rapid infuser?  This potentially places the deteriorating patient’s health at risk if the anaesthetist uses the wrong one? It is also inappropriate for any healthcare professional to make such a disparaging comment to a fellow colleague and for a healthcare professional to react in a negative way by walking away from a patient. As this is a deteriorating patient could the anaesthetist’s behaviour be mitigated against the urgency of the situation?  

Legal:

Duty of care

Healthcare professionals own their patients a duty of care. This is irrespective of whether they are military or civilian and regardless of the location or the circumstances in which they give this care. This legal principle protects patients because the concept of a duty of care provides an overall framework for the huge variety of situations in which accountability may arise. If the healthcare professional accepts the responsibility and undertakes the treatment and the patient submits to their direction and treatment accordingly, they owe a duty to the patient.  The concept of owing a duty of care to a patient, therefore, provides a framework that ensures that all healthcare professionals are accountable to their patients. It can be argued that the duty of care concept is comprehensive and goes to the very essence of ensuring that it sets clinical boundaries for all healthcare professionals, irrespective of their being either civilian or military.  This is so that they remain accountable for their acts or omissions and are liable for the consequences of careless behaviour. Both the anaesthetist and the Sergeant owe the patient a duty of care.

General standard of care

The general standard of care expected by the reasonable man is an objective one.  In the English case of Blyth v Birmingham Water Works, Lord Alderson (1843-60 at paragraph 480), stated ‘negligence is the omission to do something which a reasonable man, guided upon those considerations which ordinarily regulate the conduct of human affairs, would do, or doing something which a prudent and reasonable man would not do’.  The standard expected is not to reach perfection, but only a reasonable standard.  However, a breach of a standard of care will occurs when a defendant has not taken the steps that a reasonable man would be expected to take in the circumstances at that time.

Professional standard of care 

This is the standard that healthcare professionals are legally required to provide reasonable care when performing an act (or omission) that could otherwise cause harm to a patient. Experts and professionals with particular skills are judged by the standards of the reasonable man with those specialist skills.

With the Sergeant walking away it raises the potential of breaching a duty of care to the patient. In doing so, does this cause harm to the patient? The International Council of Nurses Code of Ethics is at: https://www.icn.ch/sites/default/files/2023-04/ICN_Code-of-Ethics_EN_Web_0_0.pdf . Nurses primary professional responsibility is to people requiring care and whilst the anaesthetist’s comments is inappropriate it could be viewed as equally inappropriate and unprofessional to walk away from the patient. If this caused the patient harm, it could be construed as a breach of a standard of care and potentially a negligent act if this action directly caused the patient harm.

Societal/Military: The patient’s condition is deteriorating, and as such they may be some mitigation for the anaesthetist’s comments although this raises the question of their professional behaviour towards a colleague.  The Sergeant has made both an offensive comment to a senior officer and walked away from the patient and this could be viewed as both a disciplinary matter, as well as professional one. 

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

This scenario raises the discussion between professional behaviour and military rank structure regarding a deteriorating patient in what would evidently be a stressful situation for the healthcare team.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

The Adjutant should be given factual information regarding the professional behaviour towards the Sergeant and the Sergeant’s actions following.  One of the key issues here is, has the patient suffered harm and did the Sergeant actually give a rapid infusion incorrect bore size for a deteriorating patient?  Is the Sergeant incompetent and is there any questions regarding his competency in such an area? Does the anaesthetist have any justification whatsoever for making the comments he did to the Sergeant? Conversely, was the anaesthetist actually given the right bore size and is it the anaesthetist who is actually not competent to deal with this deteriorating patient?  Should he apologise to the Sergeant?

References and Further Reading

Blyth v Birmingham Water Works [1843-60] All ER Rep 478

International Council of Nurses (Revised 2021), The ICN Code of Ethics for Nurses at Code. Available at ICN_Code-of-Ethics_EN_Web_0_0.pdf; accessed 24 August 2023

Nursing Midwifery Council: Future nurse: Standards of proficiency for registered nurses. Available at future-nurse-proficiencies.pdf (nmc.org.uk); accessed 24 August 2023

Nursing Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates - The Nursing and Midwifery Council (nmc.org.uk) accessed 24 August 2023

Nursing and Midwifery Board of Australia. Available at https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx; accessed 24 August 2023

Contributor - Lt Col Janet Kelly VR RGN RM DIpHSM MA (HRM) LLB (Hons) PGHCE PhD. Senior Lecturer in Midwifery, Healthcare Law & Ethics; University of Hull. Chair for the Nursing Midwifery Council's Fitness to Practise Conduct and Competence Committees (2013 to 2021). She has served as a commissioned officer in Queen Alexandra's Royal Army Nursing Corps both as a regular and reservist for over 30 years and is now at the rank of Lieutenant Colonel.