Nursing Chain of Command – Collaboration (Nursing)

by Christy Hennessey (Davidson), DNP, RNC-OB

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    00:00 Hi everyone and welcome back. So imagine as a new nurse, you're on a unit and you encounter a situation where you need help and you don't really know where to go or you're having a situation with a colleague or maybe even with a physician and you're not sure how to resolve it. One tool that you can use is the Nursing Chain of Command. The Nursing Chain of Command is the line of authority and responsibility along which orders are passed within the nursing department, the hospital, and between various departments. Now, every organization is just a little bit different but this is a great representation of what the average common line of authority might be. If you start on the nursing unit with the staff members there, if you start with the unlicensed assistive personnel, the person they would go to next might be the nurse. The nurse then might go to the charge nurse. The charge nurse then goes to the nurse manager. The nurse manager would go to a role very similar to what might be called a director of nursing. And finally, the director of nursing would go to the highest nursing position within the organization, the chief nursing officer.

    01:06 It's also important to remember that the physicians have their own line of authority and it escalates all the way to a similar role called the chief medical officer. So let's talk about some concerning situations which might be a great example of why someone might start the Nursing Chain of Command. For example, the provide has not responded to a deteriorating patient condition or the nurse questions or disagrees with the provider's orders, plan, or care. The nurse believes that the provider's response to a situation doesn't fully address the patient issues. The nurse's assessment actually differs from the provider's assessment or the nurse witnesses unprofessional behavior which might jeopardize patient care. A good example of this might be where you suspect that a provider or another team member could be impaired. Also, a patient's end-of-life wishes differ from the opinions of the family and/or the provider. The nurse believes that a patient's discharge is too early. So, what can you do? First, don't remain silent if you are worried. Review your organization's chain of command policy and procedure very carefully.

    02:23 Once you've reviewed your organization's chain of command policy, that gives you the opportunity to know who you should contact and what information will be needed, and very important document thoroughly. This helps protect you in the case of litigation. So here is a great example. John is a new nurse on a pediatric unit. A newly admitted child is having increasingly difficulty breathing.

    02:46 John has placed several calls to the pediatrician but has not received a return call. The charge nurse for the day has left the unit for lunch and is not responding to John's attempt to reach her either. Who is the next person in the chain of command that John might call? Would it be the unlicensed assistive personnel, the nurse manager, a charge nurse, director of nursing, chief nursing officer, or another nurse? If you selected the nurse manager, that is correct.

    03:21 Typically, the charge nurse answers to the nurse manager and in this situation the charge nurse happen to be off the unit for lunch and he could not get in contact with her so the next best option is to go to the next step in the chain of command which is the nurse manager.

    03:35 So remember, use the chain of command to advocate for your patients and to protect yourself from liability. So what do we learn today? Nursing's chain of command may vary slightly from institution to institution, but the organizational chart of the chain for nursing staff often starts with the charge nurse and then continues to ascend with the chief nursing officer being the last person in the nursing hierarchy. The nursing chain also includes the physician and he or she has a chain of command as well. Often the chief nursing officer and the chief medical officer are needed to resolve a patient care issue that involves both nursing and physicians. And finally, the chain of command is extremely important when providing nursing care especially if patient care is compromised in some way. I hope you've enjoyed this video on the Nursing Chain of Command.

    04:26 Thank you so much for watching.

    About the Lecture

    The lecture Nursing Chain of Command – Collaboration (Nursing) by Christy Hennessey (Davidson), DNP, RNC-OB is from the course Leadership and Management (Nursing).

    Included Quiz Questions

    1. Chain of command
    2. Authority hierarchy
    3. Jurisdictional structure
    4. Charge order
    1. Charge nurse
    2. Nurse manager
    3. Director of nursing
    4. Attending physician
    1. Do not remain silent.
    2. Look into the situation.
    3. Check hospital or unit policy.
    4. Become familiar with the appropriate chain of command.
    1. Document thoroughly.
    2. Follow up with the person they reported to.
    3. Check to make sure the situation was remedied.
    4. Offer any further assistance as needed.
    1. To advocate for your patients and protect yourself from liability
    2. To avoid conflicts of authority and ensure the appropriate process occurs
    3. To facilitate the proceedings and prevent time delay in backtracking
    4. To ensure that correct documentation occurs and the facility is protected from liability

    Author of lecture Nursing Chain of Command – Collaboration (Nursing)

     Christy Hennessey (Davidson), DNP, RNC-OB

    Christy Hennessey (Davidson), DNP, RNC-OB

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