Policy briefing

COVID-19: when you can refuse to treat a patient due to inadequate PPE

The implications for nurses of RCN guidance on care provision and inadequate personal protective equipment

Picture shows two medics in discussion. Lack of personal protective equipment allows nurses to take a decision to protect themselves, RCN guidance says.
Picture: iStock

Essential information

COVID-19 has swept across the world since it emerged in China late in 2019.

Following confirmation of the first cases in the UK in January 2020, concern has grown among nurses about shortages of personal protective equipment (PPE), as well as the quality of equipment available.

A Nursing Standard survey in early April found that more than two thirds (67%) of almost 3,500 respondents did not feel they had sufficient PPE, and the RCN has continued to raise the issue with the government.

What’s new

RCN guidance on the pandemic states that nurses are entitled to refuse to treat patients ‘as a last resort’ if they do not have adequate PPE to protect themselves.

While acknowledging that this would be a ‘difficult step’, the college says nurses must consider their own safety.

But such a move could leave nurses open to potential legal consequences, including dismissal, being sued for clinical negligence by a patient, and fitness to practise proceedings by the Nursing and Midwifery Council (NMC), the document states.

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There is also the potential for nurses to be criticised at an inquest, and even face charges of neglect or manslaughter. Criminal cases and investigations may also appear on a nurse’s disclosure and barring service certificate.

But the college maintains members who take this decision and are later criticised will be provided with legal representation and other support through any proceedings, without judgement.

The RCN says a shortage of PPE means nurses face difficult decisions on whether to provide care.

Initially, nurses should escalate concerns about PPE locally and work with managers and colleagues to try to reduce risks.

But if adequate PPE is still not provided, then nurses have the right to refuse to tend to patients.

An NMC statement on PPE reaffirms that under the Code nurses need to consider their own safety as well as that of their colleagues and patients.

The regulator acknowledges that nurses may have to refuse to treat patients. If concerns are raised about a registrant, the NMC says it will ‘consider the context of the current pandemic, including the risks that the individual registrant was exposed to and how they exercised and recorded their professional judgement in line with the Code’.

Expert comment

Picture of Ann Gallagher, professor of ethics and care at the University of Surrey’s International Care Ethics Observatory. Lack of personal protective equipment allows nurses to take a decision to protect themselves, RCN guidance says.Ann Gallagher, professor of ethics and care, International Care Ethics Observatory, University of Surrey

‘While the rationale for this new RCN guidance is made clear in the introduction, it is acknowledged that it is ethically challenging.

‘It is helpful for nurses to have a good grasp of what PPE is necessary in different care contexts, and the process to raise and escalate concerns should this PPE be inadequate.

‘The guidance states that “if you have exhausted all other measures… you are entitled to refuse to work”. It rightly says that for nurses “this will be a last resort… and a difficult step”.

‘Our profession takes pride in our mission to care for all, regardless of individual or environmental circumstances. I hope health and social care leaders will supply what nurses need in order for them to provide compassionate care to all patients, and that no nurse will decide to refuse to care at this extraordinary time when they are most needed.

‘Perhaps a care ethics mantra summarises our core mission – treat often, cure sometimes, care always and abandon never.’


Implications for nurses

  • Consult RCN guidance on PPE to check if adequate equipment is being provided.
  • Remember that when considering your own safety you are not simply taking your personal well-being into account. If you become unwell you might spread infection through your community, including to high-risk patients. You will not be available to provide care to others and you might put your own family at risk.
  • You must take part in identifying changes to the way you work that reduce the risk to yourself, short of refusing to provide treatment at all. Can treatment be delayed or provided differently, can alternative practices reduce the risk of transmission, and can staff with greater vulnerability be put in roles that carry lower risk? Working with your manager and colleagues, your clinical expertise and knowledge of your patients will be invaluable.
  • You must be able to justify your decisions as reasonable, so keep a written record of whatever safety concerns lead you to withdraw treatment, using incident reporting software such as Datix where possible.

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