The Nursing Assistant Asked to Give Insulin
In a 150-bed hospital in Birgunj, the medical superintendent instructs that, because of a nursing shortage during a dengue surge, nursing assistants with three months' in-service training and no NNC registration will give IV ceftriaxone and subcutaneous insulin on the medical ward. The nursing in-charge, Pratima, objects. The ward manager replies that doctors have 'delegated' the tasks and that 'the council only regulates nurses, not assistants.' That night, a nursing assistant prepares 2 g ceftriaxone in 100 mL and asks Pratima to sign the medication chart because 'you are the registered one.' A patient with dengue has a platelet count of 18,000/µL and is due for insulin. Pratima is one of two registered nurses on duty for 40 patients.
1. Is the medical superintendent's instruction lawful and professionally defensible? Apply scope-of-practice and delegation principles.
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No. The instruction confuses medical delegation with lawful authority to perform a nursing task. A doctor can delegate a task only to a person who is competent and authorised to perform it. A nursing assistant who is not NNC-registered does not acquire authority to give IV antibiotics or insulin merely because a doctor or manager says so. Those are invasive medication tasks carrying real risk of anaphylaxis, hypoglycaemia, and infection.
The ward manager's argument that 'the council only regulates nurses' misses the point. The hospital still has a duty to ensure that whoever performs a clinical task is trained, competent, supervised, and legally permitted to do it. The registered nurse who supervises an assistant remains accountable for the delegation decision. Asking Pratima to sign for a drug prepared by someone else would also make the record false, because the signature would imply that she administered it.
Scope of practice is not a staffing convenience. If the hospital cannot provide registered nurses, it must reduce services, transfer patients, or obtain additional qualified staff, not reallocate regulated tasks to unregulated workers.
2. What should Pratima do on that shift?
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She should refuse to sign the chart for a drug she did not prepare or administer. She should take over the insulin administration herself after checking the prescription, dose, expiry, and patient identity, and she should assess the patient for hypoglycaemia risk given the dengue illness and low platelets. She should stop the assistant from independently giving IV ceftriaxone and allow the assistant only to perform tasks within documented training and direct supervision, such as fetching supplies or recording observations.
She should inform the medical officer on duty and the administrator on call that the ward has an unsafe skill mix. If no registered nurse is available for a due medicine, the safe action is to escalate and prioritise the most time-critical medicines, not to let an unregistered person proceed alone. She should make a contemporaneous note of the instruction, her objection, and the action taken, and she should complete an incident report. Refusing an unsafe delegation is not patient abandonment; abandoning the ward would be.
3. What should she report afterwards, to whom, and how can she protect herself from retaliation?
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She should submit a written incident report to the nursing director and the medical superintendent, copied to the hospital quality or patient-safety committee. The report should describe the instruction, the specific tasks, the patients at risk, the action taken, and the response of managers. If the practice continues, she should escalate to the NNC and the relevant health authority because it is a continuing risk to patients, not a single shift problem.
To protect herself, she should keep dated copies of her objection and the roster, avoid unsigned verbal challenges, and frame the issue as patient safety rather than personal conflict. She should ask for the hospital's delegation policy in writing and for training records of the assistants. Retaliation against a nurse who reports an unsafe practice is itself a governance failure. The strongest protection is a clear, factual paper trail showing that she acted within her scope, escalated promptly, and did not falsify records.