Imagine that you are a new nurse, about six months out of school and working on a cardiac floor at a large teaching hospital. It is Christmas Eve and you report to your unit to work the night shift. The nursing supervisor calls and tells you to go to the oncology unit – you’ve been floated. You tell the supervisor you’ve never worked oncology. She says you are just going to help out, do general basic nursing care; the regular staff nurses will handle everything else. When you get to the unit, the charge nurse gives you a fast report on your assigned patients. Contrary to what the supervisor said, you have most of the sickest patients on the unit and it is a regular patient care assignment, including administration of chemotherapy for which you are not qualified. What do you do?
Consider another situation: You are an experienced nurse. Your unit has a 6-bed intermediate care or step-down unit that is staffed at a “1 nurse to 3 patients” ratio. The unit also has 18 general medical beds. When you arrive for the day shift, you have a full house and you discover that one of the two step-down nurses is out sick. Then the nursing office pulls one of the two RN’s on the rest of the unit, leaving two LPNs and a tech for the 18 beds. You not only have all 6 step-down patients, you are now charge over the other 18 beds. By mid-morning, you have two disoriented step-down patients, including one who pulls out his IV and fights with his family, and your LPNs can’t give IV meds. The nursing office says it has no one to help you for at least another 4 hours, if that. The ICU wants to give you a new patient and things are going from bad to worse. What do you do?
Unfortunately, many nurses – and many leaders — will answer the question with some form of “suck it up and do the best you can.” And while I know that questioning an assignment, let alone refusing it, is hard, this is exactly what you must consider doing. Think about it this way: if you were a new airplane mechanic and were assigned to work solo on a new type of engine that you haven’t seen before, knowing that the plane was due to fly over 300 passengers and crew in 2 hours, would you do it without objection? If you were an internal medicine physician and told that you, as the only doctor available, had to perform a craniotomy, would you do it?
The shortage of qualified practicing nurses is not new. Neither are nurses’ legal, professional, and ethical duties. The American Nurses Association has backed the nurse’s right to refuse an unsafe assignment since at least the 1980s. The current position statement, “Rights of Registered Nurses When Considering a Patient Assignment,” (ANA, 2009) expressly states that nurses have “the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.” (Emphasis added.)
In addition, the ANA’s Code of Ethics for Nurses (2001) spells out the RN’s accountability “for judgments made and actions taken in the course of nursing practice, irrespective of health care organizations’ policies or providers’ directives”, (Provision 4).
Nurse leaders should take note of Provision 6: “acquiescing and accepting unsafe or inappropriate practices, even if the individual does not participate in the specific practice, is equivalent to condoning unsafe practice.”
Most state/territorial nursing associations and state boards of nursing echo these statements and many states have statutes that protect nurses who point out unsafe conditions. In Texas, it is called the “safe harbor” provision and other states, although they may not use that term, have similar policies or statutory wording. Nurses and leaders must speak up when circumstances put the nurse and the patient at risk of harm. Boards of nursing will discipline nurses and leaders who knowingly allow or foster unsafe practices.
Even if you have never been in questionable situation, you should know your organization’s policies and your state’s laws and regulations regarding refusing an assignment. Objections must be in writing so check to see if your facility or state has a form and keep several blank copies in your locker or backpack.
When a potential situation arises – either at the beginning of the shift or later on if conditions deteriorate – try to identify exactly what the problem is. Are you unqualified to care for the patients assigned? Is the assignment outside the scope of your practice or your experience and knowledge level? Has the assignment changed since you accepted it – have you received new patients or has a patient’s condition deteriorated?
Be polite and factual when you follow the chain of command through the charge nurse, unit leader, or nursing office. “I am not qualified to care for these patients because I don’t have the knowledge or the experience. I am concerned for the patients’ safety and I need your help to find a safer way to take care of these patients.” “I cannot accept this assignment because my lack of knowledge or experience will put these patients at risk of harm. What else can we do to ensure their care and their safety?”
Put your objections or refusal in writing. State facts, include the date and time, and why you are refusing or objecting. Don’t use subjective or accusatory terms such as “short-staffing.” Sign it. Give a copy to your leader and keep a copy for yourself. Understand that sometimes you must care or continue to care for the patients because not caring is the greater harm.
If you are a leader, do not punish the nurse objecting or refusing the assignment. This is retaliation and it is barred by law and professional practice rules. Listen carefully, consider all available options, and thank the nurse for having the courage to speak up. Document carefully and use the experience to identify potential staff or policy needs and ways to respond to future such situations. The ANA position statement is an excellent resource to start.
As for the two examples at the beginning, they happened and I was the nurse. In the first situation, the supervisor told me to do the best I could, and none of my patients died that night. In the second situation, one of the attending physicians saw what was happening and went to the nursing office himself. I got some help. My head nurse, who was off that day, phoned and accused me of deliberately trying to make her look bad to senior management. This was the latest of many staffing incidents at this facility. I had the next two days off; I interviewed at another hospital where I was immediately hired. I worked my two weeks’ notice under the icy glare of my head nurse, knowing I’d done the best I could to keep my patients safe.
Remember that it could be you or a loved one in the patient room someday. Don’t hope that everything will be alright. Ask for help and help your colleagues when they are facing an unsafe assignment.