When an Assignment is Unsafe

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.

BJ Strickland

Beth J. (“BJ”) Strickland is from Tennessee. She is an RN with Bachelor’s and Master’s degrees in nursing and a Master’s degree in history from Vanderbilt University. She is also a licensed attorney with her Juris Doctor degree from the University of Tennessee. She has practiced nursing since 1976 and has experience in clinical nursing, administration and teaching in several clinical areas. She has practiced law in state and federal courts in Tennessee since 1996 with an interest in healthcare risk management, employment law and medical malpractice. She retired from the U.S. Army in 2015 as a Lieutenant Colonel. This article is not legal advice. It is offered only as information about nursing topics of interest. If you have legal questions, please speak with a licensed attorney in your area. Neither the author or the website publisher are responsible for any actions a reader may take based on material in this article or on this website.

8 thoughts on “When an Assignment is Unsafe

  • December 18, 2018 at 8:10 am

    Thank you for this article. I appreciate the legal advice. Nurses are warm, compassionate and forgiving to a fault. Unfortunately, the legal system is just, not fair. When considering how to proceed in a difficult legal, ethical and professional situation, solid advice grounded in the law, which is backed by the American Nurses Association, is the best way to proceed. It is not enough to say that we want what is best for our patients; we must also do what is best for our patients. “Acqeisising and accepting unsafe or inappropriate practices is equivalent to condoning unsafe practice.” (Prov. 6, ANA, 2009)

    • January 4, 2019 at 4:29 pm

      I agree! I reference the ANA Code often with my students! Thank you for your comment.

  • April 28, 2019 at 7:38 pm

    Thank you so much for this article! I’m in the first stages of getting into nursing school and this article basically sums up my concerns and addresses them exactly! Thank you!

  • June 27, 2020 at 8:23 pm

    a Supervisor in Kindred Hospital in West Minister California has a Habit of assigning RN to a patient in 2 different departments, So when a call light is on 1 patient , you cannot see or hear your other patient, And if refuse this assignment , you are reprimanded by your superiors, The CNA rep also has no idea to battle this on going problem. please help the nurses reason legally to this unsafe patient services

    • June 28, 2020 at 1:05 pm

      You cannot be responsible for patients in 2 different locations (units, departments) at the same time UNLESS a qualified provider is covering the other patient. It is one thing to have patients on a unit and one goes to radiology. Then radiology is taking care of the patient FOR A SHORT TIME. If we’re talking about a full-shift assignment, the facility is setting itself up for a malpractice suit and likely sanctions from the licensing/accrediting body, which could result in large fines, even revocation of Medicare status. A CNA is not legally sufficient full-shift coverage for patients assigned to an RN. This is such an unsafe situation for everyone. I don’t understand why any supervisor would put him or herself, the facility, the patients, and the nurses in this situation. The supervisor can be legally held liable for failure to properly assign, supervise, delegate and so could the hospital in the event of patient injury or death. I strongly recommend contacting your state board of nursing, state nurses’ association, and the state facility licensing board to find out what their regulations are. The federal level (CMS) requires certain staffing too. I am so sorry you are going through this. If you don’t have your own malpractice/professional liability insurance, you should invest in coverage immediately because the facility will likely try to shift blame for any patient injuries or deaths to the individual nurse. Adequate coverage runs about $10-12/month and many policies include a legal representation benefit if your BON tries to discipline you. Good luck!

  • January 28, 2021 at 11:19 am

    I work at a Children’s and Women’s hospital. I have worked NICU for 31 years. Recently our hospital has opened an adult unit as an overflow from the University hospital. Our hospital is expected to staff this unit. Nurses are being pulled from the NICU to take care of these adult patients, some of which have tracheostomies, closed head injuries, etc.
    My question is this. For a nurse like me who has zero adult experience can I be forced to take care of these patients? They are not providing any cross training at all.

    • February 4, 2021 at 10:28 am

      My apologies for not answering sooner. I had a very similar question from another nurse recently where the NICU nurses were being used as “sitters” due to reduced NICU census. In your situation, it is absolutely unwise to assign you to direct patient care for any patients you do not feel qualified to care for. That is something you need to address with your risk manager AND absolutely worth a phone call to your state board of nursing for their guidance. No nurse, from a patient safety and legal liability standpoint, should ever be assigned primary care responsibility for patients that they are unqualified to care for — yes, your license says you MAY care for these patients BUT that is only AFTER you’ve had training and supervision. Yours is a specialization and you can’t be “transplanted” to another area — imagine if any of the adult care nurses were suddenly told they had to care for NICU patients without training and supervision. You have a duty to protect the patients and the general public. Your license is not a free pass for employers to use you anywhere they feel a need. Contact your BON for guidance, and if you have your own malpractice insurance (and I believe every nurse should, beyond any coverage provided by the employer) contact the carrier’s risk management service for additional perspective. In the meantime, make sure you document what you were told, who told you, what they said verbatim, when, etc. and keep a record of everything. I hope you’ll never need it but under current circumstances, you may. Good luck!


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