How do I recognize an unsafe assignment? Can I refuse an assignment without being fired or disciplined for patient abandonment?
If you are feeling overwhelmed, confused or even down right scared at times, you are not alone! Nurses continue to receive incomplete, confusing and conflicting advice when it comes to whether or not they should take an assignment. From my perspective, as a nurse attorney who defends individual nurses in protection of their licenses, my passion is caring for those who care for others…and that means YOU! I have no interest in getting along with management or convincing you to stay in a position that continues to place you and your license at risk.
YOUR LICENSE is more important than
ANY JOB
NO JOB is worth risking EVERYTHING for!
AN unsafe assignment, the one-time occurrence that could not be helped, is exceedingly rare. The phenomenon of recurring unsafe assignments…correctly referred to as an unsafe position…is becoming all too common.
Surviving that first encounter with an unsafe assignment relatively unharmed tends to create a false sense of security. As nurses struggle through fears of inadequacy and the possibility of termination, their egos, loved ones or other nurses may convince them to go back for more. Eventually, some nurses begin to believe, “it is just not possible to get everything done in nursing” as they lower their standards and expectations to justify staying.
There is a difference between being stressed or uncomfortable and being unsafe. Only you will know where to draw that line. You should be fully aware of the type of assignments you will receive before you start a position. Discuss your expectations and limitations with your supervisor up front or as soon as you recognize there may be a problem.
Forget about the numbers for a minute. While great efforts are made to determine what number of patients makes an assignment safe, nurses are not created equal. We all have our strengths and weaknesses. One nurse’s nightmare may be another nurse’s dream shift.
When nurses fixate on ratios and receive more patients than they believe they should, they are more likely to feel anxious, disappointed, defeated or betrayed. They may consider their assignment unfair, unsafe or a total disaster waiting to happen. Unless something changes, it is only a matter of time before they make a mistake or have a melt down and walk out. However, experience and competency are far more important than numbers.
As a new (and naïve) nurse being sent to CCU, I was nervous but assured that it was “no big deal, it’s just for an hour.” When I arrived, I was given four ventilator patients on insulin drips with vitals and blood sugar testing every fifteen minutes. When a vent alarm began beeping, I was told to just silence and ignore it. By the time I realized what I had gotten myself into, I had already accepted the assignment without any detailed report.
Fortunately, I survived the hour and so did the patients but as soon the CCU nurses returned, I complained to staffing that I should never have been given such an assignment as a new nurse with no critical care experience and insisted that I would never be put in that situation again. By the end of the day, I was labeled a “crybaby” who was scared to go to CCU for a few minutes. However, they never did ask me or anyone else from my floor to float to CCU after that day. This was an unsafe assignment and I was not about to let that happen again.
The day I came in to work and learned that it was just going to be Paz and me with three CNAs and a secretary, I was actually excited…We both were! We rose to the challenge and tackled the day with so much positive energy we couldn’t help but have fun as we ran down the halls working together to ensure every med was given, every dressing was changed, every assessment was charted, and most importantly, every patient was safely cared for. Was this a safe assignment? On that day, with that team…Absolutely! Had I been with anyone else, maybe not. Obviously, this was an extreme shortage and most nurses would have thrown their hands in the air and stormed out. Somehow I knew with Paz by my side and the best CNAs we could hope for, we could handle it.
Even when the numbers look right, patients can destabilize in a heartbeat. Sometimes, the most important factor is whom you will be working with and whether you will truly be supported. No one prefers to work when staffing is short. But, personally, I would rather work with just one positive, supportive, competent, and confident nurse than with five other nurses who could care less if I was drowning and would refuse to lift a finger to help unless it meant giving them the opportunity to write me up. That would have made this or any assignment completely unsafe and I would have been crazy to accept it as a new-grad.
Nurses not only have the power to accept or reject assignments, they have a duty to speak up when assignments are truly unsafe for them to personally accept, regardless of what anyone else can handle.
Charge nurses and supervisors are responsible for any errors or omissions committed under their watch. When nurses knowingly assign other nurses or nursing assistants to patients they could not possibly care for safely, they risk disciplinary action for improper delegation, failure to supervise, failure to collaborate with the healthcare team, patient endangerment, neglect, and so on. If viewed as a pattern of behavior, repeated improper delegations could result in probation or worse.
However, after that first unsafe assignment, where perhaps the nurse just didn’t see it coming, responsibility begins to shift. Managers may say they gave you a chance to prove yourself and you did just fine. As long as there was documented competency on file, they would have no reason to doubt your abilities and since you came back for more they figured you could handle it, regardless of your complaints.
Hit me once, shame on you…Hit me twice, three times, or every other day and its shame on me!
Once you accept an assignment, it is your responsibility to get your patients through it safely. As soon as your safety threshold is crossed, you must take action. For example, imagine you have too many patients or lack the skills necessary to adequately care for a patient who is not doing well. You ask for help but none is available. Sometimes, you just need to think outside the box. Try calling the doctor…perhaps the patient should be transferred elsewhere to ensure proper care. Chances are, management would much rather call in more support than upgrade or lose a patient. Maybe the charge nurse from ICU can help. Follow policy, be professional but put your patients’ safety first and when help is really needed, don’t take no for an answer. Those who fail to call for help believing such efforts would be futile are often disciplined. It’s not okay to just fill out a form.
Nurses across the country are advised to document when they don’t agree with an assignment…Just complete and sign a ‘Refusal of Work Assignment’ form acknowledging in detail why the assignment is unsafe and continue with the assignment. Some organizations advise nurses will be protected from disciplinary action by completing forms with phrases like, “This assignment is accepted because I have been instructed to do so, despite my objections.” Really?
In some states there may be agreements or even statutes preventing such forms to be used against nurses. However, while these forms may provide evidence of an unsafe assignment they do little to protect you from liability, termination, disciplinary action or even criminal action when a patient is harmed during your shift. There is no such thing as a get out of jail free card in nursing.
REFUSAL FORMS DO NOT PROTECT
NEVADA NURSES
FROM LIABILITY OR DISCIPLINARY ACTION
Please understand, at least in Nevada, refusal forms do not create a safe haven for nurses. Policy may prevent you from being fired for submitting certain information in writing. But, forms do not protect you from liability for your mistakes. If and when something goes horribly wrong, you will not only be fired, you will likely be reported to the Board for all sorts of violations and that form you signed will NOT likely become part of the record. If so, it could be viewed as further evidence that you knew the assignment was unsafe but you accepted it anyway. Knowingly placing your patients in danger is never okay and the defense, “I didn’t want to but they made me” will never work. The first thing our Board will ask is, “Why didn’t you just quit?” You are a licensed professional with an obligation to protect your patients and that includes protecting them from you when you cannot handle the assignment.
Nurses need to work and they often live in constant fear of losing their jobs. Even when they know an assignment is too much for them, they may hesitate to say anything because they are afraid they will be written up, suspended or terminated and in an at-will state, they very well might be. After all, if you can’t handle it, there are other nurses out there who can (or are at least willing to pretend they can) and while they cannot fire you for letting them know an assignment was unsafe or that you needed extra help (that would be retaliation); employers have the right to terminate those who admit they are not willing or able to do the job they were hired to do.
What is the answer? Stop complaining and start refusing to place your license at risk. If assignments are repeatedly unsafe, do something about it…now! Request a group meeting with your supervisor to discuss the challenges you face calmly, professionally and respectfully adding specific suggestions for improvement. If he or she refuses to address your concerns, take things to the next level. If management refuses to help, change your approach following the proper chain of command. Be prepared for resistance and remember that complaints alone rarely result in positive outcomes.
If you are the only one who believes assignments are unsafe, or the only one willing to admit there is a problem, and your concerns and suggestions are ignored, then perhaps nothing is going to change and it may be time for you to resign before it is too late.
Patient abandonment occurs when a nurse assigned to care for patients accepts responsibility for those patients and leaves without ensuring safe transition to another nurse who can safely care for those patients. Patient safety is key. Refusing an unsafe assignment, demanding that someone else come in to assist you or take over an assignment may still get you fired. However, waiting until you just cannot take it anymore and storming out without giving report will definitely put your license at risk.
My advice for nurses who continue to receive unsafe assignments after voicing their concerns and limitations to management is to resign or request a transfer to a better-suited position. I also recommend furthering their education, starting with a course on the Nurse Practice Act, which may be found at www.learningext.com and/or other courses relevant to their situation. Continuing education in nursing is essential and when you are struggling with something at work whether it has to do with documentation, certain procedures or interpersonal skills, there are almost always courses on point available to help you. Take charge of your career, take care of your license and don’t let anyone pressure you into keeping an unsafe position.
