Assignment Objection/Unsafe Staffing Form

  1. Sample from the Oregon Nurses Association/ANA/UAN:

    STAFFING REQUEST AND DOCUMENTATION FORM REQUEST TO:

    (Name of shift supervisor, nurse manager):
    FACILITY
    (Name of site):
    DATE OF REPORT ........
    TIME .........
    UNIT .........
    SHIFT ........

    REASON FOR REPORT: I am hereby informing you that, in my professional nursing judgment, I am unable to assure the delivery of safe or adequate nursing care on the unit with the current configuration and/or number of staff assigned to the unit. I request the following additional staff be assigned to my unit immediately:

    RN(s) ......
    LPN(s) .......
    CNA(s) .......
    Wardclerk ........
    OTHER: ........

    This request is based upon the following conditions (CHECK ALL THAT APPLY):

    Assigned staff have insufficient orientation ......
    Inadequate/inoperable equipment ........
    Inappropriate category (by diagnosis or acuity) of patients .........
    Acuity of patients is too high .........
    Patients jeopardize staff health/safety ........
    Inappropriate mix of staff (RN,LPN, CNA, Wardclerk) for patient group due to lack of experience ........

    Inadequate number/kind of staff:
    Even though assigned staff meet guideline/matrix ...........
    Staff do not meet guideline/matrix ........
    OTHER: .........

    I indicate my acceptance of the assignment under protest. It is not my intention to refuse to accept the assignment and thus raise questions of meeting my obligations to the patient nor am I refusing to obey an order if such were given. However, I hereby give notice to my employer of the above facts and indicate that for the reasons listed, full responsibility for the consequences of this assignment must rest with the employer. Copies of this
    form may be provided to any and all appropriate State and Federal agencies.

    Nurse Name: ...........
    Signature: ...........

    ACTION SUMMARY:
    Start of ........
    Shift End of .......
    Shift Admissions........ Discharges ......... Transfers.........
    In/Out Nurse/Patient Ratio ........
    Patient Census ...........
    Number of RNs ............
    Number of LPNs ............
    Number of patient aides .......
    Unit Secretary ...........

    Outcome Summary ........
    Staff that were requested: .........
    Arrived (Time of Arrival) .........
    Were not sent .........
    Negative patient outcomes that occurred: (Check all that apply)
    Delayed/postponed/omitted medical treatment .........
    Delayed/omitted self care instruction ........
    Delayed/omitted hygiene .........
    Inadequate observation/assessment/monitoring .........
    Delayed/incomplete documentation ...........
    Compromised safety/injury ........
    Omitted psychological support (patient/family) ........
    Inadequate management of emergency situation .........
    Incedent report filed for .............
    Commments:


    Copy for RN filing objection form
    Copy to Nurses Association and bargaining unit representative.

    http://www.oregonrn.org
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  2. 9 Comments

  3. by   Jenny P
    Julie, I tried to fill one out just last week at the end of the shift and found to my surprise that the form language was changed slightly so I couldn't fill it out.
    The charge nurse on evenings had tried to get another nurse for the night shift when a patient coded and couldn't be paired with a stable post op open heart patient. Both the supervisor and staffing were notified, then there were 2 codes at change of shift at 11PM (1 being the previously mentioned pt. and the other code in CCU). We'd called (but not me personally!) to try to get another RN but there weren't any available. My patient was 89 yrs old, fresh out of heart surgery, on a IABP with multiple vasoactive drips (etc.), slightly confused, and renal insufficiency. They moved the stable post-op into our room and I got him plus my other one. The night charge nurse had tried to talk to the supervisor but the supervisor didn't return the call. My charge nurse knew I was going to file the unsafe staffing report, but I didn't get to it 'til morning because of the assignment.
    Guess what? I had not personally tried calling the supervisor or MD (and what does HE have to do with staffing anyway?), so I couldn't file the report! Only the charge nurse could do that!

    Moral of the story for those of you with unsafe staffing documents: Keep up with any changes on them and fill them out at the beginning of the shift!!!!!!
  4. by   -jt
    <Guess what? I had not personally tried calling the supervisor or MD (and what does HE have to do with staffing anyway?), so I couldn't file the report! Only the charge nurse could do that!>

    You lost me here. I dont get it. Why not just fill out what you could & submit it anyway. Its very existence is documentation enough should something have happened that you could be held liable for - but which could have been prevented had there been adequate staffing. As long as the supervisor is made aware of the unsafe situation & that an objection was being made to it, I dont think it matters who calls whom. File it & let the supervisor explain why she didnt answer & didnt call whomever she was supposed to call. They can be filed at anytime during the shift when the situation becomes dangerous & is not remedied. It may not always be at the beginning of the shift.
  5. by   mustangsheba
    I'm with jt. File the report. That's bunch of crap. (sorry!) Why wasn't this 89 yo in ICU?
  6. by   NRSKarenRN
    Sample form courtesy of Florence Project, INC. , website below.

    ASSIGNMENT DESPITE OBJECTION

    ________________________, a registered nurse employed at ________________________Hospital on _______(shift), _______(unit), hereby object to the assignment as:

    ___charge nurse ___primary nurse ___team leader ___team member/patient care assignment made to me by __________________(supervisor) at _______(time) on ________(date) despite my objections on the grounds that I was: (check appropriate description)

    a)___not oriented to the unit

    b)___not trained or experienced in area assigned

    c)___given an assignment which posed a serious threat to my health or safety

    d)___given an assignment outside my current job description

    e)___case load assignment is excessive and interferes with delivery of adequate patient care

    f)___not given adequate staff for acuity (check appropriate description)

    ___staffed with excessive registry personnel

    ___staffed with unqualified registry personnel

    ____staffed with excessive number of unlicensed personnel

    ___short staffed

    ___not provided with unit clerk

    g)___transferred or admitted new patient(s) to unit without adequate staff

    e)___other: (please specify)________________________________________
    __________________________________________________ ___________
    __________________________________________________ ___________

    This assignment is accepted because I have been instructed to do so, despite my objections.

    STAFFING COUNT on date of objection:

    regular float/casual registry/agency staff currently employed on unit

    RN________________________________________________ __

    LPN_______________________________________________ __

    AIDE______________________________________________ _

    Unit Clerk yes__ no__

    CENSUS (on date of objection): ACUITY: high average low (circle one)

    Number of patients on unit___ Unit capacity___

    Brief statement of the problem:__________________________________________ ___

    __________________________________________________ __

    ACTIONS TAKEN BY NURSE:

    Notified Head Nurse:___________________time_______date__________ _

    Notified Nursing Supervisor:______________time_______date__________ _

    Notified Doctor________________________time_______date_____ ____



    Printable form is available at the Florence Project Website.

    See disclamer re using this form@
    http://www.florenceproject.org/adodisclaim.shtml

    Form itself@
    http://www.florenceproject.org/ado.shtml
  7. by   OC_An Khe
    JP
    We utilize the inadequate staffing forms also, and they can be filled out by any RN who feels their assignment is unsafe, not just the charge nurse, Can also be filled out at anytime. You could also let them know your are saving copies to provide the JCACHO the next time the come to inspect your facility.
  8. by   Jenny P
    Okay, I know all of that; I was just pointing out that the forms DO change in their wording from time to time, and this was a big surprise to me to see how it was worded now. I will fill out the form since I plan on calling MNA today if I get up early enough (this is when the night shift is inconvenient--- when you sleep through the times businesses are open). Even if I sleep through the day, I will fill out the form to the best of my ability here at home today.
    Mustangsheba, I work CV-ICU and the patients were both still in the unit.
  9. by   mustangsheba
    Sorry - I must have missed that.
  10. by   hoolahan
    I wish there was such a form tonight!
    BTW JennyP, I worked in a CT ICU for years and I can say that assignment is very dangerous. I was lucky enough that in my unit that guy would be a 1:1. All IABP's were always 1:1. Have you ever seen a rupture? I feel for you girlfriend!

    I oriented with an agency to a rehab facility tonight. The actual assignment wasn't awful, but the chaos around it was. Here's what happened...

    Start of 3-11 shift, I am supposed to be 1:1 with another RN to orient. We have 10 pt's, rooms 17B to 23B. ON the other team, the relief nurse wasn't scheduled to arrive until 4pm, but days can leave since they tape report. The only person "covering" was the CNA, no nurse is "officially" covering, we're all supposed to, but of course, since there were 2 of us, no one else did. Helen was supposed to be there at 4.

    The super comes up and say she may have to pull Helen, meaning we would have to change our entire assignment. My preceptor voiced her objections, as we had those 10 pt's to do, plus an admit for the other team. The other team had an RN, but they only get one admit per team. So the supervisor says she'll see what else she can do.

    4:30, Helen isn't there yet, who the heck knows what her pt's need? I was running to get all our VS and assessments done. 5 minutes later, 4:35, they say Helen's coming. At 5:10, the supervisor calls back, Helen was on the floor for 30 minutes, now they are pulling her. So our assignment changes to rooms 21 to 29B! Now, we quickly covered out BS though dinner trays were already passed, then had to get report on the new pt's. Still haven't even looked in on the admit yet! I am so frustrated I want to scream! I can't pass meds until the other nurse checks me off, so now we have no VS, no assessments, and nothing else done for these pt's who were neglected for 2+ hours. So, I painstakingly gave the meds, I am very slow since it is my first time there and the medex's are so different from anything I have ever seen before. Of course the last thing I want to do is make a med error. I wanted to combine VS, assess, and meds, but the other nurse kept rushing me, up my a$$, so she could just check me off. I felt for her, I know how far behind we were, but what else could I do? Finally, we finshed the 4:30, 5:00 meds at 7pm. ONly checked BP's or apicals if the med required. Thank God it's a rehab and everyone is in pretty good shape, or I'd be freaking out about not taking VS. Even in HH, we always get VS!

    WE finally get to the admit, get interrupted many times for the CNA letting us know a pt needs pain meds, etc...She has to come with me to see me sign out a narc. Then she even wanted to watch me do a dressing on a toe wound. OMG, I have done wound care a gazillion times, please I need some space! But, b/c she was doing what she was supposed to, and checking me off, everything took so freaking long to do. NO notes were done until 11:30!! I finally convinced her at 11 to let me st cath a pt myself so we could get done!! I didn't finish notes, b/c then she had to review all my paperwork, etc... Left at 12:45.

    Dogs barking, stomach growling, peed once the whole shift.

    Does anyone else experience tis stupidity with assignment changes? It pi$$ed me off something bad!! I am not sure I will EVER go back there as the staff tell me this is a regualr occurance. The supervisor had a look like her eyes glazed over. I swear, it seemed like she was stoned, but really I think she may just be an idiot! If I don't go back and put in 36 hours, I never will be paid the $hitty $10 per hour for orientation! I may go in on 11-7, since the meds are waaaaay lighter, and most of the pt's are settled in, and many can't move w/o assist to get up, so at least I would start out in one place. I think I'll try a night and see if there is a diff, but if they ever do that to me, I will pitch a hissy FIT!

    BY 7p, I was ready to call my agency and tell them to get me out of there, I would not go back again. But the nurse who oriented me, though anal, and I can relate b/c I am anal too, was very nice and remained pleasant despite all our grief. None of the other nurses seemed to be team players either. God forbid someone else get your pt's pain med for you. I am just not used to that mentality. IN the ICU's where I have worked, we all helped eah other when we saw someone else was drowning. This was different.

    Anyway, thanks for letting me vent!
  11. by   -jt
    You dont need an official form to do something about this. Copy & print you post & send it to your manager, her supervisor, the DON, & the risk management dept of your hospital. If the nursing office wont pay any attention to it, the lawyers how worry about hospital liability & lawsuits will. You could have also written an incident report for Unsafe Staffing. Your responsibility was to inform the supervisor of the situation. What she does about it is out of your control. The point is not so much the form but the fact that it is documented & that the supervisor has to then address it.

    Also, you would have proof for your defense should a pt or family member complain about you or something harmful happens that could have been prevented if you had adequate staff. So keep copies for yourself.

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Assignment Objection/Unsafe Staffing Form