Can I Refuse an Assignment?

Dear Nurse Beth Advice Column - The following letter submitted anonymously in search for answers. Join the conversation!

Updated:  

Can I Refuse an Assignment?

Our most recent PEDS patient, one year old, had back to back seizures and because we are a small facility, he was transferred to a children's hospital once he was stabilized. I'm trying to find out the legal way to handle this situation and whether we have the right to refuse to care for these PEDS patients, at least until we are sufficiently trained. I am not only concerned from a liability standpoint for myself, but extremely concerned for these patients who have nurses with little experience caring for them and even new grad nurses with NO experience with children beyond their college training.

Share this post

+ Add A Comment

13 Answers

Specializes in Tele, ICU, Staff Development.

Dear Can I Refuse an Assignment,

This is serious. Pediatric patients are not little adults and require specialized skills and knowledge.

The bottom line is that you can refuse an unsafe assignment and you can also lose your job by doing so.

 Here are a couple of things to consider.

Your Responsibility

You have a professional right and obligation to refuse any patient assignment that harms the patient or yourself. Lack of training is a legitimate reason to refuse a patient assignment.

The Patient Safety: Rights of Registered Nurses When Considering a Patient Assignment is clear. However, neither the ANA, Georgia BON, nor the Georgia Nurse Practice Act has jurisdiction over your employer and cannot protect your job.

While the Georgia BON cannot intervene between you and your employer, it could remove your license if you are negligent and cause harm.

The Hospital's Responsibility

Providing adequate staffing is the responsibility of the employer, not the staff.  

However, there may be situations where a facility is unable to provide the necessary level of care due to staffing or resource limitations. In such cases, it's crucial to follow established protocols and procedures to ensure patient safety and facilitate appropriate transfers to more specialized facilities. Ask to see the protocol in such situations.

Regulatory Bodies

The Georgia Department of Community Health Division licenses hospitals that receive Medicare/Medicaid reimbursement. The Joint Commission accredits hospitals.

A facility could get in trouble during an accreditation survey with either regulatory body if an astute surveyor asked to see how patient care assignments are made (should be competency-based).

Unfortunately, sometimes it takes an adverse event or complaint to prompt a state investigation. If the facility were at fault, it would have to submit a corrective plan of action to include sufficient orientation/training.

Your Strategy

Georgia is an at-will employer, meaning you can be terminated without cause. You can lose your job by doing the right thing (not taking an unsafe assignment). Here are some considerations:

  • Preemptive: Make an appointment with your supervisor. What are the requirements for caring for peds patients? Is there a policy or a competency checklist? Are PALS required? An orientation? This puts her on alert and may prompt needed training.
  • Once you accept an assignment, the patient is your responsibility until you are relieved of duty. Never refuse an assignment after you have accepted it (received report). If you refuse an assignment, do it before taking report (otherwise, it's considered abandonment).
  • Refusal. At the point of being sent to Peds or given a Peds patient, "I am sorry, I am not safe caring for this patient as I do not have the competencies. I do not want to put my license, this facility, or this patient at risk. Is there another assignment I can take for which I've been trained?"
  • Before refusing, consider if there are any ethical concerns. As a simplified example, if there were only 2 nurses available to take the patient- you and a brand-new grad-then you are the best alternative until the patient can be transferred. The important thing is that you think through the decision critically and that you're able to articulate your rationale, with patient safety as the driving concern.

Sometimes the Staffing Coordinator or House Sup will not put forth the effort to find a qualified RN if a float readily agrees. Personally, I would expect the RN manager of a Peds unit to take patients before assigning an unstable patient to a float.

Note: If yours is a critical access hospital, different rules apply. Good luck; please let us know how it goes.

I witnessed this a few years ago with a cath lab in a small hospital. They had been accredited to take STEMI (ST elevation MI) patients, but didn't have enough trained staff. The accreditation required that nurses have 500 hours training in a level I cath lab, but they would often use nurses from their step-down unit to circulate during cases. They didn't like it, but they were told....do it our you're out of here.

One morning, they had a STEMI come through the ER, and they were short-staffed, so they had an ER nurse circulate the case. This type of case highly specialized, as you can imagine.

The state regulatory board was called to investigate, probably by the ER nurse or her colleagues, who thought "OK, this isn't right.".

Bottom line in this case. The state found no wrong-doing. Nurses, in their mind are trained to do what the hospital wants them to do. They really didn't find that this type of specialized assignment was a problem. I only heard the hallway conversations, but this was the result.

As for the accrediting agency. It seems the accreditation pays pretty well, so they are hands-off once they give the accreditation, unless serious problems force them to take the accreditation away. I think they were contacted about this, but considered once-in-a-while needs to be ok.

Your best bet is to move on, if you are not comfortable with the assignments you are given.

On graduation day my mom gave me one piece of advice "you can get another job, you can't get another license" It has served me well for 20+ years. Know that if anything happens the hospital will NOT support you or back you up.

You need to protect yourself. It may mean going to another facility. It is right. It isn't fair. Been there. Done that. After spending 1/3 of my life (16 of 48 years) at one hospital, I left. A narcissistic manager whose primary goal was to make herself look good to admin put nurses in these same type of situations. It made me sad and angry to leave, but it would have been worse to be involved in an adverse event. You are there to protect patients, not cover the hospital's a$$.

Specializes in Orthopedics, Med-Surg.

When I was in the (nights) permanent float pool, the hospital would occasionally send me to either Peds, PICU, and once, even NICU. This is from an orthopedic joint background. I had no choice; I was expected to go where they sent me. In the ICUs I'd immediately ask for any kid that was vented or in a coma. When asked about my request, I'd honestly tell them I didn't like kids and if I had to care for one, preferred not to have to listen to him.

This accomplished a couple of things: I generally got those kids since the average peds nurse wasn't comfortable with vents and I was. I developed a reputation within the peds community as the guy you really didn't want coming to your unit. Maybe they really didn't need help but it was offered and they thought, "what the hell... we'll take more help if it's offered". Well, when they found out it was me maybe they didn't need help so much after all. Finally, they'd stop pestering the nursing office for float pool nurses when they found it not all that rewarding.

I got into a conversation with a few peds nurses on how I could dislike kids. I asked them if they'd enjoy taking care of old people. "Yuck!", they'd reply. "I love old people. I enjoy taking care of them and I enjoy talking to them. We all have our niche. Mine isn't kids. Yours isn't geriatrics." So I would get a bit of a pass for not being totally heartless. But I digress.

If worse comes to worst and a lawsuit develops, your protection is: 1) Don't own anything worth a lot of money; 2) Don't carry professional . The hospital is the deep pockets and they're the ones who got you into this pickle. They will be named in the suit even if it's totally your fault. Their lawyers can't protect them without by extension protecting you. It's like an airline crash: the pilot can't save himself from a crash without hauling you along and saving you at the same time.

I was involved in giving a deposition after making a med error one night. The couple blamed every dissatisfaction in their lives on me when in fact, all I'd really done was inconvenience them, causing the wife to stay in the hospital an extra day at no cost to them. So they sued me and the hospital for a ridiculous amount, no doubt hoping for a nuisance payoff. Well, at the end of the deposition (less than an hour; the plaintive's deposition took almost 11 hours), the last thing I was asked by the plaintive's attorney was: "Do you have any professional liability insurance?". "Not a penny", I said. That let all the wind out of his sails as I'm sure he would have gone after the insurance company if there's been one. Deep pockets...

If you do own a house or some other significant property, either transfer it to someone you absolutely trust or get the insurance. I could only get away with blowing the insurance off because I owned nothing of real value at that time. Thankfully, that's no longer my situation but I no longer nurse either. Retired in 2010.

This is the reason I've come to despise nursing. I refused an assignment on a unit that had just opened up in our facility. It was for new "psych" patients...I worked psych primarily level 2, these were level 4 equipped with a take down team. The other patients only needed to be de-escalated. I'd never been trained on the unit, never even visited the unit...I was told to work OR else. Needless to say I was afraid of providing adequate patient care, safety of my staff and my protection too(the day before a nurse had to lock herself in med room until 911 arrived - she refused to ever work it again. I turned in my resignation effective immediately and cited the reason why. A few months later I recvd a notice from board citing patient abandonment. I opted not to hire an attorney (idiot moment ) I explained to detective to retrieve video from facility since we had cameras. They had been recorded over. BON found me negligent, had to hire an attorney to fight the charge 5k, reduced charge to public censorship. I had to pay the attorney another 750 as a final attempt pleading to take a closer look at the case. Review statements from my witnesses and to also take into consideration that I had retained counsel against the facility for defamation etc. Thankfully the last letter I recvd stated that it was an employer vs employee issue and all charges were dropped. I suffered for 2 years. I'm afraid to even work. I was advised against filing complaints against administration and staffing coordinator/lpn. It's scary to think that anyone can file a charge that's a blatant lie with no accountability.

Specializes in Family Practice.

When it comes to my license I take it very seriously. I refused to do charge on my unit when my manager thought it was acceptable to staff me with just 2 nurses and one on-call with a mom threatening to deliver her 24 week twins, not to mention L&D's status board was lit up like a Christmas tree. I was livid. I let my manager have it. I stressed to her that I am licensed by the state of California not your facility. If I lose my job so what. If I lose my license I lose my livelihood, pursing education endeavors, and my career. Why acute care facilities think a nurse should sacrifice his or her hard earned credentials because they are too damn cheap to staff appropriately!!!! I see new nurses scared to speak up I never been afraid I always had a lack of patience with buffoonery. I just love it when they say do a statement of concern when you feel your assignment is not safe or staffing inappropriate. I laughed and simply said I will simply refuse and go home. You cannot force me to work in unsafe conditions. It is getting worse and I really feel for the patients because as nurses we get the blunt of everything. If they only knew!!!!!

I was a new nurse, had no idea I could buy professional . Needless to say it's still BS when you have to defend yourself against lies! I every time I think about it i get livid. Wrong is wrong and they had no right to turn me into the board...

Yes, you can refuse an assignment. Here's how. Quit your job and find one where you don't have to worry about pro management, anti nurse, managers jeopardizing your career. They do exist. Opportunities abound for BSN nurses. Create your own niche.

Specializes in Orthopedics, Med-Surg.

I have been involved in two lawsuits. One was my fault and the other I was merely one of a cast of dozens who may or may not have been involved. (Truthfully, I didn't remember the patient or the incident... the news came out of the blue as far as I was concerned.) But it doesn't matter whether you screwed the pooch or you didn't. The result will probably be the same. More on that later...

Don't worry about your professional reputation. Your agency isn't going to advertise any lawsuit as it makes *them* look bad. People won't remember your name but they'll remember the hospital got sued (again). But that's only if the lawsuit makes headlines. The vast majority of lawsuits never even get whispered about outside of the agency. The only way people not directly involved will ever know is if you tell them. If you're smart you'll wait 15 years before you do so.

Let's say you did something wrong and the lawsuit is really your fault. Perhaps your hospital fires you. Maybe they don't but merely save it for a rainy day. Either way, your reputation is safe.

If you get fired, no human resources department is going to mention your mistake or that you've been fired. All they're going to give up is 1) yes, you worked there from this date to that date; 2) they may also mention how much you were paid. They won't pass along any of the juicy details of how you came to be on the job market again because there's no quicker road to a successful lawsuit that violating a (former) employee's privacy.

I mentioned I was involved in two lawsuits. I got fired over an accumulation of one of the lawsuits and a second med error that did not go anywhere. When I applied to another hospital in the area, I was hired immediately. Nobody ever really knew why I had left the first job. I chose not to share it and went on to stay at the second facility 12 years until I retired. I did retire in good standing after not having had a writeup literally in years.

I know it is true that nurses can be pulled to any post and can be fired for refusing, but I wonder if a quiet, anonymous notification to the media will help curtail this insanity.

HR or a former manager can verbally state things they won't put in writing (in giving a reference).

Specializes in Psych,LTC,.

I can't say this is a fact because it is second hand. When the facility settles a nuisance suit it goes against your professional reputation. The facility will protect you when it goes in their best interests. If you have insurance that offers legal protection, you may have a lawyer there to protect your interests, which includes your professional reputation.

+ Add a Comment