can you refuse an assignment?

Ruby Vee, BSN · Sep 26, 2006

years ago, i was working an oncology floor. there were 15 patients and two staff -- usually an rn and an aide. this particular night there were two rns -- myself and and orientee. the nursing supervisor came around and said i needed to float to micu to do charge. their charge nurse had called in sick, and the only nurses they had were agency -- and they were good, experienced nurses but they couldn't do charge. she wanted me to do charge in micu, my orientee to do charge on our floor, and she'd float us an aide from the micu. (this was years before my first icu job! i'd never even seen the inside of an icu.)

when i refused, the supervisor told me "don't worry, i'm making the staffing decision so it's my license."

i told her that if i screwed up, it was my license, too.

she then told me that if i refused the assignment, she'd have my job.

"i'd rather lose my job than my license," i said.

miraculously, she found another staffing solution for the micu, and she never tried to push me around again. it could just as easily gone the other way, and i would have been looking for another job. but you have to draw the line for yourself, you have to draw it somewhere, and you have to stand up for yourself!

James Huffman · Sep 27, 2006

My previous DON stated to me that we could not refuse an assignment. Now....I'm confused. I thought the Nursing Practice Act stated that we had the "right' to practice safe nursing. Other staff members said the same thing. I would be interested in hearing other's opinions on this. This has bothered me ever since the statement was made to me. And no, I did not refuse the assignment. I was only questioning the safety of the assignment.

I'm not familiar with the Illinois practice act (the one you're under, I'm assuming) but there are a couple of general things we need to keep in mind.

First is, generally speaking, under a nurse practice act, you (as a nurse) don't have "rights," but you have responsibilities. One of those responsibilities is to provide safe, responsible, professional care. Your DON is wrong: it is a professional responsibility to decline assignments that put patients in unsafe positions, where you, as the nurse would be ultimately responsible for the patient being under unsafe care.

I am sympathetic with those nurses who have spoken about unsafe conditions, and taking extremely difficult assignments. However ... you -- as a nurse -- are not the one who has the ultimate responsibility for making sure there are enough nurses. This is the hospital's responsibility. I can guarantee you that if it came down to a complaint before the BON, you would not have the hospital there to tell about how they had too many patients. One thing we can be sure of is that when we tolerate unsafe staffing, we will get more of it. When a situation happens more than once, it becomes, not an emergency, but a situation that needs dealing with.

In an unsafe situation, the nurse must be prepared to stand ground, and -- as an earlier post suggested -- must be prepared to be fired. ALWAYS, always, it's better to be fired than to lose one's license. Likewise, in an unsafe situation, the nurse must stand up, state precisely that you WILL NOT ACCEPT this assignment, and not back down. Do not whine, do not complain, do not cry. Just say no. Period. After having said that, mentally tune out the whines, threats, or whatever else your manager may say to you. It's the manager's job to ensure safe staffing levels. If the manager doesn't do that, or can't do that, it is not your issue. Make the hospital and nursing administration do their jobs.

Nurses sometimes talk about emergency situations, but the situations described here are not aftermath-of-terrorist-attack times. These are just times when -- to be frank -- the hospital administration has chosen not to do their jobs, and nurses are being asked to cover administration backsides.

mamason · Sep 27, 2006

Mr. Huffman, thank you for clarifying right vs responsiblity. I found your post very empowering.

pyegirlrn · Jan 2, 2012

I worked until recently on a "critical care area" called Neuro-Stepdown. We routinely accepted ventilator dependent, hemodynamic altering drips, multiple tubes and frequent OTBS with a staffing matrix that states we should have a 1:4 ratio. Gradually the ratio increased to 1:5, but recently and more frequently was 1:6. On many occasions, my co-workers and I had talked about how taking more than 5 patients on our floor is dangerous. Now was the test time, 3 nurses scheduled with 6 patients a piece, one pct, and 1/2 shift unit clerk/monitor tech. Two of the three nurses refused to take that assignment, but we were looking for alternatives. The supervisor, NM, and Director of Critical Care told us "there is no help to send you and no beds to move any patients to. Either take report or consider yourselves voluntarily resigned." We left and in 2 hours 2 nurses were brought in to take our 6 patients, but "there is no help to send you" rang through my mind.

I am planning on still attempting to receive unemployment since I believe I was left no choice, but to lose my job, a patient, or possibly my license. You must draw a line somewhere and stand by it. I will not put my patient's lives in jeopardy for a hospital or money. I have been in this situation once before and patients died, because of short staffing. Now there is

research showing what safe staffing levels are and there is no more excuse for managers or nurses. That level is 2 in ICU, 4 in PCU/Stepdown, and 6 on the medical/surgical floor.

Meriwhen, ASN, BSN, MSN, RN · Jan 2, 2012

You have the right to refuse an assignment, especially one that you think is unsafe...because if something happened on this assignment that resulted in you going in front of the BON, they're going to hold you accountable because you took that assignment on.

However, the right of refusal doesn't protect you from being disciplined or even fired

dishes, BSN, RN · Jan 2, 2012

pyegirl

Check the labour law for your area, there may be something stating that resignation must be voluntary, not threatened or coerced, since you were forced into resigning, you may have grounds for legal action. I think that nurses need more education on how to advocate for their right to provide safe patient care. Where I am, our union informs nurses of the steps they need to take correct excessive workloads and unsafe patient care environments. We have a professional responsibility decision tree that helps guide us http://www.ona.org/documents/File/professionalpractice/ProfessionalResponsibilityDecisionTree_Hospitals_201004-English.pdf and an electronic professional responsibility workload report form that we complete and submit to our employer if we have workload concerns Ontario Nurses' Association - Professional Responsibility Workload Report Forms

I realize that the workload report forms won't help in your situation, at this point, but it may provide ideas for nurses who want to document and report to their employers excessive workloads and unsafe patient environments inthe future.

dishes

imintrouble, BSN, RN · Jan 2, 2012

You can refuse a pt, but it could cost you your job. You already know that from previous posters.

Oddly enough, the most pressure I've ever felt to take more pts than is safe, was from my fellow floor nurses.

If I took a stand, refused the assignment, who do you think was going to have to pull that extra weight? Yep, the nurse working beside me. There would be anger. The silent treatment. Slamming, banging, raised voices.

Tremendous pressure to buckle, and do what I felt unsafe to do.

I don't know about the rest of you, but I find it much harder to say no to the nurse I sit next to all night, than the nurse I see a few minutes every hour.

leslie :-D · Jan 3, 2012

i've refused unsafe assignments, but when i knew that others would have to carry the extra load, i have accepted the assignment...

noting on the assignment sheet "accepted under duress".

i also made my own personal notes as well.

it really isn't all that clear cut...

knowing that when a nurse refuses, other nurses will only be further burdened, making it even more unsafe.

i do believe that cn's, um's, should be made to take pts when staffing is so low, it's dangerous.

everyone needs to step up to the plate, and it needs to be enforced.

leslie

KelRN215, BSN, RN · Jan 3, 2012

I agree that the "higher ups" need to step up to the plate and do patient care when staffing is dangerous (they all have active nursing licenses, do they not?) but that never happens in my facility. My manager has been known to say that she "can't do patient care". I believe that is unacceptable.

We have had several shifts recently where staffing is dangerously tight. We have patients on my floor that are so sick they're meant to be 2:1 and end up being 5:1 or sent to the ICU because of staffing. And then TPTB get mad that said patient got sent to the ICU/that we couldn't handle them on the floor. If they require 2:1 and we can't provide that, then they belong somewhere that can. The biggest problem is that staff on my floor- including charge nurses- are AFRAID to speak up to our manager when things like this happen.

Quickbeam, BSN, RN · Jan 3, 2012

I have refused to take an assignment that was unsafe given my skills. This only happened when I was in a hospital setting and floated out of my specialty area. And the issue was cancelling travelers vs making me take patients I had no business taking care of (I'm a physical rehab RN, the floor was ICU).

Once I said out loud :"I am refusing this assignment", everyone knew I was serious. I literally thought people would die because of my ineptitude. My decision to say those words out loud caused a cascade of changes which still go on today.

I think you need to stand up for patient safety. I was willing to be fired, I felt so strongly. On the other hand, I have taken insane assignments within my skill set and just did a crazy amount of triage and priority setting.

I do think we all have the obligation to say no for patient safety.

caliotter3 · Jan 3, 2012

I work in extended care home health, where refusing a case or asking to be removed from a case is accepted policy. However, one 'employer' used that fact to see that my unemployment was stopped. Although the interviewing EDD employee told me that he understood that home health nurses can refuse cases, the EDD still took my unemployment away from me. And the one case that this particular employer had offered me was refused three months prior to me even applying for unemployment. Unintended consequences of doing your job according to business as usual.

classicdame, MSN, EdD · Jan 3, 2012

the BON has no control over your employer, so you can refuse an assigment but you might get disciplined by the employer for doing it. That is when you decide if your license is more important than your job. The DON might need to be educated on this to avoid complaints to the BON