Can nurses refuse patient assignments? How? In which situations? Can’t they get fired?
Find the answers to all these questions and more in this article, which covers everything you need to know about refusing patient assignments as a nurse.
Patient Assignments: An Overview
Nurse-patient assignments refer to pairing nurses with patients based on the nurses’ skills and experience and the patients’ acuity, among other factors. Patient assignments are typically made by each unit’s charge nurse or nurse manager. Adequate pairing is essential since these assignments can affect patient, nurse, and hospital outcomes.
Considerations about Patients
When the charge nurse or nurse manager creates nursing assignments, they must consider various factors about patients and the care they need, including demographics, acuity, workload, safety measures, psychosocial support, and care coordination. For example, a patient who only speaks Spanish will likely be paired with a bilingual nurse; a high-acuity patient will likely be paired with the most experienced nurse, and so on.
Considerations about Nurses
Likewise, nurse managers must consider the characteristics of the nurses in their respective units to guide optimal patient assignments. Therefore, nurse managers consider nurse demographics, preferences, and competence. For example, although continuity of care is typically ideal, nurses may request not to be assigned a particular patient on their next shift. Nurse managers may be able to oblige, but often, patient assignments must depend on which nurses are most qualified to care for particular patients based on education, certification, and experience.
Other Considerations
In addition to considerations regarding the patients and nurses, charge nurses must consider factors such as the physical layout of the unit, the average patient length of stay, and nurse-to-patient ratios when determining patient assignments.
Can a Nurse Refuse an Assignment?
The short answer is, “Yes, nurses can refuse patient assignments.” However, this is not a simple matter.
The American Nurses Association (ANA) states that registered nurses (RNs) have the “right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm.” Not only is it their right, but it is also their professional obligation to voice concerns regarding risky patient assignments. These concerns may be based on state laws, rules, and regulations governing nursing practice, including each state’s Nurse Practice Act.
Furthermore, the Bill of Rights for Registered Nurses states that nurses have “the right to freely and openly advocate for themselves and their patients, without fear of retribution.” However, refusals to accept a patient assignment should not be based on personal preference, prejudice, bias, convenience, or arbitrariness.
These same guidelines apply to PRN nurses and travel nurses as well. Whether they are employees or independent contractors, nurses must assess the risk of any given patient assignment to determine whether or not they should accept it.
When Can a Nurse Refuse a Patient Assignment?
According to the ANA, a nurse’s primary commitment is to provide healthcare services to their patients. Nurses are morally obligated to care for any patient that needs their services. However, certain situations may present risks that outweigh this moral obligation. Accepting the risk becomes a moral option instead of an obligation in these situations. When nurses face threats to their professional or personal integrity, nurses must only accept the compromises that preserve their moral integrity and do not jeopardize their dignity or wellbeing or that of others.
The National Council of State Boards of Nursing provides the following framework guidelines to help make decisions regarding patient assignments.
Assuming that a particular activity, intervention, or role is permitted by the Nurse Practice Act and other applicable laws, rules, and standards, charge nurses and nurses assigned particular patients must ask the following questions:
- Is performing the activity, intervention, or role consistent with evidence-based nursing and healthcare literature?
- Has the nurse completed the necessary education to perform the activity, intervention, or role safely?
- Does the nurse have sufficient resources to perform the activity, intervention, or role in the practice setting?
- Is the nurse prepared to accept accountability for the activity, intervention, or role and the related outcome?
If the answer to any of these questions is “No,” a nurse should not accept the patient assignment.
Consequences of Refusing an Assignment
As mentioned, nurses have the right to advocate for themselves and their patients without facing negative consequences. However, the reality is that refusing an assignment may have both formal and informal consequences. A nurse can even be fired for refusing an assignment.
Informal consequences may include animosity from team members, especially if refusing a patient assignment resulted in another nurse having a greater patient load.
Formal consequences may result in disciplining a nurse’s license. However, this disciplinary action typically occurs if a nurse does not adequately refuse an assignment or if there is patient abandonment.
What Are Patient Abandonment Laws?
A nurse’s actions may be considered patient abandonment if the following occur:
- A nurse accepts a patient assignment and is responsible for patient care but then abandons or neglects a patient needing nursing care without making acceptable arrangements for the continuation of care.
- A nurse leaves their job without providing sufficient notice and under circumstances that seriously impair patients’ quality of nursing care.
How to Refuse a Patient Assignment
The following are the steps a nurse should follow if they believe they should refuse a patient assignment:
- A nurse should consult with the supervisor and state that they cannot accept the assignment. The refusal should be communicated as soon as possible to allow for alternate arrangements for patient care.
- In addition to verbal communication, nurses must communicate to their supervisor in writing the perceived discrepancies between the required competence and the nurse’s knowledge, skills, and abilities. The nurse should keep a copy of the documentation and any steps taken to remedy the situation for future reference.
- If supervisors insist that a nurse accept an assignment against the nurse’s judgment, the nurse should fill out an Assignment Despite Objection (ADO) Form. Filling this form protects a nurse’s license and transfers the responsibility to management.
- When a nurse refuses an assignment, they must be prepared for possible disciplinary actions, such as sanctions by the facility. By reviewing specific policies or contractual grievance procedures, a nurse can prepare options to contest the disciplinary action.
- If a nurse feels unprepared for the patient assignments they receive, they should request additional training if the nurse is an employee of the facility, so that the nurse can practice safely.
- Furthermore, regardless of whether a nurse plans to accept or reject an assignment, identified risks should be communicated through the appropriate institutional channels so adequate precautions can be taken.
The Bottom Line
In the context of an ongoing nurse staffing shortage, with high nurse burnout and turnover rates, nurse managers are often forced to juggle more patient assignments than they have staff to cover. They may assign nurses more patients than they can reasonably care for or patients with higher acuity than the nurses are prepared to handle. Ultimately, it is often up to nurses themselves to refuse inadequate assignments. Therefore, nurses must understand both their rights and responsibilities to help them make informed and safe decisions.
Make sure you stay informed as a nurse by reading more articles on Nursa’s blog covering all things nursing.
Sources:
