How To Refuse an Unsafe Patient Assignment as a Nurse

You walk into work, ready to spend the next 12 hours taking care of your patients and providing them with the best nursing care possible.  You look at your patient assignment and see you have one extra patient than usual, as well as only one CNA for your entire nursing unit.  Your charge nurse has a full patient assignment too, making her less available to offer help and support.  You hear machines beeping, bed alarms sounding, and patients yelling, and you stop and think to yourself “is this safe?”

Does this scenario sound familiar to you as a nurse?  

Being given an inappropriate assignment can be very overwhelming and stressful.  Your patients need you to show up and take care of them, and your nursing team needs you, and you want to help.

But where do you draw the line, and say “NO”, to a patient assignment?  What is an unsafe assignment, and can a nurse refuse an assignment?

What is a Safe Nursing Assignment?

An appropriate nursing assignment is any patient assignment where the nurse can safely and effectively provide all the necessary care for their patients, and have the necessary tools, training, medications, knowledge, resources, and equipment to perform their nursing duties for those patients.

The definition of a safe and appropriate nursing assignment is variable, has to do with much more than patient ratios alone, and will vary by state and facility.

Per the American Nurses Association (ANA), nurses have not only a right but also an obligation to assess and determine if they can safely and appropriately provide care on any given patient assignment.  They provide this list of questions that every nurse should be asking themselves before accepting any patient assignment.

When Should you Refuse an Assignment?

What does an inappropriate or unsafe patient assignment look like, and what are some reasons you might stop and consider refusing the assignment or asking your leader for changes to the assignment?

• Too Many Patients

There are only 2 states in the US that have laws mandating nurse-to-patient ratios, California and Massachusetts.  Some states, but not all of them, have mandatory reporting requirements for staffing.  Others have staffing committees with some nurse members to assist in making staffing decisions, but still no mandated ratios.

You will learn as you gain more nursing experience how many patients are too much for you as one nurse.  This will depend on your unit’s acuity level, patient population, and the individual staffing policies at your facility.

• Inappropriate distribution of patient acuity

5 “walkie-talkie” patients are vastly different from 5 patients on high-level oxygen.  The ability to understand what constitutes high acuity will also come with more nursing experience.  You may not know or understand, what the acuity level is of a COVID patient on continuous BIPAP, until you have cared for that type of patient.

Also take into consideration how many discharges or empty rooms you have, if you have any patients on continuous drips or pain pumps, your patient’s mobility level, and if your patient is scheduled for any procedure that will warrant intense post-procedure monitoring when they return.

A particular patient’s acuity can change with each shift, which means nursing management must be in close communication with the team and get accurate patient acuity updates before making each assignment.

• Inadequate knowledge or training

Are you being asked to care for a post-surgical patient on gynecology, when you normally take care of patients recovering from a stroke?  Are you being asked to care for pediatric patients when you have only ever cared for adults?  Maybe you are being asked to do something you think may be out of your scope of practice as a nurse.  This would be a reason to voice concern and ultimately refuse a particular assignment.

• No Supplies or Help

Do you have all of the equipment you need to do your job?  Do you know where your code cart is, and can you safely and effectively help your patient in an emergency?  Are your medications stocked, machines in good working order, and can you get extra help if you need it?

If you don’t have all of the above, keeping your patients safe could be a challenge, and this alone would deem your assignment unsafe.

If you find yourself in any of the above situations, or others in which you feel your license and patient safety are in jeopardy, can you refuse to take the assignment?

The ANA upholds that “registered nurses – based on their professional and ethical responsibilities – have the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.”  Read the full ANA position statement here.

It is not only your right as a nurse, but also your duty, to raise concern and ultimately refuse an unsafe, inappropriate assignment.  Here are some tips on how you can bring up these concerns and refuse your assignment as a nurse.

How to Refuse a Patient Assignment

• Know your rights, and be prepared to state them

It is solely your responsibility as a nurse to know your rights, as well as your responsibilities, in the state in which you practice as a nurse. Each state has its own Nurse Practice Act, which defines by law what you can, and cannot do, as a nurse.  It also contains your nursing scope of practice.   Visit the NCSBN website to quickly navigate to each state's Nurse Practice Act.

The NCSBN also provides a great decision-making tool to help explain the proper process of determining whether or not a certain activity is within the nurse’s scope.

Be prepared to refer to the Nursing Code of Ethics, and verbalize any statement of your nursing rights when communicating about your patient assignment with your leader.  By knowing your rights as a nurse, and being ready to state them, you can clearly and effectively communicate with your manager why you want to refuse an assignment when placed in an unsafe situation.

• Don’t Create a Nurse-Patient Relationship

Before you decide to accept any patient assignment, you need to avoid any activity that could be considered creating a nurse-patient relationship.  There is a fine line between refusing a patient assignment, and nurse abandonment, which also varies state by state.  

For example in Arizona, the board of nursing defines patient abandonment as a nurse severing or ending the nurse-patient relationship, after creating the relationship, without giving handoff or reporting to another capable nurse to take over that patient's care.

Here are some things that may be considered for establishing a nurse-patient relationship:

• Viewing the patient’s electronic medical record

• Saying hi to the patient, or going into their room at all

• Taking orders from a doctor regarding that patient

• Administering any type of patient care such as assisting them to the bathroom, taking them a food tray, or administering them any medications.

It is critical to read up on your state’s Nurse Practice Act and get a very clear definition of what patient abandonment is in your state.  Your state’s board of nursing will have the resources needed to give you directions on the correct process of refusing an assignment in your state of licensure.

• Do Your Research and Be Prepared

Nurses are always thinking ahead, preparing for what can go wrong with our patients, and ready to act in case of any emergency.  We know exactly what equipment we will need for our patients, and would never allow our patients to be without adequate IV access.

Apply this same principle to the safety of your nursing license, your patients, and your team, by doing your research on the process of refusing a patient assignment correctly.  Study your facilities policies, your nursing rights, and your state’s Nurse Practice Act.

It is your responsibility to know these things, and you don’t want to be scrambling at the very last second trying to do this research when you are being pressured at the moment to take a dangerous assignment.

• Keep Everything in Writing

If you do end up voicing any sort of staffing or patient safety concerns, or ultimately refusing an assignment, always make sure you are communicating it to all of the appropriate leaders and follow your chain of command.

Send an email to all members of your leadership team to summarize the situation, and provide thorough documentation of why you are refusing an assignment, with adequate details.

Keep any paper records for yourself, just in case.

• Help Find Solutions

Refusing a patient assignment will have an impact on all of the patients in the unit, the entire hospital, as well as the rest of the members of the healthcare team.  It is your right, and duty, to refuse an inappropriate assignment.  But try to be as professional and flexible as possible, keeping the ultimate goal of patient safety in mind.

Can you and your team brainstorm with your nursing leader on other ways to make everyone’s assignments safe and appropriate, such as:

• Calling in a resource RN to help with patient care tasks

• Re-arranging the patient assignment to re-distribute patient acuity better among all nurses

• Obtaining a 1:1 sitter for all confused patients, ensuring their safety and also freeing up your extra time for your other patients?

• Better assigning the patients to nurses based on their appropriate certifications, and expertise?

Ultimately you are a team, and you are there for your patients and each other.  The goal is patient safety, and if you don’t speak up and refuse to take an inappropriate assignment, your patient’s well-being and your nursing license are on the line.  

Be prepared to have these conversations, and be well-versed in your rights as a nurse.  By refusing inappropriate assignments, you are advocating for yourself, and your patients, and being a voice for positive change in healthcare.