Should a Nurse Refuse a Patient Assignment?

In today’s healthcare climate, patient acuity has increased and patient care assignments have become more labor intensive for clinical nurses. When is it acceptable for an RN to refuse a patient assignment?

With the national shortage of RN’s, facilities are increasing the nurse-patient ratios, resulting in heavier workloads and busy patient assignments for nurses. In critical care units today, an average assignment, which previously consisted of one or two patients per nurse, now includes three patients in many instances. On the telemetry and med-surg units, each RN may typically be assigned six, seven or eight patients.  Frustration and the sense that the work is never finished is a very common feeling of nurses in these situations.

Patient safety is at the core of any reason for a nurse to refuse a patient assignment. Individual state nurse practice acts describe circumstances in which a nurse has the right to refuse a patient assignment. The Texas Board of Nursing, which clearly “permits a nurse to refuse an assignment when the nurse believes in good faith that the requested conduct or assignment could constitute grounds for reporting the nurse to the board.” The Texas Nurse Practice Act further states that “all nurses have a duty under rule 217.11(1)(B) to maintain a safe environment for patients/clients and others for whom the nurse is responsible.”

Reasons to refuse a patient assignment

• Lack of competency and specific skills needed for the assignment.
• Nursing actions outside the scope of the state’s Nurse Practice Act. If the assignment involves nursing duties that are not within the scope of the state’s nurse practice act, the nurse actually has a legal duty to refuse the assignment, or risks discipline by the state board of nursing.
• Health of the nurse or her fetus is jeopardized.
• Lack of adequate orientation to the unit, especially with regard to emergency equipment, and jeopardizing patient safety.

Options when refusing an assignment

If the nurse assesses and believes that the assignment jeopardizes patient safety, communication of this assessment must follow the chain of command, and the nurse must immediately notify the nursing supervisor. It’s also suggested the nurse document this in writing also, such as in-hospital e-mail, so evidence exists to document the situation, which possibly may be significant at a later time.

The other option for the nurse to consider is the issue of patient abandonment. “Abandonment occurs when the nurse refuses to care for the patient and no one else is available to do so; it involves negligence.”  Patient abandonment requires “a nurse-patient relationship and a duty to provide care to the patient or patients.”

Once a nurse has received report on a patient and accepted a patient assignment, alternative arrangements to care for the patient must be made prior to the nurse refusing to care for the patient. If a nurse leaves in this situation, the case for patient abandonment is likely to go against the nurse. Transfer of patient care must occur before a nurse refuses or relinquishes care of the patient.

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Have you ever felt the need to refuse a patient assignment? How was it handled?

Would love to hear of your experiences, so please leave a comment.

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