Nursing Critical Care:
Brooke, Penny S. MS, APRN, JD
Penny S. Brooke is director of outreach and professor at the University of Utah's College of Nursing in Salt Lake City. Adapted and updated from Brooke PS. Legally speaking ... when can you say no? Nursing. 2009;39(7):42–46. The author has disclosed that she has no financial relationships related to this article.
Accepting responsibilities that are beyond the scope of your nursing license or skill level can have serious consequences for you, your patients, and your nursing career. Because of understaffing and other pressures, you need to know when (and how) to say no so you can manage your time efficiently, keep patients safe, and protect yourself from burnout and legal repercussions.
* Saying no to overtime. Can you legally say no to mandatory overtime without career-threatening repercussions? That depends on state law and facility policy. A growing number of states are enacting laws to prohibit mandatory overtime; check with your state board of nursing or state attorney general to determine your state's status. If mandatory overtime is permitted under state law and facility policy, explain to the nurse manager why you need to say no to working an additional shift. Document your concern with a Protest of Assignment form, if your facility has one. If inadequate nurse staffing is a pattern, submit an event report to risk management.
* Saying no to a heavy caseload. Refusing to accept an assignment after arriving for shift report puts you at risk for being charged with abandonment if you walk away without placing your patients safely into the care of another qualified staff member. If you don't have a written agreement with your employer about staffing expectations, you may have to accept the caseload. Next time you're interviewing for a nursing position, ask for copies of the facility's policy on mandatory overtime and typical nurse-to-patient ratios. Keep copies as evidence of what you were promised when you were hired. If the employer won't give you written confirmation, you may not be able to say no to demands that go beyond what you were told you could expect.
* Saying no to an assignment outside your scope of practice. If you suspect that your employer's policies, procedures, or protocols require you to perform tasks outside your scope of practice, clarify your concern with your nurse manager. Numerous courts have upheld the principle that facilities can't require nurses to perform tasks that are beyond the scope of their licensed responsibilities. If your employer resists your challenge of the policies or procedures, contact your state board of nursing.
* Saying no to an assignment beyond your skill level. If you're being floated or transferred to another unit, let the assigning nurse know when you're not current on a specific skill needed and if you feel providing certain care would be unsafe. Supervisors who delegate care to someone they know can't safely provide it become vicariously liable for harm caused to the patient.
* Saying no when you're busy with a patient. Before you agree to help a colleague, consider whether you'd be neglecting your assigned nursing duties while taking on an additional responsibility. In an emergency, evaluate if your patient's care can safely be postponed for the time needed to help another healthcare team member.
* Saying no to inappropriate delegation. To delegate safely and appropriately, you must know the scope of practice, skill level, and limitations of the RN, LPN, or unlicensed assistive personnel (UAP). If you assign tasks to UAP that are beyond their skill level and a patient is harmed, you'd be liable for inappropriate delegation. Be sure to document the supervision your provide as proof that you met your duty to supervise delegated care.
If your "no" isn't being accepted, repeat it politely and assertively until it's heard and accepted. Don't become angry or defensive, and don't feel guilty for protecting your own (and your patients') needs.
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