What to Do About an Unsafe Nursing Assignment

If an assignment feels unsafe, speak up before you accept it, propose specific solutions, and take your concern up the chain of command if it is not resolved. Document your objection the way your facility requires, then give the best care you can and keep communicating. What protects you varies by state and facility, so learn your own rules before you need them.

What makes an assignment unsafe

An unsafe assignment is one where the workload, patient acuity or skill requirements exceed what you can safely handle with the resources available. It is not the same as a hard or busy shift. Common warning signs:

• Too many high-acuity patients for one nurse, or several patients who each need frequent interventions
• Patients who need skills or equipment you have not been trained on
• Being floated to a specialty unit without orientation (see Floated to Another Unit? How to Handle It)
• No support staff, no charge nurse free to help, or no one to cover breaks
• Missing equipment or supplies needed for safe care
• Being too fatigued to work safely, for example after mandatory overtime

Trust your clinical judgment. You know the difference between "heavy but doable" and "someone could get hurt."

Before you accept: assess and propose

Take a minute to look at the whole assignment before report. Ask yourself which patients worry you most and why. Then go to the charge nurse with specifics rather than "this is too much."

Ways to frame it:

• "Bed 12 is on a drip I'm not checked off on, and bed 14 needs frequent neuro checks. With the rest of this assignment, I can't safely do both. Can we move one of them?"
• "I can take this assignment if I don't get the next admission. Can we hold it or give it to someone else?"
• "Can the resource nurse help me through the first couple of hours?"

Possible fixes include redistributing patients, adding a nurse or tech, holding admissions, assigning a resource nurse or pairing you with someone. Charge nurses are often working with the same shortage you are, so a concrete proposal makes it easier for them to say yes.

Use the chain of command

If the charge nurse cannot fix it, go up the chain your facility uses. A common order is:

1. Charge nurse
2. House supervisor or nursing supervisor
3. Nurse manager or director, or the administrator on call after hours

Stay calm and factual at each step. State the safety concern, what you have already tried and what you need. Note who you spoke with and when.

Document your objection

Facilities handle this differently, so learn your policy in advance.

• Objection forms. Some facilities and many union contracts use a form, often called an assignment despite objection (ADO) form or something similar, that records that you accepted the assignment while raising a safety concern. If one exists, ask for it and complete it.
• Formal review processes. Some states and facilities have a process for nurses to request a review of an assignment they believe is unsafe. Your state board of nursing, professional association or union can tell you what applies to you.
• Incident or safety reports. If patient care was affected, or nearly affected, use your facility's reporting system.
• Your own notes. Keep a factual record of times, conversations and what you asked for.

Keep patient charting clinical. Staffing concerns usually belong in the objection form or safety report rather than the patient's medical record, but follow your facility's policy. Nursing Documentation Tips That Protect You has more on charting well.

Refusing an assignment versus abandonment

This is where many nurses feel least certain. Boards of nursing often draw a line between declining an assignment before you accept it and leaving patients after you have accepted report. Patient abandonment generally refers to leaving patients you have accepted responsibility for without a proper handoff, and it can carry licensing consequences. Declining an assignment you believe is unsafe, before you accept it, is often viewed differently by boards, though it may still have employment consequences.

The exact definitions and positions differ from state to state. Look up your state board of nursing's guidance or position statement on patient abandonment and on accepting or declining assignments, and read your facility's policy and any union contract. If you face a decision with real stakes, talk it through with your union representative, a professional association or an attorney who works with nurses.

If you take the assignment

Most of the time, nurses accept the assignment under protest and do their best. To keep patients as safe as possible:

• Prioritize hard. Start with airway, breathing, circulation and the patients most likely to deteriorate; How Nurses Prioritize Care: ABCs and Beyond explains the thinking.
• Delegate appropriately to techs and other staff within their scope.
• Communicate early. Tell the charge nurse as soon as you start falling behind or a patient changes.
• Escalate clinical changes to providers promptly, and call a rapid response when criteria are met.
• Give a thorough handoff so the next nurse knows what is still outstanding.

After the shift

Follow up with your manager when things are calmer. Bring your notes and the specific safety concerns, and ask what will change. One unsafe night is a problem; a pattern is a staffing issue management needs to address. If you have a union contract, it may include staffing language or a process for raising concerns; Union Nurse Contracts: Pay Steps and Raises explains how contracts generally work.

Chronic short staffing is one of the causes of stress and burnout in nursing. Talking it through with peers helps, and the Working Nurses group is a place to ask how others have handled it.

If nothing changes, it is reasonable to look elsewhere. Browse nursing jobs, and ask about staffing, support and float practices in every interview.

Next step

Before your next move, read what nurses say about staffing and safety at specific employers in NurseTide's workplace reviews.

General information for nurses, not medical, legal, tax or financial advice. Follow your facility's policies, your state board of nursing and the terms of your employer or contract.