January 5, 2018

Unsafe Nursing Assignments | Documentation Strategies


You've clocked in and just finished the morning huddle. You received your assignment and begin bedside report. While getting bedside report, you notice the assignment is unsafe based on either your training, patient presentation or scope of practice. You have two options here, you can stop the reporting process altogether and refuse the assignment (see endnote), or you can take the following steps in case things go sideways and you see yourself getting caught up in legal matters later on.

The first thing you need to do is notify management and do this immediately. I get it, the nurse giving report wants to leave, but the priority is notification and quickly. Don't allow time to pass. Don't let things to get comfortable, and then your voice concerns later in the shift. It loses it's urgency the longer you wait, and your stance seems unreasonable the longer you delay notification. And by notification, I mean verbal AND written. If your charge nurse for the shift is mid-report, simply say excuse me and explain your case. Explain the assignment is unsafe and explain the reasons why (be concise and use specifics, no generalizations). You must elaborate on your concerns as to why the assignment is unsafe, and you must remain calm and professional while doing so. Oddly enough, sometimes assignments are made last minute, and management is unaware of the inappropriate assignment selection. Notification alerts management to this problem and changes can be made. Let's say the verbal notification does nothing. Your next move is to document the notification. If you don't document it, the conversation never took place. You must skillfully and professionally state your concerns in the chart. I'm all about teamwork, but I refuse to allow something I have no control over to result in me losing my nursing license. I've been in this situation before and here is a template I've used in the past:

07:15 PM: Oncoming nurse notified nursing management (PM charge nurse) of patient assignment and safety concerns. Nursing management and oncoming nurse reviewed patient's current condition and needs. A decision by nursing management was made to keep the assignment as is, unchanged. The oncoming nurse will continue to monitor safety concerns. 

The goal is to document your concerns. You don't want to create a problem, but you also don't want your concerns to be ignored if future litigation occurs. Again, this is your nursing license. You worked very hard to get to where you are as a nursing professional. Don't dismiss your concerns and don't miss an opportunity to document them either. Documentation is the name of the game. Conversations can be forgotten, and people an overlook things. But a documentated encounter is a different beast. During this conversation, you could also mention your unit's scope of practice and your training, if applicable. There have been times (when I was a graduate nurse) that I was assigned a patient who was on a particular initiative (Code Cool, CRRT, or Nimbex) I hadn't been trained on it yet. I simply explained I didn't have the training to meet the patient's needs. I have nothing to prove and I don't want to kill someone because of ego. There is a difference between having a professional drive and rising to the occasion versus drowning and potentially causing someone permanent harm. Know your professional limitations and vocalized them when necessary.

If nursing management still isn't listening and you feel you can't take the assignment, you must escalate this situation to the nursing house supervisor. You've already told the charge nurse. He or she has heard your concerns and deemed them unimportant. Simply notify your charge nurse that you will be calling the nursing supervisor as you are passionate about safety matters. This happened to me once and I made sure I remained calm throughout the entire process. No one will take a hysterical person seriously. You must express your concerns in a professional manner while explaining them in great detail. Don't merely state, "because it's not safe." What does unsafe mean to you? Explain all the possible outcomes that could occur if the assignment remains the same. I'm really big on emphasizing patient outcomes, and I lay them out so all parties involved are aware of what a "no" could result in. It's easy to say "no" when you haven't heard terms such as falling, brain injury or bleeding risk. But once you hear these phrases, they paint a picture. Oh, don't forget to document this encounter as well. This will display your repeated attempts to advocate for your patient.

07:30 PM: Oncoming nurse escalated concerns to nursing house supervisor. Nursing house supervisor and oncoming nurse reviewed patient's current condition and needs (second review). A decision by the nursing house supervisor was made to keep the assignment as is, unchanged. The oncoming nurse will continue to monitor safety concerns. Escalation of concerns completed at this time. Oncoming nurse obtained bedside report as required by institutional standards.

And if all else fails and you are stuck, you will make it work. But you have clear, detailed documentation of your attempt to right a wrong. I've worked in private and government sectors of nursing, travel and permanent positions. Inappropriate nursing assignments happen in all settings and to AM and PM nursing staff. You have done your job, you have gone above and beyond for patient safety. If any legal ramifications occur due to management's decision or lack thereof, you are covered. Are you legally covered 100%? I can't answer that for sure. But this documentation method has helped me months later when I'm asked what happened, in what order, and why. These tips aren't meant to blame anyone or incite a riot. These tips are simply meant to document a series of events in the most professional way possible. But when someone is documenting, roles will need to be mentioned (for event sake), and results will need to be specified (for accountability sake). If someone feels uneasy about a decision being documented, perhaps it's the wrong one. But I'm not going to fall on the sword so other parties can keep working while I'm without a nursing license and career. Healthcare is a business. Businesses can cause individuals to cut corners and make decisions that don't favor the community. Don't get caught up or overwhelmed by the series of events. You have no control over how management will respond or react. You are simply advocating for your patient.

Note: Please check your state nurse practice act regarding this topic. When you take the report (redline and all, report completed) in some states you are "accepting" the assignment as is. You can't refuse later or it's "abandoning" your patient in some states.