Four Options As To Taking Or Refusing The Assignment Desk

Refusing a patients assignment When should you say no to receiving a patient?


Refusing a patient assignment is almost unheard of.

It’s because the decision to refuse a patient assignment is a wrenching one. It poses a difficult dilemma for the nurse who is concerned for patient safety and also concerned about possible employment consequences.

Reasons for refusing a patient assignment

Refusing a patient assignment should be done for one reason only-patient safety.

It takes insight and education to know when it is appropriate to refuse a patient assignment and it takes courage to speak up when patient safety is compromised.

Here are some reasons for refusing a patient assignment:

Reasons for refusing a patient assignment

  • too many patients
  • acuity too high
  • being too fatigued (too many hours without a break)
  • lack of qualifications or training
  • receiving a patient without communication or report (they show up in a bed)

Prevention: monitor the situation before it becomes overwhelming

Much like preventing a code, an unsafe patient situation can often be prevented before it reaches a crisis. The key is to know yourself so you recognize when you’re approaching your tipping point. Every nurse has a different tipping point, and your tipping point readjusts as you gain experience.

But practicing beyond your tipping point- when you’re in chaos, disorganized, and have lost control- is dangerous.

Picture yourself working on an assembly line, making widgets. It’s your first day. The assembly line belt runs fast but you keep up.

Then they crank the speed up higher and you miss a couple of widgets. You still feel mostly in control, but you’re becoming concerned.

They set it faster, and you blame yourself for not keeping up. Quality goes out the window.

Then it goes faster still, and now widgets are piling up and spilling off the belt, and it still keeps running! You have lost control.

When did the tipping point occur in this scenario? When did you lose control?

Request immediate assistance and activate the chain of command if necessary for patient safety.

When you are busy, you know that you’re supposed to ask the charge nurse for help, but what if he’s busy helping someone else, or he/she has patients as well?

You also know you’re supposed to rely on your coworkers, but everyone’s slammed. You look down the hall and no one makes eye contact. You look up the hall and there is no one to be seen. Every one is in their rooms.

You know you’re supposed to take a lunch break and clock out within six hours of beginning your shift, but lunch is absolutely the lowest priority on your list right now.

The speed on the assembly line belt gets cranked up another notch. Now the widgets are being self-propelled into the air due to the huge pile up. Watch out! You’re about to get hit!


This situation can actually be traumatic, especially for a new grad. Emotions take over, you feel helpless. Despair. You fight back the tears that threaten to flood.

Refusing a patient assignment is almost unheard of. How do you know when you should say No?

You’re afraid of making a mistake. You have a feeling you’re missing things, but you don’t know what.

There are at least twenty (thirty? one hundred?) things to do but you’re paralyzed, and you can’t pick what thing to do next. Call for the blood? Restart the IV? Pass meds? Call in your critical lab? What if you pick the wrong thing to do first?

Your phone rings and the monitor tech says your patient who you’re in the process of discharging just had a sustained burst of           V tach. Your CNA approaches to say Mrs. B has asked for her pain med twice now, Mr. L’s B/P is 192/102, and he’s complaining of his IV site hurting. It’s just too much.

And now you see your charge nurse coming down the hall towards you, no doubt to give you another patient. You want to run.

You’re fatigued, hungry, thirsty, and completely and utterly overwhelmed. Is this what sinking in quicksand feels like?

What to do

Keep in mind: Providing adequate staffing is the responsibility of the facility, the employer; not the individual staff nurse.

Refusing a patient assignment should never be done in an outburst of emotion. Be professional.

The suggestions below work better for you if you have established rapport and mutual respect with the Charge Nurse or House Supervisor, but patient safety is not dependent on these relationships.

  • Never cry wolf. Refuse a patient assignment only when patient safety is endangered, and when you’ve exhausted all other possibilities.
  • Never use the word “No” Instead say “Yes” (but not now).
  • Try to offer a solution. Your charge nurse is under pressure from the House Supervisor, who is responsible for patient throughput to the CNO, who answers to the CEO, who only sees empty beds on a screen on his desk, and wants those beds filled without delay. Trickle down pressure.
  • Keep in mind that solutions need to serve the best interests of all people involved in given situation. You are one of many stakeholders here.

Let’s look at how best to negotiate, set boundaries, and decline or delay a patient assignment until patient safety can be assured.


CN: “I need you to take a patient in 7204 from ED.”

You: “OK. I’m absolutely swamped right now.  Lab is tubing my blood up now. Can you start the transfusion in 7207 for me? That would free me up enough to do the admit.”

Set Boundaries

CN: “I need you to take a patient in 7204 from ED.”

You: “Sure, I’d be glad to, just as soon as I’ve grabbed some lunch.”

CN: “They need to come up right away, they’re holding (fill in a double digit number) patients in the hall and in overflow”

You: “It’s 1510, and I haven’t had a break at all this shift. Are you saying for me not to take a break?” (said calmly, nicely, and inquisitively)

Decline patient assignment

CN: “I need you to take a patient in 7204 from ED.”

You: “I can’t safely monitor an additional patient right now. Here’s what’s going on (explain). I’ll re evaluate as soon as I catch up.”

Ask the charge nurse for more help

It is the charge nurse’s responsibility to make safe patient care assignments, matching the needs of the patient with the competency of the nurse. Let your charge nurse know what’s going on with your team so he/she can help you.

You: “My patients are all such high acuity that I can’t safely care for them. Two of them are pretty much 1:1. I need another nurse to help me. What resources do we have right now? I’ll keep checking back with you until we can find some help.”

You: “I’ve never cared for a post-op patient with a bladder irrigation before. I’m not sure how to calculate true urine output, or manage bleeding. I’ll need some help to get started and make sure I’m doing it right.”

You: “I have never seen or operated a blood warmer before. Is there someone who can orient me to the device?”

You: “I’m letting you know this situation is unsafe, and  I need assistance. When can I expect some help?”

You: “I don’t have the training or experience for this kind of patient. I need to be assigned to patients I can safely handle right now.” (ex. floating to another unit where you haven’t been oriented)

You may be concerned about patient abandonment if you refuse a patient assignment. Abandoning a patient means that you first have accepted responsibility for that patient.


When does acceptance of an assignment or delegation occur?

Acceptance of a patient assignment occurs when a nurse has heard the patient report/status directly and agrees to the assignment. This includes receiving complete patient information and having the opportunity to ask relevant clarifying questions. A nurse can not be cited for abandonment unless they have accepted an assignment.

Likewise, a request to take an additional patient in the middle of the shift is an additional assignment which also requires acceptance by the nurse.

If, mid-shift, a nurse finds the assignment is beyond what she/he can safely complete, request immediate assistance. If assistance is not readily available, follow the chain of command and call the next supervisory person, repeatedly if necessary.

Obtain assistance from your colleagues.

Do not suffer through hoping to get through the shift without incident

Bear in mind that once an assignment is accepted, the nurse is responsible for its completion unless responsibility can be transferred to another qualified person.

Why is it OK to allow nurses to get overwhelmed?

To close, and while we’re on the topic, are nurses so accustomed to being overwhelmed on the job that this has just become a part of the job? Baptism by fire? Is this nursing’s dirty little secret? If so, why?

Nurses themselves are often complicit in that they:

  • fail to delegate
  • blame themselves when it is not them, it is the situation! (misplaced blame)
  • blame the previous shift when everything doesn’t get done (everyone’s angry!)
  • don’t speak up (not assertive)
  • don’t ask for help (lone hero mentality)

Working hard is one thing, but being completely and utterly overwhelmed on the job when you’re licensed by your state for said job and responsible for human beings is another.

Routinely skipping lunch, being constantly interrupted during lunch, and clocking out at the end of your shift to finish documenting is also not OK.

By contrast, here is a heartwarming story I read recently:

I only once ever refused to take another patient when I had only 4 to begin with. The charge nurse evidently reported me to the super who reported me to the CNO. The CNO came to the floor in scrubs and grabbed me and said “If you’re refusing a patient I know you need help, I’m here”. is that not too awesome?

With that I ask you, have you been overwhelmed to the point of refusing a patient assignment? Leave me a comment, I’d love to hear. Be sure to read Nurse-Patient Ratios: a Biased View.

Nursing’s Dirty Little Secret

Until next time,

Nurse Beth

Author “Your Last Nursing Class: How to Land Your First Nursing Job..and your next!” 

Related posts:

Student to Staff Nurse Transition

10 Rookie Nurse Mistakes to Avoid

First Day off of Orientation


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I think that PPs may be confusing Safe Harbor protections with governmental protections for Whistle Blowers. Safe Harbor is strictly limited to nursing practice issues & must be invoked at the onset of an assignment. The 'short form' must be followed with submission of the 'long form'. All SH incidents must be reviewed by the organization's Peer Review Committee. If Peer Review is not being administered properly, the Nurse Leader (DON, CNE, CNO, etc) is in violation of the Nurse Practice act... specifically, "unprofessional conduct" and her/his license could be in jeopardy. So, if any Tx nurse believes that these mandatory functions (Peer Review & Safe Harbor) are not being managed according to the law - this needs to be reported to the BON. This would take courage, because the 'reporter' would not be covered by any Whistleblower protections - which are specifically connected to compliance with Federal/State regulations, not BON.

Texas mandated Peer Review because we are the ONLY state with a legally defined Nurse-Patient duty (since 1984). As a result of that legislation, the BON's mandate for monitoring individual practice increased dramatically -- but of course, no additional resources were forthcoming to manage all the extra work. So, Tx created a process whereby the Peer Review process would begin at the local/employer level & only 'serious' issues would be taken on to the BON level. It works very well if an organization manages it correctly. I believe that Kansas also has mandated Peer Review now... so that makes 2 states.

I also want to point out that Safe Harbor protection is not just for bedside nurses. It can be applied whenever a nurse is asked to do something that s/he believes is contrary to out NPA. For instance, if a nurse educator is asked to train non-nurses to perform a nursing-only task, he could declare Safe Harbor so that the issue could be formally reviewed. All of us need to be very familiar with our NPAs - especially as they relate to our everyday work.

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