Assignment Despite Objection

Phone

This field is for validation purposes and should be left unchanged.

Purpose

To document your advocacy for patient safety per your professional nursing judgement.

To notify your supervisors/managers that due to a lack of resources, you have been put in a situation that may place (a) patient(s) at risk. This form serves to document that you notified your supervisors/managers of the risk, that you intend to do whatever you can to safely carry out the assignment with the resources that your supervisors/managers provided and that you may not be able to meet all needs of the patient due to a lack of resources that your supervisors/managers are responsible for providing.

Remember

DO NOT INCLUDE ANY HIPAA SENSITIVE INFORMATION ON THIS FORM. All patient information must be handled in accordance with HIPAA regulations. Confidentiality and privacy must be maintained at all times to protect patient rights.
REPORT ANY INSTANCES OF RETALIATION TO YOUR CHAIR(S), LABOR RELATIONS SPECIALIST AND/OR STEWARD(S) PROMPTLY.
UNION MEMBERS HAVE WEINGARTEN RIGHTS: Union members have the right to ask for union representation to be present if the discussion could lead to disciplinary action for the union member.

You can find your Nurse Practice Act here: https://www.ncsbn.org/policy/npa.page.

Instructions

One or more nurses may complete this form. If there is more than one nurse advocating for improved patient safety and/or they witness your advocacy for improved patient safety, ask for their consent to enter their name below, located in the Required Documentation field following I/We.
As soon as a potentially unsafe situation is identified, you must verbally protest the assignment utilizing the facility's Chain of Command policy. Call up the Chain of Command until the situation is rectified, or the Chain of Command is exhausted.
If the situation is not rectified per your professional nursing judgement, document your advocacy for improved patient safety on this form AND document the facility supervision's response, or lack of response. If you do not get an immediate response, confirm with whoever you are speaking with when you can expect a response. Be sure to document the names, titles, credentials of all the people you spoke with AND the times you spoke with them on this form. It is encouraged to document direct quotes of the people you spoke with.
Ensure all required documentation is accurately completed, both on this form and within your facility’s reporting mechanisms.
An electronic copy of the completed form will be sent to you, the supervisor(s) you speak to and enter on your ADO form, your Chairs, your Nurse Practice and Education Specialist, and the appropriate Labor Relations Specialist. Members are encouraged to retain a copy for your records.

Minnesota Nurses Association Assignment Despite Objection

345 Randolph Avenue #200, St. Paul, MN 55102
651-414-2800 / 800-536-4662
Fax: 651-695-7000
Web: mnnurses.org

I/We(Required)

Nurse(s) employed at(Required)

Hereby protest my/our assignment as(Required)

On date(Required)

YYYY dash MM dash DD

and time(Required)

Hours

Minutes

AM/PM

As a patient advocate, this is confirmation that I notified you that, in my professional nursing judgement, the conditions of my/our assignment place my patient(s) at risk due to a lack of resources that the supervisors/managers are responsible for providing. As a result, the facility may be responsible for any adverse events on patient care. I will, under protest, attempt to carry out the assignment to the best of my ability.

This field is hidden when viewing the form

Facility Label

Unit/Department(Required)

Shift(Required)

Shift, Other

Description of Patient Safety Concern(Required)

Do not include any HIPAA sensitive information on this form. All patient information must be handled in accordance with HIPAA regulations. If you chose “Other”, please include facility and unit in your description.

What resources and/or modifications did you advocate for? How did you advocate for them?(Required)

Supervisor(s)(Required)

Name & Credentials

Work email address

Response to your request (quotes when able)

Notified on Date

and Time

Enter up to five supervisors you notified

I am protesting the aforementioned assignment on the grounds that(Required)

Select all that apply

Direct patient care duties did not allow time for charge nurse duties – clinical supervision/coordination of care

Patients on the unit require a higher level of care than can be provided

Inadequate resources I need such as supplies, equipment, or medications

Systems failure such as computers, EMR, or medication dispensing machine

I was given an assignment which posed a threat to the health and safety of my patients

I was given an assignment where I did not receive or complete Orientation to the unit/clinical area

I was given an assignment where I did not receive or complete Validation of current demonstrated competency

Staffing/skill mix is/was insufficient to Meet the individual patient care needs/requirements of my patients due to a failure to provide adequate staff based on patient acuity or nursing intensity

Staffing/skill mix is/was insufficient to Perform effective assessments of patients assigned to me

Staffing/skill mix is/was insufficient to Meet the teaching/discharge needs identified by my patient's condition

Staffing/skill mix is/was insufficient to Prevent overtime due to post-shift documentation requirements

Staffing/skill mix is/was insufficient to Provide uninterrupted breaks by a direct-care nurse to prevent fatigue, accidents, and/or errors