Whose decision is it anyway?

By Carrie Mortrud, RN

MNA Policy Project Specialist

Imagine this scenario.

You arrive at work at 3 p.m. and receive your 4-patient assignment. You begin reading about your patients prior to receiving report from the nurses on the day shift who cared for them before you. From the patient Kardex’s and flow sheets (I just dated myself) it seems as though this 4-patient assignment might be too much, unsafe, unrealistic, and impossible to progress the plan of care for the patients. Still, you reserve judgement until you hear from the nurses who cared for them during the day.

Patient 1 is heavy. He is slightly confused and post op day 1 from open heart surgery, but he had family with him during the day so he might be fine. After patient 2 is reported to you, you see the family for patient 1 leave, and they mention to you they are leaving and won’t be back until tomorrow morning. You quickly ask the day shift nurse for patient 1 to put in a request for a 1-to-1 sitter if she thinks he won’t be able to follow instructions and call for help when getting up to the bathroom or up to eat dinner. You finish report after interrupting it to try to figure out safety precautions for patient 1.

Patient 2 has had an increase in pain within the last hour and is breathing a bit more rapidly and even a bit shallow. You place a call to the primary physician. As you begin the report on patient 3, it becomes clear you cannot take a fourth patient and keep patient 1 safe, determine the clinical situation with patient 2, and care for and educate patient 3 on their recent diagnosis of heart failure. You finish report on patient 3. Then you have to find the day shift nurse for patient 4 and explain why you believe the assignment is unsafe as you decline to accept report on patient 4.

You and the day shift nurse go to the evening and day charge nurses who are in the middle of report and express your concern and ask for an adjustment to the assignment. The evening charge nurse seems receptive and even gets up to make a call, likely to the evening supervisor or the staffing office. However, the day charge nurse (who made the assignment) says the assignment is fine and that you, as a 2-year nurse on the unit, should be able to handle an assignment like this one.

So, whose decision is it? Who gets to determine what is safe or unsafe? Who decides whether or not you are competent to deliver care? How does a new nurse to the unit or new to nursing finish up orientation? Is it when the manager says, “you’ve completed the allotted time for orientation, now you are now deemed safe and competent?” NO. There is a meeting to discuss your progress and whether or not you need an extension or if you have successfully completed enough to be done with orientation.

According to the MN Nurse Practice Act, you and only you are responsible for the care you deliver. MN Statute 148.171 Subd. 15 (17), the registered nurse is accountable for the quality of care delivered, recognizing the limits of knowledge and experience; addressing situations beyond the nurse’s competency; and performing to the level of education, knowledge, and skill ordinarily expected of an individual who has completed an approved professional nursing education program as described in section 148.211 subd. 1.

No one, not another nurse or a non-nurse provider can determine if your patient assignment is safe except you. This is particularly important considering 148.261 Grounds for disciplinary action, Subd.1 (6). The final sentence in this paragraph states actual injury to a patient need not be established under this clause. This means you could be disciplined by the Minnesota Board of Nursing even if there isn’t a negative patient outcome. You and only you can determine if your assignment is safe and, you and only you will be defending your decision if you decided to accept an assignment that was unsafe. Protect yourself, your license and your patients. This is your profession, and it’s your patient’s care/life.