Legally speaking…When can you say no?

By Penny S. Brooke, APRN, MS, JD

Nursing2009, July 20091.8 ANCC contact hours

Online: www.nursingcenter.com

© 2009 by Lippincott Williams & Wilkins. All world rights reserved.

Reasons for saying no

Manage your time efficiently

Keep patients safe

Protect yourself from burnout and legal repercussions

Overtime can lead to

High stress environment

More errors

Burnout

Saying no to overtime

Depends on state law and facility policy

A growing number of states are enacting laws prohibiting mandatory overtime

Contact your state board

More on state laws regarding overtime

Laws typically include provisions for protection from disciplinary action, retaliation, or discrimination for refusing mandatory overtime

Under these laws, mandatory overtime is permissible in an emergency when you’ve signed a contract to accept or volunteer for it

Facility policy and procedure regarding mandatory overtime

Should reflect requirements of state law

If overtime is permitted by state law and facility policy, you’re agreeing to it when you accept employment

Discuss patient safety with your nurse manager and document attempts to communicate your concerns

Facility policy and procedure regarding mandatory overtime

A pattern of inadequate staffing should be reported to risk assessment team; could lead to injuries

If facility consistently asks that staff work overtime, give written communication to managers about the need for more staff support

Saying no to a heavy caseload

If you refuse a work assignment after arriving for shift report, you may be charged with abandonment if you walk away without placing care of your patients with a qualified staff member

When interviewing for a nursing position, always ask for written job expectations

Saying no to an assignment outside your scope of practice

Always refuse assignments outside your legal scope of practice as defined by your state’s nurse practice act

If you accept responsibilities outside your scope of practice, you may be charged with practicing medicine/pharmacy without a license

Examples of practicing outside nursing scope of practice

Selecting medication for a patient not ordered by a HCP with prescriptive authority

Dispensing a drug permitted by physicians or pharmacists only

Other team members ask you to do something outside your scope of practice

Saying no to an assignment outside your skill level

Harmed patients can sue nurses for unsafe care within their scope of practice but that the nurse is not trained or educated in (e.g., a nurse being assigned to another unit; medical-surgical to ICU)

Always make manager aware of your skill level and refuse tasks beyond this level

Saying no to an assignment outside your skill level

Never attempt to perform treatments or use equipment without the knowledge required

Ask yourself if this is what any “prudent” nurse would do

Judges and juries consider your actions in light of well-established standards of care

Saying no when you’re busy with a patient

Consider whether you’ll be neglecting assigned duties while taking on additional responsibility

Instead of leaving your patient, find patient’s assigned nurse

In an emergency, evaluate the needs of your patient to assist another

Saying no to providing your own care strategies

If you’re knowledgeable about other care strategies, resist sharing with the patient unless you have HCP consent (in writing)

Speak with HCP if you believe the alternative to be beneficial and complies with protocols

If you proceed without consent, you may be charged with interfering with physician-patient relationship

The case of Nurse Tuma

In 1979, a nurse practicing in Idaho, Jolene Tuma, RN, MSN, was asked by her patient to provide information on an alternative therapy

She didn’t consult with patient’s HCP before giving the patient advice

The case of Nurse Tuma

Even though patient didn’t stop the medical regimen ordered by the HCP, Ms. Tuma was charged with interfering with the physician-patient relationship

Idaho State Board of Nursing suspended Ms. Tuma’s license to practice nursing for 6 months

The case of Nurse Tuma

If Ms. Tuma had initially approached patient’s HCP and discussed patient’s desire to learn more about an alternative therapy, the HCP may have given her permission to provide information

The HCP may also have learned of an alternative therapy that could benefit his patient if Ms. Tuma had taken this opportunity to inform him of alternative therapies available

Saying no to inappropriate delegation As an RN, you may delegate care to LPNs or

UAPs, but you’re responsible for the care

Know your colleagues scope of practice, skill level, and limitations to delegate safely

Document the supervision you provide

You can be held legally liable for inappropriate delegation if colleague harms the patient doing a task you delegated

How to say no like a professional Be assertive; give reasonable explanations

Be respectful; offer helpful suggestions

Have a clear sense of your own priorities

Weigh the personal/professional risks of accepting/refusing a request

Determine how to set limits without jeopardizing your career

Six tips for saying no assertively

1. Listen politely to the request being made; avoid interrupting and objecting right away

2. Restate the request if you need clarification

3. Determine if you need time to verify if you can accept the assignment

4. If further deliberation results in having to say no, respond quickly to minimize delays for the nurse manager, who has to find someone else

Six tips for saying no assertively

5. Offer suggestions or alternative solutions when you say no to a request if you have ideas that may be helpful

6. If your no response isn’t being accepted, repeat it politely and assertively until it’s heard and accepted; don’t become angry or defensive, and don’t feel guilty for protecting your own (and your patients’) needs