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WSNA Guidelines for the Registered Nurse in Accepting or Rejecting an Assignment
Professional Practice Issues
The Nurse Practice Act of Washington (WAC 246-840-700) states
that “the nurse shall be responsible for the quality of nursing care
given to clients.” This language charges the individual nurse with
responsibility for the quality of care delivered once the nurse has
accepted an assignment. In the Uniform Disciplinary Act (18.130
RCW), conduct that may be deemed unprofessional for any health
care professional includes “incompetence, negligence or malpractice
which results in injury to a patient or which creates an unreason-
able risk that a patient may be harmed” RCW 18.130.180(4), and
“failure to adequately supervise auxiliary staff to the extent that
the consumers’ health or safety is at risk.” (RCW 18.130.180(14)).
The intent of these laws is to establish expectations toward a mini-
mum standard of care to be delivered once a licensee has accepted
responsibility for a particular patient assignment.
These minimum expectations are further elucidated in the Standard
of Nursing Conduct or Practice (WAC 246-846-700). Language in
the introductory portion of the rule states that the nurse’s respon-
sibility for the quality of nursing care given to clients “cannot be
avoided by accepting the orders or directions of another person.”
The rule goes on to outline expectations about the minimum be-
haviors necessary for safe nursing practice.
Subsequent language in the next rule (WAC 246-846-710) is even
more instructive, as it spells out exactly what constitutes a violation
of standards of nursing conduct or practice. Included in this rule are:
improper delegation of nursing care functions or responsibilities
(2)(a); “failing to supervise those to whom nursing activities have
been delegated” (2)(b); and “performing or attempting to perform
nursing techniques and / or procedures for which the nurse lacks
the appropriate knowledge, experience, and education and / or
failing to obtain instruction, supervision and / or consultation
for client safety” (3)(a). Section (4)(b) of this same WAC deems
it a violation to practice “nursing while impaired by any mental,
physical and / or emotional condition to the extent that the person
may be unable to practice with reasonable skill and safety.”
The above-cited rules and other portions of the Nurse Practice Act
indicate that the expectation is placed upon nursing staff to deliver
no less than minimum-standard nursing care once an assignment
has been accepted; to be prepared mentally, physically and edu-
cationally to deliver safe care; to delegate care appropriately; and
to adequately supervise those to whom care has been delegated.
Failure to practice within these constraints may result in action
being taken against an individual nurse’s license by the Washing-
ton State Nursing Care Quality Assurance Commission (NCQAC).
Another pertinent section of the rule is WAC 246-840-710(4)(c),
which defines a violation of the standards as “willfully abandon-
ing clients by leaving a nursing assignment without transfer-
ring responsibilities to appropriate personnel or care giver when
continued nursing care is required by the condition of the client.”
Nurses occasionally report that an immediate supervisor will cite
this rule to pressure them into accepting an assignment the nurse
feels is unreasonable or unsafe. However, NCQAC’s policy states
that abandonment occurs only when the nurse willfully leaves an
assignment he or she has accepted without transferring responsi-
bility to appropriate personnel (see Appendix V).
Liability for Nurses
Beyond considerations of action against one’s license, a nurse must
also weigh the risks of harm which may befall patients in his /
her care if the nurse accepts an unreasonable assignment. Recent
court decisions have held nurses to strict professional standards of
knowledge and performance. Thus, if the “average prudent nurse”
would not have accepted a particular assignment, the nurse who
does decide to accept it will be judged by that professional standard.
For example, if the nurse chooses to provide care to patients in an
area with which she/he is not familiar, and the nurse violates the
standard of care expected of a nurse in that area, then the nurse
and the employer may be held liable for the harm that results.
Employment & Contract Issues
Nurses who refuse to obey an employer who assigns them to a
particular work area risk disciplinary action from their employer.
In situations where a nurse judges that he/she is unable to accept
an assignment without serious risk to patient safety, the nurse has
the right — and the obligation — to inform the employer that he/
she does not feel comfortable and able to provide safe care. The
Washington State Nurses Association has developed a form for
informing employers about unsafe assignments. This form is the
“Assignment Despite Objection” (ADO) form (see Appendix III).
Filling out and delivering a copy of this form to the immediate
supervisor does not automatically guarantee protection from any
action taken against the nurse’s license nor will it always protect
the nurse from a malpractice suit in the event a patient is injured
as a result of the care the nurse is able or unable to deliver. It can,
however, specifically document a situation and can be a very effec-
tive tool for the Practice Committee or Conference Committee to
bring an issue to management’s attention. Documentation on the
LEGAL & PROFESSIONAL ISSUES
There are considerations in law, regulation and precedent that nurses should be aware of when
deciding upon a course of action regarding a patient care assignment. These considerations can
be divided into professional practice issues, and employment and contract issues.
LEGAL & PROFESSIONAL ISSUES