Application of the Guide for Decision-Making
Every nurse will be faced with making a decision to accept or reject a work assignment (see Algorithm 1). The nurse also may be faced with decisions about delegation of nursing functions to licensed or unlicensed assistive personnel (see Algorithm 2).
An issue central to such decisions is:
• The right of the patient to receive safe quality nursing care at an acceptable level.
Accepting/Rejecting an Assignment
Each nurse is directly accountable for the safety of nursing care he/she provides [MGL 112 § 80B]. Decision making utilized by the nurse when accepting/rejecting an assignment should follow a logical progression (see Algorithm 1).
Rejecting an Assignment
If the nurse is given a work assignment and then believes he/she may not have the knowledge, skills, or experience to perform the assignment, he/she must consult with the supervisor and state that he/she cannot accept the assignment. In doing so, because of the disciplinary consequences of refusal, the nurse is responsible for three additional steps.
Step 1: The nurse needs to verbally, and in writing, inform the agency’s manger/supervisor of the perceived discrepancies between the required competence and his/her own knowledge, skills, and abilities. The nurse should keep a personal copy of this documentation and the steps taken to remedy the situation. Documentation provides a record of the situation for future reference. Documentation done at the time of the incident is more accurate and complete than documentation done at a later date.
Step 2: The nurse should complete and file a “MNA Objection and Documentation of Unsafe Staffing/Unsatisfactory Patient Care Form” if available or otherwise document the situation. A nurse may conclude that it is necessary to refuse to accept a work assignment. It is important for the nurse to be aware of the consequences of his/her decision to accept or refuse the work assignment. You have the right to report this practice to a public body (outside agency). (See MGL, Chapter 149, Section 186 (c) (1), An Act to Protect Conscientious Health Care Employees (The Health Care Workers Whistleblowers Protection Law).
Step 3: The nurse needs to be prepared for disciplinary actions, which may follow as a result of the decision to reject an assignment. This action may include sanctions by the employer. The nurse should be aware of options to contest the disciplinary action. These options are found in employer policies or contractual grievance procedures. The nurse has the responsibility to request that the employer provide additional training/orientation for the nurse to practice safely.
Delegation to Licensed/Unlicensed Assistive Personnel.
Delegation of nursing activities to licensed or unlicensed assistive personnel (UAP) follows a pattern similar to that of evaluating the appropriateness of a work assignment [244 CMR: 3.05(2)]
Step 1: Assess patient first, then state clearly the tasks to be delegated. What aspects of care will be delegated? What specific tasks are to be done? What is the condition of the patient? Is the patient’s condition stable or unstable?
Step 2: Assess the competency of the licensed/unlicensed individual. Does the unlicensed person have the documented competencies needed to do the task? Can the task be performed without requiring nursing judgment? [CMR: 3.05:(2)(c)]
Step 3: Confirm or reject delegation. If competencies are documented, delegation may occur. If delegation is rejected, the nurse has the responsibility to personally perform the care or seek alternate ways to provide the care. Notify the supervisor of this decision.
(See Algorithm 2 for delegating an assignment to licensed or unlicensed personnel.)
It is within the scope of the individual licensed nurse’s professional judgment to make the final decision, in any given situation, as to what nursing activity can safely be delegated to a UAP.