refuse assignment nurse

How To Refuse an Unsafe Patient Assignment as a Nurse

What is a safe nursing assignment, when should you refuse an assignment, how to refuse a patient assignment.

You walk into work, ready to spend the next 12 hours taking care of your patients and providing them with the best nursing care possible. You look at your patient assignment and see you have one extra patient than usual, as well as only one CNA for your entire nursing unit. Your charge nurse has a full patient assignment too, making her less available to offer help and support. You hear machines beeping, bed alarms sounding, and patients yelling, and you stop and think to yourself “is this safe?”

Does this scenario sound familiar to you as a nurse?

Being given an inappropriate assignment can be very overwhelming and stressful. Your patients need you to show up and take care of them, and your nursing team needs you, and you want to help.

But where do you draw the line, and say “NO”, to a patient assignment? What is an unsafe assignment, and can a nurse refuse an assignment?

An appropriate nursing assignment is any patient assignment where the nurse can safely and effectively provide all the necessary care for their patients, and have the necessary tools, training, medications, knowledge, resources, and equipment to perform their nursing duties for those patients.

The definition of a safe and appropriate nursing assignment is variable, has to do with much more than patient ratios alone, and will vary by state and facility.

Per the American Nurses Association (ANA), nurses have not only a right but also an obligation to assess and determine if they can safely and appropriately provide care on any given patient assignment. They provide this list of questions that every nurse should be asking themselves before accepting any patient assignment.

What does an inappropriate or unsafe patient assignment look like, and what are some reasons you might stop and consider refusing the assignment or asking your leader for changes to the assignment?

Too Many Patients

There are only 2 states in the US that have laws mandating nurse-to-patient ratios , California and Massachusetts. Some states, but not all of them, have mandatory reporting requirements for staffing. Others have staffing committees with some nurse members to assist in making staffing decisions, but still no mandated ratios.

You will learn as you gain more nursing experience how many patients are too much for you as one nurse. This will depend on your unit’s acuity level, patient population, and the individual staffing policies at your facility.

Inappropriate distribution of patient acuity

5 “walkie-talkie” patients are vastly different from 5 patients on high-level oxygen. The ability to understand what constitutes high acuity will also come with more nursing experience. You may not know or understand, what the acuity level is of a COVID patient on continuous BIPAP, until you have cared for that type of patient.

Also take into consideration how many discharges or empty rooms you have, if you have any patients on continuous drips or pain pumps, your patient’s mobility level, and if your patient is scheduled for any procedure that will warrant intense post-procedure monitoring when they return.

A particular patient’s acuity can change with each shift, which means nursing management must be in close communication with the team and get accurate patient acuity updates before making each assignment.

Inadequate knowledge or training

Are you being asked to care for a post-surgical patient on gynecology, when you normally take care of patients recovering from a stroke? Are you being asked to care for pediatric patients when you have only ever cared for adults? Maybe you are being asked to do something you think may be out of your scope of practice as a nurse. This would be a reason to voice concern and ultimately refuse a particular assignment.

No Supplies or Help

Do you have all of the equipment you need to do your job? Do you know where your code cart is, and can you safely and effectively help your patient in an emergency? Are your medications stocked, machines in good working order, and can you get extra help if you need it?

If you don’t have all of the above, keeping your patients safe could be a challenge, and this alone would deem your assignment unsafe.

If you find yourself in any of the above situations, or others in which you feel your license and patient safety are in jeopardy, can you refuse to take the assignment ?

The ANA upholds that “ registered nurses – based on their professional and ethical responsibilities – have the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.” Read the full ANA position statement here.

It is not only your right as a nurse, but also your duty, to raise concern and ultimately refuse an unsafe, inappropriate assignment. Here are some tips on how you can bring up these concerns and refuse your assignment as a nurse.

Know your rights, and be prepared to state them

It is solely your responsibility as a nurse to know your rights, as well as your responsibilities, in the state in which you practice as a nurse. Each state has its own Nurse Practice Act, which defines by law what you can, and cannot do, as a nurse. It also contains your nursing scope of practice. Visit the NCSBN website to quickly navigate to each state's Nurse Practice Act .

The NCSBN also provides a great decision-making tool to help explain the proper process of determining whether or not a certain activity is within the nurse’s scope.

Be prepared to refer to the Nursing Code of Ethics , and verbalize any statement of your nursing rights when communicating about your patient assignment with your leader. By knowing your rights as a nurse, and being ready to state them, you can clearly and effectively communicate with your manager why you want to refuse an assignment when placed in an unsafe situation.

Don’t Create a Nurse-Patient Relationship

Before you decide to accept any patient assignment, you need to avoid any activity that could be considered creating a nurse-patient relationship. There is a fine line between refusing a patient assignment, and nurse abandonment, which also varies state by state.

For example in Arizona, the board of nursing defines patient abandonment as a nurse severing or ending the nurse-patient relationship, after creating the relationship, without giving handoff or reporting to another capable nurse to take over that patient's care.

Here are some things that may be considered for establishing a nurse-patient relationship:

Viewing the patient’s electronic medical record

Saying hi to the patient, or going into their room at all

Taking orders from a doctor regarding that patient

Administering any type of patient care such as assisting them to the bathroom, taking them a food tray, or administering them any medications.

It is critical to read up on your state’s Nurse Practice Act and get a very clear definition of what patient abandonment is in your state. Your state’s board of nursing will have the resources needed to give you directions on the correct process of refusing an assignment in your state of licensure.

Do Your Research and Be Prepared

Nurses are always thinking ahead, preparing for what can go wrong with our patients, and ready to act in case of any emergency. We know exactly what equipment we will need for our patients, and would never allow our patients to be without adequate IV access.

Apply this same principle to the safety of your nursing license, your patients, and your team, by doing your research on the process of refusing a patient assignment correctly. Study your facilities policies, your nursing rights, and your state’s Nurse Practice Act.

It is your responsibility to know these things, and you don’t want to be scrambling at the very last second trying to do this research when you are being pressured at the moment to take a dangerous assignment.

Keep Everything in Writing

If you do end up voicing any sort of staffing or patient safety concerns, or ultimately refusing an assignment, always make sure you are communicating it to all of the appropriate leaders and follow your chain of command.

Send an email to all members of your leadership team to summarize the situation, and provide thorough documentation of why you are refusing an assignment, with adequate details.

Keep any paper records for yourself, just in case.

Help Find Solutions

Refusing a patient assignment will have an impact on all of the patients in the unit, the entire hospital, as well as the rest of the members of the healthcare team. It is your right, and duty, to refuse an inappropriate assignment. But try to be as professional and flexible as possible, keeping the ultimate goal of patient safety in mind.

Can you and your team brainstorm with your nursing leader on other ways to make everyone’s assignments safe and appropriate, such as:

Calling in a resource RN to help with patient care tasks

Re-arranging the patient assignment to re-distribute patient acuity better among all nurses

Obtaining a 1:1 sitter for all confused patients, ensuring their safety and also freeing up your extra time for your other patients?

Better assigning the patients to nurses based on their appropriate certifications, and expertise?

Ultimately you are a team, and you are there for your patients and each other. The goal is patient safety, and if you don’t speak up and refuse to take an inappropriate assignment, your patient’s well-being and your nursing license are on the line.

Be prepared to have these conversations, and be well-versed in your rights as a nurse. By refusing inappropriate assignments, you are advocating for yourself, and your patients, and being a voice for positive change in healthcare.

Amy was surgical PCU/Telemetry unit as a new grad for over 10 years; the last year and a half of that time being Telemetry COVID nursing. She stepped away from the bedside and is currently working PRN as a concierge nurse. Amy has a passion for budgeting. Follow her on Instagram, Facebook, and on her website Real Desert Mama , where she talks about budgeting, saving money, and tips and motivation on how to live a great life and achieve your financial goals through budgeting

Plus, get exclusive access to discounts for nurses, stay informed on the latest nurse news, and learn how to take the next steps in your career.

By clicking “Join Now”, you agree to receive email newsletters and special offers from Nurse.org. You may unsubscribe at any time by using the unsubscribe link, found at the bottom of every email.

Understand Your Rights to Refuse a Patient Assignment

A dejected nurse sitting on a hospital bed

Can nurses refuse patient assignments? How? In which situations? Can’t they get fired?

Find the answers to all these questions and more in this article, which covers everything you need to know about refusing patient assignments as a nurse.

Patient Assignments: An Overview

Nurse-patient assignments refer to pairing nurses with patients based on the nurses’ skills and experience and the patients’ acuity, among other factors. Patient assignments are typically made by each unit’s charge nurse or nurse manager. Adequate pairing is essential since these assignments can affect patient, nurse, and hospital outcomes.

Considerations about Patients

When the charge nurse or nurse manager creates nursing assignments, they must consider various factors about patients and the care they need, including demographics, acuity, workload, safety measures, psychosocial support, and care coordination. For example, a patient who only speaks Spanish will likely be paired with a bilingual nurse; a high-acuity patient will likely be paired with the most experienced nurse, and so on.

Considerations about Nurses

Likewise, nurse managers must consider the characteristics of the nurses in their respective units to guide optimal patient assignments. Therefore, nurse managers consider nurse demographics, preferences, and competence. For example, although continuity of care is typically ideal, nurses may request not to be assigned a particular patient on their next shift. Nurse managers may be able to oblige, but often, patient assignments must depend on which nurses are most qualified to care for particular patients based on education, certification, and experience.

Other Considerations

In addition to considerations regarding the patients and nurses, charge nurses must consider factors such as the physical layout of the unit, the average patient length of stay, and nurse-to-patient ratios when determining patient assignments.

Can a Nurse Refuse an Assignment?

The short answer is, “Yes, nurses can refuse patient assignments.” However, this is not a simple matter.

The American Nurses Association (ANA) states that registered nurses (RNs) have the “right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm.” Not only is it their right, but it is also their professional obligation to voice concerns regarding risky patient assignments. These concerns may be based on state laws, rules, and regulations governing nursing practice, including each state’s Nurse Practice Act .

Furthermore, the Bill of Rights for Registered Nurses states that nurses have “the right to freely and openly advocate for themselves and their patients, without fear of retribution.” However, refusals to accept a patient assignment should not be based on personal preference, prejudice, bias, convenience, or arbitrariness.

These same guidelines apply to PRN nurses and travel nurses as well. Whether they are employees or independent contractors, nurses must assess the risk of any given patient assignment to determine whether or not they should accept it.

When Can a Nurse Refuse a Patient Assignment?

According to the ANA, a nurse’s primary commitment is to provide healthcare services to their patients. Nurses are morally obligated to care for any patient that needs their services. However, certain situations may present risks that outweigh this moral obligation. Accepting the risk becomes a moral option instead of an obligation in these situations. When nurses face threats to their professional or personal integrity, nurses must only accept the compromises that preserve their moral integrity and do not jeopardize their dignity or wellbeing or that of others.

The National Council of State Boards of Nursing provides the following framework guidelines to help make decisions regarding patient assignments.

Assuming that a particular activity, intervention, or role is permitted by the Nurse Practice Act and other applicable laws, rules, and standards, charge nurses and nurses assigned particular patients must ask the following questions:

Is performing the activity, intervention, or role consistent with evidence-based nursing and healthcare literature?
Has the nurse completed the necessary education to perform the activity, intervention, or role safely?
Does the nurse have sufficient resources to perform the activity, intervention, or role in the practice setting?
Is the nurse prepared to accept accountability for the activity, intervention, or role and the related outcome?

If the answer to any of these questions is “No,” a nurse should not accept the patient assignment.

Consequences of Refusing an Assignment

As mentioned, nurses have the right to advocate for themselves and their patients without facing negative consequences. However, the reality is that refusing an assignment may have both formal and informal consequences. A nurse can even be fired for refusing an assignment.

Informal consequences may include animosity from team members, especially if refusing a patient assignment resulted in another nurse having a greater patient load.

Formal consequences may result in disciplining a nurse’s license. However, this disciplinary action typically occurs if a nurse does not adequately refuse an assignment or if there is patient abandonment.

What Are Patient Abandonment Laws?

A nurse’s actions may be considered patient abandonment if the following occur:

A nurse accepts a patient assignment and is responsible for patient care but then abandons or neglects a patient needing nursing care without making acceptable arrangements for the continuation of care.
A nurse leaves their job without providing sufficient notice and under circumstances that seriously impair patients’ quality of nursing care .

How to Refuse a Patient Assignment

The following are the steps a nurse should follow if they believe they should refuse a patient assignment:

A nurse should consult with the supervisor and state that they cannot accept the assignment. The refusal should be communicated as soon as possible to allow for alternate arrangements for patient care.
In addition to verbal communication, nurses must communicate to their supervisor in writing the perceived discrepancies between the required competence and the nurse’s knowledge, skills, and abilities. The nurse should keep a copy of the documentation and any steps taken to remedy the situation for future reference.
If supervisors insist that a nurse accept an assignment against the nurse’s judgment, the nurse should fill out an Assignment Despite Objection (ADO) Form . Filling this form protects a nurse’s license and transfers the responsibility to management.
When a nurse refuses an assignment, they must be prepared for possible disciplinary actions, such as sanctions by the facility. By reviewing specific policies or contractual grievance procedures, a nurse can prepare options to contest the disciplinary action.
If a nurse feels unprepared for the patient assignments they receive, they should request additional training if the nurse is an employee of the facility, so that the nurse can practice safely.
Furthermore, regardless of whether a nurse plans to accept or reject an assignment, identified risks should be communicated through the appropriate institutional channels so adequate precautions can be taken.

The Bottom Line

In the context of an ongoing nurse staffing shortage , with high nurse burnout and turnover rates, nurse managers are often forced to juggle more patient assignments than they have staff to cover. They may assign nurses more patients than they can reasonably care for or patients with higher acuity than the nurses are prepared to handle. Ultimately, it is often up to nurses themselves to refuse inadequate assignments. Therefore, nurses must understand both their rights and responsibilities to help them make informed and safe decisions.

Make sure you stay informed as a nurse by reading more articles on Nursa’s blog covering all things nursing .

ResourceGate: The Nurse-Patient Assignment Process: What Clinical Nurses and Patients Think
American Nurses Association Position Statement on Risk and Responsibility in Providing Nursing Care
Massachusetts Nurses Association: Accepting, Rejecting & Delegating a Work Assignment: A Guide for Nurses

Laila is a contributing copywriter and editor at Nursa who specializes in writing compelling long-form content about nursing finances, per diem job locations, areas of specialization, guides, and resources that help nurses navigate their career paths.

Sign Up with Nursa and Request PRN Jobs near You

Interested in healthcare shifts, related blog posts.

Is Nursa a Staffing Agency? How Nursa Works

Choose Multiple PRN Shifts on Your Schedule

Nursa isn't just about finding a job ; it's about crafting your ideal work schedule by selecting shifts. Once you create a Nursa profile, you will experience the convenience of scheduling shifts in real-time.

See More Shifts and Apply Now

Explore and find where you would like to work

Pick Up a Job Today

Find per diem PRN job opportunities in your area . High paying CNA, LPN and RN and many more are now available now.

Post Your Jobs Today

Facilities who use Nursa fill 3 times as many open per diem shifts , on average, compared to trying to fill the shifts themselves.

Most Common Situations When Nurses Are Within Their Rights To Refuse A Patient

From the time patients enter any healthcare facility, nurses play a vital role in providing quality patient care. Patients, their loved ones, and our team members look to us for help and encouragement. In some situations, however, nurses are faced with the dilemma of deciding whether accepting an assignment for patient care is appropriate or if they should refuse a patient. Many nurses wonder, "Can nurses choose when to accept a patient assignment, and if so, when are nurses within their rights to refuse a patient?" Knowing your rights as a nurse and how to protect your patients and yourself is essential. In this article, I will share with you 10 most common situations when nurses are within their rights to refuse a patient. Every nurse and patient is different. So, it is important to consider each situation carefully and know your rights before deciding whether to accept a patient assignment or refuse.

When are Nurses Within Their Rights to Refuse a Patient?

Situation #1: religious conflicts, situation #2: excessive patient load, situation #3: personal illness, situation #4: patient being aggressive or threatening, situation #5: lack of training/competence, situation #6: unsafe work conditions, situation #7: when beneficence conflicts with patient autonomy, situation #8: controversial procedures, situation #9: unequal distribution of low- and high-acuity patients, situation #10: lack of essential equipment, my final thoughts, list of sources used for this article.

When to Refuse a Nursing Assignment

Being assigned to an unfamiliar clinical area is one thing, but what if you are ordered to perform an unfamiliar procedure or a task that’s outside the scope of nursing practice? When should you refuse an assignment?

#Articles #Broker #BusinessPractices #Documentation #Incident Reports #Individual #Medication #Patient Safety #Risk #School #Social Media

Share this article:

Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)

What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency?

The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear.

How does a shared limit policy work?

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.

We have a shared limit policy. Are employees covered if they practice outside our office?

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.

There are plenty more where those came from.

See more FAQs

NSO Learning Center

More insights from some of the best minds in nursing.

Create effective anti-bullying policies

Workplace bullying contributes to decreased team cohesion, burnout, retention issues, and absenteeism. This article will help managers and other nurses influence policy development with suggestions on crafting usable and effective anti-bullying policies.

End of Life Care: Responsibilities and Risks

Nurses can make a major contribution in easing the transition from aggressive treatment to palliative care, regardless of the setting. To do so, they must be prepared to make ethical and humane decisions while also avoiding professional liability exposures.

Overcoming the pitfalls of medication reconciliation

Any time there’s a hand-off in patient care, there’s an increased risk for a medication error. Medication reconciliation has been used to help bridge this hand-off communication on admission, between transfers in the hospital, and at discharge.

Protect Your Professional License, Protect Your Livelihood

When you purchase your own professional liability insurance policy through Nurses Service Organization (NSO), you have peace of mind knowing that you have the resources available to protect your license and your right to practice.

Find a Nurse
Make a Complaint
File a Report
Self Assessment
Self Reporting
Scope of Practice
Standards & Guidelines Self

As nurses, your primary accountability is to patients. When deciding whether to provide care in a particular situation, exercise your professional judgment and follow an ethical decision-making process.

Abandonment occurs when a nurse accepts an assignment and discontinues care, without:

the patient requesting the discontinuation
arranging a suitable alternative or replacement service; or
allowing a reasonable opportunity for alternative or replacement services to be provided

Nurses may be concerned that declining work could be considered abandonment. There are many situations that can lead nurses to think about refusing assignments or discontinue care. For example, working in practice environments outside of their knowledge, skill and judgement, workload issues or even workplace strikes.

When deciding whether to refuse an assignment or discontinue nursing care, you are accountable to:

Assess the potential for harm to yourself and your patients Consider the circumstances of the situation and your practice setting. Continue to work within your knowledge, skill and judgement and complete a point-of-care risk assessment.
Use evidence-based sources to inform your decision-making and consider the context of the situation
Communicate your concerns to your employer Tell your employer that you are considering refusing an assignment or discontinuing nursing care. Discuss your concerns with your employer and consider their response. If, after doing so, you choose to refuse the assignment or discontinue care, work with your employer to develop a plan to ensure that safe patient care continues.
Ensure your patient(s) continue to receive care You must ensure that a suitable alternative for care is available for your patient(s) or allow reasonable time for alternate or replacement services to be arranged.
Document your decision-making process, actions and decision

For more information, read the following resources:

You have the right to refuse unsafe assignments

July 11, 2019.

Unsafe Assignments

According to the American Nurses Association , Nurses have the "professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered Nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm." In short, Nurses are empowered to say "no" when management puts our patients at risk by violating safe staffing laws. Here are some articles that explain this right—and how to claim it.

Think your assignment violates the law? Follow this flow chart!

"Unfortunately, many nurses – and many leaders — will answer the question with some form of “suck it up and do the best you can.” And while I know that questioning an assignment, let alone refusing it, is hard, this is exactly what you must consider doing." —Nurse Guidance

When an Assignment is Unsafe (via Nurse Guidance) The scenarios described in this quick read might sound too familiar to Nurses that work in chronically understaffed hospitals. But fear not Nurse Guidance has you covered with great tips on what to do when it's time to say "I refuse."

California Code Regs Disciplinary Action for Nurses There are laws that protect Nurses so we can practice our profession ethically. Know the Codes!

Moral Resilience: Managing and Preventing Moral Distress and Moral Residue Moral resilience is defined by the author of this paper as “the ability and willingness to speak and take right and good action in the face of an adversity that is moral/ethical in nature.” Nurses that say no to unsafe assignments need plenty of this.

When an Assignment is Unsafe

Imagine that you are a new nurse, about six months out of school and working on a cardiac floor at a large teaching hospital. It is Christmas Eve and you report to your unit to work the night shift. The nursing supervisor calls and tells you to go to the oncology unit – you’ve been floated. You tell the supervisor you’ve never worked oncology. She says you are just going to help out, do general basic nursing care; the regular staff nurses will handle everything else. When you get to the unit, the charge nurse gives you a fast report on your assigned patients. Contrary to what the supervisor said, you have most of the sickest patients on the unit and it is a regular patient care assignment, including administration of chemotherapy for which you are not qualified. What do you do?

Unfortunately, many nurses – and many leaders — will answer the question with some form of “suck it up and do the best you can.” And while I know that questioning an assignment, let alone refusing it, is hard, this is exactly what you must consider doing. Think about it this way: if you were a new airplane mechanic and were assigned to work solo on a new type of engine that you haven’t seen before, knowing that the plane was due to fly over 300 passengers and crew in 2 hours, would you do it without objection? If you were an internal medicine physician and told that you, as the only doctor available, had to perform a craniotomy, would you do it?

The shortage of qualified practicing nurses is not new. Neither are nurses’ legal, professional, and ethical duties. The American Nurses Association has backed the nurse’s right to refuse an unsafe assignment since at least the 1980s. The current position statement, “Rights of Registered Nurses When Considering a Patient Assignment,” (ANA, 2009) expressly states that nurses have “the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.” (Emphasis added.)

In addition, the ANA’s Code of Ethics for Nurses (2001) spells out the RN’s accountability “for judgments made and actions taken in the course of nursing practice, irrespective of health care organizations’ policies or providers’ directives” , (Provision 4).

Nurse leaders should take note of Provision 6: “acquiescing and accepting unsafe or inappropriate practices, even if the individual does not participate in the specific practice, is equivalent to condoning unsafe practice.”

Most state/territorial nursing associations and state boards of nursing echo these statements and many states have statutes that protect nurses who point out unsafe conditions. In Texas, it is called the “safe harbor” provision and other states, although they may not use that term, have similar policies or statutory wording. Nurses and leaders must speak up when circumstances put the nurse and the patient at risk of harm. Boards of nursing will discipline nurses and leaders who knowingly allow or foster unsafe practices.

Even if you have never been in questionable situation, you should know your organization’s policies and your state’s laws and regulations regarding refusing an assignment. Objections must be in writing so check to see if your facility or state has a form and keep several blank copies in your locker or backpack.

When a potential situation arises – either at the beginning of the shift or later on if conditions deteriorate – try to identify exactly what the problem is. Are you unqualified to care for the patients assigned? Is the assignment outside the scope of your practice or your experience and knowledge level? Has the assignment changed since you accepted it – have you received new patients or has a patient’s condition deteriorated?

Put your objections or refusal in writing. State facts, include the date and time, and why you are refusing or objecting. Don’t use subjective or accusatory terms such as “short-staffing.” Sign it. Give a copy to your leader and keep a copy for yourself. Understand that sometimes you must care or continue to care for the patients because not caring is the greater harm.

If you are a leader, do not punish the nurse objecting or refusing the assignment. This is retaliation and it is barred by law and professional practice rules. Listen carefully, consider all available options, and thank the nurse for having the courage to speak up. Document carefully and use the experience to identify potential staff or policy needs and ways to respond to future such situations. The ANA position statement is an excellent resource to start.

As for the two examples at the beginning, they happened and I was the nurse. In the first situation, the supervisor told me to do the best I could, and none of my patients died that night. In the second situation, one of the attending physicians saw what was happening and went to the nursing office himself. I got some help. My head nurse, who was off that day, phoned and accused me of deliberately trying to make her look bad to senior management. This was the latest of many staffing incidents at this facility. I had the next two days off; I interviewed at another hospital where I was immediately hired. I worked my two weeks’ notice under the icy glare of my head nurse, knowing I’d done the best I could to keep my patients safe.

Remember that it could be you or a loved one in the patient room someday. Don’t hope that everything will be alright. Ask for help and help your colleagues when they are facing an unsafe assignment.

written by BJ Strickland

Contact Info

BJ Strickland

Beth J. (“BJ”) Strickland is from Tennessee. She is an RN with Bachelor’s and Master’s degrees in nursing and a Master’s degree in history from Vanderbilt University. She is also a licensed attorney with her Juris Doctor degree from the University of Tennessee. She has practiced nursing since 1976 and has experience in clinical nursing, administration and teaching in several clinical areas. She has practiced law in state and federal courts in Tennessee since 1996 with an interest in healthcare risk management, employment law and medical malpractice. She retired from the U.S. Army in 2015 as a Lieutenant Colonel. This article is not legal advice. It is offered only as information about nursing topics of interest. If you have legal questions, please speak with a licensed attorney in your area. Neither the author or the website publisher are responsible for any actions a reader may take based on material in this article or on this website.

When the Nurse is the Patient…..

Crossing the Boundary

Me Too – Nurses and Sexual Harassment

8 thoughts on “ when an assignment is unsafe ”.

Thank you for this article. I appreciate the legal advice. Nurses are warm, compassionate and forgiving to a fault. Unfortunately, the legal system is just, not fair. When considering how to proceed in a difficult legal, ethical and professional situation, solid advice grounded in the law, which is backed by the American Nurses Association, is the best way to proceed. It is not enough to say that we want what is best for our patients; we must also do what is best for our patients. “Acqeisising and accepting unsafe or inappropriate practices is equivalent to condoning unsafe practice.” (Prov. 6, ANA, 2009)

I agree! I reference the ANA Code often with my students! Thank you for your comment.

Thank you so much for this article! I’m in the first stages of getting into nursing school and this article basically sums up my concerns and addresses them exactly! Thank you!

a Supervisor in Kindred Hospital in West Minister California has a Habit of assigning RN to a patient in 2 different departments, So when a call light is on 1 patient , you cannot see or hear your other patient, And if refuse this assignment , you are reprimanded by your superiors, The CNA rep also has no idea to battle this on going problem. please help the nurses reason legally to this unsafe patient services

You cannot be responsible for patients in 2 different locations (units, departments) at the same time UNLESS a qualified provider is covering the other patient. It is one thing to have patients on a unit and one goes to radiology. Then radiology is taking care of the patient FOR A SHORT TIME. If we’re talking about a full-shift assignment, the facility is setting itself up for a malpractice suit and likely sanctions from the licensing/accrediting body, which could result in large fines, even revocation of Medicare status. A CNA is not legally sufficient full-shift coverage for patients assigned to an RN. This is such an unsafe situation for everyone. I don’t understand why any supervisor would put him or herself, the facility, the patients, and the nurses in this situation. The supervisor can be legally held liable for failure to properly assign, supervise, delegate and so could the hospital in the event of patient injury or death. I strongly recommend contacting your state board of nursing, state nurses’ association, and the state facility licensing board to find out what their regulations are. The federal level (CMS) requires certain staffing too. I am so sorry you are going through this. If you don’t have your own malpractice/professional liability insurance, you should invest in coverage immediately because the facility will likely try to shift blame for any patient injuries or deaths to the individual nurse. Adequate coverage runs about $10-12/month and many policies include a legal representation benefit if your BON tries to discipline you. Good luck!

I work at a Children’s and Women’s hospital. I have worked NICU for 31 years. Recently our hospital has opened an adult unit as an overflow from the University hospital. Our hospital is expected to staff this unit. Nurses are being pulled from the NICU to take care of these adult patients, some of which have tracheostomies, closed head injuries, etc. My question is this. For a nurse like me who has zero adult experience can I be forced to take care of these patients? They are not providing any cross training at all.

My apologies for not answering sooner. I had a very similar question from another nurse recently where the NICU nurses were being used as “sitters” due to reduced NICU census. In your situation, it is absolutely unwise to assign you to direct patient care for any patients you do not feel qualified to care for. That is something you need to address with your risk manager AND absolutely worth a phone call to your state board of nursing for their guidance. No nurse, from a patient safety and legal liability standpoint, should ever be assigned primary care responsibility for patients that they are unqualified to care for — yes, your license says you MAY care for these patients BUT that is only AFTER you’ve had training and supervision. Yours is a specialization and you can’t be “transplanted” to another area — imagine if any of the adult care nurses were suddenly told they had to care for NICU patients without training and supervision. You have a duty to protect the patients and the general public. Your license is not a free pass for employers to use you anywhere they feel a need. Contact your BON for guidance, and if you have your own malpractice insurance (and I believe every nurse should, beyond any coverage provided by the employer) contact the carrier’s risk management service for additional perspective. In the meantime, make sure you document what you were told, who told you, what they said verbatim, when, etc. and keep a record of everything. I hope you’ll never need it but under current circumstances, you may. Good luck!

scrapebox blog comments

Refusing a patient care assignment

March 16, 2020 • less than 1 minute to read

You may have to make a decision about accepting an assignment involving abnormally dangerous conditions that pose an imminent risk to your safety and health, and could potentially cause serious injury or death.

If you have already accepted the assignment your professional license may be at risk if you fail to continue that assignment, unless you have handed off the assignment and been relieved of responsibility for the patient. If you decide to refuse the assignment, you should remain at the workplace and offer to perform other work that does not pose an imminent risk to your safety and health (e.g., an assignment for which you are provided proper safety equipment and training).

A decision to refuse an assignment could result in disciplinary action taken against you by the employer. Under the collective bargaining agreement between the employer and WSNA, there must be "just cause" for any discipline. WSNA would defend you if you are subjected to unjust discipline, but resolution of any such discipline would likely be delayed and the outcome may be uncertain as a result of the current national and state emergency declarations.

Search form

Unsafe assignments.

We have an obligation to carry out the assignments we are given. But as patient advocates, we also have an obligation to report and try to correct unsafe assignments.

Unsafe can take many forms: short staffing, floating to units where we do not have the proper training, improper equipment, and more.

If you are given an unsafe assignment:

Tell your manager the assignment is unsafe and why. Ask them to correct the situation.
Fill out a Protest of Assignment. A Protest of Assignment is a written document explaining why, in your professional judgment, the assignment is unsafe. It helps protect your license and also helps us as a union correct patient care problems.
Talk to your NYSNA delegate or rep about how to prevent this situation from happening again.

We can most effectively prevent and address unsafe assignments through collective action.

Connect With Us

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
My Bibliography
Collections
Citation manager

Save citation to file

Email citation, add to collections.

Create a new collection
Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

Search in PubMed
Search in NLM Catalog
Add to Search

Position statement. The right to accept or reject an assignment. American Nurses Association

PMID: 8716506

The American Nurses Association (ANA) believes that nurses should reject assignment that puts patients or themselves in serious, immediate jeopardy. ANA supports the nurses obligation to reject an assignment in these situations even where there is not a specific legal protection for rejecting such an assignment. The professional obligations to the nurse to safeguard clients are grounded in the ethical norms of the profession, the Standards of Clinical Nursing Practice and state nurse practice acts.

PubMed Disclaimer

Publication types

Search in MeSH
Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Cover of Nursing Management and Professional Concepts

Nursing Management and Professional Concepts [Internet].

About Open RN

Chapter 2 - Prioritization

2.1. prioritization introduction, learning objectives.

• Prioritize nursing care based on patient acuity

• Use principles of time management to organize work

• Analyze effectiveness of time management strategies

• Use critical thinking to prioritize nursing care for patients

• Apply a framework for prioritization (e.g., Maslow, ABCs)

“So much to do, so little time.” This is a common mantra of today’s practicing nurse in various health care settings. Whether practicing in acute inpatient care, long-term care, clinics, home care, or other agencies, nurses may feel there is “not enough of them to go around.”

The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work (i.e., floating), implementing mandatory staffing and/or overtime, utilizing travel nurses, or using other practices to meet patient care demands.[ 1 ] Staffing strategies can result in nurses experiencing increased patient assignments and workloads, extended shifts, or temporary suspension of paid time off. Nurses may receive a barrage of calls and text messages offering “extra shifts” and bonus pay, and although the extra pay may be welcomed, they often eventually feel burnt out trying to meet the ever-expanding demands of the patient-care environment.

A novice nurse who is still learning how to navigate the complex health care environment and provide optimal patient care may feel overwhelmed by these conditions. Novice nurses frequently report increased levels of stress and disillusionment as they transition to the reality of the nursing role.[ 2 ] How can we address this professional dilemma and enhance the novice nurse’s successful role transition to practice? The novice nurse must enter the profession with purposeful tools and strategies to help prioritize tasks and manage time so they can confidently address patient care needs, balance role demands, and manage day-to-day nursing activities.

Let’s take a closer look at the foundational concepts related to prioritization and time management in the nursing profession.

2.2. TENETS OF PRIORITIZATION

Prioritization.

As new nurses begin their career, they look forward to caring for others, promoting health, and saving lives. However, when entering the health care environment, they often discover there are numerous and competing demands for their time and attention. Patient care is often interrupted by call lights, rounding physicians, and phone calls from the laboratory department or other interprofessional team members. Even individuals who are strategic and energized in their planning can feel frustrated as their task lists and planned patient-care activities build into a long collection of “to dos.”

Without utilization of appropriate prioritization strategies, nurses can experience time scarcity , a feeling of racing against a clock that is continually working against them. Functioning under the burden of time scarcity can cause feelings of frustration, inadequacy, and eventually burnout. Time scarcity can also impact patient safety, resulting in adverse events and increased mortality.[ 1 ] Additionally, missed or rushed nursing activities can negatively impact patient satisfaction scores that ultimately affect an institution’s reimbursement levels.

It is vital for nurses to plan patient care and implement their task lists while ensuring that critical interventions are safely implemented first. Identifying priority patient problems and implementing priority interventions are skills that require ongoing cultivation as one gains experience in the practice environment.[ 2 ] To develop these skills, students must develop an understanding of organizing frameworks and prioritization processes for delineating care needs. These frameworks provide structure and guidance for meeting the multiple and ever-changing demands in the complex health care environment.

Let’s consider a clinical scenario in the following box to better understand the implications of prioritization and outcomes.

Imagine you are beginning your shift on a busy medical-surgical unit. You receive a handoff report on four medical-surgical patients from the night shift nurse:

• Patient A is a 34-year-old total knee replacement patient, post-op Day 1, who had an uneventful night. It is anticipated that she will be discharged today and needs patient education for self-care at home.

• Patient B is a 67-year-old male admitted with weakness, confusion, and a suspected urinary tract infection. He has been restless and attempting to get out of bed throughout the night. He has a bed alarm in place.

• Patient C is a 49-year-old male, post-op Day 1 for a total hip replacement. He has been frequently using his patient-controlled analgesia (PCA) pump and last rated his pain as a “6.”

• Patient D is a 73-year-old male admitted for pneumonia. He has been hospitalized for three days and receiving intravenous (IV) antibiotics. His next dose is due in an hour. His oxygen requirements have decreased from 4 L/minute of oxygen by nasal cannula to 2 L/minute by nasal cannula.

Based on the handoff report you received, you ask the nursing assistant to check on Patient B while you do an initial assessment on Patient D. As you are assessing Patient D’s oxygenation status, you receive a phone call from the laboratory department relating a critical lab value on Patient C, indicating his hemoglobin is low. The provider calls and orders a STAT blood transfusion for Patient C. Patient A rings the call light and states she and her husband have questions about her discharge and are ready to go home. The nursing assistant finds you and reports that Patient B got out of bed and experienced a fall during the handoff reports.

It is common for nurses to manage multiple and ever-changing tasks and activities like this scenario, illustrating the importance of self-organization and priority setting. This chapter will further discuss the tools nurses can use for prioritization.

2.3. TOOLS FOR PRIORITIZING

Prioritization of care for multiple patients while also performing daily nursing tasks can feel overwhelming in today’s fast-paced health care system. Because of the rapid and ever-changing conditions of patients and the structure of one’s workday, nurses must use organizational frameworks to prioritize actions and interventions. These frameworks can help ease anxiety, enhance personal organization and confidence, and ensure patient safety.

Acuity and intensity are foundational concepts for prioritizing nursing care and interventions. Acuity refers to the level of patient care that is required based on the severity of a patient’s illness or condition. For example, acuity may include characteristics such as unstable vital signs, oxygenation therapy, high-risk IV medications, multiple drainage devices, or uncontrolled pain. A “high-acuity” patient requires several nursing interventions and frequent nursing assessments.

Intensity addresses the time needed to complete nursing care and interventions such as providing assistance with activities of daily living (ADLs), performing wound care, or administering several medication passes. For example, a “high-intensity” patient generally requires frequent or long periods of psychosocial, educational, or hygiene care from nursing staff members. High-intensity patients may also have increased needs for safety monitoring, familial support, or other needs.[ 1 ]

Many health care organizations structure their staffing assignments based on acuity and intensity ratings to help provide equity in staff assignments. Acuity helps to ensure that nursing care is strategically divided among nursing staff. An equitable assignment of patients benefits both the nurse and patient by helping to ensure that patient care needs do not overwhelm individual staff and safe care is provided.

Organizations use a variety of systems when determining patient acuity with rating scales based on nursing care delivery, patient stability, and care needs. See an example of a patient acuity tool published in the American Nurse in Table 2.3 .[ 2 ] In this example, ratings range from 1 to 4, with a rating of 1 indicating a relatively stable patient requiring minimal individualized nursing care and intervention. A rating of 2 reflects a patient with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex patient who requires frequent intervention and assessment. This patient might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk patient. For example, this individual may be experiencing frequent changes in vital signs, may require complex interventions such as the administration of blood transfusions, or may be experiencing significant uncontrolled pain. An individual with a rating of 4 requires more direct nursing care and intervention than a patient with a rating of 1 or 2. [3]

Example of a Patient Acuity Tool [ 4 ]

View in own window


Q8h VS A & O X 4	Q4h VS CIWA < 8	Q2h VS Delirium CIWA > 8	Unstable VS
Stable on RA	O2 < 2L NC	O2 > 2L NC	O2 via mask
VS	Temp < 98.7 F Pacemaker/AICD HR > 130	Change in BP Temp > 100.3 F	Unstable rhythm Afib
PO/IVPB	TPN, heparin infusion, blood glucose, PICC for blood draws	CBI 1 unit blood transfusion Fluid bolus	> 1 unit blood transfusion Chemotherapy
< 2 JP, hemovac, neph tube	Chest to water seal NG tube	Chest tube to suction Drain measured Q2 hrs	Drain measured Q1 hr CT > 100 mL/2 hrs
Pain well- managed with PO or IV meds Q4 hrs	PCA, nerve block Nausea/Vomiting	Q2h pain management	Uncontrolled pain with multiple pain devices
Stable transfer, routine discharge	Discharge to outside facility	New admission, discharge to hospice	Complicated post-op
Independent	Assist with ADLs Two-person assist out of bed Isolation	Turns Q2h Bedrest Respiratory isolation	Paraplegic Total care

Read more about using a patient acuity tool on a medical-surgical unit.

Rating scales may vary among institutions, but the principles of the rating system remain the same. Organizations include various patient care elements when constructing their staffing plans for each unit. Read more information about staffing models and acuity in the following box.

Staffing Models and Acuity

Organizations that base staffing on acuity systems attempt to evenly staff patient assignments according to their acuity ratings. This means that when comparing patient assignments across nurses on a unit, similar acuity team scores should be seen with the goal of achieving equitable and safe division of workload across the nursing team. For example, one nurse should not have a total acuity score of 6 for their patient assignments while another nurse has a score of 15. If this situation occurred, the variation in scoring reflects a discrepancy in workload balance and would likely be perceived by nursing peers as unfair. Using acuity-rating staffing models is helpful to reflect the individualized nursing care required by different patients.

Alternatively, nurse staffing models may be determined by staffing ratio. Ratio-based staffing models are more straightforward in nature, where each nurse is assigned care for a set number of patients during their shift. Ratio-based staffing models may be useful for administrators creating budget requests based on the number of staff required for patient care, but can lead to an inequitable division of work across the nursing team when patient acuity is not considered. Increasingly complex patients require more time and interventions than others, so a blend of both ratio and acuity-based staffing is helpful when determining staffing assignments.[ 5 ]

As a practicing nurse, you will be oriented to the elements of acuity ratings within your health care organization, but it is also important to understand how you can use these acuity ratings for your own prioritization and task delineation. Let’s consider the Scenario B in the following box to better understand how acuity ratings can be useful for prioritizing nursing care.

You report to work at 6 a.m. for your nursing shift on a busy medical-surgical unit. Prior to receiving the handoff report from your night shift nursing colleagues, you review the unit staffing grid and see that you have been assigned to four patients to start your day. The patients have the following acuity ratings:

Patient A: 45-year-old patient with paraplegia admitted for an infected sacral wound, with an acuity rating of 4.

Patient B: 87-year-old patient with pneumonia with a low grade fever of 99.7 F and receiving oxygen at 2 L/minute via nasal cannula, with an acuity rating of 2.

Patient C: 63-year-old patient who is postoperative Day 1 from a right total hip replacement and is receiving pain management via a PCA pump, with an acuity rating of 2.

Patient D: 83-year-old patient admitted with a UTI who is finishing an IV antibiotic cycle and will be discharged home today, with an acuity rating of 1.

Based on the acuity rating system, your patient assignment load receives an overall acuity score of 9. Consider how you might use their acuity ratings to help you prioritize your care. Based on what is known about the patients related to their acuity rating, whom might you identify as your care priority? Although this can feel like a challenging question to answer because of the many unknown elements in the situation using acuity numbers alone, Patient A with an acuity rating of 4 would be identified as the care priority requiring assessment early in your shift.

Although acuity can a useful tool for determining care priorities, it is important to recognize the limitations of this tool and consider how other patient needs impact prioritization.

Maslow’s Hierarchy of Needs

When thinking back to your first nursing or psychology course, you may recall a historical theory of human motivation based on various levels of human needs called Maslow’s Hierarchy of Needs. Maslow’s Hierarchy of Needs reflects foundational human needs with progressive steps moving towards higher levels of achievement. This hierarchy of needs is traditionally represented as a pyramid with the base of the pyramid serving as essential needs that must be addressed before one can progress to another area of need.[ 6 ] See Figure 2.1 [ 7 ] for an illustration of Maslow’s Hierarchy of Needs.

Maslow’s Hierarchy of Needs places physiological needs as the foundational base of the pyramid.[ 8 ] Physiological needs include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second level of Maslow’s hierarchy reflects safety needs. Safety needs include elements that keep individuals safe from harm. Examples of safety needs in health care include fall precautions. The third level of Maslow’s hierarchy reflects emotional needs such as love and a sense of belonging. These needs are often reflected in an individual’s relationships with family members and friends. The top two levels of Maslow’s hierarchy include esteem and self-actualization. An example of addressing these needs in a health care setting is helping an individual build self-confidence in performing blood glucose checks that leads to improved self-management of their diabetes.

So how does Maslow’s theory impact prioritization? To better understand the application of Maslow’s theory to prioritization, consider Scenario C in the following box.

You are an emergency response nurse working at a local shelter in a community that has suffered a devastating hurricane. Many individuals have relocated to the shelter for safety in the aftermath of the hurricane. Much of the community is still without electricity and clean water, and many homes have been destroyed. You approach a young woman who has a laceration on her scalp that is bleeding through her gauze dressing. The woman is weeping as she describes the loss of her home stating, “I have lost everything! I just don’t know what I am going to do now. It has been a day since I have had water or anything to drink. I don’t know where my sister is, and I can’t reach any of my family to find out if they are okay!”

Despite this relatively brief interaction, this woman has shared with you a variety of needs. She has demonstrated a need for food, water, shelter, homeostasis, and family. As the nurse caring for her, it might be challenging to think about where to begin her care. These thoughts could be racing through your mind:

Should I begin to make phone calls to try and find her family? Maybe then she would be able to calm down.

Should I get her on the list for the homeless shelter so she wouldn’t have to worry about where she will sleep tonight?

She hasn’t eaten in awhile; I should probably find her something to eat.

All of these needs are important and should be addressed at some point, but Maslow’s hierarchy provides guidance on what needs must be addressed first. Use the foundational level of Maslow’s pyramid of physiological needs as the top priority for care. The woman is bleeding heavily from a head wound and has had limited fluid intake. As the nurse caring for this patient, it is important to immediately intervene to stop the bleeding and restore fluid volume. Stabilizing the patient by addressing her physiological needs is required before undertaking additional measures such as contacting her family. Imagine if instead you made phone calls to find the patient’s family and didn’t address the bleeding or dehydration – you might return to a severely hypovolemic patient who has deteriorated and may be near death. In this example, prioritizing emotional needs above physiological needs can lead to significant harm to the patient.

Although this is a relatively straightforward example, the principles behind the application of Maslow’s hierarchy are essential. Addressing physiological needs before progressing toward additional need categories concentrates efforts on the most vital elements to enhance patient well-being. Maslow’s hierarchy provides the nurse with a helpful framework for identifying and prioritizing critical patient care needs.

Airway, breathing, and circulation, otherwise known by the mnemonic “ABCs,” are another foundational element to assist the nurse in prioritization. Like Maslow’s hierarchy, using the ABCs to guide decision-making concentrates on the most critical needs for preserving human life. If a patient does not have a patent airway, is unable to breathe, or has inadequate circulation, very little of what else we do matters. The patient’s ABCs are reflected in Maslow’s foundational level of physiological needs and direct critical nursing actions and timely interventions. Let’s consider Scenario D in the following box regarding prioritization using the ABCs and the physiological base of Maslow’s hierarchy.

You are a nurse on a busy cardiac floor charting your morning assessments on a computer at the nurses’ station. Down the hall from where you are charting, two of your assigned patients are resting comfortably in Room 504 and Room 506. Suddenly, both call lights ring from the rooms, and you answer them via the intercom at the nurses’ station.

Room 504 has an 87-year-old male who has been admitted with heart failure, weakness, and confusion. He has a bed alarm for safety and has been ringing his call bell for assistance appropriately throughout the shift. He requires assistance to get out of bed to use the bathroom. He received his morning medications, which included a diuretic about 30 minutes previously, and now reports significant urge to void and needs assistance to the bathroom.

Room 506 has a 47-year-old woman who was hospitalized with new onset atrial fibrillation with rapid ventricular response. The patient underwent a cardioversion procedure yesterday that resulted in successful conversion of her heart back into normal sinus rhythm. She is reporting via the intercom that her “heart feels like it is doing that fluttering thing again” and she is having chest pain with breathlessness.

Based upon these two patient scenarios, it might be difficult to determine whom you should see first. Both patients are demonstrating needs in the foundational physiological level of Maslow’s hierarchy and require assistance. To prioritize between these patients’ physiological needs, the nurse can apply the principles of the ABCs to determine intervention. The patient in Room 506 reports both breathing and circulation issues, warning indicators that action is needed immediately. Although the patient in Room 504 also has an urgent physiological elimination need, it does not overtake the critical one experienced by the patient in Room 506. The nurse should immediately assess the patient in Room 506 while also calling for assistance from a team member to assist the patient in Room 504.

Prioritizing what should be done and when it can be done can be a challenging task when several patients all have physiological needs. Recently, there has been professional acknowledgement of the cognitive challenge for novice nurses in differentiating physiological needs. To expand on the principles of prioritizing using the ABCs, the CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras.[ 9 ]

“Critical” patient needs require immediate action. Examples of critical needs align with the ABCs and Maslow’s physiological needs, such as symptoms of respiratory distress, chest pain, and airway compromise. No matter the complexity of their shift, nurses can be assured that addressing patients’ critical needs is the correct prioritization of their time and energies.

After critical patient care needs have been addressed, nurses can then address “urgent” needs. Urgent needs are characterized as needs that cause patient discomfort or place the patient at a significant safety risk.[ 10 ]

The third part of the CURE hierarchy reflects “routine” patient needs. Routine patient needs can also be characterized as “typical daily nursing care” because the majority of a standard nursing shift is spent addressing routine patient needs. Examples of routine daily nursing care include actions such as administering medication and performing physical assessments.[ 11 ] Although a nurse’s typical shift in a hospital setting includes these routine patient needs, they do not supersede critical or urgent patient needs.

The final component of the CURE hierarchy is known as “extras.” Extras refer to activities performed in the care setting to facilitate patient comfort but are not essential.[ 12 ] Examples of extra activities include providing a massage for comfort or washing a patient’s hair. If a nurse has sufficient time to perform extra activities, they contribute to a patient’s feeling of satisfaction regarding their care, but these activities are not essential to achieve patient outcomes.

Let’s apply the CURE mnemonic to patient care in the following box.

If we return to Scenario D regarding patients in Room 504 and 506, we can see the patient in Room 504 is having urgent needs. He is experiencing a physiological need to urgently use the restroom and may also have safety concerns if he does not receive assistance and attempts to get up on his own because of weakness. He is on a bed alarm, which reflects safety considerations related to his potential to get out of bed without assistance. Despite these urgent indicators, the patient in Room 506 is experiencing a critical need and takes priority. Recall that critical needs require immediate nursing action to prevent patient deterioration. The patient in Room 506 with a rapid, fluttering heartbeat and shortness of breath has a critical need because without prompt assessment and intervention, their condition could rapidly decline and become fatal.

In addition to using the identified frameworks and tools to assist with priority setting, nurses must also look at their patients’ data cues to help them identify care priorities. Data cues are pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition. For example, have the patient’s vital signs worsened over the last few hours? Is there a new laboratory result that is concerning? Data cues are used in conjunction with prioritization frameworks to help the nurse holistically understand the patient’s current status and where nursing interventions should be directed. Common categories of data clues include acute versus chronic conditions, actual versus potential problems, unexpected versus expected conditions, information obtained from the review of a patient’s chart, and diagnostic information.

Acute Versus Chronic Conditions

A common data cue that nurses use to prioritize care is considering if a condition or symptom is acute or chronic. Acute conditions have a sudden and severe onset. These conditions occur due to a sudden illness or injury, and the body often has a significant response as it attempts to adapt. Chronic conditions have a slow onset and may gradually worsen over time. The difference between an acute versus a chronic condition relates to the body’s adaptation response. Individuals with chronic conditions often experience less symptom exacerbation because their body has had time to adjust to the illness or injury. Let’s consider an example of two patients admitted to the medical-surgical unit complaining of pain in Scenario E in the following box.

As part of your patient assignment on a medical-surgical unit, you are caring for two patients who both ring the call light and report pain at the start of the shift. Patient A was recently admitted with acute appendicitis, and Patient B was admitted for observation due to weakness. Not knowing any additional details about the patients’ conditions or current symptoms, which patient would receive priority in your assessment? Based on using the data cue of acute versus chronic conditions, Patient A with a diagnosis of acute appendicitis would receive top priority for assessment over a patient with chronic pain due to osteoarthritis. Patients experiencing acute pain require immediate nursing assessment and intervention because it can indicate a change in condition. Acute pain also elicits physiological effects related to the stress response, such as elevated heart rate, blood pressure, and respiratory rate, and should be addressed quickly.

Actual Versus Potential Problems

Nursing diagnoses and the nursing care plan have significant roles in directing prioritization when interpreting assessment data cues. Actual problems refer to a clinical problem that is actively occurring with the patient. A risk problem indicates the patient may potentially experience a problem but they do not have current signs or symptoms of the problem actively occurring.

Consider an example of prioritizing actual and potential problems in Scenario F in the following box.

A 74-year-old woman with a previous history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital for pneumonia. She has generalized weakness, a weak cough, and crackles in the bases of her lungs. She is receiving IV antibiotics, fluids, and oxygen therapy. The patient can sit at the side of the bed and ambulate with the assistance of staff, although she requires significant encouragement to ambulate.

Nursing diagnoses are established for this patient as part of the care planning process. One nursing diagnosis for this patient is Ineffective Airway Clearance . This nursing diagnosis is an actual problem because the patient is currently exhibiting signs of poor airway clearance with an ineffective cough and crackles in the lungs. Nursing interventions related to this diagnosis include coughing and deep breathing, administering nebulizer treatment, and evaluating the effectiveness of oxygen therapy. The patient also has the nursing diagnosis Risk for Skin Breakdown based on her weakness and lack of motivation to ambulate. Nursing interventions related to this diagnosis include repositioning every two hours and assisting with ambulation twice daily.

The established nursing diagnoses provide cues for prioritizing care. For example, if the nurse enters the patient’s room and discovers the patient is experiencing increased shortness of breath, nursing interventions to improve the patient’s respiratory status receive top priority before attempting to get the patient to ambulate.

Although there may be times when risk problems may supersede actual problems, looking to the “actual” nursing problems can provide clues to assist with prioritization.

Unexpected Versus Expected Conditions

In a similar manner to using acute versus chronic conditions as a cue for prioritization, it is also important to consider if a client’s signs and symptoms are “expected” or “unexpected” based on their overall condition. Unexpected conditions are findings that are not likely to occur in the normal progression of an illness, disease, or injury. Expected conditions are findings that are likely to occur or are anticipated in the course of an illness, disease, or injury. Unexpected findings often require immediate action by the nurse.

Let’s apply this tool to the two patients previously discussed in Scenario E. As you recall, both Patient A (with acute appendicitis) and Patient B (with weakness and diagnosed with osteoarthritis) are reporting pain. Acute pain typically receives priority over chronic pain. But what if both patients are also reporting nausea and have an elevated temperature? Although these symptoms must be addressed in both patients, they are “expected” symptoms with acute appendicitis (and typically addressed in the treatment plan) but are “unexpected” for the patient with osteoarthritis. Critical thinking alerts you to the unexpected nature of these symptoms in Patient B, so they receive priority for assessment and nursing interventions.

Handoff Report/Chart Review

Additional data cues that are helpful in guiding prioritization come from information obtained during a handoff nursing report and review of the patient chart. These data cues can be used to establish a patient’s baseline status and prioritize new clinical concerns based on abnormal assessment findings. Let’s consider Scenario G in the following box based on cues from a handoff report and how it might be used to help prioritize nursing care.

Imagine you are receiving the following handoff report from the night shift nurse for a patient admitted to the medical-surgical unit with pneumonia:

At the beginning of my shift, the patient was on room air with an oxygen saturation of 93%. She had slight crackles in both bases of her posterior lungs. At 0530, the patient rang the call light to go to the bathroom. As I escorted her to the bathroom, she appeared slightly short of breath. Upon returning the patient to bed, I rechecked her vital signs and found her oxygen saturation at 88% on room air and respiratory rate of 20. I listened to her lung sounds and noticed more persistent crackles and coarseness than at bedtime. I placed the patient on 2 L/minute of oxygen via nasal cannula. Within 5 minutes, her oxygen saturation increased to 92%, and she reported increased ease in respiration.

Based on the handoff report, the night shift nurse provided substantial clinical evidence that the patient may be experiencing a change in condition. Although these changes could be attributed to lack of lung expansion that occurred while the patient was sleeping, there is enough information to indicate to the oncoming nurse that follow-up assessment and interventions should be prioritized for this patient because of potentially worsening respiratory status. In this manner, identifying data cues from a handoff report can assist with prioritization.

Now imagine the night shift nurse had not reported this information during the handoff report. Is there another method for identifying potential changes in patient condition? Many nurses develop a habit of reviewing their patients’ charts at the start of every shift to identify trends and “baselines” in patient condition. For example, a chart review reveals a patient’s heart rate on admission was 105 beats per minute. If the patient continues to have a heart rate in the low 100s, the nurse is not likely to be concerned if today’s vital signs reveal a heart rate in the low 100s. Conversely, if a patient’s heart rate on admission was in the 60s and has remained in the 60s throughout their hospitalization, but it is now in the 100s, this finding is an important cue requiring prioritized assessment and intervention.

Diagnostic Information

Diagnostic results are also important when prioritizing care. In fact, the National Patient Safety Goals from The Joint Commission include prompt reporting of important test results. New abnormal laboratory results are typically flagged in a patient’s chart or are reported directly by phone to the nurse by the laboratory as they become available. Newly reported abnormal results, such as elevated blood levels or changes on a chest X-ray, may indicate a patient’s change in condition and require additional interventions. For example, consider Scenario H in which you are the nurse providing care for five medical-surgical patients.

You completed morning assessments on your assigned five patients. Patient A previously underwent a total right knee replacement and will be discharged home today. You are about to enter Patient A’s room to begin discharge teaching when you receive a phone call from the laboratory department, reporting a critical hemoglobin of 6.9 gm/dL on Patient B. Rather than enter Patient A’s room to perform discharge teaching, you immediately reprioritize your care. You call the primary provider to report Patient B’s critical hemoglobin level and determine if additional intervention, such as a blood transfusion, is required.

2.4. CRITICAL THINKING AND CLINICAL REASONING

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 1 ] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action. Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [2]

When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet patient-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their patients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their patients may be late if one of the patients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the patient-care team.

Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Patients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of patient-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with patients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today’s health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe patient care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.

2.7. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

Temperature	98.9 °F (37.2°C)
Heart Rate	182 beats/min
Respirations	36 breaths/min
Blood Pressure	152/90 mm Hg
Oxygen Saturation	88% on room air
Capillary Refill Time	>3
Pain	9/10 chest discomfort

Physical Assessment Findings
Glasgow Coma Scale Score	14
Level of Consciousness	Alert
Heart Sounds	Irregularly regular
Lung Sounds	Clear bilaterally anterior/posterior
Pulses-Radial	Rapid/bounding
Pulses-Pedal	Weak
Bowel Sounds	Present and active x 4
Edema	Trace bilateral lower extremities
Skin	Cool, clammy

Nursing Action	Indicated	Contraindicated	Nonessential
Apply oxygen at 2 liters per nasal cannula.
Call imaging for a STAT lung CT.
Perform the National Institutes of Health (NIH) Stroke Scale Neurologic Exam.
Obtain a comprehensive metabolic panel (CMP).
Obtain a STAT EKG.
Raise the head-of-bed to less than 10 degrees.
Establish patent IV access.
Administer potassium 20 mEq IV push STAT.

The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among C ritical needs, U rgent needs, R outine needs, and E xtras.

You are the nurse caring for the patients in the following table. For each patient, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.

	Critical	Urgent	Routine	Extra
Patient exhibits new left-sided facial droop
Patient reports 9/10 acute pain and requests PRN pain medication
Patient with BP 120/80 and regular heart rate of 68 has scheduled dose of oral amlodipine
Patient with insomnia requests a back rub before bedtime
Patient has a scheduled dressing change for a pressure ulcer on their coccyx
Patient is exhibiting new shortness of breath and altered mental status
Patient with fall risk precautions ringing call light for assistance to the restroom for a bowel movement

II. GLOSSARY

Airway, breathing, and circulation.

Nursing problems currently occurring with the patient.

The level of patient care that is required based on the severity of a patient’s illness or condition.

A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.

Conditions having a sudden onset.

Conditions that have a slow onset and may gradually worsen over time.

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[ 1 ]

A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 2 ]

A strategy for prioritization based on identifying “critical” needs, “urgent” needs, “routine” needs, and “extras.”

Pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition.

Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.

Prioritization strategies often reflect the foundational elements of physiological needs and safety and progr ess toward higher levels.

A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.

A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.

A prioritization strategy including the review of planned tasks and allocation of time believed to be required to complete each task.

A feeling of racing against a clock that is continually working against you.

Conditions that are not likely to occur in the normal progression of an illness, disease, or injury.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 - Prioritization.
PDF version of this title (18M)

In this Page

PRIORITIZATION INTRODUCTION
TENETS OF PRIORITIZATION
TOOLS FOR PRIORITIZING
CRITICAL THINKING AND CLINICAL REASONING
LEARNING ACTIVITIES

Other titles in this collection

Open RN OER Textbooks

Related information

PMC PubMed Central citations
PubMed Links to PubMed

Recent Activity

Chapter 2 - Prioritization - Nursing Management and Professional Concepts Chapter 2 - Prioritization - Nursing Management and Professional Concepts

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

IMAGES

Can I Refuse an Assignment?
Patient refusal: when nurse assignments are rejected by patients
Fillable Online Refusing Assignments and Discontinuing Nursing Services
Patient refusal: when nurse assignments are rejected by patients
Patient refusal: when nurse assignments are rejected by patients
Can You Refuse An Unsafe Assignment?

COMMENTS

How To Refuse an Unsafe Patient Assignment as a Nurse
Send an email to all members of your leadership team to summarize the situation, and provide thorough documentation of why you are refusing an assignment, with adequate details. Keep any paper records for yourself, just in case. Help Find Solutions. Refusing a patient assignment will have an impact on all of the patients in the unit, the entire ...
Rights of RNs When Considering a Patient Assignment
Summary. The American Nurses Association (ANA) upholds that registered nurses - based on their professional and ethical responsibilities - have the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation ...
Can a Nurse Refuse a Patient Assignment? Know Your Options
The short answer is, "Yes, nurses can refuse patient assignments.". However, this is not a simple matter. The American Nurses Association (ANA) states that registered nurses (RNs) have the "right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm.".
Most Common Situations When Nurses are Within Their Rights to Refuse a
One of the most common reasons nurses refuse to provide patient care is because of an ethical dilemma, such as a religious conflict. While nurses may not try to impose their beliefs on patients or coworkers, if a procedure conflicts with a nurse's religious beliefs, then nurses are within their rights to refuse a patient assignment. For ...
Patient refusal: when nurse assignments are rejected by patients
When faced with patient refusal of a nurse assignment, nursing leadership and the organization must balance their obligations to the patient and the nurse. Organizations should develop policies and procedures with input from frontline nurses that supports nurses, and managers must be authentic allies of marginalized groups.
When to Refuse a Nursing Assignment
Call your state Board of Nursing or consult your facility's policy manual if time permits. If the procedure cannot be delayed and there's no one else available to handle it, however, consider accepting the assignment. Refusing the assignment under these circumstances could lead to charges of patient abandonment and is not recommended ...
Questions to Ask in the Decision to Accept Assignments
Questions to Ask in Making the Decision to Accept a Staffing Assignment for Nurses. Registered nurses need to know their rights and responsibilities when considering a patient assignment. If you feel that you lack expertise on a unit and patient population , you don't just have the right to refuse an assignment there, you have an obligation ...
Accountabilities when discontinuing or declining to provide care
When deciding whether to refuse an assignment or discontinue nursing care, you are accountable to: Assess the potential for harm to yourself and your patients. Consider the circumstances of the situation and your practice setting. Continue to work within your knowledge, skill and judgement and complete a point-of-care risk assessment.
PDF PRACTICE GUIDELINE Refusing Assignments and Discontinuing Nursing Services
nduct related to refusing an assignment or discont. nuing nursing services. Each situation would be assessed on its own merit.The relevant definitions of pro. 1 (1) Contravening a standard of practice of the. profession or failing to meet the standard of practice of the profession. ompetent(5) Discontinuing professional.
Guidance on Declining Unsafe Assignments
COVID-19 Guidance: Declining Unsafe Assignments. Updated March 16, 2020. ONA has received requests from nurses as to their options for declining a patient assignment if they believe the available personal protective equipment (PPE) is inadequate to ensure the nurse's own safety. Following is a best practices protocol for those circumstances:
You have the right to refuse unsafe assignments
Unsafe Assignments. According to the American Nurses Association, Nurses have the "professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered Nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients ...
Accepting a patient care assignment reaffirms nurses' contract with society
Refusing an assignment can become quite entangled ethically and legally, and may entail consequences that can be personally devastating for the nurse. Once a patient care assignment is accepted, refusal to care for a patient may lead to charges of abandonment. Thus, the act of accepting the patient care assignment needs to have proper attention ...
A Nurse's Right to Refuse a Patient Care Assignment
This article discusses criteria by which a nurse can refuse a patient care assignment and those by which a nurse manager can require that a nurse perform a patient care assignment. AORN J 62 (Sept 1995) 412-418.
When an Assignment is Unsafe
Neither are nurses' legal, professional, and ethical duties. The American Nurses Association has backed the nurse's right to refuse an unsafe assignment since at least the 1980s. The current position statement, "Rights of Registered Nurses When Considering a Patient Assignment," (ANA, 2009) expressly states that nurses have "the ...
Unsafe Patient Assignments: a Professional Dilemma
AN unsafe assignment, the one-time occurrence that could not be helped, is exceedingly rare. The phenomenon of recurring unsafe assignments…correctly referred to as an unsafe position…is becoming all too common. Surviving that first encounter with an unsafe assignment relatively unharmed tends to create a false sense of security.
PDF Giving, Accepting, or Rejecting an Assignment
erning unsafe or unprofessional conduct as required in WAC 246-840-73. Other: ly. practice nursing in the state of Washington witha current Washington license;7. Th. l. censed nurse shall not permit his or her license to be used by another person;8. The nurse shall have knowledge of the statutes and rules govern-i.
Refusing a patient care assignment
If you decide to refuse the assignment, you should remain at the workplace and offer to perform other work that does not pose an imminent risk to your safety and health (e.g., an assignment for which you are provided proper safety equipment and training). A decision to refuse an assignment could result in disciplinary action taken against you ...
Unsafe Assignments
A Protest of Assignment is a written document explaining why, in your professional judgment, the assignment is unsafe. It helps protect your license and also helps us as a union correct patient care problems. Talk to your NYSNA delegate or rep about how to prevent this situation from happening again. We can most effectively prevent and address ...
PDF STRICTLY CLINICAL When a patient refuses a nurse assignment
A 60-year-old White man arrives in the emer-gency department with shortness of breath caused by an asthma exacerbation. When he's admitted to the telemetry unit, he's greeted by a Black female staff member. The patient im-mediately asks if she's the nurse's aide. She re-sponds, "No, I'm your assigned nurse.".
Position statement. The right to accept or reject an assignment
Abstract. The American Nurses Association (ANA) believes that nurses should reject assignment that puts patients or themselves in serious, immediate jeopardy. ANA supports the nurses obligation to reject an assignment in these situations even where there is not a specific legal protection for rejecting such an assignment.
Chapter 2
The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work ...
A&E doctor 'refused' to see woman before she died
A senior doctor refused to see a woman who died of an asthma attack after 39 hours sitting in a chair in A&E, an inquest heard. Marina Young died at the Royal Preston Hospital on 22 June 2022 ...
ob gyn remote nurse jobs in Genesee, ID
15 Ob Gyn Remote Nurse jobs available in Genesee, ID on Indeed.com. Apply to Registered Nurse - Catheterization Lab, Pain Management Nurse, Travel Nurse and more! ... Nomad Health seeks an experienced Cath Lab registered nurse for a travel assignment in ID. We have removed some job postings very similar to those already shown.