1. Legally speaking… When can you say no? By Penny S. Brooke, APRN, MS, JD Nursing2009, July 2009 1.8 ANCC contact hours Online: www.nursingcenter.com © 2009 by Lippincott Williams & Wilkins. All world rights reserved.

2. Reasons for saying no Manage your time efficiently Keep patients safe Protect yourself from burnout and legal repercussions

3. Overtime can lead to High stress environment More errors Burnout

4. Saying no to overtime Depends on state law and facility policy A growing number of states are enacting laws prohibiting mandatory overtime Contact your state board

5. More on state laws regarding overtime Laws typically include provisions for protection from disciplinary action, retaliation, or discrimination for refusing mandatory overtime Under these laws, mandatory overtime is permissible in an emergency when you’ve signed a contract to accept or volunteer for it

6. Facility policy and procedure regarding mandatory overtime Should reflect requirements of state law If overtime is permitted by state law and facility policy, you’re agreeing to it when you accept employment Discuss patient safety with your nurse manager and document attempts to communicate your concerns

7. Facility policy and procedure regarding mandatory overtime A pattern of inadequate staffing should be reported to risk assessment team; could lead to injuries If facility consistently asks that staff work overtime, give written communication to managers about the need for more staff support

8. Saying no to a heavy caseload If you refuse a work assignment after arriving for shift report, you may be charged with abandonment if you walk away without placing care of your patients with a qualified staff member When interviewing for a nursing position, always ask for written job expectations

9. Saying no to an assignment outside your scope of practice Always refuse assignments outside your legal scope of practice as defined by your state’s nurse practice act If you accept responsibilities outside your scope of practice, you may be charged with practicing medicine/pharmacy without a license

10. Examples of practicing outside nursing scope of practice Selecting medication for a patient not ordered by a HCP with prescriptive authority Dispensing a drug permitted by physicians or pharmacists only Other team members ask you to do something outside your scope of practice

11. Saying no to an assignment outside your skill level Harmed patients can sue nurses for unsafe care within their scope of practice but that the nurse is not trained or educated in (e.g., a nurse being assigned to another unit; medical-surgical to ICU) Always make manager aware of your skill level and refuse tasks beyond this level

12. Saying no to an assignment outside your skill level Never attempt to perform treatments or use equipment without the knowledge required Ask yourself if this is what any “prudent” nurse would do Judges and juries consider your actions in light of well-established standards of care

13. Saying no when you’re busy with a patient Consider whether you’ll be neglecting assigned duties while taking on additional responsibility Instead of leaving your patient, find patient’s assigned nurse In an emergency, evaluate the needs of your patient to assist another

14. Saying no to providing your own care strategies If you’re knowledgeable about other care strategies, resist sharing with the patient unless you have HCP consent (in writing) Speak with HCP if you believe the alternative to be beneficial and complies with protocols If you proceed without consent, you may be charged with interfering with physician-patient relationship

15. The case of Nurse Tuma In 1979, a nurse practicing in Idaho, Jolene Tuma, RN, MSN, was asked by her patient to provide information on an alternative therapy She didn’t consult with patient’s HCP before giving the patient advice

16. The case of Nurse Tuma Even though patient didn’t stop the medical regimen ordered by the HCP, Ms. Tuma was charged with interfering with the physician- patient relationship Idaho State Board of Nursing suspended Ms. Tuma’s license to practice nursing for 6 months

17. The case of Nurse Tuma If Ms. Tuma had initially approached patient’s HCP and discussed patient’s desire to learn more about an alternative therapy, the HCP may have given her permission to provide information The HCP may also have learned of an alternative therapy that could benefit his patient if Ms. Tuma had taken this opportunity to inform him of alternative therapies available

18. Saying no to inappropriate delegation As an RN, you may delegate care to LPNs or UAPs, but you’re responsible for the care Know your colleagues scope of practice, skill level, and limitations to delegate safely Document the supervision you provide You can be held legally liable for inappropriate delegation if colleague harms the patient doing a task you delegated

19. How to say no like a professional Be assertive; give reasonable explanations Be respectful; offer helpful suggestions Have a clear sense of your own priorities Weigh the personal/professional risks of accepting/refusing a request Determine how to set limits without jeopardizing your career

20. Six tips for saying no assertively 1. Listen politely to the request being made; avoid interrupting and objecting right away 2. Restate the request if you need clarification 3. Determine if you need time to verify if you can accept the assignment 4. If further deliberation results in having to say no, respond quickly to minimize delays for the nurse manager, who has to find someone else

21. Six tips for saying no assertively 5. Offer suggestions or alternative solutions when you say no to a request if you have ideas that may be helpful 6. If your no response isn’t being accepted, repeat it politely and assertively until it’s heard and accepted; don’t become angry or defensive, and don’t feel guilty for protecting your own (and your patients’) needs