KENTUCKY NURSES ASSOCIATION

ASSIGNMENT DESPITE OBJECTION FORM

Purpose: The purpose of this form is to notify hospital supervision that you have been given an assignment which you believe is potentially unsafe for the patients or staff (KRS 216B). This form will document the situation. You may use it to address the problem. INSTRUCTIONS: PLEASE PRINT. ONE OR MORE RNs MAY COMPLETE THIS FORM. One Copy to KNA, one copy to your supervisor, one copy to facility and keep one copy.

SECTION I: Before assuming the assignment and completing this form, you must give your supervisor (not the charge nurse) notice of your objection to the assignment. Please put the complete name of the person making the assignment and receiving the objection. Please complete the response section with the supervisor’s response, as the date/time of the response. If you do not receive a response from your supervisor, submit a copy of this completed form to the next level(s) of administration. Complete the section “Other Persons Notified” below if you notified any other persons (head nurse/clinical manager of the unit, etc.).

I/We_____________________________________________________________________________________

Registered Nurse (s) employed at (Facility)________________________________ on (Shift)_______________

Hereby protest my/our assignment as: ___ Primary Nurse ___ Charge Nurse ___ RN Pulled to Unit ___ Other made to me/us by (Supervisor’s Name)________________________________________________________ at (Date/Time) _______________________________despite my objection.

Response: ________________________________________________________________________________

Other Persons Notified:

(Name)_______________________________________________ (Date/Time)__________________________ (Response)_________________________________________________________________________________

(Name)_______________________________________________ (Date/Time)__________________________ (Response)_________________________________________________________________________________

SECTION II: Please check all appropriate statements. I am objecting to this assignment on the ground that:

	Staff not trained or experienced in area assigned.		The assignment posed a serious threat to health and safety of staff.
	Staff not given adequate orientation to the unit.		Comments:
	Inadequate staff for acuity (short staffed).		The assignment posed a potential threat to the health and safety of the patients.
	The unit was staffed with excessive registry.		Staff involuntarily forced to work beyond scheduled hours.
	The unit was staffed with unqualified personnel or inappropriate _____________ of personnel.		Other (please explain):
	New patients were transferred or admitted to the unit without adequate staff.		Other (please explain):

SECTION III: Complete to the best of your knowledge the patient census at the time of your objection. From your assessment, indicate for each acuity level, the number of patients on the unit, which fit into the category. If there are acuity factors not listed, please specify what they are.

Census and Acuity

Patient Census: Start _____ End _____ Unit Capacity _____ Admissions _____ Discharge _____

Acuity Levels: High _____ Average _____ Low _____

Factors influencing acuity. Check those that apply:

___ on respiratory treatments

___ complete care

___ on ventilators

___ on isolation precautions

___ restrained

___ suicide precaution

___ immediately post-op (less than 4 hours)

___ receiving blood products/transfusions

___ require vital signs/nursing assessment more frequently than routine

___ emergency surgeries

___ other (please specify)

SECTION IV: Complete to the best of your knowledge.

PATIENT CARE STAFFING COUNT

	RN	LPN	AIDE	OTHER	CLERK / SECRETARY	PREVIOUS NUMBER OF STAFF FOR EQUILEVANT CENSUS / ACUITY
Start of Shift
End of Shift

SECTION V: Complete this section if you think the situation cannot be explained adequately in Section 2 and 3, or if you think additional information is relevant. Brief statement of problem: _____________________________________________________________________________________________________________

As a patient advocate, in accordance with the Nurse Practice Act, this is to confirm that I notified you that, in my professional judgment, this assignment is unsafe and places the patient or staff at risk. I indicate my acceptance of the assignment under protest. It is not my intention to refuse to accept the assignment and thus raise questions of meeting my obligations to the patient or of my refusal to obey an order, which was given; however, I hereby give notice to my employer of the above facts and indicate that for the reasons listed, full responsibility for the consequences of this assignment must rest with the employer. Copies of this form may be provided to any and all appropriate State and Federal Agencies.

_______________________________________            ________________________________________________

Nurse Signature                                                           Print Name

White: Supervisor     Canary: DON/Administrator           Pink: KNA or Unit President            Gold: RN

PATIENT CARE STAFFING COUNT

OTHER

White: Supervisor Canary: DON/Administrator Pink: KNA or Unit President Gold: RN