KENTUCKY BOARD OF NURSING 312 Whittington Parkway, Suite

AOS #19 Patient Care Assignments

(Revised 12/2018)

KENTUCKY BOARD OF NURSING

312 Whittington Parkway, Suite 300

Louisville, Kentucky 40222-5172

http://kbn.ky.gov

ADVISORY OPINION STATEMENT

RESPONSIBILITY AND ACCOUNTABILITY OF NURSES

FOR PATIENT CARE ASSIGNMENTS AND NURSING CARE DELIVERY

Rationale for Advisory Opinion

The Kentucky Board of Nursing has received multiple inquiries regarding the appropriate utilization of

licensed nursing personnel in the delivery of nursing care. Inquiries sought guidelines related to the roles

of nurses in accepting or rejecting an assignment in a specialized care area for which the nurse is

unfamiliar, as well as nurse/patient ratios.

The Kentucky Board of Nursing is authorized by

Kentucky Revised Statutes (KRS) Chapter 314 to

regulate nurses, nursing education and practice,

promulgate regulations and to issue advisory opinions on

nursing practice, in order to assure that safe and

effective nursing care is provided by nurses to the

citizens of the Commonwealth.

The Kentucky Board of Nursing issues advisory opinions

as to what constitutes safe nursing practice. As such, an

opinion is not a regulation of the Board and does not

have the force and effect of law. It is issued as a

guideline to licensees who wish to engage in safe

nursing practice, and to facilitate the delivery of safe,

effective nursing care to the public.

Opinion: Responsibility and

Accountability of Nurses for Patient

Care Assignments and Nursing Care

Delivery

Approved Date: 10/1988

Revised: 1/1993; 6/1996; 4/2002;

2/2005; 12/2018

Editorial Revision: 12/2005; 1/2011;

5/2012, 4/2015; 5/2018

Reviewed: 1/2011

Accountability and Responsibility of Nurses

In accordance with KRS 314.021(2), nurses are responsible and accountable for making decisions

that are based upon the individuals’ educational preparation and current clinical competence in

nursing, and requires licensees to practice nursing with reasonable skill and safety. Nursing practice

should be consistent with the Kentucky Nursing Laws, established standards of practice, and be

evidence based.

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After review of the statutes governing nursing practice and study of the issues and concerns, the

Kentucky Board of Nursing adopted an advisory opinion statement addressing nurses' responsibility and

accountability concerning patient care assignments and nursing care delivery.

Advisory Opinion

Nursing Assignments

All nurses share in the responsibility, within the context of their positions, for assuring that nursing care is

provided in a safe and effective manner. In order to assure this provision of care, patient care

assignments should be commensurate with the qualifications of each nursing staff member, the nursing

needs of the patient, and the prescribed medical plan of care.

KRS 314.021(2) imposes individual responsibility upon nurses to undertake the performance of

acts/procedures for which they are prepared by virtue of their education and experience in nursing. Acts

which are within the permissible scope of practice for a given licensure level may be performed only by

those nurses who personally possess the education and experience to perform those acts safely and

competently.

In order to make a determination as to the appropriateness of a nurse being assigned to provide patient

care in a specific area, the following factors should be considered:

1) The kinds of acts being performed;

2) The condition of the patient for whom the acts are being performed;

3) The situation in which the acts are performed;

4) The preparation and experience of the nurse performing the acts; and

5) The ability of the nurse to recognize adverse reactions and the capability to take appropriate

actions in order to protect the patient.

Temporary Reassignment to Specialized Care Areas

When a nurse is temporarily assigned to an unfamiliar, specialized, or "high-tech" patient care area, the

nurse is expected to utilize core knowledge and competence to provide patient care.

The duties expected of the nurse should be outlined, and the nurse should have the ability to perform

those duties. Further, the nurse in such a situation should be under the on-site supervision of a

registered nurse who is prepared by virtue of education and experience to practice competently in the

specific area.

A nurse who doubts his/her competence to perform a requested act has an affirmative obligation to:

1) Collaborate with the appropriate supervisory nursing personnel to assist in the performance of the

act; and

2) Request the educational preparation and supervised clinical practice necessary to perform the act.

If the appropriate training or supervision is not provided, then the nurse is obligated to refuse to perform

the act and to inform the supervisory nursing personnel, and/or the prescribing physician/provider, as

applicable.

Nurse/Patient Ratios

The Kentucky Board of Nursing does not establish a ratio for the given number of patients for which a

nurse may be assigned. Pursuant to the KRS Chapter 216B, the Cabinet for Health and Family Services

promulgate administrative regulations requiring that health care facilities employ a sufficient number of

qualified personnel to meet the needs of the patients [902 KAR 20:016; 048; 051]. A patient/nurse ratio

should be minimally based upon the qualifications of each nursing staff member, nursing care needs of

the patient, and the patient's prescribed medical and nursing care requirements set forth in a plan of care.

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When patients do not receive necessary care because of understaffing, then the specific facts of the

given situations should be documented and reported to the nurse's chain of command as well to the

Cabinet for Health and Family Services, Office of the Inspector General, Division of Health Care Facilities

and Services, (502-564-7963), and to the Joint Commission on Accreditation of Healthcare

Organizations.

If a nurse judges that he or she is unable to provide safe and competent care related to the number of

patients to be assigned to that nurse, then the nurse is obligated to refuse to accept the assignment and

to inform the supervisory nursing personnel, and/or the prescribing physician/provider, as applicable.

If a nurse accepts an assignment believed to be unsafe, or for which the nurse is not

educationally prepared, the nurse assumes the potential liability that may occur as the result of

the assignment. Others may equally or concurrently be held responsible, accountable, and liable

for the nurse's actions.

Health care facilities are responsible for maintaining adequate staff. The nurse administrator(s) who

determines staffing patterns and/or appropriate assignments shares in the responsibility for assuring that

staff are available to provide safe and effective nursing care, and that staff are appropriately distributed,

utilized, oriented, and have available resources necessary to provide care. Nurses should work in a

collaborative, cooperative, responsible relationship to assure these outcomes.

Nursing practice should be consistent with the Kentucky Nursing Laws, established standards of practice,

and be evidence based.

ANA Position Statement 2019

The American Nurses Association has also addressed this matter. In the Position Statement entitled

“Patient Safety: Rights of Registered Nurses when Considering a Patient Assignment” the ANA states, in

part,

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 to raise concerns regarding any patient

assignment that puts patients or themselves at risk for harm. The professional obligations of the

registered nurse to safeguard patients are grounded in the Nursing’s Social Policy Statement

(ANA, 2003), Code of Ethics for Nurses with Interpretive Statements (ANA, 2001b), Nursing:

Scope and Standards of Practice (ANA, 2004), and state laws, and rules and regulations

governing nursing practice.

(https://www.nursingworld.org/practice-policy/nursing-

excellence/official-position-statements/id/patient-safety-rights-of-registered-nurses-when-

considering-a-patient-assignment/ )

The Kentucky Board of Nursing issues advisory opinions as to what constitutes safe nursing practice. An

opinion is not a regulation of the Board and does not have the force and effect of law. It is issued as a

guideline to licensees who wish to engage in safe nursing practice.

Determining Scope of Practice

KRS 314.021(2) holds all nurses individually responsible and accountable for the individual's acts based

upon the nurse's education and experience. Each nurse must exercise professional and prudent

judgment in determining whether the performance of a given act is within the scope of practice for which

the nurse is both licensed and clinically competent to perform.

In addition to this advisory opinion statement, the Kentucky Board of Nursing has issued Advisory

Opinion Statement #41 RN/LPN Scope of Practice Determination Guidelines which contains the KBN

Decision-Making Model providing guidance to nurses in determining whether a selected act is within an

individual nurse's scope of practice now or in the future. A copy of the KBN Decision-Making Model for

Determining Scope of Practice for RNs/LPNs may be downloaded from the Board’s website

https://kbn.ky.gov/practice/Documents/41%20KBN%20Decision-

Making%20Model%20for%20Determing%20Scope%20of%20Practice%20for%20RNs-LPNs.pdf.

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Applicable Statutes From the Kentucky Nursing Laws

KRS 314.011(6) defines "registered nursing practice" as:

…The performance of acts requiring substantial specialized knowledge, judgment, and nursing skill

based upon the principles of psychological, biological, physical, and social sciences in the

application of the nursing process in:

a) The care, counsel, and health teaching of the ill, injured or infirm;

b) The maintenance of health or prevention of illness of others;

c) The administration of medication and treatment as prescribed by physician, physician

assistant, dentist, or advanced practice registered nurse and as further authorized or limited

by the board, and which are consistent either with American Nurses' Association Scope and

Standards of Practice or with standards of practice established by nationally accepted

organizations of registered nurses. Components of medication administration include, but are

not limited to:

1. Preparing and giving medication in the prescribed dosage, route, and frequency, including

dispensing medications only as defined in subsection (17)(b) of this section;

2. Observing, recording, and reporting desired effects, untoward reactions, and side effects

of drug therapy;

3. Intervening when emergency care is required as a result of drug therapy;

4. Recognizing accepted prescribing limits and reporting deviations to the prescribing

individual;

5. Recognizing drug incompatibilities and reporting interactions or potential interactions to

the prescribing individual; and

6. Instructing an individual regarding medications;

d) The supervision, teaching of, and delegation to other personnel in the performance of

activities relating nursing care; and

e) The performance of other nursing acts which are authorized or limited by the board, and which

are consistent either with American Nurses' Association Standards of Practice or with

Standards of Practice established by nationally accepted organizations of registered nurses.

KRS 314.011(10) defines "licensed practical nursing practice" as:

…The performance of acts requiring knowledge and skill such as are taught or acquired in

approved schools for practical nursing in:

a) The observing and caring for the ill, injured, or infirm under the direction of a registered nurse,

advanced practice registered nurse, physician assistant, a licensed physician, or dentist;

b) The giving of counsel and applying procedures to safeguard life and health, as defined and

authorized by the board;

c) The administration of medication or treatment as authorized by a physician, physician

assistant, dentist, or advanced practice registered nurse and as further authorized or limited

by the board which is consistent with the National Federation of Licensed Practical Nurses or

with Standards of Practice established by nationally accepted organizations of licensed

practical nurses;

A copy of the Kentucky Nursing Laws may be downloaded from the Kentucky Board of Nursing website at

http://kbn.ky.gov.

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d) Teaching, supervising, and delegating except as limited by the board; and

e) The performance of other nursing acts which are authorized or limited by the board and which

are consistent with the National Federation of [Licensed] Practical Nurses' Standards of

Practice or with Standards of Practice established by nationally accepted organizations of

licensed practical nurses.

KRS 314.021(2) holds all nurses responsible and accountable for making decisions that are based upon

the individuals' educational preparation and experience in nursing.