How to Manage an Assignment Despite Objection: 5 Tips for Facilities

In healthcare, Assignment Despite Objection (ADO) paperwork is used to document a situation in which a nurse feels that a patient assignment is unsafe. It serves as a formal notice to leadership as well as a papertrail that may provide licensure protection down the line (for instance, if a mistake is made or patient harm occurs).

In most cases, the ADO process is designed to be used only after other steps have been taken to try to rectify the unsafe situation. It can be viewed as a last resort and safety net, not a first line of defense against poor staffing practices. This article will discuss the purpose of ADO forms in more detail. We’ll review an example scenario that highlights the ADO paperwork submission process and list five tips for facilities looking to appropriately manage ADO situations to ensure staff protection and patient safety.

What Does Assignment Despite Objection Mean?

The term Assignment Despite Objection is used to describe a situation in which a nurse has been made responsible for an unmanageable patient load. Despite making it clear to unit leadership that the staff member feels unsafe, unqualified, or unsupported in managing the care of that particular assignment, they have been mandated to assume care for that assignment.

A nurse may complete an ADO for a number of reasons, including:

• Being assigned to care for a number of patients that falls outside of any legal nurse-to-patient ratio.
• Feeling inexperienced or untrained in a particular area or specialty.
• Experiencing a shortage of support staff that would make the assignment manageable.
• Lacking sufficient safety equipment or machinery to provide care effectively.
• Being forced to work overtime or miss meal breaks.

What Is an ADO’s Purpose?

ADO paperwork helps provide legal protection for nurses who believe they may be put in an unsafe patient care situation. “Whistleblowing” the potential for patient harm doesn’t completely remove liability from the nurse, but it does raise concerns for facility leadership and can put them on notice of elevated patient care risks. State nursing boards and nursing unions encourage staff to complete ADO paperwork to protect themselves and their patients.

What Is an ADO Process Typically Like?

The process for filing protest documentation may look different depending on facility protocols, union status, and state laws. Depending on the systems in place, the documentation may be called a staffing objection form, unsafe staffing report, objection to assignment (OTA), or assignment under protest (AUP). In most cases, formally documenting an unsafe nursing assignment occurs as a part of the following process:

• A nurse gives leadership a verbal notification about the safety issues involved in the assignment, and reasoning for protesting the assignment.
• If the nurse receives an order to provide care without a resolution, filing an ADO (or similar documentation) is the next step.

Some facilities have additional steps for internal reporting purposes, such as filing an incident report to contribute to quality improvement efforts.

What Does ADO Paperwork Look Like?

Each state nursing board or nursing union utilizes its own version of an ADO form, which covers employees working in that state. While they all vary in terms of layout or design, each form contains similar elements, including:

• The nurse’s name, license number, and place of employment.
• The supervisor’s name and date/time of notification.
• The reason for the nurse’s objection.
• The unit’s census details, including the number of patients and staff members.
• A space to outline any actual or potential patient harm that may have been caused.

Assignment Despite Objection: Example Scenario

The ADO process can seem confusing out of clinical context. The table below details the steps involved when a nursing professional files an ADO, along with a scenario to help highlight the process in a realistic clinical situation.

Managing an ADO: 5 Tips for Facilities

As you review how the Assignment Despite Objection form submission process works, you’re probably looking for tips on how to effectively manage these situations in your unit or facility. Below, we provide five key strategies for managing an ADO safely and effectively.

1. Ensure All Patient Assignments Meet Mandated State Staffing Ratios

A key step to keeping clinical operations running smoothly is to prevent ADO situations from arising in the first place. Adhering to your state’s legally mandated staffing ratios is the first step to ensuring compliance and safety. Acuity concerns can also initiate an ADO, meaning in healthcare environments like inpatient settings, the severity and complexity of each patient’s condition must be accounted for when creating assignments.

2. Provide Staff Training on ADO Protocol

Many nurses might not be familiar with the ADO process. They may not know how to speak up if they find themselves in a situation where they aren’t able to practice safely or competently. One way to prevent this from happening is to include Assignment Despite Objection education as part of your employee onboarding training.

Be sure to show staff where to find the forms, explain how to complete them, and relay who to submit them to when necessary. This not only helps your staff feel empowered and supported, but also ensures that your patients receive the best possible care.

It’s important to be transparent about the potential consequences of refusing an assignment. Provide training regarding how the protest documentation relates to refusal policies. For example, you may want to answer the following questions for your staff:

• Can a nurse be fired for refusing an assignment?
• Can a nurse refuse an assignment?
• Why would I continue to provide patient care if I feel the assignment is unsafe?

Answering these questions by citing facility- and state-specific regulations will help nurses understand the disciplinary action that may follow the decision to reject an assignment. Accepting the assignment under objection is an alternative.

3. Encourage Team Cohesion

As the term “objection” implies, ADO submissions can become contentious if management and nursing staff perceive each other to be on separate teams. It’s important that both sides abandon the “them versus us” mentality and understand that the entire unit is focused on preserving staff and patient safety.

Team bonding activities can help to unite facility leadership and bedside staff and ensure that no side feels like they’re fighting against the other. Collaborative team meetings can also help clinical leaders and staff work side-by-side to discuss mutual issues and problem solve together.

4. Incorporate Per Diem and Float Pool Nurses to Cover Schedule Gaps

One of the most common reasons an ADO arises is due to short staffing. By utilizing flexible staffing solutions, you can ensure that all patient assignments can be safely distributed, even during high census.

Per diem nurses, who work only one or two shifts a week, could be added into the staffing matrix on busy shifts or during predictable nursing shortages like maternity leaves or staff vacations. Float pool nurses, alternatively, could be requested on short notice to assist with unpredictable staff shortages like sick calls.

5. Review Submitted ADO Paperwork to Plan Long-Term Solutions

The submission of an ADO form only means that the situation has been documented. It doesn’t mean that the situation was handled safely or that outcomes were improved.

Therefore, it’s essential that facility management reviews those forms and performs a root-cause analysis to prevent future improper patient assignments. Typically, this is done in unit leadership meetings or in a facility-wide shared governance committee.

Discover More Ways to Promote Patient Safety in Your Facility

Safely managing an Assignment Despite Objection situation prevents future patient harm and ensures your staff members practice safely and effectively. Follow along in our expertly written newsletter for additional tips and strategies on encouraging employee engagement and optimizing care quality.

Legal Disclaimer: This article contains general legal information, but it is not intended to constitute professional legal advice for any particular situation and should not be relied on as professional legal advice. Any references to the law may not be current, as laws regularly change through updates in legislation, regulation, and case law at the federal and state level. Nothing in this article should be interpreted as creating an attorney-client relationship. If you have legal questions, you should seek the advice of an attorney licensed to practice in your jurisdiction.