How to Manage an Assignment Despite Objection: 5 Tips for Facilities
Nurses are legally accountable for the quality of care they provide to patients. Under that responsibility, they must ensure that they’re competent to provide the treatment necessary for each individual assigned to their care. While most supervisors attempt to allocate patients according to each nurse’s ability, there are instances where a nurse may believe that their assignment places themselves or their patients at risk.
In these situations, it is the nurse’s duty to complete an Assignment Despite Objection (ADO) form. You may be wondering — What does ADO paperwork look like, and what are the steps required to ensure the forms are completed appropriately?
In this article, we introduce the purpose of ADO forms, 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.
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 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 lists the steps involved when a nursing professional files an ADO, along with a scenario to help highlight the process in a realistic clinical situation.
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| Step | Example |
| 1. The RN expresses concern to their supervisor. | Nurse Emily has been assigned the care of three complex patients in her ICU unit. According to her state’s nurse staffing ratios, she should be responsible for a maximum of two patients at any given time.
Upon receiving her assignment, Emily raises her concerns about patient safety and the inappropriateness of the assignment to her unit manager. |
| 2. If no resolution is found, the RN then completes an ADO. | Emily finds a copy of her state’s ADO form on her hospital’s website and completes the form, filling in details about the assignment and her attempt to find a resolution.
She submits copies to her supervisor, the facility’s professional practice committee (PPC), and her labor representative. She also keeps a copy in her own personal records. |
| 3. Facility management receives and dates the form. | Emily’s unit manager signs and dates the form once it has been received. |
| 4. Management responds to Emily and notifies the PPC of the situation. | Emily’s manager has one week to process and review the form, and respond to her submission.
When she receives her response later that week, it contains a written apology from Emily’s unit manager for placing her in that challenging situation and outlines a plan forward to prevent the situation from happening again in the future. |
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 review 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.
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.
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.