Disclaimer – The Usual Warning Label
This article represents my personal reflections, observations and experiences as an Upper Gastrointestinal Clinical Nurse Practitioner working within the NHS. All opinions are my own and do not necessarily reflect those of my employer, colleagues, the NHS or any professional organisation. The clinical situations described are hypothetical or generalised illustrations of healthcare practice. They do not relate to identifiable patients, colleagues or specific clinical incidents. Patient confidentiality and professional boundaries are respected in accordance with the Nursing and Midwifery Council’s Code and social media guidance. This article is intended for general discussion, professional reflection and a modest amount of workplace humour. It does not constitute clinical, employment or legal advice and should not replace professional judgement, local policies, appropriate delegation or established escalation procedures. Saying no should never mean abandoning patients, declining essential care without appropriate arrangements or failing to escalate urgent clinical concerns. Patient safety must always remain the priority. Finally, any suggestion that NHS nurses survive entirely on cold coffee, interrupted lunches and an increasingly impressive collection of unfinished jobs is intended as humour. Although the evidence may be compelling. No nurses, registrars, consultants or discharge letters were harmed in the writing of this article. At least not knowingly.
There are many important words in healthcare.
“Emergency” is one. “Sepsis” is another. “Discharge” is particularly popular with hospital management, especially when followed by the words “before lunchtime”.
But today I want to discuss a rather controversial word.
No.
Yes, you read that correctly. No.
Not “no” as in refusing to help someone. Not “no” as in ignoring a deteriorating patient. And certainly not “no” as in declining to answer your bleep because you have finally managed to locate a cup of coffee that is still above room temperature.
I mean the positive, constructive, professionally responsible no.
The one that prevents you from taking on seventeen additional jobs when you already have twenty-three outstanding.
The one that protects your patients, your colleagues and, perhaps most importantly, your remaining sanity.
Because, somewhat paradoxically, saying no can be one of the most positive things you do during a working day.
And I think nursing could benefit from doing it a little more often.
The Great Nursing Tradition of Saying Yes
If you have worked in nursing for any length of time, you will probably recognise the following conversation.
“Could you just do this quickly?”
“Yes, of course.”
“And could you also chase that blood result?”
“Yes, no problem.”
“Can you speak to the family?”
“Absolutely.”
“And can you sort out the discharge paperwork?”
“Leave it with me.”
At which point you look down at your job list and realise that you have inadvertently agreed to perform the duties of approximately four healthcare professionals, two administrators and a moderately efficient personal assistant.
All before lunch.
Which, incidentally, you are unlikely to have.
I think this is particularly problematic for newly qualified nurses.
During your student placements, you have a mentor who seems capable of organising an entire ward with little more than a pen, a drug trolley and an increasingly suspicious cup of tea.
You observe, assist and gradually develop your confidence.
Then you qualify.
Suddenly, the telephone rings every forty seconds. The healthcare assistant is asking you for advice rather than your mentor. The ward manager wants to know when the next patient is going home. Someone needs intravenous antibiotics, another patient requires analgesia, and a relative would like an update.
Meanwhile, the computer has decided that today would be an excellent opportunity to install an update.
And still, when someone asks whether you can do another job, your instinctive response is:
“Yes, of course.”
Because you want to be helpful. You want to be a good nurse. You want your colleagues to think you are capable.
And somewhere along the line, being helpful becomes confused with being permanently available. This is where the problems begin.
Is This a Particularly British Problem?
To a certain extent, I wonder whether this is a particularly English phenomenon.
There is something wonderfully British about agreeing to something you absolutely do not have time to do, apologising for the inconvenience and then thanking the person for giving you the additional work.
I grew up in Germany, where communication can occasionally be a little more direct.
If something cannot reasonably be done, the response might simply be:
“Nein.”
Followed, perhaps, by an explanation.
In Britain, the equivalent sometimes sounds more like:
“I’m terribly sorry, I was just wondering whether perhaps it might be possible for me not to do that immediately, if that’s alright?”
By which point the person asking has probably given you three more jobs.
Now, this is a cultural observation rather than a scientific conclusion. There are plenty of wonderfully direct British colleagues and equally accommodating Germans.
Nevertheless, I have always found that being clear about what I can and cannot do is considerably more productive than agreeing to everything and hoping that an additional eight hours somehow materialise during my shift.
Spoiler alert: they don’t.
Two Things I Learnt Relatively Early
There are two things I realised quite early in my nursing career.
Firstly, I had absolutely no desire to climb the traditional ward management ladder.
Becoming a ward manager never particularly appealed to me.
I have enormous respect for those who choose that path. Managing staffing, sickness, complaints, rotas, budgets, patient flow and the seemingly endless pursuit of available beds requires a very particular set of skills.
Not to mention a remarkable tolerance for meetings.
Personally, I prefer the clinical side of nursing.
Which is probably why I ended up in Upper GI surgery, where life is certainly not without its complications, although these usually involve gallstones, pancreatitis or the occasional gastrointestinal tract deciding to become particularly uncooperative.
Secondly, I realised that saying no is not necessarily a negative behaviour.
Quite the opposite.
Provided it is reasonable, respectful and explained appropriately, it can be a sign of professional maturity.
I rarely say no without explaining why.
More importantly, I usually try to offer a reasonable alternative.
For example:
“I cannot do that immediately because I am dealing with something more urgent. However, I can look at it afterwards.”
Or:
“I don’t have the capacity to take that on safely at present. Can we discuss who else might be available?”
This is not refusing to work.
It is recognising that there is a finite amount of time in the day and, unfortunately, I have yet to discover a reliable method of cloning myself.
Although I suspect the NHS would find a use for the technology almost immediately.
When Saying No Becomes a Patient Safety Issue
There is a serious reason behind all this.
Healthcare professionals cannot safely perform an unlimited number of tasks simultaneously.
Research has repeatedly demonstrated associations between excessive workload, insufficient staffing and professional burnout.
Dall’Ora et al. (2020), in a review of 91 studies examining burnout in nursing, identified high workload, time pressure, inadequate staffing and reduced professional autonomy among the factors associated with burnout.
Similarly, Ball et al. (2014) demonstrated an association between staffing levels, workload and nursing care being left undone in English NHS hospitals.
In other words, when people have too much to do, some things simply do not get done.
Not because nurses are lazy.
Not because they lack commitment.
But because there are only so many minutes in an hour.
The Nursing and Midwifery Council (NMC, 2018) requires nurses to preserve safety, recognise the limits of their competence and raise concerns when patient safety may be compromised.
Therefore, recognising that your workload has become unsafe is not a professional weakness.
It may actually be an essential part of practising responsibly.
Let’s take a fairly ordinary example from my current Upper GI role.
Imagine that I have been asked to complete a discharge letter.
An important task, certainly. We want our patients to leave hospital with the correct information, appropriate medications and a clear management plan.
At precisely the same moment, my bleep goes off.
A patient is critically unwell and requires urgent clinical assessment.
Now I have two jobs.
One is administrative, although clinically important.
The other involves a patient who may deteriorate rapidly.
The priority is obvious.
I attend the critically unwell patient, ensuring an appropriate emergency response and escalation, while the discharge documentation waits or is reassigned if necessary.
If someone asks whether I can complete the letter immediately, the answer is:
“No, not at present. I am attending a critically unwell patient. Once that situation is safely managed, I can review the discharge paperwork.”
Usually, that explanation is perfectly sufficient.
Occasionally, someone might point out that the patient is waiting for transport.
Unfortunately, the ambulance service has not yet developed the technology to make clinical priorities disappear.
And that is really the point.
Urgency is not determined by who asks most frequently or who speaks the loudest.
It is determined by clinical need, risk and patient safety.
Other Occasions When No Is Entirely Appropriate
There are several situations where saying no, or at least “not right now”, is not only reasonable but professionally important.
1. Being asked to undertake a task outside your competence
Nobody should feel pressured into performing a clinical procedure they have not been trained or assessed as competent to undertake.
A perfectly acceptable response is:
“I am not competent to perform that independently. I am happy to assist, but we need someone appropriately trained.”
The NMC Code specifically supports recognising professional limitations and seeking assistance when required (NMC, 2018).
Confidence is admirable. Unjustified confidence with a cannula, prescription chart or invasive procedure is rather less so.
2. Being given additional work during an already unsafe workload
If you are responsible for multiple complex patients and someone asks you to take on another time-consuming task, it is reasonable to explain your current workload and request help prioritising.
Saying yes without identifying the capacity problem does not magically create additional staff.
It simply makes the problem less visible.
3. Being asked to compromise established safety procedures
Whether it involves medication administration, patient identification, clinical documentation or appropriate escalation, shortcuts should never become acceptable merely because everyone is busy.
There is a difference between working efficiently and cutting corners.
One saves time.
The other may eventually require a Datix and a very uncomfortable meeting.
4. Being asked to take on additional shifts when you are exhausted
We all know colleagues who seem to work every available shift.
Their dedication is impressive.
Their relationship with their own fatigue is perhaps less reassuring.
Rest matters, and accepting every available overtime shift is not necessarily sustainable.
5. Being asked to complete something that is not a current clinical priority
Sometimes a task simply needs to wait.
That is not necessarily a failure.
It is called prioritisation.
Although I appreciate that in the NHS, the phrase “Can you just quickly…” is frequently used to introduce a task that is neither quick nor particularly simple.
But How Do You Actually Learn to Say No?
For someone who has spent years agreeing to everything, saying no can feel surprisingly uncomfortable.
Fortunately, it is a skill that can be developed.
Start by stopping before answering.
You do not have to respond immediately to every request.
Take a few seconds to consider your existing responsibilities.
Ask yourself: Is this urgent? Am I the right person? Can I do it safely? What happens to my other tasks if I agree?
Sometimes five seconds of thought can prevent fifty minutes of regret.
Use the phrase “not right now”.
If a complete refusal feels uncomfortable, explain when the task could reasonably be undertaken.
“I cannot do that immediately, but I can review it after the ward round.”
This acknowledges the request without creating an unrealistic promise.
Explain your priorities without becoming defensive.
You do not need to deliver a lengthy legal argument every time you decline an additional task.
A brief, factual explanation is usually sufficient.
“I am currently managing two urgent clinical issues and cannot safely take on another task without support.”
That is clear, professional and reasonable.
Offer alternatives where possible.
Perhaps another appropriately qualified colleague is available.
Perhaps the task can wait.
Perhaps the person requesting it can assist.
Or perhaps it needs escalation to someone who can redistribute the workload.
Remember, delegation does not mean simply handing a problem to someone else. The task must be appropriate for that person’s competence, capacity and responsibilities, with appropriate supervision.
Practise being comfortable with a little disappointment.
This is probably the hardest part.
Not everyone will be delighted when you say no.
Some people may even look mildly offended.
That is fine.
You are responsible for communicating respectfully and practising safely.
You are not responsible for ensuring that every colleague agrees with every decision you make.
When No Is Not Really an Option
Of course, there is one rather significant complication.
Sometimes, particularly during an on-call shift, saying no is not a realistic option.
The bleep continues.
New admissions arrive.
Patients deteriorate.
The emergency department requests reviews.
Another ward wants advice.
And the job list grows at a speed that would make a particularly aggressive spreadsheet jealous.
In those situations, we cannot simply decline clinically necessary work and hope somebody else deals with it.
However, we can change how we manage the pressure.
First, prioritise by clinical urgency rather than the order in which jobs arrive.
A deteriorating patient takes priority over routine administration.
A time-critical intervention takes priority over a non-urgent review.
And tasks that can safely wait should be identified as such.
Second, make the workload visible.
One of the worst things healthcare professionals can do is struggle silently.
If you have fourteen outstanding jobs, several urgent reviews and another six requests arriving, tell the registrar, consultant, nurse in charge or appropriate senior colleague.
Ask for help prioritising and reallocating tasks.
Not every job needs to be completed by the person whose bleep happened to ring first.
Third, communicate anticipated delays.
Sometimes a simple explanation can prevent unnecessary frustration.
“I have received your referral, but I am currently attending an emergency. I cannot review the patient immediately. If their condition changes, please escalate through the appropriate urgent pathway.”
Importantly, urgent requests still require timely assessment, appropriate handover or escalation rather than being left unattended.
Fourth, use structured communication.
The Agency for Healthcare Research and Quality (AHRQ, 2023) promotes the TeamSTEPPS CUS approach when raising safety concerns:
- C – Concerned: “I am concerned about the current workload.”
- U – Uncomfortable: “I am uncomfortable that I cannot complete these clinical reviews safely within the available time.”
- S – Safety: “I believe this is becoming a patient safety issue and we need additional support.”
Sometimes stating the problem clearly is considerably more useful than soldiering on until everything falls apart.
Fifth, take a brief moment to reorganise.
When the workload becomes overwhelming, stop briefly when clinically safe to do so, review outstanding jobs and establish priorities.
A written list is invaluable.
Not because it reduces the number of jobs, unfortunately, but because it prevents important tasks disappearing into the increasingly crowded space between your ears.
And finally, take your breaks when it is safe and possible, arrange appropriate cover, and escalate persistent problems rather than accepting missed breaks and excessive pressure as inevitable.
You cannot deliver safe care indefinitely on caffeine, adrenaline and half a biscuit.
Although several NHS departments appear determined to test that hypothesis.
The Burnout Problem
There is a wider issue here.
Saying yes to everything does not simply increase your workload for one afternoon.
If repeated over months or years, it may contribute to an unhealthy working pattern.
The World Health Organization (WHO, 2019) describes burnout as an occupational phenomenon associated with chronic workplace stress that has not been successfully managed.
Its characteristics include exhaustion, increased mental distance or cynicism towards work, and reduced professional effectiveness.
Importantly, burnout is not simply a problem of individuals failing to manage their workload.
Organisational factors, including staffing, leadership, workload distribution and working conditions, also matter.
Dall’Ora et al. (2020) reinforce this relationship in their analysis of nursing burnout.
Therefore, while learning to say no is useful, it should never become an excuse for organisations to place responsibility for chronic understaffing entirely on individual healthcare professionals.
You can learn every time-management technique available.
You can colour-code your job list.
You can prioritise with military precision.
But if there are more essential tasks than the available workforce can safely complete, the answer is not simply to become more efficient.
Sometimes the answer is more support.
And sometimes the answer is an honest conversation about what can realistically be achieved.
The Positive Side of No
Ultimately, I think we need to change how we perceive the word no.
It does not automatically mean that somebody is unhelpful, difficult or unwilling to work.
Sometimes it means they understand their limitations.
Sometimes it means they are protecting their patients.
Sometimes it means they have recognised that agreeing to another task would compromise something already important.
And sometimes it simply means they would rather finish their shift having completed ten jobs properly than twenty jobs badly.
Having worked in nursing for quite some time, I have become increasingly comfortable with explaining what I can and cannot reasonably achieve.
That does not mean I never feel overwhelmed.
I certainly do.
Particularly during busy Upper GI on-call periods when the inpatient list expands, referrals arrive from several directions and the bleep apparently develops a personal vendetta against me.
But I would much rather have an honest discussion about workload than promise something I cannot safely deliver.
Perhaps this is my German upbringing.
Perhaps it is experience.
Or perhaps, after enough years in the NHS, I have simply learnt that saying yes to everything is an excellent strategy for becoming everybody’s favourite colleague and your own worst enemy.
So the next time somebody asks whether you can squeeze another job into an already impossible shift, remember that you have options.
You can say yes.
You can say not yet.
You can suggest an alternative.
And, when it is appropriate, you can say no.
Because being a good nurse does not mean being available for everything, all the time.
It means knowing what matters, recognising your limits and ensuring that the care you provide remains safe.
And if anybody disagrees with that, they are more than welcome to discuss it with me.
Just not while I am attending a critically unwell patient.
Or, preferably, during my lunch break.
Assuming I manage to have one.
Which, admittedly, remains an ambitious objective.
Some References to underpin my remarks
Agency for Healthcare Research and Quality (AHRQ) (2023) Tool: CUS. Rockville, MD: AHRQ. Available at: https://www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/cus.html (Accessed: 14 October 2026).
Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E. and Griffiths, P. (2014) ‘Care left undone during nursing shifts: associations with workload and perceived quality of care’, BMJ Quality & Safety, 23(2), pp. 116–125. https://doi.org/10.1136/bmjqs-2012-001767.
Dall’Ora, C., Ball, J., Reinius, M. and Griffiths, P. (2020) ‘Burnout in nursing: a theoretical review’, Human Resources for Health, 18, article 41. https://doi.org/10.1186/s12960-020-00469-9.
Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: NMC. Available at: https://www.nmc.org.uk/standards/code/ (Accessed: 15 October 2026).
World Health Organization (WHO) (2019) Burn-out an occupational phenomenon: International Classification of Diseases. Geneva: WHO. Available at: https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases (Accessed: 15 October 2026).
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