Nurses pulling rank on assignments

Extra Pickles · Jan 31, 2017

Sounds more like she was saying "you should as long as someone doesn't have a hissy and really really want that patient". No, I've never heard of "pulling rank" for an assignment. Having a more experienced nurse take on a certain patient, yes absolutely. But if it's working for two shifts, no reason to switch unless there is a specific issue or complaint.

Sour Lemon · Jan 31, 2017

I thought that was sooo weird. This nurse had been doing a good job at taking care of the patient for 2 days. Why wouldn't she get the same pt back?
Is this someone you guys come across at all? I would be pissed if I was taking care of the same assignment for 2 days, and had to switch for my 3rd.

I prefer to have the same patients back if I worked the night before, but it doesn't always happen for various reasons. It's simply not possible to accommodate every nurse's preferences and whims.

I'm not sure I understand the "pulling rank" comment in this context.

Been there,done that, ASN, RN · Jan 31, 2017

ICU's are staffed with "strong personalities". The ability to pull rank says a lot about the culture of the unit.

The patient would benefit most, from continuity of care. I would never let another nurse take over my assignment.

Sounds like you need to get ready for that scenario.

llg, PhD, RN · Jan 31, 2017

I don't think it is necessarily a bad thing. Perhaps a senior nurse requesting a particular patient has some reason to do so.

Perhaps the inexperienced nurses taking care of the patient for the last 2 days haven't done everything as well as they could be done -- and getting some involvement from an experienced nurse would be a good thing.

Perhaps the senior nurse has taken care of that patient on previous hospitalizations and is actually the "real" continuity here.

Perhaps the senior nurse requests that assignment because that particular patient will pair well with the other patient she is taking -- who has special needs that few staff members can handle.

Perhaps the senior nurse is precepting an orientee who "needs the learning experience" that patient would provide. That would probably be seen as a higher priority than the nurse in the OP's preference to keep the same patient.

Perhaps a lot of things. My point is that the senior staff members of a unit might choose to assign patients in certain ways for a wide variety of reasons that the OP is unaware of. Assigning patients is an art that requires the balancing of many different needs that sometimes conflict with each other. Sometimes, what is best for the unit as a whole (and the majority of patients) may not be what pleases 1 nurse -- or match her perception of what would be best. Until the OP (and we) know the whole story of any particular instance in which a senior nurse pulled rank to get an assignment, we don't know if it was a good or bad judgment. We should give the Charge Nurse the benefit of the doubt until we get the full story.

calivianya, BSN, RN · Jan 31, 2017

We have all kinds of rules for who can take what patients in my unit. Here's what I take into consideration when I'm making assignments:

1. Float pool nurses can't have CRRTs.

2. Travelers also can't have CRRTs.

3. We are supposed to give travelers the easier assignments until they prove themselves.

4. New grads are not supposed to have the most difficult assignments.

5. New grads are not supposed to be tripled for a bit if we can help it.

6. It's pretty much an unspoken rule to triple the float pool and travelers first before tripling regular staff. I try not to do that regularly so the travelers will want to extend, and so the float pool people won't refuse to come to my floor (they're allowed to do that if they get abused).

7. Another unspoken rule - don't triple the same person more than one night in a row. Spread the misery around.

8. Charge is not supposed to take the most difficult assignment. (no free charges here, yo, and you can't be a resource if you're drowning all night)

9. Charge is also not supposed to have a CRRT - because anyone with a CRRT is supposed to sit with the machine in view all night and it would prevent the charge from helping anyone else.

So, when there were five of our regular, experienced people in my section last night (we have 3 charges, each making assignments for one section), but tonight I show up and my section's me, a traveler, two float pool staff, and a regular unit person - that regular unit person might not get their patients back because they're the most flexible worker in my section, where everyone else is restricted on what assignments they can have. And of course most people who get moved pitch a fit but my hands are tied a lot of the time. :dead:

I almost never see anyone pull rank asking for a particular assignment, but... we have some real nightmare families on my unit and it's not uncommon to have four or five families at a time that no one can tolerate being around for more than one shift. Requests to NOT have a patient back are way more common, and it's often a nightly issue. There's one guy I've successfully refused for more than a month now. He's been with us for three months. Coded 11 times now, I think, unless he's coded again since the last time I worked, and he's on and off CRRT every other week. If I have all five staff refusing to take him, sometimes making the assignments involves a whole bunch of people yelling "Not me!" and the one who yells it last has to take him. Or we have settled it with coin flips before.

Been there,done that, ASN, RN · Jan 31, 2017

We have all kinds of rules for who can take what patients in my unit. Here's what I take into consideration when I'm making assignments:
1. Float pool nurses can't have CRRTs.
2. Travelers also can't have CRRTs.
3. We are supposed to give travelers the easier assignments until they prove themselves.
4. New grads are not supposed to have the most difficult assignments.
5. New grads are not supposed to be tripled for a bit if we can help it.
6. It's pretty much an unspoken rule to triple the float pool and travelers first before tripling regular staff. I try not to do that regularly so the travelers will want to extend, and so the float pool people won't refuse to come to my floor (they're allowed to do that if they get abused).
7. Another unspoken rule - don't triple the same person more than one night in a row. Spread the misery around.
8. Charge is not supposed to take the most difficult assignment. (no free charges here, yo, and you can't be a resource if you're drowning all night)
9. Charge is also not supposed to have a CRRT - because anyone with a CRRT is supposed to sit with the machine in view all night and it would prevent the charge from helping anyone else.
So, when there were five of our regular, experienced people in my section last night (we have 3 charges, each making assignments for one section), but tonight I show up and my section's me, a traveler, two float pool staff, and a regular unit person - that regular unit person might not get their patients back because they're the most flexible worker in my section, where everyone else is restricted on what assignments they can have. And of course most people who get moved pitch a fit but my hands are tied a lot of the time.
I almost never see anyone pull rank asking for a particular assignment, but... we have some real nightmare families on my unit and it's not uncommon to have four or five families at a time that no one can tolerate being around for more than one shift. Requests to NOT have a patient back are way more common, and it's often a nightly issue. There's one guy I've successfully refused for more than a month now. He's been with us for three months. Coded 11 times now, I think, unless he's coded again since the last time I worked, and he's on and off CRRT every other week. If I have all five staff refusing to take him, sometimes making the assignments involves a whole bunch of people yelling "Not me!" and the one who yells it last has to take him. Or we have settled it with coin flips before.

How does this answer the OP's question?

VANurse2010 · Jan 31, 2017

I don't think it is necessarily a bad thing. Perhaps a senior nurse requesting a particular patient has some reason to do so.
Perhaps the inexperienced nurses taking care of the patient for the last 2 days haven't done everything as well as they could be done -- and getting some involvement from an experienced nurse would be a good thing.
Perhaps the senior nurse has taken care of that patient on previous hospitalizations and is actually the "real" continuity here.
Perhaps the senior nurse requests that assignment because that particular patient will pair well with the other patient she is taking -- who has special needs that few staff members can handle.
Perhaps the senior nurse is precepting an orientee who "needs the learning experience" that patient would provide. That would probably be seen as a higher priority than the nurse in the OP's preference to keep the same patient.
Perhaps a lot of things. My point is that the senior staff members of a unit might choose to assign patients in certain ways for a wide variety of reasons that the OP is unaware of. Assigning patients is an art that requires the balancing of many different needs that sometimes conflict with each other. Sometimes, what is best for the unit as a whole (and the majority of patients) may not be what pleases 1 nurse -- or match her perception of what would be best. Until the OP (and we) know the whole story of any particular instance in which a senior nurse pulled rank to get an assignment, we don't know if it was a good or bad judgment. We should give the Charge Nurse the benefit of the doubt until we get the full story.

None of those are legitimate reason except perhaps the orientee. I am an experienced ICU nurse.

VANurse2010 · Jan 31, 2017

We have all kinds of rules for who can take what patients in my unit. Here's what I take into consideration when I'm making assignments:
1. Float pool nurses can't have CRRTs.
2. Travelers also can't have CRRTs.
3. We are supposed to give travelers the easier assignments until they prove themselves.
4. New grads are not supposed to have the most difficult assignments.
5. New grads are not supposed to be tripled for a bit if we can help it.
6. It's pretty much an unspoken rule to triple the float pool and travelers first before tripling regular staff. I try not to do that regularly so the travelers will want to extend, and so the float pool people won't refuse to come to my floor (they're allowed to do that if they get abused).
7. Another unspoken rule - don't triple the same person more than one night in a row. Spread the misery around.
8. Charge is not supposed to take the most difficult assignment. (no free charges here, yo, and you can't be a resource if you're drowning all night)
9. Charge is also not supposed to have a CRRT - because anyone with a CRRT is supposed to sit with the machine in view all night and it would prevent the charge from helping anyone else.
So, when there were five of our regular, experienced people in my section last night (we have 3 charges, each making assignments for one section), but tonight I show up and my section's me, a traveler, two float pool staff, and a regular unit person - that regular unit person might not get their patients back because they're the most flexible worker in my section, where everyone else is restricted on what assignments they can have. And of course most people who get moved pitch a fit but my hands are tied a lot of the time.
I almost never see anyone pull rank asking for a particular assignment, but... we have some real nightmare families on my unit and it's not uncommon to have four or five families at a time that no one can tolerate being around for more than one shift. Requests to NOT have a patient back are way more common, and it's often a nightly issue. There's one guy I've successfully refused for more than a month now. He's been with us for three months. Coded 11 times now, I think, unless he's coded again since the last time I worked, and he's on and off CRRT every other week. If I have all five staff refusing to take him, sometimes making the assignments involves a whole bunch of people yelling "Not me!" and the one who yells it last has to take him. Or we have settled it with coin flips before.

Really? You triple the travelers and floats first - the ones who bail you out of staffing clusters? What a s show of a unit.

Cowboyardee · Feb 1, 2017

"Pulling rank" sounds like a senior nurse can request an assignment and expect to get it. On the one hamd, i dont think I'd like to work in that kind of environment. On the other hand, if it happened all that much on your unit, you likely would have noticed it in your first four months there. So I wonder if something is getting lost in translation here.

The only real "rank pulling" you might see on units where I've worked is preceptors with an orientee picking their assignment, usually wanting a sick patient or something the orientee hasn't yet encountered. However, we frequently have to shift around assingments to accommodate triples and/or 1:1s, and some of the newer nurses (or, in truth, even some of the senior nurses who can't see beyond their own noses) don't seem to understand why they don't always have their patients back. This seems to be the M.O. at most ICUs, but your milage may vary.

Julius Seizure · Feb 1, 2017

Really? You triple the travelers and floats first - the ones who bail you out of staffing clusters? What a s show of a unit.

Crappy unspoken rule, but not at all uncommon. Funny though, that travelers can't be trusted with any but the easiest patients until "proving themselves", but they can be trusted to manage a heavier patient load over regular staff. Or float to whereever in the hospital before any one else is considered. But yes, they can barely be trusted. :)

Calivianya, this wasn't meant to be a dig at you. Its about the way that hospitals across the country treat travelers. I appreciate that you say you try not to always do that, because yeah, it gets old!

BSN16 · Feb 1, 2017

we never have nurses pull rank....but generally if we have an extremely sick patient that hasn't previously been assigned it will probably go to a more experienced RN.

that being said, we also believe in continuity of care