Forced to Take an Assignment You Can Not Handle

[1RN4Christ]

Hello! I am a nurse who has been practicing in MO for a little over a year. This is a new profession for me in a new state. I previously attended nursing school in Texas and learned about Safe Harbor there.

Safe Harbor applies when a nurse believes an assignment may place patient's at risk of harm, thus violating the nurse's duty to the patient and also protecting the nurse's license. I searched the Missouri BON site and could not find anything regarding laws that govern duty to the patient such as this one. So, what options does the nurse have regarding this issue? Chain of command?

The reason I ask is because of the assignments I am forced to take when the acuity of my present patients is high. We never go on diversion, even when short-staffed, and are often left without employees to sit on one-on-ones with confused patients although ordered. This makes the shift VERY stressful for everyone and quite unsafe. Then, when a blood transfusion and surgical patient has been added to that workload and you end up with 5 patients and you KNOW you can not tend to everyone following standards of practice, what do you do?

I told my manager I did not have lunch (around 1430) and my patient who needed to be a one-on-one (that the doctor would not order) was getting out of bed every 5 minutes until a point was reached where someone forgot the patient's bed alarm and she almost fell when someone found her out of bed. The patient receiving the transfusion had to wait 3 hours before the 1st unit of PRBC's could begin and their Hgb. was 5.9. The surgical patient was seen once post-op by this nurse and one set of vital signs was recorded (they came to the floor around 1540, toward the end of the shift and had been in recovery for several hours and were supposed to go home that day but nausea and pain were not controlled). There was only one aid on the floor for 21 patients. I was constantly running to the confused patient's room until the time they were found out of bed...after I placed the patient back in bed and put the alarm on I went into the patient's bathroom and cried. The post-op patient had previously complained that no one was caring for her and was an employee of the hospital. I was embarrassed and could not blame her for the complaint as what was happening was unsafe practice.

I did not want to receive the post-op patient because my workload was already heavy and I had started the day with 2 confused patients...thankfully one was eventually discharged. I felt neglectful of the other 4 patients because the very confused patient I was left with practically needed her own nurse.

Sometimes I feel that nurses need advocates, too.

I want to provide the best care possible and feel it is almost impossible on days such as previously described.

Please help!

[martymoose, BSN, RN]

omg , you're describing a typical day for me. It sucks. Those are days you keep saying "time to find a new job", yet there are no other jobs. Nothing like feeling unsafe.Nothing like management saying "sorry, we have no more staff". I feel for you, just don't know what to do about it.

[MunoRN, RN]

That actually sounds pretty typical. I know it sucks, but I know of places where you'd have 7 of those patients, with no additional aide help.

[Sun0408, ASN, RN]

I have to echo what MunoRN says.. I was that nurse with 7 pts with half of them crazy confused climbing out of bed or trying to beat me up. It is pretty typical, although sad. I hope you have a better shift.

[DoeRN]

Unfortunately it is like that everywhere. At least you had 5 patients instead of 7 or 8. Just remember there are other things you can do besides bedside nursing.

Sent from my iPhone using allnurses.com

[1RN4Christ]

Thank you for the responses. I'm amazed at what I'm hearing... I am thankful it's not worse. I just can't believe that this is "normal." Jrwest - THAT is EXACTLY what I think. I love the patient care but I don't know that patient safety and my license is worth the sacrifice...that and I lost partial vision in my left eye from the stress (temporarily).

[Icmhrn]

That is typical hospital nursing. Perhaps you would be happier in homecare? I do both. They are completely different types of nursing, and different types of stress. Just a thought.

[herring_RN, ASN, BSN]

Just because unsafe care is common does not mean we have to risk our patients and our license.

At minimum tell a supervisor or your manager about your concerns. Keep a diary at home and write about every shift, eliminating any potential HIPAA violations. When it is so unsafe yot have to tell a manager or supervisor write who you told, what you said, and how he or she answered.

If there is harm to a patient or you make a mistake the fact that you reported unsafe conditions can mitigate your punishment if reported to the board of nursing or help in court if you are one of the rare nurses sued for malpractice. (I think malpractice insurance is worth the

If you are bold and work with other nurses willing to do so speak up at a staff meeting. Take notes.

You can put your concerns in writing. Write it twice or make a copy and give it to a management person with the authority to obtaine more staff.

If all the above don't help you can write your concerns in detail and sent them to the hospital attorney.

If there is whistleblower protection for nurses in your state you can report unsafe conditions to the state agency that licenses hospitals. Or report to CMS.

Most hospitals make a profit. There is currently no shortage of nurses. There is no excuse for them not to provide sufficient staff to care for patients and meet their needs.

[Becca608]

Unfortunately, it all comes down to money. Experienced nurses are moving to less stressful jobs and the newer nurses are getting thrown out on the general wards. My first 2 years on a med-surg floor were horrible. I went' home and cried almost everyday and ended up on antidepressants. Finally I found a position doing the same thing at a smaller, not for profit hospital. It is much calmer there.

Not everyone is meant to do floor nursing. You have to develop a really thick skin and fast response time to repriortize your entire POC for everyone based on what is happening at that moment. That's just something that comes with time. What concerns me is that I have only been a nurse for 5 years and I see newer nurses coming in that want to sit and 'think' about what to do. When your client with esophageal varices is bleeding out while the post-op patient is demanding pain meds, the confused person is climbing over the bedrails and the other confused person is yanking out her IV, you have to repriortize super fast.

It gets easier as you gain more experience, but some shifts are just shifts from hell. There is no avoiding it.

[oldladyRN]

Call the Dept of State Health Services for the state in which you work.

I'm a Nurse Surveyor for the State of Texas. The State regulations for Texas hospitals (and this applies to acute care hospitals, psychiatric hospitals and critical-access hospitals) contain an entire section devoted to specifics on the "Nurse Staffing Committee". For Texas, this nurse staffing committee must meet at a minimum of annually. The committee must consist of AT LEAST 60% registered nurses who spend at least 50% of their time providing direct patient care. There is also to be a nurse present from PI or Infection Control. This assures input from more than just the paper-pusher nurses who look at a grid, compare it to the census and # of nurses staffed and say "Mmmm, yeah, looks okay to me". Specific topics are to be discussed in these meetings, and the recommendations are then to be presented to the Governing Board and the Performance Improvement committees.

Too many times I have investigated a complaint of "unsafe staffing" only to find that the hospital considers these meetings superfluous and doesn't even have them...has the meetings but the committee is made up of nurses in management positions...the findings and recommendations of the committee are never to be discussed again or any combination thereof. There must be formal meeting minutes taken along with a roster of the attendees. Many facilities are under the misguided notion that these meetings are optional because they have no intention of taking ANY recommendations to the GB or PI committees. A hospital can be met with a pretty stiff civil fine (at least here in Texas) for not following the regulations that pertain to the Nurse Staffing Committee.

Once presented with the findings and recommendations (which are, unfortunately, accompanied by an increase in medication errors, patient falls, hospital-acquired infections etc), the GB and PI committee take action.

I hope this information helps.

oldladyRN

[RainMom]

Was there family that could have been contacted for your confused pt? If no staff is available to sit, we try to contact family who I have found are often willing when you let them know the pt is agitated, getting up, & you are concerned for their safety. Our management is also pretty understanding if we are able to find staff who was not scheduled to work but who are willing to be called in to sit because of the safety issue.

[imintrouble, BSN, RN]

I sympathize with you completely, but 7 is the average pt load where I work. Your shift sounded typical to me.

If you can survive the stress, it does get easier to juggle.