Accepting or not accepting the client which jeopardizes the license the most?

Littlewonder · Jul 12, 2005

If I understand right, it would be better to refuse the new admit. I do not think you could be "abandoning" a client who you had not taken report on and not cared for - just as if you come to work and are told you are to care for 16 people you would not be accused of abandonment if you refused report and simply ran away!!! (You might lose your job but...) I suppose that mass trauma situation might have been different, but in the case you described, there WERE other nurses who could have taken (and possibly should have taken) the new admit.

BETSRN · Jul 12, 2005

I had a discussion with my wife this morning concerning a situation she faced last night. She is a relatively new nurse with six months RN experience on a med/surg trauma floor at a large urban hospital. Last night they gave her four initial patients two of which were heavy loads with hourly meds, and barrier isolation. About three hours into her shift she was already slammed running late on two of her meds, several assessments, and a Q4h accucheck at which time they added a fifth new admission to her load. Note, that there were several much more experienced nurses on the shift who only had three clients, and even those three were of the easier non isolation variety. In the morning she was chastised during report for running late on her accuchecks and meds. She was also told that she needed to spend more time reading the patient histories (she didn't even have time to take a lunch or break during her 12 hour, which turned into a 13.5 hour shift). Although, she did not feel that she could safely take a fifth client she said that she had been taught in nursing school that her license (not just her job) could be in jeopardy for refusing an assignment under the doctrine of patient abandonment (she even detailed the scenario they had discussed in nursing school of new ICU nurse losing her license for refusing to take a third client during a mass trauma situation). I told her that our nursing instructors had taught us just the opposite, specifically that your license was most endangered by agreeing to a task or assignement that you knew (or should know) exceeded your abilities to safely undertake. Which interpretation (if either) if the most accurate or does it vary from state to state?

She needs to talk with her nurse manager. Make sure she writes up the incident (without emotion) with all the facts so that she can present it accurately. There is no reason she should have to take an additional patient especially if the more seasoned nurses had fewer patients each with less acuity. That sounds just like dumping to me. Of course, I don't have all the facts either.

Tweety, BSN, RN · Jul 12, 2005

I agree with you. She may be confusing refusing and assignment with abandonment, which are two different things.

Accepting and an unsafe assignment is not advisedi. I guarantee if she made a serious mistake and went before the board, and she tried to say her assignment was overwhelming and unfair the #1 question from the stone-faced boards would be "why did you accept the assignment, did you use your chain of command" and she would be fried.

New grads don't like to rock the boat, (which is sometimes why the new grad is given the admission rather than the more vocal seasoned nurses, but a good charge nurse understands the limitations of the new grad), but she needs to be just a bit more assertive. A good charge nurse knows when a nurse is overwhelmed, and if he/she doesn't when told by the nurse "I can't hand another patient right now.", reassesses the situation. She might have been pleasantly surprised that the admission was negotiable.

If she did speak up for herself and was told to take the admission anyway, that's another story. Then it's time to use the chain of command.

These stories are fairly typical the first year, and you're surely going to be hearing more, if not on a daily basis, often. It's overwhelming, there's so much to do and not enough time to do it. There's so much pressure from peers and management. Please continue to listen to her, without judgement, and support her and understand. We've all been there.

mommatrauma, RN · Jul 12, 2005

What about simply asking the other staff to help her? If they aren't that busy or have less patient load, why not delegate some things to other staff, ie accu check? Getting the adm settled for her? Teamwork, not everyone realizes someone needs help if they don't ask...5 patients on a urban med-surg trauma floor doesn't sound to me like an unreasonable patient load, especially since I'm sure there are hundreds on med surg nurses out there that would love to have only 5 patients. Time management is a big factor too. Maybe she needs to sit down after her shift and just reevaluate what she could have done differently get things done more efficiently...hind site is 20/20 and maybe it will help her for the next time a similar situation arises. As for refusing to take a patient, I think there are other ways around it rather than refusing, but if she is continually falling behind, she needs to ask for more support from the other staff, ,be it nurses or techs, during her shift, before she gets too behind. Maybe she could sit down with the nurse manager and they could come up with a plan together so that the manager is on the same page with her, and maybe make it easier for her to get support from the other staff.

elkpark · Jul 13, 2005

Refusing an assignment that you (the nurse) consider to be unsafe, whether because of sheer numbers/workload or because of your limited knowledge/skills with a particular type of patient or diagnosis, does not jeopardize your license (it may well jeopardize your job, but that's a whole 'nother matter and was not the original question ...)

Failing to provide safe, competent care to your assigned patients after you've accepted the assignment does put your license at risk, and there is no good (acceptable) excuse -- "I had too many patients," "The workload was just too heavy," "I've never had a patient with (X) before" -- NONE of these absolve you (the RN) of your responsibility once you've accepted the patients. This is why it is much safer to refuse the assignment than to take the assignment and just hope everything works out okay ...

I agree with the other posters who suggested that your wife sit down with her NM and work out a plan to ensure that she does not find herself in this situation again (probably a plan that includes both improving her own clinical and time management skills and making sure that other staff will not be taking advantage of her). If the NM is not open to working with her on that, and this was not an isolated incident, she may want to carefully consider whether she wants to continue working there ... However, this is not an uncommon scenario for new grads -- the culture shock of adjusting to being a "real" nurse instead of a student is significant, and six months is not all that long (I agree that most med-surg nurses in a busy urban hospital would be thrilled to have only five heavy patients). Hang in there (both of you) and keep slogging along, and she will probably survive this phase of her career, as we all did ... Best wishes --

Tweety, BSN, RN · Jul 13, 2005

What about simply asking the other staff to help her?

Excellent point. New grad nurses, along with being assertive need to learn this skill. Ask for the help you need.

RoxanRN · Jul 13, 2005

What about simply asking the other staff to help her? If they aren't that busy or have less patient load, why not delegate some things to other staff, ie accu check?

This was something that as a new grad I had to work on. It wasn't until the later parts of my last semester that we were allowed to delegate tasks (ie: we did total nursing care). While I've always been very confident in the skills of the CNAs to whom I delegate, I'm just now to the point of comfort. Even asking other RNs for assistance has been difficult. It has taken me quite some time to get used to the idea.

TiffyRN, BSN, PhD · Jul 13, 2005

Do you have anything like Safe Harbor in your State? I agree that refusing an assignment is not the same as abandoning an assignment but if nothing else there would be Safe Harbor. There are several threads about this that go into way more detail. But I don't think it's law in every State (I do know we have it in Texas). Usually all you have to do to get consideration from the charge nurse or House Super is ask how to print up the forms. They will try to convince you how hard it is to fill out the forms, don't listen just insist on it. They have to fill out 4X as much paperwork and they don't want any part of it.

suzanne4, RN · Jul 13, 2005

Safe Harbor doesn't come into play here as there is adequate number of staff to care for the patient load. Safe Harbor comes into play when there is not enough staff. If several staff have only three patients each, then there is definitely no "Safe Harbor" needed for this unit....perhaps just a better charge nurse........but remember that we are only hearing one side of the story. As new nurses most of us ran around, and it looked like others were just sitting around, and patients with the same acuity, etc. As we gtt more experience, we were able to use our time better, and this only comes with experience, not something that can be learned right away.

This problem needs to be addressed with the Nurse Manager as soon as possible, so that everyone feels comfortable.

Roland · Jul 13, 2005

She did ask for and did receive some help from two of her fellow nurses (and former ASN classmates). The problem is that those nurses also had four patients and are struggleing clinically even more than my wife (which is to say that by helping her they were seriously risking and worried about"falling off the edge" themselves). I'm surprised to hear that many of you think that five patients is a relatively light load. In this case we are talking about a level one trauma facility with three of her patients having multiple IV's with at least one of the IV's on each client being triple lumen PICC's having multiple infusions, and two having clients needing hourly meds. To complicate things further she had a client with significant, emergent arrhhythmias which had to be managed, but there were orders not to call the doctor unless they progressed to ventricular tachycardia (it turns out the problem was probably with the noncapturing pacemaker). In addition, her barrier isolation clients were located on the opposite hallway from the rest of her clients so that she had to cover a great amount of distance between patients. I think what irked her the most was that one of the nurses who criticised her in the morning for being late on the accuchecks was the same one that told her previously that she doesn't even bother with Dr's orders for insulin unless they are at least for five units (the lady where she was late on the accucheck had no history of DM, but was on TPN).

What about simply asking the other staff to help her? If they aren't that busy or have less patient load, why not delegate some things to other staff, ie accu check? Getting the adm settled for her? Teamwork, not everyone realizes someone needs help if they don't ask...5 patients on a urban med-surg trauma floor doesn't sound to me like an unreasonable patient load, especially since I'm sure there are hundreds on med surg nurses out there that would love to have only 5 patients. Time management is a big factor too. Maybe she needs to sit down after her shift and just reevaluate what she could have done differently get things done more efficiently...hind site is 20/20 and maybe it will help her for the next time a similar situation arises. As for refusing to take a patient, I think there are other ways around it rather than refusing, but if she is continually falling behind, she needs to ask for more support from the other staff, ,be it nurses or techs, during her shift, before she gets too behind. Maybe she could sit down with the nurse manager and they could come up with a plan together so that the manager is on the same page with her, and maybe make it easier for her to get support from the other staff.

student4ever · Jul 13, 2005

She did ask for and did receive some help from two of her fellow nurses (and former ASN classmates). The problem is that those nurses also had four patients and are struggleing clinically even more than my wife (which is to say that by helping her they were seriously risking and worried about"falling off the edge" themselves). I'm surprised to hear that many of you think that five patients is a relatively light load. In this case we are talking about a level one trauma facility with three of her patients having multiple IV's with at least one of the IV's on each client being triple lumen PICC's having multiple infusions, and two having clients needing hourly meds. To complicate things further she had a client with significant, emergent arrhhythmias which had to be managed, but there were orders not to call the doctor unless they progressed to ventricular tachycardia (it turns out the problem was probably with the noncapturing pacemaker). In addition, her barrier isolation clients were located on the opposite hallway from the rest of her clients so that she had to cover a great amount of distance between patients. I think what irked her the most was that one of the nurses who criticised her in the morning for being late on the accuchecks was the same one that told her previously that she doesn't even bother with Dr's orders for insulin unless they are at least for five units (the lady where she was late on the accucheck had no history of DM, but was on TPN).

Sounds like she is seriously being dumped upon by the more seasoned nurses who don't sound as if they care much about following protocol, but want to make it sound to management like they are watching protocol on everyone else. Your wife needs to sit down with the NM immediately and explain the situation, what specifically was overwhelming her, and what she wants to have help with in order to become more efficient. It sounds like the more seasoned nurses aren't open to helping, but unless she specifically asked them, I wouldn't advise bringing that up to the NM at risk of sounding petty. If she asked them for help and they turned her down flat, that does need to be brought up in this meeting. Your wife should outline that she felt overwhelmed because she hasn't gained enough experience nursing on her own, and that her main reason for concern is not because she doesn't want to work hard, she just doesn't want to jeopardize the care her patients are receiving. She needs to ask for help now before she keeps getting dumped upon with management thinking she can handle it and something really bad happens. I wish her all the best in this situation, and applaud you for being so supportive of her.