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

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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?

Specializes in CCRN, CNRN, Flight Nurse.
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).
This sounds like they were ICU patients. If so, then 5 is an entirely unsafe number of patients.
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Specializes in Geriatrics/Oncology/Psych/College Health.

JMO - no one should ever get two isolation pt's unless everyone else already has one. On first blush, it sounds like your wife was hosed by the more seasoned nurses who either didn't realize she was drowning or didn't care. Since we weren't there, we can't know all the dynamics, but assure her that suggesting another nurse might be in a better position to take a new admission does NOT put her at risk for losing her license for pt abandonment.

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No this wasn't ICU where the acuity level would have been even higher.

In any case the consensus seems to be that you cannot easily lose your license for refusing to take extra clients out of a concern for being able to safely care for them.

Someone made a good point about the seasoned nurses. I think that the hospital is so afraid of losing their more experienced nurses (probably with good reason) that they cator to them. For example several of the seasoned nurses typically call in before their shifts and request certain clients, and or types of clients.

This sounds like they were ICU patients. If so, then 5 is an entirely unsafe number of patients.
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I would suggest looking for another job!!

It's getting worse for all of us. I work in acute rehab. The other night we had 15 patients, 2 nurses, 2 aids and 6 admissions. More than half were DM and several of those are britle.

Multiple IV's, several isolations, 2 very unstable, several dialysis and poor acuity levels............was I stresses?? :rotfl: oh yeah!!

And they wonder why we aren't happy?? Does it take a rocket scientist to figure that out??

ps. I'm looking elsewhere too.

Good luck

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Specializes in ER.

Is anyone else having an issue with this story?? I work in a level 1 trauma center...however this nurse is working on a med/surg trauma floor? A patient having "emergent arrhythmias" on a med/surg floor? How do they know the patient was having arrhythmias?? med/surg floors aren't monitored...if it was a patient with emergent arrhythmias that she had to monitor, you'd think 1.the patient would have to be on a monitor..and 2.If it was a non-capturing pacemaker..the patient would be in the ICU or a step-down type unit at the very least and have a transcutaneous pacer, or a transvenous floated in anticipation for a pacer replacement...It just doesn't make sense that this type of patient would be on any kind of med-surg floor unless they were a DNR, which would probably still not qualify since it is a non-capturing pacer reversible situation...I'm not saying that there aren't nursing floors that aren't stressful with higher acuity patients and that new nurses don't get dumped on, but some of the patient care situations described sound a little unrealistic to be on a med-surg trauma unit...

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as a practical matter, does anyone know of anyone losing their license over anything less than outrageous misbehavior? nursing school teaches an element of paranoia that you've always got to be defending your license, etc. how much of a problem is this in the real world, as in disciplinary cases brought before license boards?

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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).

your wife needs to grow some b***s

pardon the language.

when the 5th admit was being assingned... she should have just said

'there's no way that i'm taking a 5th pt when some here have only 3...nope, it aint gonna happen. you can call the supervisor, the fire department or jesse jackson, i don't care, but it aint gonna happen!'

these 'seasoned nurses' are middle school bullys with gray hair. put your foot down early and they'll stop messing with you.

what's the worse thing that could have happened. they'd get all pissy???? they're already pissy and have been for years. call em on it i say!!! there are over 1000 other jobs out there if you want to leave... they're stuck there bc they don't want to start all over.

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It is for this very reason that safe staffing ratios should be legally mandated GLOBALLY! When I first started out (with that deer caught in the headlights look) I wrked in an ICU and per hospital policy "only" was required to care for 2 patients. This was written in the contract with the agency that I work for.

I was notified by the CN that I was receiving a patient from ER and told to receive report. I said, " No thanks!" and continued to care for my patients. There was a moment of pregnant silence and then I was berated for my insubordination. Being registry I am very familiar with BRN standards and policies and cited the fact that I could not safely provide care for an additional high acuity patient.

Here in California we have had to fight very long and hard to bring ratios into place, overall I see a lot of positive. We achieved this by documenting the exact situation that Rolands spouse found herself in and speaking up.

I'm saddened to hear that the old timers didn't step in to help. I myself have never refused to help another co worker and go out of my way to do so. It also would never occur to me that a co worker would decline if I asked for help. Sad situation, also scary.

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Specializes in Case Mgmt; Mat/Child, Critical Care.
Is anyone else having an issue with this story?? I work in a level 1 trauma center...however this nurse is working on a med/surg trauma floor? A patient having "emergent arrhythmias" on a med/surg floor? How do they know the patient was having arrhythmias?? med/surg floors aren't monitored...if it was a patient with emergent arrhythmias that she had to monitor, you'd think 1.the patient would have to be on a monitor..and 2.If it was a non-capturing pacemaker..the patient would be in the ICU or a step-down type unit at the very least and have a transcutaneous pacer, or a transvenous floated in anticipation for a pacer replacement...It just doesn't make sense that this type of patient would be on any kind of med-surg floor unless they were a DNR, which would probably still not qualify since it is a non-capturing pacer reversible situation...I'm not saying that there aren't nursing floors that aren't stressful with higher acuity patients and that new nurses don't get dumped on, but some of the patient care situations described sound a little unrealistic to be on a med-surg trauma unit...

You know,I've been wondering the same thing, each post this unit sounds more and more like it's either step-down/sub-acute care/tele unit. Because 4 or 5 pt's on a MS floor really is pretty good. New grads are usually dis-organized, these are busy floors w/lots of tasks, meds, etc.What concerns me is all this cardiac stuff happenning.

The wife really needs to speak up, assert herself now. Don't wait to get into "trouble"...sink, in other words. We've all been there and like another poster said...who cares what the charge or the other "seasoned" nurses think. If one of your staff is struggling, someone needs to take things in hand and help out....direct her, delegate some tasks for her, basically help her get caught up. I would definitely object to 2 isolation patients, also.

It is very hard for new nurses to speak up, but she has to realize, no one else is gonna do it for her. :stone

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So...what do you do? If you are working short and no one can or will come in, what choice do you have? If everyone already has four or five (or nine) patients, someone has to take the admission...someone has to provide care for that patient. I don't think that someone with four should be given an admission when everyone else only has three, but it happens all the time...often our charge nurses assign the admits to the people who b***h the least.

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So...what do you do? If you are working short and no one can or will come in, what choice do you have? If everyone already has four or five (or nine) patients, someone has to take the admission...someone has to provide care for that patient. I don't think that someone with four should be given an admission when everyone else only has three, but it happens all the time...often our charge nurses assign the admits to the people who b***h the least.

You have the choice (indeed, the responsibility) to refuse the (additional) assignment if you truly feel you are unable to provide safe care for your patients, and, if everyone on the unit feels that way and refuses the new patient, it is the responsibility of the house supervisor or whomever from nursing administration is "on" to make some other arrangements (even if that means, GASP, coming in and helping out herself). The bottom line is that, if you're a staff nurse, it's nursing administration's problem, not yours. If the doo-doo hits the fan and something bad happens to one of your patients, I guarantee you that none of your superiors is going to step forward and say, oh well, it was really my fault; s/he didn't feel comfortable taking the additional patient but I told her/him s/he had to ... I also guarantee you that the Board of Nursing will not consider:

If you are working short and no one can or will come in, what choice do you have? If everyone already has four or five (or nine) patients, someone has to take the admission...someone has to provide care for that patient.
to be a reasonable excuse/rationale for your failure to provide safe, competent care to all of your assigned patients.

The hospital will leave you dangling in the breeze at the first opportunity; the Board of Nursing exists to protect the public, not nurses; and nobody is looking out for you and your license but you.

I don't mean to sound like I'm frothing at the mouth or anything, and I've certainly gone along and taken my share of chances in understaffed situations. But I think it's important to be aware that nurses do have a choice in these situations, even though it's not a v. pleasant choice. Sometimes patient advocacy means refusing to care for patients, when your employer is attempting to put you and the patient(s) in an unsafe situation ...

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i have seen monitors on a med=surg floor but they usually are more stable, such as just exiting a step-down unit, and they needed a little bit of follow-up

however..i have also seen very bad pts on med surg because there was no room for them in icu..we once had a woman with calcium level of 16+ . family was beside themselves because they didn't think we knew how sick the woman was. believe me we did but until a md could be convinced to move his pt our of icu or if someone on the unit died we had to do the best we could in addition to a full team that we had

so. depending on the circumstances you can have more than you can handle but sometimes you can't do much except go with the flow

however, other posts are right, this cannot be an ongoing situation..if she cannot get satisfactory back up from higher ups she needs to take her license somewhere else

tell her good luck with what she decides

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