Assignment of Patients-- "You are too outspoken!"

[TallGirlAni]

I am a new grad RN, and have been at my first job for four months. On my floor (post-surgical/ortho, with overflow of medicine patients), we have a pretty spread out floor, mostly private rooms, and is divided up into a north and a south side. Patients are not assigned with an acuity in mind. They are blindly assigned as a room number by the charge nurse, who also happens to take patients. The various RNs who take charge and make out the patient assignments factor in the previous day of trying to give nurses the same patients they had the day before. We have LPNs and RNs on the floor working, and the patients are usually divided up equally among the RNs and LPNs, with no regard to the level of care they will need. For instance. RNs cover the LPNs because LPNs (per policy) DO NOT hang IV piggybacks, push IV drugs, hang the first IV bag of fluids, call doctors for any problems the patients may be having and take verbal or telephone orders, take phone report for an incoming patient (from recovery, the E.R. or another floor, even if it is going to be assigned to the LPN), listen or chart lung or heart sounds, or take off the orders in the computer. Ultimately the RN is responsible for the patient and should do an assessment on the patient, as well as the LPN. Sometimes an RN may have to cover 2 patients from one LPN, and another from another LPN. With assigning patients this way, one can either have a very good day, or a very BAD day.

For instance, let s say I have a couple of stable patients and a couple of patients going downhill, that is work enough. Now, let's say that you are covering LPN's patients who came from recovery as a fresh post-op who needs IV push morphine q1h, another needing IV antibiotics, another who has Blood pressure requiring a phone call to the doctor, another with blood sugar of 50.......you get my drift.

My suggestion to my manager was that we should (like the medicine floor below us), assign patients based on acuity and factoring in if this is a patient requiring RN tasks (hanging piggybacks, calling docs because patient is taking a turn for the worse, etc.) It could be done by the previous shift just updating the charge nurse ( on a piece of paper) if the acuity is a 1,2, or 3, and some basic info on what the patient is getting, needing. Also, I pointed out that since the charge nurse takes a lesser assignment to be available "to help," that the RNs and LPNs patient assignment should not be divided equally, since it is apparent that the RNs are doing things that the LPNs cannot do. Please do not let this turn into a RN vs LPN thread, as that is not my intention, I am just stating the fact that the RNs are responsible for more. My manager said that the nurses on the floor see that 20/5= 4, and that is the way the floor nurses have always assigned patients. So, shot down with that one. As far as assignment by patient acuity, she said that another nurse was already working on that (she was on military leave at the time). When that nurse got back, she said that she was looking into to maybe coming up with something, but hadn't even started. To make matters worse, another new grad RN had previously proposed the acuity assignment of patients and had presented our manager with a proposal and a system that she worked out. Our manager told her that it was a good try, but the military leave nurse was coming up with something. So, as you can see, months later, we still don't have a system for assigning patients other than charge nurse makes it out randomly assigning patients according to their room number.

Fast forward to the present. Sorry this is so long. I have been working for the last three days with the same patients. I know them and their issues very well at this point. One has high b/p, low pulse, s/p ileus issues. Another has foot debridement dressing changes and pain management issues, the other has high blood pressure and blood sugar (low and high) issues. I have had to call the docs numerous times on two of these patients and have tended to them just fine.

I am fine with having patients spread out, as I don't mind walking. Our charge nurse for today (who is a part-timer, maybe works 2 days a week--I am there five days a week), does not like to walk, and makes her patients very close, all within 2 feet of each other. We are both assigned to work on the south side, with me covering patients on the north side. She has not worked on the floor in several days, while I have been there for the last 3 days with the same patients. Her LPN-covered patients were very stable, by the way, mine were not. She assigned herself TWO of my patients, since they were right next door to her's! Meanwhile, she assigned me a patient I did not know, also one door down to my patients that she assigned herself. Then, she has me walking up the hallway a few doors up to my other new patient.

So, I speak up. I state that due to continuity of care for the patients, that would like the same patients that I had. She said that she didn't want to be spread out (but she spread me out!) She was not even spaced that far apart. By the way, no other nurses who were present backed me up. They all remained silent, even though they have had this happen to them many times. She put up a fuss, but I persisted, and she reassigned my patients back to me.

When my patients had issues, I was able to come up with a plan, call the on-call doctor, and with my knowledge of what I had done previous days, collaborate effectively with the doctors.

The tone was definitely set for the night. One of the day nurses, who happened to be working this PM shift took me aside later in the evening and said that I was too outspoken, and since this was a very cliquey shift, I was setting myself up to being fired. She said, "Watch your back."

Now, it is true that I am outspoken, and I will stay that way. I see that we have very few of those nurses, and I do not want to cower down so that certain nurses can bully others. I feel that if this is not the floor or hospital for me, then I want to know before my first year is up, anyway.

My question to all of you out there is: Do others out there feel that they must not speak up for fear of retribution or backlash? I think it is a shame that when patient care is at stake, that a nurse is made to feel like he or she must just remain silent and not stick up for himself or herself. I have seen this behavior with another charge nurse who makes out a cushy assignment, while overloading the other RNs, and hiding out so that it is hard to find the said RN when it is time to ask for help.

Any thoughts....?

[bethem]

It's hard to deal with colleagues like that, but I say: Are you there to make friends, or are you there to provide the best care and advocacy possible for your patients? Fight for what you believe in, and if you get called on it, explain your reasons.

Good luck.

[telehead]

Stick to your guns. I've been fighting this battle for the past year and a half. People complain when I'm charge because I spread patients throughout the four hallways we have but I don't care... I look at acuity... If they get angry enough (some of the nurses do, but then they are the same ones that complain about difficult assignments so they're going to be pissed either way) and complain enough to get me fired, so be it... I believe this is the proper way to do it...

[TallGirlAni]

Thank you for your support. I will be sticking to my guns. I believe that my patients come first. Since the other nurses are silent when it comes time to back me up (although this happens to them, as well), it is nice to get support from you on allnurses. Keeps me going with the fire buring beneath me!!!!

[Joan1199]

Keep being patients' advocate. We need nurses with a voice! It's a shame the other nurses don't support you. It has been proven that nurses who work together can resolve situations. Nurses who work together have power! So, keep on doing what you are doing! If they fire you for being an advocate, contact yourr Board of Nursing.

[NurseCard, ADN]

I wish that we could staff based on acuity on my floor. Our floor is set up very similar to yours, Ani, and assignments are NEVER made based on acuity because no one ever wants to walk. Therefore many nights you'll have one nurse on one hall who has ALL the bad patients, and another nurse at the end of the other hall who doesn't even have any meds to pass after 4 or 5 am, no finger sticks, NOTHING, just the total cake walk hall.

[canoehead, BSN, RN]

I think you are right, but I also think that since they say it is a cliquey floor that you will pay for being right. Watch out for increased incident reports being filed against you, and chart defensively. If you can't go with what has existed for years then you will very likely find the job not worth the emotion you are putting into it within a year or so. Perhaps a PRN position on the side in the same hospital would be a good fall back position. It'll give you a manager that thinks you are good, and support you financially if you ever choose to dump your original job.

I have been there, and since then have never gone without a second prn position or a solid savings account for insurance. You also want someone on your side that will say something nice about you after you walk out of a room. It's possible that some of the silent nurses agreed with you but didn't jump into the fight. Do an informal poll on your breaks.

If the charge nurse doesn't like you make sure you have a knowledgeable and respected nurse to go to for second opinions on your patients. Even if you know what you are doing saying "I consulted with xxx" will be a great back up when someone disagrees with you.

[christvs, DNP, RN, NP]

I wish that we could staff based on acuity on my floor. Our floor is set up very similar to yours, Ani, and assignments are NEVER made based on acuity because no one ever wants to walk. Therefore many nights you'll have one nurse on one hall who has ALL the bad patients, and another nurse at the end of the other hall who doesn't even have any meds to pass after 4 or 5 am, no finger sticks, NOTHING, just the total cake walk hall.

Oh my God, this is exactly like my med/surg/tele unit! For the past few weeks I have been stuck in the "horrible" hallway. My patients are always so complicated and heavy and have sooooo many things going on it is nuts. Other nurses help me out but it's still not enough, cuz the list of things to do is literally neverending. Augh. I honestly cannot wait until I am an NP. I've only been an RN for one year and I'm already tired. We also have to cover the LPN's patients, regarding Iv pushes, PICC and central lines, hanging blood and TPN, initial assessments, phone orders, etc...and it can be a lot to handle in addition to my own patients too.

[llg, PhD, RN]

Of course it is the "right thing to do" to speak up and be an advocate for better patient care and for better working conditions.

However, one of the things that you can learn through experience is HOW to be a successful advocate. Establishing positive working relationships and using effective communication techniques will yield you much more success than getting yourself fired ever will. In fact, getting yourself fired (or maginalized as a political force on your unit) will not help the patients at all and may actually cause more harm than good.

Not knowing the people involved in your particular situation, it is difficult for me to give advice on the best strategies to use. But I urge you to find a mentor -- someone who does know the people involved -- who can give you some good advice on how to work with your colleagues and stimulate the changes you believe should be made.

Good luck to you. I hope you don't burn yourself out or damage your career before you have had a chance to develop the political skills you need to be a good nursing leader. Too many new nurses have gone that route and never fulfilled their potential.

llg

[jansailsea]

I TOTALLY BELIEVE IN ACUITY ASSESSMENT RANKING:

Our Med/Surg does not assign pts by acuity, so it's possible to end up with 3 contact precautions pts (one of which was obese fluid overload/weeping edema & unable to move), & 1 dementia pt who needed 2 staff members in order to stand- but kept trying to get up & leave, among a total assignment of 6 pts.

Constantly gowning & gloving up to go in 3 pts' rooms, having to beg & wait for another staff member to help with the obese pt, running at the sound of the bed alarm going off all night, & having one of the contact precautions pts' on 4 hr BS checks.

Meanwhile, everyone else is enjoying themselves eating birthday cake, gossiping in the outer hallway with nurses working on other floors, reading magazines & books, etc.

Ended up having to personally take the obese pt up to ICU at shift change of all times (made me popular) & give report as VS dropped significantly.

Thank goodness the charge RN realized how bad it had been for me & offered to do my I & Os that morning.

Plus, one nurse who was standing directly outside the dementia pt's room quickly grabbed the pt -who absolutely could not stand unaided- before they managed to fall yet with it enough to figure out if the gown was off- the alarm did not go off!

When I complained my load was too heavy...the other staff members said they had contact precaution pts & dementia pts too- yes, they each had ONE!

I had 3 contact precautions & 1 dementia pt.

I believe there would be less burn out among nurses & less job hopping if hospitals adopted an acuity pt profile ranking system & applied it.

I'm an older, went-back-to school LPN II, IV therapy certified, perform insertions, hang IVs & IVPB, push most meds in our hospital- just licensed 09/28/05.

[ColetteFL]

I'm an LPN on a Med-Surg floor. We don't assess acuity, but there is always an effort for continuity of care. Also, LPN's do ALL the same stuff that an RN does; we only have to have an RN there to sign off for certain stuff, like hanging blood. In my hospital the LPN's are respected, and just as capable as the RN's; in some cases, more so. Having said all that, there are still cases of favoritism, or charge nurses giving themselves easy assignments, or not taking an admission even when they have fewer patients with easier acuity. (If our census is high, charge nurses don't take patients, but when it's low, they do). I've learned just to take what's given to me, and do the best I can. And I get back-up for all major (and some minor) decisions, and I chart everything. My advice to you is: find a place where people get along, mostly. One year on a resume looks good, you won't look like a "job hopper" if you've stayed a year. There is something to be said about quality of life! No need to be miserable where you work! Good luck!

[DarlinNurseRed]

Gosh-this sounds like my hospital...it is awful. I went home crying the other day. I have decided that our patient load is too heavy, I don't feel safe anymore.

I am very competent in my skills, but having 12-15 patients with team nursing is too much for anyone. You get too busy to be able to worry about acuity anymore,,,all you are able to do is react.

I was talking to a travel nursing recruiter the other day, and she said it's the "Southern Nursing approach"-because we have worked this way so long that we don't know any better.