One Charge RN with all LVN staff in busy ER

  1. I am the charge RN in an innercity 40 bed ER that averages 250-300 patients per day. Many are hight acuity, telemetry or ICU patients since this hospital is a large heart - lung transplant center. I know many hospitals will not hire LVNs to work in the ER, but we do. We run a hefty "fast-track" business and the patients on that wing were appropriate for the scope of practice for an LVN staff and one NP. When we remodeled, someone had the bright idea to cancel the fast track idea and mix all patients into the one big new ER. The LVNs came with it. Initially the LVNs were dispersed equally on each shift, but over the last two years as bid for shift came around all the LVNs have come to nights. Now on each night shift we are down to 2 RNs and 3-4 LVNs. Since one RN must be the charge nurse and the other RN must do triage that leaves all LVNs to care for patients. It is not unusual for our ER to be giving three cardiac meds/drips at the same time or cardiac push meds at the same time. What a nightmare it has become when I am trying to go to each room and monitor the cardiac patients and their meds as well as run the department. We are a teaching hospital as well so I spend a great deal of my shift making sure the newbie residents don't kill any patients. In this week's charge nurse meeting our nurse manager asked that RNs cosign all LVN charts on tele and ICU patients. She says that their scope of practice doesn't cover these high acuity patients and that the RN should become familiar with these patients enough that we are comfortable with the care being given by the LVN and give all the cardiac meds and sign off on the chart stating that appropriate care was given and we agree with the LVNs care. I AM FURIOUS!!!!!! On the day shift where the staff is all RN with the exception of one LVN, this may not be a problem, but on nights this essentially means that I must essentailly take care of all the cardiac patients, ICU patients, run the department, arrange transfers to other hospitals, facilitate department flow, guard patients against dangerous residents and push all cardiac meds and manage all cardiac drip meds. AM I CRAZY, OR HAS MY NURSE MANAGER JUST HAD A TIA????? Would this bother you guys? Let me know what you think.
  2. Visit pointhope profile page

    About pointhope

    Joined: Sep '02; Posts: 26; Likes: 1
    ER Charge Nurse


  3. by   P_RN
    You are definitely NOT the crazy one, BUT neither should you allow her to be putting you into this situation.
  4. by   pointhope
    Well, I have a meeting scheduled with her on Thursday, but I don't see an immediate solution. I told her that I will not sign off on the charts of the LVNs and that if she didn't think their scope covered the kinds of patients we get in this ER then why did we hire them. She said that when we were short staffed she thought that LVNs were better than nothing. My reply was that at this point it appears that that is exactly what I have NOTHING. If I am expected to do so much work for them and then sign their charts as if I have been intimate in the care of each of their patients. Oh well, thanks for the support.
  5. by   fab4fan
    I am totally with you; a while back there was a thread about LPN's in the ED, and I really got flamed by quite a few people for saying that I felt LPN's should not be in the ED (our ED doesn't have a fast-track). It is very disruptive to have to be charge, have your own pts, and keep up with what is going on with the LPNs' pts, give their cardiac meds for them, etc.

    I hate to say this, but you may have to consider getting another job...sounds like your license is very much at jeopardy, and mgmt. is not going to back you up.
  6. by   SherRN
    Your NM is smoking some strange ----. There is no way in the world I would pick up that bag of worms. Why don't you call your BON and lay that little scenario on them. They will tell you. Or better yet email them and get the answer in writing. Best of luck!~ Keep us posted.
  7. by   AngelGirl
    Poimthope....I'll bet you get to man the phone for all of the MICN ambulance calls, too! I can't imagine the pressure you endure. I was an LVN (in CA it's LVN) in the ER for a year , long ago, before becoming an RN. Now, I'm back and, WOW, what a switch!! My responsibilities have changed DRASTICALLY. I've worked in more than one hospital ER since becoming an RN. Some units assign LVN staff to do fairly insignificant jobs, which is insulting, really, because they are functioning barely more than 'glorified' EMT's. Whereas other ER's assign them rooms and give them full charge of pts. As in your cases, however, the Head Nurse must sign off their charts. Since you seem to have no support, I can offer one bit of advice. If you want, as in REALLY, REALLY, REALLY WANT to keep this position, you will have good and adequate help IN THE FUTURE (because this will take some time), if you get those LVN's to go back to school. Does your facility have a tuition assistance program? Many teaching hospitals do. See which of your LVN's (who have a.s degress already)are motivated enough to take the 2 semesters to complete the ADN. Some Online courses are available.

    You haven't mentioned the opinion of your MD's in the ER. Can anyone there back you up? Seeing as many pts as you do on your shift, you must have more than one fully licensed MD to talk to about this. Of course, he/she may have hands full just tracking the moves of your residents.

    This situation brings you to the point of 'payment.' Ask yourself, "How high a price am I paying for this abuse?" Then, if it's too high (I'd say that it is), stop payment. Good luck!!!

  8. by   plumrn
    I think I would stroke out after one shift! Too much responsibility on one person. Ask that manager if she will come work a few shifts alone to see what has you so worked up.
  9. by   LilgirlRN
    Time to find a new job, that's too dangerous.
  10. by   pointhope
    You know, AngelGirl, I actually have encouraged our LVNs to return to college, commenting on what competent clinicians they are, but to no avail. Not one of them will make the effort to go back to school. They talk about the time commitment or the financial commitment, even when I have told them that the hospital will reimburse all classes where the grade is above a C. I, for one, don't understand these excuses, since nursing is my second career. I worked as a police dispatcher and jailer for a city of 300,000 before I bit the bullet and accepted the financial hardship of returning to school. I spent 4 years of sacrifice to get my BSN and feel that every minute was worth it. I actually think that some of the LVNs at my hospital are happy to be relieved of some of the high acuity patients. It seems they are satisfied to make the pay they are making. I don't know what else would motivate them. Three of them have been LVNs for over ten years. I told them that even new grads are making more than they are after ten years of experience. No one budged. Humpf? I will keep on trying and I hope my meeting goes well. I have done nothing but emergency medicine for years and love it. I can even say that I love this hospital so I hope it works out. Would hate to leave.
  11. by   BadBird
    They will only give as much crap as we will take, why are you still there? Transfer to ICU or go to another ED. I would never risk my license like that and you know your meeting is useless. Not until RN's speak with their feet walking out the door will anything be done. Suggest using Agency RN's or hiring travelers in the mean time. good luck.
  12. by   ER_RN07

    I am an LPN in the fast track of a level 1 ED. On occasion we are pulled to the Main ED to take a GYN or hallway assignment. What your manager is making you do is just plain dangerous! We are never expected to take patients above our scope of practice, the only thing we get that is above our scope of practice is IVP meds. Though we get thoes often (even in fast track).
    I'm not saying that LPN's are not capable of taking care of critical patients (I know many who can) but the fact is alot of the care is beyond the scope of practice so that leaves you to do at least 3/4 of the care for all thoes patients?????
  13. by   AngelGirl
    I hope things go well for you, too, pointhope. It seems that there must be watchdog agencies available to help you put teeth into you demands. Even using names such as "Labor Board" and "Board of Registered Nursing" should cause some hair to raise and palms to sweat. And, seeing that you are located in the innercity, how 'bout some attention from the media. That will DEFINITELY cause heat and hives under more than a few collars!

    As for your LVNs, they see your plight and think, "Is that the job I want foisted on me when HE/SHE burns out? (I'm sorry, I don't know your gender) Survival is a strong instinct.

    So, assemble your tactics, prepare to drop a few names if need be, and go into that meeting knowing that, if you quit, they won't find ANYONE one nurse willing to take your place. You are gold. Demand that they pay the price. You're worth it.

  14. by   AngelGirl
    pointhope, I was just at the home page of this Website, and clicked on the story "Nursing Shortage....." by Carol Kleinman. In it, she discusses an organization called AFSCME, American Federation of State, County and Municipal Employees. It is a group which represents nurses and their issues. I wonder if this could be of help to you. Sounds as though it is for nurses who are employed by the government, which it sounds as though you may be (County Hospital?).

    Hope it helps,