Endorsing to the next shift.

[dudette10, MSN, RN]

I know we've talked about this before, but a situation came up recently where I wasn't quite sure what was "right."

I'm pretty easy-going when it comes to stuff endorsed to me on day shift. The night shift nurses usually are apologetic or feeling overwhelmed (mostly new nurses) when they have to endorse stuff. I've gotten my work flow and efficiency pretty much air-tight so I rarely have to stay late for anything, which I think is the reason having stuff endorsed to me doesn't bother me. That is, I know it won't put me behind too much.

What does bother me, however, is when a nurse expects me to pick up their slack and is particularly ungrateful and downright annoyed by my reluctance to do a few things.

The other day, a newer nurse (new to acute care, limited experienced in extended care) didn't endorse anything to me, but a quick look at the chart indicated there were quite a few things she missed, specifically admission flowsheet charting, blood draw off a central line, 0600 EKG, notifying an MD of a UOP problem. I tracked her down in a central charting room to discuss the missed orders/notifications. She endorsed a "busy night" with two admissions and she hadn't done any charting...when it was busy really because of her inefficiency. Not unusual, I know.

What got me, though, was when I suggested to split the tasks that she missed. I told her I could delegate the EKG immediately and do the admission flowsheet charting (history questions that don't require an assessment), but she would need to do the blood draw and notify the MD.

My ire quickly ignited when she sighed and said, "I'm tired, and I had a busy night. I want to go home. Why can't you do them?" I'll admit that it was pretty apparent I was royally ticked through my tone of voice and facial expression: "Because these were duties for your shift, you failed to properly endorse them to me, and I'm still offering to do half of them because I can do fairly quickly."

I had decided to split the tasks in this situation. I could have done them all without a real drain on my time (paging doc about the previous UOP as I'm walking from room to room and doing the blood draw during first rounds), and I could have saved the working relationship. The nurse has yet to speak to me--even after greeting her casually during subsequent shift changes--but that could just be me making up stuff in my head, I acknowledge. I feel like my decision to put my foot down on splitting tasks was because I was bothered by her attitude, rather than by how far doing the stuff would put me behind. That is to say, if she had approached me with a different attitude, I might have done them all. That's why I'm not sure if I was "right." My emotional reaction directed my actions, which is why this still bothers me.

So, I have two questions: 1) what is your opinion on the situation described above and 2) what are your "rules" for receiving or giving endorsement for nursing tasks?

[MunoRN, RN]

Is your computer substituting "endorse" for various words for some reason?

Nursing is a 24/7 job and I don't think I've ever asked an offgoing nurse to keep working to knock more things off the list. For every patient we essentially make a long list of things that could be done for that patient, we then prioritize that list and however far down the list is how far we get. When a new nurse comes on they basically just take over the list, if I were to expect every offgoing nurse to hand me an empty list then they would never leave.

A new nurse in acute care will need sufficient support, this includes having a charge nurse and even other nurses on their shift who take some responsibility for at least guiding the nurse in their time management, that doesn't always happen and results in things that should have been higher priority not getting done, but that blame falls just as much to those other nurses as it does to the new nurse.

[icuRNmaggie, BSN, RN]

1) It is good that you let her know that you will not be an easy target for this kind of deception and manipulative behavior.

2) If the coworker is consistently a slacker when it comes to labs due on his or her shift, I will put my foot down and say "you need to send this."

I agree with how you handled it because you were direct and honest.

She apparently doesn't like that she has been exposed for her lousy work ethic and lack of integrity. She is not trustworthy and if she wants to behave like a child who cares?

[dudette10, MSN, RN]

Is your computer substituting "endorse" for various words for some reason?

Nursing is a 24/7 job and I don't think I've ever asked an offgoing nurse to keep working to knock more things off the list. For every patient we essentially make a long list of things that could be done for that patient, we then prioritize that list and however far down the list is how far we get. When a new nurse comes on they basically just take over the list, if I were to expect every offgoing nurse to hand me an empty list then they would never leave.

A new nurse in acute care will need sufficient support, this includes having a charge nurse and even other nurses on their shift who take some responsibility for at least guiding the nurse in their time management, that doesn't always happen and results in things that should have been higher priority not getting done, but that blame falls just as much to those other nurses as it does to the new nurse.

"Endorse" is the word I've always heard used at both facilities I've worked in when tasks need to be handed off. Your verbiage may be different.

So you're saying that in your area, whatever doesn't get done just gets handed over without question. That was one of the questions I asked...your unit has no parameters for what is expected to be done or not done, and everyone is ok with that.

[dudette10, MSN, RN]

She apparently doesn't like that she has been exposed for her lousy work ethic and lack of integrity. She is not trustworthy and if she wants to behave like a child who cares?

I think she's inefficient and missed/forgot the orders, not that she has a lousy work ethic or lacks integrity, but missing the orders is even more worrisome, ya know? I went to speak with her initially because I thought, "What if she had handed off to another new grad who may not be efficient enough to check orders quickly within an hour of shift?" I do feel she behaved immaturely, but, then again, maybe I did too because I reacted emotionally rather than rationally.

[Aurora77]

For me it depends on the nurse and if there is a pattern of behavior. We all have crazy shifts and have to pass things to the oncoming nurse occasionally but if it's a frequent occurrence by the same person, I'm going to refuse.

I thought you were completely appropriate in splitting up the tasks that didn't get finished. I'd be grateful for that kind of help if I had a crazy shift and was behind.

ETA: We don't have a specific rule about leaving things for the next shift, but it's our culture that nothing gets passed on without specifically notifying the next nurse.

[icuRNmaggie, BSN, RN]

Ok. I was getting mental images of some characters from my past jobs who were notorious for doing the least amount of work possible.

I would ask someone, a charge or senior nurse, on her shift to help her with her time management and staying on schedule with the routine tasks, as well as helping her out if she becomes overwhelmed.

[Karou]

I acknowledge they nursing is a 24/7 job, and that it is necessary for some things to be passed off to the next nurse. It is sometimes appropriate to pass off tasks, like blood draws, EKG, occasional medication administration, IV changes, and admission charting. Admission charting at my facility has 24 hours to get done and frequently will get passed around shifts. It is always better if you are informed of these things in report and if the off going nurse is apologetic or nice about leaving it for you.

I draw the line and changes in patient condition and critical results. Whoever took the critical results needs to be the one to call the physician. If there is a sudden change that requires notification, the off going nurse needs to be the one to call because they actually know the patient better. Low urine output surely wasn't just noticed (and it if was, shame on that nurse), and he/she needs to be the one to call the physician.

I had a nurse try to leave in the middle of report on our last patient as I was calling a rapid response. We do bedside report and the patient was in distress. My charge nurse wouldn't let her leave as we weren't even done with report on this patient!

If you have a nurse repeatedly leaving tasks, then your supervisor needs to be notified and someone needs to talk to them about poor time management.

[MunoRN, RN]

"Endorse" is the word I've always heard used at both facilities I've worked in when tasks need to be handed off. Your verbiage may be different.

So you're saying that in your area, whatever doesn't get done just gets handed over without question. That was one of the questions I asked...your unit has no parameters for what is expected to be done or not done, and everyone is ok with that.

Charting is the only thing that's been an absolute requirement anywhere that I've worked. Nurses are expected to prioritize and critically think, I don't think replacing that with rigid requirements does anybody any good.

For instance, given one particular context, not doing an 0600 lab might be considered inexcusable, depending on the particular lab, how it relates to the patients course, what other competing priorities exist at that time, etc. Given a different context, drawing that lab at 0600 might be just as inexcusable if it meant other higher priority things weren't done, so a flat rule doesn't work. If the lab didn't get drawn because they were goofing off then yes, I would expect them to stay over and do it, if it wasn't drawn due to appropriate prioritization then I'd pick up and run with the patient's to-do list just like anything else.

[BiohazardBetty]

The problem with her letting 6am lab draws get passed along is its most likely going to end up being YOUR problem because the results may not be posted by the time the MD rounds... He ordered them for 0600 for a reason. Then you have to answer to both the doctor and the patient for HER inefficiency. On my heme/onc unit I have seen delayed lab draws ultimately delay patients' discharges by 10-12 hours because the doctor would not /could not put in discharge orders until he saw the lab results, but after he rounded on the unit at 7 he was at the clinic until 5 & would not be back on the unit until 530-6 that evening. What a mess!

Sometimes new nurses, especially those on nights, don't see how the whole puzzle fits together & see their inefficiency/passing along tasks as harmless when eventually someone still has to answer for the tasks being late or not getting done. I think you were generous to offer to do a portion of the tasks she left. The only thing I may have done differently is educate her on how her choices can impact patient care, not just your night.

[Here.I.Stand, BSN, RN]

So, I have two questions: 1) what is your opinion on the situation described above and 2) what are your "rules" for receiving or giving endorsement for nursing tasks?

Efficiency doesn't magically happen overnight, and nursing is a 24hr job. In that regard I'm pretty laid back about *most* things being handed off. If it's me that passes off to the next nurse I tend to be apologetic although it's not a betrayal or something that needs to be forgiven...but I do feel bad about adding to his/her workload.

What concerns me about this colleague however, is not so much that she couldn't get to everything, but that she apparently missed the orders altogether. An EKG, lab draw, low UOP are pretty important things. And then, she didn't seem disturbed about having missed them.

My "rules" are based on urgency. Tasky things like a routine dressing change....outdated PIV that is patent and w/ no signs of phlebitis....preop EKG...admission documentation for a pt arriving near the end of the shift.... Fine. Pass it on--just be clear that it needs to be done. It's simple communication.

Things related to a change in pt condition should at least be begun. The off going RN should be communicating with the dr because he/she has just spent the past 8-12 hrs w/ the pt and can give a more thorough assessment. So take the low UOP example: you just noticed low numbers on the flowsheet, say, 50 ml at 1800 with no other output for 4 hours prior. The off going RN should know right away other needed information, e.g. is the pt tachycardic, is the CVP high or low, what color is the urine, what are the pt's lung sounds, what are the renal labs, etc. The oncoming RN would have to dig for all of that information. Plus, the oncoming RN wouldn't even know whether or not the dr. had been called.

[Adele_Michal7, ASN, RN]

In regards to the OP... It's hard for me to answer without knowing the culture of where you work. My first reaction is that I don't think you were unreasonable.

I'm usually pretty laid back in these situations, but it depends on a few things. If an off going nurse tries to pass off a COC to me (where she hasn't called the doctor yet, the RP, or anything else) I'm going to ask her to stay and handle it.

However, that's the policy where I work. It's also a policy that any orders that come in on your shift will be faxed to pharmacy, entered in MAR, charted on, etc. Same goes for lab orders. If it's a very non emergent order, some nurses will leave the order for the next shift and it's not that big of an issue.

It depends on who is coming on after me, too. There's certain nurses who will not, in any situation, accept any kind of unfinished work to do from a prior shift...