Ethical/Professional situation....

Editorial Team / Moderator · Jun 5, 2009

Because we're a freestanding ED, we have very finite resources on which to draw -- so if there's a disaster of some sort, or if we're seriously getting our @$$es handed to us, we call the nursing supervisor for reinforcements. The few times we've done that, we've gotten SOMETHING. Not always the cavalry, but something.

We had one such disastrous day that I remember, back when I was a tech -- it was before noon, so we had one doc on duty, no PA, and we had two codes going at the same time. We have one code-worthy room, so we had to do some quick maneuvering to create another code room. In addition to the codes (both of which were workable, so we did), we had some very, very sick people in that day -- we were totally full, and then some. Our charge nurse made a few phone calls, and the next thing I know, our nurse manager and HER boss (who is our CNE) show up to work. :) We rocked it.

As an RN, I've found that there are times when having 3 really sick patients + one not-so-sick can be as overwhelming and feel like 8 pts. I've become very good at prioritizing my work quickly in my head and taking care of my pts., but I'm not too shy to ask for help if I need it -- especially if I can do that before I'm actually drowning. A couple of weeks ago, I had two pts who were seriously circling the drain, another who didn't look as bad at first glance (until you put her on the sat probe and saw 88%, yep) but had terrible pneumonia, and another patient with abdominal pain who was drinking for a CT who needed IV/labs/line/meds. I told my charge nurse, "I need help." He said, "I can't help you, I'm helping [other nurse who can't keep up], I'm sorry." So that established my resources -- me, and my faithful tech who seriously helped me out with some of the EKGs, IVs, labs, blood cultures, Foleys, etc. Did I monopolize his time? Sure. The splints waiting for him in fast track were definitely a lower priority.

I haven't been in a truly overwhelming, dangerous situation -- yet. I'm sure it will happen, eventually. If I were an RN on the day of the dueling codes, I might have a different post for you. As a tech, I knew we were stretched beyond our limits. After our codes were done, I ran around like an idiot, going from bed to bed -- monitor/EKG/saline lock/labs, rinse and repeat x 10. I think we were also short a nurse in the first place that day, which didn't help at all.

I think the important thing is to identify as early as possible that some extra hands are needed, and start calling people in to help. In the case of a serious MCI, we'd treat it like a disaster and call people in.

In the past, some of the night charge nurses have "closed" beds in the ER due to short staffing -- usually beds 11-15. I don't see that often, though.

MsKittyRN · Jun 5, 2009

In my state once you receive report the patient is yours. I look at the assignment before I take report and will have the knowledge before accepting the assignment. Also, if a patient is called up from the ED and I am already swamped I have the right to say I can't safely handle another patient at this time. It usually does not go over well with the ED but as a professional I am held accountable for taking on more than I can handle. Usually the supervisor is called and other arrangements are made. I am no stranger to hard work but patient safety is most important.

GilaRRT · Jun 5, 2009

I would always come in a little early and scope things out before I clocked in or took report from anybody. No warm fuzzie, no punch in or take report.

Take care,

chbare.

Medic/Nurse, BSN, RN · Jun 5, 2009

There was a time in my career that I would buck up, gear up and (no matter!) get to getting it done.

That TIME has passed.

Like chris (GilaRN) I show up and scout it out - if the situation looks like one where I could envision a career-ender ---- easy - I just don't clock in, take report, go home - period.

Realistically - you either close beds to a safe ratio, go on diversion, call an internal/system wide disaster and get patients that depend on us the care they need and deserve. This "keep on, keeping on" is outdated, crap thinking that has consequences that will be most likely "dumped" down to the primary nurse by the "system" that allowed this "chaos" to develop.

I had an issue with this very issue - I'd been taking all 4 resus beds for weeks (and getting resus level patients, almost by myself, I had a discussion and it ended with - "Well IF you weren't comfortable or couldn't handle it - you should NOT have accepted the assignment." OK. Got it!

We teach folks how to treat us.

I am good at what I do - even so, with this "getting good" - I KNOW where my limitations are.

Practice SAFE!

talaxandra · Jun 5, 2009

That's where legally mandated ratios are brilliant. It's illegal so I won't do it - get more staff or don't admit them to the ward.

Not much help to you, though.

classicdame, MSN, EdD · Jun 5, 2009

Texas has a Safe Harbor law to protect nurses. The first thing to do is instigate the chain of command. Next, contact the BON within 24 hours (a form is online). If you leave after you learn what the assignment will be, whether accepted or not, you make it difficult to support your claim of patient safety. After all, if there are not enough nurses to take care of the patients and you leave, then there are fewer nurses for the same amount of patients and you have just made a bad situation worse. The Safe Harbor Act states the nurse who follows the plan will be protected. People mess up by not instigating chain of command and then leaving the unit, thereby putting the patients at more risk. If you stay, your license is protected (under this Act) and you have the option never to return again.

NurseDiane · Jun 5, 2009

ClassicDame, the Safe Harbor Act sounds like something great that Texas has instituted. However---having done some med mal consulting in the past---try to use that as a defense in a court of law if, God forbid, something untoward happened to a patient. If you end up being sued, chances are you won't "lose your license", so this Act isn't as great as it sounds. Now, if that Act protected the nurse inasmuch as not being able to be sued or liable and requiring the hospital to take 100% responsibility for anything "bad" that happens as a result of inadequate staffing, that would be great!! In New York, where most hospitals are unionized, I remember being able to submit something to the union about unsafe patient ratios that you had to submit for each shift that you took care of too many patients to be safe or competent. States that have implemented nurse-patient ratios is good too---except I don't know of too many hospitals that are following those guidelines, using "we can't afford to hire more nurses" as their excuse. SO DON'T ADMIT AS MANY PATIENTS!! Only admit the numbers of patients that can safely be taken care of by the number of nurses that you have on staff!!

litbitblack, ASN, RN · Jun 5, 2009

LOL yes texas has safe harbor. Employers don't take kindly to it being used. I threatened it once, had the papers ready to fill out, the DON showed up to find out what was going on that wasn't safe. After i explained she stated "well unfortunately we don't have the staff to send you to help" and I said "well unfortunately this is an unsafe environment and i am calling safe harbor." with in 15 minutes i had 5 nurse managers on the floor ready to do what needed to be done. I don't do that with accepting pts. If we can't handle them and i am the charge i refuse. It has had to go all the way to med surg director and we didn't get the pt but after awhile these facilities want to get new nurses in who will take the crap. I no longer work in the hospital. After having new nurses who were not qualified or experienced to work on my floor even after multiple compliants to the manager, after having an house supervisor tell me that taking care of my pt that might have had a stroke was no excuse for not discharging the 5 pts that went home between 3-7pm with no unit rep to put charts together for the 9 admits we got during that same time all so nite staffing would not be messed up, really did it for me. Gone are the getting griped out by docs for something done or missed on a previous shift that you had no control. Gone are making decisions that had you went the other way with it you still would get in trouble.....i really don't miss it....i like rehab and long term private alz care.

MurseMikeD · Jun 5, 2009

Makes me glad I work in California where we have a fixed patient-to-nurse ratio by specialty.

wooh, BSN, RN · Jun 6, 2009

I just say no. If they HAVE to find staff, they WILL find staff. And believe me, if you typically take 5, and accept 6 in an "extreme" situation, they'll realize you can "handle" 6 and will make that the norm. Then the "extreme" becomes 7, and soon that's the norm. How do I pitch in and help out? I'll work over 4 hours if I don't have to work the next day and don't have somewhere I need to be. I'll be an extra nurse when it's needed, but I just have learned, I have a limit. My usual (peds dayshift) is supposed to be 4 with 5 on occasion. I absolutely WILL NOT take a 6th. I've been asked, I say no. I was once told it should be ok because the 5th and 6th were brothers. Like adding a name alert to the mix would make it safer!!

The big problem is the nurses that will just shut up and take it. Don't want to make a fuss. It just makes it worse for all of us. Whether we're union or not, we do have to stick together!!

mwboswell · Jun 6, 2009

...but patient safety is most important.

That's probably the BEST statement overall!

Patient safety even trumps our own license although the two are intrinsically intertwined.