If "normally" your assignment is "X" patients and due to an "overwhelming census" you are now expected to care for "X" + 25% number of patients, and everyone is doing the same, and you feel this is an UNSAFE number of patients for you - what do you do? (Pretend "X" is the usual, maximum normal amount of patients you could have; and now add 25% to that....Example: if you normally would only take 4 patients and now you have to take 5; or if you normally take care of 6 patients each and now you have 8)
Realize/Assume the following:
1) If you accept the assignment (IE: take report from triage or EMS in those rooms) you have just accepted a "duty to act" ("duty to care") and begun a nurse-patient relationship
2) If you communicate with your Nurse Manager your displeasure with this assignment, and they do not modify your assignment/ratio - you are still on the hook with a "duty to act" ("duty to care").
So what do you do to protect yourself?
What processes do you have in place in YOUR workplace, or YOUR state nursing scope of practice to you have to help with this situation?
What if it's just a busy night?
But what if it's a MCI or disaster?
Would you do things differently?
Open forum folks, no right or wrongs here, just want to see how people handle the stresses of our jobs!
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
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.
But why must you wait for something to be "legal" to say NO.
Why not just say NO when you know it's unsafe?
Follow up point: If YOU don't take the patient, then what happens to the Emergency Dept RN who can't get them admitted then --- and THEN what happens to the Emergency Dept pt's who are STILL in a waiting room who haven't even been seen or evaluated yet???
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
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!!
I like your implementation of the "give them an inch they'll take it a mile" theorem!
That being said, when you "work over" a bit to help in a pinch --- what if "they" come to start expecting that also? This may be a slippery slope by itself.
I'll never forget this 'famous holiday' shift I worked last year. We were packed to the gills - absolutely packed. Triage was backed up by at least 20 patients (on average). The wait time was over 3 hours in the waiting room (at least 4 hours before being seen by a doc). Sometimes we were sharing three different patients on the same hall-way stretchers (or using chairs for some of the 'walking wounded') because we ran out of stretchers.
There was no food left in the department, we were starting to run low on bedpans/urinals... even freaking gauze!! Pharmacy was running to re-stock our Pyxis q hour because we were going through meds like they were going out of style!! I think we ran out of Reglan at one point and Pharmacy had to raid the ICU Pyxis. I'm telling you, it was nuts!
I remember clearly right around shift change time when my shift began, we'd shipped both our ICU patients to the two remaining ICU beds that were open, thus freeing up our two (of three - last one had an active code in progress) code rooms. Almost immediately two squads pull in - one patient was having a possible stroke while the other patient was going in and out of V-TACH
Here I am, with 3 patients already (one of them with a low BP and new C-diff who was going about every 15-20 minutes) - with no techs/CNAs (all of 'em are occupied on suicide watch). So no one to help get vitals, EKGs, place pts. on monitors etc. etc. etc. We work 2 nurses per pod with a theoretical 8 beds i.e. 4 pts./nurse (of course, this never happens; especially on the acute side)
I can't call on my buddy-nurse working my pod with me - she has all the other (eight!) patients in our pod!!
It was absolutely BRUTAL.
I had no one to help me when I had to run my stroke pt. to CT scan (where of course, we find a head bleed and pt. needs to be shipped STAT to the Neurospecialty Hospital!) or to help put a line in my paroxysmal V-tach pt. (who was from a group home, with severe contractures and aphasia).
It was an absolute miracle that no one died in our department that day (despite some patients actively trying to, if you know what I mean). How we pulled that shift off, I'll never know.
Specifically to the ED follks, how do you limit unsafe assignment numbers?
I'm not really sure there's anything the individual nurse can do in that regard. I mean, there is no "fixed" amount of patients in the ED. You could walk into work and have 6 patients in the entire department with nurses swarming each patient like ants on a crumb...
... and half an hour later a bus could crash on the highway and you get swamped.
I think the biggest key (at least in my ED) is the charge nurse. A good charge nurse knows their staff - who works best with whom? The skill and competence of each staff member - who is suited for what? Keep a continuous eye on over all patient flow in the ED (e.g. if one pod just got slammed with 4 simultaneous patients, try to work the newly triaged ones to other areas to give slammed pod time to catch up). Pitch in when you see someone is struggling (arrange for patient transport, start an IV/foley etc.)
I've worked with both kinds - the demanding (but supportive) ones and also the indifferent (and unsurprisingly, the un-helpful) ones.
I'll take the demanding but supportive ones any hour of the day. Yes, they may ride my butt mercilessly about getting this done or that; but they respect me and support me. I'll take that over the 'indifferent shrug' I get when I approach the charge nurse about being assigned 3 "chest pains" in the space of 5 minutes... with no tech/CNA assigned to me.
What's your protections
I think as far as the 'general picture' goes, we have certain 'guidelines' regarding staffing allocation and "Divert" (critical care or general ED/hospital) status. I could be wrong but IIRC, the charge nurse tallies the:
* 'State of the House' i.e. No. of beds - Tele, Med Surg and Critical Care - open in the hospital.
* 'State of the ED' i.e. No. of beds open in the ED, Staff (Docs, nurses, techs) on hand, No. of ventilators on hand, waiting time in waiting room, triage time and time to be seen by a Doc.
The sum of these tallies gives us a number. And based on how high the number goes, charge nurse gets to call in extra personel and if need be, makes the demand to hospital adminstration to go on Divert# (Critical Care divert if we have no more Critical Care beds available - CCU AND ED included... or general Divert if there is just no room left period).
Now of course, like "safe nursing/patient ratios", what 'qualifies' as "Divert" is highly debatable.
For example, if we had a "4 pts./nurse" ratio, there is a world of a difference between having 4 'abdominal pain' pts. versus having 4 'intubated/mech. ventilated' patients - in both cases, while the "ratio" hasn't been violated... it isn't the same bag of tricks! (Yes I know it doesn't work that way everywhere, I'm just trying to give an example).
Similarly, at what 'magic number' qualifies Staff to ask for Divert status might not reflect the true status on the ground.
responsibilities?
I'm not sure I understand what you're asking. Clarrification please (with examples if possible) :)
cheers,
# : Of course, those of us who work ED/EMS already know that 'declaration of Divert' doesn't mean patients stop signing in ... or even that EMS won't bring patients in anymore (by law, EMS can't transport patients to a hospital they don't want to go to). So how 'effective' is it to declare "Divert"? Subject for a good discussion/research topic I guess...
mwboswell---I actually thought about that when I was writing my post because I used to work in the ED. Well, in that situation, people have to stay in the ED until a bed is available, which sucks----but, if it is bad enough, then it is time to call for a diversion if the hospital can't handle what is there.
And, I have to say that I do agree with the "accept one more patient, two more patients, and then they expect you to do that all the time", and it becomes the norm. This is how hospitals have come to function on a "skeleton staff"---because they have figured out that if one nurse was able to take care of 10 patients, then why can't they do it all the time?? That's how staffing has gotten to the point where it is today. And, the supervisors and nurse managers will try to sweeten you up and coerce you, somoehow teying to convince you that it is safe to be taking care of so many patients. I remember being a supervisor (a role which I hated), and having to cover sick calls when I got them. Instead of just calling an agency from the get-go (because we didn't have a per diem pool to pull from), first I had to call all the nurses who were off and who were on vacation---and you know damned well none of them wanted to come in. And, of course, I had to document the whole thing and exactly what the nurses said and the reason they woudln't come in (as if they had to give a "reason"---as if the "reason" was that it was their day off wasn't good enough, for Christ's sake!!), then I had to go ask the nurses on the unit if they wanted to stay and do a double (and they all said no, because they had already worked short for 12 hours and just wanted to go home), so, by the time I could actually call an agency (which I had to ask permission to do from the DON), the agency was out of nurses for the shift because they had already been placed at other hospitals who were covering sick calls too. And you end up literally BEGGING nurses to come in on their day off or to stay an extra shift. This is a practice that is rampant. There is NO OTHER JOB on the face of this earth that can MANDATE you to stay for another shift if there is nobody to relieve you!! And then, you can't count on the nurse who was mandated to call out sick for the next day. So, you are doing this same thing over and over again, day after day---and you end being the bad guy, when you are only doing what you are told to do by the ADMINISTRATORS!!!
It makes me sick at how the hospitals cry poverty---but look at the administration in some of these hospitals. Why do units need nurse managers, assistant nurse managers and charge nurses? It has all gotten completely out of hand. As if the hospitals needs managers to police the other managers...........then there's the CEO, assistant to the CEO, DON, assistant DON, assistant to the assistant DON.........you get my drift on this one. However, when it comes to hiring more staff nurses to actually do the work, well then WHOA!! We don't have any money. It's ******** if you ask me. All this stuff was not "needed" before big business entered the picture and decided to run hospitals as for-profit institutions. That is why nurses need unions to protect them against all this crap. Some of the state nursing associations have gotten involved---but the excuses and rationalizations and justifications for why the hospital is being run the way it is makes me sick to my stomach when I hear it. There is no loyalty for a hospital's employees anymore----BUT, they want you to be loyal to them and work like a literal dog just so they can continue socking away money hand over fist. Very little of that money ends up in a nurse's pocket. However---we rarely hear about the year-end bonuses that the adminstrators get because it would make us IRATE.
Times are certainly much different than they were 20 years ago. Patients that used to go to ICU now are put on med-surg floors...............and nurses have to take care of more patients than they used to, even with the patients being much sicker..................post-op patients are being pushed out the door whether they are ready to go home or not........"protocols" are being implemented instead of actually looking at the patient and treating them like an individual and concentrating on their individual problems.............EVERYTHING is to get more patients in and more patients out, increase turnover and increase profit----TIME IS MONEY, NURSES!!!! Never mind the juggling act and prioritization we as nurses have to pull to be able to take care of these patients.
Am I jaded? Yes. Am I cynical? Yes. If I had to do it all over again, I definitely wouldn't choose to be a nurse. Not when I am working my ass off, running around for 12 straight hours, working overtime and making less than my hairdresser makes. And, my hairdresser doesn't run the risk of sticking herself with a needle or being coughed on and contracting TB or making a med error and hurting someone or worse, killing them.
We work 2 nurses per pod with a theoretical 8 beds i.e. 4 pts./nurse (of course, this never happens; especially on the acute side)
mwboswell
561 Posts
But why must you wait for something to be "legal" to say NO.
Why not just say NO when you know it's unsafe?
Follow up point: If YOU don't take the patient, then what happens to the Emergency Dept RN who can't get them admitted then --- and THEN what happens to the Emergency Dept pt's who are STILL in a waiting room who haven't even been seen or evaluated yet???