Accept or refuse an assignment - page 2
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Feb 10, '02I have a question that may seem stupid regarding accepting a patient assignment and abandonment. I work in a CCU, and usually have only 2 patients but if staffing was bad I might need to take 3 patients. This would not be a problem if all patients were stable or being held in the unit due to no floor beds. If I was given a 3 patient assignment one shift, how would I know it would be unsafe until I got report?
What I am trying to ask you all is that it seems to me that you can only make the call that an assignment is unsafe after receiving report on the patients, but then it is too late to refuse the unsafe assignment. Perhaps I am missing something, and I would appreciate any insights that you all may have.
I hope this posting makes sense!
Thank you all in advance!
Feb 10, '02When you get to the floor, how soon do you see your assignment? I hope it is before you sit down to report.
I believe your best bet would be to assume the worst case scenario. 3 patients is too many for ICU. I think I would refuse to accept more than the mandatory 2.
Feb 10, '02I agree with P_RN. In ICU, 3 patients are too many and I would refuse the assignment. If they are patients who are there because of a no-bed situation, they will tell you right away as soon as you refuse the assignment.
Feb 10, '02Thanks askater11! I appreciate your response to me!
This is for "Squirrel":
You asked, "How would I know it would be unsafe until I got report?"
My response would be this:
Liken it to sitting for an interview. You hear what the job entails from the employer, you ask questions of a specific nature that clarifies the job description and responsibilities more to your pondering. Then, you---and only you---make the judgment call as to whether or not you accept the job.
You go to report. You listen to report. You---the Professional Nurse that you are (keep in mind all those $$$$ you paid to gain your professional status)---determine whether or not you can SAFELY care for the patient assignment "offered" you (GIVEN YOU??? NO, NO, NO, SQUIRREL!!! Now, I KNOW that's how nurses look at it, but we as nurses MUST 'retrain the brain' to professionally and safely say..."patient assignment OFFERED you" ) If the assignment is something you can SAFELY AND PROFESSIONALLY handle, then, and only then do you accept the assignment. If--in your infinite and professional wisdom--you determine the assignment is UNSAFE and beyond your professional ability to handle, you say:
"I will NOT accept this assignment as it stands due to the unsafe nature in which it would put the patients at risk, not to mention jeopardizing my nursing license in the process. However, I know 'patient X, and 'patient Y', and feel I can safely handle them, but 'pateint Z' is another story entirely due to his/her particular health problems requiring one on one care (or whatever the case may be)".
No law is going to fault a nurse for "hearing report" on patients! The nurse is only legally guilty if she/he "willingly accepts" the assignment.
You may be fired, but you can hire a lawyer who will rightfully and legally prove your case to be more worthy of attention than the employer who fires you, thus, you win back pay for time off the job not due to any fault of your own, and you may even win other monetary damages, as well as bringing the issues of nurse/patient abuse to light before the media.
No one wants to BE the example, but everyone wants to benefit from another person having stood the ground necessary to make the much needed changes in nursing care!
THINK ABOUT THIS NURSES!!!
HOW WILLING ARE YOU TO STAND FOR WHAT IS RIGHT EVEN IF YOU ARE THE ONLY ONE STANDING? BY STANDING for what you know is necessary to stand for, you make changes that will POSITIVELY EFFECT future healthcare around the world!
Feb 10, '02Thank you all very much for your responses! You have really helped me!
Where I work, the nurses all do 12 hr shifts and in the beginning of the shift they all get a general report from the offgoing charge nurse on all the patients, then every oncoming nurse states what he/she feels a reasonable assignment would be. I think this works well and I work with a great group of nurses who look out for everyone. I work per diem with variable hours, and when I do 12 hr shifts this is not a problem for me.
I tend to work 4 or 8 hour shifts to cover staffing, so when I get to work I do not get a general report on the patients and am told by the charge nurse what patients I have been assigned to. Again, I am very fortunate to work with a great group of nurses who I do not believe would not give me an assignment that they would not take themselves, but I was concerned that if I say to the charge nurse "OK" regarding the assignment without getting some information on the patients first, that I could be caught in a difficult situation. I guess if I requested a "general report" from the nurse I was relieving first before saying that I officially accept the assignment my worry can be alleviated.
Another issue of concern regarding refusing assignments is being floated to other units. I know this topic has been discussed in other threads, but I have worked in places where nurses are floated to other units without orientation to those units which I feel is setting that nurse up for a disaster. If the nurse accepts the assignment and something goes wrong he/she is blamed for accepting the assignment, but if he/she does not accept the assignment he/she is looked at as being noncompliant, not a team player, and can be disciplined. I am very fortunate that I do not have to work full time and can quit to save my license, but I feel for those who are placed in these situations and are dependent on full time employment.
I recently interviewed for a postion in a different hospital as per diem to supplement my experience at my current hosptial, and asked about floating. I was told that if I was asked to float to an area I was not familiar with, I would work as a nursing assistant and not take an assignment. I think this policy is fair, helps the unit in need of extra help, and prevents resentment from the nurse forced to float to an unfamiliar unit.
Thank you again very much! I learn so much from this bulletin board.
Feb 10, '02Hello again Squirrel!
Having been a traveling nurse before, I would have to say that travelers do that a lot -- going to hospitals/working on units that they do not receive orientation for, or preceptors to work along side of them, etc., etc., etc.. Maybe that's why I'm such a tough cookie today when it comes to standing my ground professionally and personally. As a traveler, we show up on the unit we've been assigned, and there we be. We get report and we go to work. If the assignment is more than we can safely handle, I don't know about other travelers, but I SPEAK UP! I can honestly say on all the traveling nurse assignments I've completed, I have always been recognized as a nurse who can stand her ground independantly of the others on the unit, and get the job done to the hospital's and the contract agencies satisfaction. I leave one assignment anxious to start another one. The adrenaline stays pumped, I stay hyped, and in 13 weeks, I'm out of there!
Any nurse can refuse to accept a patient load that they feel is unsafe regardless of whether or not you have received report on that patient. Just because "everybody else does it" doesn't excuse another nurse when she/he takes on more than he/she knows is SAFE or RISKY for the patient as well as the nurse. Don't buy into the drama just to be sweet! I've worked with some terrific nurses over the years, but I don't owe any of them my nursing license just because I'm trying to prove to them how much I like them, therefore putting up with the unsafe patient assignments just because "they do it". Sure, it's rough on all nurses, but not all nurses will lose their license if only one nurse screws up by taking on more than is adequately safe for her/him as a nurse.
Nurses, our problem most of the time is we don't know how to be tough enough to stand our ground. Maybe in every "unsafe" situation, nurses need to put on their "Mother Hen hats" as if someone is about to put your child's or children's life in jeopardy. Every mother reading this knows what I'm saying here because as mothers, we get tough and in a fighting stance when our children's lives depend on it, so why can't we apply that toughness to our jobs as nurses? JUST SOME FOOD FOR THOUGHT!
WARNING: An LPN cannot work as an RN unless she/he also carries an RN license. A RN cannot work as a LPN unless she/her also carries an LPN license. An RN cannot work as a CNA unless she/he has a CNA state board letter of certification stating she/he can work as such. TRUST ME ON THIS: IF you are floated to a unit that you are "unfamiliar" with, and told that you are not held accountable for anything except CNA duties, let something happen to a patient that you (an RN) has witnessed while in the room with that patient, and LEGALLY, you will be held accountable--not as a CNA or nurse assistant--but as a RN. Don't let those supervisors lead you to believe otherwise. Call your state board of nursing's legal department and present this question to them, and see what response they give you, then report back here and let us know. If I'm wrong, I'll apologize to you. JUST LOOKING OUT FOR YA, THAT'S ALL!Last edit by live4today on Feb 10, '02
Feb 10, '02Renee:
Thank you very much for your insights and information! I think I was trying to make this a black and white issue to help me understand the legalities, and it is a grey area. I think I was looking for an absolute definition of the term "accepting an assignment", and realize that it may depend on the situation and that just because I agree to hear report on a patient does not mean I am accepting the patient as an assignment. Do I have it right?
Thank you for the information about working as an nursing assistant while being an RN. I did not think of the implications that you brought up. It makes sense that if I am an RN I will be held to those standards regardless of what my role would be at that time. I really wish that a reasonable solution could be found for floating.
Feb 10, '02Hi Squirrel! You're in New Mexico--I'm your neighbor in Texas! Interesting to hear the comments from other ICU nurses regarding 3:1 staffing in their critical care areas. Unfortunately, we are seeing this become a real problem here in Texas. What we used to do in a 'pinch' now is being expected, so we are having to backtrack.<sigh>
So..this is how we handle it now. I will accept a third patient for me or one of my staff ONLY if my other two are STABLE and my third is on the list to move to PCU asap. Those of us in charge are learning to be very tough about this to protect all of us, and we are voicing our objections loudly to management and the docs (who take our side surprisingly..LOL!)
Feb 10, '02mattsmom81:
Howdy neighbor! Thanks for your input regarding the 3:1 critical staffing. Somebody once said to me that if you do something for someone one time it is a favor, but the remaining times you do it it becomes a job. You give an inch and they take a mile, ect ect. We want to be team players but we should not be martyrs. I think this is the most difficult issue in nursing today (among many others).
Something else I thought of regarding abandonment: I remember reading something many years ago about a hospital that had a policy that one of the ICU nurses go to every code in the hospital, which I think is common in non-university hospitals where there is no code team. One day there was a code in this hospital and the assigned ICU nurse went to the code and left her patients for the other nurses to care for while she was gone. The ICU was very busy and none of the nurses were able to watch her patients because they were so busy with their own patients. One of the code nurse's patients had some incident happen while she was gone and died. If I remember the story correctly, the code nurse was charged with abandonment because she left her patient to go to the code and did not make sure her patients in the ICU would be properly cared for. Talk about a no win situation!
It was said that her primary responsibility was to her ICU patients and not the patient coding on the floor, but if she did not go and the coding patient died my guess would be that she would be held accountable for that.
I read this many years ago, but I wonder if anybody recalls this story or a similar one? If you work in an ICU that has this policy how do you assign the code nurse?
Thank you all again!
Feb 10, '02Code nurse in our cardiac ICU covers the whole hospital; is an expected part of the code team (another assigned nurse--from the cardiac stepdown unit--goes to the code also). Usually code nurse has the "easiest" assignment in the unit. We ALWAYS have a float charge nurse, who can take on the absent nurse's assignments in a pinch. We have strict 2:1 staffing of which I am VERY thankful. Seeing how sick some of our patients have been lately (some one on one, two on one care), we could not possibly do 3:1. Sometimes we have two balloon pump patients, sometimes CRRT (which "used" to be one on one--now is paired with a "stable" pt).
Feb 10, '02I don't care if it is a Psych Unit, Med Surg or even Pediatrics unsafe staffing is just that. I like what Renee states to the point refuse, go home protect your hard earned license. You are licensed by your state not by facility.
When I was working as a LVN on a rehab floor the 2 RN'S attempted to give me 20 patients while they cover my IV's ! I laughed and stated I will not accept this assignment please call our supervisor I am leaving. Needless to say they broke down the assignment more fairly. I don't tolerate anyone or facility jeopordizing my license. Remember when in doubt don't do it. No board of nursing will penalize you for not accepting a dangerous assignment.
Feb 10, '02You've got it Squirrel! That's exactly right!
Squirrel, you are a professional registered nurse no matter where in the hospital you are floated to, no matter what the supervisors "call you". Legally, an RN is an RN is an RN, and in a court of law, that is how you will be viewed and judged. Have a great upcoming week, Squirrel! Be strong and be encouraged!
Just because someone is in a position of authority over you does NOT make everything they say "sound judgement" for you to follow.
Feb 10, '02Ok, I am reading everyone's post and I have a better idea.
I would speak to the Administrator and th CNO, immediately. I woul tell them that I feel uncomfortable with this and that I spoke to my Nurse Manager at length, first. I would also talk with the Risk Manager and tell her what is happening here.
If there is no staff coming in to relieve you, you must chart something defensive that will state that staffing is short and that you had for example asked for a sitter for this patient because he needs to be a 1:1 for his own safety. I would then state in my notes who refused you.
In another situion, I would state that Nurse Manager and perhaps CNO not able to supply sufficient staffing and I would state what the patient's witnessed behavior is upon as frequent rounds as can be made and state that x-amount patients assigned to you for the day.
What I am saying is to defend yourself with something that will stand up for you in court. To state this is a legally binding patient record. It IS the hospital's fault if something occurs since you can not be in 10 rooms simultaneously.
I would very much like to ask the responders what they could say that would help you out further and also, I am so disturbed that Nurses are so over the barrel! Go start to protect your back some. State what the conditions are and if something should arise, it is well documented. This will all stop in time when they can not defend their unsafe staffing practices and drive good Nurses out of the profession because of fear of license.