Hemodialysis Nurse : Forced to work overtime or face abandonment?

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Dear Nurse Beth,

I have worked as an acute hemodialysis nurse for more than 4 years. My question has to do with the long hours we are sometimes required to work. Often, after being at work 12-15 hours an emergent pt will show up in the ED requiring one of us to stay another 3-4 hours (or even longer). If we refuse, it could be called abandonment, but if we stay we may be so fatigued that it could be unsafe. How is this type of situation viewed by the BON and is it even legal for a nurse to work this many hours?

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31 Answers

Specializes in Tele, ICU, Staff Development.

Dear Required to Work Overtime,

You are so right, working when you are fatigued is not safe for you or your patient. If a mistake is made because you are exhausted, it is still a mistake, and you are no less responsible.

Here's the problem:

Providing adequate staffing is the responsibility of the facility, the employer; not the individual staff nurse. The employer needs to have a contingency plan to deal with emergencies instead of relying on whoever is on duty to stay an additional 4+ hours. It sounds like the facility is offering a twenty-four hour service (hemodialysis) that it is not prepared to cover.

It is not abandonment until you have accepted care of the patient. If you are at the end of a run on one patient and preparing to go home, and are called to the ED- you do not have to go. I'm sorry, I am not able to work overtime today.

Acceptance of Patient Assignment

Remember the key is acceptance of patient assignment. Acceptance of a patient assignment occurs when a nurse has heard the patient report/status directly and agrees to the assignment. This includes receiving complete patient information and having the opportunity to ask relevant clarifying questions. A nurse can not be cited for abandonment unless they have accepted an assignment.

Likewise, a request to take an additional patient in the middle of the shift is an additional assignment which also requires acceptance by the nurse.

Bear in mind that once an assignment is accepted, the nurse is responsible for its completion unless responsibility can be transferred to another qualified person. You cannot leave until you have handed off care to another nurse.

The American Nurses Association (ANA) opposes the use of mandatory overtime, and supports the Safe Nursing and Patient Care Act which would limit the number of overtime hours a nurse may be required to work.

Hope this helps

Oooooof.

Nurse Beth, I love your posts, but it is not a clear line in acute hemodialysis. In fact, of all the specialties I've worked, this one is the most difficult to staff. And I've worked acutes for many, many years.

1.) A sizeable chunk (read that > 60%, I'd assume) of hospitals contract their dialysis services to outside dialysis companies, and these companies must keep the hospital happy in order to retain the contract. Yes, that means 24 hour coverage, and the hospital doesn't care how it's staffed, as long as their needs are met.

2.) Acute Dialysis needs within any given hospital on any given day (or week or month or year) fluctuate wildly. This makes it very challenging for the contracting company to staff accordingly. In fact, there is no "accordingly." In other words, we might need one hemodialysis nurse on one day, eight hemodialysis nurses the next day, and three the day after that but maybe by midday of that same day they find they only need one, or six, or two.

3.) remember that overtime (in most states) is accrued after 40 hours in a week. So...it gets tricky on a day-to-day basis. Really tricky.

I do not agree with these mega-shifts, but for many facilities it is very difficult to get around this problem, or find staff willing to participate long term.

Guttercat said:
Oooooof.

Nurse Beth, I love your posts, but it is not a clear line in acute hemodialysis. In fact, of all the specialties I've worked, this one is the most difficult to staff. And I've worked acutes for many, many years.

1.) A sizeable chunk (read that > 60%, I'd assume) of hospitals contract their dialysis services to outside dialysis companies, and these companies must keep the hospital happy in order to retain the contract. Yes, that means 24 hour coverage, and the hospital doesn't care how it's staffed, as long as their needs are met.

2.) Acute Dialysis needs within any given hospital on any given day (or week or month or year) fluctuate wildly. This makes it very challenging for the contracting company to staff accordingly. In fact, there is no "accordingly." In other words, we might need one hemodialysis nurse on one day, eight hemodialysis nurses the next day, and three the day after that but maybe by midday of that same day they find they only need one, or six, or two.

3.) remember that overtime (in most states) is accrued after 40 hours in a week. So...it gets tricky on a day-to-day basis. Really tricky.

I do not agree with these mega-shifts, but for many facilities it is very difficult to get around this problem, or find staff willing to participate long term.

Having just come off an 18 hour shift due to this very situation, it is the responsibility of the on call nurse to take care of that last patient - often times after working all day. On call (at least for me, not sure for Guttercat or idialyze) is 6 pm to 6 am the next morning. So it could come to fruition that we wind up working 24 hours because of being on call. Guttercat I wish I could like this twice

Nurse Beth said:
It's the same arrangement Surgery, PACu, Cath Lab and others have..being on call after working all day. Brutal. Twinmom06, are you OK with it, or what are your thoughts?

One thing our tidy little group of dialysis nurses do is to not schedule any nurses to be on call following their regularly scheduled shift. I've done that before, and it is not pretty.

Our program is small enough that we are able to do this. It gets increasingly difficult to schedule this way in larger systems. For one thing, patient volume can be so high on any given day that scheduling one RN to be on-call might not be sufficient, therefore, the RN's who have been working all day either stay and get the patients dialyzed, or the patients simply do not receive their treatment.

Hiring and scheduling more RN's is not the answer, because when loads are light, no one is getting their hours. Scheduling more RN's to be on-call also doesn't work because then you are pulling from an already set number of RN's, which increases the likelihood that they're already scheduled that day, or are already scheduled multiple days that week with regular shifts--you end up working 5-6 days a week on rotating shifts.

The other thing we have going for is are a group of nephrologists that communicate closely with the staff and try their best not to overload us...if we are overloaded and a patient can be safely postponed to the following day, they will do that for us. Not all nephrology groups are that kind.

I don't know what the solution is.

There is also the issue of space. The hospital I'm in 90% of the time (we fluctuate between hospitals) we only have 2 dialysis rooms (although one has 2 machines in it now). Our boss could put 5 of us there but if we don't get another room (sometimes we can borrow an empty ICU room although that is really scarce now) then we're there 18+ hours to dialyze the 10-12 pts per day. Sometimes we cut treatments to 3 hours but we can't always get the docs to agree to that.

To answer your question Beth - it is what it is. One one hand the hours are brutal, on the other, I'm not running around a floor after 7 patients, toileting/medicating etc. My only focus is the patient in the bed in front of me - since they are inpatient acute, they aren't allowed out of bed and if they need meds, their primary nurse from the floor has to come give them.

Some employers do require mandatory overtime. I'm not at all sure it's legal.

Some staff refuse and get disciplined, others refuse and nothing happens to them.

Beth's statement of what constitutes acceptance of an assignment and when abandonment can be charged is different from what I have heard before. That is, some employers tell you that you have accepted an assignment by arriving at work. Also, that you took off your coat and put your purse/lunch away means you accepted the assignment.

I guess each of us has to decide what we will tolerate regarding how many hours we can work. The trouble is that employers have a need and staff need the job. Same old stuff. We each have to stand up for ourselves.

What does your state board say? What do some employment attorneys say?

Specializes in Infusion Nursing, Home Health Infusion.

Nurse Beth is correct...Nurse Practice Acts state that you MUST accept the assignment. In accepting it you must know what it entails. If you complete your shift and you are NOT on call you do not have to take the assignment. It's tricky though because you want to be a team player and you may feel an obligations to take care of the patients in need of your services. Your employer may twist the facts of the law because it meets their needs so they use the, "You are abandoning the patient", as a tool to get you to do it. It relieves the employer of their duty to come up with a viable plan so their employees do not have to do the horribly long shifts!

Specializes in Dialysis.

As long as everyone is profiting nothing will change. The nephrologist makes money on a patient he didn't have to get out of bed to see. The hospital charges for an emergent treatment ($2.300) that would only cost $250 if the patient went to his clinic. The dialysis nurse gets time and a half for getting called in or staying over and gets to keep it as long as they don't wrap their car around a telephone pole when they fall asleep on the way home. And dialysis patients continue to be the largest expenditure in the medicare budget. I wonder why?

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

A while back, they were paying out a huge sign-on bonus for inpatient/acute dialysis and I was asked a couple times to go. This is why I did not. The whole thing about going in and not knowing when I would go home----working 16, 18 or 20 hours or not at all if low census. It does not fit into my plan.

NO ONE offers a big bonus like that, without darn good reason. I did not take the bait.

I will not do acute dialysis anytime if I can help it. I like my set hours, thank you. I did the whole overtime/low census thing for years as an inpatient/acute care RN. No more.

Specializes in Dialysis, Telemetry.

This is not a unique situation. I just quit a job where I was required to work 22 and 24 hours. I am also a dialysis nurse and I was working for one of the big dialysis companies. I have worked in both chronic and acute settings and my last job I was told in my interview that I had a "choice" of coming in at 10 am on days where I would be on call. They had you on call on days you are scheduled to work. I was being called and pressured to come in at the normal starting time of 7 am due to a heavy patient census. On the two occasions I agreed to do so, I worked 22 and 24 hours on those days. I did not feel at all safe as I was driving home after working those hours and I did not feel safe as a nurse during the last four hours of my long day.

After those two incidents I flatly refused to come in early on my call days and was pretty much treated like a trouble maker because I was not willing to do that or work without breaks or lunch and dinner breaks. There are other options they have to prevent those happenings but they just do not care so long as they have a body in place.

Specializes in Corrections, neurology, dialysis.

Dialysis services get around the rule that nurses can only work a certain number of hours because the rule applies to who are employed by hospitals. And since a dialysis service isn't a hospital they can't get in trouble for asking you to work longer hours.

If if a service doesn't have enough nurses to cover all their patients, that's a management problem, not yours. You are not responsible for making sure they have enough coverage. Now having said that, they can find ways to bully you into working 16+ hours a day. They can say that you refused your assignment or that you're difficult and uncooperative. And they can fire you for insubordination. You just have to hope your manager doesn't take it to that extreme, but they can if they want to.

Meanwhile stand your ground. If your manager has any common sense they'd rather keep you around for the hours you can give them rather than fire you and have one less nurse to provide coverage. As you know, not everybody thinks logically. If your manager is the mind that goes on power trips it could get ugly. If your manager is reasonable you can set a boundary and stick to it, and eventually they'll leave you alone when they see they can't get you to work overtime every day.

So what is the solution?

As an Acute Dialysis Nurse for many years, I am hesitant to place any blame on my superiors. They are equally stretched to the limits.

The point of any business is to stay viable over the long run. We all want that. But Acute Dialysis is a unique beast that doesn't fit into traditional hospital staffing models...it's much more difficult.

I know what my limits are, and I set them. If this doesn't work for the company, I get that. The company owes me zilch. I also do not think the company is some evil entity hell-bent on destroying the little people. We are trying to run a unique system based on healthcare models designed for "normal" staffing, and then we get all bent out of shape when it doesn't work.

Sweeping change in how Acutes are staffed might be realized, but staff would have to realize that such change would come with concessions on their own part.

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