Leadership and risk management?

UM Review RN, ASN, RN · Feb 3, 2005

Ok can anyone help me with this scenario: Due to the increasing rate of retirement of the staff at your local hospital and the difficulty in attracting nurses to come and work in your town (remote) it has become comman practice to to ask all nurses in the hospital to work extra shifts in other specialty areas that they are not used to. You arrive at work and find out that you've been relocated to a specialty area you have never worked before and are also told that due to short #'s you will in charge of the unit for the shift. You are told that there is nobody else to that can come in to work that area, and the hospital is counting on you. What would you do?!

Clarify the assignment.

Refuse the assignment.

Leave the facility joyfully knowing that I haven't endangered any innocent patients nor jeopardized my license trying to do something I was not trained or oriented to do properly.

Get another job in the morning.

llg, PhD, RN · Feb 3, 2005

I hope I would not wait until it got to that point to act. I wouldn't work for any hospital that "floated" nurses to floors to which they had not been oriented. If I worked for a hosital that did float people like that, I would insist on a proper educational program for everyone. I wouldn't wait until it was my turn to float before I would be making arrangements to get the proper education.

All that (above) is assuming I wanted to remain working for that facility. In other words, if I decided that I wanted to work there, I would do my best to make it a good safe place to work. As in many of these difficult situations, I think anticipation, planning, and prevention are the best options. It sounds to me as if this case is not a sudden, unexpected event -- and that plans for preparing the staff could have been in advance.

If not ... I would try to clarify the assignment, assess whether I had the proper knowledge and resources to carry it out safely, etc. If I could not do it safely, I would refuse the assignment and be prepared to fight the legal battle if I were fired for the refusal.

llg

meownsmile, BSN, RN · Feb 4, 2005

Happens all the time here. Go to work, number of assigned staff not needed according to matrix, extra nurses float to other areas and they call people off. They rotate the call off list so if its not your turn you get floated. It's a small hospital so if you go to a unit that you arent completely oriented too the regular nurses cover the stuff you havent done. Still stinks to now know where you are going to work from one day to the next.

BETSRN · Feb 4, 2005

Happens all the time here. Go to work, number of assigned staff not needed according to matrix, extra nurses float to other areas and they call people off. They rotate the call off list so if its not your turn you get floated. It's a small hospital so if you go to a unit that you arent completely oriented too the regular nurses cover the stuff you havent done. Still stinks to now know where you are going to work from one day to the next.

I think (in a pefect world) I would FIND ANOTHER JOB, ASAP! Very unsafe. You are risking your license every time you go to work!!

llg, PhD, RN · Feb 4, 2005

Happens all the time here. .

What are you doing about that? Are you getting the education/orientation you need to do the job safely? If not, you need to take action or some sort.

To simply accept unsafe conditions is to allow their continuation.

llg

meownsmile, BSN, RN · Feb 4, 2005

Maybe you misunderstand me. We float, but if we arent comfortable doing something we dont do it. I wouldnt go read telemetry not having any training for it. I wouldnt mess with a vent settings if i hadnt had any training. I wouldnt monitor a L/D without orientation/training. As i said, there are things that when people are floated doesnt rest on their shoulders if they havent been trained. But, it is all about numbers isnt it? As long as they can staff enough bodies to meet their matrix thats what they do. My point is we never know from one day to the next if we will be working on our own unit or floating to another. Im a med/surg/ortho nurse, and i have floated to ICU,ambulatory surgery, and telemetry, occasionally peds(which i worked during LPN days). But if im not comfortable and dont know what im doing im not going to do it. I was always taught to know what it is you dont know. There are others that can help out with those procedures.

NurseConnieR · Feb 6, 2005

Clarify the assignment.
Refuse the assignment.
Leave the facility joyfully knowing that I haven't endangered any innocent patients nor jeopardized my license trying to do something I was not trained or oriented to do properly.
Get another job in the morning.

I suppose we really need more details to make a judgment. I'm going to add some "facts" and see how it changes the picture? You're a med/surg nurse with 6 years of experience and a specialty certification in medical/surgery nursing. You frequently are in charge of your own unit, have a proven track record of good judgement and have the full confidence of administration. The specialty unit you've been asked to take charge of for a shift is the step down unit. The nurses on this unit have been there less than one year but are competent to oversee their patient population. There are two patients with non-titrating vasoactive drips with specific orders from the physician regarding parameters of notification, two patients with invasive lines (CVP) and one patient on a home ventilator. They are all on telemetry that is monitored at the central monitor station. The patients are just coming out of a period of instability and need a little closer monitoring, hence they were placed on the step down unit where the nurse/pt ratio is 4 or 5 to 1. If you accept the assignment to take charge of this unit for a shift, there will be no more than 4 patients per nurse. If you refuse to take charge, there is no one else as qualified as you to take the position and the patient ratio will be 6 to 1 for the other two nurses working.

What would you do?

I would look at the patients, the skills of the nurses with whom I am working and ancillary staff (i.e. respiratory therapy). If I felt it was unsafe, what could be done to make it more safe? I would notify my supervisor verbally of my assessment of unsafe patient care delivery and my ideas to address the immediate problem (ie. appointing an ICU nurse to be a resource person who could help problem solve if needed) but I would follow up my concern in writing. I, however, would take the assignment as to refuse the assignment would not make the patients any more safe - it would actually make them LESS safe. In a rural healthcare setting as outlined by the author of this thread there is often not an option to find another more qualified nurse. To simply say I would refuse an assignment and by having done so the patients are safer is an assumption rural nurses (and in some cities - city nurses as well) cannot make.

In the Oklahoma Nurse Practice act the basis of action against your license is based on what a "prudent" nurse would do. Prudent means "Wise in handling practical matters; exercising good judgment or common sense". It seems selfish to me NOT prudent to refuse an assignment and make an already unsafe situation worse but better. However, a prudent nurse would also work WITH administration to find a safer way. The Oklahoma Nurses Association has begun a "workplace advocacy" program which many states already have in place. If you're not already familiar with the protection offered to both you and your patients, please check it out.

TheTexas Nursing Associaiton actually has a plan to protect nurses from just this type of situation - it's called the Safe Harbor-Peer Review. "Safe Harbor-Peer Review is a formal process for questioning an unsafe practice setting without fearing employer retaliation or action by the Board of Nurse Examiners (BNE) of Texas." It's a great plan and one I wish Oklahoma had.

Great questions droopy.

UM Review RN, ASN, RN · Feb 6, 2005

I suppose we really need more details to make a judgment. I'm going to add some "facts" and see how it changes the picture?

I disagree. First of all, your scenario is putting words in someone's mouth and essentially changing the question, so I normally wouldn't even answer, but since you chose to use my quote, I will elaborate. I have never, in my experience as a Med-Surg or Tele nurse, accurately been informed of the patient acuity and mix before I took an assignment. However, I have been dumped on quite a lot and have since learned to protect my potential patients and my license by saying no. I am not the saviour for the hospital. It's been proven time and again that if they need someone else, 99% of the time, they're asking you because you're there and you're cheaper.

It was evident from reading the OP's post that she was not turning backflips at this assignment and every nurse who's ever been trained in every nursing school in the nation knows better than to accept liability for an area that she has not been oriented or trained to and which, even so, TBTB have deemed her to be the most experienced over a group of nurses.

BIG red flag there, folks.

That's just asking for disciplinary problems with her license should a problem arise. And in today's litigitous society, you can bet that at some point there will be questions about whether or not the assignment was safe to accept or not.

I have been in this position before, in which I have been asked to go to CCU and take care of a patient who was a "fairly stable" patient alongside a tele patient. I refused. Legally, until both patients are downgraded to my tele unit, I am responsible if either of them should take a turn for the worse, and skills beyond mine become necessary.

People, if these patients were that "stable" they would NOT be in the hospital. Period.

IMHO, nurses have a duty to protect their potential patients from the harm that can result if they do not know an area and accept an assignment like that.

UM Review RN, ASN, RN · Feb 6, 2005

I also submit this case from NSO's website:

http://www.nso.com/case/cases_area_index.php?id=56&area=Hospital

An excerpt:

The plaintiff also contended the hospital was understaffed with nurses. She produced hospital documents and testimony from current and former employees, showing that the hospital purposefully understaffed in order to increase profits, thus exposing patients to risk of injury.

It's one thing to be victimized by poor staffing, it's another to be complicit in it. Just MHO.

jnette, ASN, EMT-I · Feb 6, 2005

IMHO, nurses have a duty to protect their potential patients from the harm that can result if they do not know an area and accept an assignment like that.

I wholeheartedly agree. Thank you.

NurseConnieR · Feb 7, 2005

However, I have been dumped on quite a lot and have since learned to protect my potential patients and my license by saying no. I am not the saviour for the hospital. It's been proven time and again that if they need someone else, 99% of the time, they're asking you because you're there and you're cheaper.

You make some valid points Angie. Specifically, it was good to be reminded that there are many hospitals so lacking in responsible, trustworthy leadership that they would purposefully put patients in unsafe situations. It's been a while since I've worked in such an institution, thankfully.

I'm curious. Do you know what the law for patient abandonment is in your state? I worked in a state where if you were on hospital property and refused an assignment, it would be considered patient abandonment. I believe that has since been changed (hallelujah). In other states, if you clock in and refuse an assignment it's patient abandonment.

I suppose there are two foundational reasons for my point of view which differ greatly from yours. 1) in rural healthcare there is often NO immediate option. We could contract with a traveler but when census drops I sit at home using vacation time while the traveler works. Most of the time, we understand that we'll have to make some sacrifices (like working extra shifts) but the rest of the hospital makes sacrifices as well. When census is low at your hospital is it the direct caregivers that are sent home (nurses, respiratory therapy, etc)? At my hospital, if census is low EVERYONE is required to work fewer hours from housekeeping to the head of accounting. 2) I think I have a different relationship with the administration at my hospital. My hospital does back flips to educate nurses on fiscal realities of healthcare today and includes us on decision making (yes, the bedside nurse is included). As a result, my anger, disillusionment, frustration, etc has refocused my energies to working with my congressman and my state nursing chapter to change laws and educate the public on the healthcare crisis we face.

However, I HAVE worked in hospitals where I did not trust or respect the administration. In a situation like that where you can trust nobody - not even the nurses giving you report - I would not only refuse the assignment but, as you stated, begin looking for a new job in the morning. As they say, been there, done that.

I did a poor job of making my point previously which was this: there are often other viable options rather than refusing an assignment and that not being oriented to an area is not a black and white issue. Schools of Nursing teach us to critically think - and that same skill should be applied to this decision.

I am new to allnurses but I am greatly enjoying all the different points of view. It also makes me very happy with the hospital and environment I am in and reminds me how important trust is to relationships of all kinds.