So Ive been working in the ICU for about 4 months now, and am still getting used to the this new environment and how the nurses work together.
Well there was a very sick patient that had been deteriorating for several days now. Very complicated pt that was assigned to someone with a lot of experience in ICU, but only in this unit for about 2 years.
Well I overheard this nurse asking the charge if she was going to have the same assignment for the next day, and the charge replied, "you should as long as someone doesn't pull rank."
I thought that was sooo weird. This nurse had been doing a good job at taking care of the patient for 2 days. Why wouldn't she get the same pt back?
Is this someone you guys come across at all? I would be pissed if I was taking care of the same assignment for 2 days, and had to switch for my 3rd.
If someone is precepting, they may need that assignment. For instance, one of the things we have to check off on our orientee's skills list is LVAD. If the patient has an LVAD and my orientee needs that experience, we would get dibs (or "pull rank") on that assignment. An orientee that is at the end of her orientation may just lack one or two experiences to complete their skill's list, so the orientee that is closest to the end of the orientation without checking off that particular skill, device or experience is the one who will get the assignment, regardless of who had the patient yesterday.
I would not consider that "pulling rank". Thats a legit scenario where orientees need to get exposed to certain situations.
Now if some prima donna waltzed in after their 4 days off and had a fit that she wants that LVAD patient because shes got seniority and has worked here for 30 years, there is no way she is being trippled even though its her turn and there are plenty of other nurses skilled enough to care for the patient and no other reason than that, then I would call it "pulling rank". And I would also call it BS. :)
But for the learning needs of staff, thats much different.
Specializes in NICU, PICU, PCVICU and peds oncology.
When I worked as a staffing relief nurse way back when I first graduated, I was the one with the crap assignment. Every. Dang. Time. One unit I was sent to several times was a huge, heavy medical unit with intersecting hallways. Half of my patients would be at the very end of each hallway, and the other half would be the ones with DTs, or the psych patients in with acute medical issues. It was brutal.
I often have a different assignment every day of a stretch. I'm one of the most experienced nurses on the unit, but often have the chronic kiddos who just can't be cared for outside the ICU. There are a couple of people who "pull rank" and we all know who they are, so when we see their name on the assignment sheet we know they're going to have a certain type of assignment, no matter how many days the nurse has already been with them. But what really sticks in my craw are the ones with weight restrictions. Not all children are small. If you can't look after a patient over 10 kg, then perhaps you should be looking at NICU. If I've been with a tiny person for the last 6 shifts in a row and have to give up that assignment to someone who needs a tiny patient... well, I'm not happy.
The notion of people "pulling rank" and getting away with it is definitely a sign of an unhealthy work environment but I'd say there aren't many truly healthy work environments out there. If it's not this, it's something else just as odious.
One thing I don't see mentioned is when a nurse "pulls rank" to get an easier assignment. I worked 2 12 hr night shifts with one charge nurse and my 3rd with a different charge nurse. The 1st 2 shifts, the CN tried to make the assignments "even" with everyone having a "heavy" and couple of "light" patients as census would allow...we were also very good at helping each other if need be. The 3rd night, the other CN would make the assignment to where she had most of the lighter patients, completely changing everyone's assignments from the last 2 shifts....not because she was in charge (with 3 RNs we all kinda did our own thing on nights) but because she didn't want to work that hard.... her words!!!
One thing I don't see mentioned is when a nurse "pulls rank" to get an easier assignment. I worked 2 12 hr night shifts with one charge nurse and my 3rd with a different charge nurse. The 1st 2 shifts, the CN tried to make the assignments "even" with everyone having a "heavy" and couple of "light" patients as census would allow...we were also very good at helping each other if need be. The 3rd night, the other CN would make the assignment to where she had most of the lighter patients, completely changing everyone's assignments from the last 2 shifts....not because she was in charge (with 3 RNs we all kinda did our own thing on nights) but because she didn't want to work that hard.... her words!!!
I've experienced this. At least one placed that I worked, there were a certain few ICU nurses who never, ever had a paired assignment, let alone tripled.
As a former traveler I have seen this first hand. Travelers can't be trusted to do anything, yet when we ask for help finding things or on how the 9th documentation program we've learned in 1 year works we get looked upon with scorn and pity. We can't possibly have experience carving for high acuity icu patients. We are only here to ensure the permanent staff can stay in their unit and not have to take more than 2 patients. Sorry for the rant....I'm tired of being abused. Good thing I got out of bedside nursing and got my np.
Specializes in Cardiac (adult), CC, Peds, MH/Substance.
As a former traveler I have seen this first hand. Travelers can't be trusted to do anything, yet when we ask for help finding things or on how the 9th documentation program we've learned in 1 year works we get looked upon with scorn and pity. We can't possibly have experience carving for high acuity icu patients. We are only here to ensure the permanent staff can stay in their unit and not have to take more than 2 patients. Sorry for the rant....I'm tired of being abused. Good thing I got out of bedside nursing and got my np.
I mean, it's the devil known and accepted. You get the short end as contract, until you don't. If you don't, it's usually because they want you to stay, even though they know you're paid better. They're human. It annoys then at first that they know you make more, but eventually they're annoyed to see you go.
I am pro report, report and report. Bring these issues out in your staff meetings. Find an ally that will side with you to get these kinds of discussions in the open.
I can remember a long time ago, I mean really long as I now have 42 years in nursing, when I got the worse of assignment in OB.
I treated those assignments as learning experiences. I learned so much from each and everyone of the pts I did not get to take care of two days in a row. It also was kinda of difficult as I worked in L&D in my early years of nursing. So my discussion would have been getting the worse of the pts especially those with 900 drips.
I know I speak from the administrative point of view as I am not at the bedside. However, the old nurses would let you talk to them and then come to an agreement. The question is not just getting the same pt but what is happening to the group who see each other sometimes more than they see their families.
"Can we just all get along?"
Learn from all of your pts whether you care for them one day or 15 then teach what you have learned.
I can at least see that reasoning a bit. But when the charge comes up to you and cockily says "I'm tripling your assignment. That's why you make the big bucks." Well, that's harder to find reasonable.
I've had that said to me a couple times in my life and it is totally not cool. Also totally not cool: ICU tripling up patients at all. Happens all the time these days and it's wrong. Taking away secretaries, pulling techs, and then tripling--or quadrupling--nurses up and still expecting the same level of care. Not easy and many times not possible. It's unfair to patients and staff, but on and on it goes. I like my current job and feel like the unit I'm in is a good place to be most of the time. That being said, I'm really glad I am not a new nurse with a lifetime of nursing in front of me. ICU and 1:2 ICU ratios are becoming an inconvenient suggestion vs. a standard of care. Patients that are truly 1:1's are rarely given that distinction. I left the floor 17 years ago and went to ICU to get out of the seat of your pants nursing care environment. I figured it may be just as busy or busier in many ways, but at least it would be possible to give good nursing care. Now with the increased patient loads, decreased ancillary staff, and increased charting requirements, even that comfort is crumbling.
Here in Alaska, even if all three hospitals in Anchorage are on divert, all three hospitals will NEVER give a nurse 3 true ICU patients. You will only ever get three patients on the unit if they are borders (awaiting to be transferred to step down, PCU, medical, etc). AND we don't even have laws in Alaska that dictate how many patients a nurse can get! This is what scares me about working in the lower 48 - the UNSAFE nursing staffing!
I want to move out of Alaska SO bad because of the miserable weather and seclusion, but the one thing I will tell you- Alaskan nurses get paid a decent salary (It's almost three years I've worked as a nurse and I made $76,000 last year. On high census days they will ask us to come in extra for time and a half plus bonus (bonus is an additional $25 dollars/hr) Providence and ARH are both union hospitals, so you get paid by years of experience - I never got paid more to work in the ICU when I transferred. BUT, you get CNAS, you get Lift Team, we have ample supplies, and you will NEVER get three true ICU patients during your shift. I think it's the same at ANMC, also (they are owned by the federal government). No wonder why we have so many travelers come up here and never leave!
I usually prefer variety. That is, I don't want the same patients every time I work. I also don't want to be done dirty (like getting the heaviest load too often).
Creamsoda, ASN, RN
728 Posts
I would not consider that "pulling rank". Thats a legit scenario where orientees need to get exposed to certain situations.
Now if some prima donna waltzed in after their 4 days off and had a fit that she wants that LVAD patient because shes got seniority and has worked here for 30 years, there is no way she is being trippled even though its her turn and there are plenty of other nurses skilled enough to care for the patient and no other reason than that, then I would call it "pulling rank". And I would also call it BS. :)
But for the learning needs of staff, thats much different.