Nursing Student Needs Help!

[NCNocRN]

These days, short staffing, which used to be for emergencies only, is now becoming an unfortunate everyday occurrence. I know many people are confused as to what constitutes "abandonment." Below is a statement on short staffing from the NCBON which will clear up confusion for nurses practicing in NORTH CAROLINA. The BON would not consider refusing a patient assignment prior to receiving report as abandonment. Clocking in would not constitute accepting an assignment.

NORTH CAROLINA BOARD OF NURSING

Interpretive Statement

QUESTIONS REGARDING SHORT STAFFING & ABANDONMENT

The Board receives many calls from nurses who are concerned about jeopardizing their licenses due to inadequate or short staffing. With the current cost-containment trends in health care delivery systems, some nursing services are having to "down-size" or "right-size" their workforce. From time-to-time, staffing situations arise that may be considered unsafe for the clients who are being served.

ACCEPTING ASSIGNMENTS:

The licensed nurse is accountable for the care that he/she provides to the client , as well as all nursing care which the nurse delegates to other staff members. Therefore, it is essential that each nurse have the knowledge and skill to perform an activity safely before accepting such a responsibility.

When a licensed nurse comes on duty to find that the mix or number of staff is not adequate to meet the nursing care needs of the patients, what should he/she do? Before accepting the assignment, the nurse should contact the immediate supervisor to report the unsafe situation and ask for assistance in care planning based on the available resources within the agency. Such assistance may include:

- acquiring more staff

- negotiating "periodic" assistance from the immediate supervisor for delivery of specific care activities

- prioritizing the care activities that will be delivered during that shift or tour of duty; and

- notifying other health care providers regarding the limitations in providing optimal care during periods of understaffing.

Although it may be impossible to deliver the type of nursing care that would be delivered with a full complement of staff, there are certain activities that must be carried out regardless of staffing. These activities include:

- accurately administering medications and implementing critical medical treatment regimens;

- protecting clients at risk from harming themselves;

- monitoring client's response to medical and nursing interventions consistent with each client's health care problem;

- notifying the physician of deteriorating or unexpected change in a client's status; and

- accurately documenting the care delivered to the clients.

WHAT CONSTITUTES ABANDONMENT?

The following activity may result in disciplinary action by the Board: . . . "abandoning or neglecting a client who is in need of nursing care, without making reasonable arrangements for the continuation of care." [21 NCAC 36.0217 © (10)]

Abandonment can only occur after the nurse has come on duty for the shift and accepted his/her assignment. If the licensed nurse leaves the area of assignment during his/her tour of duty prior to the completion of the shift and without adequate notification to the immediate supervisor, it is possible that the Board would take disciplinary action. However, when a nurse refuses to remain on duty for an extra shift or partial shift beyond his/her established schedule, it is not considered abandonment when the nurse leaves at the end of the regular shift, providing she/he has appropriately reported off to another nurse. NOTE: If a nurse resigns and does not fulfill the remaining posted work schedule, this is not considered abandonment under Board of Nursing regulations.

NURSE MANAGER ACCOUNTABILITY:

During periods of understaffing, the nurse manager may have to reassign staff to different patient care areas, as well as approve extended tours of duty (i.e.: double shifts) for nurses who volunteer or agree to work extra. If a nurse has agreed to extend his/her hours of duty due to short staffing, but has informed the nurse manager of a limit to the extra hours they will work, the nurse manager is responsible to provide a nurse who can accept the report and responsibility for the patients from the over-time nurse. If a replacement nurse cannot be found, the nurse manager is responsible for providing the coverage. The nurse manager is accountable for "assessing the capabilities of personnel in relation to client need and plan of nursing care . . . and delegating responsibility or assigning nursing care functions to personnel qualified to assume such responsibility or to perform such functions. " [21 NCAC 36.0224 (i) (2) (3)] This includes making a judgment about situational factors which influence the nurse's capabilities for delivering safe nursing care to clients. For example, the staff nurse who accepts a "double shift" and then must return for the next regularly scheduled shift with only a few hours off may be significantly sleep deprived, and thereby, not competent to provide safe care. The nurse manager must carefully assess the capabilities of this nurse before delegating nursing care activities/responsibilities to him/her.

It is important for nurse managers to remember that they could be liable for disciplinary action by the Board for delegating responsibilities to a staff nurse when the manager knows or has reason to know that the competency of the staff nurse is impaired by physical or psychological conditions . . . [21 NCAC 36.0217 © (6)].

WORKING TOGETHER TO PROVIDE SAFE CARE:

Both nurse managers and nurses in direct client care positions are accountable for providing safe nursing care to their clients. During periods of understaffing or limited numbers of well-qualified staff, it is essential that nurse managers and nursing staff work together to provide safe care to all clients in a manner consistent with nursing law.

If you need further information regarding the legal scope of practice for licensed and unlicensed personnel, you may contact the Board of Nursing. You should also refer to your Nursing Practice Act and previous publications of the BULLETIN which contain important information regarding nursing practice in North Carolina.

9/90, Revised 1/91, 12/96

http://www.ncbon.com/prac-rnistate.asp#QUESTIONS updated 6/24/04

[NRSKarenRN, BSN, RN]

PSNA has posted the PA SBON Position on this topic under "Hot Topics" @ http://www.psna.org

Clarification

Mandatory Overtime and Patient Abandonment

PSNA has recently begun to dialogue with legislators to ascertain the level of interest in sponsoring legislation on mandatory overtime, reflecting PSNA's platform on workplace advocacy as well as addressing the nursing shortage.

In the meantime, the PSNA office continues to receive numerous calls and e-mails from staff nurses on mandatory overtime. The three most frequently asked questions are:

1. Can the Employer mandate me to stay?

Answer - Yes, unless there is a contract in place prohibiting.

2. What can happen to me if I refuse?

Answer - If there is no contract or agreement prohibiting mandatory overtime, you can be fired for insubordination if you refuse to stay.

3. If I refuse can I be charged with patient abandonment by the Pennsylvania State Board of Nursing?

Answer - No - see below.

In the early 1990s, various groups requested that the Pennsylvania State Board of Nursing define what is meant by the term "abandonment" as it appears in regulations, outlining standards of conduct for both the RN and the LPN. Under Chapter 21, Section 21.18 (b)(7), it states that the RN may not "knowingly abandon a patient in need of nursing care. Abandonment is defined as the intentional deserting of a patient for whom the nurse is responsible." Section 21.148 (b)(7), makes the same statement for the LPN.

When the Board was asked to further define the term abandonment, the Board stated that "this provision applies only to a nurse's normal working hours and would not prohibit a nurse from refusing to stay for a second shift when there is a shortage of staff." This statement clarifies that refusing to accept mandatory overtime does not constitute patient abandonment and is not grounds for disciplinary action in the State of Pennsylvania.

Documentation for this can be found in the Pennsylvania Bulletin, Vol. 23, No. 18, May 1, 1993, Pages 2115, 2116, 2117.

PSNA Position statement on Mandatory Overtime -added 6/24/04

http://www.psna.org/c_PosStat_OT.htm

[Mito]

Please tell me I don't have to face this situation daily as a new RN in three years.

[ERICUEMS]

Originally posted by Mito:

Please tell me I don't have to face this situation daily as a new RN in three years.

OK.... We won't tell you....but I'm afraid you'll find out for yourself..... we're running 4 out 5 days short staffed now @ my hospital ---- Listen, there is still alot about Nursing that's wonderful, so don't get too put off....this is just one thing....

[Mijourney]

Hi all. Thanks for bringing to our attention the various state board policies for patient abandonment.

Question. Would the board policies for patient abandonment cover nursing strikes? Are all nurses who participate in strikes offically reprimanded or fired? Sorry for my ignorance on this.

[PeggyOhio]

In Ohio the same is true as far as the definition of abandonment. And while your license won't be effected by refusing to take an assignment or refusing to be mandated, you can be disciplined by the facility were you work. Which would include everything from written disciplinary action in your file ( which may effect any jobs you might want to apply for in the future at that facility), to suspension, or termination.

Peggy

[This message has been edited by PeggyOhio (edited March 02, 2001).]

[OC_An Khe]

Originally posted by Mijourney:

Hi all. Thanks for bringing to our attention the various state board policies for patient abandonment.

Question. Would the board policies for patient abandonment cover nursing strikes? Are all nurses who participate in strikes offically reprimanded or fired? Sorry for my ignorance on this.

Strkes are not patient abandonment. To over simplify you are just not accepting assignments en mass. Each state has its own laws, as well as federal labor laws that protect all workers taking job actions that are within the scope of the laws. Most states have a notification period that is required before Nurses can strike.

Some states have strong laws protecting workers from reprimands/firings. Others like right to work states offer little or no protections to workers who are organized.

[canoehead, BSN, RN]

How do you know an assignment is unsafe without taking report?

What about the patient that crashes midway through the shift? And still you need to maintain care for the other 11 people.

These boards seem to have given a half assed response at best.

[LaurieCRNP2002, MSN, RN, APRN]

I have a question for Nurseaaron: RE: Safe Harbor: "It is set up to protect the nurse from losing their license but not liability." Does this mean a nurse could still get sued in civil court if something happens to a patient under her care?

Thanks for any info you can provide!

Laurie

[SUBQ]

Hey:

I just quit my job in 1-2000. I was tired of having my license being put at risk--so I quit.

I came to work and was assigned 12 heavy patients. The normal is 8. They refused to bring in help. Therefore, I quit.

I flat out REFUSED the assignment.

The bottom line:

If you accept the assignment, you can and will be held accountable for those patients.

If you can't take care of the patients, you better walk...it is better to lose your job than it is to lose your license; or worse, a patients life.

[Jenny P]

You know your assignment is unsafe by looking at the number of patients you're assigned to for the shift-- most of us know what the standard assignment per nurse is for the unit they work on. If a patient crashes part way through the shift, notify the immediate charge nurse and then the supervisor ASAP so that someone else can take over the other patient's care for you. I have received report on patients and then told the charge nurse that the assignment is too heavy; I got help at intervals and my patients didn't get my usual level of care. I work CV-ICU, and our assignments are either 1:1 or 1:2, but sometimes the 1:2 can be unsafe. It is imperative that you notify your immediate supervisors when you deem that the assignment is unsafe.

It is interesting that the PA BON says that you can be mandated to stay overtime; but it is not determined to be patient abandonment if the nurse refuses to stay for a second shift.

Ericuems, we all fervently hope and pray that none of us will have to be dealing with this situation in 3 years; it may not be solved completely by then, but I think that if we all do something to fix the problems now, then things will be better then. In my 32 years of being an RN, I have never been mandated to work overtime; I have volunteered, but have never been mandated.

[Jenny P]

I forgot to mention that my hospital is unionized by my state nursing association, and mandatory overtime hasn't been allowed since 1987. Maybe that will be the norm when you graduate in 3 years!