Got to thinking about the different hazards that the "admin/business end" vs "safe nursing practices" pose to working nurses.
Since there is no standard patient/nurse ratio law anywhere but California, many institutions vary in this regard.
I know it falls on the individual nurse to determine if they are capable and safe enough to provide care for "x" number of patients that they are assigned to at the facility they work.
From my area of the country, I've heard med/surg ratio's anywhere from 6 (sometimes 7) from one hospital, and 7-8 (sometimes 9) from another.
Since I guess I'm pretty jaded about the money makers, I got to wondering what has happened to nurses that have drawn the line and refused additional patients when the nurse feels like it would endanger the patients and also their license? If your hospital norm is say, 6 (sometimes 7), but occasionally 8, then census increases and they want to assign 9 patients, where does the line stop? 10-11?
I know acuity has alot to do with differences, but I'm curious to know what has been the reaction of the hospital and nurse administrators towards nurses who have refused additional patients due to safety concerns.
Thanks to anyone who can give me some insight. I graduate in May and often wonder about things like this. Just trying to prepare myself for the "real" world.
As someone has previously mentioned, legally it is the responsibility of the individual RN to refuse unsafe conditions...that is what the BON standards state. If administration insists that the RN cannot refuse and the RN does not feel comfortable resisting and risking discipline, then the nurse should document on assignment despite objection form, keep a copy for her/his own records, the situation, the names of administrators/managers spoken to and their response and send a copy to HR. If for some reason there would be legal action at least the nurse can demonstrate she/he saw the risk and attempted to go through the appropriate channels to rectify the situation.
If you have a cohesive unit that backs one another up, then each of you could simply refuse the extra patient.
By the way, the media would probably like to hear about the unsafe conditions...
On nights we can get up to 8-9 patients per nurse. If the ER tries to send more, I always call the supervisor before accepting to see if they are aware. If we are having a good night, I tell them that we are going above our ratios, but I will accept the patient THIS time. This tends to help me when we are having a bad night, and they are more understanding that some nights we just can't accept another patient. If I feel overwhelmed, I will ABSOLUTELY not accept another patient...ESPECIALLY if the ER is not busy. Sending the patient to an already busy floor will do them no good...I've seen nurses accept patients from the ER and not look at them for the first 2 hours they are on the floor.
It's taken me a little while, but I've learned how much I can handle, and it changes based on patient acuity. Luckily most of my supervisors know me well enough that when I say no, I really mean no!
I had 7 patients a few months ago (very rare at our facility). one had just returned from surgery, one was getting blood, one was up to the BR every hour, another had hourly neurochecks, and we had not a tech. ER called to give me report on a new patient. I told our supervisor I wasn't taking another patient, and I was told I had no choice, because all the other nurses were just as swamped. So, I called our DON, told her the position I was in. It was about 5 hours till the end of the shift. She came in, and we redivided patients, and she took the new admit.
I was very impressed by her reaction, and i was told we should have called her a long time ago. The supervisor was told not to have us working under those conditions again, even if that meant she had to take patients. I would hope that is the reaction any DON would have.
When I was hired, I was told that we "rarely" have to take more than our normal load (6 pts) because they're good about getting other staff / agency nurses to come. But in the 6 months of my preceptorship, I've seen it happen 3 times already. That's was more than RARE!
It scares me because, as a new grad, I'm all about the safety of my patients and what I'm truly capable of handling. I know I have the RIGHT and RESPONSIBILITY to refuse an unsafe assignment. Although 2 extra pts may not seem like much, I know I'm not capable of handling that (at least, not at this point), and - therefore - would be possibly imposing unsafe conditions on my patients... I'm all about the Nurse Practice Act and what my RON has to say, at that point!
2 years ago i had a family member in a well known medical center.She had surgery -gyn surgery -and died 4 days post op.The night of surgery-when I asked about her care we were told "on tje night shift we sometimes had 8-9 patints-so we might have to send her to
ccu for closer monitoring.They never did and to this day I still wonder if I had stayed would she still be alive.I work on a 66 bed med-surg unit at a rurall hospital {and diff hospital} and if the night shift has 6 or more patients that is rare.We may not have a charge nurse as all of the nurses are put out on the floor.We have been running almost full census.Day shift they like to start them with 4[no more than 5] and 3-11 4-5 pts.
It used to be 1 big unit-they divided it into 2 units but when we all full we more or less convert back to 1 unit-just wrap the nurses around the hall.
Now unfortumately the cna's may have 8-9- pts on days and evenings:night shift may have 10-13pts.The RN's on my floor feel this is too much and have voiced our opinions but to no avail.But as you know the RN's usually are the last to leave-to get all their work finiah:nurse:
it is for this reason that nursing will be losing not only one more nurse (me) but another potential, cause i talked our tech out of attending nursing school. it is ruining my mental health because believe it or not, i like nursing, and when forced to do what is practically impossible (loads) i actually give a crap about doing my job right - it stresses me out that i cant take care of my people properly. add on top of that the worry of being found negligent cause i couldnt do my job properly - do you think some family member is going to care that you were short staffed? after confused grandpa falls and breaks his hip cause we cant be in 10 places at the same time do you think that the family is just going - gee she must have been too busy??? no, you bet your azz i am going to get blamed for it. after all, the "corporation" (hospital admin, ha) will just can you and hire more of the new grads that the schools are spitting out. because i actually have a conscience, i would absolutely feel horrible if harm came to someone, and i had no control over it. with the new customer service model (what a joke) pts and more so their families expect you to bring crap to them on a gold platter - i have actually had a family member c/o pt not getting washed up (gee maybe they could do it themselves, what would they do if they were at home???) and got upset that i didnt drop everything i was doing and help them. gee sorry, maybe my guy with chest pain is more important right now than your family members clean armpits!(yes we had no techs that day). its just a shame it has to come to this. i wish i could just talk everyone out of becoming a nurse - the most pathetically treated profession there is.
amen!
nursing as a profession is targeted for marginalization in a health care system under siege. profit motivation driving growing public demand is transforming health care into just yet another service sector economy e/b the so called 'customer service model' and like marketing concepts we're all directed to swallow.
so what are we to do? stand by while desk jockeys bastardize our core principles; decide what more we can do to serve their interests? or should we run away for sanity sake, expatriate ourselves from our 'pursuit of happiness'. you'll only be replaced by someone potentially less concerned than you. many professions fervently maintain and defend themselves from tampering. professional unions and colleges seek to define and coalesce the interests of a distributed work force. what's preventing professional nurses from executing the same plan of protection? are we not talented enough or strong enough or motivated? or is it the culture of subservience that deadens our resolve?
Its so hard being caught in the middle...You risk your license if you refuse patients and you risk it if you screw up and something happens to one of your patients because you have too many patients...
Something is very very wrong.
Referring back to JRWest's post, had a patient that came in last night for anemia and elevated coags. Her hemoglobin is 5.9 so when she got to my unit, she IMMEDIATELY wanted valium. I wasn't trying to be mean or rude, cuz I know some people out there are going to think this was. I flat out told her, that I would call the doctor when I had a free moment but right now, valium wasn't important at the moment, getting that next unit of PRBCs was. She wasn't even anxious or anything to begin with. Thats my rant.
And I didn't feel the least bit guilty about saying that to her either.
I worked in a small Community Hospital in Hawaii when my husband was stationed there. Our DON tried to work one shift a week. She was great, and morale was great. Of course she did extract a sweet revenge - we had to rotate doing the work schedule. What a pain that was......
...However, if the powers that be say you are taking "x" amount of patients no matter what and you can't leave (because that's abandonment), what is a responsible person supposed to do?
As I've learned it, it's only considered abondonment if you take report because you've explicity taken responsibility for those patients. If you refuse the assignment beforehand, however, it's not a legal concern of abandonment - though there still would be repercussions from the unit or facility. :argue:
i have, written and submitted, "assignment accepted under protest": or "assignment accepted under duress".
i don't know if that would help me in a court of law- but felt it important enough to know that i did not take the assignment willingly...
that i recognized (and disagreed with) the dangers in accepting such a pt load.
leslie
As a new grad, that's a great idea to know. If I'm forced to take the pt load, just knowing how to word that I've UNwillingly accepted those pts is critical.
Would it also be appropriate to document that I stated to my charge or DON that I've stated that I feel UNSAFE taking this assignment - or would that come out worse, esp. from a legal perspective?
Would it also be appropriate to document that I stated to my charge or DON that I've stated that I feel UNSAFE taking this assignment - or would that come out worse, esp. from a legal perspective?
what i have done, is verbally discuss concerns w/nm or cn.
when either tells me "tough luck" type thing, i quickly write a brief cover letter, citing concerns i had with __________: and that extra pts were still assigned...and that i want this protest form w/cover letter, added to my file.
so it's brief cover letter w/actual paper declaring duress/protest-
or, i have also put it on 1 paper, writing down contents of conversation and subsequent protest in accepting.
make copies and submit.
they're not too happy, but it beats giving and getting ultimatums.
I too was under the impression it is only abandoment if you have taken report. My facility work really hard to keep our assignments on my tele floor to 1:4. On rare occasions we take 5 and I find my workload increased to hectic. So all I can say to those who take 5 and more patients good luck and strength, and I hope you dont get burn't out. So much is expected of us I really dunno how we could cope with so many more patients
got to thinking about the different hazards that the "admin/business end" vs "safe nursing practices" pose to working nurses.
i got to wondering what has happened to nurses that have drawn the line and refused additional patients when the nurse feels like it would endanger the patients and also their license?
when i worked the med/surg floor our ratio was 5/6. we could not under any circumstances give a nurse 7 patients. it wasn't state law but hospital rule. nights the ratio was 6/7.
i only once ever refused to take another patient when i had only 4 to begin with. the charge nurse evidently reported me to the super who reported me to the cno. the cno came to the floor in scrubs and grabbed me and said "if you're refusing a patient i know you need help, i'm here". is that not too awesome?
having been a charge nurse the problem comes when it is the same nurse who is continually refusing to take another patient. in other words the lazy nurses who complain about anything they have to do.
cjmjmom
109 Posts
As someone has previously mentioned, legally it is the responsibility of the individual RN to refuse unsafe conditions...that is what the BON standards state. If administration insists that the RN cannot refuse and the RN does not feel comfortable resisting and risking discipline, then the nurse should document on assignment despite objection form, keep a copy for her/his own records, the situation, the names of administrators/managers spoken to and their response and send a copy to HR. If for some reason there would be legal action at least the nurse can demonstrate she/he saw the risk and attempted to go through the appropriate channels to rectify the situation.
If you have a cohesive unit that backs one another up, then each of you could simply refuse the extra patient.
By the way, the media would probably like to hear about the unsafe conditions...