Refusing unsafe RN:pt ratio

wjf00 · May 23, 2006

You are always responsible for being a patient advocate. Refusing an unsafe assignment is being a good patient advocate. If you feel the asignment is unsafe refuse it. Check your state's nurse practice act.

TachyBrady · May 24, 2006

In my opinion, it is not so much the number of pts., but the acuity. You can have 3 crappy patients (and run your butt off all night) or you can have 7 easy patients requiring very little care or interventions making for an easy night. If in report, you feel that you cannot manage the acuity or number of your pts., then by all means, talk with the charge nurse. Sometimes we have call offs or all beds are filled and we must take on extra pts. Most of my coworkers are willing to pitch in and take on more and/or help each other out in these instances. If this is a habitual problem for your department, then I would talk with the UM. If it is an isolated incident and you are overwhelmed to the point of jepardizing safety, then you are justified in refusing.... talk with the charge nurse. Maybe he/she just needs to adjust the assigments.

shape0fmyheart · May 24, 2006

Our normal load is 6-7, lately 7. A few nights some nurses have had to take 8 patients each. I have not been faced with that yet but I have said that I will refuse. It's MY license on the line and our patients are usually high maintenance, I barely feel safe with 6. I am on Med-Surg with Oncology and Hospice thrown in the mix.

liljsmom02 · May 31, 2006

our night assisgnment are 6-8 pts.i have to agree that the acuity does matter but the fact that most institutions don't like paying overtime for nurses staying late and the amount of charting that is involved should also be considered. when i have 7 or 8 patients, i spend more time in front of the computer than i do with the patients. bring it up to someone such as your unit manager. no one should feel unsafe when it comes to pt care. good luck.

grinnurse, RN · Jun 3, 2006

Hi..I work on a med-surg unit, nights. Normal pt. load is 6...the other night it creeped up to 7 (I was off) Can you refuse to take 7?? I feel that 6 is a lot..I couldnt imagine 7. If my license is on the line I would think that is my right, but no one said anything. Any advice much appreciated

I don't know how it is in all states, but, in Texas we have "Safe Harbor" but, just b/c you clain SH doesn't mean that you will not get that 7th pt, it just means that you are letting it be known that you feel it is unsafe for you to provide safe care to the pts that you have should something happen and it come up in peer review. Or that was my understanding when it was discussed at my nursing orientation for a the new hospital that I begin at on Monday. IMO, SH really doesn't seem to help the nurses at all if it works the way it was explained.

In the job that I left, I refused an 8th pt 2 times in one month but did not have to go as far as SH, thank goodness!! They didn't like it but oh well!! IMO, just b/c they had run off all the nurses with the inability to properly staff didn't mean I was going to jeapordize my license for them.

MrsWampthang, BSN, RN · Jun 3, 2006

At the LTAC where I work, 7 patients per nurse has become a standard unfortunately. I had 8 patients the other night, but, thank goodness, they weren't really hard patients. I just got everything done for them, even though I was passing 2100 meds at 2230. I finally got finished around 2330 with everything that I had to do for the evening. I guess for starting at 1900 that isn't bad. Unfortunately right now the powers that be don't look at the acuity of patients when making assignments and everyone gets the same amount of patients no matter what. I work nights, but I know that dayshift ratios have slowly crept up too, they used to just have 5-6 patients apiece, now their all lucky to only have 6, sometimes they have 7 a piece and on days, that's just too much.

When I am in charge on nights I always go around and ask my nurses if there is anything I can do for them, or do they need anything and they appreciate it. I answer call lights, I change beds, I help turn patients, I clean patients up, but I am the exception rather than the rule at this LTAC. I wish that when I am working the floor, the other charge would do this but she doesn't. I think if you have a good charge who is willing to jump in and help, then it makes all the difference. If you know your call lights are going to be answered while you are busy doing assessments, etc then it helps. Guess I am just hyper, but when I'm charge, I won't let call lights go unanswered, nor will I leave a pump beeping that is finished infusing an ATBS.

But I guess I digress, as for the OP, I don't think that I can ever refuse a patient load. I had to take 7 patients one night and also be charge. I had to take them until a nurse came in at 2300 and I was in tears practically the whole four hours. I called my NM and told her that this was too hard and it hasn't happened since. If it does, then the admin on call is going to come in and be charge for the first half of the shift so I can take care of my patients. I can handle patients the last half of the shift because the morning stuff isn't usually as bad as the night time stuff. But again, I don't think I can refuse, all I can do is voice how I feel about the situation, and hope they listen.

I has become a sad state of affairs that the powers to be covet their bonuses more than they care about good patient care. I know not all LTACs are like that in my area, I think our LTAC is the exception to the rule hereabouts.

I don't know what the charge nurse can do if you refuse the assignment. I guess they can just dole the extra patients out to your coworkers or take the patients themselves, but there is little else. The charge nurse usually doesn't have control over how many patients are on the floor or how many nurses are working. (Just a thought there.)

Sorry I don't have any good advice for you.

Pam

Tweety, BSN, RN · Jun 3, 2006

Yes you can refuse any assignment that you feel is unsafe. That's your obligation.

Sometimes we creep above our normal ratio and I realize that it's just an occasional occurrence that can't be helped and I don't make a big deal over it.

They are just numbers. People sometimes get so caught up in the number of patients it can be irritating. Sometimes I have five patients and the charge nurse wants me to take a sixth and I simply can't, so I have to beg off. Sometimes I have six and I volunteer to take a 7th so save someone else who is busy. It all depends on the patients, not the number.

bahamabread · Jun 3, 2006

I was used to 14 pts and sometimes 16..........and I dared not complain! ( wouldn't have made any sense to complain anyhow)

I agree with the fact that it's not the number but the types of cases. Sometimes the numbers went down to 9 and it was more stressful than the usual 14.

I can only say that if it is common practice then by all means complain and refuse. But an isolated incident.............you can manage for one night or two. I can tell you though............the more patients you have.............the more you have to prioritize. You have to know what you need to pay attention to and what you can overlook ( so to speak) That means some patients will get no " maid service.........or pillow fluffing" I also think ( at least it worked where I lived.........but I dont know the legal aspects here) But I found that when I explained to my pts......." Hey.........there is a fellow in the front of the ward who is really not doing too well tonight..........he may take up alot of our time...........so I apologize but can you help us out tonight by doing as much for yourself as you can." It was usually not a problem and it always surprised me how much they were willing to help afterward once they knew you werent " sitting down drinking tea"

But my culture is different and do not expect sooooo much attention or demands......and the family pitches in very well. I had males who I NEVER had to help with any hygienic care. Our women feel it's their duty to bathe thier husbands or their daddy or their mummys............and would be embarrased to know the nurse had to do " their job". But then again ALOT of things are different where I come from. If they had to pay for hospital care like they do in the US..................Im sure they would expect me to not only feed them...........but digest their food for them and ( probably poop it out too)

bahamabread · Jun 3, 2006

And I forgot to add............If you constantly refuse pts over a certain " number" you will over time build up a reputation of not being able to handle your workload or more importantly become known as not WILLING to handle it. When you can manage it......do so..........and when you then say " I can NOT take any more patients" Your co-workers will KNOW and RESPECT that because you are already known to pitch in wherever you can..........you have already built that reputation.

Thunderwolf, MSN, RN · Jun 3, 2006

I don't know what the charge nurse can do if you refuse the assignment. I guess they can just dole the extra patients out to your coworkers or take the patients themselves, but there is little else. The charge nurse usually doesn't have control over how many patients are on the floor or how many nurses are working. (Just a thought there.)

I echo, Traumamamma, on this. These type of decisions come about by those higher up in the hospital food chain. The charge nurse works from the guidelines given to them. Folks need to realize this. Being in charge is not a coveted position...it is often a position caught between a rock and a hard place...but, someone has to step up to the plate any way.

Tweety, BSN, RN · Jun 3, 2006

And I forgot to add............If you constantly refuse pts over a certain " number" you will over time build up a reputation of not being able to handle your workload or more importantly become known as not WILLING to handle it. When you can manage it......do so..........and when you then say " I can NOT take any more patients" Your co-workers will KNOW and RESPECT that because you are already known to pitch in wherever you can..........you have already built that reputation.

I've heard and seen that before.

All it takes is honesty "no I can't handle it, it's unsafe" or "yeah I think I can manage if it can't be helped". It can't always be one answer each and every time they ask. Fortunately, as I've said where I currently work it's not common for them to ask us to go over our established ratio, and when they do I'll answer honestly.

Not speaking up for yourself does indeed tend to get you taken advantage of, not because they are deliberately taking advantage of you, but because you're not speaking up. Sitting around surfing the internet and reading a magazine and refusing to help out with another patient because "I'm not going over my number" won't win you any respect either as a former charge nurse I saw that a lot and it was frustrating.