Safe Harbor/Unsafe Staffing Levels?

[Bortaz, MSN, RN]

So, at my clinical site today (Peds floor at a children's hospital), at the change of shift, it became apparent that there were staffing issues going on.

With a census of 34 patients, they had 4 RNs and 2 CNAs. The day shift charge nurse spent about an hour trying to call in nurses to work, and calling to discuss the situation with the nurse manager/house supervisor.

The day shift floor nurses flat out said "I'm not taking 8 or 9 patients. No way. Not going to happen. The nurse manager needs to come down and pick up a few patients."

They (and the noc nurses who were still hanging around) kept encouraging the charge nurse to ask for Safe Harbor documentation, but she refused to do it, saying it was worthless.

Finally, they found a nurse who would be willing to come in at 11 am, and the noc charge nurse agreed to stay till 10 am, so they (kind of) had adequate coverage. However, the NM/HS never stepped foot on the floor.

I'd like to think this isn't a common occurence, but I bet that's just dreaming. IS it common? Should the NM/HS have come to the floor to cover some patients?

The worst part of the whole shebang was when the NM told the Charge nurse "Assign a patient or 2 to each of your students!", and my instructor about went ballistic. (Instructor is an RN on the same floor, but was there as an employee of the school, not of the hospital, and had already explained that she coulnd't/wouldn't pick up 5 or 6 patients.)

The nurses were highly frustrated, and were adamant that they were NOT going to put their patients and their license at risk. A common phrase was "I'm not doing it. If you do it once, they'll expect you to do it all the time!"

Have you experienced this at all?

[RN1982]

Would they be putting their licenses at risk if they didn't care for the patients? I've worked on a progressive care unit and we'd be down to one CNA for 24 patients and have no secretary but management would still not come and help out on the floor. So yeah it does happen.

[Bortaz, MSN, RN]

They didn't refuse to work, they just refused to accept that number of patients. They all said "No more than 7. Preferably 6."

Would it be unsafe for an RN to care for 8 or 9 pedi patients of varying acuity?

[PICNICRN, BSN, RN]

"Would it be unsafe for an RN to care for 8 or 9 pedi patients of varying acuity?"

YES! "Recommended" pedi ratio is 4:1. I do believe this is the case in states that have adopted safe staffing ratios like CA- I'm sure some one on this site will correct me if I am not correct.

I have seen floors that will go up to 6:1 which IMHO is not the best practice. I do think 4:1 is becoming more of the standard.

8-9 would be CRAZY!!!

[StNeotser, ASN, RN]

I saw a similar situation happen to our night shift on Sunday where the nursing management was absolutely no help whatsoever. I think in that situation yes, the NM/HS should have stepped in. Asking your clinical instructor and the students to step in was totally unprofessional.

This sort of thing obviously happens all the time.

[CHATSDALE]

some mgrs will chip in

some never do

some will if they aren't overwhelmed in their office, getting reports out, getting payroll ready for the office etc

[lyceeboo]

A common phrase was "I'm not doing it. If you do it once, they'll expect you to do it all the time!"

And that's EXACTLY why NM/HS wouldn't pick up any pts. I've been in similar day shift staffing situations way too many times in various hospitals around the country. (9 ortho/med/surg pts)...I've NEVER seen a NM/HS help us out.

It's been awhile since I've worked in TX, but I always felt "safe harbor" wouldn't actually provide much protection. But I think the charge should have filed the paperwork anyway.

IMO -- The most obnoxious thing the NM did here was try to get the instructor AND worse yet THE STUDENTS to pick up pts! Excuse me, but you're paying tuition to learn. Students as free labor for hospital CEO's?

No if I were that instructor, that would have made my blood boil too. Sounds like you have a good clinical instructor.

[Batman24]

The nurses were smart to unite and stand their ground. Bravo!! I wish more nurses would do that. We are totally within our rights to not accept a shift that we fill is unsafe for patients and a risk to our license.

The NM is out of her mind asking that students take over patients. The instructor was right to not allow it. My NM has helped out but I'm one of the lucky ones.

[BillEDRN]

It's been awhile since I've worked in TX, but I always felt "safe harbor" wouldn't actually provide much protection. But I think the charge should have filed the paperwork anyway.

I am unfamilar with the term "safe harbor" as it is not common here. But, I assume that it documents an unsafe staffing situation. If so, I agree that it should be filled out for each and every occurence like the one described by the original poster. In regards to the issue of "it doesn't do anything" I have to disagree. The fact that it does not appear to have any immediate effect on the current staffing issues does not make the documentation useless or unproductive.

If an untold effect happened and a patient was harmed as a result of the staffing issue, that documentation could go a long way to protect the nurse assigned to the patient that was harmed in any subsequent legal action.

Additionally, oversight and regulatory agencies (such as Joint Commission, CAMS, DoH) can use those types of reports for mandating corrective actions, especially if injuries or sentinal-type events happen.

Think of it this way: Does the fact that you document the coumadin given to a patient prevent a stroke or DVT? No, of course not. But, does that same documentation protect you 3-4 years from now when that stroke or DVT patient tries to sue you and the hospital, claiming that if you had given him his meds he wouldn't have had the stroke/DVT? Yep, you bet.

[Daytonite, BSN, RN]

You must have had an real eye-opener of a clinical day. Let me put in my with my experience as a supervisor and manager. My field of experience was medical stepdown and the ICUs and CCUs, but we had a pediatrics unit that we supervised. This must have upset your entire group including your instructor today. I hope your instructor reports this to your dean of the nursing program.

No one likes to work short staffed. It happens. No ones plans for it.

When it gets to be a regular occurrence is when there is a problem and it is time to pack up and move on.

(1) If this is a regular problem, please don't look for work there. They have some major staffing issues going on. Staffing issues come up from time to time everywhere. Once in a while, a night shift person might get asked to stay over for an hour or two. However, the nurse manager was irresponsible and put the facility at potential liability to suggest dividing the patients up to students and asking your instructor to take responsibility for 5 or 6 patients. I have never heard of this happening! I would have called the nursing office and gotten other facility nurses involved first! This must be a very inexperienced manager, a sign of poor administrative decision-making going on. That is a problem that runs deeper than a staffing problem. There are most likely bigger problems elsewhere including mismanagement of all kinds of stuff.

(3) The NM/HS were probably on the phones trying to find help which is part of the reason they never got to the floor. Or, they, too, are part of those bigger management problems. I was stuck in one management job where I was doing my management job and working 3-11 as staff almost every day because we were so short staffed. By the end of the week I was dead.

(2) I worked in a hospital very early in my career where all the nurses who worked in the ICU and CCU units decided to call off in a massive display to protest their continued complaints of the unsafe staffing of those units. The result was the hospital was forced to call in the nursing managers to staff all the units, PRN nurses and forced to use temporary staff, something they had never done before. The ICU and CCU nurses all eventually quit. For the next 2 months the ICU and CCU were staffed with temporary staff only. That was when traveling nurse agencies first started. Those first nurses cleaned up and made a fortune at this hospital, but eventually the hospital changed their staffing rules and hired new nurses at better working conditions for the hospital. They got away with the poor staffing levels for as long as they did because the hospital was in a rural area and there was no competition for jobs. Now, with the California Staffing ratio law, they can't do that anymore.

[Riseupandnurse]

The instructor should have pulled those students right off the floor and gone to education. What terrible publicity for the hospital! I doubt that any of those students will be overly eager to ever become nurses on that zone.