Should I sign in agreement? Long read, but need advice.

[HeartOfGlass]

Hi, I have an issue that I need some help with. I am currently in my first nursing career so I've never faced this before. I work in a psychiatric and behavioral health facility. I have been working there for 2 years, I was first a PRN nurse, then I was offered a full time float position, then 1 month later offered a charge nurse position. I have been a charge nurse on the child and adolescent unit for roughly 20 months.

I had a baby in January, and was on 12 week FMLA leave. I returned, and only was back for 5 days. In that 5 days, it was absolutely crazy. I had 13 seclusion/restraints and a huge patient load. I am currently out because I got sick on my 5th day, and I have been diagnosed with C Diff (I was on broad spectrum antibiotics for double ear infections on maternity leave). I cannot return until I am negative for C Diff, I finish my course of antibiotics on Friday and will be getting a test ran again then, so if I am negative, I will return sometime next week. Joint Commission is coming in May so of course administration is buckling down on all of the nurses and corporate is doing monitoring. My building was flagged for many seclusion/restraints and now it is my understanding that all charge nurses have to sign a new policy saying that we are fully responsible for our tech's behavior during a seclusion/restraint incident. I need to give you a run down of how my unit works, and what staffing is like in order for you to understand my concerns on this new policy.

In the child/adolescent building there are 2 units. First there is the unit with aggressive and psychotic teenagers, and then there is a combined unit of children and acute adolescents. I charge the combined unit. My children's issues range from depression, aggression, abusive, and psychotic cases, and my teenagers are mostly suicidal and addicted to drugs. I have never had to deal with a teenager on my unit being aggressive, however since there is no limit as to what type of case I get with my children, I often get highly aggressive children that require seclusions or restraints (we do not use actual restraints, but a therapeutic hold which is a restraint none the less). I am the only nurse on my unit. I am in charge of it all, I do the admissions, discharges, doctor's orders, meet with parents, handle phone calls, pass meds, relieve for breaks, coordinate visitations, etc. etc. I have two core techs that are assigned to my unit at all times, one for the child unit if there are more than 5 (if less, she gets floated to other areas mainly), and one for my teenagers, who sometimes has to also run the child unit as well. They do 15 minute checks (our protocol), tend to taking them to dinner, tend to lounge time, take them outside, do vital signs, etc. The highest number I have ever had as the only nurse is 38 patients before assistance has been pulled (quite overwhelming considering my shift is the busiest, with visitation occuring on my shifts and our high flow of admissions and discharges). I will on occassion get another tech staffed to my unit when an aggressive patient requires a 1 on 1 order. I usually do not get another staff if I have someone who is ordered on a line of sight (constant visuals) because our nursing station is set up to be in between two rooms, where we sleep those patients. If I have more line of sights than what those rooms fill, then I will get another tech. I do not get to choose who these techs are, they are assigned by the staffing coordinator of the hospital. Often, its someone I do not know who does not regularly work in the child/adolescent building.

Being as though I am the only nurse, it gets busy. I have to leave the unit to do an admission, because I have to meet with parents to go over the inpatient program, get a medical history, and get paperwork signed. I am mostly quite swift yet accurate, but sometimes there are the difficult parents (understandably) who require more time with me. I have to leave the unit to do a discharge, because I have to meet with the parents, go over medications, follow up outpatient appointments, and get paperwork signed. At this point, my kids are with my techs and I have to trust them to make proper decisions if a crisis occurs. Often, this is WHEN a crisis occurs. When a patient becomes a danger to others, to self, or becomes out of control, a decision has to be made, and my techs have to initiate a therapeutic hold and escort to the "quiet room" (it is not a seclusion unless the door is closed, and often we have to close due to the behaviors that are occuring, it is then the responsibility of whomever is present to have constant visualization on the patient via the window in the door). It is their responsibility to immediately notify me. Usually, I can hear the issue happening in the halls, or a therapist notifies me, and I go assess the situation and take over my tech's 15 minute checks on the other patients. So, now I'm in the situation where I have a lot going on- I'm having to do the tech's job as well as my own, and begin filling out the lengthy paperwork and making the notification phone calls, obtaining PRN med orders, etc. sometimes an admission is happening, or a discharge occurs. Many times, I notify my house supervisor what is going on, and I am told there is no extra staff in the hospital to be pulled to assist me. It would be ideal if another tech came, maintained visuals, while my core tech continued patient monitoring on the other patients, and I was able to do my part. This would be realistic and safe practice, but it rarely ever happens.

Sometimes, a negative experience occurs. I have been lucky enough to not have this happen to me, but I have seen it go down. A tech will not do a proper form in a hold, injuring a patient, or will respond negatively by reflex when attacked (for example, hold arms out, which is immediately considered a push, understandably). A patient may complain that they hit their head, or their arm hurts, which of course I have to report and it is investigated. I have had this happen, but there was no cause noted by risk management via camera review, fortunately. If a bruise occurs, it must be documented and reported. Guardians MUST be notified, and usually they are very understanding (because they brought their child for this reason), but some are not and threaten lawsuits, etc. The department of children services always come out and assess their own patients by interviews, and if the patient complains, they do their own investigation. It is overall a scary situation, and like I said, I have been fortunate to not encounter anything that has gone wrong. But that doesn't mean I am immune. My first week back after maternity leave, I was given a new tech (remember, I do not get to choose my staff) for one of my aggressive one on one patients. The patient willingly walked to the quiet room to calm down, and this tech decided to just close the door since the patient wasn't following directions. I was pretty upset, and I immediately handled the situation by opening the closed door, and notifying my supervisor. I was then told to destroy the packet I was working on since he was new and it would be dismissed. I of course let the family know because its the right thing to do, and they were very understanding. Once again, a fortunate ending.

It has been noted that tech's tend to talk on their phones or text, or not maintain constant visuals on the patient when in a seclusion. The seclusion room is NOT on my unit. I have to walk off of my unit to assess the situation. This is fine when my kids are in group with a therapist, but if my kids are all on the unit, I cannot leave them unsupervised to assess, especially when I am denied extra staff when I expresss a need. We are now being required, as charge nurses, to sign that we are fully responsible for the tech's behavior in all seclusion/restraint incidents. If something goes wrong, we go down too. I understand delegation is part of my job, but I've never been in this situation before and it is quite scary to know that if I am off with a family during an admission, and something goes wrong, I will get the consequences whatever they may be, or if I am on the unit doing my tech's rounds because he/she is in seclusion monitoring, and I cannot leave the patients alone, and my tech looks at their phone even though they are fully educated not to, I will get consequences. All is now being reviewed by corporate before joint commission comes. I definetely don't like C Diff, but I have heard I currently have 41 patients on my unit, with many seclusions/restraints being carried out and I'm relieved I'm home right now. Quite scary, and conflicting. However, I will have to return to work and I will be asked to sign. Should I sign this form, or should I refuse and most likely risk losing my job?

[miasmom]

Run as fast you can. Soneone is playing blame game instead of looking for solutions.

[HouTx, BSN, MSN, EdD]

Disclaimer - not a psych nurse.

I am seeing some obvious red flags.

I do not get to choose who these techs are, they are assigned by the staffing coordinator of the hospital. Often, its someone I do not know who does not regularly work in the child/adolescent building.

As the RN, you are responsible for delegating responsibilities to unlicensed staff. In order to do this, you need to validate the individual's competency for the task. How can you do this if you do not know them? Are they competent to work with your population at all? How do you know this?

"I have to leave the unit to do a discharge, because I have to meet with the parents, go over medications, follow up outpatient appointments, and get paperwork signed. At this point, my kids are with my techs and I have to trust them to make proper decisions if a crisis occurs. Often, this is WHEN a crisis occurs. When a patient becomes a danger to others, to self, or becomes out of control, a decision has to be made, and my techs have to initiate a therapeutic hold and escort to the "quiet room"

OMG - an unlicensed person making the decision to implement what is essentially an emergency intervention... without your assessment??? This is a huge professional liability issue. I can't see how it is justified at all. You have already pointed out the serious problems that can occur. IMO, you should be immediately summoned to assess the situation & directly supervise any interventions that are needed.

" I was then told to destroy the packet I was working on since he was new and it would be dismissed"

Falsification of medical records - seriously?? You don't want to be a party to this.

"The seclusion room is NOT on my unit. I have to walk off of my unit to assess the situation. This is fine when my kids are in group with a therapist, but if my kids are all on the unit, I cannot leave them unsupervised to assess, especially when I am denied extra staff when I expresss a need. We are now being required, as charge nurses, to sign that we are fully responsible for the tech's behavior in all seclusion/restraint incidents."

Your employer is asking you to violate your nurse practice act by not only allowing this process to continue, but provide a formal attestation that you are OK with it.

Agree with PP..... terminate your employment. And, as an RN, you are at least ethically bound (if not legally by your own NPA) to follow up with a report of these issues to the appropriate agencies.

[Jory, MSN, APRN, CNM]

I would be looking for another job. You cannot have more than 5 children to 1 adult in most DAYCARE situations, where everyone is healthy, in the vast majority of states. I am shocked that this is allowed in an in-patient setting.

They are setting you up to be the scapegoat. Make your issues known, that you have no intentions on signing. Tell them that you will agree to COUNSEL on inappropriate restraints if they were applied. Following-up to make sure the 15-minute checks are being done (but with up to 38 people...I don't they are) and the paperwork is signed off on.

However, no way are you responsible if a tech doesn't something idiotic. There is a point where the tech has to take responsibility.

You have too many skills and have been a nurse long enough you will have no trouble finding a better environment.

[HeartOfGlass]

Thank you for the responses. Very valid points have been brought up. I will not be signing this form. I am going to print a copy of my nurse practice act, and I will explain why I will not sign this form. My license and providing for my family is much more important to me, this is too unsafe. I have gone above and beyond with this facility to assist when needed, I am a teamplayer, and have great reviews by families and the doctors that I work with, if my concerns are not resolved and my place of employment cannot provide me the resources to provide safe and effective care to all of my patients, I will be looking for another place of employment.

[Esme12, ASN, BSN, RN]

I would be looking into the regulations about staffing and pediatric/adolescent psych and what the staffing requirements are.....all the way around this seems to be a dangerous situation. I am not a psych nurse but having to leave the patients you are responsible for without being relieved by another competent licensed personnel can be considered abandonment....leaveing them with techs is not ok and dosn't relieve you of liability. If you ahve malpractice insurance I would call them and ask to speak to someone...because as of right now every patient you have cared for you are responsible for and they can sue for whatever reason until 7 years past the age of majority which is 18 unless they were an emancipated minor.

I would not sign that I am responsible for the techs....how do they document that the techs have been trained/educated and competent to deal with the pediatric population (another JACHO requirement)

I know jobs are scarce...but I would run, not walk, to the nearest exit. ((HUGS))

p.s. sorry about the C-diff that's miserable....CONGRATS on the baby!!!!