Unsafe assignments/volumes

Published Feb 6, 2020

495 Posts

Specializes in Surgical Specialty Clinic - Ambulatory Care.

Hello, RN of over a decade, HH x 2 years. I have been averaging a case load of 18ish for the last year. Have several that should really be hospice but aren’t ready so I’m having to do stuff I can’t delegate to LPN like hang bolus peripheral IV fluids 2-3x a week on a guy who’s BP gets down to 80s/40s. Of course my management is wanting me to keep everyone even if they really are just a little over our acuity level. I am delegating the visits I can. And for the most part was dealing until 2 weeks ago when 5 nurses quit. Suddenly my case load went up to 24 (some of which I have had as a manger for two weeks now and have yet to see them) and they just added two newly admitted people to my load, so now I am at 26.

Now I’m starting to have near misses with orders and problems keeping up with other administrative tasks....much less keep my visits to an 8 hour day and get my charting done. I did send my manager an email, prior to receiving these two new admits, that I have reached my maximum capacity and that I was only willing to take additional patients that did not need nursing services (like PT only patients). She sent me back an email that said they are looking at case loads.

So, when I worked the floor and the charge was trying to push more people on me once I reached my max ratio, and especially when I had max ratio + 1 or 2 and some really high acuity ones, I’d start going up the chain. Like I would tell the charge I would not accept another patient. Then she would try to get me to take one and I would call the house supervisor. The house supervisor would also try to get me to see why it was necessary to take the next patient and I would say no. Then when they eventually just kind of forced the next patient on me by telling everyone else that it was my patient even after I said no. Then I would chart a note in the patient’s chart that I had not accepted responsibility for the patient and had informed both the charge and the house supervisor. That both of them did not accept my refusal and that is why I was caring for the patient anyway. Then I would fill out an incident report...,and when they came at me again with the next one I would do it all again. Because, ya know, I couldn’t leave because that was abandonment, so like what else could I do? My manger was often irritated with me about the charting and the incident reports and kept trying to gaslight me into believing that the RN/patient ratios that I agreed to do upon hire were like part of my imagination? Or like really the ratios were just a suggestion but when need arose I would just have to step up to the plate. And because I was younger and dumber I often feel for this tactic in many of my jobs year 1-5.
But I’m a big girl now and I just find this sooooooooo annoying. It’s a math problem. I can only take care of so many people properly and if I’m keeping up when we are appropriately staffed, then the problem when we are short staffed isn’t me. And I will step up and take on as much as I can because I know we are short, but if it is a heavy acuity caseload then I can’t take as many as I could if they were all like teaching/education patients. Also, I don’t give a poo poo what nurse so-n-so is able to keep up with. I’m not her and I’m not a bad nurse....remember that award I got just like a month ago?
So I’ve started to push back in the same manner I use to on the hospital floor. I feel like I gave fair warning with my maximum capacity email. But now I will be filling out an incident report for each additional patient I get assigned to me until my case load drops to a more manageable level. I will also be sending my manager, my director, and the CNO an email with each additional patient I get until I am back down to 20. The email will state the patient that was added to my caseload was done under objection by this RN. That my current ratio is an unsafe assignment.
Interestingly I went and read my Illinois state practice act. There are no guidelines on what to do about an unsafe assignment. And here I thought the BON was suppose to be protecting the public. ??

Anyway, it all kind of makes me sad, because I really like Home Health compared to all other nursing I’ve tried. And I actually like my managers. But I know this is going to ruffle feathers, it always does (and then I get a talking to like I’m being some sort of princess instead of a team player). However I’m 8 months pregnant. I’m going to need my license for the next 22 years. I refuse to be one of those nurses I read about that gets their license taken away because we have no rights and are bullied into doing unsafe things because we have no power and no support for safer practices (ahem...BON?). So I guess if I have to get bullied by management and possibly fired it should at least be for the right reasons. Not that those are ever easy to explain in an interview....guess it’s just a good thing most employers are looking for a licensed warm body. Not like I can’t find a new job in a week or less if I have to.

Anyone else have a plan for when the employer is asking to much?