# Sal, Joey or Mikaela



## E tank (Apr 19, 2020)

ER nurse in an overwhelmed hospital recounts 'impossible' decision she had to make
					

Mikaela Sakal, on being an ER nurse in an overwhelmed hospital and the decision she had...




					www.sfgate.com
				




If I ever see these names come across my desk for advanced practice in anesthesia, they can consider themselves dead in the water....just sayin'...


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## DrParasite (Apr 20, 2020)

So they refused to clock in, and forced their day shift to stay on OT while short staffed... while they sat their in their scrubs.... during a pandemic.  They should have been terminated with cause, with complaints filed with the nursing board to suspend their license for failure to do their jobs.

I've worked in bad systems, during MCIs, and ran my butt off during my shift; I feel bad for the patients in this ER.   to be perfectly honest, if I was a hiring manager, and a nurse applied to work for me, and in their last job, they just walked out, making the situation worse because they forced dayshift to continue working because of their entitled attitudes, then I would tear up their application in the middle of my interview with them.  They are all an embarrassment to the nursing profession.


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## johnrsemt (Apr 24, 2020)

What DrParasite said
I would have fired them before 9pm  Dayshift staying to help, but they refused to go out and work.  They were complaining they needed more staff, but they had day shift staying over to work with them


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## RocketMedic (May 23, 2020)

Contrary view: those nurses are still accountable, and responsible, for their patients. Their organization failed them on multiple levels and violated ethical, clinical and professional standards in the process. These nurses simply refused to tolerate the status quo any further.
It’s functionally no different than a shift of paramedics refusing to go to work in an unsafe system.


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## Tigger (May 23, 2020)

RenegadeRiker said:


> Contrary view: those nurses are still accountable, and responsible, for their patients. Their organization failed them on multiple levels and violated ethical, clinical and professional standards in the process. These nurses simply refused to tolerate the status quo any further.
> It’s functionally no different than a shift of paramedics refusing to go to work in an unsafe system.


So I guess you just leave the patients then, right? The day shift isn't "supporting them," they're providing care that their colleagues wouldn't.


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## RocketMedic (May 23, 2020)

Tigger said:


> So I guess you just leave the patients then, right? The day shift isn't "supporting them," they're providing care that their colleagues wouldn't.


They refused to accept an unsafe assignment and demanded appropriate resources. Refusing to work was the only way to get their complaint actually addressed- do you think an administrator would have actually become involved if they were working?

You say “pandemic” like it’s an acute emergency. Guess what...it’s the new normal. A constant emergency. And accepting assignments in dangerous circumstances, or when failure is nearly guaranteed by controllable issues like staffing- that is foolish. This hospital wanted these nurses to accept inappropriate staffing ratios; the nurses took a principled stand for patient safety. It’s no different than the nurses who refused to work without appropriate PPE or in a setting they’re not trained for.
It is the role of the organization and administration to ensure that they are appropriately staffed and equipped. That was clearly not done. It took this to publicize it, but those nurses did the right thing.


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## silver (May 23, 2020)

RenegadeRiker said:


> They refused to accept an unsafe assignment and demanded appropriate resources. Refusing to work was the only way to get their complaint actually addressed- do you think an administrator would have actually become involved if they were working?
> 
> You say “pandemic” like it’s an acute emergency. Guess what...it’s the new normal. A constant emergency. And accepting assignments in dangerous circumstances, or when failure is nearly guaranteed by controllable issues like staffing- that is foolish. This hospital wanted these nurses to accept inappropriate staffing ratios; the nurses took a principled stand for patient safety. It’s no different than the nurses who refused to work without appropriate PPE or in a setting they’re not trained for.
> It is the role of the organization and administration to ensure that they are appropriately staffed and equipped. That was clearly not done. It took this to publicize it, but those nurses did the right thing.



There are other ways to protest an assignment for sure.

I wasn't in Detroit, but rather in NY and would say it was an acute emergency where anything goes. In my unit we staffed 3-5 critically ill patients per non-ICU nurse. The doctors/NPs/PAs did all the sedation and vasoactive medication titration (ICU nursing task) and all the respiratory care on top of their provider duties. The doctors also took out the trash, cleaned the floor, brushed patient's teeth, helped turn the patients. Whatever needed to happen all of us did together. None of that was normal and never will be normal. More staff came to help, but it took days to weeks not 2 hours one evening. If the nurses and doctors weren't there, no body would be there for these people...

Around this time in early April was also Easter. Interestingly, Dante begins his famous journey through hell during holy week. In the Inferno, Dante must pass through hell to ultimately reach paradise in the epic. At the vestibule of hell Dante hears the screams of the first sufferers, the uncommitted, those who were opportunists and only concerned for themselves. 

We certainly travelled through hell and in our journey to paradise have no room for the uncommitted.


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## ffemt8978 (May 23, 2020)

RenegadeRiker said:


> They refused to accept an unsafe assignment and demanded appropriate resources. Refusing to work was the only way to get their complaint actually addressed- do you think an administrator would have actually become involved if they were working?
> 
> You say “pandemic” like it’s an acute emergency. Guess what...it’s the new normal. A constant emergency. And accepting assignments in dangerous circumstances, or when failure is nearly guaranteed by controllable issues like staffing- that is foolish. This hospital wanted these nurses to accept inappropriate staffing ratios; the nurses took a principled stand for patient safety. It’s no different than the nurses who refused to work without appropriate PPE or in a setting they’re not trained for.
> It is the role of the organization and administration to ensure that they are appropriately staffed and equipped. That was clearly not done. It took this to publicize it, but those nurses did the right thing.


Where exactly did Tigger use the word "pandemic" in this thread?


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## mgr22 (May 23, 2020)

RenegadeRiker said:


> It’s functionally no different than a shift of paramedics refusing to go to work in an unsafe system.



I can't imagine doing that.


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## RocketMedic (May 23, 2020)

mgr22 said:


> I can't imagine doing that.


Well maybe those nurses have more courage than we do as paramedics. It did seem to have gotten the attention they needed it to- their hospital “passed” a state review with regards to staffing, which either means weak regulations or they added staff.

Accepting unsafe work assignments because of a servants heart is a great way to make sure they stay unsafe.

this is also the “dead bodies in random back rooms of the hospital” hospital so there’s that:https://wdet.org/posts/2020/05/14/8...-storage-photos-says-state-not-investigating/


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## silver (May 23, 2020)

RenegadeRiker said:


> Accepting unsafe work assignments because of a servants heart is a great way to make sure they stay unsafe.



So the alternative is for the individual to actively choose to make it a substantially less safe environment and screw your colleagues?


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## Carlos Danger (May 23, 2020)

RenegadeRiker said:


> Well maybe those nurses have more courage than we do as paramedics.



Let me make sure I understand….. 

Some nurses were sick of being understaffed and overworked. So they forced other nurses to work for them. The nurses they faced to work for them: 

Had already worked a full shift 
Were presumably also sick of being understaffed and overworked  
Had no choice in the matter because they had no one to report off to 
Were likely (at least some) scheduled to be back the next morning  
And you call that courageous?


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## RocketMedic (May 23, 2020)

silver said:


> So the alternative is for the individual to actively choose to make it a substantially less safe environment and screw your colleagues?



it is not the primary responsibility of the employee to ensure safe staffing ratios. That is solely the responsibility of the employer. The day shift ED admin was perfectly aware of the staffing problem and neglected to do anything about it before the night shift was scheduled to come in. The night shift nurses just called their bluff.

Imagine, if you will, that you and your partner are the only crew clocking in for a shift in a busy 911 system. Just one truck, and you’re normally busy- but you’re also going to be held accountable for the outcomes of everyone who calls 911, not just the ones you’re able to respond to. That’s why these nurses refused to work. Because it was the only way that their hospital was going to address the problem.

Yes, it did force their colleagues to stay over. Yeah, that sucks. But more importantly they forced the hospital to bring in more nurses and actually fix the problem, not make excuses.


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## Carlos Danger (May 23, 2020)

RenegadeRiker said:


> it is not the primary responsibility of the employee to ensure safe staffing ratios. That is solely the responsibility of the employer. The day shift ED admin was perfectly aware of the staffing problem and neglected to do anything about it before the night shift was scheduled to come in. The night shift nurses just called their bluff.
> 
> Imagine, if you will, that you and your partner are the only crew clocking in for a shift in a busy 911 system. Just one truck, and you’re normally busy- *but you’re also going to be held accountable for the outcomes of everyone who calls 911,* not just the ones you’re able to respond to. That’s why these nurses refused to work. Because it was the only way that their hospital was going to address the problem.


Except that isn't at all how it works.

There were other alternatives.


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## RocketMedic (May 23, 2020)

Carlos Danger said:


> Except that isn't at all how it works.
> 
> There were other alternatives.



really? Like what? They’re the ED nursing staff, they’re going to be held accountable for all of the care provided (or not) within that ED. What other alternatives do they have? An emergency complaint to the nursing board? Acceptance of their assignment? A strongly-worded letter to the media (that actually got one of their colleagues fired, see the “bodies in back rooms” report)?


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## Carlos Danger (May 23, 2020)

RenegadeRiker said:


> really? Like what? They’re the ED nursing staff, they’re going to be held accountable for all of the care provided (or not) within that ED. What other alternatives do they have? An emergency complaint to the nursing board? Acceptance of their assignment? A strongly-worded letter to the media (that actually got one of their colleagues fired, see the “bodies in back rooms” report)?


Look, if you are dead set on believing that the ONLY WAY to address this problem was to screw their co-workers and essentially abandon their patients like they did, I'm not going to waste my time trying to convince you otherwise. 

But it doesn't really take too much imagination to think up other strategies. It isn't as though this problem has never existed anywhere else.


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## RocketMedic (May 23, 2020)

Carlos Danger said:


> Look, if you are dead set on believing that the ONLY WAY to address this problem was to screw their co-workers and essentially abandon their patients like they did, I'm not going to waste my time trying to convince you otherwise.
> 
> But it doesn't really take too much imagination to think up other strategies. It isn't as though this problem has never existed anywhere else.


They acted in the best interests of their patients and colleagues and forced the hospital to staff appropriately.


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## Carlos Danger (May 23, 2020)

RenegadeRiker said:


> They acted in the best interests of their patients and colleagues and forced the hospital to staff appropriately.


Yeah, I can see how forcing the day shift nurses to endure an assignment AFTER THEY HAD ALREADY WORKED ALL DAY that the night shift nurses didn't want to accept when they were fresh was definitely in everyone's best interests. 

Do you think the staffing situation for the night shift magically improved for everyone when the night shift nurses went home? Where did this extra staffing magically come from?

Have you ever worked as a RN in a busy urban ED?


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## ffemt8978 (May 23, 2020)

RenegadeRiker said:


> They acted in the best interests of their patients and colleagues and forced the hospital to staff appropriately.


No, they acted in their own self interest.  The best interest of the patients would have been to have rested nurses on duty taking care of them, instead of the previous shift having to work extra.

Besides, until they clock in and receive a report from the previous shift, they don't have any patients to look out for.


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## RocketMedic (May 23, 2020)

ffemt8978 said:


> No, they acted in their own self interest.  The best interest of the patients would have been to have rested nurses on duty taking care of them, instead of the previous shift having to work extra.
> 
> Besides, until they clock in and receive a report from the previous shift, they don't have any patients to look out for.



Which means that not only are they accepting responsibility for those patients, they are accepting the inadequate and unsafe conditions propagated by their employer. Their refusal to clock in and assume care forced hospital administrators to actually deal with the problem, not just shrug their shoulders.
E Tank, you’re a niece anesthesist, right? Would you deliberately assume care in this circumstance?


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## RocketMedic (May 23, 2020)

Carlos Danger said:


> Yeah, I can see how forcing the day shift nurses to endure an assignment AFTER THEY HAD ALREADY WORKED ALL DAY that the night shift nurses didn't want to accept when they were fresh was definitely in everyone's best interests.
> 
> Do you think the staffing situation for the night shift magically improved for everyone when the night shift nurses went home? Where did this extra staffing magically come from?
> 
> Have you ever worked as a RN in a busy urban ED?



Sucks to suck. Not their fault, it’s the fault of the hospital and ED admin, who scheduled for inadequate staffing.


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## silver (May 23, 2020)

RenegadeRiker said:


> Sucks to suck. Not their fault, it’s the fault of the hospital and ED admin, who scheduled for inadequate staffing.



What makes you so sure that people didn't call out? Or that the ED nursing admins didn't call their nursing pool and asked to cover OT shifts?


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## ffemt8978 (May 23, 2020)

RenegadeRiker said:


> Sucks to suck. Not their fault, it’s the fault of the hospital and ED admin, who scheduled for inadequate staffing.



Nobody is disputing that.  What is being disputed is the appropriateness of the actions of those three nurses.  Their actions may or may not have contributed to the hospital increasing staffing, but they also short staffed the ED even more by not clocking in.  It sounded like the hospital was already trying to get more staffing for night shift, but those 3 decided it wasn't enough.

Rather than being part of the solution, they chose to make the problem worse in an effort to resolve it.  Now they will forever carry a reputation of screwing over their coworkers in the name of what they felt was right.


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## RocketMedic (May 23, 2020)

ffemt8978 said:


> Nobody is disputing that.  What is being disputed is the appropriateness of the actions of those three nurses.  Their actions may or may not have contributed to the hospital increasing staffing, but they also short staffed the ED even more by not clocking in.  It sounded like the hospital was already trying to get more staffing for night shift, but those 3 decided it wasn't enough.
> 
> Rather than being part of the solution, they chose to make the problem worse in an effort to resolve it.  Now they will forever carry a reputation of screwing over their coworkers in the name of what they felt was right.


Better that than professional censure for accepting an unsafe assignment. Also, sounds like their day shift colleagues were supportive.


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## RocketMedic (May 23, 2020)

silver said:


> What makes you so sure that people didn't call out? Or that the ED nursing admins didn't call their nursing pool and asked to cover OT shifts?



Apparently none of them showed up, so I guess those RN credentials held by the ED admin are just for show.


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## ffemt8978 (May 23, 2020)

RenegadeRiker said:


> Better that than professional censure for accepting an unsafe assignment. Also, sounds like their day shift colleagues were supportive.


Supportive according to those who refused to clock in.  Nobody has actually talked to the day shift and asked what they thought about it as far as I'm aware.

And your point about professional censure just goes to show that they were worried about themselves and not the patients.


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## RocketMedic (May 23, 2020)

ffemt8978 said:


> Supportive according to those who refused to clock in.  Nobody has actually talked to the day shift and asked what they thought about it as far as I'm aware.
> 
> And your point about professional censure just goes to show that they were worried about themselves and not the patients.


Those interests can align.


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## ffemt8978 (May 23, 2020)

RenegadeRiker said:


> Those interests can align.


True, but they can also be divergent.

Does anyone know for certain if there is a hard and fast patient limit per ED nurse, or are the limits more of a guideline?

I ask because I wonder what these three would have done if they started receiving several dozen or a hundred patients from a disaster such as a plane crash or earthquake.  Would they have refused to clock in because they had more patients than they could "safely" take care of?


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## RocketMedic (May 23, 2020)

ffemt8978 said:


> True, but they can also be divergent.
> 
> Does anyone know for certain if there is a hard and fast patient limit per ED nurse, or are the limits more of a guideline?
> 
> I ask because I wonder what these three would have done if they started receiving several dozen or a hundred patients from a disaster such as a plane crash or earthquake.  Would they have refused to clock in because they had more patients than they could "safely" take care of?



I don’t know, but I also know there’s a massive difference between an acute, unforeseen traumatic emergency mass-casualty situation and a completely predictable, slow-moving public-health disaster.


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## ffemt8978 (May 23, 2020)

RenegadeRiker said:


> I don’t know, but I also know there’s a massive difference between an acute, unforeseen traumatic emergency mass-casualty situation and a completely predictable, slow-moving public-health disaster.


Then it's not really about patient safety then, is it?  It becomes more about how they felt and wanted the ED to be staffed.


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## RocketMedic (May 23, 2020)

ffemt8978 said:


> Then it's not really about patient safety then, is it?  It becomes more about how they felt and wanted the ED to be staffed.



I love how you’re deliberately obtuse. Patient/staff ratios are a pretty common predictor of outcome, particularly when there’s a lot of high acuity patients with multiple interventions. The operators of the ED sound like they were willfully flirting with disaster by staffing three nurses for 26+ patients, especially while remaining open for incoming patients.

The right way to handle this would have been to declare an internal disaster, recall off-duty employees, move all available hands to needed areas and arrange for emergency staffing. Not schedule three people for the jobs of nine and call it a day.

Would you go to work for someone who staffed at 33% and held you accountable for all of the care demanded, not just who you were able to reach?


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## ffemt8978 (May 23, 2020)

RenegadeRiker said:


> I love how you’re deliberately obtuse. Patient/staff ratios are a pretty common predictor of outcome, particularly when there’s a lot of high acuity patients with multiple interventions. The operators of the ED sound like they were willfully flirting with disaster by staffing three nurses for 26+ patients, especially while remaining open for incoming patients.
> 
> The right way to handle this would have been to declare an internal disaster, recall off-duty employees, move all available hands to needed areas and arrange for emergency staffing. Not schedule three people for the jobs of nine and call it a day.
> 
> Would you go to work for someone who staffed at 33% and held you accountable for all of the care demanded, not just who you were able to reach?


That's why I asked if there was a hard and fast number.  If there was, I'd be more understanding of their actions.

What we don't know from the biased article was what the hospital was actually doing to remedy the situation.  We don't know if they were working on trying to recall more staff, we don't know if they were short staffed because others called in.  All that was reported in the article was one self-serving side with no independent investigation or reporting.

I have no doubt the three people in the article thought what they did was the right and safe thing to do.  I have serious doubts that it was the right and safe thing to do.


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## Carlos Danger (May 23, 2020)

RenegadeRiker said:


> Better that than professional censure for accepting an unsafe assignment.


You aren't a nurse and you don't have any idea what you are talking about, do you?


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## RocketMedic (May 23, 2020)

Carlos Danger said:


> You aren't a nurse and you don't have any idea what you are talking about, do you?



nor are you, so there’s that.


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## silver (May 23, 2020)

RenegadeRiker said:


> nor are you, so there’s that.


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## Carlos Danger (May 23, 2020)

RenegadeRiker said:


> nor are you, so there’s that.


Wrong again.

In addition to my EMS career, I've been a RN for 15 years and a CRNA for 5. So there's that.

Unlike yourself, I have also actually worked as a RN in busy, understaffed urban ED's. So there's that, too.

I can tell you that administrators can't snap their fingers and conjure qualified RN's out of thin air. I have never seen a reserve supply of ED RN's hanging out in a break room somewhere, sipping coffee and watching Netflix, just waiting to be summoned. If the ED was that short, likely the floors and units were also not overflowing with extra staff, especially those oriented and qualified to work in the ED.

There is also no such thing as "professional censure for accepting an unsafe assignment" because you show up to work and happen to be short staffed. That's absurd. In fact, I would suspect that this act could potentially be cause for action by the BON.

The ED in a busy urban center is a very hard place to work. Even harder at night, quite often. Harder still when you are short staffed. Yeah, it does suck. But taking this crappy assignment certainly didn't present any kind of "danger" to anyone. It's ok to go home from work stressed and tired sometimes. I promise. It's also OK to look for a different job.

To be clear: I am not defending the hospital for failing to find a way to address chronic understaffing issues, if that is indeed what was going on. But there is no way that any good was going to come from the unprofessional stunt that these whiny, entitled baby nurses pulled. It certainly didn't fix a chronic problem. In fact, at least for one shift, it probably made things a lot worse for everyone - including the patients.

If I were the NM of that ED, I would have fired this crew on the spot, and notified the BON immediately.


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## E tank (May 23, 2020)

I think the deal is (was) that this was an acute multi casualty incident, albeit a prolonged one...even the event in NYC dropped off precipitously, such that there was an identifiable demarcation in the ebb of the wave of casualties as would be expected in an MCI. These nurses did not recognize or appreciate the situation in which they found themselves and conflated it with lousy, normal operations staffing.

Major party fail....

(former inner city, urban jungle trauma/ER nurse here...)


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## Carlos Danger (May 23, 2020)

E tank said:


> I think the deal is (was) that this was an acute multi casualty incident, albeit a prolonged one...even the event in NYC dropped off precipitously, such that there was an identifiable demarcation in the ebb of the wave of casualties as would be expected in an MCI. These nurses did not recognize or appreciate the situation in which they found themselves and conflated it with lousy, normal operations staffing.



I wondered if it was something along those lines, though lousy normal operations staffing certainly isn't unheard of in places like that, either.


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## Tigger (May 23, 2020)

RenegadeRiker said:


> You say “pandemic” like it’s an acute emergency.


In which part did I say that? Go ahead and use the quote feature and include it. 

Unsafe staffing ratios are not really that uncommon. They happen in EMS too. As you say, the key is more staff. Good luck calling it a "safety issue" when you refuse to work, therefore making working conditions _more_ unsafe. Sure, some changes might happen eventually, but what happens in the interim?  

I don't really want to be party to a situation where I knowingly cause my coworkers to provider care in unsafe situations, so I'm out on that.


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## DrParasite (May 24, 2020)

Carlos Danger said:


> There is also no such thing as "professional censure for accepting an unsafe assignment" because you show up to work and happen to be short staffed. That's absurd. In fact, I would suspect that this act could potentially be cause for action by the BON.


Ok, good.  I was pretty sure @RenegadeRiker was full of **** when he made that claim.





Carlos Danger said:


> If I were the NM of that ED, I would have fired this crew on the spot, and notified the BON immediately.


See, we can agree on some things.

And @Tigger I think I was the one who referred to it as a pandemic.


RenegadeRiker said:


> It’s functionally no different than a shift of paramedics refusing to go to work in an unsafe system.


Lets think about this...  you want to compare it to paramedics refusing to work in an unsafe system; ok, how were the Nurses in any danger?  You mentioned "professional censure" (which I didn't think existed for nurses, and @Carlos Danger confirmed), but the truth is, they can complain to their union, and do a dozen other things... but at the end of the day, they still had an obligation to their patients, and they refused to do it.  Now, if you want to say they refused to work because they lacked proper PPE, I could see where the parallels are.  But that's not what happened.

I've worked in overworked EMS systems, and still have former co-workers who are working in the COVID hotspots... one is now an ER nurse who tested positive for the virus.  It's not fun.  my former EMS agency helped out the ER after they got off shift (the entire shift, and it was likely a busy shift, because they are all busy shifts), because the ER was overwhelmed.  No one refused to work because they were too busy.


RenegadeRiker said:


> The right way to handle this would have been to declare an internal disaster, recall off-duty employees, move all available hands to needed areas and arrange for emergency staffing. Not schedule three people for the jobs of nine and call it a day.


here is the other thing that you seem to not realize: what if there weren't any other options?  no available nurses, no more staffing, no more rooms?  You work in the ER, you can't turn critical people away if they walk in the door.   You can't always recall people (especially since the people you are recalling likely have to work other shifts too, and are sleeping if they work nights), and you can't always move people; remember, just because the ER is getting slammed, doesn't mean you can move an ortho nurse to the ER and expect that he or she will not completely fail because they aren't trained for ER work.   Oh, and while your statement about Administrators with RN certs is valid, when managers are working staff positions, they aren't managing.  So no one is managing the "internal disaster" as you recommend, because the mangers are working as line personnel.

These three were incredibly selfish, looking out for themselves and no one else (not their coworkers, not the patients, and definitely not their employer); if the ER wasn't already short-staffed, I think they would have been terminated.  their employer should file a complaint with the BON over their actions.


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## Peak (May 25, 2020)

Refusing an unsafe assignment is not patient abandonment, abandonment requires an established relationship of care.

You may be able to argue some form of professional neglect, dereliction of duty, failure to act/rescue, et cetera. I doubt they’re are any criminal convictions for this though related to refusing an assignment prior to clocking in.

Nursing boards vary state to state and that is largely what controls the refusal of an unsafe assignment. Most states allow for a complete or partial refusal of an unsafe assignment.

I have received several emails from my malpractice carrier about how to refuse an assignment in general and during COVID, so I doubt this is an isolated inciden

I don’t think that sitting in the break room for four hours and having a pout is appropriate. If they were so inclined to refuse then they should have said that and left. In my opinion what they did wasn’t refusing an assignment, that was trying to manipulate management.


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