By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist
“If you don’t stay and work extra, who will take the admission that’s coming? There’s no one else.”
If you’ve been told by your nurse manager that you must work “mandatory” overtime, don’t buy it! Under Minnesota state law, nurses cannot be disciplined for refusing overtime if, in the nurse’s judgment, it would be unsafe for the patient.
Study after study show that unplanned overtime assignments have a high potential to be unsafe. Working more than 10 hours in a given day, when unplanned, results in lower quality of care, higher RN burnout, decreased patient satisfaction, and increased errors.
Whether the overtime is planned or unplanned does make a difference: we plan to get extra sleep, bring an extra meal, and mentally prepare when we know overtime is coming; when it’s not, we’re caught between pleasing our supervisor and doing what’s best for the patient.
What happens if your nurse manager tells you that if you do not accept an overtime assignment, you are abandoning your patients? Again, don’t buy it!
Generally speaking, patient abandonment occurs when a nurse leaves a patient without handing off that patient’s care to another nurse. If you refuse mandatory overtime for the purposes of protecting your patients, you will need to hand off the care of your patients to another RN, which can include your nurse manager (i.e. give report). Remember that under the language of the overtime law, healthcare facilities are forbidden from reporting nurses who refuse mandatory overtime to the Board of Nursing.
When employers ask for or “mandate” overtime, it means the hospital is desperately short of staff. Accepting overtime assignments enables and perpetuates this unsafe staffing by allowing hospital administration to get away with not hiring enough nurses. So, the next time you’re asked to take on mandatory overtime, just say no.
National Nurses United this week endorsed the U.S. Presidential candidate who agrees with nurses’ values and is an ardent advocate for issues important to the nursing profession, like expanding Medicare, the Robin Hood Tax to ensure Wall Street pays its fair share, and proper safety and protections from infectious diseases for nurses and patients.
National Nurses United announced on August 10 the endorsement of Vermont Senator Bernie Sanders for President at a “Conversation with Bernie” at NNU’s national offices in California. Hundreds of RNs cheered Sanders on at the California event, and thousands more watched on live stream at 34 watch parties in 14 states, including Minnesota.
“I have spent my career fighting for something that I consider to be a human right,” Sanders told the crowd. “That human right is health care.”
He said it’s time for a Medicare for All single-payer health care program in the U.S.
“We have got to move toward a health care system which is based on providing quality care to all of our people rather than worrying about the profits of the insurance companies,” he said. “We have got to move toward a health care system which ends the absurdity of Americans paying, by far, the highest price for prescription drugs in the world.”
MNA President Linda Hamilton had the honor of being one of the NNU members introducing Senator Sanders. Hamilton said the members she represents are looking forward to issue-based discussions in the campaign. She said Senator Sanders will address the real problems that patients and the country face.
According to NNU Executive Director RoseAnn DeMoro, NNU has adopted a call to Vote Nurses Values – Caring, Compassion, Community.
“Nurses take the pulse of America, and have to care for the fallout of every social and economic problem – malnutrition, homelessness, un-payable medical bills, the stress and mental disorders from joblessness, higher asthma rates, cancer, heart ailments and birth defects from environmental pollution and the climate crisis,” she said. “Bernie Sanders’s prescription best represents the humanity and the values nurses embrace.”
Last fall, my grandmother was admitted to the hospital after a TIA that left her oriented only x1. Or, more correctly, we thought she was admitted. As it turns out, she was in the hospital for several days in an outpatient status, known in Medicare parlance as “observation status.”
Unfortunately, what “observation status” meant for Grandma was that she did not meet the Medicare requirement for a 3-day inpatient stay at the hospital in order to qualify for discharge to a skilled nursing facility. Thus, despite the fact that Grandma was certainly not in any shape to discharge home; and despite the fact that she had entered the hospital from a nursing home, she was not able to go back to the nursing home.
Such situations occur more frequently than you might think: according to a 2014 report by the Medicare Payment Advisory Commission, 1.8 million observation claims were submitted in 2012, an 88 percent increase from six years earlier. While observation status was originally implemented to allow hospitalists to determine whether or not patients should be admitted, it has grown into a kind of purgatory that allows hospitals to reduce penalties from the Hospital Readmission Reduction Program (since observation status patients are not technically readmitted) and shift services to more profitable outpatient areas of the hospital.
On top of not counting toward the 3-day requirement for discharge to a skilled nursing facility, observation status stays are charged on an outpatient basis (i.e. under Medicare Part B). This can often mean higher out-of-pocket costs for Medicare beneficiaries—for example, Medicare Part B services have a deductible and 80/20 cost sharing (80 percent Medicare/20 percent beneficiary) that is applied to all services provided and does not cover the cost of pharmaceutical drugs used in the hospital.
So what can nurses do? The first step is to advocate for our patients. Ask the hard questions – why are our patients in the hospital being charged for services if the physician is unsure whether or not a hospital admission is medically necessary? Equally important is communicating with the patient. Our patients deserve to know whether or not they are on observation status. Furthermore, they absolutely must understand what “observation status” entails: they will be charged for services under Medicare Part B (80/20 cost sharing and a deductible), the cost of medications will not be covered, and the patient’s time in the hospital will not count toward the 3-day requirement for discharge to a skilled nursing facility.
As of July 1, such communication with a patient is in fact required under state law — but in order to properly communicate with and advocate for our patients under observation status, we must first understand it ourselves. Read more about the issues with observation status here or here.
Nurses throughout Minnesota know of instances of employers intimidating and retaliating against staff for a wide variety reasons, like reporting unsafe staffing, speaking up when they disagree with a program or pilot, reporting managerial unethical or illegal behavior, engaging in union activities, and many more.
These types of incidents can cause managers and administration some headaches, but they are all part of the ebb and flow of the employer-employee relationship. Unless, of course, the employee is punished for legal and ethical actions.
Unfortunately, retaliation in the workplace is all too commonplace – and not just in hospitals.
For nurses, the opportunities for retaliation are higher than in many other fields. In addition to issues with employers over the way they conduct business, nurses’ licenses require them to follow an additional set of rules that often contradict their employers. They are responsible for ensuring that every assignment they accept is safe for the patient, refusing overtime if they don’t feel safe, and reporting situations in which a patient is injured or in grave danger.
Because of that, the opportunities for “disappointing” the employer increase in the nursing field, as are the opportunities for retaliation.
Some recent examples show that retaliation in the healthcare field is not improving:
- The National Labor Relations Board issued a formal complaint last October against North Memorial Medical Center in Robbinsdale for harassing and intimidating staff for their participation in an informational picket calling for safe staffing levels. The hospital fired one employee, revoked work agreements and forced employees to work weekends, “repeatedly interrogated” staff about their union activities and falsely claimed that talking about union activities was prohibited.
- A nurse at another Metro hospital was recently targeted by management and her CNO for speaking up about a pilot project that she and many others thought was endangering patient safety. After her union colleagues protested, the nurse was asked to “review hospital policy” that she never violated in the first place.
- After a nurse filed a Concern for Safe Staffing form, she was called into the office and asked why she went to the union with her concerns. The nurse defended her actions, and said her union was the proper place to share concerns. The hospital attempted to terminate her a short time later, but MNA rose to her defense.
- A nurse who refused an unsafe assignment was berated in front of colleagues, pulled into a manager’s office and berated some more. Other nurses were so upset at the treatment, that they stood up and defended the member.
As you can see, hospitals have many ways to retaliate against nurses and other staff.
The good news is that nurses do not have to put up with this. The law and your union – your colleagues – are on your side.
It’s illegal for employers to retaliate against you for any concerted activity about the terms and conditions of employment, such as speech or other actions that don’t disrupt the workplace in a private or public facility; and it’s especially illegal for employers to retaliate against nurses for blowing the whistle on a situation that in the nurses’ professional judgment risks patient safety.
If you have experienced workplace retaliation, share you story with us.
Filing Concern for Safe Staffing Forms and speaking out about unsafe staffing do make a difference. Just ask Surgical/Trauma/Neuro RNs at Hennepin County Medical Center in Minneapolis.
Nurses mobilized and forced the hospital to end a pilot program in the STN unit that increased the number of patients a nurse cared for at one time.
The pilot was implemented in January 2015 without Nurses’ input. They knew from day one the pilot was endangering patient safety and stretching each nurse too thin.
The increased number of patients was “overwhelming” to the nurses and other staff.
“You can’t keep track of that many people,” said RN Sue Oberg. “The push was to work at the top of our licenses, which was ridiculous. You need so many other people to take care of a patient. It was also pulling nursing assistants out of their areas of practice.” They were put in a position of taking over at the bedside because RNs had so many patients they couldn’t spend the proper amount of time in each room.
The situation was so bad that the RNs were worried about their licenses.
The pilot took its toll on nurses mentally and physically.
Some nurses were ready to look for another job.
Patients noticed a problem when they wouldn’t see a nurse for hours.
The nurses stood up and fought the pilot. They spoke loudly and strongly about the damage the pilot was causing. They talked to managers one-on-one and at meetings – and filled out the Concern for Safe Staffing forms. The forms showed that this issue was a concern on days, nights, and afternoon shifts. MNA received 45 forms from HCMC between January and the middle of February.
Nurses also shared their concerns with physicians, who saw what was happening and supported nurses by signing letters.
HCMC backed off the pilot under the pressure.
*This post was updated on July 31, 2015 to clarify some minor details.
It is with growing concern that MNA has received reports of increasingly ineffective charge nurse utilization in our hospitals. If you’ve been in nursing for more than a few years, you’ve seen the trend yourself: charge nurses have quickly gone from having no patient assignment, to having a few admits or discharges as needed, to always having half of an assignment, to always having a full assignment… to having two floors?
This alarming new trend is to assign the nurse variously described as a given unit’s “resource,” “foreperson,” and “air-traffic controller” to two units at once. This disastrous model stretches already thin nurse staffing even thinner while eliminating an essential resource for both routine and emergency nursing care. Furthermore, it requires the charge nurse to be in two places at once while making safe, accurate, and timely staff assignments without knowing half the staff being assigning.
When a hospital requires a charge nurse to take on a full patient load, or to be in two places at once, that hospital is putting its bottom line ahead of patient safety. This is dangerous for both the hospital and the charge nurse. In fact, many experienced nurses are now turning down charge nurse assignments due to their unwillingness to take on the legal risk such unsafe assignments entail.
Charge nurses are essential tools to ensure the right nurse is assigned to the right patient, to help navigate crisis situations, and to ensure care that would otherwise be missed is performed. As one researcher put it, the role of a charge nurse is a “skillful balancing act.” But how can one perform a skillful balancing act on two floors at once?
Is this the end of the charge nurse as we know it? Maybe. It’s up to nurses to stand strong together: do not accept unsafe charge nurse assignments. Do not enable your facility to cut corners and put patients at risk. Do not perform your skillful balancing act with a full patient load on two floors at once. Our patients deserve better.
By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist
With Minnesota’s medical cannabis law set to take effect on July 1, Minnesota nurses will likely be asked to administer medical marijuana in the hospital setting. But are you ready to do so? Here’s what you need to know about the new law.
- Patients will not receive a medical marijuana “prescription” from a physician or APRN. Instead, a patient’s provider will certify that the patient has a medical condition that qualifies for medical cannabis use. The patient will then need to register with the Minnesota Department of Health in order to be eligible to utilize the medication.
- Patients will not be able to pick up medical cannabis from the local pharmacy. There are eight locations in the state that are licensed to dispense medical marijuana.
- Patients will not be able to smoke their medical cannabis. Raw leaf, flowers, and edibles are not allowed under the Minnesota law: only pills, oils, and liquids are allowed.
- Your facility may ask you to administer medical cannabis. Each facility will surely have its own policy and procedure on patients who are admitted and bring their own medical cannabis. It is possible that your facility may ask the patient to turn the medications over to the hospital pharmacy, which would then ask you to administer the medical cannabis.
- You and your facility are protected under state law while administering or providing care to someone who is taking medical cannabis. Minnesota recently passed an amendment to the medical cannabis law. Per the MN Department of Health:
The amendment extends protections and immunities to employees of health care facilities to possess medical cannabis while carrying out their employment duties. These protections include providing care or distributing medical cannabis to a patient on the Minnesota medical cannabis patient registry who is actively receiving treatment or care at the facility. The amendment also allows health care facilities to reasonably restrict the use of medical cannabis by patients. For example, the facility may choose not [to] store or maintain a patient’s supply of medical cannabis or that use of medical cannabis may be limited to a specific location.
- Federal law still prohibits the distribution and use of medical cannabis. Under federal law, medical cannabis remains a Schedule I drug. Given state law protections, however, the potential liability and level of concern for individual nurses who are asked to administer medical cannabis per hospital policy should be low.
By Mathew Keller RN JD, MNA Nurse Practice & Policy Specialist
In a cost-cutting move, many Minnesota hospitals are asking registered nurses to take on more pharmacy duties. Where there may have once been pharmacy staff available 24/7 to answer questions, compound pharmaceuticals, and dispense medications, many nurses are finding that such coverage is now limited to 9-5 with an outsourced pharmacist in another city (or state) available by telephone after hours to answer questions and certify prescriptions. This can lead to potentially dangerous situations for patients as well as nurses’ licenses when nurses are asked to dispense and/or compound medications in the absence of a pharmacist.
One disturbing trend we are tracking is nurses being asked to fill the Pyxis or other automatic dispensing machine on the overnight shift. Non-pharmacy staff filling a Pyxis is unacceptable pharmaceutical practice. Furthermore, it is outside the scope of RN practice.
Under state law, only pharmacists are legally qualified to dispense medications, although they may be assisted in the task by up to two pharmacy technicians at one time. Dispensing is defined as “delivering one or more doses of a drug for subsequent administration to, or use by a patient.” When a nurse fills a Pyxis or other automatic dispensing machine, that nurse is delivering doses of drugs for subsequent administration to a patient.
While nurses may legally administer medications, they may not legally dispense them. Filling a Pyxis is outside the scope of RN practice and can lead to discipline against one’s nursing license as well as charges of practicing pharmacy without a license. In addition to scope and licensure issues, a nurse who fills a Pyxis assumes legal liability for any and all errors or patient harm resulting from improper dispensation (e.g. putting the incorrect medication in a Pyxis drawer).
Another common issue involves nurses being asked to mix IV medications in the absence of pharmacy coverage. The propriety of this practice is situationally dependent: reconstituting medications is acceptable nursing practice; compounding medications is not. Compounding is defined as mixing, packaging, and labeling a drug for an identified individual patient’s use. The determining factor in whether or not you are compounding medications is whether the medication is for immediate use or not. If a medication is being mixed for immediate use, it is acceptable reconstitution. If the medication is being mixed for storage and later use, it is unacceptable compounding.
Lastly, many nurses are being given pharmacy access for after-hours care. Under Minnesota rules, after-hours nurse access to the pharmacy should fulfill the following guidelines:
- Withdrawal of medications must be limited to “emergency” situations, interpreted broadly by the Board of Pharmacy to include any time a necessary medication is needed but unavailable;
- Only one designated RN on a given shift may have emergency access;
- The standard of practice is that narcotic access is limited to a locked narcotic drawer with a small supply of available medications, not full access to the narcotics safe;
- The designated RN must properly document medications removed from the pharmacy;
- The designated RN should have proper training from the pharmacy staff in pharmacy policies and procedures, as well as specific training regarding after-hours access.
MNA has and will continue to work with the Minnesota Board of Pharmacy in order to ensure that our patients are protected through proper pharmaceutical and nursing practice. Have you been asked to fill a Pyxis or compound medications? Please let us know at Mathew.email@example.com.
 MN Statute §151.01 Subd. 27 (2)
 MN Rule 6800.7100
 MN Statute §151.01 Subd. 35
 MN Rule 6800.7530
By Mathew Keller, RN JD, MNA Nurse Practice & Policy Specialist
“Samuel’s Law,” under consideration in the South Carolina Senate, would require the South Carolina Board of Nursing to revoke a nurse’s license “upon the board’s finding that a licensed nurse misreads the physician’s order and overmedicates or undermedicates a patient.”
While the circumstances surrounding the introduction of Samuel’s Law, involving the fatal overmedication of a 7-year old, are tragic, the bill is an inappropriate response and does nothing to correct the systems-level failures that are often the basis of medication errors.
As a systemic review of 54 studies on medication errors puts it, since “nurses find themselves as the ‘last link in the drug therapy chain’ where an error can reach the patient, they have traditionally been blamed for errors. However, the reality is that the conditions within which the person responsible for the error works, as well as the strategic decisions of the organization with whom they are employed, are often the key determinants of error.”
Therefore, any law that purports to reduce the incidence of medication errors ought to focus on systems-level failures that can lead to medication errors, including inadequate communication pathways (e.g. illegible prescriptions, poor documentation, lack of transcription), problems with pharmaceutical supply and storage, unmanageable workload, availability and acuity of patients, staff fatigue and stress, and interruptions or distractions during drug administration.
Correcting or addressing the above issues, rather than punishing unintentional errors with the loss of one’s livelihood, will go a long way toward addressing the root cause of medication errors Samuel’s Law seeks to address. It also fits with the model of “just culture,” widely accepted and adhered to in both the medical and aviation industries, which seeks to create an environment that encourages reporting mistakes so that precursors to errors can be understood and systems issues can be fixed.
As Lucian Leape, MD, member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, said in testimony before Congress, “Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.” (Leape, 2000).
Samuel’s Law, while well-intentioned, uses the wrong approach to prevent medication errors. How would you change the language to better prevent errors? Share your thoughts in our comment section below.
 Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence. Drug Safety, 36(11), 1045–1067.