Meeting the Challenge of Difficult Staffing Decisions

Leah Curtin, RN, ScD(h), FAAN


Am Nurs Journal. 2019;14(8):50 

You're the nursing supervisor responsible for staffing the night shift. You have one less intensive care unit (ICU) nurse than required; the hospital's staffing policy requires an ICU staffing ratio of 1:2. Five patients are in the ICU, so you should have three RNs on duty. However, two of the patients are being held there only because no beds are available in the telemetry unit. You've called every qualified RN, and no one can (or will) come in to cover the ICU. You've also checked with your staffing agency, and no RNs with ICU experience are available. You notify the ICU nurse manager, who says she can't come in and tells you to do whatever you can.

If any more patients are admitted to the ICU through the emergency department (ED), the situation will come to a head. What's your personal legal liability if you pull a med-surg nurse to cover the ICU, and the med-surg unit experiences an incident with negative patient outcomes related to low staffing? What do you do if the staff nurse on the med-surg unit refuses the assignment because he or she doesn't feel competent to work in the ICU? What if you force the issue, and he or she makes a mistake? And what if you don't pull a nurse, and a patient who is admitted to the ICU has a bad outcome because of low staffing?

Here is what I'd do in this situation:

  • Inform the ICU nurse manager that it's an essential part of her role to staff the unit safely.

  • Visit the ICU personally to assess the situation and ask the nurses for their assessment.

  • If necessary, I would then visit other nursing units to determine which is the least stressed and then ask the charge nurse on that unit for an assessment of the situation to determine if an ICU patient could be transferred there.

  • Decide whether and whom to pull based on these assessments. If necessary, I'd ask the administrator on call about putting the hospital on ED diversion.

  • If I can't find a low-stress unit and the administrator on call won't put the hospital on ED diversion, I would consider holding new admissions in the ED until the day shift comes in or sending them to the postanesthesia care unit where a nurse is always on call. If none of this works, I would either go to the ICU to help with the least critical patients or pull a more competent nurse from a stressed unit and go to that unit to help until the shift ends (presumably, I can still be paged by other units).

  • Talk to administration about the ICU head nurse who failed to staff the unit properly. I also would ask nursing administration to consider starting an ICU internship program for staff who are interested in working in the ICU, thus creating a pool of nurses who could safely be pulled to work on the unit.

Although one must be prepared for contingencies, it usually is stressful as well as unproductive to anticipate disaster on every shift. All RNs, including nursing supervisors, are accountable (liable) for the professional decisions they make. If you make a staffing decision that your reasonable and prudent peers would agree is appropriate, you'll be as safe from litigation as possible. Forcing any RN who believes he or she is incompetent to work on a particular unit is neither reasonable nor prudent. We have a professional duty to handle the problems associated with the roles we've accepted. Part of that duty is to respect everyone involved—patients and personnel.