Charge Nurse Assignment: Matching Scope, Competence, and Acuity
You are the charge nurse on a 32-bed medical-surgical unit. Staffing: yourself (largely out of assignment), one RN with 1 year of experience, one LPN with 15 years of experience, one UAP, and a float RN from the orthopedic unit who says, 'I've never taken care of a tracheostomy.' Patients include: (A) post-op day 1 with a new tracheostomy requiring q2h suction and frequent respiratory assessment; (B) a stable patient with a unit of packed RBCs ordered now; (C) a patient with C. difficile diarrhea on contact precautions needing frequent linen changes; (D) a stable patient awaiting discharge teaching on a new insulin regimen.
1. How will you assign these patients to best match skill, scope, and safety?
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Assign by acuity and scope, not by counting patients.
- Patient A (trach) goes to an RN with airway competence - you or the experienced RN. Assessment of a new tracheostomy, suctioning decisions, and recognizing an airway emergency are RN assessment functions and cannot be delegated. A nurse who has never managed a trach cannot take this patient independently, regardless of license.
- The float RN is paired with a resource RN. Give her a stable assignment she is competent to deliver and verify skills before she works independently. Insulin teaching (D) is an RN function but requires competence in diabetes education; transfusion (B) is an RN function requiring two-nurse verification and 15-minute vital signs. Choose the one she can do safely with a resource, and be explicit about when to call you.
- The LPN can take stable patients, administer routine medications, perform dressing changes, and contribute to C within scope - but not the initial trach assessment or independent discharge teaching.
- The UAP handles vital signs, intake and output, weights, ambulation, and linen changes for C with correct PPE, plus glucose checks only if competency-validated.
- The new RN gets a lower-acuity, stable pair with you as a visible resource.
2. How do you respond to the float RN's statement, and what are the limits on what she can be assigned?
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Her statement is a safety gift - treat it at face value and thank her rather than pressuring her.
- Orient her to the unit, the equipment, the emergency process, and where the resource nurse is.
- Assign only what she is competent to perform. Licensure defines the legal scope; competence defines what is safe tonight. Both must be satisfied.
- Every nurse has the right and the obligation to refuse an assignment they cannot perform safely. Support that, and do not document it as insubordination.
- Escalate if staffing cannot cover the need: notify the house supervisor, request a nurse with airway competence, or reassign the trach patient to yourself or the experienced RN. Do not leave the patient covered only by someone 'watching.'
- Document the conversation, the assignment decision, and the escalation.
A plan must exist for the emergency, not just the routine - suction equipment at the bedside, backup call bell, and a named responder.
3. What will you delegate to the UAP, and how will you follow up?
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Delegate (tasks, not patients):
- Vital signs and SpO2 on stable patients
- Intake and output, daily weights
- Blood glucose checks if competency is validated
- Linen changes and hygiene for the C. difficile patient with proper PPE and hand hygiene
- Ambulation with fall precautions already set
- Specimen transport, restocking
Do not delegate: assessment, evaluation, patient teaching, tracheostomy suctioning, blood product administration, IV push medications, or discharge instructions.
Follow-up: use the rights of delegation (right task, circumstance, person, direction/communication, supervision/evaluation) and closed-loop communication - state the task, the patient, the time frame, the expected findings, and the specific threshold for reporting. Then check back at a set time and ask for findings, not 'everything fine?' If the UAP reports a change, you assess before acting.