Charge Nurse on a Short-Staffed 28-Patient Unit
You are the charge nurse on a 32-bed medical-surgical unit for the 1500–2300 shift. The staffing plan is one RN to five patients. Two RNs called in sick; one was replaced by an agency RN who has never worked on this unit. Your team is four RNs (one is a new graduate in week 12 of orientation), two LPNs, and two unlicensed assistive personnel (UAPs). Twenty-eight beds are occupied. The ED has called report on two admissions: a 58-year-old being ruled out for acute coronary syndrome and a 70-year-old with cellulitis and a new order for IV antibiotics. One RN is scheduled to leave the floor at 1600 for a mandatory education session. The unit secretary reports a family in the hallway demanding to speak to "whoever is in charge" about a call light that went unanswered for 25 minutes.
1. Make the patient and staff assignments for the shift. Justify each placement using acuity, competency, and continuity rather than seniority or convenience.
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Start by sorting the 28 patients into stable/standard and unstable/complex. The two admissions must be placed only after review.
- Agency RN: take a full team of stable patients with routine orders, but first give a 10-minute unit orientation (crash cart, code process, EHR workflow, who to call) and pair her with a buddy. An agency nurse should not be given the ACS rule-out on an unfamiliar unit.
- New graduate: keep her with stable patients plus the LPN supporting her medication administration. Do not give her the ACS rule-out alone; she has not yet demonstrated independent interpretation of chest pain or serial troponins.
- Charge nurse: take the ACS rule-out admission plus the two UAPs' high-risk patients. The charge nurse retains the unstable patient and the admission requiring complex assessment.
- LPNs: stable patients needing oral medications, dressing changes, and tube feedings, with an assigned RN for IV push medications and initial assessments.
- Education session: reschedule. Staffing takes priority over a non-mandatory, non-expiring program; document the reason after making the decision.
2. List the specific tasks you may delegate to the UAPs and LPNs tonight and the tasks you must keep at the RN level, including what you would delegate for the chest-pain patient.
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May delegate to UAPs (with specific instructions, timeline, and reporting expectation): vital signs on hemodynamically stable patients, intake and output, weights, blood glucose checks per policy, ambulation and repositioning, hygiene, specimen collection from stable patients, and hourly rounding with call-light response.
May delegate to LPNs (per state nurse practice act and facility policy): administration of oral and subcutaneous medications to stable patients, wound care, catheter care, and monitoring of established IV infusions.
Must remain with the RN: the initial and ongoing assessment of the ACS patient, interpretation of serial troponins or ECGs, patient teaching, evaluation of the plan of care, administration of IV push or titrated medications, and discharge teaching. For the chest-pain admission, the UAP may obtain vital signs and report immediately, but the RN must perform the admission assessment, apply and interpret the monitor, and reassess with every complaint.
Give the UAP a closed loop: "Vitals on rooms 12, 14, and 17 by 1530, and tell me immediately if the chest-pain patient's heart rate goes above 110 or systolic drops below 100."
3. The new graduate privately tells you she forgot to give the 1400 dose of sliding-scale insulin and is afraid of being fired. Simultaneously, the family in the hallway is demanding to speak with you. Describe your response to both.
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Patient first. Every time. Check the current blood glucose, give correction per the sliding scale, notify the provider if the glucose is outside the parameters, and document. The error is the secondary problem; the patient's glucose is the primary one.
Then apply a just culture approach: determine whether this was human error, at-risk behavior, or reckless behavior. A missed dose during a shift in which she has been assigned an unsafe workload is a system issue, not a firing offense. Ask what happened, adjust the assignment, and complete an incident report. The incident report is not part of the medical record and is not a disciplinary document; say that clearly to her.
Family: use service recovery rather than defensiveness. Acknowledge the delay, apologize for the experience without assigning blame, explain what you will do now, correct the problem, and follow up later. Document the conversation and the action taken. Responding to the family in the hallway is not the place for a detailed clinical discussion; move them to a private area. A satisfied unit and a frightened new graduate are both leadership outcomes of the same 10 minutes.