Responsibility Without Authority

Responsibility without authority is a prescription for failure.

Culture of Nursing.

I could just stop there and all the nurses who stop by this blog would understand exactly what I am writing about. For it is not a new concept or phenomena in nursing circles to assign a responsibility to a nurse but not give them the authority to solve the problem. One way in which this scenario plays itself out is by institutions not designating a person to be in charge. The charge nurse position as we used to know it has been done away with in many institutions. The replacement system has been to rotate the charge position on the floor to whoever draws the short straw. This is kind of an Edwards Deming approach which I just hate.

This system has the advantage of allowing the institution to not pay for someone to actually be in charge but some poor schmuck has to take the responsibility of being in charge. Along with that responsibility the authority is completely withdrawn to make any meaningful decisions or changes. A script is written by management (policies and procedures) and the poor peon nurse who is “in charge” is always in danger of falling outside the predicted scenarios.

This is not a problem during the weekday day shifts because the nurse in charge has a plethora of management suits to fall back on and get an actual decision with authority. Should a nurse on the night shift or on the weekend have an unusual problem they have the responsibility to make a decision but not the authority to make the decision. This is where I developed my theory of nursing, namely: No decision ever goes unpunished. It does not matter what decision you make it will always somehow be wrong once the suits get a hold of it. Fear not though, they won’t fire you, after all, they need you more than you need them. What they will do is write everything up and threaten to give you a bad reference should you ever tire of slaving away at their particular sweat shop. They will also use your helpless situation to give you a job evaluation of “adequate.”

No nurse ever does a good job, especially not an excellent job. I’m speaking of course of management’s position on the nurse not the patient’s perception of how hard the nurse is working. The institution would actually have to pay you more if you were doing a good job. If you are merely doing an adequate job then they don’t have to feel bad about that 1.5% pay raise they gave you this year.

This culture of foisting responsibility on the nurse but not giving them the authority to make decisions was a prime reason I was motivated to return to school. Recently at work I was asked if I would be interested in taking a position as a team leader. I told them I would be willing to talk with them about the position. And I did.

When I started this long term care stuff I was given the companies most time intensive problem child building. I have written a little about the problems encountered at this one care center. A short synopsis: the nurses DC orders for treatments they don’t like or find inconvenient, change drug orders without speaking to the doctor or me, send patients to the hospital without calling the doctor or me, and the list goes on. The DON of this building hates me. She does not disguise her hate of me. She could be the poster child for obstructive management types. We have all run into these types of people, I just seem to get more than my share of them. They exist for one solitary reason, to obstruct any semblance if getting some productive work done. Think postal worker temporally assigned to working at the department of motor vehicles. The last meeting we (the company) had at this facility with the DON and nursing staff did not go well. I commented to the suits from my company that I thought it would be a good time to chuck the whole thing and say good-bye to this potential lawsuit.

I was not well received and the suits said they had a contract with the parent company and could not pull out of this building. My bullshit meter started spinning immediately. (Mandatory John Kerry reference removed) Since that meeting my patient population at this facility has steadily grown, much to my dismay.

Since discussing the Team Leader position with my company two months ago, I have had several situations where I needed to call the Team Leader and ask for help. In any organization there is a chain of command which one may access to consult, problem solve, and ask for help from above. Over the past two months I have received absolutely no help from management.

On Thursday one of my patients with renal failure and bacteremia needed to continue her IV antibiotics. She was feeling better and really did not meet criteria for admission to the hospital. She was of course at the problem building. I called a nurse at the facility to make sure they (the care home) would be ok with giving antibiotics over the weekend. They assured me she would be fine. Not five minutes later I received a call from the same nurse telling me that they could not give my patient her antibiotics because there would not be an RN available. Certain LPN’s can give premixed IV medications but I was told no one on the weekend shift would be able to give the drugs. I was told the DON, the old gray moldy pile of jello herself, had told the nurse to demand that I admit the patient to the hospital. (I wish someone would just throw a bucket of water on this ancient DON. Sounds of witch melting)

I called the Team Leader and explained the problem. Our company policy is to call the Team Leader for all admissions, which is what I was doing. I suggested we have the patient transferred to another facility which has a post acute unit. I speak to the patient and explain the problem and the patient tells me she wants to move back to the other inst. I hear from the team leader what do I want to do about it. Keep in mind it’s now 16:58 in the afternoon and I can hear institution. I hear the Team Leaders kids crying and playing grab-ass in the background and have to refocus her attention to my problem several times. The Team Leader tells me that since I want to be a Team Leader (a decision I have not made yet) that I should solve this problem as a Team Leader would. Fine, I say, and in not the most neutral tone. I’m not getting paid to be a Team Leader. I hear hesitation on the other end of the phone.

I’ll make the call if you don’t want to, she responds. Now I’m thinking about the difference between responsibility and authority. I have just been given the responsibility to solve this problem with no authority to do so. Maybe a short story from the past would help.

When I was in the Air Force someone had to stand watch in the barracks 24 hours a day. Fortunately, I rarely was assigned this duty because I was in a one person shop and couldn’t miss work to police the barracks. One of the favorite games was to lean a trash can against a neighbor’s door and fill it with water. When the airman opened the door, 30 gallons of water would dump in the room. Top didn’t like this “game” and left instructions to stop anyone from doing this. That was just fine, but while we had the responsibility to stop the behavior, we had no “authority” to do so. In fact, if it happened while you were in charge of the barracks, you were punished for letting it happen. Everybody knew a lowly E-2 had no authority to stop one from doing this and would tell you to piss up a rope if you tried to stop them. It was a responsibility without the authority to do anything meaningful. Should you report the behavior to Top, you were punished for “ratting out” a brother rather than solving the problem yourself.

I believe the proper response to the DON demanding that we send the patient to the hospital would be for management, a suit, to call and tell them why that is inappropriate. They dumped this on me. Someone who has no authority to speak or act for the suits. The best I would be able to do is piss off the DON and then have to answer to the suits for her complaints. Had they given me the authority to say, look, the law states you must have an RN on duty 24 hours a day, she can give the meds, the problem would have been solved. But they did not do that. They told me to solve the problem without giving me any tools with which to act. This is typical of nursing and happens all the time.

I ended up admitting the patient to the hospital after three long conversations with the PCP, Medical Director, and the Renal Doctor. I called the Team Leader to tell her I was admitting the patient to the hospital. When I told her this there was a long, pregnant pause. She started to ask me why I was admitting this patient to the hospital. I let her start to berate me for my decision. I then told her the patient’s creatinine was elevated greater than 50% and that at the current level the proper course of treatment was to admit her. Silence at the other end of the phone.

Responsibility without authority is a prescription for disaster.

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