Fewer RNs, more support staff in the ED?

oramar · May 20, 2009

Thanks for posting this, this needs to be debated. It is deskilling plain and simple. Deskilling usually does not have good outcomes. It is almost always fueled by desire to reduce cost. My complaint is that if any of those persons fails to do their job correctly the RN will be blamed. Meanwhile, that increases the number of patients the RN is responsible by 4 times.

mwboswell · May 20, 2009

Thanks for posting this, this needs to be debated. It is deskilling plain and simple. Deskilling usually does not have good outcomes. It is almost always fueled by desire to reduce cost. My complaint is that if any of those persons fails to do their job correctly the RN will be blamed. Meanwhile, that increases the number of patients the RN is responsible by 4 times.

Right, I understand your point, but what about what the presenter said in that we need to find a way for RN's to quit having to do non-RN "stuff"? And focus on those things that make the RN the RN and not a tech or secretary?

Editorial Team / Moderator · May 20, 2009

Usually when I run into the issue of needing more RNs and not so much support staff is when I have multiple patients needing multiple meds or close monitoring. Yes, sometimes the task-oriented things are where I need assistance and a tech could fill that role, but not always.

For example, the other day, I had a patient who had fallen at the nursing home, and was stable (good BP, heart rate her usual 50's, O2 sats of 95%) when she went to x-ray. She came back from x-ray hypoxic, bradycardic, and hypotensive. Sats of 81% (!!!), HR 38, BP 95 systolic. Why? I can only guess it was the morphine she was given. She went over to x-ray while I was at lunch, and the nurse watching my pt. gave her morphine for pain before she went. That is the only thing I can think that would have caused a change in vitals -- she's 88 years old, so it must have been a reaction to the morphine, and she rolled back from x-ray with these changes when I had just come back from lunch, while at the same time, I got a new patient in the next bed -- 78 y/o male, sats 89% on a NRB @ 15LPM, tachycardia, fever, had been refusing food for a week, now had pneumonia (probably from aspiration), trying to go into the light. (Both of these two patients were DNRs, btw ... but I didn't want them to go, and at the same time, for crying out loud!) Then about five minutes later, rescue brings me another 80 y/o patient who initially looked not-so-bad, but whose sats were 88% on room air, coughing, fever of 103, weakness x 1 week ... yep, pneumonia. So I really would have loved the help of an RN to get all of these patients stabilized -- antibiotics that needed mixing/hanging for the pneumonia patients, close monitoring for the two that were trying to take a dirt nap, to put it bluntly. However, it was just me and my tech. And thank goodness for my tech that day -- he put a Foley in my 78 y/o male, did his EKG, then went next door and did two sets of cultures and the EKG on my other new pneumonia woman, while I gave a fluid bolus to my hypotensive/bradycardia woman (whose O2 sats came up nicely on a NRB ... it really must have been the morphine; however, she remained at a HR of about 38 to 40 until she left to be admitted to Tele). My charge nurse was busy helping the RN on the other side of the room, who was under a heavy patient load of her own (not as high acuity as I had, but I was managing).

I think it also depends on the scope of the techs. Ours cannot hang fluids, nor can they give meds; I know some places have paramedic techs with expanded scopes, and I'd love to see that -- fluids and PO meds, at the very least. Our unit secretaries rock -- they get all the orders put in, page docs, call x-ray, etc., in a very efficient manner. I'd rather give up a tech than our secretary, as much as it would increase my workload in the task area.

Lately we've been short in the tech department, so there have been days in a row in which we have no tech, or the tech has to be the secretary. We've found we cannot do without a secretary, but the place where we have more "give" is with the techs. The RNs can do everything the techs can do, for the most part ... we do have some RNs who claim that they cannot splint, no matter how many times they're shown how to do it. I'm self-sufficient in that area, having been a tech for nearly 4 years before becoming an RN.

Our optimum day, in my opinion: when we have a secretary, a tech, and an RN who floats, AND our charge is out of staffing. But due to budget cuts, we no longer have that float, and some days, if we're really short, our charge takes an assignment. And we may or may not have a tech.

Just for the record, I work in a 15-bed, freestanding ED. We don't have the resources of a hospital -- no anesthesiologists, no RTs, one doc, one PA who comes in at noon. We do zone assignments with 5 beds in each zone. Our minimum staffing is four RNs -- one charge, one in triage and the 5 fast-track beds, one in beds 6-10, and one in beds 11-15. Some days we only have 3 RNs, and the charge takes an assignment. Those aren't the best days. We couldn't have fewer RNs!! We'd be unsafe. We've cut RNs and NOT added support staff. Meh. I'd always rather have more RNs! But I know budget-wise, that isn't reality.

allnurses Guide · May 20, 2009

Its been shown that higher RN to patient ratios have better outcomes. "Freeing" the RN to do RN stuff by using that ratio means the RN will be doing less nursing and more staff management and supervision. Doing ADLs is when we assess skin, swallowing, respiratory effort during exertion, functional abilities, family interactions, responses to meds, etc. How is that not nursing or an RN responsibility? In the ER we only have a brief (comparitively) time to assess people. Calling xray? my secretary does that but often has to ask me for details, so that scenario of 1 RN instead of 4 means I would have to be totally up on the details of 4 patient loads instead of 1.

I now have techs and paramedics in the ER, and I can't really see that the paramedics have lightened my load or freed me to do more RN tasks. Nice to have the extra hands during traumas or codes, but on nights the paramedic usually is out in triage which gives me an extra nurse in the back (because we are chronically short staffed as it is). But her judgement of acuity level is questionable, I have to review her charts very carefully (I admit, this is just one person and most paramedics are not likely to have this problem).

GilaRRT · May 20, 2009

Its been shown that higher RN to patient ratios have better outcomes. "Freeing" the RN to do RN stuff by using that ratio means the RN will be doing less nursing and more staff management and supervision. Doing ADLs is when we assess skin, swallowing, respiratory effort during exertion, functional abilities, family interactions, responses to meds, etc. How is that not nursing or an RN responsibility? In the ER we only have a brief (comparitively) time to assess people. Calling xray? my secretary does that but often has to ask me for details, so that scenario of 1 RN instead of 4 means I would have to be totally up on the details of 4 patient loads instead of 1.
I now have techs and paramedics in the ER, and I can't really see that the paramedics have lightened my load or freed me to do more RN tasks. Nice to have the extra hands during traumas or codes, but on nights the paramedic usually is out in triage which gives me an extra nurse in the back (because we are chronically short staffed as it is). But her judgement of acuity level is questionable, I have to review her charts very carefully (I admit, this is just one person and most paramedics are not likely to have this problem).

I think you are on to something. When considering the latest and greatest idea, we as progressive professionals must look at the evidence. What does the evidence say about having less RN's and more UAP's? While the concept may sound good, what is the actual efficacy of this theory in practice?

Medic09, BSN, RN, EMT-P · May 20, 2009

Ditto to JBudd and Gila.

Direct, repeated contact with patients and their families has measured benefits (evidence) and intuitive benefits - for me and the patient both.

I would also be afraid that reducing the RNs and increasing support or non-RN staff would make communication and decision making unwieldy and potentially more risky. Now, when I want to adjust patient care, I can do so directly. If I need to talk with the doc, I do so based on my impressions and can carry on the conversation as someone who has been monitoring the patient over time. As it is, I often don't see things until a tech notices and notifies me. If I spend even less time with my patients, I have less clinical impression and assessment to share with the doc. So much clinical decision making is based on the nuanced considerations that are outside the data on a screen or lab printout.

I think I'd rather see us consider additional models of nursing education. We have several techs, for instance, who I'd really like to see become nurses. They already show compassion, intelligence, skill, and good sense. But they can't afford the time and money to go to school. Maybe we need to think again about hospital based nursing programs where we could somehow cover part of their educational requirements even while they're doing their work in the hospital? Isn't that how part of an MD's education happens?

Neveranurseagain, RN · May 20, 2009

RN's need to do total care as it part of assessing and caring for pt.'s as a whole. Calling the lab and XRAY reminds the RN to check for incoming labs and xrays, and also gives her the chance to review the orders for completeness. How many times has an RN gone to an MD and said, "Do you also want a ....to go with that lab or xray?" RN's are a check and balance that is needed in the health care system. Even fetching a blanket can trigger the need for a reassessment. Why does my pt. need another blanket? Is he now febrile? BP drop? Is he shocky and decompensating? By piece mealing out "tasks," the RN has less contact with the pt. yet is still held responsible for complete care, including supervising the tech's. With the model of "ONE RN, 8 techs and 2 secreatary", the RN will still be held accountable for overall care of up to 50 pt's!!!!

Altra, BSN, RN · May 20, 2009

This is an interesting and important question to consider - thanks for posting. I'm going to have to give this some thought.

Larry77, RN · May 20, 2009

Is it only me or have we been through this before? There is this cycle of less RN's more support staff for awhile until it doesn't work, then we get more RN's less support staff, then now it looks like they want us to go back...

Same thing with LPN's, we use them, then we don't, then we use them...

Anyone thought that maybe there isn't a "perfect" ratio and that it's just tough job, and we just do our best with what we have?

GilaRRT · May 20, 2009

Is it only me or have we been through this before? There is this cycle of less RN's more support staff for awhile until it doesn't work, then we get more RN's less support staff, then now it looks like they want us to go back...
Same thing with LPN's, we use them, then we don't, then we use them...
Anyone thought that maybe there isn't a "perfect" ratio and that it's just tough job, and we just do our best with what we have?

The difference being, EBM is now a standard way of basing our medical decisions. Why should it be any different with staffing considerations? When debating the optimal staffing solution, would EBM not be a proper way to objectively justify or disprove our theories?

Editorial Team / Moderator · May 20, 2009

What really bothers me is that patient acuity isn't a factor in determining our staffing. I was just saying this the other day -- there should be a weighted score based on acuity. As it is, a cardiac arrest has the same weight as a patient who comes in for suture removal. I think that is ridiculous. Since we use a five-level triage system, there SHOULD be a way to assign a multiplier to the patient numbers, like a Level 5 = 1, Level 4 = 1.25, Level 3 = 1.5, Level 2 = 1.75, Level 1 = 2. Because there are days where we might see only 40 patients, but many of them were heading for the celestial care unit, or needed moderate sedation, or were vented, one-to-one pts headed for ICU, that kind of thing. We need to see something close to 50 pts. in a 24-hour period in order to be "productive" at full staffing.

Does anyone out there factor acuity into their numbers?