being railroaded by management

  1. so, here's the situation. 16 bed intermediate intensive care unit with 5 of those hard-wired beds usually occupied by ICU patients-fresh vents, drips, art lines, etc. --all tele. monitored-----high aquity--you get the picture. In the last 3 weeks several highly paid executives got the axe- including VP of nursing--an IICU ally. Now the manager has made a blanket statement that 4 nurses per shift irregardless. and she's not about to budge, and we have no-one to complain to that will get us immediate attention to this issue.
    what do we do? give me some ideas you guys? we are providing substandard care at best, negligence at worst, standards of care are obsolete, next- patients will suffer.
    I'm the most experience nurse at 15 years and they have hired 9 GN's that are now interning!
    the staff looks to me as a solution provider, but I'm not sure where to start on this one.

    P.S. the manager is a nim-whitt---first time managing
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  2. 11 Comments

  3. by   P_RN
    This is not an exact comparison with your situation, but when our floor started with acute and chronic pain management in 1992 we had similar questions. We asked the Board of Nursing. They issued a statement about the staffing, training and types of patients. Since this was a fairly new inpatient concept, we were limited in the number of patients. We also had to have formal training, not just on the job training. I would suggest you and others concerned contact the Board.

    As far as the manager....I don't know. Perhaps she is only trickling down MESSAGES from the powers that be!
  4. by   Jenny P
    Maybe AACN could give you standards of care for ICU. The State Board of Nursing would be the best place to start; then the Dept. of Health, JCAHO, and any other regulatory body you can think of. How about risk management for your hospital? Or try mass resignations-- the public needs to be aware of this.
    Somehow 4 RNs for 16 beds is not any type of ICU staffing that I've ever heard of. Could you get the manager to come and do patient care once with that type of staffing? (Giving her 4 heavy patients just may change her mind, maybe).
  5. by   OC_An Khe
    Wildtime
    Simply put two wrongs do not make a right. Both the national standards and the new JCAHO standards put this level of care as substandard.
  6. by   Janet Barclay
    Hey Wildtime,
    It's not a competition!
    I would never downplay how hard emerg nurses work and the heaviness of their assignment. Several friends of mine have floated between emerg and ICU, so I hear the stories.
    First, correct me if I'm wrong, but your five or six patients plus the hallway are not all ventilator dependant, and hemodynamically unstable on multiple inotropes. (don't get me wrong, not all patients in ICU are like that either, that's why we can take more than one patient). In my institution, they would never float a PA catheter, run hemo, or CRRT in emerg. None of my ER friends have ever had to accompany a Doc to a one hour family conference 'cause the family needs extra information or emtional support. The patients that sit in emerg because of a lack of ICU beds generally don't get a q4 (or better) head to toe assessment simply because the numbers of nurses can't support that.
    We do different jobs, in different areas, with different types of patients. If you think that we sit on our butts for 12 hours then I'd suggest you do a shadowed shift in the other area.
    Any ICU nurse that thinks emerg nurses (or any other area) don't work had should walk a mile in their duty shoes
    Peace, Janet
  7. by   -jt
    <we have no-one to complain to that will get us immediate attention to this issue.>


    First of all it is not "complaining"! It is expressing your serious concerns as a professional regarding the situation you and your pts have been put into. (Immediately changes the connotation when you do not use that whiney word "complain".)

    I take it you are not unionized. Too bad. But unless you are not in the USA, you still have places to turn to get some attention to the problem - the State Dept of Health, the State Board of Nursing. DOCUMENT DOCUMENT DOCUMENT - keep a journal on pts & MR #s, acuities, situations that are unsafe. And keep it to yourself! Also put your concerns in writing with letters to the unit manager, her supervisor, the hospital's CEO, the hospitals Board of Directors, the hospitals Risk Management Dept (so the lawyers can get on their case about liability).

    Since you dont have union protection, dont take this all on yourself - it might be dismissed as just one disgruntled old nurse & you could be targeted as a "trouble-maker" who needs to be dealt with. Instead, get the entire RN staff of that unit to sign the letters & keep copies for yourself. If you get no response, there is always your community's newspaper, local news channel, the list is endless.

    Keep in mind that nurses are held to a Code of Ethics & a state Nurse Practice Act that obligates you to prevent harm to the pt and report that which may be unsafe for them. Doing nothing when you know pts may be harmed unless things change may be deemed unprofessional and unethical & can leave you liable and open to discipline on your license if something happens. The excuse "We had no one to complain to" will not help you in that event. This is why it would be important to notify you state Board of Nursing of what is going on there - maybe annonymously too.

    Staffing for an ICU should be no more than 2:1 pt:RN ratio. They are getting by with the 4:1 because they call your unit an Intermediate ICU. You need to keep a record of pt's - including Medical Record # & dates, pt assignments, acuities, treatments, procedures, & pt situations to prove that you are not functioning as an Iintermediate ICU & these pts can really be classified as ICU pts. You need documentation to show that the acuity calls for critical care ICU staffing ratios & not Intermediate staffing ratios. You cant just "complain" without backing up your concerns with fact.

    In the meantime, you can call the State Dept of Health - even annonymously - give them a few pt names, dates, & circumstances that you felt were unsafe for them & let them start their own investigation, while you start keeping a detailed record.
  8. by   -jt
    the nurse can not take report because they are too busy with their 2 or 3 to 1 assignment or they refuse to take a patient in an empty bed because they do not have enough staff.>>

    Good for them!! Thats what should be happening instead of unsafely bringing a new pt into the ICU when there is no one to care for her. Do you see what you are doing? Typical nurse behaviour that has gotten us into this mess......

    Instead of turning on each other, direct your anger to the real culprits - the administration that is keeping your staffing below what is needed - & do something pro-active to get the staff you need. Fighting with each other & hurling the horizontal violence at one another just absolves the administration of its responsibility to provide appropriate staffing levels & lets them just use peer pressure to put even more on the already over-burdened nurses in both units. Your work is different than an ICU RNs work. Just because an ER ratio is different from an ICU ratio does not mean anyone is working harder or better than someone in the other unit. If the nurse says she cant take the pt at that moment because of what else is going on in the ICU, accept it as her professional judgement to know what is safe. You are not in her unit to see what they are dealing with at that moment.

    Yesterday in my ICU, we had a pt having emergency cardioversion, another being intubated, another appearing to be having a PE..... the ER was calling & the PACU was calling to send admissions. We said Sorry, not right now. Those pts had to wait at least another hour until things settled down & they could get the attention they needed. We took the ER pt first & the PACU pt stayed right in PACU till the next shift.

    If that kind of thing causes you a hardship in your ER, instead of attacking the nurse, do something to get more ER & ICU staff cause its obviously needed.
  9. by   beckymcrn
    We had a similar situation on our unit. I did work on an busy oncology unit. The staffing was changed because of man hours. We spoke to our supervisor and explained why this would not work, a few of the night shift threatened to quit. However the thing I think made the most difference was one of our doc's. He is a very outspoken and influential doc in our hosp we c/o to him telling him the "powers that be" wanted to leave "1" nurse alone on the unit with 6 pts on the night shift and he spoke to them in our behalf.

    The staffing grids were ultimately changed.
  10. by   Mijourney
    Hi. Is this manager a nurse? If so, it's really disheartening to see nurses in management that end up being nothing more than "sellouts." These people get into management, they get their agenda from people above them, and they don't question it. Patients and staff alike suffer greatly. These managers turn a blind eye toward the staff as long as they feel they're getting an endorsement from higher ups. I agree with the previous posters recommendations regarding the state boards, other accreditation and licensing agencies, standards, and hospital policy. Best wishes.
  11. by   momfirst
    Amen, jt!

    Adequate staffing is a problem almost universally, but that reality doesn't mean that we should just accept it, nor criticize those nurses that are trying to maintain safe conditions...If it was you or your family member that needed to be stabilized in ICU, I'm sure you would be behind those nurses that make sure you are stable before spreading thin the care and accepting more patients.

    I empathize with wildtime88 regarding the heavy workload faced in the ER. It sounds like you are doing the best you can, but maybe feeling underappreciated and overworked.

    Reality is what we allow it to be. If all we do is complain and blame other nurses, nothing will change. The administrators and higher-ups will continue to abuse and overwork nurses. We need to direct our concerns to the appropriate people, and remember that we are ultimately responsible for how we are treated.

    The bottom line is patient safety and advocacy. If we don't work for that, then why be nurses?
  12. by   prmenrs
    I have some ?? re: the original problem. [if you think I'm getting into that er vs icu thing, you're mistaken]
    Do you have a medical director for your unit? Is s/he aware of this situation? Can they support you and your staff?
    Do you have any kind of acuity classification system that you are using? If you did, the numbers would support your staffing.
    Have there been any errors? Meds, treatments missed, orders not done, labs not phoned back or reported to the MDs? Have there been any "near misses"? If so, be sure that an Incident report [or whatever it is in your hospital] is used to document the problem. In our hospital, they are called "quality variance reports" and whenever something happens or doesn't happen that causes the care the patient and family receives to be less than what the "core values" of the institution state, we fill them out. That makes someone accountable--even if that "someone" is staffing--or lack thereof! We fill them out all the time--if pharmacy doesn't bring a med on time, if equipment doesn't work, if the lab screws up, if a patient's d/c is delayed. One of our managers then has to follow/up, and decide what needs to be done, sends it to the other department for eval, and eventually risk management gets it.
    Sooo, this manager that is trying to limit staffing without taking acuity into account could wind up with a LOT of incidents to explain to someone else! Seems like it would be easier just to staff the unit correctly!!!

    Good Luck!!
  13. by   Rita Marie
    Although I live in a fairly small community (about 100,000 in the whole county) the physicians here have really been helpful during times like the ones you describe.

    Is it possible that the doctors can put pressure on the administration to provide more complete coverage on your unit? I am not sure how they have done things here, but I know our docs have made administration sit up and listen from time to time.

    It is truly an amazing thing to behold!

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