Set Up For Failure

I work at two rehab nursing facilities. One is a pleasure to work at, the other not so much. My day-to-day responsibilities, the average patient acuity level, and the charting systems are the same. It all seems to boil down to the nurse-to-patient ratio. How do we advocate as nurses for patient safety when administration does not want to increase staffing? Nurses Announcements Archive Article

Set Up For Failure

I have been a nurse for two short years. I chose to work as a rehab nurse instead of a hospital nurse for the time being because of the job flexibility (PRN) and to work days/evenings right out of school. Yes you caught me, I am trying to avoid night shift at all costs. I did it for a few months in nursing school and became a terrible version of myself. So here we are!

I work as a rehab nurse in two different sub-acute facilities. In terms of the amount of despair I feel in a given shift, these facilities seem like night and day.

At Facility A I work with approximately 10-12 patients in a shift - passing medications, hanging IV's, providing wound care and other treatments, performing head-to-toe assessments, educating patients and their families, contacting doctors and pharmacy as needed, and of course, documenting. I have 1.5 CNA's for the 10-12 patients (three total for 20-24 patients).

At Facility B I have two CNA's and I work with 21 patients. I have the exact same responsibilities and as far as I can tell I have patients with similar acuity levels. That seems reasonable!

At Facility B I have spent just about every shift feeling extremely overwhelmed. On a recent evening shift I cared for three high fall risk patients - alert and oriented only to self and agitated, with no sitter in sight - seven insulin-dependent patients, three patients with IV antibiotics, one with TPN, and several dressing changes. This along with one to three admissions, passing medications for 21 people, assessments, and talking with families - it's no wonder I'm feeling close to entering burn-out land.

I am providing what I believe to be sub-standard care, which at times can be downright dangerous given some patients' acuity level. I have talked with multiple people in administration about this issue and wrote an email to the DON on the subject (mostly so it could be in writing - hey, C.Y.A), but it usually comes back around to money (no surprise).

If nothing else, poor staffing feels like a set-up for failure.

And you know what poor staffing leads to? Poor staff. I was "trained" over four days as a new grad which consisted of shadowing whichever nurse was on the schedule for that day, whether they were fit to train a new RN or not. I worked with a great nurse and more than one crappy nurse. They exist everywhere, right? Well this sort of environment only serves to accentuate the crappiness. Lots of short cuts, lots of charting that something was done when it most certainly was not, and lots of really bad attitudes with a side of lashing out at patients.

It's no surprise that nurse turnover at Facility B is high - with a staff of about 15 nurses I see a new nurse being trained once a month. Some just don't come back after a few days on "orientation".

In a 2007 Rehabilitation Nursing article, the authors discuss the consistent pattern of research results showing that higher RN staffing levels are associated with a higher likelihood of discharge to home, decreased adverse events, higher functional status, and lower mortality rates for patients (Nelson et. al. 2007). Yes, this is obvious right? At least to a point, more staff should equal better patient outcomes. How can two seemingly similar facilities be so drastically different on this point? I know that there is a whole financial piece I am missing, but how much would it cost to staff a float nurse between 42 patients (Facility B has two floors) each shift relative to the gains made in patient outcomes?

This isn't just a rant about my job. Every job has its ups and downs, and many nurses across different specialties are spread thin. It's about the staffing contrast between my two jobs that I experience so acutely, and how it can affect patient outcomes.

I don't plan to stay forever. I have my sights set on becoming an ER nurse. For better or worse, working at Facility B has drastically improved my time management and prioritization skills. And of course it has given me perspective. As a previous bright-eyed new grad having done all of my clinicals in a magnet hospital, this experience has allowed me to see the depths of nursing I didn't know existed. Which, if I don't stay long enough to acquire bad habits, will serve as a useful professional and personal life experience.

Sources Cited

Nelson, A. (2007). Nurse Staffing and Patient Outcomes in Inpatient Rehabilitation Settings. Rehabilitation Nursing, 32(5), 179-202.

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rehab_nurse

About rehab_nurse, LPN, RN

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Specializes in Utilization Management.

I just wanted to clarify: Do you work in subacute rehab or inpatient rehab? There is a difference. The ratios for inpatient rehab are typically much lower, like anywhere from 6-12, depending on the facility. Subacute ratios can be anywhere from from 15-??, again, depending on the facility. You are right though, unfortunately it all does come down to money.

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Specializes in Emergency Nursing, Pediatrics.

That's completely typical for rehabs.

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They are both subacute.

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