Nurse: Patient ratios - page 4

Hi, I was wondering what kind of nurse: patient ratios you have in the ICU. Here in NM we try to stick to 2:1 (1:1 for the very ill), but I have also worked in TX where we routinely had 3:1 and in... Read More

  1. by   ratchit
    Thanks for the praise. <G> Never enough of that in nursing!!

    I have not been around as many blocks as other people, but I have been around enough. I was a bedside nurse for 9 years, about 5 of it as a traveler (so a lot of time spent at hospitals that had serious staffing and morale issues since hospitals with adequate and happy staff don't need travelers...) and about 6 of it in critical care.

    I just recently left bedside nursing. I was really sick of the games and fighting and the types of things you described- I was tired of awful schedules and having to fight for the staff, supplies, and even linens needed to take care of my patients. I hated the bed availability game- we KNEW we were going to get slammed and tried to get patients out but there were no floor beds.. Until a doctor wanted their patient in the unit. Then it was all frantic rushing and somehow the nurse's fault that the move wasn't organized. I got tired of being injured and tired all the time. I hated how pharmacy, transport, dietary, and maintenance got to dictate to nurses about nursing care. I wasn't completely burned out, but I was getting there fast.

    Sounds like you're at the point I was at a couple months ago with your job. You have superiors that think they know your job better than you. You can't help your subordinates out because you are being denied the resources. Your reasonable requests to your boss to look at what is needed for safe care are being dismissed out of hand. Is she seeing you as a manager or is she treating you as what she considers lowly staff?

    I think you have 2 choices.

    1) You can suck it up and count the days until you are hated and hate yourself for being a part of a system that abuses nurses and puts patients at risk. Or-

    2) You can go to your boss and say you will be going to her boss because you cannot in good conscience be part of care as your hospital currently provides it. Have numbers to back you up- typical ratios, other state's staffing laws and the increased risk with higher ratio studies that back them up. Maybe budget numbers that include the increased cost of recruiting and orienting people to replace those she has driven out, not just the cost of maintaining a 2:1 ratio. Then if she doesn't budge, go over her head. You have a chain of command; IMHO if things are that bad you are obligated to use it. Could you sleep at night knowing you could have prevented a bad outcome and didn't? Do you want to be on a witness stand saying "I was just following orders?"

    Sadly, you are likely to be fired for this. The hospital might say it is better to lose you than her since she is the bad guy for them... Or she might be in the same position you are, just a couple rungs up the ladder- the board may have told her how it will be and she is toeing the company line.

    You sound like a decent person to work for- but if the organization stinks from the top down, a manager in the middle can't fix it. I think you need to go to the top or get out.

    Of course, this is all very easy for me to say. <g> I was looking for a way out and only responsible for my own nursing care when I got a call offering me a job that treats me well, pays me fairly, and lets me work with nurses. I got really lucky.
  2. by   butterphlyrn
    I work in an icu in michigan. Or nursing rations are 2:1, unless a fresh post of heart, which in 1:1 for 4 hours or unless unstable, cvvhdf if always 1:1, and any patients on echmo (although we don't run the echmo a perfusionists stay at the bedside and it is only for our open heart patients if they can't get them off bypass). Some extremely sick patients have required 2 nurses and our unit has done that. Sometimes we do take three patients but only the ones that are awaiting stepdown beds can be tripled off. There has been times when we have done write up (that is what any complaint in my hospital is called) for unsafe patient practice when staffing is so short (To help save our licenses). that usually works and they seem to find someone to send us.
  3. by   Vikingnurse
    Wauw!! Our patient : nurse ratio is 1:2 in the daytime monday-friday - yes! that is 2 nurses per patient, and this is an MICU. The rest of the time it is 1:1, exept in the very critically ill where it is 1:2 24 hours all week.

    Mind you though, that we are NOT all intensive care nurses - about 50% of the staff is IC nurses, the rest do not have the 2 year IC education - but a thourough training program (4-5 months). But here it is more a title than anything else (and a bigger pay check). There are no difference in the type of patients you have.

    Vikingnurse
  4. by   healingtouchRN
    I would like to be your patient Vikingnurse! I can't imagine all the attention! Wonderful!!! kudos to your facility! :hatparty:
    Quote from Vikingnurse
    Wauw!! Our patient : nurse ratio is 1:2 in the daytime monday-friday - yes! that is 2 nurses per patient, and this is an MICU. The rest of the time it is 1:1, exept in the very critically ill where it is 1:2 24 hours all week.

    Mind you though, that we are NOT all intensive care nurses - about 50% of the staff is IC nurses, the rest do not have the 2 year IC education - but a thourough training program (4-5 months). But here it is more a title than anything else (and a bigger pay check). There are no difference in the type of patients you have.

    Vikingnurse
  5. by   lyndac918
    I also would like to commend Vikingnurse's organization on recognizing acuity and patient safety. Im moving to Norway.
    Id also like to say "Hi" to Sue and Lisa who told me that they have seen my questions and responses on here. Stick with it girls...things will get better!!!

    Quote from healingtouchRN
    I would like to be your patient Vikingnurse! I can't imagine all the attention! Wonderful!!! kudos to your facility! :hatparty:
    Last edit by lyndac918 on Apr 28, '04 : Reason: misspelling
  6. by   Vikingnurse
    I must say I am extremly happy with the focus we have on nursing here, allthough I miss my old unit in Denmark (1:1,7 ratio). Even though we are 2 nurses we often find time to short..... so there MUST be a catch somewhere. Because I can NOT imagine how 1 nurse could manage 2 or 3 patients.
    You must have alot of support from others, like fysiotherapists and so on.
    We are nothing but nurses in our ICU - well we have our physisians...
    Could you please try to explain a typical day - if you can have one of those in an ICU..
    How do you mobilise your patients? how often? Do you have step down units to take care of the patients when they are off the ventilator....?
    Last edit by Vikingnurse on Apr 28, '04
  7. by   healingtouchRN
    last night on 3rd shift) I took 2 patients. Both on vents (one trached & one intubated & on contact isolation for draining foot wound). Both were not really the most responsive, but did have gag & cough reflexes. So I hung new drips & tubings, changes site dressings, total bathes & turning every 2 hours ( I ask for help to push a pillow wedge behind). I document on these in our computer, & since I am in charge of all the nurses in my 12 bed CCU, I had 5 RN's (one of whom floated from a telemetry floor, so she "couldn't" take vents or balloon pumps. So the "real" ICU nurses pick up the slack & give her the stable patients.). I make assignments & then do the chores of checking drug descrepancies, check staffing for the next shift & make those assignments, & play housekeeper...we all get to clean up the dept! We also draw blood for morning labs, check the next days MAR's & do 24 hours chart checks to make sure we haven't missed anything. We have no tech or secretary so we do it. What do you think?
    QUOTE=Vikingnurse]I must say I am extremly happy with the focus we have on nursing here, allthough I miss my old unit in Denmark (1:1,7 ratio). Even though we are 2 nurses we often find time to short..... so there MUST be a catch somewhere. Because I can NOT imagine how 1 nurse could manage 2 or 3 patients.
    You must have alot of support from others, like fysiotherapists and so on.
    We are nothing but nurses in our ICU - well we have our physisians...
    Could you please try to explain a typical day - if you can have one of those in an ICU..
    How do you mobilise your patients? how often? Do you have step down units to take care of the patients when they are off the ventilator....?[/QUOTE]
  8. by   critcarenurse16
    Our ICU/CCU staffs 2:1 or 3:1 if stable. 1:1 for any very critical pt. We call in an extra RN ad lib when we have many critical pts.
  9. by   heart queen
    'been there done that have stock in the T-shirt market. Did asistant management where the bottom line HWPPD was GOD, work 'em harder longer to the max, each shift. ='d BURNOUT, callin's, quitting. no one learned, heard or cared to listen, the manager had to delegate it or quit to a new person who would play that game. I worked 70 hrs. a week staffing to lighten the load but that gets old fast. Non union.

    I have had WAY too many nights with 4 instead of 5 nurses. Being the only senior staff, in charge, with the heaviest assignment... had to be done or the newbies would tripple and drown, only to have to watch out like a hawk for the other 8, plus precept on one of my crashing patients....

    have the ulcers for proof. not the managers fault, she couldn't staff, lack of skills, and no one (BURNOUT) would come in extra to help. a vicious cycle.

    In fairness, the hospital closed beds when they could... but if you're full when you walk in already short staffed, no one can transfer and three of ten are on their heads... the manager can't staff.... to quote her "do the best you can".

    A few times we signed "assignment under protest", a few times we, or the staff refused to accept assignments. the paperwork only created the spanish inquisition that exhausted an already exhausted staff... which only cleared admin. in the end, making no changes in policy. Refusing the assignment, with no relief in site, just kept day shift there until night shift relented, days had already been through battle, were exhausted and no more staff would come, no patients to transfer out. The paper can't save our butt in a lawsuit because your licensing board says "just say no". but it's not that simple.

    so, long story short, I take usually the sickest two vents, so I can't get a third which is guarenteed to two other nurses. one of the two should be a 1:1, plus the other 2 ptient assignment should usually be a 1:1. Plus I've paired balloon pumps, or taken a fresh pump with a septic shock maxed on a wall of drips, each equalling a 1:1.

    It's easy to say just quit but there are no other options for employment but 75 minutes away. So I quit and moved 700 miles away, and things are better.

    Morale, many are still stuck in this battle. hindsight tells me, each shift needs to say NO. Nights or days can't relent until the manager and her boss come in at 2am, each night or no assignments will be transfered 'till the next shift. ONly then will it stop. But you need all the staff to support this, that means US!

    Sorry for the tirade, the wounds are still fresh. thanx for at least listening.
  10. by   lyndac918
    I am the manager of an ICU and I do come in and work the units...Day shift, night shift, weekends and holidays. But it still doesnt change because my boss isnt forced to come in and face the problems. I have worked ICU for 17 years and the last 2 as manager. I cant even get my boss to realize that there are 1:1's in ICU. Her background is med-surg and case management. I have told her she needs to come in and take care of a AAA and vents, a septic shock and lets add a Detox patient to that mix. Because, until you have lived it, you have no idea.



    Quote from heart queen
    'been there done that have stock in the T-shirt market. Did asistant management where the bottom line HWPPD was GOD, work 'em harder longer to the max, each shift. ='d BURNOUT, callin's, quitting. no one learned, heard or cared to listen, the manager had to delegate it or quit to a new person who would play that game. I worked 70 hrs. a week staffing to lighten the load but that gets old fast. Non union.

    I have had WAY too many nights with 4 instead of 5 nurses. Being the only senior staff, in charge, with the heaviest assignment... had to be done or the newbies would tripple and drown, only to have to watch out like a hawk for the other 8, plus precept on one of my crashing patients....

    have the ulcers for proof. not the managers fault, she couldn't staff, lack of skills, and no one (BURNOUT) would come in extra to help. a vicious cycle.

    In fairness, the hospital closed beds when they could... but if you're full when you walk in already short staffed, no one can transfer and three of ten are on their heads... the manager can't staff.... to quote her "do the best you can".

    A few times we signed "assignment under protest", a few times we, or the staff refused to accept assignments. the paperwork only created the spanish inquisition that exhausted an already exhausted staff... which only cleared admin. in the end, making no changes in policy. Refusing the assignment, with no relief in site, just kept day shift there until night shift relented, days had already been through battle, were exhausted and no more staff would come, no patients to transfer out. The paper can't save our butt in a lawsuit because your licensing board says "just say no". but it's not that simple.

    so, long story short, I take usually the sickest two vents, so I can't get a third which is guarenteed to two other nurses. one of the two should be a 1:1, plus the other 2 ptient assignment should usually be a 1:1. Plus I've paired balloon pumps, or taken a fresh pump with a septic shock maxed on a wall of drips, each equalling a 1:1.

    It's easy to say just quit but there are no other options for employment but 75 minutes away. So I quit and moved 700 miles away, and things are better.

    Morale, many are still stuck in this battle. hindsight tells me, each shift needs to say NO. Nights or days can't relent until the manager and her boss come in at 2am, each night or no assignments will be transfered 'till the next shift. ONly then will it stop. But you need all the staff to support this, that means US!

    Sorry for the tirade, the wounds are still fresh. thanx for at least listening.
  11. by   Vikingnurse
    I sounds like you work REALLY hard - my deepest respect for HealingtouchRN, Heartqueen and all the others. It isn't because we don't work hard here, but yes! we have a lot of time for our patients and I really enjoy my work when I know we have made a good days work - without having to use ALL our resources... I can only try to imagine the kind of workload you all have. Plus I know you US nurses have much more documentation than we do, and thus more time wll go from the patients.
    Iyndac918 I'm sure you will be more than welcome here in Norway or Denmark for that matter. Just remember the salery is lower and the tax is higher. In Norway 36 percent, and most things are very expensive food for example. Well in Denmark you pay 45 percent tax (allthough it is about to fall a bit), but it is much cheeper to live here, and all healthcare is for free
  12. by   a_clay
    Quote from burt
    At my hosp in Dallas, we routinely have 2 patients each with a floating charge nurse. This is a surgical, trauma, neuro, OB ICU. Lately, things have been extremely busy with acuity sky high. We have had several patients who should have automatically been 1:1 because of CVVHD, multi gtts (8-10) double lumen ETT with bilateral vents, etc. Management would place an "easy" patient next to one of these very sick patients. Needless to say, the easy patient got very little critical care-we were lucky nothing bad happened. Most of the time we do a great job with the staffing situation we are given and mgt. counts on it. It takes a nurse with guts to stand up and say no, I will not accept such an unsafe assignment. Of course, that nurse always gets labeled and we hear such statements as "all the other nurses were able to handle the assignment, why can't you" I am so sick of seeing fellow nurses made to feel bad, inadequate, etc. I will always stand up and say no to any unsafe assignment given to me and support such a stand in others. We should not let ourselves be forced to put patients or our nursing licenses at risk!!!
    Burt,

    Which Dallas hospital is this? I am in Dallas and I sure don't wanna be at that place.

    Amy
  13. by   suetje
    Quote from blueskatkimmy
    (cont) we need to start standing up and saying NO!! The hospitals and managers aren't looking out for our nursing licenses. When i accept that pt, i am responsible and i'm putting my license on the line---administration doesn't care. All they do is support the budget. Well, my license supports my budget and puts food on my table, so i have to take care of myself. Incidents reports are good for reporting unsafe conditions--do we do it? No, we'll be labeled as the trouble-makers. I've decided i would rather lose the job than to lose my license, cause i can always get another job! They just don't GET IT-- sometimes the workload is IMPOSSIBLE--IT CAN'T BE DONE!!! Then if you are really lucky, you get that nasty 'ole nurse to follow you who rolls her eyes and starts stomping around and huffing and puffing because you had to leave things undone. It's a no-win situation!!! We need to give each other a BREAK!!!! So, as i drag my bedraggled butt home after 12 hours of pure frustration and rage from trying to do the impossible, i wave good-bye to the CEO, AS HE DRIVES OFF IN HIS JAGUAR. You know the one, the one that keeps telling you that that hospital is broke and may have to close down in 2yrs, so we need to tighten our belts and they need to lay off staff or there will be no raises this year!!!! I'M NOT STUPID!! I can see the incongruencies and lies. What drives me crazy is that many nurses don't. WHY??? I think they are just caught up in the whole system of denial and enabling and helplessness. Do any of you nurses out there also see this??? disillusioned!!
    Right on! If you don't speak up, you only have YOU to blame! If I have a double (or a triple, which is rare) and one pt. goes bad and I know I am not watching the other one, I let the charge nurse know that I need them to intervene. I review legal cases in my 'spare' time and believe me, if you knew you liability by simply accepting the assignment even tho you can't do it, you are still at fault. I don't care if they get mad, it's MY license!

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