What happens in your NICU when you are short staffed?

Specialties NICU

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Our unit has been chronically short staffed forever. However, lately the situation has gotten really,really bad. Last week the RN's had assignments ranging from 4 ICU babies each plus admissions to 8 special care babies without any NA/extern help. And I'm talking sick and tiny babies. And the charge nurses are often taking a full pt. load too. Fulltime nurses already have to work a mandatory OT shift. What does your unit do as an incentive to get nurses to come in when they know they will be slammed with a high pt. load/acuity? Do you have incentive or crisis pay? Do you use agency or travelers?

No offense Sparky, but I would not want to work there or have my baby there.

Specializes in NICU.

I think it'd be harder to have 8 babies in the newborn nursery than 8 in a Level II or step-down NICU. The 8 in the nursery would most likely be off monitors and PO ad lib, not to mention needing to go out to their mother's rooms, etc. I know that when I have 6 kids in our step-down area, at least all of them are on monitors. We also have at least two staff members (2 RNs, or 1 RN and 1 RT) in each area (12-14 babies) at all times. Plus you've got NG tubes and scheduled feedings in the NICU, with less PO ad lib kids, so you can at least formulate some sort of schedule for each shift. I don't think having more than 3 kids with IVs is safe, though, because sometimes that can take up so much extra time. Everybody does hourly IV site checks, I'm assuming?

One thing that really helps is not having every kid on the same exact feeding schedule. I know that on plenty of nights I'll have 3 q3h feeders, each due on a different schedule. It's great because only one baby is due each hour so I can spend plenty of time with that baby and its family while the others sleep. So even when I do have 6 kids, the chances that all 6 are due at the same time are extremely rare.

Specializes in NICU.

I can't believe you are talking about having that many babies to one nurse. 8:1 and 6:1! That's why we have Ratios in California. No more than 4:1 in the level 2, and 2:1 in the level 3. Usually we try to start with 3:1, then we have some leeway for transfers during the shift. Don't forget all the teaching we have to do, and the documentation that justs gets worse. I'd rather take the sick ones than the screamers who are feeling better and want to eat NOW. Preferably every two hours.....then the little sweeties sleep all day. Come night shift, they are back on the job!

To me, those patient loads are disasters waiting to happen. It's sad when management thinks that is appropriate, and I can't imagine any of them able to care for even two of those babies.

I don't live in Cali. but some of our nurses have no problems with calling the Department of Health in our state and if they come in and find unsafe ratios it's a 50,000 fine to the hospital so they are really good about making sure the assignments are safe.

Specializes in NICU.
I can't believe you are talking about having that many babies to one nurse. 8:1 and 6:1! That's why we have Ratios in California. No more than 4:1 in the level 2, and 2:1 in the level 3. Usually we try to start with 3:1, then we have some leeway for transfers during the shift. Don't forget all the teaching we have to do, and the documentation that justs gets worse. I'd rather take the sick ones than the screamers who are feeling better and want to eat NOW. Preferably every two hours.....then the little sweeties sleep all day. Come night shift, they are back on the job!

To me, those patient loads are disasters waiting to happen. It's sad when management thinks that is appropriate, and I can't imagine any of them able to care for even two of those babies.

I still can't believe that California is the only state to have safe staffing laws at this point. It seems that it should be a national thing, no?

We never start with 6:1 ratios, though. It's just that we might end up like that if we get more than 3 admits on any given shift. We are only allowed to have one admission nurse assigned per shift, but we do have a second nurse in mind when making the assignments anyways. It's when you get more than those two admissions that things get crazy. Since it's almost impossible to get extra help in the middle of a night shift, sometimes we have to make do until the morning. Again, none of these kids have IVs and all are on monitors in plain view of the nurses working in that area, and we always need the two staff members at all times watching these kiddos. As far as discharge teaching and things like that, again, this kind of shift is a once in a blue moon kind of a thing, so if for one night we don't get to do as much teaching, it's understandable. Actually sometimes the parents like it - if they've already given a bath with the nurses, they'll offer to do it themselves (they're in our eyesight, of course) and seem to enjoy having more independence.

Curious - what happens in California if you get like five or six admissions on one shift? Do they call in nurses in the middle of a shift to come in, get agency help, float from other areas? I just don't know how you can plan for that many surprise admits and staff the unit safely without pulling people out of bed in the middle of the night.

We do all of the above Gompers. We also have a transport nurse and a mentor nurse who are available to pick up assignments in addition to the charge nurse. On occasion we do get slammed with admissions and make do, but I have NEVER seen ratios like you and some others have described.

Specializes in NICU, Infection Control.

We had 1st, 2nd and 3rd admits. If they weren't busy, they could help in the intermediate nurseries. (In reality, if I had a baby that needed to be held or fed, I would just take it over there and hand it to whoever was sitting around.

I do remember a shift when we got 8 admissions/deliveries we had to attend and brought the baby back to the nursery in 2 hours! Another day, they admitted a singleton, twins, triplets and quads in a 12 hour shift! Nobody can plan for such an event. The charge nurse doesn't take an assignment, unless absolutely desparate! People do get called to see if they can possibly come in, and some do. Hopefully, the folks you help will help you some day.

Wow 8 babies. I can't imagine. Do you guys have techs? Our unit does and a while ago we really had to sit down and justify them being there or our director was going to let them all go. I'm glad she kept them around. I saw her point though, before we changed a few things they really didn't do anything but stand around all night (the director came around on several occassions and was very disturbed by this). Now they can take vitals, feed babies, prepare feeds for the next shift, help take babies to procedures (only if they are in Room Air), help out the unit secretary, stock the linen cabinets, draw labs (heelstick) on babies over 1000 grams, give baths, etc. It makes it nice to have them around. Our unit usually feeds all babies at the same time. We have an hour and a half to get the babies done. We give our babies 20-25 minutes tops to PO feed after that it's down the tube. When things get busy we have a charge nurse and a stabilization nurse that can help out with assignments (feed, start IV's, assess etc). Also the other nurses are very good at helping if their assignment isn't too heavy and they are done early. We encourage our parents to come around during feeding times so that they get used to being able to feed their baby long before they are ready to go home. The rare occasion that you have 4 babies usually it's only one or two people that have 4 baby assignments and usually if they have an NPO baby they will include it in that assignment or a continuous feeder. The worst it's gotten has been having a float that refuses to assess the babies, then someone may have to assess all the babies and give all the IV meds in the room (we have 9 babies per room) but the float will feed and do vitals. I'm finishing up my clinical requirements for NNP school now but I feel bad for ever complaining about my assignments. :uhoh21:

We occasionally will have a nursing student as an extern. She will be assigned to help with feedings and baths, stocking the supply cabinet, answering the phone and setting up admit beds. However, there is no one there on a regular, scheduled basis because of their school schedule.

We had 1st, 2nd and 3rd admits. If they weren't busy, they could help in the intermediate nurseries. (In reality, if I had a baby that needed to be held or fed, I would just take it over there and hand it to whoever was sitting around.

I do remember a shift when we got 8 admissions/deliveries we had to attend and brought the baby back to the nursery in 2 hours! Another day, they admitted a singleton, twins, triplets and quads in a 12 hour shift! Nobody can plan for such an event. The charge nurse doesn't take an assignment, unless absolutely desparate! People do get called to see if they can possibly come in, and some do. Hopefully, the folks you help will help you some day.

This happened here a couple of weeks ago...I guess the chg nurse ended up with 5 babe's herself...they were just too busy to call for help they said. But that's the most we've now ever had is 8 in a 12 hour period. --- broke my old record of 6 :(

Specializes in NICU, Peds, Med-Surg.

Wow....this thread has brought back some BAD memories. (and some great ones, too! :) .....I'm an LPN who used to work NICU, so I didn't care for babies that were very unstable, on cpap, vents, etc. but I did care for babies with UAC lines, under oxyhoods--grunting and retracting, RDS, mec aspiration, etc.......My WORST assignment was probably 5-8 babies---a few stable feeder/growers, a heroin withdrawl , and a baby under bili lights who screamed allllllll night long!

To clarify, the ONLY time I ever took care of more than 4 babies were the nights we had admissions, and I'd take over a baby or two for each RN who had to admit .......hey, when it's 3 am and there are 28-week triplets on the way, what are we gonna do?? :rolleyes: I have to say, we pitched in and DID work as a team, and I miss that sooooo much!

Can I also say that it made me laugh that for the six years I worked there, they wanted to go "all RN", but could NEVER get staffing, and the turnover on nights was BAD----so they continued to ask us "lowly LPN's" to come in all the time! Management acted like we were lower than pond scum most of the time, but as some of you may know, an experienced NICU LPN can be a great help! :) (even though I felt bad when an RN was already slammed and I had to ask them to hang my blood, TPN, and/or get my labs for me.....) But even though I couldn't do ceratin things, the RN's treated me like GOLD and I'll always remember that..... :p

We had the WORST nurse manager, and I kid you NOT---when they called her at home to tell her how horrible the staffing was, often times, there was NO response from her. The next day she'd say she lost her beeper or some other lame excuse.

When I worked in regular newborn (ahhhh, that was like a vacation! :p )......Honest to goodness, one night I had SIXTEEN babies all by myself......ALL the other nurses needed to be in NICU, and even my nurse aide called in sick. Being well newborns, you may be thinking they went to their mothers--------NOPE! That particular night, most of them stayed with me, and I assessed/ took vitals/ changed diapers/ fed, and charted on them the best I could. I did get feeding and changing help from some nurses and aides from other floors, but sometimes that's a pain because they are so intimidated by babies and are NOT happy to be working there! ....

The next morning, I saw my nurse manager (the same awful one from the NICU) and her smug expression made me sick as I told her how terribly UNSAFE it was for me to take care of 16 babies, I started crying my eyes out from all the stress. She looked at me with a blank stare and asked how my wedding plans were going...... ?????:angryfire I'm talking about babies choking and dying and how am I going to explain that to the parents, and her only reply is about my wedding???

Thank goodness she was fired, but not for about 2 more years............We all figured she either knew someone in high places or had some dirt on someone to have been kept around that long! :angryfire

Specializes in NICU.
To clarify, the ONLY time I ever took care of more than 4 babies were the nights we had admissions, and I'd take over a baby or two for each RN who had to admit .......hey, when it's 3 am and there are 28-week triplets on the way, what are we gonna do?? :rolleyes:

That's what I was trying to say earlier in the thread - it's one thing to START a shift with crappy staffing. It's another if things go crazy in the middle of the night - then you DO have to pick up more babies and work together as a team. I don't know of any hospitals that call extra help in, mid-shift, day or night. They just try to get more help for the next shift.

Specializes in NICU.

Curious - what happens in California if you get like five or six admissions on one shift? Do they call in nurses in the middle of a shift to come in, get agency help, float from other areas? I just don't know how you can plan for that many surprise admits and staff the unit safely without pulling people out of bed in the middle of the night.

We do almost all of the above, no agency nurses though. We have a supervisor on nights that makes phone calls, gets help from other areas of MCH, in the evening will call people at home. We have an admit nurse, goes to deliveries, c/s, checks babies on the floor to see if it's really a problem. Sometimes I'll bring a kid in for transition, and if it improves, it'll go back to mom/baby care. I'll do an admit, eg septic work-up, IV, first set of meds, and then turn it over to the nurse taking 1st admit. If another one comes along, or we have a delivery, it gets turned over earlier. Sometimes babies graduate to the special care nursery during the night, when we go crazy with admits. If we get a really sick one, that ends up on a vent and with lines etc. etc., I work with the nurse taking that admit until something else happens. Of course, there are nights (and days) when nothing goes right, and some nurses end up with four or five babies.

Right now, I'm off work, had shoulder surgery...and they have been very busy without me. It's nice to be missed!

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