Who decides which patient you'll be assign to?

  1. I just had a "discussion" with the dayshift staff nurse about the patient-nurse assignation. I wonder what you think of it...

    I work nightshifts in a 24 beds ICU. Our ratio is 1:1 or 1:2 for medical, cardiosurgery and trauma patients and 1:3 for cardiology patients. All those patients are on the same floor, in the five rooms of the ICU. So, the staff nurse decides which room I'll be in and the choice of which patient(s) I'll take care of is mine within this room. If I was there yesterday and my patient is still there too, he'll be my patient. The remaining patients are assigned by a draw among the rest of the nurses, onless one wants a particular patient or don't fell able to take charge of one (ex: new nurse with very unstable trauma...)

    Now, this staff nurse was horrified by this "drawing" thing stating that it was very unprofessionnal and unrespectful for the patients.

    But we never did this in an unrespectful way (we don't draw patients in front of them!)
    Our staff is very young (3 years or less of experience as nurses) or "old" (10 +). This way of assigning permits that very heavy patients are not always taken care of by "old" nurses, that confused or unpleasant ones are not always taken care of by nurses who just can't say no, and that every nurse can take care of the wide diversity of patients the unit has, not just the ones who "interests" her/him the most. It's like an unwritten rule but it has been working well ... and I personnally don't see it as a bad thing.

    What do you think?
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  2. 14 Comments

  3. by   SharonH, RN
    Weird, I've never heard of such a thing. Ideally, the charge nurse assigns patients based on acuity and the skill level of the nurse. In reality, patient are based on who had the "team" yesterday, who *****es the most about their assignment, etc.
  4. by   canoehead
    Charge from the previous shift makes the assignments, although if you've had a toughie for a couple of days you can request a break. All requests are taken into account, along with the skill levl and acuity.

    Where I trained in nursing school the assignments were based on room, so med nurse got room 1 and 2, LPN room 3, 4, 5, RN got 6, 7, 8, etc. It was interesting.
  5. by   deespoohbear
    Our assignments are broken down by the way the patients are distrubited on the unit. If you worked the day before, you should get most of the same pts back. Occasionaly one of the nurses will want to trade a pt before the shift begins because they are related to that pt, had bad experience before with the pt, or they just plain need a break from a pt (or more likely a family. ). We usually don't have an arguement over the assignments. If there is an unstable/very sick pt on the floor the supervisor will try to put one of the more skilled and knowledgeable nurses on that group. In my experience the nurse with the most years or the most seniority is not always your strongest nurse. The previous shift supervisor makes out the assignment sheet. Hope this helps answer your questions.
  6. by   MollyMo
    The charge nurses come in 15 minutes early to get report from the off going charge. She then makes assignments based on whether or not the nurse was there yesterday and wants the same team back; they try to divide high acuity patients between everybody(doesn't always work). You also have to take into consideration empty beds and it you have admits or transfers coming. If your drawing works,if it's done fairly and not done in front of the patients, do it. Let something about your shift be easy.
  7. by   OBNURSEHEATHER
    We make our own. We gather in the report room in the morning and divide the patients up before we listen to report. We'll take into consideration first continuity. Then we divide up things like day of sections, 1 day sections, high acuity, etc.

    Kinda sounds like a poker game in there. "I'll give you my gestational diabetic on q4 hour accuchecks for your new section on triple antibiotics..."

    Heather
  8. by   Dazedgiggle
    On our unit the charge nurse on the previous shift assigns patients and takes patient acuity and nurse experience into account. I don't think there's anything wrong with your method, RoadRunner...it sounds like everyone is satisfied with it and it sounds fair. What I think is unprofessional is a nurse who complains loudly about what they think is an unfair assignment! (This happens often where I work, and the assignment is usually really not unfair) I think you should keep doing what you're doing!
  9. by   Zee_RN
    18-bed Intensive Care Unit. Charge Nurse has no patient assignment. The charge nurse from the outgoing shift makes the assignments, taking into account who was there the day before (and whether they wanted their patients back or not) and the patient acuity. Works out pretty well. Sure, some people still bytch but you're never going to please all the people all the time. For the most part, it works out. Sometimes when we report off to oncoming shift (12-hr shifts), we'll tell our replacement if we do or don't want our assignment back if we're coming back the next day. If it's possible, they always try to honor our request.
  10. by   rebelwaclause
    We work off of PCH scores. The nurse who was the caregiver on the shift prior (PM's for me) determines the patients acuity by how much nursing care, acuity of care, etc was provided and is still needed. Each intervention is given a certain amount of points, for example, Pain intervention = 0.5 points, 1-5 med trips = 1.0, 6-10 trips = 2.0; Simple dressing change = 1.0, moderate dressing change = 2.0, etc; Patient feeds self = 1.0, fed by staff = 2.0, and a host of other interventions like IV drips, PCA's, the ability to ambulate self, etc..... (I'm sure my scores are not correct - just giving you an example). They enter the information in a system that fields are prompted, and a PCH score is generated. A normal PCH is around 10.4, a high one can be around 24.5, low 7.4. The higher scores usually are when a patient is assigned a CNA as a sitter in place of restraining them.

    With the scores, the assignments are generated. Everyone is given a fair share of patients from low to high acuities.

    As a LVN, I'm usually assigned a higher PCH score and extra patients because a RN covers my IV abx's and initial assessments with care plan if I have an admission. I try to take extra patients to free up my RN's from having to do patient care on their assignment AND cover me.

    By the way, since its impossible to make everyones assignment the same total PCH score, the person with the lowest score accepts the first admission, second goes to the person with the second lowest score and so on.

    Its not perfect, but its the fairest we've got so far. When it doesn't work is when nurses try to manipulate the system so patients with actual high PCH's look like they are low care, and get assigned to an unsuspecting nurse who also has to take the first admission or more patients, AND possibly cover a LVN. This usually happens when the assigning nurse is attempting to "hook up" a "nurse buddy" who is coming on shift, or dog someone they have it in for. Rare, but still happens.
    Last edit by rebelwaclause on Oct 7, '02
  11. by   whipping girl in 07
    It sounds like all the ways to make assignments sound pretty fair, and that's the point. I work in a (supposed to be) 14 bed ICU. Our fresh CABGs are 1:1 until extubated, balloon pumps are 1:1, and we have a sheet to fill out to make a patient 1:1 if they meet certain criteria (doesn't do you much good if you don't have enough nurses to make that patient 1:1 though). Organ donations are also 1:1 (since the OPA is paying the nurse's salary for the shift). We generally get back our assignment from the day before (unless we need a break from patient/family). We also make assignments based somewhat on geography (we try not to give 1 and 10 to the same person ) and on acuity. Sometimes a nurse will say after a particular assignment that those two patients together were just too heavy and we'll split them for the next shift, even if according to acuity they add up to being an equal assignment with another pair. The charge nurse makes the assignments but takes input from the staff. If the charge nurse is particularly busy, someone else makes the assignments. If we have to use pull or pool nurses, they get the "lightest" patients, and we don't leave them open for first admit. When we have new nurses just out of orientation, we give them "light" patients for awhile so they can get their wings, and then after they are more comfortable leave them open for first admit so they can get experienced with admissions.

    Of course, when day shift comes in, sometimes they change it. Can't please everyone.
  12. by   Nurse Ratched
    It depends on who is charging. First, we do our own assignments on our own shift. I'm fascinated by the previous shift making assignments for the oncoming shift. I wonder what the logic is?

    A lot of the charge nurses try and assign the same patients to the same nurses for continuity of care, but then if a nurse is on who hasn't been there for a couple of days, she by default gets the newer and more critical patients, while the nurses who have been there are getting the folks who are improving, becoming walkie-talkies, etc.

    I try and go by who nurses have had previously, but also dividing the newer patients up among all the nurses. On a much less sccientific scale than Rebel's facility, I assign a general acuity number to the people (1, 2, or 3 - 1's are on their way to discharge, 3's are more critical or new patients that you know the doc is gonna write a slew of orders on. Extra credit for PIA's . I divvy up as equally as possible from there. Seems convoluted to some of the nurses, but no one ever complains about unfair assignments when I do it.
  13. by   jilpil3
    The night shift charge makes assignments for days, and then they in turn make assignments for nights. We have a staffing grid
    that we have to go by for how many nurses and other staff. We just finished JCHO with great scores....but we are suppose to take accuity into account when making assignments are made, well that doesn't happen. We can tell the House Sup that we have some high acuity patients and need another nurse, but most of the time, she will say, "Call your Director and get apporval
    for the extra nurse." We also work 12 hour shifts, but we do staffing every 8 hours, so usually at 2300 we will have to loose at least one nurse, sometimes two. Does any one else have any similar problems, any sugestions would be great..

    Jil
  14. by   renerian
    OUr charge used to do it and it went by the acuity not the location which was kind of a pain if people were at one end of the hall and the other end.

    renerian

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