I realize understaffing is nothing new for nurses, but this issue has become increasingly worse on my unit recently and I am fighting for safe(r) staffing, but it looks like that's not going to happen as long as it eats away at upper management and admin bonuses.
Anyway... I work an an Acute Medical Detox unit that is adjacent to a Geri-psych unit but completely separated by walls and magnetic locks. The main detox hall, observable from the station holds 12. We have a new spillover area for detox after a recent renovation that opens up at the end of one hall that holds 10 more, so 22 total. I work nights and until recently, our average census has been 8-12 on detox... staffed by either one RN and one LPN or MHT OR
two RNs, functioning in both nursing and tech capacities, which is no problem until we get slammed with admits- and anyone who works detox knows the majority are admitted at night (at least in my experience).
Lately, we've had an influx of detox admits, while nextdoor on geri, they have seen a decrease. The detox matrix has never exceeded 15 beds and 2 staff from 11p-7a, so when we started having 18, 20, 22 patients/MAX.... admin didn't know what to do... we got one additional staff member at night. So basically, we two RNs would be admitting almost our entire shifts, and ONE tech rounding every 15 minutes on 20+ patients, not to mention new admits on detox get vitals q1h x 4h, then q2h x 4h, q4h x 3 days... so V/S are non-stop. Add assessments on patients already there, meds, doctors that round late, and any other procedures (i.e. dressing changes as we have no med nurse), and that we also have to chart q4h per pt. whereas the other 5 units in the hospital chart once per shift and PRN and get V/S once per shift... we're already non-stop busy.
This week, because the geriatric census dropped to 3, the CEO decided there's no reason to staff it separately and tacked it onto us, or rather, combined these two (medical) units into one floor/unit, and said "just use the 3rd floor matrix to staff"-- this would be sub-acute/high functioning, self-care psych patients. I argued this was both unsafe and inappropriate considering the acuity of detox patients and especially total-care Geri patients, and that we were to operate from the larger detox nurse's station with a single door connecting to geriatrics propped open. Even then, we cannot hear the call bell, bed alarms, etc.
My argument was met from my nurse manager with, "Well, *COMPANY* doesn't staff by acuity. *COMPANY* has always staffed by census/number of patients... I was speechless.
I further argued that even though that may be true, I know the hospital has an obligation to staff safely (which we all know is laughable by admin standards), and I am tempted to dig out the Nurse Practice Act or state law regarding the issue because I am sure it says somewhere that acuity must be considered when staffing (PLEASE correct me if I am wrong).
So two nights ago, we started out with 15 detox and three Geri patients combined to one unit. After 11p we had 2 RNs and 1 tech (also a tech with the 1:1 which I do not count). I'm used to it so that was okay UNTIL we got 4 admissions, raising our "floor" cenus to 22, received no additional staff. We got through the night. the supervisor had to come help several times as no one can possibly round q15 min on 22 pts while recording roughly 60 sets of V/S between the new admits and other patients, prepare paperwork for the following day while we (2 RNs) assessed, administered meds, accuchecks, insulin, assessments, geriatric wound care and dressing changes- AND, at night after the switchboard leaves at 2200, EVERY single call is sent to our unit, including calls to two other adjoining facilites: a 60 bed adolescent residential Tx center and inpatient substance abuse recovery center (post-detox), the five other floors, and any calls from med-surg hospitals requesting psych assessments... Unit secretary (WHAT IS THAT!?)
Both the other RN and I were there until 9am the next morning in the back charting and completing our admissions when our Nurse Mgr. comes to the floor and eventually makes her way back... "What's keeping y'all here?".... Not to mention neither of us got breaks. After all of this, she still tried to justify it as acceptable (of course. She has to defend *COMPANY*)... Here is my point (if you've read this far, thank you):
Am I wrong in thinking I read that, although there are no set nurse
atient ratios (excepting Calif.) that a hospital must ensure adequate/safe staffing of a which one criterion is the consideration of patient acuity? We all know a total-care geri patient is equivalent to 3 or 4 (or more) independent/high-functioning patients. Can hospitals that use census-based vs. acuity-based staffing legally staff the same for units that have MUCH more patient care on more unstable patients as they do on the other floors?
Is it LEGAL to combine geriatric patients, considered a vulnerable population, with other patient populations? (if it were known the same nurse treating a geriatric patient was also treating 11 detox patients and there was no staff continuously on the Geri "side", but only a standard size door propped open between the 2 units and a call/emergency bell that cannot be heard from the nurse's station where the RN is stationed, I would think that Medicare would frown on that and likely would refuse to pay.)
I know that the CEO, nurse manager, and corporate "higher-ups" who develop the staffing matrix don't care about us lowly floor nurses, BUT if we arrive to work and accept the assignment not knowing we may have 4, 5, 6 admits on the way and will receive no additional staff... it is OUR licenses on the line. What recourse is there? What is the best thing to do? File an official grievance? I can't afford to put my job in jeopardy, but I also have a strong sense of ethics and am deeply disturbed by just how wrong this is... I also know, should something happen, God forbid, management isn't going to back me up in any way, shape, or form... I've only been nursing a little over a year. Should I direct complaints to HR or to nursing administration and just hope I don't become a "target"... I am not one to complain, but things are becoming impossible. I just feel stuck between a rock and a hard place. I am passionate about this field of psych (addiction), but I see what I am risking and know this is unsafe... Any suggestions?
Is there any way to officially document to attest that I have requested additional staff and received none. On the assignment sheet? Progress notes? Where should I document that I notified/requested to the supervisor that more help is needed?
Thank you all.
What they are proposing, should be criminal. I would call the State Attorneys General's Office, and file a complaint. Nurses do not use the legal remedies that are available to help them. If more nurses called the authorities, and had these clowns brought up on charges, it would stop immediately.
I would also call the papers, and the news, and give them a detailed report of what they want to do. Our silence on these issues is deafening.
JMHO and my NY $0.02.
Lindarn, RN, BSN, CCRN
Somewhere in the PACNW
Last edit by lindarn on Sep 21, '12