Opinions/Advice on how to handle short staffing

[NYnurseatheart]

Hi,

I am sure this subject has been discussed to death, but in looking through other threads about short staffing I did not come across anything specifically like our situation. I work in a tiny facility - all the RN's are cross trained to work in ICU (from the Med-Surg floor). The ICU is a 4 bed unit, and is staffed with only 1 RN, except when they have more than 2 patients, then someone is either called in (ha ha - not likely), or floated from the Med Surg floor. The Med - Surg floor has a 25 bed capacity. On any given day there are 10 - 12 patients on the Med Surg floor, with numerous short stay surgicals scheduled (lap - appe's, Chole's, Arthroscopy's, kids with T & A, etc). For instance, the other morning, there were 13 patients on the floor when I left from the night shift (we do not have an aide on the night shift and they do not plan on hiring one for us - and there was myself and an LPN for those 13 patients). Anyhow, when I left, they had one RN, an LPN, and two aides. They had 7 surgicals scheduled, plus one in the ER, awaiting admission orders. That would be 21 patients (of course there could be some discharges prior to the surgicals coming - but only 2 were anticipated).

My question is this - do you, or would you consider this adequate staffing? Recently our DON (or whatever her title is) decreed that nurses (no distinction between RN or LPN) would need to take up to 8 patients each, regardless of whether or not there are aides. I take issue with this when I am the only RN, and have to do all the IV push meds, all the admission assessments and care plans, as well as be the one who has to talk with the doctor for all the patients (obtain orders etc). While I have worked many other hospitals where I have had 9 or 10 patients (on Telemetry), or even days when people have called in and have taken 12 or 13 patients - it has always been with aides to help out. I think the facility I work for has lost sight of the forrest for the trees (if you understand my analogy). Why on earth they would not try to hire more aides (the most cost effective staffing), is beyond me.

The reason I mentioned the ICU staffing in the beginning is this: Often if we have 3 nurses on the Med Surg floor, if the ICU gets a third patient (or sometimes it is a second patient who is simply work intensive - though I use that phrase hesitantly because the acuity level of the ICU patients is often less than what I would take care of on a Telemetry floor - give me a vented and sedated patient any day over one who is a climber with Alzheimers) they will take one of the med surg nurses, ship them to the ICU for the rest of the shift. This leaves the Med Surg floor (usually happens on evenings) with two nurses and an aide for 15 or more patients, while the ICU may have 2 or three patients and 2 nurses. How is this safe or fair?

I have spoken with a few of the doctors at the facility - to make them aware of what is happening. A few of the physicians have suggested that we (the nurses) band together and go to the CEO with our concerns. How do we do that? The last person who tried to go to the CEO above the DON was fired (of course she was by herself - and she was the head of a department no less). In trying to talk with the other nurses about what to do - I feel at risk of being fired.

Sadly, I think my best option is to look into another job. I have been an RN for over 15 years and know I can get another job in a heartbeat - but I don't want to be scared away from the one I have.

Any advice?

NYnurseatheart

[RN1982]

With all due respect, patients are in the ICU for a reason because they need close monitoring and care. I don't think it's fair to the ICU nurse to care for more than two patients when they are in ICU and can become quite unstable at any moment. The acuity level of one ICU patient could match about 2-3 tele patients depending on what is going on with the ICU patient. I think its unfair for you to assume that just because a patient is vented and sedated that the ICU nurse is not having any problems with the patient.

If you disagree with the current staffing and have voiced your concerns to no avail then perhaps finding a new job is in order. It is your license.

[RN1982]

I just want you to know that I agree with your concerns about staffing on med/surg. Too many patients not enough nurses. I disagree with your comments about ICU. Here's an example

Say for instance, the ICU receives a patient from another floor who just coded or they received a patient from OR who just had a liver transplant. There are already two other patients in the ICU and just one RN. It WOULD be extremely unfair to those two patients if their nurse had another patient tacked onto their assignment because 1. the patient who coded, might code again and 2. If you have ever taken care of a liver transplant patient post/op, they require multiple blood products, I've hung at least 20 units of PRBCs plus a countless number of FFP, platelets, cryo and albumin on one liver transplant patient in one 12 hour shift..

[NYnurseatheart]

Hello there MichiganRN - thanks for your response. I guess to give you a better picture of what I mean, because I too have worked in ICU for quite a few years. As a matter of fact I am often in the ICU working...

Anyhow, a typical patient in the ICU at this factility is a post-op patient who has a history of sleep apnea (that is their protocol, to keep them in ICU overnight). Rarely does the ICU patient even have a central line here (let alone an Art. line or Swan. Occasionally we will have patients who are vented (couldn't be weaned quickly after surgery). More times than not the ICU patient is a DNR. Another frequent type of ICU patient is the r/o MI, and depending on which doctor is on call for the ER, will either go to Med-Surg on Tele, or to the ICU. Granted there are occasionally patients who need close monitoring, I don't deny that. When I have been pulled to the ICU to float, leaving my co-workers on Med Surg short staffed (most recently it was to leave an RN and a new grad who hadn't even passed her boards yet) with 14 patients. When I went to the ICU it was to admit a patient who was from a nursing home who had had a seizure (with a known seizure disorder), who was post ictal - didn't even have an IV order except to give Ativan if she seized again. Anyhow - the other nurse in the ICU was caring for a patient who had coded earlier that day - and was vented and sedated - sadly that patient was full of cancer and had been a DNR, but at the last minute the wife didn't want to let him go - so she had him put on life support - then 2 days later agreed to terminate the life support...

So, there I was admitting and taking care of that seizure patient (why not just have me admit the patient and give her care over to the other nurse who only had the one other patient), and my co-workers were busting their butts with admissions on the Med-Surg floor. I felt powerless. Thank goodness the next shift supervisor (I was on a 12 hr shift), who came in after 4 hrs saw it my way and let me go back to staff the Med Surg floor. This is the kind of thing that happens all the time. Now that they are calling off nurses so that the staffing ratio is 8 patients to one nurse, I do think my only option is to leave. I am willing to put in a few more weeks to see if admin. pulls it's head out of its....however, I am not willing to keep working like that on purpose. It is one thing if someone calls in, quite another when staff is called off.

Just my two cents.

[RN1982]

Thanks for the clarification because I was starting to get a bit offended by your original post and was under the assumption that you felt ICU nurses had it easy. I get frustrated when other nurses think that ICU is "so easy" because of 1-2 patients we are assigned. Do you work at a small community hospital? After rereading your post, I got that impression but could be wrong. Do they not have a stepdown unit at your hospital because that seizure patient could have gone there instead of ICU.

[NYnurseatheart]

Yes I do work at a small community hospital - there is no step-down unit - as a matter of fact, having recently worked in another hospital that is much larger - the types of patients I now see in the ICU at the small community hospital would not be candidates to go to the ICU at all. They have no acuity tool at the place I currently work at. I think I should look into that issue...

By the way - thanks for your replies. I don't like to bust on ICU nurses (having been one), but can certainly see the irony in having one ICU nurse take care of one mostly stable patient, while another nurse takes care of 8 patients who aren't far behind that ICU patient in acuity level.

[racing-mom4, BSN, RN]

I dont think they are going to change thier staffing ratios, I dont think they are going to change thier policies on pulling the MS nursing staff over to ICU. I think since they have gotten away with it for so long they are not going in thier minds shell out more money in pay roll to make nurses lives "easier" I think that is sad. I dont forsee any changes happening, you can only control youself and that may mean getting a new job.

[Nightshifter-RN]

I work at a tiny hospital that sounds almost exactly the same as yours... same number of med surg beds, a 4-bed- low acuity ICU and everyone has to be cross-trained and are required to float wherever (incl. ER, postpartum). That said... I know exactly what you mean!

Sometimes it is so absurd when the lucky person who happens to be in ICU is sitting on their butt all night surfing the internet while their r/o MI snoozes quietly in their bed(with ambien on board of course!) and the poor schleps who are stuck in med surg are literally running around like chickens with their heads cut off with 7 pts a piece. Some of which are fresh post ops, and many which are confused old folks trying to get out of bed every 5 minutes! It feels like a nut house with the call lights, bed alarms and IV pumps beeping non-stop!

Sometimes the ICU RN will take pity on us and do our chart checks for us and that helps but some other RNs literally just sit there! I've seen some reading novels, watching TV shows/movies online, even playing cards! Something tells me that you would be the one trying to help.

The saving grace for us is our CNAs. I'd rather take more pts and have aides than less pts without an aide. If I were you I would beg, borrow, steal, do whatever you can to convince those cheapskates to get you some aides. It seems like the squeaky wheel is the only one who gets the oil where I work so start squeaking! Good luck!

[NYnurseatheart]

Hi NightshifterRN,

Are you sure you aren't working at my hospital??? Actually - we have had no aide on the night shift (except one perdiem who works every other weekend) for 3 months now - and no applicants. The hospital pays their aides significantly lower than any other facility around, so we are not likely to get applicants either. Can you imagine my delight at not only being the only RN on some nights, with no aide, and 14 or more patients and an LPN for a co-worker. I am not knocking LPN's (there are a few of them that I would much rather work with than a few of the RN's on staff), but being the only one who can take off orders for an admission, the only one who can do care plans, and having to get my own vitals, as well as answer call bells (to take 3 patients to the bathroom at roughly the same time...), pass meds, IV checks, chart checks, and hopefully prevent the confused patients from crawling out of bed and breaking a hip.

It is a wonder I get anything charted sometimes. Oh, and that is not to forget if there are any peds patients or patients getting blood - our facility mandates charting hourly on peds patients, and LPN's are not allowed to give blood, as well as any IV push meds the LPN's patients have to be given. I hate to complain, but some nights I never see the bathroom, much less the breakroom to get a bite to eat. This is starting to remind me too much of my ER days (working in a Trauma unit with 27 beds, and never more than one tech to help, and 5 nurses - one on triage). I sure hope things change, or I will have to be the one changing. I don't mind being the squeaky wheel - have tried numerous times to talk to our NM - to no avail.

Thanks everyone for your replies.

[nord11]

To give you an example of what we nurses did at my hospital (small 25 or so bed hospital - 3 bed ICU). We are union here in Montana (for what good it does?). We had a day where we had 3 RN's (no Lpn's work for the hospital) and 1 Cna - 18 pt's plus 2 in ICU, plus 1 in the birthing room trying to deliver. That meant 1 RN in the ER, 1 in ICU, and the RN who does OB was to do the delivery AND cover the floor (18 pts). The management saw this staffing shortage more than a week before this day came up - not one call to try and get another RN or anything by the managers (we did try ourselves before without luck the day before this but did not tell the management that we did this). We nurses made an agreement among ourselves that if we come in and nothing was done - we would ALL walk - no one taking report or anything before we found out what the situation was going to be. We felt it to be VERY UNSAFE for us as well as the pt's. So management get's called in because we sit and refuse to take report till they do something about staffing. They show up 30 minutes later, huff and puff and we basically tell them in a professional way to kiss our ass - it won't happen. They suddenly find some staff and we eventually worked. The primary manager did not roll up his sleeves and say lets get this done - too good to work since he was knighted with a title I guess. This particular manager, I still do not speak to - what a TURD. We all still wish that we would have walked, but it made my decision about not staying where I am. I will hold my tongue if possible and wait till the end of May when my daughter gets out of school. Then it's off to the southwest for something new. Most hospitals where I have worked in my 20 years have treated nurses like a number - they will just replace you. My license is what allows me to put money in my pocket and if anything threatens this - I will not do it whether I lose my job or not. You can always get another job.

[michiganurse]

REPORT THAT STAFFING TO OSHA AND CEMS. THAT IS COMPLETELY UNSAFE BS--aides or no aides--well tell the frikin DON to come do some baths and pass meds! If baths can't be done and family complains, give them the DONs number, and tell them SHE made it not priority

[General E. Speaking, RN, RN]

Wow, it has been many many years since I worked in small rural hospital but sounds like nothing has changed! I recall in one night covering the ER- had numerous patients but thankfully they were mostly clinic stuff. Hard though because we did all our own EKGs and RTs. No secretary or tech. Suddenly, a very pregnant woman shows up dilated to 9cm and I was pulled into the delivery. After the delivery, I came out and cared for the mom and the baby! It was so long ago, I swear I even mopped up the delivery room.... maybe I dreamed that part.