Complicated Staffing Question

  1. Ok, I know there are a lot of threads out there regarding staffing. I've looked at a lot of them and still cannot find an answer. Here's the problem. We are a very small unit: 3 labor rooms, 4 "other" rooms. We have 200+ deliveries a year. We are an all RN unit. We usually staff 2 nurses per shift (12 hour shifts). We have no unit clerk, no aids, the only other help we have is housekeeping to clean the patient rooms.

    Our nursing staff has recently voiced concerns about staffing. Our nurse manager thinks it's appropriate for one nurse to have 3 stable couplets. Now I don't have a problem with that at all. But she says that the other nurse can go home on call. Leaving one nurse on the unit with essentially 6 patients.

    The other day she sent one of the nurses home when we had one stable couplet and one late post-partum bleed who was receiving blood. That's just not safe!

    My other concern is that she just doesn't "get it". She hasn't been a staff nurse for a long time and has never been a staff nurse at our hospital. She also won't help out when we need it, or else she doesn't realize that we need help and will just leave at the scheduled 3pm.

    My problem with the staffing guidelines posted is that they don't take into consideration a small unit with total care. And I mean total care as in total care of the whole unit, which includes stocking, making charts, answering phones and all of the other piddly stuff that needs to get done.

    Do any of you out there have staffing guidelines for a smaller total care unit? I think we need to get guidelines and stick to them or else our patients are going to be in danger.

    Of course the reasoning for this is the almighty dollar.
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  2. 17 Comments

  3. by   RN1989
    EVERY hospital I have worked at required there to be 2 nurses on the floor at all times for safety. If the census was so low, 1-2 patients, then those patients were transferred to another unit. You should never be left alone withou some help. Something could happen while you were in a room with someone else.

    I would discuss this with the manager. If she doesn't do anything I'd go to the CNO. After that - I'd be calling JCAHO and your states regulatory agency expressing concern.

    Make sure you document well, each and every time this occurs and anything that does/does not happen.

    I would also look at AWHONN guidelines and see if they can help give you concrete ammunition.
  4. by   cmo421
    I could be wrong, but I think that the national standards are that there be two licenced people on any unit at all times. Now I am sure there are exceptions, but I do not think I would worked alone in a situation where anything could go wrong at any time. Even if they had a LPN with you to help and run if anything went wrong,or if a resident/intern was staying in the unit. What happenes if you have to use the bathroom or get ill?
    In a union facility it would be part of the contracted language.
  5. by   imenid37
    Not safe! You can't plan for every emergency, but you must be as ready as possible. You need at least two nurses all of the time. After all, a mom could come in ready to deliver and pop out a baby for the one nurse who was there that needed some resuscitation. That is a pretty realistic scene, not something from Mars. AAP does say each newborn needs a person at the delivery specifically responsible for him/her. What about the PP pts? What if a PP mom fell and slipped in the shower at the same time as there is a delivery or if she's large, how are you to get her up???Suppose one threw a PE and coded. Whatcha gonna do? Start CPR or call the code. A lawsuit waiting to happen. See what else is going on in hospitals around you. Not just to get an idea for another job, but to prove to admin. this is NOT okay. A tech to run, stock, and answer the phone would be good too. She/he could be off sometimes for low census, but not the RN. The peds unit at our hospital, and sometimes, but less often, OB goes down to one pt. If peds is open there must be two nurses, even for one pt. OB never closes and at least two nurses are always there.
  6. by   grandee3
    Wow! I do not work L+D but I would think a unit should have 2 nurses at all times. A few questions.
    Who goes to lab and get blood
    Who checks it with you
    Who covers for you when you on lunch break
    Who answers the phone when you are tied up in a room
    Who helps you transfer pt to post par after delivery
    What if you have 2 women delivering at the same time (I know you have someone on call but babies don't wait until that nurse get there.)
    Please bring this to your NM and if you do not get any answers, please follow chain until you get someone to listen to you. This is a dangerous situation.
    Good luck:angryfire
  7. by   NRSKarenRN
    michigan: bureau of health systems

    minimum standards for hospitals
    r 325.1027 patient care.
    4) the hospital shall employ professional and auxiliary personnel to give patients necessary services.
    (a) the nursing service shall be in the charge of a graduate nurse
    registered to practice in michigan.
    (b) each nursing shift shall be personally supervised by a graduate
    nurse registered to practice in michigan.
    (c) personnel assigned to the maternity service, including the formula room, and all food handlers shall have a written record of pre-employment and annual physical examination.

    additional requirements for maternity hospitals and departments ---
    does not address staffing but room size, equipment, storage and supplies for maternity unit. more regs re seperate "formula room" than actual patient care needs.

    health facility whistleblowers' protection act

    hospital whistleblower poster required by health facility whistleblowers' protection act
    notice of whistleblowers' protections and obligations



    i would focus on leaving only one staff on unit unsafe. need at least nursing assistant answer phones, run errands, stocking so rn can focus on patient care needs, especially per above regs. if one mother/newborn needs sudden acute intervention, who does admin expect to be called to assist crisis? lawsuit over patient death worse and more $$$$$ than cost at least nursing assistant.

    if verbally can not get resolved, place concern for patient care in writing, submit to unit director/ nursing admin and risk management.
    in 2007, leaving a seperate nursing unit with only 1 staff member is unsafe and lawsuit waiting to happen.
    Last edit by NRSKarenRN on Sep 23, '07
  8. by   cmo421
    Quote from nrskarenrn
    bureau of health systems

    minimum standards for hospitals
    r 325.1027 patient care.
    4) the hospital shall employ professional and auxiliary personnel to give patients necessary services.
    (a) the nursing service shall be in the charge of a graduate nurse
    registered to practice in michigan.
    (b) each nursing shift shall be personally supervised by a graduate
    nurse registered to practice in michigan.
    (c) personnel assigned to the maternity service, including the formula room, and all food handlers shall have a written record of pre-employment and annual physical examination.

    additional requirements for maternity hospitals and departments ---
    does not address staffing but room size, equipment, storage and supplies for maternity unit. more regs re seperate "formula room" than actual patient care needs.

    health facility whistleblowers' protection act

    hospital whistleblower poster required by health facility whistleblowers' protection act
    notice of whistleblowers' protections and obligations



    i would focus on leaving only one staff on unit unsafe. need at least nursing assistant answer phones, run errands, stocking so rn can focus on patient care needs, especially per above regs. if one mother/newborn needs sudden acute intervention, who does admin expect to be called to assist crisis? lawsuit over patient death worse and more $$$$$ than cost at least nursing assistant.

    if verbally can not get resolved, place concern for patient care in writing, submit to unit director/ nursing admin and risk management.
    in 2007, leaving a seperate nursing unit with only 1 staff member is unsafe and lawsuit waiting to happen.
    question, is this just covering the state of michigan? i have looked and do not see one for ri? i learn so much here, really. i would love to know, i have a meeting with the majority leader next week about some issue and will bring thisn law either way. thanks!
  9. by   crysobrn
    UNSAFE...We have a small unit similar to what you're describing. We always have two OB RN's in house... We would like to keep them both on the floor but if there are NO patients then the management cannot stand to have two people "sitting around" although there is tons of stuff to do, clean, stock, make up charts, make up packs for moms etc...

    Anyway as an example of why we think it's unsafe to have ONE nurse. We had a mom come in and literally delivered within 3 min of arrival, barely got to the bed, pants off and the baby was born... STILLBORN... At that point, if you are alone, you have a mom and a dead baby, a hysterical family, who calls your other person in, how long does it take her to get there, who calls your OB in, there is just too much to do for one person.

    As a nurse I'd rather have two of us sit around and "do nothing" all year and have us both there in case of an emergency, than save money sending someone home and then have one day that could change your entire life/nursing career... Not to mention the liability of the hospital. uggh
  10. by   canoehead
    How much do you want to bet the OP's manager will tell her that the supervisor, or an Rn from another floor is always available in an emergency?
  11. by   crysobrn
    Quote from canoehead
    How much do you want to bet the OP's manager will tell her that the supervisor, or an Rn from another floor is always available in an emergency?
    You're probably right. Our higher ups say that if someone is coming down the hall then one of the nurses on the other floors will drop what they're doing and come help... We are so offended by that because no one wants to come to OB to help even when it's good, let alone when it's bad. Plus other floors/supervisors are busy. Again... uggh.
  12. by   Jolie
    Quote from canoehead
    How much do you want to bet the OP's manager will tell her that the supervisor, or an Rn from another floor is always available in an emergency?
    This raises all kinds of infection control issues. It is inappropriate for a nurse to be pulled to OB from med/surg, peds, ER, or any other unit where s/he has had contact with infected patients. And these days, who isn't infected with something? Even with universal precautions, it is necessary for the nurse to shower, change clothes, and scrub prior to working on the OB unit. In the case of an abruption, prolapsed cord, or precipitous delivery, we all know that ain't gonna happen.

    I would also get the OBs on your side. Do they know that they are admitting their patients to a unit that is not properly staffed to handle emergencies? It hospital administration truly believes that their staffing plan is safe and adequate, then ask them to put it in writing to the attending physicians and potential patients. It would read something like this, "Our beautiful birthing unit is staff by highly qualified professional nurses who will provide 1:1 care to you during your labor, unless you happen to arrive in the middle of the night. Then we suggest that you call ahead so that we can phone your nurse at home and ask her to get here before you do.
  13. by   JenTheRN
    Thanks for all your replies!

    To the poster who asked who gets blood (we do), gives breaks (we eat in the unit), answers the phone while we are in a room (we bring the cordless phone in there). Let me say that most of the time we do have two nurses. If we do only have one, we can call the aid from med surg to 'watch the unit' for 5 mins while we go to lab, pharmacy, whatever.

    To the poster who said that management says that someone from another unit can help us: YES! That's exactly what she says. But that's crazy. I mean, most of them wouldn't know what to do.

    My thoughts are that as long as we have patients on the floor we should have two nurses. It's just unsafe otherwise.

    I think that hiring a desk clerk or aid would be a good solution too. She/he could be called off when not needed. It's just the worst when we have a busy day and then we have to worry about getting the chart ready, putting stickers on, punching holes etc etc. (We still have paper charting.)

    I did talk to one of our OBs yesterday. He agrees with me. He says it's frustrating when he gets a stat page and then no one answers the phone ('cause we're in the room with the pt).
  14. by   KeyWestRN
    I work at a hospital that has 4 L&D rooms with 2 "backup" rooms where we can monitor but they have regular hospital beds not delivery beds. We do 250 to 350 deliveries a year.
    When we have no patients on the unit, usually sunday nights one nurse is put on call and one has to stay and float to other units with a spectralink phone in case a patient presents to ER .

    We all feel this is incredibly unsafe but we are told that they can't staff for "what if"!
    We keep saying its not "what if" Its WHEN something happens. I have had to work alone several times. I tell the house supervisor (who is there only until 9pm on weekends) How uncomfortable I am being alone. I tell Respiratory that If I call they better come running and the charge nurse on the tele unit on the same floor that if I call they better come!.

    I am worried should something go wrong I will lose my Licence!

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