Oncology Patient Ratios

[kelliegbsn]

Hi all,

I have looked at many posts on the site with this subject and cannot find a specific answer. So here is my question...

I work in an acute care inpatient hospital. I am a night shift nurse in the Oncology unit. I am trying to compare my unit with other units with the same patient population. We do not have BMT but we do hang chemo on both days and nights.

Our staffing has been recently changed and not necessarily for the better of the patients. Also does anyone have articles about oncology staffing specifically? According to our p & p we are to be staffed based on acuity but all I ever hear about is the number of patients.

OK so here is the specific criteria I am trying to get answered.

Inpatient only, oncology with non tele med surg overflow, no bone marrow transplant, chemo is hung, we also have day stay patients for chemotherapy treatment as well.

Anyone with that same criteria please share your staffing guidelines so that we can continue to provide excellent care to our beloved patients.

Thank you.

[blondy2061h, MSN, RN]

I work on a heme/onc/BMT unit with tele and also med/surg overflow, and we take six patients each night. It sometimes gets to be a little too much, especially for a new nurse like me.

6 patients with BMT? That's ridiculous.

[eternalsunshine]

i work on the same type of floor (oncology with nontele med srug overflow). we have 2 nurses one cna and our assignment ranges from 6-9 patients

Rissa - is that 6-9 patients each or 6-9 patients between you and the other RN?

Also may I ask what a CNA is? (I am a UK nurse)

thanks :)

[Sammi15]

I work on a oncology mixed with med/surg floor. We have 35 beds on our unit and on day there are 5-6 nurses and night only 4 nurses, sometime 3 if we're short. Day nurses take 5-7 patients each and night nurses (myself included) take 9-12 patients . I really hate working on my floor b/c at night we've no secretary or helper nurse which mean we do all the admission and entering and picking orders. Being a new nurse is even harder to handle this kind of workload! I really want to leave soon and find a better working environment.

I think we should have a mandate law (like Cali) where each nurse can take up to certain amount of patients. A lot of time, I feel unsave taking care of so many patients at once.

[nursemary9, BSN, RN]

Hii,

My floor sounds a lot like yours. Our staffing is the same for all 3 shifts. We get 5-6 patients.

If staffing is as it shoud be, we have 4 RN's. 2 CNA's (Certified Nursing Assistants) and a Clerk.

We each take 5 pt's with the Charge RN getting 3 pt's.

I feel like at Nite, it's OK this way-----I work nites--- However, I feel like they could really use more staff on Days & PM's.

Hope this helps.

[schlemj]

I am currently in outpatient but I worked on a unit for 7 years with that exact pt. population. 22 patient unit 4 RN's and one charge on days, 3 RN's on eves, 2 RN's on nights.

[BrandyL1193]

Inpatient hospital Medical Oncology with some med surge overflow. Our staffing is max 5 for days. patients gettng high dose IL2 have a 1/3 ratio for days 1/4 for nights and AML patients have 1/4 on days or 1/5 on nights. Day shift charge nurse carries no patients during the week, evenings carry 3 or 4 and nights usually carry 4 or 5.

[rn undisclosed name]

I work days on an oncology/tele floor and our ratio is 5:1. We hardly ever have 5 patients cause they know it is not ideal to do that. Usually though it is 3 or 4 patients. If we have a patient who is really sick and needs a lot of 1 on 1 (but they don't deem ICU worthy for whatever reason) they are usually very accomodating and we get our way. I have done 1 on 1 with cisplatin desensitization and that is a dream assignment (as long as the pt does not react).

[catherine_cardella]

I work as an aide on a strictly BMT floor. On day and afternoon shifts, it's 3 patients per nurse. For nights, it's 4 patients per nurse because we are currently understaffed for night shifts.

[nursenu22]

Yikes I'm thankful for our staffing ratio. We typically have a 4:1 ratio plus 2 CNA's and a clerk. We also have a charge RN that doesn't take an assignment. My unit a 16 bed unit that does take a lot of overflow no bmt, but we do a lot of chemo and short stay recovery type pt's. Also we have an ortho dr. that loves us so he sends us all his pts.

[southernbelle08]

I work nights. I have anywhere from 6-9 patients.

[mmatlab]

i have checked for the evidence based practice for pateint ratio

developing indicators

developing indicators for nursing is challenging, but with the current change on nurse to patient ratio, it provides both an opportunity and an imperative for nursing to measure and evaluate nursing's contribution to patient care. indicators serve to foster understanding of a system and how it can be improved, and to monitor performance against agreed standards or benchmarks. crucially, indicators provide a mechanism by which care providers can be accountable for the quality of their nursing services.

in most cases the main determinants of outcome are patients themselves, not care inputs, however, three domains of quality measurement that reflects nursing contribution seem to prevail in the current literature: safety, effectiveness of nursing care and compassion. safety refers to adverse effects of care, effectiveness refers to positive benefits and compassion refers to aspects of patient experience such as perceived dignity, respect and quality of communication.

to be useful, indicators must be measurable with available data. there must be evidence that the quality or quantity (nursing staffing) of nursing substantially contributes to changes measured by the indicator. in considering nursing-sensitive outcomes and experience, we must identify elements of variation that can be attributed largely to nursing care/ nurse staffing. to do this we must seek evidence of correlation with nursing as well as evidence that this correlation is a plausible consequence of variation in nursing rather than other factors. developments of indicators must build on existing evidence and initiatives for consistency across settings and to ensure that best practice is used.

the national quality forum (2003) requires indicators to be scientifically sound:

* precise specification of the indicator

* reliability and validity of measures and

* adequacy of risk adjustment.

so nursing indicators must be measurable with available data, coding

and recording must be consistent and complete and measures must be valid. if an indicator is to measure and evaluate staffing level and the impact on quality of nursing, it must be attributable to nursing in a number of senses, including:

* evidence of sensitivity to nursing

* recognition of the phenomenon's importance

* recognition as a nursing contribution (owned by nurses and acknowledged by others)

* recognition as nurses' responsibility in terms of legitimate authority, self-perception and

sphere of practice.

what are the evidences?

doran (2003) asserts that a wide range of potentially measurable indicators of nursing care quality can be identified from nurse-sensitive outcomes. these outcomes are aspects of patient experience, behaviour or patient outcomes that are determined in

whole or part by nursing care received and variations in its quality or quantity.

pencheon (2008) reports that among the most widely used indicators are safety measures such as failure to rescue (death among patients with treatable complications), falls, healthcare associated infection and pressure ulcers. there is strong evidence supporting an association between nurse staffing levels and mortality (kazanjian et al, 2005), but mortality is determined by many causes and is not likely to be a useful quality measure for nursing.

kane et al. (2007) provide the strongest single source of evidence for a link between nursing and outcomes. this systematic review examines the impact of a general nursing variable, the quantity of nursing care available, and assesses the extent to which nursing influences the indicators. the review included 96 studies linking nurse staffing to patient outcomes.

increased rn staffing was associated with lower hospital-related mortality (per additional

full-time equivalent nurse per patient day) in:

* intensive care units (odds ratio 0.91, 95% confidence interval 0.86-0.96)

* surgical units (odds ratio 0.84; 95% confidence interval 0.80-0.89)

cardiac arrest (all groups)

failure to rescue (surgery)

mortality

kane (2007) takes a cautious epidemiological approach to interpreting causation. causality is supported by evidence of a 'dose-response relationship' which appears curvilinear as increased staffing at the highest levels yields diminishing returns. the evidence is consistent across study designs (including the use of risk adjustment) and while different designs give some modifications in estimates, overall conclusions are unchanged. evidence supports a temporal association as some studies demonstrate that adverse outcomes occur immediately after periods of low staffing, although there is a lower estimate of effect on failure to rescue in studies assessing this temporal association. there was no consistent association between nurse staffing and patient falls, pressure ulcers or urinary tract infections, outcomes among the indicators most frequently identified. although there is some evidence to support these, their appearance on lists of indicators is clearly more predicated upon a convincing theoretical proposition than the strength of the evidence.

of the four most prominent outcome indicators identified (failure to rescue, falls, hcai

[pneumonia], pressure ulcers), only failure to rescue and hcai pneumonia are supported

by kane's (2007) review.

suggestions of indicators to measure the impact of nurse: patient ratio

of the range of potential indicators, a number emerge as potential "front-runners".

most strongly advocated patient safety indicators

safety

1) failure to rescue

2) health care associated infection,

3) pressure ulcers* (process indicators should be used with caution because of potential for gaming and difficulty in linking specific processes and patient outcomes)

4) falls

.

effectiveness

1) staff satisfaction

2) staff perception of the practice environment

compassion

1) experience of care (patient reported)

2) communication (patient reported)

* patient experience of compassionate care is an important outcome in its own right

and may provide the best measure of the nursing contributions to shared outcome

and evaluation of complex processes that are otherwise elusive.

doran d. (2003) preface. in: doran d, editor. nursing-sensitive outcomes: state of the science.sudbury / london: jones and bartlett pub.,:vii-ix.

kazanjian a, green c, wong j, reid r. (2005) effect of the hospital nursing environmenton patient mortality: a systematic review. j health serv res policy;10:111.

kane r, shamliyan t, mueller c, duval s, wilt t. (2007) the association of registered

nurse staffing levels and patient outcomes: systematic review and meta-

analysis. med care 2007;45(12):1195.

national quality forum (2003). a comprehensive framework for hospital care performance evaluation: a consensus report. washington: national quality forum

pencheon d. (2008) the good indicators guide: understanding how to use and choose

indicators. warwick: nhs institute for innovation and improvement.

best regards,

mamoon matalb

oncology nursing educator

ssh, ksa