Nurse to patient ratios and acuity in YOUR PICU

Our nurse manager is so far out in left field checking out the dandelions that she doesn't even know enough to do the assignment. Our nursing director thinks we're all a bunch of whiners and need more to do. The hospital CNO is a figurehead. Last summer, when we had a different patient care manager, she actually was on rounds when our MD suggested taking a kid with an open abdomen outside and she spent quite some time arranging for it to happen. So to make a short story very long... NO. The turnover in our management is almost as great as it is in bedside staff, and they can't keep anyone in the job. None of us has had a performance evaluation in 2 1/2 years. And we've got new staff who are maybe marginally competent being shuffled through orientation because they will be one more name on the assignment sheet. It's getting harder and harder to get out of bed and go to work.

Canoehead, I can't even get them to agree to sign professional responsibility forms when we're so short-staffed no one pees for 12 hours except the patients. There's a climate of fear (of management and administration) in our unit that you'd have to see to believe, and as a result there is very little team spirit. Everyone looks out for their own interests. Those who do look out for others, like myself and a few others... all older and very experienced nurses, are the ones who keep the unit safe (all things being relative). We have a very high staff turnover rate, as I've already discussed, but at the same time we have a huge number of nurses who have never worked anywhere else and don't know that a lot of the things that are forced on us are not normal. And for every new hire we get that has at least some nursing experience (not even ICU experience, but nursing in general) we get 10 who are fresh out of university. I've had people come to me six months after they've finished their orientation telling me they have to put a foley in their patinet and they've never done it on a person before. And they're working in a quaternary care PICU. They're not likely to foresee all the potential disasters awaiting when you take a chronically critical kid out for a walk because they can't even foresee the effect of taking too long to change out your epi syringe. I've worked on this unit for 6 years as of September 9. There are times when I walk into our report room before a shift and I've got more time on the unit than every single other person in the room combined.

Our standards used to be very high. But lately they've been allowed to slip. Patients aren't being turned or bathed, they aren't receiving oral, eye or foley care, they may be found lying in stool (Oh, when did he do that?), dressings are being left on for days, the list is endless. We've recently seen an upswing in unplanned extubations, dislodged NG/NJ tubes, self-d/c'd foleys and chest tubes, central lines and left atrial lines that "fall" out, pressure related injuries in places that shouldn't have them (heels being a big one lately), interstitial IVs left running for hours (one had 3% in it and the kid has a Stage 3 extravasation injury) and on and on. I'm getting tired of filing incident reports. Usually the blame is placed on staffing.

I found out on Wednesday that the purpose for the meeting that provoked this thread in the first place is not what I was expecting. There are big changes coming to the way we do our scheduling and there will be some very annoyed people. The changes have all been scrutinized by our union and found to be contractually compliant (very important in Canadian hospitals) and very good for the unit, but they will result in some people having to work nights, weekends and holidays where they've managed to schedule themselves not to for years. There will be a more balanced number of staff on each shift and our OT should finally subside a bit. Right now there are shifts where we might have 9 scheduled (baseline is 18) and others where we have 24. I expect there will be a mass resignation shortly after the meeting. I might even make an Amazing Karnak list of the people how will be on the train, just for laughs.

I want to thank all of you for your input and support. I still want to try and bring this unit back to what it was when I started here and you're helping me do that.

Oh, I also meant to say something about palliative care. We are often forced to admit kids who are DNR. The physicians believe that if the kid is admitted to PICU, then the question of resuscitation won't arise... they'll already be electively intubated and on pressors before they reach coding territory. For example, we have two little girls who have spinal muscular atrophy, both of whom have greatly exceeded the average life expectancy of such a diagnosis. They both are admitted to PICU for BiPAP when they start having respiratory issues. They then progress to hypotension and we start them on dop. When their gases start looking a little crappy, they are electively intubated, where they remain for weeks because they don't have the respiratory muscle strangth to overcome the atmosphere. Then they go back on BiPAP for several weeks until they finally graduate to CPAP and can go to the respiratory ward. Another little girl has Bowen Conradi syndrome (PM me for more info), which is a highly lethal congenital disorder found almost exclusively in Hutterite populations. Death is usually within the first months of life. The last time she was admitted with respiratory distress, she was already a year old. Her family has agreed to DNR, but she still comes in occasionally for BiPAP. Something she absolutely hates! I always look after her because I have more knowledge of BWCNS than the average person - my daughter is a genteicist and her best friend has done the gene mapping for it, so her parents ask for me. Each time she comes in I pray she decides she's done.

There are a number of other seriously compromised kids who have outlived their expected lifespan who come in routinely for several weeks. We do everything but compressions and send them on their way again eventually.

RNNPICU, thanks for your input. The computer learning packages I was referring to aren't for CEUs or annual recerts, they're things like learning to use the Smart Pumps, learning about the changes to our cytotoxics policy, our disclosure-of-adverse-events policy and wound care practices, patient safety issues and so on. Things that our educator should actually be educating us on. But she doesn't have time, she's too busy orienting new staff.

I have about a week to pull together everything shared here before our big meeting. I've just sent out a notification to our staff that they really need to be at this meeting in big numbers and (totally unprecedented!!) the hospital will pay straight time for attendance. I talked to our PCM this morning before I came home to sleep and told her quite bluntly that if she expects people to come in from home for a meeting, the agenda for which I'm not allowed to discuss, out of the goodness of their hearts, then there will be just her, the CNO and me in the room. Then I discovered just a little while ago that although she asked me to set up this meting and communicate it to the staff, she's changed the time and the place without telling me. I think this meeting might be make or break for me. I can't imagine not working in peds critical care, but this unit is killing me.

Thanks PICNIC. I'm feeling a little more optimistic that we'll have a few people turn out for the meeting, since she agreed to pay them. Up to now, all our staff meetings have been on a volunteer basis... if you just happened to be disorganized enough to be on your lunch break when the meeting started in our staff break room, you "volunteered" to attend. Not that anything ever came out of those meetings except more frustration. I could take the minutes from the last ten meetings and without looking at them, tell you exactly what was discussed and what the plans were.

It IS a very challenging place to work. Since yesterday was a holiday, there was no manager on in the unit, only someone on call. She told the charge nurse to cancel all the overtime for the night shift (there were three people booked) because it was quiet. We had a transport nurse and a resource nurse but no admitting nurse. HELLO!! It's Labour Day!!!! The transport team went out at 2100 to pick up a 30% 2nd and 3rd degree burn. At 2130 we received an 11 year old special needs kid who had fallen in the tub and was down more than 30 minutes before ROSC. In the first two hours after his admission, there were three physicians two RTs and four nurses working on him trying to get lines, continue with the resus and whatever. I held his contractured leg in abduction for more than 30 minutes while our fellow put in a central line using Doppler to find a vessel. When he finally died at 0300, his epi was at 1, his norepi at 0.5 with a systolic of 65, his stats hadn't been above 55% for hours and he was in DIC. The family withdrew. Meanwhile, we admitted another kid from one of the floors who had bowel surgery yesterday, now in shock at around 2300. He needed RSI, lines, fluid resus and pressors. I didn't even look at my patient, a fresh trach from suppertime, for four hours. For a while, one of our junior nurses was responsible for four kids! PCM's reaction? "Good job. That's team work."

Okay, so. I had two meetings today, one with our director of critical care nursing and our managers and one with a good portion of the staff. Both went much better than I was expecting. The bomb the admin dropped was not the bomb I was thinking was coming. And when it was all laid out for me this morning, I was very relieved. We will be hiring 13 more full time nurses for our unit (if we can find 13!!) and increasing our baseline staffing dramatically. The master rotation is being revamped to reduce the number of short shifts and the collective agreement is going to be enforced. (We have a significant group of people who never work a weekend, stat holiday or night, even though we do rotating shifts and the CA says full time people work every other weekend.) My rotation isn't being touched because it's already contractually compliant and it's a very manageable one! There were some disgruntled people but I think when it is in place and they see how much better it is, they'll come around.

All that aside, I still found the information you provided to be very useful. When I put it all into a spreadsheet, I was able to distill the important information to our situation and will be bringing it forward at our next team-building meeting. Thank you so much.