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Am I incompetent or is it a staffing vs. pt acuity issue?

Sorry this is long, but I would appreciate any input...........Please! :innerconf

I work in a rural hospital on the general medical floor and there are nurses, mostly RN's, with differing years of experience from 20 years. The majority probably have an average of 1-7 years experience. I know I am a new nurse, just passsed my 1 yr anniversary, but I question my competency a lot. I work nights because I had trouble leaving on time doing 3-11 shifts and I occasionally still leave late when I do 12 hr night shifts. We do our staffing according to the census and not pt acuity. At times I feel the pt load is too much and/or the assignments are unsafe due to numbers &/or acuity. I am afraid to say something to the NM because I don't see others struggling like I sometimes do.....so it makes me think that it's just me & if I'm a 'squeeky wheel' I won't 'get the oil' but rather get replaced. I put my pt's needs first and usually have to finish charting after giving report. I still ask a lot of questions and ask for help when I'm falling behind, but I don't want to burden my co-workers. I DON'T like staying late or when people say "You're still here!" and the hospital is really watching overtime due to budget issues. I worry about the liability of being an RN, missing something in my assessment, not doing the right intervention, not calling the Dr. when needed or calling when it's not necessary (I had a Dr. get upset with me once for this) etc. and think my charting takes too long & is too detailed because of these worries.....how do you get past that? Does anyone staff according to the pt's acuity? And if so what kind of rating system do you use? I was told my facility used to staff by acuity, but that they found the nurses rating most of the pts high acuity so they could have smaller pt loads.


Specializes in Orthopedic, Med/Surg.

I would ask some of the other nurses on your floor how they organize their work and incorporate some of these suggestions into yours. I'm sure that some of the other nurses have time saving techniques that do not compromise pt care. Try to chart as you go. You will be find that it will be a lot easier to go back and assess/reassess things that you forgot or that needed more attention (and you won't have to wake a pt to do it). At the end of your shift you will just have to a short final note which should cut down on the OT.

As for calling Drs. you will always find a couple that don't like to be "bothered" for any reason. When this happens you can either grin and bear it or ask the doctor what changes in assessment they would like to be called for.

Please don't think your incompetent. Staffing by acuity is a thing of the past. I'm sorry if I seem bitter but staffing by census is nothing more than a way to save a buck and has nothing to do with patient care. In these hard economic times the workload for Nurses is only getting heavier. Please find the time to look up safe nurse to patient ratios for your state, see if legislation is being worked on and get involved. Get out and vote for people who support safe staffing, write letters to congressmen, let others you work with know about it and try to get others involved. I live in PA and as of July 1 we are now mandation free :yeah:. Yes, we can make a change!

Thanks for the input nurselori001...I'll keep in mind what you said.

A recent shift went better....and I try to chart as I go but currently we have so many heavy care pts and/or unstable pts that I couldn't chart until after 0130. I guess that's the chance you take in nursing...I was just having a looooong stretch of bad shifts and still being somewhat new it did nothing for my self-esteem!!

I like what you said about contacting congressmen & voting.....I'm not into politics but I think I need to be now! This might be a dumb question but what do you mean when you say you're mandation free?

SummerGarden, ADN, BSN, MSN, RN

Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.

earned_rn_2008. do not assume that the other nurses are doing their job. i used to work late on med surg and think there was something wrong with me too. i found out after observing my co-workers and talking to a few gossipy ones that many of the nurses on my former med surg floor cut corners so they could go home on time. for example, some nurses do not actually complete patient care, finish paper work (i have known some who say they will chart on their next shift..), and some who just pretend that something did not happen so they do not have to accept responsibility (ever had a patient’s iv fall out at change of shift or an order of blood not get hanged because the doctor mysteriously just wrote the order that is listed 2 hours ago???). in other words, you are working hard to keep up with a load and acuity that is not humanly possible to do by yourself!!! so ask for help and show no shame.

plus, gain a reputation for being a nurse that will go home on time! the other nurses are getting away with murder because you are being too nice. nursing is 24-7 in the hospital so the next shift has to work. sorry... but that is what they are paid to do. as for your charge nurses who think that pilling more on you is going to be ok, stop them! let them know you are going home on time or that they will be staying late with you... they will find another nurse to pick on once you stop letting them dump on you.

if none of what i say actually works or you are still fed up with your current employer, then find another employer as soon as you can outside of med surg.... i did!!! good luck!


Specializes in Not specified.

I discovered early on in my first year that after I got report and completed my physical assessments and reviewed labs and ensuring I had a good clinical picture of each of my patients (this took a good 1 at minimum) many of my colleagues were pulling out meds and I know that they had not even gone into the the patient's rooms yet or completed any physical assessments or reviewed vital signs. Stick to your good habits, learn to let go of things you can't control, trade tasks--I'll start an IV for you if you do accuchecks, and try to consistently be assigned to the same patients. Having the same patient three days in a row makes a huge difference and reassures the patient with a familiar face.

Ayvah, RN

Specializes in Med Surg, Specialty.

In my few years as a med-surg nurse I've been surprised that when I really sit and talk with other nurses that seem to float through their shifts with ease (outward appearance) I find out they share many of the same concerns and stresses that I do, but they are afraid to speak up for fear of being reprimanded/fired. The best thing you can do for your confidence is find a nurse who you trust who has been on that unit for a few years and have a heart to heart with them to get their viewpoint on things along with tips. Sometimes you'll get some great ones! However, some nurses who seem to have it easy simply are cutting corners. I have seen nurses who don't assess, and those who copy and paste charting without looking at it (i.e. hmm this patient had their telemetry discontinued 2 days ago, why is it charted as still being on?), those who are not proactive in pain management, and those who leave everything for the next shift.

Obviously the more experience you have the more tricks and tips you'll have in your arsenal to make the day smoother but some things simply are due to a bad system. Some tips include bundling care (check VS/labs, then do meds/assessment/turning/pain control etc all at the same time.). Also delegate more to your CNAs (i.e. if tele calls you that the leads are off on a patient, ask your CNA to fix it instead of doing it yourself.) and if you have to pass something along to the next shift, then that's just how it works. Also always keep some basic things in your pockets like alcohol, IV caps, saline flushes (I know, you aren't supposed to), hemostats, tape, gauze, a tegaderm, and an extra pen or two.

Its hard to get into a balance, and to be honest I don't think a perfect balance will ever exist in today's hospitals with their bare-bones staffing. We just do as best we can and take things day by day.

I also just decided to leave med-surg and I'm much happier for it.

Good luck!


Specializes in Oncology, Med-Surg, Nursery.

I just made the decision to leave Med-Surg for reasons such as this.

When I started out as a nurse I worked on an Oncology unit where it was nothing for them to give a brand new graduate 8-9 patients and it had NOTHING to do with acuity. Those patients would be getting blood, chemo, etc. That is NOT safe. I decided right then and there that I had to be done if I wanted to keep my license.

However, when I found my way to a Med-Surg unit....because I had been trained dealing with 8-9 patients, I found I was able to get all of my stuff done with only 5-7 patients. Lots of nights it was a breeze for me!! Everyone has their own system though. I would always start on my row of patients and go right behind my CNA. I would get to their room and first check their vitals to see if I needed to do any manual checks, hold medication, give a medication, etc. I would then go in and assess that patient. After my assessment, I would gather my medications for them and give them. After all of that was finished I would chart on that patient before moving to the next room. Now that was an ideal night. Sure, lots of times I would have to stop where I was and go give a PRN pain/nausea medication or something, and I always kept an eye on the chart rack at the desk should anything new pop up for me to do...but that was my system. After I saw all of my patients and charted, I would then move onto my 24 hour chart checks. I was usually always done and out the door by 7:30-7:45 unless something came up right at shift change that I had to deal with before leaving.

I contribute that to how I started out. When I had 8-9 patients in Oncology I was leaving around 8:00 every morning. I am not sure my time management would have been so good on Med-Surg had I not gotten that initial training with such a huge load in Oncology. It is all about finding what works for YOU! It is trial and error. You will get there!

As for Docs that don't like to be bothered at night....so what!! You are protecting your patient and your license so oh well if he/she doesn't want to be bothered. I let them grumble and complain all they want. I will call whenever I feel it is necessary to do so. I am there at that hospital seeing the situation first hand and I feel it is my job to follow my instincts. Don't doubt that about yourself!!

Best of luck to you!!


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