Change in Matrix: pros and cons

Grumpygs, MSN, RN · Sep 1, 2011

The hospital I work for also started 'primary' nursing with a similar patient population. Also a small community hospital (our floor has between 28 and 32 beds) but almost all of the patients have a psychiatric co-morbidity and we often have up to 10 vent dependent patients and up to 15 or so telemetry patients. Fresh abdominal surgical patients, hip ORIFs, lots of CHF and COPD, some with tube feedings etc with NO flexi - seals (though I keep asking them to order them...). Seems like we get a little bit of everything.

Prior to the 'primary' nursing scheduling, we had 1 CNA for up to 32 patients and we usually assigned them approx. half of the total care patients and the nurses did the remainder of the patient care for their patients. The CNA took vitals twice during the 12 hour shift with the nurses taking the noon/midnight vitals. However, with so much psych - we often had to have sitters and the CNAs were taken for sitters more often than not - they could always staff for sitters but not for patient care... (but that's another rant!)

We have always been assigned up to 5 patients without or without a CNA and often have 2 - 3 total care patients each to care for and clean along with all the rest of the work that nurses do.

We have experienced an increase in skin break down because few of the nurses seem to be able to keep up with cleaning and turning patients while assessing, passing meds, cleaning up other patients, talking to doctors/family, documenting, new admissions, discharging patients, I could go on and on...

So, I'm NOT a fan of primary nursing with the acuity/patient load that we currently have. Though I am able to better assess my patients skin conditions than when the CNAs do most of the patient care.

I suppose there are pros and cons to every matrix of care. I wish you luck with the new matrix!

DookieMeisterRN · Sep 1, 2011

We've been doing this for a few years now. We get 2 CNAs on days for a census of 24 to help with baths but otherwise one from 15-2300 and sometimes none at noc. It might have something to do with our Magnet status or PG scores. I really don't know but the CNA usually is just only able to get vitals, toilet, answer call bells/bed alarms if able. I don't mind, I do enjoy patient care and it gives me extra opportunities to get to know my pts but I don't always have time to fluff each pillow perfectly just b/c I only have 3 pts.

Sun_danc3rRN · Sep 1, 2011

On our surgical/tele/med units we can have up to 50 patients at a time. We get 7 patients on nights, and we used to get one cna for 7 patients, but now we have gone to the primary care model..we still get 7 patients, but the cna now gets 20..so a lot of total care, having 7 patients, even though we have a CNA..personally I don't like waiting on my vitals to do cardiac meds so I end up assessing and doing vitals as I go along at the beginning of my shift, as well as pain meds, toileting, etc., then my med pass. I am frustrated with this because something is going to get missed. I cant even find an aid half the time when I need to boost a patient up in the bed, or have 2 confused people diving out of bed at the same time, while I am in the med room pulling meds. I am the only one that sees their bed alarms going off. Remedy for danger, and our admin just doesnt care because it would impact their bottom line.

TiffyRN, BSN, PhD · Sep 1, 2011

Me, I'm not so sure. I fail to see how paying someone $30-40/hr to empty the trash & linen, take grandma to the bathroom for the umpteenth time, leave the floor to fetch food, blood, wheelchairs, linens, is cost-effective, or delivers better patient care:rolleyes:.

First of all, I've been through the consultant thing and have nothing positive to say about them. The only good thing about them is they motivated me to leave my first job where I would have rotted and go traveling.

Secondly; I guess you work with better CNA's/techs than I have in general. My experience was that occasionally you got a few decent ones, and they usually burned out or graduated from RN school. I started doing all my own cares years ago because if I didn't then; 1. the trash didn't get changed, the linen didn't get changed, patients didn't make it to the restroom, food remained unfetched. . . I think you get my point.

A few years ago in a cost cutting measure, all the tech positions were eliminated, and it really didn't change my work day at all.

I'll finish up by saying that I know there are many many hard-working techs out there, I've just been really unlucky, and I'm very independent.

I would just worry that they won't stick to that 3-4 patient ratio.

evolvingrn, BSN, RN · Sep 1, 2011

That just seems inefficient to me. I can't do cares on my pts alone if i wanted to because so many are total care , or agitated, fall risk ect...... I really value the role of the CNA and its too bad they are going away from that model.

~Mi Vida Loca~RN, ASN, RN · Sep 1, 2011

I am not on a cardiac floor but with our matrix if I only have 3-4 patients then there is not an CNA. We can have a CNA for 4 hrs if we have 8 patients and we can have a CNA for the full shift is we have 9 patients on the unit. Each nurse can take up to 6 patients on nights and we will have a CNA if we are at that.

If we have 1 kiddo there has to be either 2 RN's on the unit or 1 RN and an aide. Reasoning is there has to be an extra hand available for a kiddo in case another kiddo gets admitted or the nurse needs to be off the floor at all.

Our matrix is different if we have adult patients on the unit. If we only have adults we will try to move them to other floors and close the unit. (will happen a handful of times in the summer)

I haven't had any problems when I have had 4 patients without an Aide. We try and do hourly rounding and I find that from this my patients are rarely on the call light. But for the most part it goes pretty smoothly. The only time it gets hectic is when we start off with 2-3 and then get slammed with a few admissions per nurse which has happened a couple times. I would be in the middle of one admission when I find out I have another one (it will be my turn) and then I have that admission and still need to get to my other patients. By then though that means we are reaching our 8 and will have an aide coming to lend a hand.

The winter will be interesting to see. That is when our unit stays packed with pretty sick kiddos with severe respiratory issues and I hear that it can get pretty hectic. I haven't experienced it yet.

Dietary brings the trays to the patients rooms at our hospital. So you don't have to go get anything unless it's snacks at nice which we keep right on the unit.

Housecleaning also comes and cleans the rooms when a patient is discharged. If it's something minor then we just take care of it. They also round once a shift at the beginning of shifts to clean the rooms like emptying the trash and stuff.

evolvingrn, BSN, RN · Sep 1, 2011

I am not on a cardiac floor but with our matrix if I only have 3-4 patients then there is not an CNA. We can have a CNA for 4 hrs if we have 8 patients and we can have a CNA for the full shift is we have 9 patients on the unit. Each nurse can take up to 6 patients on nights and we will have a CNA if we are at that.
If we have 1 kiddo there has to be either 2 RN's on the unit or 1 RN and an aide. Reasoning is there has to be an extra hand available for a kiddo in case another kiddo gets admitted or the nurse needs to be off the floor at all.
Our matrix is different if we have adult patients on the unit. If we only have adults we will try to move them to other floors and close the unit. (will happen a handful of times in the summer)
I haven't had any problems when I have had 4 patients without an Aide. We try and do hourly rounding and I find that from this my patients are rarely on the call light. But for the most part it goes pretty smoothly. The only time it gets hectic is when we start off with 2-3 and then get slammed with a few admissions per nurse which has happened a couple times. I would be in the middle of one admission when I find out I have another one (it will be my turn) and then I have that admission and still need to get to my other patients. By then though that means we are reaching our 8 and will have an aide coming to lend a hand.
The winter will be interesting to see. That is when our unit stays packed with pretty sick kiddos with severe respiratory issues and I hear that it can get pretty hectic. I haven't experienced it yet.
Dietary brings the trays to the patients rooms at our hospital. So you don't have to go get anything unless it's snacks at nice which we keep right on the unit.
Housecleaning also comes and cleans the rooms when a patient is discharged. If it's something minor then we just take care of it. They also round once a shift at the beginning of shifts to clean the rooms like emptying the trash and stuff.

It sounds like your on a peds floor....which is a different dynamic imho...

~Mi Vida Loca~RN, ASN, RN · Sep 1, 2011

It sounds like your on a peds floor....which is a different dynamic imho...

Yes, well our whole hospital uses the matrix and the night nurses get up to 6 patients on all the other floors as well, except ICU.

Unlike the rest of the hospital though if we don't have peds specific patients we will close our unit.(this happens only a handful of times during the summer) Anyone under 18 will come to Peds no matter what the problem is. We have pre-teen 1:1 for suicide watch and OD's and withdrawal. We can function as a pediatric step up unit as well and Pediatric ICU. The only thing we don't handle are cardiac patients and vented patients. We ship them to the Childrens Hospital in Denver. But we handle everything else. We are also the only Large Burn center in I think the surrounding 6 states, so we get all those burn patients as well. They will go to our Burn center to get their initial treatment and debredment (sp?) which is where the adults will stay, and then after that they come to our pediatric unit. Depending on the severity of the burns they might be a 2:1 or 1:1. We see A LOT of burn kiddos sadly.

If our census is lower as it often is in the summer, we will take adult patients.

I am not sure what you are trying to imply though by your comment.

RNperdiem, RN · Sep 1, 2011

This can work if there aren't too many total care patients requiring turning, feeding or incontinence care.

The new plan will work if the unit holds up their end of the deal in keeping your nursing staffing levels high enough.

You don't want your CNAs all but gone and hear "short-staffed, sorry." and have no CNA and a high patient load.

DookieMeisterRN · Sep 1, 2011

Hey if they want to pay me my $40 per hr to fetch ice water, empty trash, make lab runs and push pts out at discharge that's great as long as I don't have over 3pt....that 4th pt can sometimes push me over the edge. We do have a charge nurse that does not take any pts, a unit secretary plus a resource nurse who assists mainly with discharges along with our ACM. We have a high pt turnover rate on days and have to have the extra nurses to keep the pt flow moving. It sounds like we have the same type of unit as the OP. Just some food for thought on what other cardiology units are doing with primary nursing.

Isabelle49 · Sep 1, 2011

The major problem with the consultant's recommendation that 1 nurse take 3 to 4 patients is that hospital management will interpret it to mean each nurse take 7 to 8 patients. Management thinks the numbers are meant to be added!