Curious about NOC shift

OneDuckyRN · Dec 8, 2014

I've been working NOC shift for a little over a year now, and I can tell you we find PLENTY to keep us busy! We are a medical step-down with a respiratory focus, so we have q4h vitals and assessments on 4-5 patients. Since we're step-down and not med/surg, we have to do our own VS - the PCT's are not able to do them for us. Of course, there's the "big" med pass that happens between 2000 and 2200, but many of our patients are getting IV medications throughout the night. Our trach patients (and we usually have several of them) need to have trach care done, and most of these trach patients have tube feeds going, and the tube feed circuits and supplies get changed out at night. We have fewer PCT's at night, so the nurses do a lot of their own toileting, whether the patient is continent or not!

NOC shift on our floor does probably 80-90% of the admissions. Day shift clears us out, we fill it back up! Most of our patients come to us from the ER, but it's not unusual to get a middle-of-the-night transfer from critical care because they need beds. It's probably the same on many other floors, but our floor seems to get a lot of confused patients, and don't let anyone tell you patients just sleep all night. Sundowning is a real thing.

Some patients get aggravated when I have to wake them up, but I can usually head this off at the pass during my initial assessment. I tell them exactly what has to be accomplished during the night, and it will involve me waking them up a couple of times for vitals. I also cluster care as much as possible so even though it takes me a little longer to get done with one "round" I am running around a lot less, and waking people up less frequently.

Hope this helps!

VANurse2010 · Dec 8, 2014

I've been working NOC shift for a little over a year now, and I can tell you we find PLENTY to keep us busy! We are a medical step-down with a respiratory focus, so we have q4h vitals and assessments on 4-5 patients. Since we're step-down and not med/surg, we have to do our own VS - the PCT's are not able to do them for us. Of course, there's the "big" med pass that happens between 2000 and 2200, but many of our patients are getting IV medications throughout the night. Our trach patients (and we usually have several of them) need to have trach care done, and most of these trach patients have tube feeds going, and the tube feed circuits and supplies get changed out at night. We have fewer PCT's at night, so the nurses do a lot of their own toileting, whether the patient is continent or not!
NOC shift on our floor does probably 80-90% of the admissions. Day shift clears us out, we fill it back up! Most of our patients come to us from the ER, but it's not unusual to get a middle-of-the-night transfer from critical care because they need beds. It's probably the same on many other floors, but our floor seems to get a lot of confused patients, and don't let anyone tell you patients just sleep all night. Sundowning is a real thing.
Some patients get aggravated when I have to wake them up, but I can usually head this off at the pass during my initial assessment. I tell them exactly what has to be accomplished during the night, and it will involve me waking them up a couple of times for vitals. I also cluster care as much as possible so even though it takes me a little longer to get done with one "round" I am running around a lot less, and waking people up less frequently.
Hope this helps!

Yeah, your unit is working you harder than they have to for no real reason. Documenting q4H assessments on 4-5 non-ICU patients is ridiculous (I realize this may be an unpopular opinion).

OneDuckyRN · Dec 8, 2014

Yeah, your unit is working you harder than they have to for no real reason. Documenting q4H assessments on 4-5 non-ICU patients is ridiculous (I realize this may be an unpopular opinion).

I don't disagree with you that they're working us harder than necessary. It's not the q4h VS/assessments that bother me, it's that we have 4-5 patients. I feel like I do at least as much work (if not more) than the ICU nurses, simply because we have more pts. I understand that each of their patients is more labor-intensive, but at least they're restricted to 1 or 2 pts each, with 3 on a rare occasion.

VANurse2010 · Dec 8, 2014

I don't disagree with you that they're working us harder than necessary. It's not the q4h VS/assessments that bother me, it's that we have 4-5 patients. I feel like I do at least as much work (if not more) than the ICU nurses, simply because we have more pts. I understand that each of their patients is more labor-intensive, but at least they're restricted to 1 or 2 pts each, with 3 on a rare occasion.

You only need to be documenting q8H or q12H assessments on step-down patients. 4-5 is OK if the documentation requirements are reasonable.

CTRN'11 · Dec 8, 2014

I work on an ICU step down and we do vitals q2 and assessments q4 and we have 3 patients I cant imagine doing all of that on 5!

Cricket183, BSN, RN · Dec 8, 2014

When I graduated and started working I worked NOC on a medical oncology unit. I was amazed at how busy our shifts were. We were a 25 bed unit staffed with two RNs (me and a charge nurse who did not take patients), two LVNs and sometimes one CNA. We were almost always at full census, if not at the beginning of the shift, by the time it ended. Patients were typically split 9-8-8. I almost always had 9 patients. The charge nurse had to chart assessments for the LVNs so I was given the extra patient because I did my own assessments. I was also given the patients with blood transfusions, IV pushes and/or chemo (once I was certified) because these were RN only duties at that hospital. Often it would be 9pm by the time I made my initial rounds/assessments and 11pm or later by the time I finished my first med pass (and that is if I wasn't interrupted by timed chemo, blood transfusions, admissions, or emergencies). Then I would chart my assessments and do chart checks (midnight lines) on all nine patients. Of course during this time I was frequently getting up to complete other nursing tasks--we gave a lot of q6 antibiotics, scheduled IVPs, transfusions, frequent prns--especially IVP pain meds and anti-emetics, etc. Then at 5am I had to do labs on line draws (most of our patients had ports, PICCs, or central lines). I quickly had to develop really good time management skills and learned to cluster care. The charge nurse was pretty lazy and while she would help out the two LVNs, she didn't seem as willing to help me. Admittedly I have never been great at asking for help (character flaw).

Many patients don't sleep well in the hospital. I found this to be particularly true for our oncology patients. Whether it be due to side effects from chemo/medications, psychosocial issues, etc. sleep doesn't come easy. There is a lot of patient teaching and emotional/spiritual support that happens on NOCs.

I switched to day shift when my manager asked me to train for a charge nurse position on days. Day shift was equally challenging but in different ways. There is more to keep track of...morning labs, doctor's rounds, discharges/admissions/transfers, staffing matrix, etc. And on days the charge did all chemo orders for the shift as well as any line lab draws, admission paperwork/initial assessment, IV pushes, blood transfusions, doctor phone calls for patients assigned to LVNS. (We eventually went to an all RN unit which really worked much better for our patient population.)

I am (and always have been) a night owl so I prefer NOC from a purely physical stand point. My brain takes a while to fully function first thing in the morning regardless of what time I get up. But as far as the actual nursing duties and the flow of the shift, I prefer days.

TheCommuter, BSN, RN · Dec 8, 2014

I've been working 12-hour night shifts for the past four years. We start off by counting the Pyxis with the offgoing nurse, receiving report, and completing assessments on anywhere from 7 to 10 patients.

For the purpose of effective time management, the medication pass should be completed as we assess the patients. Also, any wound care and treatments should be performed at this time. If a patient needs a blood transfusion, we try to infuse it before they go to sleep.

If a patient receives Q4 hour or Q6 hour antibiotics during the night, we attempt to administer these without waking them. Finally, we must chart on all patients. Night shift at my workplace usually has a few hours of downtime unless one or more patients are circling the drain.

brownbook · Dec 8, 2014

It really depends on where you are working. Acute care hospital versus a long term care facility. Night shift has different priorities and tasks. It also depends on the patients diagnosis, acuity of illness, etc.

Often, unfortunately, you can't prioritize the patient getting a good night sleep. If they are sick enough to be admitted to a hospital, they are sick enough to need to be checked 24/7. Lights turned on, (sometimes a flashlight will work,), vitals taken, IV sites checked, dressings checked, etc.

If they are healthy enough to get mad when you wake them at night they may be healthy enough to be discharged. Or they can ask their doctor if they can get an order for do not disturb, do not awaken for vitals signs, when sleeping,

firstinfamily, RN · Dec 9, 2014

I agree that most patients do not sleep at night. Whether this is due to the hospital environment or just they are not able to sleep. I always check up on my patients with a flashlight at night. I usually tell them with my initial assessment that I will be checking on them throughout the night, that way they are not startled when I come in with a flashlight. We usually get a lot of admissions during the night and most recently transfers from other floors. So, just because it is night does not mean there is not enough to do!!! Night shift also does 24 hour chart checks and restocks the unit.

OneDuckyRN · Dec 9, 2014

You only need to be documenting q8H or q12H assessments on step-down patients. 4-5 is OK if the documentation requirements are reasonable.

That's great, if that's your facility's protocol. Mine requires q4h vitals and assessments charted unless otherwise ordered. It's a very rare patient that has something else ordered, usually comfort care or a terminal wean.

TU RN, DNP, CRNA · Dec 9, 2014

Acceptable stedown admission criteria varies from facility to facility - so in one place you very well could be dealing with a pretty stable patient who only needs assessments/VS q8h or q12h (same thing has gone for some of the ICU patients I've been pulled to take care of as well...) On my stepdown floor we run drips (phenylephrine, cardizem, levophed, nicardipine), take vents, and BiPAP initiations up to 3-4 patients. Take any one of those patients and assess them in q8h or q12h frequency and tell me how it goes. Tell your Liability Insurance provider while you're at it.

To answer the OP's comment more directly: I agree entirely with OneDucky. Besides the sundowners, night owls, and people who've been admitted so long they become delirious... you're looking at most of the admissions, occasional transfers to other places in the hospital, and less staff. Techs are short at night and in many places they try to increase the nurses ratio (more patients) for night shift. Bed baths for complete-care patients and morning labs are usually NOC's domains, so you will get to practice basic nursing skills. The most challenging part of night shift that I faced, in the 15 months I worked nights, was fighting the impossible exhaustion. Of course everybody handles it differently, but right around 0400 was when everything started picking up on my floor. It was right when I was losing power too. Match that up with the difficulty of sleeping during the day time and I quickly discovered that night shift was not my cup of tea. Everybody is different though, some of the nurses I work with have been on nights for 30 years. Best of luck to you!