I'm curious to see if other charge nurses have some sort of strategy for ensuring (to the best of their ability) that the assignments made for the nurses are fair in terms of acuity, time factors in care, treatments (tube feedings, straight caths), incontinents, emotional/psych issues, etc.
If anyone can post what works best for their unit or institution I'd be very happy to hear it. Currently, it seems our assignments often have no rhyme or reason: sometimes entirely light or rediculously heavy. I'd like to find a system to bring to our unit that will ensure a fair assignment is more than the opinon of whoever made the assignment.
I could use some serious suggestions to bring to this meeting next week because something has got to change. We NEED to start assigning by acuity, I can't understand why our clinical lead / nurse manager doesn't understand this. I would much rather walk a little more than do what we're doing now!!
Glad to see I'm not the only one trying to fix a broken system. Hopefully this discussion will find answers for everyone!
Since most hospitals only have an acuity system in place because JCAHO requires it, and no charge nurse in my recent experience looks upon it other than a chore to be completed; I would have to say no. i have a hard time getting a pt. transferred to telemetry, not because he needed telemetry, but beause the 4:1 ratio at least meant he would get closer observation. My most recent charge nurse on both day and night base assignments on who they don't like, and who is of certain ethnic syatus. that is why some of us work like dogs, and some of us play with the internet and text all day long.
I honestly didn't even know there was such an acuity system - at least how it relates to a nursing assignments, anyway. Must be it is done primarily for staffing of the unit only (FTE's etc.).
Can I also ask here how does your unit staff for 12 hr nurses? Where I work the 7a to 7p nurse gets an assignment and whoever follows them at 7 pm picks up their assignment and carries this through on the night shift. Unfortunately, these 12 hr night nurses assignments change constantly even when they come in for 3 or 4 days in a row because they always follow the day 12 hr assignment. This is just how it's always been done. This can make for long night shifts when the staffing goes down, and if your 4 hr eve shift assignment was on the heavy side. Plus I'm a believer in consistency and getting down a routine with treatments, meds, etc.
Also, the 7p nurse is very likely assigned an admission or picks up an admission that has come in on evening which most likely isn't done yet. Many times I've signed off admission orders that have been sitting in the chart for hours right after getting my report on my assignment. This can make for a chaotic 8pm med pass for sure.
We have been dealing with this issue on my unit forever. We have a staff meeting next week to talk about this so I would love to bring some suggestions with me. On our unit, we do NOT staff by acuity whatsoever. We staff by location. Our unit (med-surg / ortho) is 2 long hallways with groups of 4 rooms we call "pods". Our ratio is 6:1 so the rationale is to keep the nurse in 1-2 pods so he/she doesn't have to walk all over the place. However, our unit is rarely full, so half the time your 6 pts. may be spread out amongst 3-4 pods anyway, so you end up walking the entire hallway. To me, this system is insane. You may be kept in 1 pod, but every single one of those pts. in the pod is a total care, or a new post-op hip, etc. Additionally, our hospital is so small we don't have a peds unit so guess where they bring the peds pts? To us. This is also not factored into our assignment, it still goes by room location. I have had assignments where I have had 2 postop hips, a 6 month old with pneumonia, a postop spinal fusion, a confused woman setting off the bed alarm every 5 min, and a complete total care..but it was "fair" because they were all in the same 2 pods. I've also had assignments where all 6 of my pts. were self-care and stable, but another nurse is sinking, because "it goes by pods." And the real clencher is the night shift nurses make up our (day shift) assignments at the end of their shift. Not the charge nurse. No, our charge nurse is just whoever is working on the floor that day who happens to have the most experience, she still takes a full pt. load just like everyone else, the only difference is she carries the "charge phone."
Okay I realize I got off on a little rant there, but I could use some serious suggestions to bring to this meeting next week because something has got to change. We NEED to start assigning by acuity, I can't understand why our clinical lead / nurse manager doesn't understand this. I would much rather walk a little more than do what we're doing now!!
I would almost bet money that we work at the same facility.
One of the hospitals in our four-hospital chain in our city assigns by blocks--a 5-6 room stretch on Med-Surg that doesn't change, regardless of acuity. It's "this is my little corner and this is where I am usually going to work." Period. I don't work there anymore
I switched to a smaller, closer hospital in our chain where there is talk about assigning per acuity, but sometimes you will still get assigned three total cares, while someone else assigned "self care" type patients twiddle their fingers all day at the nurse's station. But there is some attempt to assign frequent IV pain/nausea push-type patient to RNs--but even that doesn't go most of the time, since LPNs are assigned their patients under an RN as a "team" so that the RN ends up doing the IV pushes.
I much rather liked a hospital in a more progressivde state where we were all RNs as LPNs were being phases out (no offense to LPNs, but they do increase the workload for RNs).
I'm a student, so all you experienced nurses can laugh me down if need be, but we're being taught to assign patients to nurses according to what it likely the best outcome for the patient. So if I have a patient who is very complex and should be watched very closely, I would assign that patient to one of my more experienced nurses. If I have a patient who is 2 days post-op, doing well, planning to be discharged today I would assign her to a recent-grad nurse who can do discharge teaching. If I have a stable pt who needs only PO meds, not on telemetry, etc., I would assign him to an LPN, and so forth.
Making assignments is difficult. I challenge anyone to try it. It is a thankless job and no matter who much time you spend on making it fair, there will be those that complain. Just remember that you are the one who knows the unit and what is going on.
My response to the grumbling and whining (why didn't I get all my patients back?, why am I spread out all over the place? why does so-in-so have all the easy patients? why do I have to give report to three nurses?, etc...) is simply "I am thinking about the entire floor and you are only concerned with yourself."
One placement I was at had the 1-4 system as well and it did work well. The nurses level of experience was also taken into account and there were certain patient types (particularly pts with subarachnoid haemorrhage) that had to be allocated to a senior nurse. Also, the nurses were allocated into 2 teams (usually 3 per team) with experience levels roughly even between them and each team had someone experienced to be team leader. The idea behind this was that you would know a enough about the patients your team members had to be able to cover them for breaks or if they needed assistance, etc. It worked very well in that ward.
Also the 1-4 system didn't need to be consistent between wards as long as it was consistent within the ward. We did have a chart to help categorise patients though
Its a shame that a nurse above calls it "grumbling and whining." There are times when unfortunately the person making the assignments is not thinking of all issues, and, unfortunately, some of the time, a hand-full of people are the ones who do seem to get the "good" assignments. Lets face it, some people are just not competant or thorough in doing this difficult job. Instead of calling it "grumbling and whining", maybe we should make a better effort to investigate why the nurse feels the assignment is not fair. Its bad for unit morale. Also, it doesn't sound like anyone else is watching out for these nurses, so I guess they do need to be concerned for themselves!
Our ward is split into bays of 4-6 beds. In bay one,two and three there are 4 beds in each and two single side rooms. Nurse A is given this end which totals 14 beds. The other end is bay four and five which have 6 beds in each and 4 side rooms. Nurse B has this end which totals 16. Bay 4 is used mainly for the wanderers/dementia/post ops as they can be kept an eye on closely. It doesnt matter how ill the patient is, if there is a space then in they go,it makes no difference how dependent the patient is.
On a good well staffed shift we run with Nurse A and an Aide down one end, and Nurse B and an aide down the other end. There is normally a 'spare' Aide who goes to which end is more heavy and the nurse in charge/sister floats but mainly deals with staffing,doctors rounds etc.We are an Ortho unit.
On the last unit I was on in NS the nurses self-assigned. Pts were assigned acuity on the report sheet (although most of them were 3's). All nurses for the shift would listen to report on all patients (32 bed unit with 4:1 ratio) and then they would divide up the patients amongst themselves. This seemed to work really well for them and patients were assigned within a couple minutes.
findingmywayRN
114 Posts
Glad to see I'm not the only one trying to fix a broken system. Hopefully this discussion will find answers for everyone!