Expecting better results with less staff and high ratios

Nurses Relations

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Management at my hospital, like a lot of places, upped nurse ratios throughout the hospital. I'm in ER where there is a huge emphasis on getting admitted pts upstairs. But now the floor nurses have higher ratios. The charge nurses now must take pts. They took away a designated admit nurse. Now, to top it off, the techs can no longer to accuchecks because of some new state regulation.

Yesterday I had a pt who came into the ER at 9:30 AM. She was marked for admit at around 11:30. Then we had to wait for a room. Of course the floors can't get rooms available until they discharge. Waited forever for that, then the room was dirty, then they changed the room assignment, and that one was a terminal clean, then the nurse was busy, after I sent the SBAR yet again because their printer was not printing right. Then the admit doc decided to change the pt to Tele. Then waited for a room, then it was dirty, SBAR sent, report given. Room a terminal. Finally, after 9 PM the pt went upstairs. The pt and family were so patient, I really had to reassure them and keep up a positive rapport though.

90% of our flow problem is because upstairs doesn't have enough help! And some of my crankier ER colleagues will then take a self-righteous attitude toward the floor nurses, severely resenting them for being on lunch when they want to give report. Yet, there is no designated charge nurse who can take report. Yeah, lets turn on one another instead of naming the true cause.

Thank you for reading.

nursefrances, BSN, RN

5 Articles; 601 Posts

Specializes in Ambulatory Surgery, Ophthalmology, Tele.

Love it and all true. :up:

Sometimes I wondered if they were trying to make us quit. :down:

Someone 'higher up' at the hospital during a budgeting meeting: "Hey! I have an idea! Let's up the acuity, drop staffing, have the CNAs go home after noon vitals, send the secretary home, get rid of medical records and let the nurses copy and breakdown the charts when they have a SNF transfer/discharge. And let's add some new documentation screens to their assessments, just for fun. Yeah that'll work!" :woot:

It just isn't cost effective and they wonder why the nurses have OT. :no:

I used to work tele overflow in the ER sometimes. I thought this was great. It was still like working tele but had a little bit of an ER feel to it. I liked to work there when I did extra days.

I would receive the patient in the ER and admit them while the patient was waiting for a "real" room. The patient could also have any ordered testing done. They would do this when the hospital was pretty full.

1fastRN

196 Posts

Specializes in Emergency Nursing.

We have a lot of the same problems at our facility! We hold admitted patients for HOURS on end, sometimes days if they're iso or they need to go to a specific unit.

Do you have to give report on each patient? We only have to give report on psych, ICU, and Step-down patients. I can't imagine doing every admission!

And we also get the run around when trying to give report. It can be very frustrating when it's an unstable ICU patient I'm trying to get to the unit on top of my other patient load. One night and ICU nurse was giving me so much attitude and asking me questions, shift was ending and I wanted to get the patient up to the unit so I wouldn't have to endorse them to another nurse and further delay their care.

Me: Hi, I'm calling to give you report on patient Mrs. Q. How is your night going?

ICU nurse: "Ummm... are going to give me report or not?" (Instant attitude, off on the wrong foot.)

Me: "Uh, yeah....so... (gives report from start to finish)"

ICU nurse: "Are you going to correct the patients potassium? What about the Hgb? Why aren't you infusing? What about the mag? What about pressors?" (sounding like a real know-it-all)

Me: "No orders have been put in yet, so far we've given xyz drugs and x amount of boluses. It's out of my scope to give meds without a physician's order... The intensivist is at the bedside now so I'm assuming he'll address these issues after he's done with the patient." (In my head, I'm thinking Rome wasn't built in a day, and if I could correct all the patient's issues within a few hours of arrival, we wouldn't need an ICU now would we!?)

ICU nurse: "(In snarky voice) Huh! You just don't want to ask the doctor!"

Me: (Trying not to freak out) "LISTEN, I gave you report and stabilized the patient. The doctor is just seeing the patient now and I have carried out all the orders thus far. I have 7 other patients right now... I would like to get this patient to the ICU so she can get the care she needs and deserves. Do you have any other questions at this point?"

After hanging up I was FUMING. I would normally take this patient up myself but I was so angry I was afraid I would freak out on this specific nurse. (I will never forget her name btw!)

Sometimes I wish us nurses wouldn't take our stress out on each other. I'm sorry you're getting another patient and I hate getting hit with new patients especially at end of shift. But it's our job, atleast in your unit you have strict nurse to patient ratios... for me, there is no standard ration and patients keep rolling in whether we have room (and staff) or not.

/end rant

Sorry if I went off on a tangent, AN is a great outlet for us to vent. :yes:

nursefrances, BSN, RN

5 Articles; 601 Posts

Specializes in Ambulatory Surgery, Ophthalmology, Tele.

Sometimes I wish us nurses wouldn't take our stress out on each other. I'm sorry you're getting another patient and I hate getting hit with new patients especially at end of shift. But it's our job, atleast in your unit you have strict nurse to patient ratios... for me, there is no standard ration and patients keep rolling in whether we have room (and staff) or not.

/end rant

Sorry if I went off on a tangent, AN is a great outlet for us to vent. :yes:

That's one of the many great things about being here, my friend. ;)

I like to have the "I'll scratch your back you scratch mine" attitude (in a positive way of course). I try to be as helpful as possible because favors do come back. Sometimes I worked in ER overflow and when I would get an ER admit (back on my normal floor) right when I was planning on going to lunch (finally), I would mention. Only if it was someone I knew. And if I had previously helped them in some way and if they weren't too busy they would say, "I will finish (whatever they were working on) and then have transport bring them up in like 25 minutes, will that help?". Loved the ER peeps!

I would do this when possible while working with any and all staff, CNAs, housekeeping, RT/OT/PT. You help people out when you can and you will be surprised out how people will return the favor when they can. It's a win-win situation.

allnurses Guide

Nurse SMS, MSN, RN

6,840 Posts

Specializes in Critical Care; Cardiac; Professional Development.

They have been toying with our ratios and the grid for the last six months. Then they wonder why patient satisfaction scores for call light responsiveness and nurses explaining things tank!!

Emergent, RN

4,226 Posts

Specializes in ER.

Then management has lots of meetings to try to figure out how to make water into wine. What new policy can we implement to make three loaves of bread and two fishes feed a crowd of 5,000?

Hmmmmm.....

RunBabyRN

3,677 Posts

Specializes in L&D, infusion, urology.

It's amazing how many cuts keep having to be made, and how often that comes from staffing. It may benefit the bottom line, but it doesn't benefit anyone else! The patients suffer, morale suffers, nurses and other staff can get downright destructive if it gets bad enough... It just baffles me how this continues in this trajectory. There has to be point at which someone (on a board) goes, "Wait a minute... Maybe we need to try another approach..."

Caffeine_IV

1,198 Posts

Specializes in LTC, med/surg, hospice.

And they wonder why we have so many patient falls. We know how to manage our time but cannot be in multiple places at once. My hospital wants to return to primary care and get rid of techs but that means MORE nurses. Not 7-8 per nurse doing everything, we are set up to fail.

allnurses Guide

Nurse SMS, MSN, RN

6,840 Posts

Specializes in Critical Care; Cardiac; Professional Development.

Yep. We are a PCU. Our grid has changed to two techs for 32 patients. We get three if we go up to 36 (full capacity). Nurse ratios are SUPPOSED to be 3-4:1 but lately have been 5:1 frequently. There are murmurings of eliminating another tech position and hiring another nurse instead. It is ridiculous. I am looking as hard as I can for a position not on the floor. My body and stress level, not to mention my sense of outrage when taken to task for patient satisfaction scores, can't take it. I'm a good nurse. I feel beaten down.

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Insanity: doing the same thing over and over again and expecting different results.

Albert Einstein

nynursey_

642 Posts

Specializes in Med/Surg/ICU/Stepdown.

I actually overheard a charge ask a staff nurse if she'd mind picking up another patient, even though it would make her out of ratio. Insanity.

RNsRWe, ASN, RN

3 Articles; 10,428 Posts

I actually overheard a charge ask a staff nurse if she'd mind picking up another patient, even though it would make her out of ratio. Insanity.

And if that's the first time you heard of that, I can assure you you're going to hear that again and again going forward.

You're supposed to have five patients, but now you need to have a sixth. You're supposed to have no more than one admit, but here's your second. Charge is supposed to have no more than (fill-in-the-blank number of patients) but now there's one more, because everyone ELSE is at their maximum, or over it.

The nursing supervisor and ED is pushing to get patients up into the rooms, but you as charge know that none of your nurses can handle one more. YOU can't handle one more, either. So you keep them at bay, somehow, for one more hour, then one more. Until the Supervisor is ready to chew your head off, and that patient WILL get into a room NOW. And then in the morning (former night-shifter here!) the unit manager will be hollering "why did you allow that patient up here if you were understaffed??" ARGH....why WERE we understaffed??? Then again, it's not "understaffing" if it's now your New Matrix. Now it's just the new standard ratio.....and it's not working.

I wish I could call it insanity, but honestly, it's just what I'd call Modern Floor Nursing. And a primary motivator for my leaving it behind a few years ago.

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