Need some advice/direction

  1. Well I think I've just had it. we are doing a new staffing matrix and its getting real scary trying to take care of patients with no staff. We worked this weekend with only 2 RNs doing complete cares for 13 pts on a med surg floor. One of the pts kept trying to get out of bed after an amputation. MD didn't want to order restraints because it would make the pt too agitated. Couldn't get a sitter because we didn't have enough pt according to the matrix. One of my pts developed metabolic acidosis, co2 was 10 and bicarb was 9. She ended up on 2hr vital signs but wasn't sick enough for the unit. Oh by the way, she also was going into dt's from ETOH withdrawal so I had my hands full with her alone, let alone my other 5 pts. The next night we earned 0.5 aides but thats because we went up to 14 pts. She was supposed to leave after 4 hiurs but we kept her and caught hell from the manager in the morning because we overstaffed.

    Now here is my question, I am tired of hearing everyone whine and complain about the situation. I want to DO something but I don't know what. I of course started with my manager but he said his hands are tied by upper management. we have a staff meeting tomorrow and I want to do something that would be more proactive than *****. I am really scared that something is going to happen to one of my pts and I'll lose my liscence over short staffing. I'm fairly new and tried to get some of the more experienced nurses to help with this but they said that wriiten letters of protest don't work. Any suggestions? Thanks for being patient with this really long post!
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    About blue280

    Joined: Mar '03; Posts: 78; Likes: 4
    Specialty: 6 year(s) of experience in geriatrics


  3. by   ainz
    Written letters of protest will do nothing, they go in the circular file. Complaining, whining, griping, accusing administration of being money-hungry and uncaring, all of this will not only do you no good but aggravate the situation.

    Unfortunately there is no short-term fix because the situation you are facing is the result of years of nursing's inability to demonstrate effectively their contribution and place in the healthcare system. An accumulation of things (some direct and some indirect) over the years has demonstrated nursing's inability to clearly identify themselves as a profession, can't define what a "nurse" does, can't define what a "nurse" is, can't clearly demonstrate the one way to become a "nurse" (LPNs, ADNs, BSNs, MSNs, PhDs, all called "nurse" and nursing can't clearly demonstrate the differences between or the advantages of one over the other), can't clearly link NURSING interventions to better patient outcomes and that to improved financial performance of the organization and the healthcare system overall.

    These days the "for-profits" are out to make money. The federal government through Medicare and states/feds through Medicaid are out to save money by cutting back on reimbursement and refusing to pay for things that used to be paid for. There is an aggressive effort to reduce the amount of money spent in the US on healthcare. Hospitals are the most expensive place to provide care so most policies are targeting the hospitals. so hospitals react by trying to control and reduce their costs.

    Nursing is the single, largest line-item expense in the hospital's operating budget. This naturally makes nursing a target for cost reduction. It is really nothing personal to the nurses, just business. Nurses usually react very emotionally and begin accusing administration of a conspiracy, greed, not caring about patients, and on and on. This aggravates the situation like throwing gas on a fire.

    The average staff nurse has no idea how their practice affects the hospital's financial performance. THIS IS THE ONLY WAY NURSING WILL GET THE ATTENTION OF ADMINISTRATION. Nurses do not seem to understand that, believe that, or even care. To improve this situation, nursing must begin to link NURSING (not medical or other professions) interventions to improved patient outcomes to improved financial performance of the organization. This must be done at hospitals all over the country, begin to appear in healthcare literature (not just nursing literature because no one else reads it), and be backed up by objective, quantified data that is presented in a professional way.

    Nursing research is almost laughed at by many corporate executives and administrations because it fails to hit home and translate into generalizable, practical, applicable nursing actions that directly improve patient care and financial performance.

    How long will all of this take? Probably years.
    Will it ever occur? Probably not because nurses aren't interested in doing the work it will take.

    What will happen in the meantime? Nurses will continue to work under the conditions they are working under and slowly be replcaced by less educated and less expensive personnel.

    Can unions help? Yes for the immediate short term but this activity is counter to everything a true profession is. True professions are autonomous, self-regulating, do not need to engage in collective bargaining and the sort. Unionization sends the message that we are a blue-collar, semi-profession, with a paid-by-the-hour mentality, and we must be managed by administration and unions because we cannot manage ourselves.

    It is sad to see what is happening, and unfortunately, I am not convinced that nursing will do what is needed to advance itself and ensure its place in the healthcare system.

    We also need to all join and be active in our association and have it truly representative of our profession so that resources and energy are focused on things that really matter. Example is the emphasis the ANA places on diversity. the principle being we should relfect the community we serve. If you look at the statistics the majority of America is caucasion, the majority of nursing is causcasion. The demographics line up fairly closely, there are a few more causcasion nurses than in the general population. But the real issue is that when it is all said and done, NOBODY REALLY CARES!!!!!!!!!!!!! They care more about good healthcare that is cost effective!!
  4. by   blue280
    I'm glad you answered ainz, cuz I think you are smart and can put this in perspective. I guess I'm wondering right now how to protect myself so I don't lose my license to practice. I already belong to the ANA but like you said this is a problem that will not have a quick fix. I'm scared of burn-out, which I can see happening. I have been up for 20hrs and I can't sleep yet cuz I can't relax enough. I can't quit cuz I signed a bonus contract ( I knew it was too good to be true, but ignored the little vice in my head) so I just want my pts nad myself to be safe. Outside of joining ANA can you think of anything else I can do to help this situation right now?
  5. by   blue280
    oh and by the way, one thing I have been doing is to remind pts to fill out their pt satisfaction surveys. If they tell me that the appreciate the job I do, I tell them its important to let administration know that it is the NURSING care they appreciated. On the other hand, if they felt they did not get the attention they deserved, I will let them know the staffing ratio for that period of time and encourage them to use that information in their complaint. I agree when nurses complain, it does go unnoticed but if we can educated pts about who does the care in the hospitals and they can relfect that in the surveys, maybe it will help a bit.
  6. by   purplemania
    It would help if the discharge summary reflected the NURSING that needs to be done at home (education, medication administration, etc.) I think the discharge nursing diagnosis and nurses plan of care for home care ought to be part of the discharge summary so people can see how impt. we are to their wellbeing. If MD orders can be standardized,so can nursing "orders".
  7. by   ainz
    If you have someone that heads up your quality management department or performance improvement function, get with them on some things. If you are starting a new matrix this is an excellent opportunity to gather data on the change.

    If you are JCAHO accredited they want to see analysis of your organization, data collection (objective data), analysis of that data concerning patient outcome, and actions by the organization to improve performance.

    This would be a good PI project I would think. I would develop a list of clinical outcomes you wanted to monitor in relation to staffing. Things like medication errors, omitted treatments, nosocomial infection rates, patient injuries, cardiopulmonary arrests and events, physician and patient complaint tracking (monitored internally and separate from the organization-wide survey). JCAHO requires organizations to monitor certain staffing effectiveness indicators and tie that to patient outcomes. You could use that information to do a focused study on your unit of the new staffing matrix.

    You can generate some objective data to see if staffing is adequate or not. I would also work with the finance people and tie in financial performance as well. The budget and department operating summaries should include revenue and expenses for each unit so look as those trends to (this will get administration's attention).

    Be prepared to objective analyze this data. It may say that your staffing is working well, then it may not. I would also include some staff factors such as number of days out sick, tardies, number of write-ups for staff errors or behavior, something to indicate how well the staff is handling the pressure and stress of the current staffing. Also look at your patient population for some objective measure of acuity.

    Your PI or Quality Management person should see this as an opportunity for a good PI project in assessing organizational performance and staffing/skill mix tied to clinical outcomes.

    If I can help offer more concrete suggestions I will be glad to, you can PM me. First see if you can get support for this project.

    Having good data to back up what you suspect you are seeing is the only way to get things changed. I will be glad to offer more specific strategies and suggestions to try and get buy-in from your nursing management as well. Just let me know and good luck.
  8. by   blue280
    ainz, great ideas and direction! This is the kind of feedback I was hoping for. We could use this as an opportunity for constructive change and if WE the nurses bring it to administration in this manner, I think we'll do a great service to the way nurses think and others view the nursing profession! I'm kinda excited, wish me luck when I propose this at the staff meeting tomorrow. I'll keep you posted. Chris
  9. by   pickledpepperRN
    I would verbally tell a manager, supervisor, or administrator that as a professional registered nurse this assignment places my patients at risk. I would notify the physicians of the assigned patients that the care could be unsafe due to insufficient staff.

    If after asking firmly and politely for sufficient staff it was still unsafe I would write as soon a possible that the hospital NOT the nursing staff is responsible for any harm that happens due to the unsafe staffing up to and including death from failure to rescue. The name of the manaagement person, date, time, and nursing staff provided would be on it. I keep a copy. After being relieved of duty write all you can remember. Report such as an unsafe matrix to a regulatory agency.

    Maybe the article pasted below will help in the longer term:

    Nurse-Staffing Levels and the Quality of Care in Hospitals
    Jack Needleman, Ph.D., Peter Buerhaus, Ph.D., R.N., Soeren Mattke, M.D., M.P.H., Maureen Stewart, B.A., and Katya Zelevinsky
    Background It is uncertain whether lower levels of staffing by nurses at hospitals are associated with an increased risk that patients will have complications or die.
    Methods We used administrative data from 1997 for 799 hospitals in 11 states (covering 5,075,969 discharges of medical patients and 1,104,659 discharges of surgical patients) to examine the relation between the amount of care provided by nurses at the hospital and patients' outcomes. We conducted regression analyses in which we controlled for patients' risk of adverse outcomes, differences in the nursing care needed for each hospital's patients, and other variables.
    Results The mean number of hours of nursing care per patient-day was 11.4, of which 7.8 hours were provided by registered nurses, 1.2 hours by licensed practical nurses, and 2.4 hours by nurses' aides. Among medical patients, a higher proportion of hours of care per day provided by registered nurses and a greater absolute number of hours of care per day provided by registered nurses were associated with a shorter length of stay (P=0.01 and P<0.001, respectively) and lower rates of both urinary tract infections (P<0.001 and P=0.003, respectively) and upper gastrointestinal bleeding (P=0.03 and P=0.007, respectively). A higher proportion of hours of care provided by registered nurses was also associated with lower rates of pneumonia (P=0.001), shock or cardiac arrest (P=0.007), and "failure to rescue," which was defined as death from pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis, or deep venous thrombosis (P=0.05). Among surgical patients, a higher proportion of care provided by registered nurses was associated with lower rates of urinary tract infections (P=0.04), and a greater number of hours of care per day provided by registered nurses was associated with lower rates of "failure to rescue" (P=0.008). We found no associations between increased levels of staffing by registered nurses and the rate of in-hospital death or between increased staffing by licensed practical nurses or nurses' aides and the rate of adverse outcomes.
    Conclusions A higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients.

    Source Information
    From the Department of Health Policy and Management, Harvard School of Public Health, Boston (J.N., S.M., M.S., K.Z.); the Vanderbilt University School of Nursing, Nashville (P.B.); and Abt Associates, Cambridge, Mass. (S.M.).
    Address reprint requests to Dr. Needleman at the Harvard School of Public Health, Department of Health Policy and Management, Rm. 305, 677 Huntington Ave., Boston, MA 02115, or at
    This article has been cited by other articles:
    * (2002). Nurse Staffing and Quality of Care. Journal Watch General Medicine 2002: 1-1 [Full Text]
    * Steinbrook, R. (2002). Nursing in the Crossfire. N Engl J Med 346: 1757-1766 [Full Text]

    The New England Journal of Medicine is owned, published, and copyrighted 2002 Massachusetts Medical Society. All rights reserved.
  10. by   gwenith
    Bingo! Darn Mom 128! Whinin gets you nowhere objectively stated concerns do!!!

    Write to the management just as you have written here listing the problems you had to deal with on your shift and why you were concerned for patient safety. Do not tell them thier matrix "stinks" and should be thrown away - that is confrontational instead suggest that there may need to altered to take into account factors such as unrestrained confused patients. Point out that perhaps there should be two levels of staffing one for unrestrained confused patients and another if restraints are permitted to be used.

    I keep coming back to nurses learning to shift problems from themselves back to other people. In pointing out that there might have to be allowances made for non restrained and if there is follow through (and stating it firmly objectively and most of all keeping copies for records) then the argument becomes managment to medical staff. I have seen this happen where the medical staff have been reluctant to sedate/restrain and nursing management have ahd to step in and discuss the realities of staffing to effect a change.

    Keep thinking of it this way "How do I make it NOT MY PROBLEM?" Somehow you have to make it thier problem.

    AINZ - I have to disagree with you on unions - I live in a country that is far more unionistic than yours and it has won us
    6 weeks paid annual leave
    10 days paid sick leave - accruable
    Long Service Leave - 0ne week holiday for every year of service after 10 years
    No lift policies for nurses so as to stop back/shoulder injuries
    38 hour week

    I could go on but the bottom line is that we ARE better off with a union and it does not seem to have affected the way the public views us at all. If anything the other professions are jealous!!!!
  11. by   pickledpepperRN
    Another article to use.
    Original Contribution

    Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction
    Linda H. Aiken, PhD,RN; Sean P. Clarke, PhD,RN; Douglas M. Sloane, PhD; Julie Sochalski, PhD,RN; Jeffrey H. Silber, MD,PhD
    JAMA. 2002;288:1987-1993.
    Context The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-to-nurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice.
    Objective To determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue (deaths following complications) among surgical patients, and factors related to nurse retention.
    Design, Setting, and Participants Cross-sectional analyses of linked data from 10 184 staff nurses surveyed, 232 342 general, orthopedic, and vascular surgery patients discharged from the hospital between April 1, 1998, and November 30, 1999, and administrative data from 168 nonfederal adult general hospitals in Pennsylvania.
    Main Outcome Measures Risk-adjusted patient mortality and failure-to-rescue within 30 days of admission, and nurse-reported job dissatisfaction and job-related burnout.
    Results After adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in the odds of job dissatisfaction.
    Conclusions In hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses are more likely to experience burnout and job dissatisfaction.

    Author Affiliations: Center for Health Outcomes and Policy Research, School of Nursing (Drs Aiken, Clarke, Sloane, and Sochalski), Leonard Davis Institute of Health Economics (Drs Aiken, Clarke, Sochalski, and Silber), Department of Sociology (Dr Aiken), Population Studies Center (Drs Aiken, Sloane, and Sochalski), and Departments of Pediatrics and Anesthesia, School of Medicine (Dr Silber), University of Pennsylvania, Philadelphia; and Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pa (Dr Silber).