Nurse-Patient Ratios

[PA_RN87, BSN, MSN, RN, APRN]

I'm still the "new kid on the block" with a little over 1.5 years experience, all on a medical-oncology unit. I'm struggling with staffing, and how it clearly has nothing to do with the acuity of the census. After basically being told to shut up and deal with it, because it's just the way things are and nothing is going to change, I'm curious about others' experiences and staffing conditions. A brief survey to open discussion:

1. What type of unit do you work on, and in what state?

2. What is your nurse patient ratio, and how does it change between day-evening-night shifts?

3. How many supporting staff (nursing aides, patient care techs, assistants, secretaries etc.) do you generally have to help?

4. Do you have a charge nurse, and what are his/her responsibilities and duties?

5. Do you feel your staffing ratios are adequate (generally speaking - I know we all have good days and bad days) for your usual census?

To start on my end...

1. Medical-oncology unit (primarily). Our hospital recently closed the surgical unit due to frequent drops in hospital census. Surgical patients now are sent to the medical unit, and medical overflow patients are sent to us, or to the overflow unit associated with our telemetry unit. We also occasionally get surgical patients.

2. Day shift 5:1, evening shift 6:1, night shift 7 or 8:1. That being said, I've occasionally had 6 patients on D shift, or 7 on E shift.

3. 95% of the time we only have 1 aide for the entire unit (up to 23 beds). Every once in a while (rare enough to be a pleasant surprise), we will have 2 aides. We always have a secretary on D shift, but maybe 50% of the time on E shift. Night shift will have 1 secretary that travels between the units.

4. We do have a charge nurse. While they are reevaluating what the role requires, currently the charge nurse keeps tabs on every patient, including most of the major and important details of each patient, and overall plan. Most of them will make phone calls to the doctors if needed. It's sort of a hybrid administrative-floor nurse role. That being said, the night shift charge nurse also takes on a full patient assignment in addition to their charge duties.

5. Most of the time, ratios are not adequate for our normal patient population. We frequently have many total patients, physically demanding patients, and MR patients from the local community home. It's not totally uncommon to finish first rounds 2 or even 3 hours into the shift, between bathroom trips, total bed changes, medication administration, etc. Occasionally we have days where there will be no aide at all. Are there good days where staffing is adequate? Absolutely. But most of the time general consensus is that staffing is inadequate.

We also don't have a pharmacist on-campus 24-hours a day, so I'm curious how common or uncommon that is? Pharmacy is available from 7a-11p Monday through Friday, and I believe 7a-7p on weekends. So if we need a medication "off hours," the order must be verified by a central pharmacist 2 hours away, then *most* medications can be obtained from our house-manager.

[workinmomRN2012, BSN]

Type of unit: M/S observation unit

Ratio: all 3 shifts 1:4

Supportive staff: 1 aid for 12 patients

Charge nurse: yes, it is one of the 3 staff RN's and a unit supervisor

I personally do feel that we are adequately staffed :)

[mmc51264, BSN, MSN, RN]

1. What type of unit do you work on, and in what state? Ortho, NC

2. What is your nurse patient ratio, and how does it change between day-evening-night shifts? 4-5 day; 5 nights (we are 12 hours shifts)

3. How many supporting staff (nursing aides, patient care techs, assistants, secretaries etc.) do you generally have to help? usually as least one aide a secretary and a charge nurse all shifts. Depending on census, charge nurse may have a pt (up to 3).

4. Do you have a charge nurse, and what are his/her responsibilities and duties? see above

5. Do you feel your staffing ratios are adequate (generally speaking - I know we all have good days and bad days) for your usual census? yes, although we could have more aides. Sometimes, when we off-service pts it is difficult to take care of some w/o help. We all pull together when the situation is not optimal

[TheCommuter, BSN, RN]

1. What type of unit do you work on, and in what state?

Acute physical rehabilitation unit, Texas

2. What is your nurse patient ratio, and how does it change between day-evening-night shifts?

Nurse/patient ratios range anywhere from 1:6 to 1:12, depending on how much staff we have. Ratios do not change from days to nights.

3. How many supporting staff (nursing aides, patient care techs, assistants, secretaries etc.) do you generally have to help?

Ideally, each nurse is paired with a CNA.

4. Do you have a charge nurse, and what are his/her responsibilities and duties?

I am one of the charge nurses. I do scheduling, handle call-outs, admissions, wound care, documentation, incident reports, address complaints, and occasionally take patients when we are understaffed.

5. Do you feel your staffing ratios are adequate (generally speaking - I know we all have good days and bad days) for your usual census?

1:6 or 1:7 would be sufficient enough to allow nursing staff to provide acceptable care. When we're up to 1:9 and beyond, we're overstretched.

[Hpy_Vly_RNBSN]

General Medicine unit Washington DC

Ratio is generally 1:5 on days and 1:6 on nights

Usually we have 3 techs split between 40 patients

Charge nurse handles staffing and patient placement and often take patients

We are understaffed most times It's a very hard urban hospital Sick and challenging patients

[grandpaj]

1. What type of unit do you work on, and in what state?

Inpatient oncology with medical overflow, lower midwest. I think our unit has 22-23 beds.

2. What is your nurse patient ratio, and how does it change between day-evening-night shift?

Days 1:4-6, Nights 1:6-8. We don't have a separate evening shift.

3. How many supporting staff (nursing aides, patient care techs, assistants, secretaries etc.) do you generally have to help?

Usually a secretary from 7a-11p four days a week and 2 aides for days, 1 for nights (16-20 pts). Typical staffing is 18 patients with 3 nurses and 1 aide from 7p-7a. A couple times a month or more, we do end up doing total patient care for 4-5 patients each.

4. Do you have a charge nurse, and what are his/her responsibilities and duties?

We have a charge nurse who has a full team of patients in addition to staffing for the next shift, assigning admissions, dealing with any drama that might arise throughout the shift, and completing administrative paperwork.

5. Do you feel your staffing ratios are adequate (generally speaking - I know we all have good days and bad days) for your usual census?

We've seen our staffing ratios cut at least once a year for the last three or four. Supposedly we staff by acuity, although we have a little matrix that shows how exactly many staff we are allowed based on the census. Not exactly acuity-based. Most nurses are very unhappy with the staffing, because when starting with the max amount of patients, admits seem to keep coming and administration continues to basically tell us we need to do more with less while simultaneously improving upon customer service.

[melizerd, ASN, RN]

1. What type of unit do you work on, and in what state? Med/surg, oncology, 19 beds, mid sized hospital. Wisconsin

2. What is your nurse patient ratio, and how does it change between day-evening-night shifts? Days 4 patients, PMs 5, nights 6. I have occasionally seen 5 during the day but it's a rarity.

3. How many supporting staff (nursing aides, patient care techs, assistants, secretaries etc.) do you generally have to help? HUC-from 0630-2300-each unit has their own, 3-4 CNAs on days and PMs, 2 CNAs on Nocs

4. Do you have a charge nurse, and what are his/her responsibilities and duties? Yes, staffing for the day and assign patients, though we work well together so we all collaborate to spread out heavy patients. They have their own patients (though usually less patients than the rest of us).

5. Do you feel your staffing ratios are adequate (generally speaking - I know we all have good days and bad days) for your usual census? Yes. I feel safe and supported.

We always have a pharmacist.

[dream'n, BSN, RN]

OP-You work Medical/Oncology and have 7-8 patients on night shift without an in-house pharmacist?? Do you not give chemotherapy on nights? I can't imagine having 8 patient's with chemotherapy being administered by me and all that entails plus post chemo neutropenics mixed in too. I would never be able to handle 8 patients like that. These oncology patients are too fragile for such a high nurse/patient ratio. My maximum patient load is around 5 and that can be really pushing it, with chemo hangs, crazy blood counts, septic neutropenics, and new cancer diagnosis education.

[melizerd, ASN, RN]

I'm in a similar type unit and chemo is done during the day. We don't do it at night and patients getting chemo almost always have one on one nurses which changes the ratios on the floor.

[Meriwhen, ASN, BSN, MSN, RN]

1. What type of unit do you work on, and in what state?

Psych, CA

2. What is your nurse patient ratio, and how does it change between day-evening-night shifts?

Because of state regulations it can never exceed 6:1 regardless of day, time, hell or high water. Usually I have a patient load of 3 or 4.

3. How many supporting staff (nursing aides, patient care techs, assistants, secretaries etc.) do you generally have to help?

1-2 techs, a unit clerk except on the weekends. It's primary nursing so the tech(s) are there mostly just for rounds and sitting on 1:1s.

4. Do you have a charge nurse, and what are his/her responsibilities and duties?

Yes. They man the nurses' station, take reports, set the unit schedule, assign patients to nurses, cover for breaks, often take a patient load of their own (not always a full load), assist with admits, transfers and discharges, and do whatever else they need to to keep things going.

5. Do you feel your staffing ratios are adequate (generally speaking - I know we all have good days and bad days) for your usual census?

To be honest, after starting my nursing career off in a non-ratio state where I've been the only nurse for up to 16 patients, I feel positively spoiled even when I have a full load of 6.

[firstinfamily, RN]

1. Telemetry/Medical 26 bed unit. North-East MD

2. 12 hour shifts: 1-6 on days, 1-7/8 on nights

3. 1 secretary full time on days, 1 who floats on nights CNAs 2-3 on days, 2 on nights

4. Charge nurse both shifts, sits tele, takes off MD orders, gives support to staff when needed, takes 2-3 patients when needed.

5. 7-8 in acute care is a lot.

I suggest you get a hold of a professional journal that specializes in your field and research what staffing ratios are throughout the country. I presented an admissions criteria for IMC a few years ago that the facility actually adopted, it was based on research at the time. Staffing is usually always done by census not acuity. Acuity rating tools were done in the past, in the 80's & 90's there were several tools available---you might try a general search for "rating acutity levels". If you can find a tool that represents your type of field, you might present it to management to see if nursing staff can be justified. Warning here: the tools used in previous times did not reflect nursing time spent on admissions and discharges and therefore were invalid because we all know those take a lot of nursing time. Good Luck!!! See it as a challenge and an opportunity to promote change in your facility.

[Here.I.Stand, BSN, RN]

1. What type of unit do you work on, and in what state?

SICU--mostly trauma and neuro, smaller general surgery and CVT surgery populations--upper Midwest.

2. What is your nurse patient ratio, and how does it change between day-evening-night shifts?

Generally 1:2. 1:1 if they are on CRRT, are wildly unstable, possibly brain-dead organ donors (can't remember offhand). 2:1 if on ECMO. All shifts have the same ratios

3. How many supporting staff (nursing aides, patient care techs, assistants, secretaries etc.) do you generally have to help?

0-3 CNAs depending on census. Sometimes will have to pull them to be 1:1 sitters if the need arises. No techs. There's a secretary M-F 9-5 but honestly I'm not sure what she does; not what I remember HUCs doing at other places I've worked...and they take lots of breaks. We have house float RNs who we can page to help out if we're drowning. We generally don't utilize transport staff in the ICU; if they're on a vent, the RN, RRT, and CNA take the pt (the CNA to help push poles and stuff.) 1-3 RRTs per shift, shared between MICU and SICU. Chaplains are heavily utilized which is a HUGE help w/ family when we're admitting someone--especially a new trauma or stroke.

4. Do you have a charge nurse, and what are his/her responsibilities and duties?

Yes. Respond to codes, a lot of the bed management, help settle admissions (and their families), do the assignments, take pts when necessary (this isn't ideal), be a resource for the RNs on the floor...there's probably other stuff, but I'm not a charge nurse myself so just trying to think offhand what they do

5. Do you feel your staffing ratios are adequate (generally speaking - I know we all have good days and bad days) for your usual census?

I think so; they're pretty standard ICU ratios.