High Acuity, Low Staffing

[RNinICU]

I had another bad night at work last night, and the worst thing about it is that nights like this are beginning to be the norm. Our community hospital became part of a major health system about two years ago, and things have been getting worse ever since. Seems the bottom line is the major motivator for these people. Last night we had seven patients in our ICU, staffed with two RNs with less than six months critical care experience, an LPN, and myself, along with a new orientee who has been with me for only a week. There was another seasoned RN scheduled, but she was given the day off for "low census." My patient was a septic shock with renal failure, CVVH, hourly accuchecks with an insulin drip, PA line, ordered q4h hemodynamics, and multiple other drips. His MAP was never above 55 all night. All of the other patients were high acuity also. There was a cardiogenic shock on an IABP, an active GI bleed, a post arrest and a massive CVA who was seizing. My patient was 1:1 so I was expected to cover the LPN, giving her IV ativan and dilantin for her CVA, calling her docs, and signing off her orders. The other two RNs were so overwhelmed with their own assignments, that they were little help. As a matter of fact, they both came to me several times through the night for help and advise. When I protested about the RN being given off, I was told "Your numbers only call for four people, and you have an orientee who can be an extra pair of hands." So I asked why one of the newer people or the LPN had not been given off instead, I was told that it was Nurse A's turn to be given off. Now the new girls and the LPN think I was complaining about them, and I wasn't. I just thought someone should have used a little common sense and looked at the staffing mix and acuity. I documented my objection to the staffing and assignments and gave a copy to my unit manager and our DON, but I don't think it will do any good. When I talked to my unit manager about the situation, she confided that she was thinking of resigning her position because of problems like these. I have always loved my work, and this hospital, but with the big corporation mentality that has taken over, I don't know how much longer I can continue to work here. The only problem is that the other hospital in our area is part of another corporation, and has similar problems. All I want is to give safe and competent care to my patients, but I feel that I can no longer do this. There are safe staffing laws before the legislature in my state. They can't be passed soon enough, IMO.

[MQ Edna]

RNinICU, I've worked for a major hospital system (nonprofit) and a small community hospital (also nonprofit). All of the safe staffing guidelines ever written under the sun won't substitute for the critical thinking skills of the professional doing the staffing mix. I worked for many years with a much-loved old ICU nurse who, to put it gently, was moseying her own low-stress way to retirement and hadn't bothered to keep up with the developments in our fast-changing field. To look at this woman's experience on paper, you would have sworn that she could run the whole unit by herself. In reality, we were gently easing her along, giving her the lightest load, until she could leave. No way could I have carried a unit-full of complex patients with her "experience" and "support". Balloon pump? Never heard of 'em. CODES??? DOPAMINE??? Didn't "do that anymore". Don't get me wrong; this woman was special and had earned her days in the sun, but our lives were hell when a new House Officer simply looked at the RN behind her name and her years of experience without knowing the whole picture.

[canoehead, BSN, RN]

Ha. An ICU RN who "doesn't do" codes anymore? What a dingbat, and dopamine is pretty basic- Sheesh.

[RNinICU]

JeannieM, What does this RN do? We have a staff member like this too. She ends up taking care of the vascular surgeries and other less complicated cases. But the RN who was given off that night was a competent, experienced RN who would have made my night much easier. This is another thing that needs to be looked at in the staffing mix. I am not putting down newbies or LPNs when I say that there are times when you need another experienced RN to help with the patient load. Unfortunately, this kind of situation is happening more frequently in our unit. Or if the census is high, we often need to pick up a third patient instead of calling another staff member in. We hear about budgets and money all the time, but little about patient safety.

[MQ Edna]

Actually, what she did do was, ultimately, to retire and then died of cancer six months after her retirement. We all loved her dearly--enough to give her the easy cases and to "carry" her until she could retire. That said, I truly hope that when the time comes that I'm a burden, rather than a help, to my colleagues, I have the grace and dignity to accept it and get out. All this woman had done for years was ICU nursing, and she had no desire to do anything else. She was also humiliated at how much we had to help her, but was self-supporting and needed to work as long as possible. She never let us know about the cancer.

That said, I think the point that I was making was that the person/persons making the staffing decisions should KNOW the strengths and weaknesses of the staff members, whatever their level of experience, or should accept the opinion of those who DO know. The reverse of that is that I've been the "strong" nurse who NEVER got an EA (excused absence) because a "strong" nurse was needed, while the poor LPN/LVN or less "strong" nurse was crying for hours. Sometimes there are no easy solutions, but what's best for the patient should take precedence.

[mattsmom81]

I've also been in this situation before in a corporate, 'bottom line' hospital...and RN's are given the nights off so the cheaper LPN's can work....or the newer (also cheaper) help.

My suggestion is to get all the strong charge nurses together with your unit manager(maybe invite your DON too) and brainstorm fast. If your manager is not going to support you in your concerns re: unsafe staffing, then you will know where you stand.

Good luck...I would not stay in a situation like you describe with the acuity levels you describe...it sounds dangerous to me.

Does your BON have a Safe Harbor Provision? If so and your coworkers may want to start documenting what is going on to protect yourselves.

God Bless....these are tough times for nurses now that money is bottom line so many places.

[lgcv]

When someone is called off for low census, don't they put them on-call in case of an increasing census? If that is not the case it should be, from then on call them in if you need more help.

If the following shift or anyone else gives you grief about it, just say patient safety, that usually shuts them up.

[RNinICU]

Yes, we do put someone on call when they are called off for low census, but in this situation, the patient load did not increase, and we are staffed by "numbers." If we received an admission through the night, I would have been allowed to call another person in. At the beginning of the shift, I had expressed concern about the staffing, and was told by the supervisor that there was no way I was calling another person in. Our unit manager has been trying to get the staffing by numbers changed, but so far has had no success. She is frustrated herself, and is thinking of leaving her position, in part because of our staffing problems.

[RNinICU]

Last night I was scheduled to work 11-7, and was afraid I was going to end up with overwhelming responsibilities again. I called my unit to ask about acuity and staffing and was told I would be there with an LPN, two newer staff, and my orientee. Two other more experienced nurse had been called off for low census. Acuity was still high. I called the supervisor, and told her if she did not call in one of the experienced staff, I would be calling off sick. Amazingly, one of the older RNs was called in, and one of the newer people was given the night off instead. Last night went much better, and I actually got to do some teaching with my orientee. We all must start making patient safety a priority, and refuse to work with unsafe staffing levels.

[fedupnurse]

I have been beating this drum for years now. I have been on the bogus hospital committees, walked the walk and talked the talk with the suits, have arranged meetings between the staff and the suits (funny, when I arranged them people showed up and now that I refuse to go hear their crap, very few go). I took their acuity system that they use inappropriately and proved that their own numbers showed we were grossly understaffed for our patient acuity. All we hear about is the budget and the bottom line, this from very well paid execs! This is how I chose my screen name here. This is exactly what I am fed up about! They want it both ways. They want to say we have quality care here and great nurses but then they tell us to shut up about the conditions. All I have gotten for my efforts is the label of trouble maker. So now I am signing up with an agency. I will stay where I am but do any extra shifts elsewhere. Many of the staff in my unit are doing the same. Maybe when we stop doing all of the OT that has saved their butts, then they will finally get the message. They think nothing of pulling us to unfamiliar floors and our licenses be damned. They think nothing of pulling inexperienced people to us. Sad thing is we are usually so overwhelmed we can't help these poor slobs out. It is just a bad, unsafe situation all the way around. I have beat my head against the wall enough. I will continue to fill out short staffing forms, I will continue to document and report unsafe conditions to the state who will sit back and do nothing about it. But as far as the head games with the suits, I'm done. If the time pans out with Agency work, I'm so out of the place where I have worked for a long time now. RNinICU and JeanneM, I do know how you guys feel. It has led me to have nothing but contempt for hospital executives who only care about the profit margain. Sorry excuses for human beings!!!

[fedupnurse]

I almost forgot. I'd love to see everyone band together and fight for safe staffing but it took years for me to get my colleagues to even fill out a simple short staffing form. They sit back and complain about how horrible their shift was and I would say "show me the form". Oh we didn't fill one out. We didn't have time. I reply "You didn't have 30 seconds to tell the supervisor that it was unsafe and then sign your name to a piece of papaer? Do you really have time to sit in court and thru depositions because you didn't document that it was unsafe?"

I hope you had better luck them me in your quest. The suits have won. I give up. I have o fight left in me to deal with their ignorance and arrogance anymore.

[oramar]

I am going to put that quote in my signature. I did a post on it and it describes this situation to a T.