How to express concerns to manager?

Nurses General Nursing

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How to express concerns to manager?

I'm currently working a geriatric extended care unit with nurse to patient rations from 1:6-1:12. Night shift generally has more patients. Although, day shift has had 12 patients. My concerns arise from the type of patients we will soon care for.

Currently, we have long term care patients with a mix of rehab patients; but we are discharging our long term care patient and will only accept rehab patients. I'm a night shifter and was told that on the 3rd shift one nurse will likely have 18 patients with how many ever nursing assistants.

This makes me a little uneasy as I'm new to this setting and have never cared for this many patients. Also, I'm concerned for my peers who do not have acute care experience and also may not be able to care for as many patients. 

I'm hoping you all could assist with explaining the difference between a SNF and nursing home.

  • Are rehab facilities considered SNFs? 
  • What are the typical nurse to patient ratios for rehab facilities?
  • Are nurse assignments based on patient acuity or location of patient rooms?
  • What solutions can I suggest to address the nursing shortage besides the obvious as we will not have any new nurses starting soon?
  • Can you point me in the direction of scholarly references as I would like to have the sources to support my argument?

Thanks in advance 

You cannot suggest a solution to the nursing shortage.  You cannot support any argument.  Administration is changing patients to rehab..it pays THEM more. Administration does not CARE how hard the hands on care givers work. Wake up and move on.

Specializes in Psych (25 years), Medical (15 years).

A valid concern, Truthseeker, feeling uneasy about abilities to care for patients, given being new to this setting and the questionable experience of peers.

Although not exactly the same, at my last position, weekend option 12 hour MN shifts, I was often the only licensed employee with 18 geriatric psych patients and a non-medical tech. The acuity of patients ranged from being totally self sufficient to multiple relatively involved comorbid medical patients.

Here's what  happened: All licensed staff voiced their concern, sometimes in writing, and I for one, refused to perform superfluous duties if overwhelmed. Eventually, Public Health entered the picture and demanded better staffing guidelines.

This solution took years to occur, and administration would fudge on the guidelines if they had trouble staffing, yet the situation improved, overall.

My nickel's worth of free advice is to give the situation a try, inform higher ups verbally and by objective documentation of concerns, and play it by ear.

Sometimes, and often, difficult working situations can lead to a greater ability at problem-solving and increase expertise.

Good luck and the best to you.

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

Agree with BTDT. You can show them scholarly articles until you're blue in the face. They. don't. care. This is a conscious decision on their part.

Specializes in Psych (25 years), Medical (15 years).

Someone once said, "The world was not changed  by quitters" and Hub McCann, in the movie Secondhand Lions proclaimed, "I like me a challenge!"

We need to think worldly and act locally in dealing with unsuitable situations and it can be done! Giving up, leaving an imperfect position, accepting other's opinions which are often based on a parochially subjective perspective and not gained empirically, is to believe online entities have all the answers without any tangible truth!

Davey Do said:

Sometimes, and often, difficult working situations can lead to a greater ability at problem-solving and increase expertise.

Joseph Campbell said, "Mystics swim in waters where others drown", and Bill Moyers noted that "A hero is just someone who hung in there five minutes more than the rest". One of the definitions of a  hero is one who redeems society through their actions.

Heroes are not, nor have ever been, quitters.

Specializes in Critical Care.

What I know is rehab units are usually part of a nursing home, one section.  It is the most profitable section because medicare pays up to 100 days of rehab a year.  Long term care must be paid by the patients who quickly exhaust their savings, can lose their home either to the NH or to the state after their death once they qualify for medicaid which pays very little.

I worked with an agency nurse who said at the NH rehab unit she worked she would have up to 14 patients per nurse on night shift with 2 CNA's, unless one was pulled to another unit.  Also she was the only RN in the building and had to help out if the NH section had an issue.  I think 18 patients is too much as these patients by definition are more acute than long term care and they discharge patients out the hospital ASAP.

I would voice my concerns and objections, but as others said they most likely will ignore you and looking for literature won't help.  There is already research of increased mortality for each patient above the CA staffing ratios, yet it is the only state in the country with mandatory staffing ratios!

If you choose to stay and see safety issues, sentinel events you can file an anonymous complaint to JACHO, but that is usually a waste of time.  You would have more luck filing a complaint with CMS since the government thru medicare is paying for care and wants quality.

The future will depend on if the nurses stay and take it or if most or all leave.  If they can't keep staff, they may be forced to change the ratios back again, but they won't do it voluntarily until they have lost their nurses or CMS or JACHO intervene. 

The good news is nurses are more in demand then ever so you don't have to stay somewhere you are overworked you can switch jobs, even try a different field like dialysis, home care or clinic nursing.  Dialysis center will train you, but if you look into that outpatient is usually better, more stable hours than inpatient hospital.

Raising patient ratios isn't new.  Even before covid  I've lived thru some increases at my hospital.  But in the 2000's they attempted to raise post op surgery to 7 patients per RN with 1 CNA, but the nurses all fled, the union picketed, the Dr's rebelled and sided with the nurses and took their patients elsewhere.  The media got a hold of this and the other hospitals in the area proclaimed they had better ratios.  So in the end the post op unit was closed for many years till they reopened it with 6 patients and 1 CNA, before it had been 5 max. 

Then with Ascension took over they quickly raised ratios to 6 on a step down with only 1 CNA for 12 patients!  A few times they tried to get a nurse to take 10 patients on days and pm's, but thankfully the nurses stood their ground and refused!  The surgical unit was closed by them, to lease the floor to an LTACH!  The med-surg, oncology floor was 7 patients, sometimes 8 on nights, with only 1 CNA for up to 14 patients and they did this before covid.  Also laid off HUC's so no one to answer phones.  Well you can imagine how that went, over 20 nurses on my floor quit that year so by the time covid hit it was a few experienced nurses, some new grads, and mostly travelers.  I was very grateful for the travelers.  

The ICU nurses were tripled with no CNA's, no HUC and usually Charge was also taking an assignment, acting as MRT code person for the hospital as well!  So then all the ICU nurses starting quitting and the older ones were targeted and fired as well.  End result they were holding ICU patients on the floor!  One time a Dr said if you don't tx my patient to ICU I will tx them to another hospital!  Twice I had tx orders and they were cancelled!  Once when the patient was at the elevator who was A&OX3 with family how to explain that, ended up going to ICU in the morning.  Another time I had a pt tx cancelled at the door of the ICU and told to take the patient back we got a Dr to make them a NC4!

Now they have succeeding in destroying the hospital.  Some days there are less than 30 patients.  It used to have over 100 after we went to single rooms and before that we had up to 200!  It amazed me how few nurses we needed compared to when I started and yet they couldn't keep staff cause they treated everyone like ***!  So from 2016 when they took over there were 400 nurses.  Last I heard it was down to around 100!  On my unit almost everyone I worked with is gone and I took early retirement end of 2020 due to the unsafe working conditions.  I'm glad to be out of there!

One of the competitors, Aurora, years before covid also had raised ratios on a tele floor up to 7 per nurse on day shift and the nurses were going to their Dr for anxiety meds and the Dr's were telling them to just quit!  One of the agency nurses told me about it how they started writing up and getting rid of senior nurses at the same time.  She had a perfect attendance record and they started going after her and HR was bewildered, but she decided to leave before they fired her and did travel and agency after that.

Going back to Ascension, they are one of the largest billion dollar corp across the country and they have finally been exposed in the last year, even a NY Times expose re the unsafe staffing, but I don't know if they changed things.  One of the hospitals by me had an expose of critical issues in the OR that lead to them suspending elective surgeries for a couple months and they were cited by JACHO.  A brave Dr spoke on the record of critical issues, sentinel events and other nurses and Dr's spoke anonymously in the article.  I hope these expose's improve things, but I wouldn't voluntarily go to Ascension knowing what I know after working for them!  I warn all my family and friends to choose another health system if they can.

 

I worked for years at a SNF. The facility figured out a way to be considered "a hospital" even tho they did not have an ED, the usual criteria. My floor had 52 residents, we were almost always full unless one of our people was out for an emergency or a family visit. There were 2 LVNs and 8 CNAs on the day and afternoon shifts, 1 LVN and 5 CNAs at night — when we were lucky and no one called in. The facility started bringing in more and more rehab patients which made things even more hectic. I know people joke about no lunches or bathroom breaks but this is a reality. We also were HIGHLY encouraged to punch out "on time" but people were staying hours after their shift ended to finish their assignment. The company philosophy was if you couldn't finish your shift you were a bad nurse. (Note: they were sued many times for this but I guess it's more financially beneficial to the company to pay a one time charge to settle than to pay all the staff their OT.) my one takeaway for you ... remember this — one medication mistake or other slip up and your license is gone, it's you or them and they will throw you under the bus so fast your head will spin! 

Specializes in ER.

Put it in writing, ONCE. And expect to be ignored. But if it ever comes back to someone (or you) not being trained, or not having staff, you have documentation that you spoke to them.

Specializes in Critical Care.
nurse_suzie said:

I worked for years at a SNF. The facility figured out a way to be considered "a hospital" even tho they did not have an ED, the usual criteria. My floor had 52 residents, we were almost always full unless one of our people was out for an emergency or a family visit. There were 2 LVNs and 8 CNAs on the day and afternoon shifts, 1 LVN and 5 CNAs at night — when we were lucky and no one called in. The facility started bringing in more and more rehab patients which made things even more hectic. I know people joke about no lunches or bathroom breaks but this is a reality. We also were HIGHLY encouraged to punch out "on time" but people were staying hours after their shift ended to finish their assignment. The company philosophy was if you couldn't finish your shift you were a bad nurse. (Note: they were sued many times for this but I guess it's more financially beneficial to the company to pay a one time charge to settle than to pay all the staff their OT.) my one takeaway for you ... remember this — one medication mistake or other slip up and your license is gone, it's you or them and they will throw you under the bus so fast your head will spin! 

Thank you for sharing this. 

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