How to respond to mgmt combining 2 high-acuity psych units in order to cut staff

Nurses Safety

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Hi there.

I realize understaffing is nothing new for nurses, but this issue has become increasingly worse on my unit recently and I am fighting for safe® staffing, but it looks like that's not going to happen as long as it eats away at upper management and admin bonuses.

Anyway... I work an an Acute Medical Detox unit that is adjacent to a Geri-psych unit but completely separated by walls and magnetic locks. The main detox hall, observable from the station holds 12. We have a new spillover area for detox after a recent renovation that opens up at the end of one hall that holds 10 more, so 22 total. I work nights and until recently, our average census has been 8-12 on detox... staffed by either one RN and one LPN or MHT OR two RNs, functioning in both nursing and tech capacities, which is no problem until we get slammed with admits- and anyone who works detox knows the majority are admitted at night (at least in my experience).

Lately, we've had an influx of detox admits, while nextdoor on geri, they have seen a decrease. The detox matrix has never exceeded 15 beds and 2 staff from 11p-7a, so when we started having 18, 20, 22 patients/MAX.... admin didn't know what to do... we got one additional staff member at night. So basically, we two RNs would be admitting almost our entire shifts, and ONE tech rounding every 15 minutes on 20+ patients, not to mention new admits on detox get vitals q1h x 4h, then q2h x 4h, q4h x 3 days... so V/S are non-stop. Add assessments on patients already there, meds, doctors that round late, and any other procedures (i.e. dressing changes as we have no med nurse), and that we also have to chart q4h per pt. whereas the other 5 units in the hospital chart once per shift and PRN and get V/S once per shift... we're already non-stop busy.

This week, because the geriatric census dropped to 3, the CEO decided there's no reason to staff it separately and tacked it onto us, or rather, combined these two (medical) units into one floor/unit, and said "just use the 3rd floor matrix to staff"-- this would be sub-acute/high functioning, self-care psych patients. I argued this was both unsafe and inappropriate considering the acuity of detox patients and especially total-care Geri patients, and that we were to operate from the larger detox nurse's station with a single door connecting to geriatrics propped open. Even then, we cannot hear the call bell, bed alarms, etc.

My argument was met from my nurse manager with, "Well, *COMPANY* doesn't staff by acuity. *COMPANY* has always staffed by census/number of patients... I was speechless.

I further argued that even though that may be true, I know the hospital has an obligation to staff safely (which we all know is laughable by admin standards), and I am tempted to dig out the Nurse Practice Act or state law regarding the issue because I am sure it says somewhere that acuity must be considered when staffing (PLEASE correct me if I am wrong).

So two nights ago, we started out with 15 detox and three Geri patients combined to one unit. After 11p we had 2 RNs and 1 tech (also a tech with the 1:1 which I do not count). I'm used to it so that was okay UNTIL we got 4 admissions, raising our "floor" cenus to 22, received no additional staff. We got through the night. the supervisor had to come help several times as no one can possibly round q15 min on 22 pts while recording roughly 60 sets of V/S between the new admits and other patients, prepare paperwork for the following day while we (2 RNs) assessed, administered meds, accuchecks, insulin, assessments, geriatric wound care and dressing changes- AND, at night after the switchboard leaves at 2200, EVERY single call is sent to our unit, including calls to two other adjoining facilites: a 60 bed adolescent residential Tx center and inpatient substance abuse recovery center (post-detox), the five other floors, and any calls from med-surg hospitals requesting psych assessments... Unit secretary (WHAT IS THAT!?)

Both the other RN and I were there until 9am the next morning in the back charting and completing our admissions when our Nurse Mgr. comes to the floor and eventually makes her way back... "What's keeping y'all here?".... Not to mention neither of us got breaks. After all of this, she still tried to justify it as acceptable (of course. She has to defend *COMPANY*)... Here is my point (if you've read this far, thank you):

1. Am I wrong in thinking I read that, although there are no set nurse:patient ratios (excepting Calif.) that a hospital must ensure adequate/safe staffing of a which one criterion is the consideration of patient acuity? We all know a total-care geri patient is equivalent to 3 or 4 (or more) independent/high-functioning patients. Can hospitals that use census-based vs. acuity-based staffing legally staff the same for units that have MUCH more patient care on more unstable patients as they do on the other floors?

2. Is it LEGAL to combine geriatric patients, considered a vulnerable population, with other patient populations? (if it were known the same nurse treating a geriatric patient was also treating 11 detox patients and there was no staff continuously on the Geri "side", but only a standard size door propped open between the 2 units and a call/emergency bell that cannot be heard from the nurse's station where the RN is stationed, I would think that Medicare would frown on that and likely would refuse to pay.)

3. I know that the CEO, nurse manager, and corporate "higher-ups" who develop the staffing matrix don't care about us lowly floor nurses, BUT if we arrive to work and accept the assignment not knowing we may have 4, 5, 6 admits on the way and will receive no additional staff... it is OUR licenses on the line. What recourse is there? What is the best thing to do? File an official grievance? I can't afford to put my job in jeopardy, but I also have a strong sense of ethics and am deeply disturbed by just how wrong this is... I also know, should something happen, God forbid, management isn't going to back me up in any way, shape, or form... I've only been nursing a little over a year. Should I direct complaints to HR or to nursing administration and just hope I don't become a "target"... I am not one to complain, but things are becoming impossible. I just feel stuck between a rock and a hard place. I am passionate about this field of psych (addiction), but I see what I am risking and know this is unsafe... Any suggestions?

4. Is there any way to officially document to attest that I have requested additional staff and received none. On the assignment sheet? Progress notes? Where should I document that I notified/requested to the supervisor that more help is needed?

Thank you all.

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Specializes in ICU.

Definitely doesn't sound safe...sounds like they should still have a nurse/tech for the geri pts who would also pick up additional pts on your side. I can't answer most of your questions, but is reporting to the BON an option? What about refusing admissions after a certain nurse/pt ratio has been met? Not sure if that last one is a possibility, but it seems like the best option after already having accepted your assignment for the night. I can't imagine doing all those VS, not to mention everything else. It's so sad that we have to put up with these kinds of conditions, bc management knows that 10 more nurses will be chomping at the bit for that job if we become too "difficult."

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Our geri-psych unit has experienced something similar.

The higher-ups simply do not care.

It's all about how they can play with the beds and decrease staff to save money.

It's total crap.

Geros need their own unit and dedicated staff because with the extremely high fall risks and medical issues, a propped door sure as heck doesn't cut it.

That's nuts!

I have no advice, just extending my sympathies.

We have argued about acuity for forever and it falls on deaf ears.

We have argued that geros should not be mixed with detoxers/adolescents/intensive psych/etc...

They just don't care.

:uhoh3:

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Just think- if nurses belonged to a national nurses union, like teacher do, we could put a halt to things like this in a heartbeat.

I hope that eveyone has been following the Chicago Teachers strike. They got everything that they wanted. Even with the economy as bad as it is.

They managed to do this because, THEY ALL BELONG TO THE SAME NATIONAL UNION THAT HAS A LOT OF CLOUT, AND THEY WORK VERY HARD TO KEEP IT THAT WAY. THEY INVOLVE ALL OF THE PARENTS, STUDENTS, AND OTHER UNIONS, AND CAN ATTAIN THE IMPOSSIBLE BECAUSE OF IT.

Nurses, on the other hand, have the largest group of martry marys, in the world. Who, instead of going after the CEOs who are responsible for the ills of bedside nursing, go after each other, which accomplishes nothing. Which, by the way, is exactly that the PTB want to happen.

Take a page from teachers- call the National Nurses United, and get the ball rolling. If nurses had unionized en masse, when we were finally allowed to do so, years ago, just think where we would be sitting now.

JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Somewhere in the PACNW

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What they are proposing, should be criminal. I would call the State Attorneys General's Office, and file a complaint. Nurses do not use the legal remedies that are available to help them. If more nurses called the authorities, and had these clowns brought up on charges, it would stop immediately.

I would also call the papers, and the news, and give them a detailed report of what they want to do. Our silence on these issues is deafening.

JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Somewhere in the PACNW

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Iagree with Lindarn ,but sounds like you need a more immediate answer. We can concur it is unsafe, but until you make your problem managements problem you are stuck. Do you get lunch and breaks? Sounds like not. Well its the law because you are not paid for those. Start calling the supervisor for relief, EXPECIALLY when all H--- is breaking loose. If they don't have to deal with it they can continue to look the other way. Should you decide to leave because the liabilty is to great for you, in a very professional manner tell the truth about why , don't sugar coat it. You don't have to shoot yourself in the foot for them to realize they will have continued turn over with this mess. If you decide to alert someone about elder care , call the state ombudsman. They will be there pronto and management have no choice but to respond. You are an ethical caring nurse . Runaway!!!! Good Luck

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I would say, if this is problematic, you should not forget to follow the chain of command. Like, telling your concern to the nurse supervisor and writing incident reports for the unsafe conditions. This is because when it comes to the courtroom, how you followed policy despite the unsafe situation will either hurt your or help you.

Maybe the union can help mediate for you.

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Specializes in LTC, Agency, HHC.

If you ask for help, and you are told no, document where, what, when, how and who you spoke to in your own journal. That way you have it if you need it. "Saturday Sept, 22, 2200, we had 4 admits and only 2 nurses. At 2230 I called manager so-and-so with nurse so-and-so listening to my end of the conversation and asked for more staff due to safety concerns. Manager so-and-so said "no sorry can't help you." I then called DON and asked for more staff and she said "......" Document, document, document. As told to me by an OSHA case manager.

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Specializes in LTC.

D: As a LTC nurse, I was always reassured that "Granny" who has been acting out a bit lately, would be kept safe and seperate, in her own little geri side of the mental health facilty.

How awful. What is WRONG with the administration?

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Honestly, best you can do is voice your concerns and leave.

If they see a spike in turnover/injuries maybe they'll think otherwise. If one of the upper management people get injured then maybe you'll get some change.

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Specializes in Psychiatric Nursing.

Just a note of empathy...

At our acute facility on nights we have one nurse and 2 MHT's for 22 patients. We have no secretary or admissions department and literally take the patients right off the stretchers from the ambulance. On the unit we have both acute psych and detoxers. The staffing in my facility and others is almost impossible and downright scary!!!

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What will it take, for nurses to unionize so we can protect our patients!!

No union contract, NO voice for our patients. It is that simple.

JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Somewhere in the PACNW

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