Level of Care

Specialties MICU


I have been a nurse for 17 years, most of which has been in a Medical ICU. Over the years I have seen a trend of decreased level of care provided to patients. It is not just because nursing time has been cut back, many times there is more than enough opportunity to meet all the needs of the patients. Has anyone else seen this trend? Any ideas why?

I see the same at the place I work. I think our staff has gotten used to the routine of working very short. I think working harder to provide more for less, we have been forced to let a lot of the things that are not absolutely essential slide. Over time we have developed this new routine. And on days that we can provide maximal care, the new routine rules. What is your view?

I am a critical care nurse. Because of RN staffing shortages, LVNs work in our critical care unit, under the supervision of the RN. Of course there are many skills out of the LVN's scope of practice, such as dealing with a Swan and taking hemodynamic measurements. I trust and have a good working relationship with the LVNs who do cross-over into the unit, but how can this skill-mix be legal? In our ICU, there is a two patient limit per RN, if acuity permits. The RNs are told that as long as there are licensed people, such as an LVN, this is legal. Could someone please respond and let me know your feelings.

We are senior students in the baccalaureate program at Sonoma State University. We are interested in your topic of level of care. Through our clinical rotations we have worked with RNs and LVNs in the Critical Care setting. How does the decreased level of care, as you see it, impact the patients' recovery time? Are they discharged earlier or later based on the care level in the unit?

SSU undergrads,

I am an SSU graduate student at HSU, hello! I believe not providing basic nursing care to any patient has the potential to prolong the illness and lengthen the stay. If pts are not turned 2 hours but are instead turned every 4 hours and they are alredy seriouly ill(on a vent with pneumonia) they will develop ulcers which in turn can get infected. You then have a mess and a sicker pt with more problems then they arrived at. Someone may ask- is it a complication of their illness or a nursing compication? I tend to believe that things like this can be prevented with good old fashion nursing provided. That's not to say that the nurse isn't to critically think through the disease process of the pt, understand it and do everything she/he can to assure that appropriate medical treatment is provided. We as nurses have a tough roll- we need to think like physicians and act like mother Teressa. It's hard and there is no way around it. However, it can be the most rewarding and challenging thing you will ever do and I guarentee you will never be board! Good luck to all of you and chat anytime. debbie @ HSU

I agree that the level of care has diminished because of the shortage of nurses. The patient ratio in my MICU/SICU/NICU is frequently three to one. What I find particularly frustrating is the inability to obtain effective equipment to help compensate for the lack of personal care. Our patients with compromised pulmonary function really need to be turned more frequently then once every two or four hours. Something as simple as an Effica bed would decrease the risk of pulm. complications and decrease the risk of decubs/tears etc. My knee pads are worn out from begging. My other pet peeve is the paperwork. I now average 90 minutes of paperwork per patient per night. Of which approximately 40% is duplicate documnentation. But - you have to chart on the form and then initial on another form that you charted the form and send copies to chart committees and summation forms, etc. etc... I'm open for ideas. I have read in "Nursing Spectrum" that at least one facility in my state has started moving to computer charting. I'd love to know if it really decreases the amount of time spent away from the patient or is it just another form to be handled? Most, if not all, nurses are aware of the changes at bedside. How do we convince the paperpushers outside of having them for patients.? I don't think we can wait long enough for that to happen.


I think the only way to show the paper pushers, ie. the administration, is to formulate the problem in terns they understand and present solutions. Nursing has a long history of complaining without offering solutions. It's time we stood up as the professionals and problem solvers that we are and take our place in changing the health care dilemia. I really believe we have more power than we think, we just need to use it. Good luck!


I think you have a good solution, QA is a good thing if we use it right. Suggest this as a problem to the QA committee and it will be addressed. Yes it takes time but at least you have made your opinion of patient needs known to someone who can make the difference. Forcing the nurses into caring for the patients needs won't happen, develop a unit pride for positive patient outcome and it will eventually be a positive thing and everyone will strive toward that goal. Teamwork is important and a feeling that you are a part of the team needs to be addressed too.

Ask any nurse when was the last time the nurse manager called you into the office to give you a positive message, you went above and beyond and provided excellent care. We all do this on a regular basis, especially with problem patients and problem families..Why dont we get the recognition? Yes I have gotten some positive things, and they are in my file...these are not shared with the rest of the unit though and others receive the same and the only way we know this happens is through shareing among ourselves. No we dont want to be competitive but there is always a 'group' who assisted in this "happy family" event and we should be allowed to share this among ourselves. Just feeling good about our jobs isn't always enough..we need the support of our peers too.

Enough venting for now


I too have seen the decline in quality of care. Computerized nursing doesn't help. Colleagues in another city use computerized nursing, but they have one terminal between 2 nurses and their assigned pts of 2-3 each in the ICU. Complaining to administration does no good, and you're right we never hear that we did well, but oh,baby if there is a complaint it must of been the nursing. So why don't we encourage the public to complain that it isn't the nurses, it is the lack of nurses at the bedside. I am sure if you take a look at the chart of the last pt to complain, the chart appears beautifully documented albeit with vitals charted in more than one place. With such perfect documentation how could such a model pt have a complaint?! Maybe because the understaffed nurse was too busy coding a pt with her colleague that the call light for a glass of water was on for 30minutes or more. Come on administration and fight for your greatest resouce-your nurses- instead of against them. By the way, have tried the QA gig and the papers either conveniently get lost or after a few years we go back to the ass-backwards way of doing things.

Specializes in Dialysis.

The care we are able to give on our unit varies from day to day, as well as being dependent on WHO is working. By this, I mean that the experienced nurses who are more knowledgeable, better organized, and are able to be more proactive in dealing with patient problems get the work done in a more efficient fashion than the new nurse who has been on the unit for six months. It's a fact of life. I would also say that, if attention were paid to the basic functions of nursing on a consistent basis, that dollars could be saved. The example of the heel ulcers is one. I just spent a month of time in a long-term care vent facility, and the condition of some of the patients' heels (who had just been discharged from an acute care hospital) was downright disgraceful! Had they been turned and their heels elevated, this would not happen.

The bottom line, however, is always dollars, but, how many nurses do you know who would be able to design and carry out a research study that related outcomes-both cost per case and morbidity-to intensity of nursing care? It has been done, but on a limited basis. Numbers and dollars and cents is where it's at for any administrator you deal with. Unfortunately, THEY are not going to help.

I have also worked with computer charting--it stinks! It's time consuming and makes it difficult to get a picture of what's gone on for several days at a time. What nurses need to do is to convince themselves to streamline their charting instead of constantly double charting everything. Enough already!

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