Manager "threatening" us with primary nursing!!!

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Specializes in Critical Care, Trauma, Neuroscience.

Hi everyone!

I've been a member of allnurses since before I started nursing school, and I've always come here to find answers to questions and see other nurses perspective on things. I sort of got a more realistic view on what nursing might be by reading the boards on here haha! I was not deterred. At least not enough to quit :-p

I am writing this post because I'm hoping to get some feedback on how you do staffing of nurse techs on your floor. My manager is tired of having to deal with nurse techs quitting/no shows, and is very interested in going over to primary nursing. I (and most/all nursing on my floor feel this is going to be a disaster). I'm trying to get some ideas on how to utilize techs better, maybe make them more happy in their job... or just be using their time better!

Some background: I'm an RN working on a busy surgical trauma floor. We have have a pretty high turnover rate both with RNs and nurse techs... it's understandable. We're very very busy, our patients are dealing with the worst moment of their lives and need someone to take it out on, and we are the only level one trauma hospital in our area. I do love my job, but it is extremely high acuity for a floor. Very very busy and most days we are running all day without a break and lucky if we get a fully 30 min for lunch.

Our typical ratio is 5:1 and we are lucky if we get three nurse techs for the whole floor of 30 beds, but often it's just 2 or even 1 because we get a call out. So even right now with the techs we have, the nurses are doing most of the toileting, cleaning up poo/pee/linen disasters, blood sugars, post-op vitals (techs will "forget"), and assist with meals. The techs primarily will do baths and assist quads/head injury pt's with feedings, along with sharing the other duties mentioned above. Depending on the tech, depends on how much you do yourself lol.

Manager is thinking of bringing in a "fluff and puff" tech who will come in and just round on pt's rooms, bring ice, be the "extra hands" to help turn pts, sit with suicide pts when their sitter needs a break, etc. She wants one of these techs on either side of the hall mon-fri 8-5, then NOTHING the rest of the time. She says our ratio will be 1:3. Not really.... not when we have call outs all the time, are getting new orientees with preceptors being taken up with only 2 pts, etc.

So here are my questions for you: How do you all do techs on your floor? What are their responsibilities? How many pt's are they assigned to? Are they content with their job and is the retention rate high? Anything else helpful you want to add?!? :) I would love any and all feedback!!!

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Specializes in Critical Care, Education.

I don't see how this would work out the way your manager says it will. The vast majority of labor budgets are based on 'hours of care' per patient day... with no real differentiation as to the type & mix of staff. Just doing the math, I fail to see how a 1:5 ratio would magically become a 1:3 ratio with the elimination of 2 nurse tech positions - on a 30 bed unit. Just doesn't add up.

There is a natural tendency of (quasi-competent) Dilbert managers to make very superficial decisions rather than actually digging in and solving problems - because that would be a whole lot more work and require more knowledge and skills than they have. Classic example: demanding an inservice to 'fix' a non-educational problem because it is much easier to blame "bad training" than face the fact that they area incompetent managers. In this case, the Dilbert manager is going to blame "bad techs" rather than devoting time and energy to find out how to train, coach & motivate the techs to do a better job.

Think about it from a CNA's perspective - just imagine what it's like to have 4 or 5 different 'bosses' pulling you in so many different directions at the same time. No wonder they just want to run off and hide.

I have worked with (& developed) a jillion different staffing models over the years... the best working arrangement I have seen is a true 'dyad' in which the RN actually selects the CNA & does his/her job performance evaluation. They work the same shifts, and are assigned a (larger) group of patients, but have very good communication & division of labor to ensure that everything gets done.

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Specializes in Critical Care, Trauma, Neuroscience.

That sounds very promising! I know there was talk for a while many months back about assigning each techs to specific RNs. But it was going to be a random thing each shift. I'm not sure my manager will go for this model of care because management on my floor tends to be VERY autocratic, and I think it would probably have a stroke if it gave us any form of autonomy at all hah! Us doing evaluations! Wow, I think management just peed itself a little bit. Though they do love to pretend they're democratic... bahahahah. We're having a meeting to "discuss" staffing soon, and I'd absolutely LOVE to hear more about this dyad model you're talking about. I feel like if I could present it in a very pleasing way, maybe we'd have a shot!

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Specializes in Critical Care, Capacity/Bed Management.

When I used to be a tech on med/surg my manager made it a point that every nurse should have one nurse's assistant with whom they would work the whole shift with (7-3). Most of the time we had 6-7 patients and all my care would be done by 11am-12pm. After that time all the nurse's assistants would help out around the unit with organization, bringing ice water, getting people in and out of bed.

If you want to retain your nurse's assistants the best way is to increase their numbers and decrease their patient load. There is no way in hell that I can possibly care for 15 patients and have 3 RN's telling me what to do. Inevitably I will not be able to accomplish some task and upset someone. When my manager left for better opportunities the replacing manager took away this model and I remember having 8-10 patients on day shift that required complete care out of my 15 and I was told to just deal with it. I promptly transferred to the ER.

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Specializes in Critical Care, Trauma, Neuroscience.

There is no way in hell that I can possibly care for 15 patients and have 3 RN's telling me what to do. Inevitably I will not be able to accomplish some task and upset someone. When my manager left for better opportunities the replacing manager took away this model and I remember having 8-10 patients on day shift that required complete care out of my 15 and I was told to just deal with it. I promptly transferred to the ER.

THAT is exactly what goes on on our floor on a daily basis. I don't blame the techs to be honest. But the nurses are left dealing with it as well. I honestly don't see increasing numbers/decreasing pt load as an option! We've been saying that forever. Whenever they ask us what can we do for you to help you/make you happier or what is it going to take to get hcahps up... that is exactly what we say. I guess the funds and the staffing grid will not allow it.

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I'm working on seeing an upside to this. This may take a while.

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1:3 with true primary nursing is quite doable, and I would be all over it in a Noo Yawk minute. When I did med/surg we were 1:4 on a general surgery floor with one aide for the whole floor who was basically responsible for stocking things, and it was like heaven, only 4 patients to deal with, knowing so much more about them than when we had 8 + one CNA or 6 with part of a CNA. Four patients? Piece o' cake. Three? Awesome! What you're describing doesn't sound like primary nursing to me, though.

To make sure, ascertain that 1:3 is really 1 RN to 3 patients, 24/7. Never fear primary nursing per se (for/by/as itself) because it's the best model there is for giving, well, primary nursing care. If your management means to staff you with RNs for that, thank your lucky stars, and stop fighting it on some sort of principle alone. However, again, no matter what you think they're calling it (or you think they're "threatening" you with) it doesn't sound like primary nursing.

I don't understand why your management doesn't hire more good techs to improve everyone's working conditions, as this would decrease turnover. Turnover is expensive, more expensive than hiring extra help and keeping them.

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Specializes in Critical Care.

If you're going from 1:5 with 2 techs per 30 patients (up to 8 staff total) to 1:3 with no techs (up to 10 staff total) then it would seem you're better off. The problem with "primary nursing" is when the total staff caring for a patient goes in the other direction in terms of total staff to total patient ratio.

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We did true Primary nursing with techs specifically assigned to the RNs with the most acute patients. Then we have one maybe two who would float b/t the rest of the nurses. It worked really well.

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Specializes in Short Term/Skilled.

If they can guarantee the ratio or close to it, I want to work primary nursing when I finish school. I'd much rather provide all the care, especially in a situation where you describe, where you're pretty much doing it anyway.

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I would love primary nursing but I would bet that if our rn increase another watd would be down an rn or 2 and would loose ghem every shift getting a tech in exc

hange

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We pretty much all do "primary nursing" here in NZ the last medical ward I was on the nurses had 7 patients and 2 HCAs to make peoples beds and help get them up to go to the toilet but there were 35 beds so you just about never saw them the whole shift.

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