Med-Surg Topic of the Week .... Nurse to Patient Ratios

For the most part from these posts, I haven't seen many day shifts taking 7-8 patients....that is what it is at my hospital. 7:1. 7A-7P, AND 7p-7A. Charge, sometimes, aides sometimes, acuity, we don't staff towards acuity. Numbers only. We have the highest nurse/pt ratio in the entire area.

Sorry for all of you night shift peeps...that the ratio goes UP! That whomps. I couldn't imagine taking care of 8-10 pts at ANY time, DAY or NIGHT! When patients go bad, they go bad.. I don't think they say, "oh, let me not take a turn for the worse during the night, they have more patients". I don't think they can choose a TIME. So why should administration CHOOSE a time for staffing ratios to change??????????????:uhoh21: OH, but 7 is also too many at any time.

I work night shift also and that comment burned my butt too. I agree with you 100%. Usually those that make comments like that thinking that night shift has it easier than dayshift has NEVER worked night shift!!!!!!!! I have worked ALL shifts, they are ALL tough. Nursing is not an EASY profession!!!!!!!

I almost let this comment go by, but I can't.:angryfire I used to work Med/Surg on the night shift. Just because is it night, it does not mean it is less work for the nurses. I find it funny that a Med/Surg unit had to have a 1:5 ratio for the day shift, but one minute past 7:00 p.m. it is alright to have a 1:8 or 1:10 ratio. I realize that a patient's status change, but not that quickly. I have been reading throughout these boards about nurse retention. One of the reasons my Med/Surg unit couldn't keep nurses, was the day shift kept telling us how overworked they were and how we, the night shift nurses, didn't do anything all night. These statements were coming from a dayshift staff that had 15-20 patients. 3 or 4 RNs, 3 CNAs, a ward clerk, and case management nurses who covered lunches and breaks. Night shift had 2 or 3 RNs or LPNs and that was it. Sometimes we would get a ward clerk until 11 p.m. or we might get a CNA, but not always. The night shift also had to do the daily "chores" of the unit such as cleaning the nurse's station, checking the crash cart, restocking the rooms, etc. I was suppose to squeze this in between assessing 10 patients (or all of them if I was working with a LPN), passing meds, providing hygiene care, helping patients ambulate in the hallway (because dayshift was to busy) and doing doctor rounds with that one doctor that waits until 10:30 at night to come and see his patients. I don't normally get on my high horse, but for some reason this comment rubbed me the wrong way today. I will just apologize now to the people I might offend.

Schroeder

[geekgolightly, BSN, RN]

i work on a neuro/stroke floor and our max is 1:6 but usually we have 1:4 or 1:5. we have many total care patients, and our population also has a tendency to do very strange things (like crouch and poop on the floor or claw out all of the lines while screeching) so i feel like i can give good care with a 1:4 ratio; 1:5 and i don't have time for a real lunch; 1:6 and i am out of my mind trying to keep up.

we have PCT's as well. theya re assigned max seven or eight. im not sure./

[talaxandra]

I work on a thirty-two bed medical specialty unit (endo, neuro, stroke, renal, rheum).

We have a charge nurse and a clinical support & development nurse Mon - Fri (non-clinical) 0800 - 1630, a resource nurse (no patient load) morning and afternoon, and a ward clerk from 0800 - 2000 Mon - Sat, 0800 - 1600 Sun.

The ratio is the same for AM (0700 - 1530) and PM (1300 - 2130) - 1:4; at night it's 1: 8 or part thereof. At present we have four closed beds because we don't have enough staff to meet the ratios, so we on nights have seven patients apiece. I'm currently resourcing, so I have that, plus my seven patients, plus traipsing down to cas to do peritoneal dialysis on a patient with peritonitis.

Ratios are law here, which allows us to close beds when we're understaffed. No negotiating with admin, no deferring to higher powers that be: no staff, no beds. I'm sure that's what's reversed the attrition trend in Victoria and brought more nurses back into the system :)

PS No LPNs and no CNAs but we do have a patient attendant help with washes Mon - Fri

[UM Review RN, ASN, RN]

Our unit does Tele/Stroke/Med-Surg, so we get quite a mix.

The night shift comment irritated me as well. I agree, it was the assumption that we don't do anything that bothered me. SO not true!

I get around 7-8 patients with a tech. We have only two techs for around 40 patients so we have more licensed support if someone goes bad. We have a monitor tech at night who does the measurements of the strips, stuffs the charts and puts in the orders for the admissions; we do the assessments, meds, help the techs with the heavier or more confused patients, answer lights, assess the monitor strips, and the 24 hour chart checks. Of the nurses on the unit, at least 2 have to be Tele nurses on the unit at all times.

I insist on taking a break and eating a little something around 0230 because if I don't I get really spacey at some point when I really need to be on my toes.

I have only been a new grad/med-surg nurse now for 11 months and consistently get 7-8 pts, sometimes 9. Last weekend (nights) I refused a 9th patient (new admit) because of the acuity of my other 8. I know I made the manager mad, but who's butt is on the line anyway? I told him, fire me, write me up, I just can't do it.

I am seriously worried about losing my license or my mind at this facility. No time to eat, sit, or catch a breath... it sends me home in tears. But, I signed a contract and have another year to go. At this point, I don't care what I owe--I just want out and am looking for another job. I feel it was a mistake to take a "free ride" from this facility in the first place by having them pay for my schooling in advance. And the shame is, I really like med-surg, but not when my patients are widgets- instead of humans. I am really comfortable at 1:6- even 1:7---

and our CNA ratio is typically 1:35

YIKES>

I had to look up where you are from. I thought I workied at the same place! That is exactly how it is where I work. It is very stressful. We don't get any help from our charge nurse either which is very discouraging. Your right, it's our license on the line. Refuse what you need to refuse. Good luck!!!!!

I have only been a new grad/med-surg nurse now for 11 months and consistently get 7-8 pts, sometimes 9. Last weekend (nights) I refused a 9th patient (new admit) because of the acuity of my other 8. I know I made the manager mad, but who's butt is on the line anyway? I told him, fire me, write me up, I just can't do it.

I am seriously worried about losing my license or my mind at this facility. No time to eat, sit, or catch a breath... it sends me home in tears. But, I signed a contract and have another year to go. At this point, I don't care what I owe--I just want out and am looking for another job. I feel it was a mistake to take a "free ride" from this facility in the first place by having them pay for my schooling in advance. And the shame is, I really like med-surg, but not when my patients are widgets- instead of humans. I am really comfortable at 1:6- even 1:7---

and our CNA ratio is typically 1:35

YIKES>

[RNPATL, MSN, RN]

As a nurse manager for a busy medical & surgical floor, hearing stories like this really upsets me. Nurse to patient ratios are a very important thing and we need to have ratios that are doable for the nurse. You are correct, patients are human beings and they deserve to be treated like they are!

For those new graduates that are just entering med/surg and find that the N/P ratio is not doable, I would encourage you to schedule a sit down meeting with your nurse manager and review the basics with them. Be prepared for the meeting with a notebook that records your thoughts and specific patient situations where you were challenged to meet the need. Ask your manager how he/she would have handled the situation and if they believe the staffing was safe!

Please remember ... nurse managers also have bosses and while you may not want to rock the boat .... there are plenty of times the nurse manager's boss is NOT aware of how the unit is being staffed. I can NOT imagine any nursing director that believes it is safe for a day shift RN on a M/S unit to have greater than 9 patients :angryfire . However, follow the chain of command. If, after you have followed the chain of command and can not get satisfaction, file a formal grievence with Human Resources, letting them know that you believe the staffing is unsafe and will be resigning your position and expect that any assistance provided for schooling should be forgiven based on unsafe staffing patterns. This way, if the hospital ever decided to come back to you for the money and you refuse to pay, at least you have a paper trail that you tried to resolve the probelm. In addition, if you had to go to court, at least you have evidence that you followed the chain of command to take care of the problem also.

Just some suggestions. I feel for you guys and hope you are able to locate jobs that treat their nurses better. If I had a bus, I would pick you all up and you could come work for me!

Hello:) Ive been an lpn for 1 year and currently doing assisted/long term.I want med/surge experience but Im afraid.Afraid of being treated like an aide"respect aide work did it for 10 years"But dont want to do all day in a hospital.I dont know if I want to be an RN,"cant afford it right now"I dont want paperwork.I love working with my hands and enjoy patient contact.I know I know nothing about med surge but 7-9 pts is a lot easier than 20-40 in long term.please fill me in and possibly help me decide how to find the right hospital.Interested in homecare & teaching in future.

sincerely julie

[RNPATL, MSN, RN]

Hello:) Ive been an lpn for 1 year and currently doing assisted/long term.I want med/surge experience but Im afraid.Afraid of being treated like an aide"respect aide work did it for 10 years"But dont want to do all day in a hospital.I dont know if I want to be an RN,"cant afford it right now"I dont want paperwork.I love working with my hands and enjoy patient contact.I know I know nothing about med surge but 7-9 pts is a lot easier than 20-40 in long term.please fill me in and possibly help me decide how to find the right hospital.Interested in homecare & teaching in future.

sincerely julie

Hi Julie .... there is really no comparison between LTC and med-surg nursing. In LTC - you may pass meds to 20-30 patients, but in acute care you do primary care for 7 patients .... that means you do it all, care, meds, treatments, etc .... it can be tough and challenging. The thing to remember also is that many of the patients your are caring for in acute care are there for a reason and their condition can change pretty quickly. In LTC, for the most part, you are dealing with stable chronic illness.

There is a pretty big difference. As an LPN, you will use many of the skills you leanred in school. There are clearly differences in scope when you work in LTC or acute care. For example ... in some states, LPN's can not take orders from a physician in acute care .... whereas in LTC, you take verbal or telephone orders routinely.

If you are interested in moving to acute care, you might want to talk to a hospital recruiter and see if they have a program that will transition you from LTC nursing into acute care nursing. There are many programs available depending on where you live and if there is a nursing shortage in your area.

In any case, good luck.

[RN-PA, RN]

I work 3-11 on the "east" side of a 61-bed med-surg unit. Our side is 29 beds and has an oncology emphasis, but we get every diagnosis imaginable as well as post-ops. Each shift is staffed 6:1. We have 12, 8, and 4 hour shifts all working together. There are no charge nurses but we have one unit clerk for 7-3 and 3-11, from 0700 to midnight. We have two PCT's (aides) for the potential 29 patients. (We usually don't have all beds full due to some rooms being kept single for neutropenic or other isolation patients.)

I don't like the "one-size-fits-all" ratios. 3-11 gets many transfers, post-ops, admissions, and 7-3 gets a lot of patient movement going to various departments for tests and/or procedures. Naturally, acuity and amount of activity is not considered when staffing. 6 patients can be fine if a few are ambulatory and require partial care vs. complete care. But as we've all experienced, your ratio could be 3:1 and one problem patient can keep you busy and even keep you there overtime with all their issues (physical, psych, whatever).

We also work with LPN's who need us to check/sign-off doctor's orders, give IV push meds, call docs for their patients, hang blood, hang TPN, initiate Heparin drips, and admit their patients on top of our own assignments due to their scope of practice.

In the next two years, our entire unit will have monitored bed capabilities, and I'm told we must also all be chemo-certified. Administration will have to lower ratios if they don't want a mass exodus of nurses.

Hi Julie .... there is really no comparison between LTC and med-surg nursing. In LTC - you may pass meds to 20-30 patients, but in acute care you do primary care for 7 patients .... that means you do it all, care, meds, treatments, etc .... it can be tough and challenging. The thing to remember also is that many of the patients your are caring for in acute care are there for a reason and their condition can change pretty quickly. In LTC, for the most part, you are dealing with stable chronic illness.

There is a pretty big difference. As an LPN, you will use many of the skills you leanred in school. There are clearly differences in scope when you work in LTC or acute care. For example ... in some states, LPN's can not take orders from a physician in acute care .... whereas in LTC, you take verbal or telephone orders routinely.

If you are interested in moving to acute care, you might want to talk to a hospital recruiter and see if they have a program that will transition you from LTC nursing into acute care nursing. There are many programs available depending on where you live and if there is a nursing shortage in your area.

In any case, good luck.

Thank you for the wonderful advice.I love this nursing site .Its so informative.I will look into a hospital recruter.My teachers in school told me to go with the hospital with the longest orientation.

I'm a recent LPN grad who has been in LTC since October. I recently landed a job on a med-surg floor in a hospital that actually allows LPNs to do everything in our scope of practice and not just pass meds like most of the hospitals around here. I'm scheduled to start in February on the 7-3 shift.

When I was interviewed, I was told that the nurse/patient ratio was 8:1 maximum. In my naiveté, comparing it to the 25 residents I now care for didn't sound so bad, but after reading some of your posts, 8 acute care patients is starting to sound very scary. I did very well in school (#1 in my class) and am extremely organized, but I am still very inexperienced and a bit leery of being responsible for 8 acute care patients.

Is 8:1 too much for a new nurse?

Michelle

I think so... On our floor the most we get on days is 7 - and that can be insane if you have a patient on peritonial dialysis...or someone who needs suctioning or a really needy family... or a lot of diabetics... or a lot of pain meds....

The acuity level of pts on medical floors is way too high now. I think there could be some pt combos that I would 8 - but I don't see it happening too often - at least at my hospital.

Good luck

Kate

PS: Also keep in mind that you will do orientation - ramp up your pt load etc.. You've taken care of a lot of pts before - your a good nurse. Just be sure you get a preceptor that really gives you what you need so that you feel confident when they turn you loose.

[RNPATL, MSN, RN]

I'm a recent LPN grad who has been in LTC since October. I recently landed a job on a med-surg floor in a hospital that actually allows LPNs to do everything in our scope of practice and not just pass meds like most of the hospitals around here. I'm scheduled to start in February on the 7-3 shift.

When I was interviewed, I was told that the nurse/patient ratio was 8:1 maximum. In my naiveté, comparing it to the 25 residents I now care for didn't sound so bad, but after reading some of your posts, 8 acute care patients is starting to sound very scary. I did very well in school (#1 in my class) and am extremely organized, but I am still very inexperienced and a bit leery of being responsible for 8 acute care patients.

Is 8:1 too much for a new nurse?

Michelle

Yes, I would have to agree that 8:1 is too much ... especially for a new nurse. 7:1 is tough enough. Of course, it really does depend on the acuity of the patient and whether you have the help of a nursing assistant. I would be very careful taking a job that has a 8:1 ratio.

I work 3-11 on the "east" side of a 61-bed med-surg unit. Our side is 29 beds and has an oncology emphasis, but we get every diagnosis imaginable as well as post-ops. Each shift is staffed 6:1. We have 12, 8, and 4 hour shifts all working together. There are no charge nurses but we have one unit clerk for 7-3 and 3-11, from 0700 to midnight. We have two PCT's (aides) for the potential 29 patients. (We usually don't have all beds full due to some rooms being kept single for neutropenic or other isolation patients.)

I don't like the "one-size-fits-all" ratios. 3-11 gets many transfers, post-ops, admissions, and 7-3 gets a lot of patient movement going to various departments for tests and/or procedures. Naturally, acuity and amount of activity is not considered when staffing. 6 patients can be fine if a few are ambulatory and require partial care vs. complete care. But as we've all experienced, your ratio could be 3:1 and one problem patient can keep you busy and even keep you there overtime with all their issues (physical, psych, whatever).

We also work with LPN's who need us to check/sign-off doctor's orders, give IV push meds, call docs for their patients, hang blood, hang TPN, initiate Heparin drips, and admit their patients on top of our own assignments due to their scope of practice.

In the next two years, our entire unit will have monitored bed capabilities, and I'm told we must also all be chemo-certified. Administration will have to lower ratios if they don't want a mass exodus of nurses.

I would love to work 4 hr shifts 7p-11p or 8hrs 7p-3am. why cant places have these more flexible hours for working moms.I could fix my kids dinner,help them with there home work n stuff without having to spend my evenings sleeping.

I work 3-11 on the "east" side of a 61-bed med-surg unit. Our side is 29 beds and has an oncology emphasis, but we get every diagnosis imaginable as well as post-ops. Each shift is staffed 6:1. We have 12, 8, and 4 hour shifts all working together. There are no charge nurses but we have one unit clerk for 7-3 and 3-11, from 0700 to midnight. We have two PCT's (aides) for the potential 29 patients. (We usually don't have all beds full due to some rooms being kept single for neutropenic or other isolation patients.)

I don't like the "one-size-fits-all" ratios. 3-11 gets many transfers, post-ops, admissions, and 7-3 gets a lot of patient movement going to various departments for tests and/or procedures. Naturally, acuity and amount of activity is not considered when staffing. 6 patients can be fine if a few are ambulatory and require partial care vs. complete care. But as we've all experienced, your ratio could be 3:1 and one problem patient can keep you busy and even keep you there overtime with all their issues (physical, psych, whatever).

We also work with LPN's who need us to check/sign-off doctor's orders, give IV push meds, call docs for their patients, hang blood, hang TPN, initiate Heparin drips, and admit their patients on top of our own assignments due to their scope of practice.

In the next two years, our entire unit will have monitored bed capabilities, and I'm told we must also all be chemo-certified. Administration will have to lower ratios if they don't want a mass exodus of nurses.

I would love to work 4 hr shifts 7p-11p or 8hrs 7p-3am. why cant places have these more flexible hours for working moms.I could fix my kids dinner,help them with there home work n stuff without having to spend my evenings sleeping.