Meeting with Management about Med-Surg Nurse to Patient Ratios

[RN-PA, RN]

I've been a member of my hospital's newly established nurse retention committee for the past few months. I represent 1/2 of our large med-surg floor. After much discussion and brainstorming about retention ideas, I decided to write a letter to my manager and unit director as well as 2 other senior managers and the CEO of the hospital. The letter basically stated that, after almost 10 years as a med-surg nurse, I'm convinced that the only way to retain nurses on our floor is to reduce the nurse to patient ratio. More money won't keep burned-out nurses at the bedside in the long run. Large recruitment bonuses will not KEEP a nurse in a chaotic, stressful environment for very long. Morale is bad, quality of patient care is down, while I think more errors are occuring. I also sited statistics from the 2002 Aiken study in my letter. http://www.dpeaflcio.org/policy/factsheets/fs_aiken.htm

We are averaging 6 to 7 patients for all shifts, 1 PCT (aide) for 12 to 18 patients some evenings I work. Acuity is not a consideration in patient assignments and staffing, and we're told that this is the "benchmark" or "norm" for med-surg units in most hospitals, and that is why we are staffed the way we are.

BUT-- If you're having trouble RETAINING your nurses and you can't RECRUIT new nurses, in spite of throwing money at them, wouldn't it be wise to consider reducing the ratios and investing that money in hiring additional help? From the Aiken study: "RNs working in hospitals with the highest patient-to-nurse ratio are twice as likely to be dissatisfied with their position and experience job-related burnout as those working in hospitals with the lowest patient-to-nurse ratio. By increasing RN staffing levels and thereby lowering the patient-to-nurse ratio, hospitals could reduce turnover rates by decreasing the job dissatisfaction and burnout that may lead to resignation." (I keep having this overwhelming desire to say DUH!) Also from the study: "Satisfactory nurse-to-patient ratios can save money as well as saving lives and decreasing RN turnover. Estimates indicate that the cost of replacing a hospital medical and surgical general unit nurse... as $42,000."

I know from reading many threads here at allnurses that 6-7 patients is generally the norm on med-surg. If my 6 patients are self- to partial-cares and none have a serious problem during my shift, I can certainly be busy, but not inordinately; I may even be able to leave the floor for a 30 minute dinner break. But USUALLY, I'm running almost my entire shift (I work 3-11) with post-ops, admissions, patients going for tests, calling doctors, hanging blood, covering LPN's patients, etc. etc. etc. I'm almost embarrassed to say we have an IV team, so we don't start our own IV's, and yet I hear that many of you have to draw your own blood for labs, start IV's, do respiratory treatments in addition to your patient load..... How do YOU do it all? Do you have more nurse's aides? I'm having trouble just managing 6-7 patients and I fortunately have IV nurses and phlebotmists to help. Nurses who work med-surg will also know that some nights, just THREE patients can be a lot of work, depending on their problems and acuity.

Anyway, a meeting is being scheduled with me and the 4 managers I wrote, and I guess they'll then report to the CEO. I'm not worried; I wrote a respectful but truthful letter about our med-surg working conditions, and I'm not afraid to talk about them. I want to work med-surg; I have no desire to work anywhere else, but I can't stand to see unhappy, stressed-to-the-max co-workers, to not be able to give the kind of care I'd like to give, to see new nurses and new hires bail after a few months, and to often dread going to work myself.

Does anyone have any words of wisdom I can take with me for the meeting?

[Nurse Nevada, RN]

I have been trying to change the nurse-to-patient ratios in Nevada. I've posted some things on my site that might be helpful. Nevada is reviewing the situation in an appointed subcommitee right now. Hope this helps. There is a lot of info out there.

Nursing Nevada

[Ned the Red]

A thought from outside health care.... I've found that meetings with upper management tend to be more productive if you can quantify things in terms of dollars and cents as much as possible.

1) Added cost for extra staff.

2) Reduced cost of turnover (hiring, training, etc.)

3) Reduced cost of employees out on sick leave, etc.

4) Increased revenues? Can the institution make more money with more staff? Not sure if this will work in your business model but, if you can prove the point you'll get their attention.

5) And, thow in some possible process improvements in addition to the extra staff request. I you can change the processes and reduce the amount of added staff you'll gain credibility by not just asking them to "throw money" at the problem.

6) Reduced cost of errors. In industry they'd call it "rework." I'm sure you can't use that term but you get the idea.

So, talk numbers, talk money and you'll get their attention.

Good luck and let us know how it works.

[redshiloh]

Absolutely right, dollars and cents is what suits listen to. Do NOT get over emotional or angry even if they appear to not be listening.

[RN-PA, RN]

Originally posted by Nurse Nevada

I have been trying to change the nurse-to-patient ratios in Nevada. I've posted some things on my site that might be helpful. Nevada is reviewing the situation in an appointed subcommitee right now. Hope this helps. There is a lot of info out there.

Nursing Nevada

Thanks, Nurse Nevada for the link-- I'm finding a lot of helpful stuff there.

I have a question related to my original post: States like California and Nevada that are working on legislation regarding ratios believe that 6 to 1 ratios are adequate staffing for med-surg, and THAT'S what I'm struggling with. My hospital thinks that if it's okay for California, it's okay for them. My question is, who came up with the 6 patients being manageable and safe when the reserach clearly indicates otherwise? (I realize the 6:1 is used as a MINIMUM staff to patient ratio.)

And to Ned the Red-- Very good advice-- Thank you! I will copy your list to give some thought and bring to the meeting. But, talking numbers is not my strength since I have minimal knowledge as a floor nurse. Not an excuse, but I'm sure they'll be "educating" ME in the meeting since they have access to all the numbers. Much of the number (cost) issues seem to be common sense to me. If you MUST give us 6 to 7 patients each, then please give us more aides-- They're less expensive than nurses and it'll keep them from being burned out and injured if they can help each other with cares, and free up nurses to do all that we have to do.

I DID mention in my letter what we nurses observe the hospital investing money in-- everything from large recruitment bonuses and advertising, high hourly rates for certain night shift positions, original artwork lining walls of one of their facilities, extensive landscaping, and they're instituting a new computer system where all documentation will be done on line by early December. I think mangement will be saying the computer will streamline our work and give us more time for patients, although I'm doubtful-- but hopeful-- that will be the case, once we learn the new system.

Originally posted by redshiloh

Absolutely right, dollars and cents is what suits listen to. Do NOT get over emotional or angry even if they appear to not be listening.

More good advice-- thanks! I understand that management MUST deal with dollars and cents, and that will be their emphasis. That's why I want to be armed with facts like those in the Aiken study and some that I'm finding on the Nevada site. I will be role-playing and preparing by discussing everything with my husband; he plays a good devil's advocate and has an MBA in management. And I will TRY not to get emotional or angry, but sometimes a little passion is a good thing in these situations.

It feels like 4 against 1 as I face this group from management, but I'm motivated and commited to try to change conditions or die trying. :)

[redshiloh]

Well, if it helps, WE are behind you...Good Luck!

[RN-PA, RN]

Originally posted by redshiloh

Well, if it helps, WE are behind you...Good Luck!

Thanks-- that helps a lot! :kiss

I love my co-workers and don't want to lose any more of them. It's difficult to work with stressed-out friends and to not be able to help much when you're nearly drowning with your own problems. I'm tired of often feeling like a masochist and martyr on the job, and of feeling that I must work double-speed to give decent care and keep up with the pace and demands, and my anger at the injustices of this "system" is motivating me to try to do something to change things. I'm trying to be optimistic but realistic about what can be accomplished by this meeting, and hope management will be open-minded at the very least.

[redshiloh]

Well, let us know how it goes. I know what you mean about being martyr sortof. Staff tends to bring anger my way, my new nickname is Target.

[RN-PA, RN]

Originally posted by redshiloh

Well, let us know how it goes. I know what you mean about being martyr sortof. Staff tends to bring anger my way, my new nickname is Target.

I'm sorry to hear that. I'm hoping MY new name won't also be "Target". I spoke to a manager who's on our retention committee and read her the letter before I sent it. She encouraged me to send it to the higher-ups, and when I asked her about repercussions or possible retaliation, she was fairly reassuring that I shouldn't have a problem.

I will report back the results of the meeting. Right now, we're trying to set a date when everyone can attend.

[Gomer]

Originally posted by RN-PA

I have a question related to my original post: States like California and Nevada that are working on legislation regarding ratios believe that 6 to 1 ratios are adequate staffing for med-surg, and THAT'S what I'm struggling with.....

The staffing ratios were developed by the unions (CNA and SEIU) and backed by the (now defrocked) governor Davis. Although they disagree on the definition of "nurse". The CNA wants only R.N.'s counted; while the SEIU wants R.N.'s and L.V.N.'s counted. Right now the ratios for Med/Surg are 1:6 and in 2005 it will change to 1:5. Oh, and California is not working on legislation -- it passed and goes into effect in January.

As for your meeting, I agree with Ned -- only talk $$$$$ and productivity as it's the only thing these people understand. Suggest you have valid dollar and cents figures to back you position and whatever you do, DON'T GET EMOTIONAL!

[Ned the Red]

One more idea... maybe from left field but it's based on the things I hear from my wife (an RN). I know that hospitals charge the insurance companies for everything. So, the better the people on the floor can document (# of aspirins, #of treatments, #number of foleys, etc) the more accurately they can pass those costs along. If you can make a case that more staff will help "capture" those billable items it should help you. Perhaps point out that there is a gap between the supplies that come to the floor and the supplies that are charged and that more staff could help with that? Again, maybe from left field since this isn't my profession (yet) but it's another area of money that should get their attention.

And, as I mentioned above, there's the issue of what we in industry call rework. If a treatment isn't done when it should be, and complications arise, and the patient must stay in the hospital longer, does that cost the institution money? The answer here might be "No" but, something to think about.

[RN-PA, RN]

Originally posted by Gomer

As for your meeting, I agree with Ned -- only talk $$$$$ and productivity as it's the only thing these people understand. Suggest you have valid dollar and cents figures to back you position and whatever you do, DON'T GET EMOTIONAL!

Thanks for the info. about California's ratios.

Okay Okay! I ~WON'T~ get emotional! And I understand the need to focus on $$$$$, but from where am I supposed to get these "valid dollar and cents figures", besides general figures from the Aiken study? I don't have access to my hospital's budget; I only know what they tell us. We just came through a rough year financially due in part to Pennsylvania's extremely high malpractice insurance costs, when the higher ratios were implemented and cutbacks made, and we're finally "in the black" again.

I believe I need to be focused on what I KNOW best: The concerns of the med-surg nurse and working conditions. Either management cares about retention or they don't. Either management has the $$$$$ or it doesn't. I don't have any illusions about what I may or may not be able to accomplish through this meeting, but I'm glad for the chance to be heard, if nothing else, but am hoping for more.