New NM having problems staffing

RN1982 · Dec 22, 2008

Do you need to hire more nurses? Perhaps you just don't have enough staff. What is maximum number of patients on your floor and what is the nurse to patient ratio? Also what is the CNA to patient ratio?

When I worked stepdown, we could have up to 24 patients max. My manager then would schedule at 6-7 nurses that so that some nurses had 3-4 patients. Stepdown nurses shouldn't have more than 4 patients. We also had a CNA for every 8 patients. I still think 4 patients is too many for a stepdown nurse especially if you have patients on drips and vents.

BellaSRN · Dec 22, 2008

We have thirteen patients max though we are not always full. We try to keep the ratio at 1:4, so I schedule three nurses a shift. We don't always have CNA in the unit but on high census days we float a CNA to help.

We don't always have vent patients, but when I have trouble staffing is when we get vent patients and I am scrambling to get an additional nurse to help out.

If I schedule four or five nurses regularly when there are no vent patients, I will run into trouble meeting budget.

Any ideas?

RN1982 · Dec 22, 2008

If that's how the staffing always is, I wouldn't stay either. I'm not trying to be harsh, just honest. You need to hire more staff. If the acuity of the patients is high, the nurses should have no more than 3 patients regardless of whether or not there is a vent patient. And no matter what the acuity is there should always be a CNA or two on each shift.

RN1982 · Dec 22, 2008

I can see how some nurses leave units such as step-downs. It's stressful. For example, the acuity on my unit was pretty high. We have vent patients, trached patients who needed frequent suctioning, patients in full DTs, patients that were confused and needed sitters, patients on insulin, heparin, dopamine, patients with multiple antibiotics and other meds, patients with wounds, patients that were 400-600 pounds and needed the entire staff to help turn. And we'd have 1 CNA for 12 patients which in my opinion was not enough help for the acuity of patients. Lots of nurses left because of the staffing because it was a skeleton crew all the time.

And I know as a manager, you need to maintain a budget but if thats the first priority over safe staffing than expect your staff to leave. Because the first priority to me as your staff RN is not the budget, it's my patients.

Again, I'm not trying to be harsh, just honest.

BellaSRN · Dec 22, 2008

We had a CNA on all shifts, but lost three CNAs recently to a nearby hospital and have had trouble recruiting. In the meantime we've been floating in help when we need it and scheduling a CNA on nights.

Even though it'll cost a lot, I think I am going to have to hire agency to keep the nurses I have and recruit with better ratios.

HouTx, BSN, MSN, EdD · Dec 22, 2008

BellaSRN,

You have my sympathy - staffing & scheduling are just about the most difficult jobs in nursing management. Did your organization provide you with any training for this or are you having figure it out as you go along?

I didn't find out until I had been in management for quite a while -- but there are well-established methods and processes for handling this stuff. There are all sorts of variables that come into play, but essentially you need to start by establishing your required staffing for weekend coverage, then work backwards. ALWAYS give your full-time staff the shifts they want first, then fill in with your Part-time and finally PRN folks. Unfortunately, most managers do it exactly wrong - offering first choice to the people who contribute the least (PRN) because it is easier.

You also need to examine your underlying labor budget assumptions such as your allocation of direct versus indirect hours per patient day. Are they accurate? What about your replacement factor to account for (budgeted) benefit time; it's usually from .14 to .23, depending on how much benefit time is offered. Finally, don't let anyone tell you not to budget in some overtime.... it is an inescapable fact. But OT should account for 5% or less of your total labor budget.

Here's another bit of 'insight' that comes from experience. Avoid "first come - first served" at all costs because some nurses are sheer geniuses at being the first to put in their requests. To ensure equity, I would recomment that each "shift off" request is counted as one request. Therefore, if someone asks for 3 shifts off in a row, that = 3 requests. If you have a mix of shifts, you may want to count 8 hours off as 1 request, and 12 hours as 1.5 requests. You can keep track of requests and balance them out over the entire staff to make sure that you avoid charges of favoritism.

Generally, you need to establish 'core' staffing that will meet your needs 80% of the time, and fill in with PRN for those census increases. That way, you will avoid too many call offs. Talk to your staff about the best way to handle unexpected increases.. they're very creative. There's no rule that shifts always have to be 12h or 8h. People are sometimes very willing to come in for 4 hours, but not the full shift.

As the manager, you have to swallow hard and realize that you don't get to be anyone's friend. The best you can hope for is to be known as fair and consistent.

Jules A, MSN · Dec 22, 2008

we had a cna on all shifts, but lost three cnas recently to a nearby hospital and have had trouble recruiting. in the meantime we've been floating in help when we need it and scheduling a cna on nights.
even though it'll cost a lot, i think i am going to have to hire agency to keep the nurses i have and recruit with better ratios.

our nm finally got a good core staff with full time, part time and prns so we rarely use agency anymore. from what i understand that really helped the budget. are you paying your cnas a decent wage also? a couple of extra bucks an hour can mean alot to your cnas. in my experience thats a sure way to attract and retain good people with little impact on your budget. what great info from rbezemek!