New RN: Let’s Talk About Staffing

[RNjuice, ADN, RN]

Before I go on, a disclaimer. As a novice nurse, it’s entirely possible and even likely that my problem lies in my own ability to manage time or tasks. I accept that, but I will also stand behind the effort and thought I put in to solving for those issues on a daily basis.

I work as a Rehabilitative RN and am responsible for up to 15 patients per shift. I have found over the past 2 months of working here that the morning and afternoon med passes plus basic nursing skills (draining an abdominal Pleurx catheter, draining a Billie tube, changing colostomy bags, etc) take up the entire 8 hour shift, even when walking up and down the halls at full speed just shy of breaking into a sprint and when administering some medications earlier than scheduled when possible. That doesn’t include charting, which requires staying past the end of my shift to complete. That also doesn’t include admissions, which may add an extra 1.5-2+ hours of overtime to a shift. Finally, that doesn’t include weekly skin checks, which sometimes requires checking multiple patients on the same day and, to be done properly, requires time to be carved out of a day of doing med passes where barely enough time exists to begin with.

I imagine some of you may be reading this and thinking “yeah, that’s nursing.” Some may even think “suck it up, if you can’t handle it, get out.” My concern is with the patients. If we have created a system where our patients have to compete with our own families for time (which is what overtime really means), our patients will eventually lose.

Are we ok with this? Is this normal?

If, for example, a facility can scrounge up the cash to make sure a nurse is present, why can it not scrounge up the cash to make sure enough nurses are present to provide patient care without being in a constant state of full-bore rushing around and having to stay hours late regularly to catch up?

Is there an evidence based process for providing staffing based on patient care needs rather than census?

If we push our nurses to do more than is possible, the ones who make a good faith effort to try are the ones you will lose to turnover. The ones who don’t do the work will be unaffected. How do we create a system that rewards nurses who make a good faith effort to care for their patients without making them trade between time with their family beyond their shift and providing adequate care to their patients and fulfilling their professional responsibilities?

Does anyone have any positive experiences to share from their work places regarding this sort of thing?

[cin808]

What is being asked of you is impossible. I didn't last two months in a sub-acute unit of a rehab facility. No amount of "time-management" is going to make up for a gross short-fall of nurses. I don't know how long facilities are going to keep up with the revolving door of nurses before they finally get it that they can't get by without MORE nurses.

[RNjuice, ADN, RN]

On 9/22/2019 at 12:27 PM, cin808 said:

What is being asked of you is impossible. I didn't last two months in a sub-acute unit of a rehab facility. No amount of "time-management" is going to make up for a gross short-fall of nurses. I don't know how long facilities are going to keep up with the revolving door of nurses before they finally get it that they can't get by without MORE nurses.

Thanks, cin, for the response. It turns out you were right.

I had to make the decision to resign immediately from the facility when I finally realized this. While two weeks is the professional standard, I also have a legal obligation not to accept assignments that aren't safe or reasonable. And if I'm not accepting any more assignments, then what I am doing?

What's frightening to me is that this is my second nursing job where the nursing staff routinely falsifies the medical record to make it look they're doing things that they did not do. If the nurses would simply be honest about the fact that it isn't possible to adequately perform all of the tasks that were being asked of them, at least the corporate owners and nurse leadership wouldn't have plausible deniability and might be forced to take some sort of corrective action to help enable nurses to complete their work. Instead, it seems like much of nursing staff was content in lying in their charting to make it appear as though they were capable of completing the necessary tasks as ordered. I know this because during my orientation and training, those same nurses encouraged me to do so as well. As a result, corporate and nurse leadership get to claim that they were unaware of the problem, and the nurses who are being misleading will take the fall in the unlikely event that they are caught or they lie about the wrong thing and it causes significant harm.

It seems like much of the nursing staff treats the job like low-risk, high-return gambling. Lie in the charting about things that it's extremely unlikely you'll ever be caught for, continue to keep a $60,000+/yr job. Maybe you get caught one day, but until then, you're still getting a decently sized regular paycheck.

My only other major nursing job was at a state Psychiatric hospital where, once again, nurses were writing entirely fictional accounts about a patient's day because the patients were off the unit and the nurse charged with charting the events of their day was confined to the unit. Instead of bringing this conflict up with leadership and attempting to resolve it, nurses would simply falsify the medical record. Most days, it made no difference because unless someone died, it's highly unlikely anyone would read or question it anyway.

It's frustrating for me in particular because every time I try to make my way into nursing, I find myself being pressured to participate in these criminal practices. Worse, I find that I seem to be the only one concerned, and am usually discouraged from speaking up or disregarded because of my lack of experience.

Now I'm forced to ask ... is this the norm? Falsification of medical records? Aversion from fixing systems and acceptance of a status quo that fails our patients?

With no job lined up, I'm in a precarious situation. But my responsibility to provide an acceptable level of care to my patients is more important than my ability to get paid a lot of money. I'll find something to do for money, even if it's minimum wage. It's why I keep expenses very low.

Are there clinical/bedside nurse roles with employers who encourage fixing broken systems so that nurses are enabled to practice within the confines of the law? Are there places where nurses come together to fix situations like what I described rather than lying to avoid rocking the boat?

[cin808]

I wish I had the answers to your questions. What I didn't get into in my first response is that I am also a new nurse having graduated Dec 2018. Our paths are similar. I also worked/work at psych facility and worked in subacute. I resigned from subacute after a very short time. I'm most likely not returning to psych facility either. It's too dangerous. A doctor was recently stabbed in the head with a pen. I've lined up a few "flu shot clinic" shifts with agencies in the area and waiting to hear back about a longer term gig doing flu shots. It sounds somewhat boring but I'm happy to add the experience to my resume, and of course get paid while I look for work elsewhere (I'm interviewing with Red Cross to be part of mobile blood drive team. I already know, after a very short time, that I'm not keen on bedside (for reasons you mentioned and others). I like less traditional nursing jobs).

What you describe (falsifying MAR, TAR) is causing you moral injury as I'm sure it does the same for many nurses but most just go along with status quo because they feel powerless. I wish I could advise you in this area but perhaps you just need to keep looking and ask the HARD questions when you interview. You may have to go on dozens of interviews to find a job that aligns with your moral code.

You sound incredibly intelligent. Maybe you should conduct a study on this issue? Who knows where that could take you.

If you don't already, follow "ZDogg." He preaches about moral injury in healthcare and also does very funny parodies that help to lighten the burden of working in this field. He also preaches about what he calls "Health 3.0" which is attempting to "re-personalize" medicine. Perhaps reach out to him with an email about your concerns and see if he has any advice.

I do hope that more experienced nurses will reach out and respond to your questions. Best of luck to you.

[AnLe, ASN, RN]

I work in a medsurg/tele unit in a 39 bed hospital. We're currently understaffed. Charge has to take 6 patients along with the other 5 nurses. We are supposed to have 3 aides, but usually it goes down to 2, sometimes 1. Although, according to our 10 year veteran charge nurse, the norm 3-4 years ago was to take 7-8 patients. Yikes! I'm already struggling with my 6. Shift starts at 1845 and I don't sit down until 0100. Assessing, medication administration, answering questions, ensuring their needs are taken care of takes a long time.

My preceptor would tell me, "15 minutes AnLe. I'm going to call you to make sure you come out on time." If I am performing my job as we were taught in nursing school, without taking shortcuts, wouldn't it take longer than that? For the first 6 months of working, I would stay until 1000, to chart. Now, the latest is 0830. My admissions take around... 20 minutes to 1 hr to complete.

I will say that I have seen a few instances where the charting appeared falsified. For example, I say appeared because the patient should've been on a waffle overlay to help prevent pressure ulcers with a Braden of 15. I got an order for one, because one didn't exist and applied it. When I went to chart, every day she had a waffle overlay documented. Could they have removed it that day? Maybe. The patient was oriented to self, she couldn't answer me.

The are so many times I want to message our director or MIDAS something to shine a light on it. Patient care comes first, it's been a long shift and it's already 0830, I need to return tonight so I'll be leaving - which is why those messages never happen.

[Subee2, BSN, MSN, CRNA]

I've never seen an article from the ANA in a newspaper alerting the public to what working conditions have become for the staff and steps that can be taken to make hospital stays safer. If our NATIONAL association won't help us, who will? The demand will have to come from the public and they have no idea how hospitals have devolved into corporations who don't respect patient safety as the top line item in the budget.

[SmilingBluEyes]

I think the ANA is useless for nurses. They do NOT have our backs. I was a member some years back and sure did not see any value in paying for membership. There is no move to improve our lot or public perception of nurses as professionals.

The public needs to know how dangerous it is these days. Literally someone has to stay in the patient's (or in LTC, resident's) room 24/7 to be assured they are getting even basic care done. They see us as nothing but a cost. No respect, no backup and definitely not worth much to the "shareholders" who demand more money all the time.

We are seen as maids, waitstaff, butlers, etc and we come with the toilet paper and towels in each admission's cost. And, the only way this could get better is if we were to itemize the skills--- (and be paid accordingly)--- we perform for each patient each day. We are worth more than a bag of normal saline. Stop with the patient/family's perception they are entering a day spa, not a hospital.

MDs bring revenue; we cost too much. Literally don't see it getting better. I am eager for retirement.

I worry for my family, loved ones and myself in the future. I don't think care is what it should be and I believe a lot of injuries and mistakes are coming in the future, endangering the patients even further.

ANA: stand up and speak the truth. And actually care about the nurses you say you represent!