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Nurse/Patient Ratios

Specializes in NICU, adult med-tele.

Hi!

I am new to this forum. I am working med/tele, recently graduated and I am starting to actively search for a position in NICU or possibly PICU. I was wondering how comfortable NICU nurses generaly are with their nurse patient ratios. The other night I had ten patients, no medicine nurse. The tech working alongside me had thirteen. There was no way that this was safe, especially with confused patients, one getting blood & IVIG, etc. I really like the people I work with but I feel like my license is in danger if I remain on this floor. That is one of the reasons I want to do a critical care unit, because if I understand correctly, you must have some kind of staffing standards?

Could you let me know how you feel about your nurse patient ratios? Do you ever have nights when you think you have to many patients to safely take care of? What happens when you are at your limit for the staffing standards but there is an admission on the way? Is someone always on call or something? Thanks a bunch.

NICU_Nurse, BSN, RN

Specializes in NICU.

Sometimes our staffing is not as good as it should be, but usually we are okay. In our Level III, it varies from 2 RN's:1 baby (very high acuity- haven't seen this yet in the time I've been there) to 1RN:1baby (HFOVents, usually, or nitrous; very critical, unstable babies) to 1:2 (can be 2 vents, sometimes one is unstable, other is better) to even 1:3 (3 relatively stable Level III babies; this is unusual, but only happens when we are super-short on staffing). I've never seen a LIII assm't with more than 3 babies- at 3 we're already calling the staffing office and screaming. Even 3 "stable" LIII's, you're running your butt off most of the time, because they have qh assessments and vitals, q2h resp tx's, meds for sedation, abx, treatments, interventions, etc. If I get a 1:1 assignment I cringe sometimes because I KNOW it's going to be tough- the babies aren't assigned only one nurse for no reason! Critical care ratios typically ARE better, but you have to remember that the babies are sicker, and more care is involved. Just depends on the babies, really, but it's rarely a cakewalk. After working critical care for 18 months, though, I do have a little more control over the quality of care I give, and would now NEVER work on a floor unit like Med/Surg. Not happening in this state- 8-11 patients per nurse is just stupid and unsafe IMO. In our Level II nursery, we can have up to 6 babies before we are considered "over"full, but 6 babies with meds out the wazoo who are refluxing all over the place and refuse to eat is A LOT to handle. One night we had 12 babies and it was just me and another nurse who'd been pulled from Inpatient Peds, and had no NICU experience at all. It was a NIGHTMARE and I came home and my husband looked at me and I just fell on the bed and cried! LOL Staffing had said, well, too bad, we don't have anyone for you, and you're right on grid. Well, great, but the grid doesn't account for babies like this, or the fact that my assistance is in the form of a completely new nurse (and I'd only been out of school for 6 months!) who doesn't even know how to apply a blood pressure cuff to a baby, much less how to draw up and give meds she's not familiar with, or work the syringe pump, which they don't use up there, or feed a baby with a feeding problem, or start a new IV on those four babies who have all suddenly infiltrated. When we are at our limit, if it's mid-shift, we're screwed. Period. Staffing won't send anyone (they're all assigned) and we don't have anyone on call ever. We just have to work together and prioritize- maybe that baby doesn't get a bath, maybe the feeds go on pumps all over the unit, we just worry about the ABC's, feeding them, giving meds. It can get really hectic, but thankfully it's not all the time, unlike regular floors. I hear horror stories all the time and think, what are they THINKING, staffing a unit like that? (The staffing personnel, I mean) Hope that's what you wanted to hear. ;>) Neonatal nursing has it's benefits, and that can definitely be one of them. I wouldn't work anywhere else in the world unless I HAD to by circumstance, and it's for more than one reason. Good luck with your search!

Kristi

NicuGal, MSN, RN

Specializes in NICU, PICU, PACU.

We can have 4 feeders if we are pushed, usually 3 feeders. The vents get matched up with other kids according to their acuity. Sometimes it is 2 vents, or 1 vent 1 feeder or 1 vent 2 feeders or even sometimes 2 vents 1 feeder. We do have our 1:1's ...they are new admits until they are done, bad Osc kids, post ops, bad kids that are just bad, the occas chronic kid that has the trach and multilple other problems.

The rare 2:1...usually the charge nurse is paired with this nurse. Usually that kid ends up shipped out.

We keep our feeders separate from the vents and cpaps.

So usually we have a lot of feeders if we are on that side. Upto 12 but we have 1 or 2 nurse Aids (not sure what it its called)with us.

We try not to have more than 2 vents per nurse but sometimes we have had 3 but then they have to be stable.

We try to have the occilator babies 1:1 and allso bad post ops and unstable others.

My unit is small and the only NICU in Iceland. Sometimes it it very buissy and sometimes nothing is going on. We dont ship anyone out exept for some of the heart surgerys and them we send to Boston Childrens, 5 Hour flight.

UTVOL3

Specializes in NICU, adult med-tele.

Thanks guys for posting in reply. Not exactly what I wanted to hear but still better than the "you take as many patients as we say you will take" we often get from our supervisors. Somebody is going to die as a result of this, hopefully it will not be on my watch.

NicuGal, MSN, RN

Specializes in NICU, PICU, PACU.

When I first started in our unit we we would take a row of kids....and whatever was in that row was yours...didn't matter if it was 2 vents, a trach and 2 feeders, it was yours. If you were in the isolation room (which could hold 4 kids) you got whatever was in there, be it 3 vents, fresh postops, whatever...they were all yours!

Things have much improved where I work over the past 17 years, and I have to laugh and roll my eyes when I hear some people in our unit complain about their assignment of 2 easy vents and a feeder LOL.

Holey Cow! Some of your assignments are positively dangerous - either that or your kids aren't susceptible to NEC, IV infiltrations and other nasties that can be picked up early by thorough assessment. Also, your parents must not be as demanding as ours. I wouldn't want my baby in a unit that staffed so terribly.

Here in CA we have state-mandated ratios: a MAX of 1:2 in NICU (RNs only), 1:4 in intermediate care nursery and 1:8 in well-baby (RNs or LVNs).

Some hospitals try to get away with higher ratios, but an anonymous call to DHS will take care of that.

So far, my unit has never had a double-vent assignment. In a pinch, we've had double NCPAPs, but usually we'll pair the easiest of the growers with a vent if we can't staff 1:1.

I agree with Nell. I'm also a CA NICU nurse, and we have mandated 1:2 ratios. The 1:2 are usually feeder/growers, or you might get a more stable vent pt. with a feeder/grower. Every once in a while, if we get an admit in the middle of the night and don't have an extra RN, the nurses in the room will just absorb the pt. Meaning. one does the assessments, one does the meds, etc. But this doesn't happen often and is usually only for a matter of hours.

UTVOL3

Specializes in NICU, adult med-tele.

Sounds like you guys in Ca have great ratios. but I've heard the pay isn't the best, comparativley. of course I live in the southeast so its bound to be better than here.

bklynborn

Specializes in GERIATRICS, DEMENTIA CARE, MED-SURG.

Well here is something to think about ......the Hospital where I work announced today (via a note attached to the fridge in the breakroom,) that they were going to be "restructuring nursing throughout the Hospital" in the note it goes on to say how all RN;s will now have a patient load of 6 with an NAC. More NAC's will be hired and some of their shifts will be expanded to 12 hours...........more 12 hour RN shifts will be made available and some of the 8 hour shifts will be eliminated.......here is the kicker.....ALL OF THE POSITIONS ON ALL SHIFTS WILL BECOME OPEN AND YOU MAY PICK YOUR SHIFT AND DEPARTMENT ACCORDING TO SENIORITY.............boy is our Hospital buzzing!!!!!!

NICUNURSE,

You are doing FEEDER/GROWERS 1:2? We are 1:3, but there is talk of dropping to 1:2 - we're afraid we'll be bored stiff...

AjaRN, I thought CA pay was better than all but the northeast. It's certainly pretty good in the SF Bay Area: I made a little over $100,000 last year (work full-time evening shift and am one rung up the clinical ladder).

UTVOL3

Specializes in NICU, adult med-tele.

$WOW$

It varies. some places it is 1:2 one stable vent and feeder grower or 2 stable vents. Sometimes it is not just the danger it is heavy with all things you have to do. No one has to accept any assignment if it is dangerous. What kills me is when the MD's try to transport a baby and we don't have the nurses to do it! That is when you know your manager and or supervisor has the balls to stand up for you!

NICU_Nurse, BSN, RN

Specializes in NICU.

1:2 feeder-growers? Good Lord, I thought that was for LIII babies. We do up to SIX F-G's per RN beore we call Nsg Serices and threaten to slash their tires. I've found that 4 is just right- any less than that and I'm falling asleep. 6, to me, is too much if three or more have feeding issues. It's allowed by our grid, however so what can ya' do? :>)

We are a closed unit and no OB or level two in our hospital....so we've done however we can to get by sometimes. This means sometimes the charge nurse and transport nurse take assignments...this after we are tight already.

Our ratio's generally go 1:1 on new admits or sicker pts esp. the 23 weekers. We have had as many as 3 NCPAP babes paired, but that is not the rule ussually 2. If an intubated pt is paired it is generally with one off NCPAP...but sometimes it's two intubated babes or one on NCPAP. ICA care pts can be upto 4 to a nurse, but ussually 3.

We have a 24 bed NICU level III. Many of our RN's (all RN staff) have at least 15 years of experience and it's the most experience ones who get the heavey assignments when push comes to shove.

We have been full or near full for over a year....and are currently hirering!

UTVOL3

Specializes in NICU, adult med-tele.

At my new job that I just got the nurse manager tells to me 1:1 or 2 in the intensive care nursery and 1:2 or 3, possibly 4 in the step down. Of course we'll see how that goes when I get out of orientation.

Mimi2RN, ASN, RN

Specializes in NICU.

Originally posted by Kristi2377

1:2 feeder-growers? Good Lord, I thought that was for LIII babies. We do up to SIX F-G's per RN beore we call Nsg Serices and threaten to slash their tires. I've found that 4 is just right- any less than that and I'm falling asleep. 6, to me, is too much if three or more have feeding issues. It's allowed by our grid, however so what can ya' do? :>)

Kristi, I don't know how you do 6 feeder growers, I would be running from baby to baby all night. Our babes take about a half hour to check, nipple and/or og feed, do teaching with parents, at the same time go to deliveries and do admits. We have an almost level II nursery, last night I started with three, did the PKU and finished up the d/c on one baby. My screaming baby was a bili baby ready to feed less than two hours after his last feeding. Started that feed, went to a delivery, turned out to be a 36 weeker, flaring, grunting...brought him back...looked ok at first then started to desat....under O2, needed an IV, labs, cxr....my other two...someone else had to finish one feed, get the other ready for mom to feed....glad she was there but she wore the kid out, he would hardly nipple the rest of the night (he's an ex 30 weeker).......That's a normal night for us, throw in 2 or 3 or more c/s and high risk deliveries, sometimes 3 or 4 admits. Thank heavens we have a ped hospitalist covering most of our admits...at least we don't usually have to deal with a sleeping doc at home.

I think I'm tired.......I would probably be bored if I didn't do the deliveries........we have a busy L&D, I think we are up to 400/month. We ship out vent babies, or surgeries.

I am amazed at how poor staffing is in many places. Somehow management always underestimates the amount of time it takes to give good, safe care. After all, they are only babies, and all we do is sit and rock them........doesn't often happen! Occasionally we have to take four or more babies, usually as core we only take 2-3, because we do the admits.

mimi

NICU_Nurse, BSN, RN

Specializes in NICU.

Oh, Mimi, don't even get me started!!! We don't do deliveries, thank goodness- we'd never have the staff for it. We're losing people left and right, but that's an entirely different thread. I'm in a large teaching hospital (we have two major medical schools nearby who utilize our facilities), so the deliveries are jam-packed with interns and residents. We like to crank call the units (we have two, linked together somewhat) and scare the crap out of the newbies by asking for the on-call resi's and screaming into the phone,

"Quick! Someone needs to get to L&D NOW! We've got a Code G coming up- triplets, 24 weekers, no PNC, two out, third on the way. Mom's a PS abuser and she just decked the attending Neo!" :devil:

You'd have to be there. Maybe that in itself is an entirely different thread. (Pardon me, the cackling...it can't be helped...) (P.S. Code G is OOH Delivery, FYI. Wow, that's a lot of initials in one sentence...)

Anyhoo.

6 F-G's IS a lot; note the "slashing tires" comment that was attached to that sentence! LOL! Our Nsg Services people are...well, I feel bad for them. It's a crappy job. Nobody likes working, right? I mean, we'd all love to stay home and attend to our personal interests, and when we're short, it's nearly impossible to get people (let's not mention the fact that if they paid more, I, for one, would gladly leave the dirty dishes to attend in someone else's place, but I digress...). Still, they're animals. Really, really rude. AND they insist that, "It's NIGHTTIME! The grid goes DOWN by at least one nurse at NIGHTTIME, so whaddyaMEAN you need more help?" Add this to the fact that WITHOUT FAIL, every time the DON comes for rounds at night, he manages to come in when we've JUST SAT DOWN for the first time all night to do our long-neglected charting (Assessments? We don't need no stinkin' assessments...) and he then runs back to the office with glee, saying, "See? I told you they don't do crapola in the nurseries. They're all sitting on their fat bums gossipping, and I could swear one of them was giving herself a facial in the back corner..."

We can't win. But I say that with a smile. Sort of. A half-smile, kind of, like the kind where you stub your toe and it hurts really bad and you smile when someone innocently asks you if you're okay, and you're not, but you can't get over the nerve of them implying that it might NOT have hurt, so you lie, and smile sarcastically while you're biting your tongue. That kind of smile. But I mean it. It's from the heart. ;>P

Kristi

I am currently on a travel assignment where it is ALWAYS 3 babies to 1 nurse. Most of these babies could easily be a 1:1 assignment at my home hospital, and certainly no more than 2:1. They get away with it by only having q4, q6, or q8 hour vital signs!! I think it is very unsafe, and I assess/do vital signs much more frequently if I have time. The thing is, last night my assignment was so heavy that I did not have time to do any more assessements/vitals than what was ordered. They are staffing regularly with 6 nurses for 21 babies.

Thank God I am not regular staff here and can leave when my contract is over. I just hope nothing bad happens during my time here. I don't know why the regular staff tolerates it.

Off to work now

:stone

I cant believe the staffing problems Im reading. Im at a level III, 30 bed NICU. All RN's. 1:3 feeder growers. 1:2 vents or CPAP. 1:1 HFV and NO. Usually send heart babies out. We attend alot of deliveries. At least 500 a year. We attend all C/S and all high risk deliveries. If we admit a baby, reguardless of gestation, we usually give up one of our assigned babies to another nurse. We strongly encourage Primary and Associate nursing. We place our own PIV's. Only a few of the RN's place PICC's. Only the NRP's and Neo's place UAC's and UVC's. 2 RT's per shift. We consider them our best friends. Sometimes things get very hetic in our unit. Especially when the census is up. We are very crowded. Plans are being made to expand. But as the saying goes, "The check is in the mail". We complain alot. But I guess we really dont have it that bad! I make about $60,000. Not great. However, comparative for this area. Full time day shift. 12 hour shifts. 2 days on, 2 days off. Then every other weekend. Night shift has a shift diff. No manditory overtime or nights. Competitive benefits. We have our own registry staff to pull help when needed. Sometimes we are still left in a bind and short staffed. However, its sure better than getting a staff nurse from med/surge, or worse, no help at all. Im not saying we are never placed in bad situations. Ive been in numerous. Sometimes it just cant be helped or anticipated. But, that just goes with nursing.

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