hunnybeeRN

"They're cutting back on overtime by pushing the new 'time management awareness' policy."

I know that the Board of Nursing's Administrative Code of my state requires that patient condition, nurse experience, and complexity of assignment be taken into consideration with nursing assignments. I'm wondering if anyone has any experience with Joint Commission's standards or input on the following: Is it acceptable to staff your nurses completely based upon patient census without taking the condition of those patients into consideration? If so, what defines the point in which staffing completely based upon numbers becomes unsafe? Seven to eleven medical surgical patients per nurse based solely on the number of patients on the floor without acuity reflected seems an unsafe way to staff a facility. As does five to six pediatric patients without the support of a tech or secretary or any other supportive staff. Any input on the legality of staffing in such a manner?

Children can have rapid changes. All peds nurses realize that. It is quite possible there was a change in condition from your last set of vital signs to the oncoming nurses initial assessment. I once had a physician tell me that "each time we go into the room, we potentially assess a different patient." He was referring to his daily physician rounds, but it's true of nurses too. My first pneumo patient was breathing in the 80's with sats below 90 on my first assessment. I had received in report that they were stable. I honestly didn't have time between frequent assessments, calls to the physician, and stat orders to worry about whether or not the child was stable a couple of hours before. I haven't questioned it since either. I have to trust in the skills of the nurse who had the patient before me and deal with the patient condition that I personally assess at the time I care for my patients. Just like if it wasn't done you can't chart that it was - if I wasn't there, I can't tell you that they were different than what was reported. Don't stress it. As for worrying over the legal ramifications...if you do that every time a patient goes bad after you've had them, you will burn yourself out very quickly. Some things you have to just let go, study what you did wrong (if anything), process the situation, learn from it, and improve from there.

There is a difference in being legitimately sick or otherwise unable to contribute and just being lazy or failing to communicate with your group. Please, don't feel bad about something you can't help. My last group project was an 8 person project that included a fishbone diagram and an academic paper of at least 10 pages. I completed it alone after everyone else in the group failed to respond to my communications. At least until it was two days until due date when it was "OMG! I completely forgot about this"/"I thought this was due next week" while still not contributing. One or two members did edit the final project for mistakes, but that was it. This was a distance class which I think really played into it. I didn't contact the instructor about that as the previous project with the same group in which two members did not contribute received the response "good teamwork" when I asked her to read the communications on the discussion board. x_x While nursing is a team effort, I think group projects in nursing education needs to reflect the participation of the members as rated by their group as part of the grade. Otherwise, it's not fair to me for someone to not do the work and accept my A as part of their grade without some type of justification for their absence. It's like being a no-call/no-show for work and yet still getting paid - just doesn't realistically work that way.

I agree with Here.I.Stand. You are entitled to a thirty minute, uninterrupted break. However, the timing of that break cannot interfere with patient care. One suggestion you could make to your employer is to allow the lunch breaks to start at 1:30pm and to allow one CNA to take their break at a time with the other two covering the patients of the one who is at break. This would allow an hour for the patients to eat and for things to be cleaned up before the first CNA was to take their break. The the other one to two CNAs can each take their break one at a time with the others covering for them. As nice as it is to take your breaks together, that may not be feasible if you are wanting to eat with the cafeteria. This way you can still have your hot lunches and the patients have the help they need without relying on the constant, consistent, and total support of staff with other responsibilities. Also if the CNAs are covering for each other during their lunch breaks then it should be possible for the one at lunch to leave - so long as they clock out of the facility and clock back in when they return. I suggest you talk with your employer. If you don't come across as oppositional in your discussions with them and are open to compromise, you may be pleasantly surprised to find them willing to work with you. Good luck!

Thank you.

Nurses are regarded differently in other countries. We once had a resident who was always willing to assist with IVs. He once told us that in his country (I forget which one - it's been so long ago > It's all perspective. How many times have we gone into a restaurant and eaten off a perfectly clean plate and not appreciated that a person who is someone worked to make sure that plate was clean? Until people can be appreciated regardless of what they do, there will always be someone willing to look down on someone else for what they think they do as they define them by it. =/

I spoke with Risk Management before I left full-time. They had started floating pediatric nurses to the medical-surgical floors to take 5-7 adult patients without orientation. This included nurses who have never worked anything other than pediatrics. It ended with our being given an "orientation book" that included the layout of the unit, where supplies were kept, and the codes to the locked doors at that time. They have since changed. There was no information on unit policy and information collected from the staff varied with who you asked and what you were asking. When concern was expressed that the drugs were different, pharmacy brought up a list of names for the most commonly used medical surgical drugs which not everyone even received - only the two people who brought that to attention got a copy. Anything further was completely brushed aside by the facility and Risk Management never responded. One of the nurses who had been floated to take patients, had 7 patients - including two on heparin drips, had never worked med-surg, and was unfamiliar with most of the drugs (we don't routinely give them in the pediatric population). When she stated she was uncomfortable taking the patients but was willing to help the unit, she was told that if she refused to take them she would be written up for patient abandonment. I consulted an attorney after that for clarification and was told the hospital could legally do that if someone had clocked in. The whole reason the pediatric staff was being floated to these floors during our summer slow months was because the hospital had lost 5-9 nurses in a two-three month window because they refused to take 7-11 patients routinely. They filled the spots with travelers for a while and then starting using the full-time staff as a float pool regardless of their experience or area of expertise. One reason I'm so frustrated is because I've exhausted the resources there without change. It's almost as if it's not going to be an issue until something happens. That's not proactive at all. What about the person it happens to when it could have been prevented? =/

I will admit, before I went into nursing, I was ignorant of what nurses actually did. I respected them because my family always thought well of those who were in the field, but I had no idea what it was all about. I wanted to be a veterinarian from the time I was old enough to voice it. When my grandfather was in the hospital with his first stroke, it was the first time I got to see what a nurse actually does. It was the nurses I always saw when I visited - rarely, if ever, the physician. My grandfather was kept clean, fed, and treated with respect when he was in a position that probably made him feel like he had lost all respect. Nothing "degrading" in that. I wanted to do what they did and went into the field of nursing myself. Most of what I hear is positive. I rarely hear any degrading comments about nursing. Because I live in the 'Bible Belt' in the south, when I have the chance to answer my answer is generally "Jesus washed the feet of a prostitute. They walked everywhere in sandals and it was considered one of the most 'degrading' things you could do in that time in society to wash another person's feet. God set the example and you're looking down on me for caring for others?" Usually gives them something to think about or shuts them up. I think a lot of it stems from the fact most people never see the phone calls we make about condition changes, the physician order errors we may catch, the things we recommend that actually help, or understand the science behind a simple nursing intervention. A lot of our work is behind the scenes.

No legal expectation of privacy isn't exactly true. You do have a say as to when and how your image is used and even the right to deny the use of your image. I will pose for photos with patients (I work peds and often times parents want a picture of their baby with the nurse) and I will tolerate being filmed by families of patients as I'm doing things. I've had a family request that they record the verbal discharge instructions on their phone for review later. That's apart of my job as far as building report with patients and families. However, I do have the right to ask someone not to take the picture or film me - such as when news cameras come around during the Christmas season for their stories of people giving to the children in the hospital. That's not a part of my job description as a registered nurse. While it benefits the hospital, I am not required to be a public advocate for them on the nightly news against my wishes. It's very much context. As far as families in codes, our policy is to allow them and to assign someone to explain the situation to them and what is being done as it is being done. Security, pharmacy, respiratory, an ICU nurse, and the chaplain all respond to codes. It is also our hospital policy that no more than 5-6 people be in the room actually working the code. All others except for family are asked to leave or wait outside. We are actually trained in simulation on how to effectively code with agitated, aggressive, or scared family members as a part of our communication training. It's been found that having family present with someone to explain the situation to them and what is being done to their loved one helps them come to terms with what the staff is doing, the purpose of it, and can also help them let go of their loved one when they do die as they have a better understanding of what was done in the attempt and the outcome of those efforts.

I worked three years as a pediatric registered nurse at a facility. I left due to patient care concerns. I returned to work PRN after three months off to find the situation unchanged and, though I wish to leave again for the same reasons as before, I find that my conscience stings in leaving such care practices still in place. The facility is a 20+ bed dedicated pediatric unit. As far as equipment they lack many 'routine' elements of acute care such as wall suction and replace it with one or two working portables for the unit. The cribs, though in working order, are older, rusting in places such as the handles, and difficult to work at times. Communication is also lacking. I returned to find the defibrillator missing. I assumed it was being repaired and the full-time nurses I was working with also did not know where it was at the time. I returned to work PRN two weeks later and again commented on the still missing defibrillator. The full-time staff, again, did not know where it was. It was discovered with communication to the on-coming shift of its absence that the old defibrillator was removed from the unit and the unit now shares a defibrillator with the adult floor on the same level of the hospital. This new defibrillator is kept behind a locked door on the adjacent adult floor to which none of the pediatric staff immediately know the code. As far as staffing, it was one of the major reasons I left full-time there. During the winter it was not uncommon to have six to seven pediatric patients per nurse without the assistance of a tech for assistance. The nurse to patient ratio by the book at that time was three nurses at nine patients. Keep in mind this is a 20+ bed unit and rarely more than three nurses were ever scheduled per shift. Acuity is never truly factored in. It is always based on numbers. Another issue was the location of the pediatric IV room which is located behind the nurses desk through a play room. As it takes two nurses to start a pediatric IV in most cases, that often left no one at the desk or within access to the other patients at the time of IV starts - particularly at night. Prior to my leaving, I wrote the hospital two letters on patient care concerns which were mailed to them return-receipt requested addressing the concerns of staffing, acuity, and patient safety. The response was basically "Thank you for bringing this to our attention. We are working to correct this." I returned PRN to find that the nurse to patient ratio for the allowance of three nurses had risen to three nurses at 10 patients - including on day shift where most of the admissions and discharges occur. The recommended nurse to patient ration for stable acute pediatrics is one to four. The unit does not have any assisting staff such as techs or secretaries. New graduate RNs are also often left in charge of the floor with LPNs or are given patients who were critical earlier in the day without the guidance of a more experienced nurse being present. Furthermore, I recently was spoken to by a charge nurse for setting up the portable suction to suction the airway of a month old baby with RSV. Granted I had to gather equipment from two different floors to even set up the suction equipment and had to use a small feeding tube (taped to create a seal) to suction the nose as the hospital does not carry specific equipment for the suctioning of small noses such as little suckers/neosuckers. I do not need a physician's order to clear an airway. I was informed by the charge nurse that "had I been the manager, I would have made you come back in and take it down." Upon bringing up the existence of such equipment as little suckers to help with suctioning over two months ago to the manager, I was informed that she had samples in her office but had never felt the need to order - even after I recommended the product to assist in oro-nasal suctioning on infants where bulb syringes failed to work well enough. "We've never had a death from lack of suctioning." As I have written letters in the past to the management expressing my concerns without result and am increasingly concerned over the issues encountered, I am seeking any advice on how to proceed. I am concerned for the safety and welfare of the patients and wish to help improve the situation for them.