RN providing total care for 4-5 patients

[_littlemissBSN]

Hi, I just felt like I needed to vent and this site has always been the only place I know where to.

I work in an acute inpatient rehab hospital. It's a newly built 3-story facility. This week, our census hit the lowest with 20-ish and the census in the floor I'm assigned to is only 9. They want to "maximize" staffing, so what they're doing right now is putting 2 RNs on that floor, with 4 and 5 patients respectively, but no CNAs. They resorted to that because they don't want to have only one RN working on a floor even if there's a CNA with them. We usually have a maximum of 8 patients with a CNA.

So for the past two days, I'm having 5 or 4 patients and I'm the one doing total care for those patients (toileting, passing trays, setting them up to eat, feeding, etc-except showering). And it was tough, especially with the patient rooms being spread apart. They're all private rooms) and management does not want to move patients around. My colleague and I tried our best to work together, especially with the ADLs, and our unit secretary helps out whenever she can. Even then it's still hard for us. Having 8 patients with a CNA to do the ADLs is barely doable, though I can manage. But this? I find it ridiculous if I'm being honest.

I've never worked in other health care settings, but I know ICU RNs also provide total care for their patients. IMO though, that type of set up just isn't possible with 4-5 acute rehab, high-fall risk patients. These are the types of patients who need to be toileted, lifted, transferred from bed to chair/vice versa on a constant basis. It's too much physical labor for a nurse and we're already swamped with other demands on the medical side of things. Perhaps I'm just tired, but I'm having a difficult time convincing myself that this is supposed to be an "effective" staffing strategy. I did not feel safe for my patients or myself at all.

Am I just exaggerating? Is this actually feasible?

Thank you all for taking the time to read this.

[jb_mmmm, BSN, RN]

That sounds hard sweetie, I'm sorry they're doing that to you. My unit tries to keep the census between 20-24 patients with 4/5 nurses so we always ended up with 5 patients (4 if it's a miracle, 6 if they really don't care about us that particular day) plus admissions. I'm two months in off new grad orientation and I remember this one week with my preceptor where we had 5 patients and three of them were quadriplegic sci patients with total care and it was literally IMPOSSIBLE. At the end of the shift we literally told the night charge nurse to take one of them off. We're chronically on 1-3 techs so I can't imagine how hard it must've been for you with no techs at all.

How long have you been in this unit?

[DeeAngel]

Our policy stated that nurses shouldn’t lift over 50 lbs. Look up the written policy because you need staffing to the point the policy can be followed.

[EDNURSE20, BSN]

I’m shocked by the responses.

This is all I’ve ever known. 4-6 pt per RN, who does all cares. Normally there’s one CNA, but that’s to help with 6-7 RNS with 30-35 pt. So only really helps with pt that are 2x assist. Even then you generally have to find another RN to help you instead of the CNA.

I think it manageable. Most of the time.

[peaceweaver]

Reading this has made me realize how messed up our staffing/workload situation is in my area... ? We don’t generally have nursing assistants on our acute care med surg floors. A few floors (including my floor) have a SINGLE personal care attendant on day shift who helps between five to seven RNs. Each RN on day shift has at least four patients, or upwards of five to six patients when short staffed. On night shift, there are four to five RNs with six patients each (or seven to eight patients when short staffed). There is no personal care attendant hired for nights.

This is a 24/7, 365 days a year sort of experience for me. On my floor, our patients are almost always min 2 person assist, one person assist if we’re very lucky. Independent patients are almost unheard of. Most of our patients are unable to go to the bathroom without assistance. The vast majority need help washing themselves. Some can’t feed themselves either. Some require a stand aid lift for toileting, some require a total lift to get in their chairs. If our single personal care attendant is not free when we need their help (which is almost always, since there are upwards of six other RNs who need their help), we then have to help one another with basic personal care, or have to do a heavy two person task all by ourselves — all while passing meds, taking vitals, doing assessments, monitoring blood transfusions, doing complex dressing changes, preparing patients for OR, receiving patients from OR, admitting patients from emerg, entering orders, calling physicians with updates on sick patients, performing EKGs after the EKG techs have gone home for the day, answering phone calls, dealing with family members, apologizing to patients who are yelling at us for being two minutes late with “the pill that starts with a D”, listening for bed alarms ringing to alert us that a confused patient is trying to climb out of bed, calling pharmacy to request meds that aren’t in the Pyxis, doing discharge teaching, preparing patients for transfers to other facilities, dropping everything to assist with codes/near codes, documenting, documenting, and more documenting, etc, etc, etc.

I know this doesn’t help you, but holy crap, I wish I worked somewhere where it was considered ABNORMAL to not have help with patients’ ADLs and personal care needs. ? When patients are heavily dependent on health care workers for assistance with ADLs, it is NOT APPROPRIATE for management to cut corners and not staff that area with an adequate number of CNAs. RNs simply CANNOT do it all. This “doing more with less” mantra that hospital administrators and managers dump onto front line nurses makes me sick. If we don’t speak up, things will never change... It’s not safe for us, and it’s definitely not safe for our patients.

[MunoRN, RN]

On 11/2/2019 at 6:19 PM, _littlemissBSN said:

Thank you everyone for your feedback!

That's mostly what our management think, but I'm not sure they know how much time it takes to do most of the ADLs like linen changes or transferring a maximum-assist patient, take them to the toilet, clean them up, and return them to their bed. I'd be lucky if they wished to stay on their wheelchair for a bit. Some of them stay on the toilet for 15 minutes and I can't leave them because they're high fall risk. We couldn't start our 8-9 meds because we had to pass breakfast trays and set patients up for meals.

I always help my CNA out with ADLs on a normal work day whenever I can, but when issues start piling up that require RN intervention, there's no one to delegate these tasks (adl's) to if I'm all by myself. Perhaps, I can handle 4 total care patients on my own without a CNA, but 5 is pushing it.

Sorry, but 8 patients for 2 staff vs 4 patients for 1 staff is the exact same workload, maybe this is a 'new math' vs 'old math' thing.

[Nunya, BSN]

4 hours ago, nznurse93 said:

I’m shocked by the responses.

This is all I’ve ever known. 4-6 pt per RN, who does all cares. Normally there’s one CNA, but that’s to help with 6-7 RNS with 30-35 pt. So only really helps with pt that are 2x assist. Even then you generally have to find another RN to help you instead of the CNA.

I think it manageable. Most of the time.

"Manageable. Most of the time." Is this what we've come to? I worry about about my 90yo Mom when she goes into the hospital, I don't want a nurse taking care of her who's just "managing, most of the time."

[peaceweaver]

5 hours ago, Elaine M said:

"Manageable. Most of the time." Is this what we've come to? I worry about about my 90yo Mom when she goes into the hospital, I don't want a nurse taking care of her who's just "managing, most of the time."

100% agreed. I’ve often said to my coworkers and family that I never want to be in hospital and never want to see any of my loved ones in hospital, as I had absolutely no idea before I entered the profession how much pressure the average nurse is under, and how frequently nurses are working short-staffed with a million and one things on their minds for way too many patients. My only “good” days occur when, by some miracle, I’m down to three patients after a discharge and don’t get an admission, or (again, by some miracle), all 4-6 of my patients are one person assist. The moment I have even one total care patient who needs two or more personnel for repositioning is the moment I start having to rush to get through my day. Add two or three such patients to the workload, and the time I’m able to spend with my patients who require less assistance is cut to the bare minimum.

RNs providing total care without an adequate number of CNAs may have worked back in the day when acuity wasn’t what it is at present. It barely works now, and many days my coworkers and I feel like we’ve made it through by the skin of our teeth. Our patients have so many comorbidities, complications, and complex higher-order care needs, and asking RNs to toilet, feed, wash, and ambulate patients with minimal to no help *in addition to* our mountain of other responsibilities is asking way too much. Management, who mostly nursed in the 70s-90s, are so far removed from the realities of current nursing. They tut tut and wag their fingers over increased rates of patient falls, staff injuries, sick calls, etc. and don’t listen when we explain that what we need is more bodies on the floor help to meet our patients’ basic personal care needs. We plead our case over and over again, and in return we get fancy, new, expensive safe patient handling equipment that STILL requires two or more health care workers to operate it.

We shouldn’t just accept the status quo of total RN care “because that’s how we’ve always done it.” Patients are increasingly older and sicker, and that’s not changing any time soon. There are honestly times when it feels like the powers that be are just waiting for all of the baby boomers to finish passing through the system so that they don’t have to cut positions and deal with the hassle of sorting out severance pay when the census eventually goes down.

[litbitblack, ASN, RN]

yes TPC for 4-6 patients was doable back when I worked med-surg in 2008. I have worked inpt rehab and the patients are going to rehab sicker than they used to. Staffing has always been an issue in nursing and it just continues to get worse. I would find another job and let them know you will not work that assignment. Can you file safe harbor? At least it would cover you if something were to happen. Management tends to not want to do the paperwork r/t safe harbor.

[Nunya, BSN]

12 hours ago, peaceweaver said:

100% agreed. I’ve often said to my coworkers and family that I never want to be in hospital and never want to see any of my loved ones in hospital, as I had absolutely no idea before I entered the profession how much pressure the average nurse is under, and how frequently nurses are working short-staffed with a million and one things on their minds for way too many patients. My only “good” days occur when, by some miracle, I’m down to three patients after a discharge and don’t get an admission, or (again, by some miracle), all 4-6 of my patients are one person assist. The moment I have even one total care patient who needs two or more personnel for repositioning is the moment I start having to rush to get through my day. Add two or three such patients to the workload, and the time I’m able to spend with my patients who require less assistance is cut to the bare minimum.

RNs providing total care without an adequate number of CNAs may have worked back in the day when acuity wasn’t what it is at present. It barely works now, and many days my coworkers and I feel like we’ve made it through by the skin of our teeth. Our patients have so many comorbidities, complications, and complex higher-order care needs, and asking RNs to toilet, feed, wash, and ambulate patients with minimal to no help *in addition to* our mountain of other responsibilities is asking way too much. Management, who mostly nursed in the 70s-90s, are so far removed from the realities of current nursing. They tut tut and wag their fingers over increased rates of patient falls, staff injuries, sick calls, etc. and don’t listen when we explain that what we need is more bodies on the floor help to meet our patients’ basic personal care needs. We plead our case over and over again, and in return we get fancy, new, expensive safe patient handling equipment that STILL requires two or more health care workers to operate it.

We shouldn’t just accept the status quo of total RN care “because that’s how we’ve always done it.” Patients are increasingly older and sicker, and that’s not changing any time soon. There are honestly times when it feels like the powers that be are just waiting for all of the baby boomers to finish passing through the system so that they don’t have to cut positions and deal with the hassle of sorting out severance pay when the census eventually goes down.

Soon enough those admin people will be in the hospital themselves...karma!

[juviasama]

Wow I'm sorry that happened to you! I once also had 7 patients on day shift with 3 to 4 totals and it's very hard, and when my totals requested shower, I felt like I wanted to cry. Not because that I dont want to help them, but I was just stressed out trying to finish everything on time ( I already got written up for working overtime and they didn't want me to work overtime). While 4 to 5 totals regardless of the number of patients you have is doable, it's really intense and stressful.

[beekindRN, ASN, RN]

Totally reasonable to be mad. Our CCU consists of an ICU and a step down unit.

In ICU, I'm doing total care, but that's q2h oral care, q2h turns, one or two baths, and a couple poops. We're so short staffed, I can do most of it myself. It's not the end of the world. They're also intubated and sedated lol so it's uncommon that they're needy. In our step down unit, we have four patients and it's hard to not have a CNA! We staff an aide in our stepdown unit before ICU!

[mmc51264, BSN, MSN, RN]

I worked ortho rehab before I worked inpatient ortho. There were 20 beds on my unit, rarely was it full but it was me and an aide. I did the med passes and assisted to bathroom and to the dining hall. The aide helped with ADLs. Most were minimal assist. I helped remind them on hip precautions. I worked 3-11 so my main thing was getting them to dinner and then ready for bed. Most days it was fine.

Now that I am on the surgical floor, we have 3-4 pts during the day (depending on # of stepdown pts) and nights have 4-5. If the census is high enough, we have 3 aides, many times they work short with one aide or none at times at night. That means we do total care for our pts that are POD #1-3. We have some that are total care. 4-5 without an aide is busy, but doable. Certainly not ideal.