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Safe Staffing Levels for In-hospital Nursing Units

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by NURS5870 NURS5870 (New Member) New Member Nurse

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This article discusses the essential role nurses play in health care, and the implementation of safer staffing ratios to promote better outcomes for nurses and patients. You are reading page 2 of Safe Staffing Levels for In-hospital Nursing Units. If you want to start from the beginning Go to First Page.

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Until management gets hauled to a board of nursing/medicine disciplinary panel and faces charges of negligence and professional misconduct for chronic unsafe staffing ratios, staffing ratios will be treated as an afterthought by management. They get all the power but none of the responsibility or the accountability when something bad occurs. The lawyers always go after the nurse, never the management team for a lawsuit.

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Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

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1 hour ago, erniefu said:

Until management gets hauled to a board of nursing/medicine disciplinary panel and faces charges of negligence and professional misconduct for chronic unsafe staffing ratios, staffing ratios will be treated as an afterthought by management. They get all the power but none of the responsibility or the accountability when something bad occurs. The lawyers always go after the nurse, never the management team for a lawsuit.

Management is not accountable to Boards of Nursing or Medicine.

The only way hospitals will be held accountable to ratios is when ratios are made law. So far this has only happened in California.

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Daisy4RN has 20 years experience and specializes in Travel, Home Health, Med-Surg.

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While I agree that ratios are important they need to be the starting point, not the end. I have worked in Ca with the ratios and my experience was not as @nursebeth described. We had minimal staff on the floor and nurses were expected to do much more than nursing duties and also the so called acuity level of patients was just ridiculous. @nursebeth hospital sounds like a dream compared to the one I worked at. I was also a patient in a Ca hospital (different one) and had a bad experience like @traumaRUs. Major abd surgery, saw a RN the first night to get me OOB to chair (got back by myself), next day saw RN in the morning for 09 meds, no assessment, didnt see anyone again until NOC shift when I called bc IV infiltrated, she came in and told me it was fine (with very obvious edema), left came back and said MD dc'd IVF/PCA. No assessment and never saw her again except once for pain meds. Next day I told MD to dc me, said he couldnt bc of being on the PCA, uhh, its been off since last night. He agrees to dc later. Not one nurse did an assessment much less  look at the incision ever! I dont know what was going on there but the ratios were not working there. The ratios alone are not the answer, there are more factors that need to go into this equation in order to support patients and nurses alike. I dont have much hope for that bc the bottom line is usually money, but overall I think that the ratios do help a little.

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TriciaJ has 37 years experience as a ASN, RN and specializes in Psych, Corrections, Med-Surg, Ambulatory.

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Yes, Oregon requires staffing committees.  They are a joke.  I was on one.  It was hijacked by the manager.  It looked good on paper that we had a staffing committee.  Staffing remained the same.

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Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

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28 minutes ago, TriciaJ said:

Yes, Oregon requires staffing committees.  They are a joke.  I was on one.  It was hijacked by the manager.  It looked good on paper that we had a staffing committee.  Staffing remained the same.

Staffing committees are like the fox guarding the hen house.

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Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

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33 minutes ago, Daisy4RN said:

While I agree that ratios are important they need to be the starting point, not the end. I have worked in Ca with the ratios and my experience was not as @nursebeth described. We had minimal staff on the floor and nurses were expected to do much more than nursing duties and also the so called acuity level of patients was just ridiculous. @nursebeth hospital sounds like a dream compared to the one I worked at. I was also a patient in a Ca hospital (different one) and had a bad experience like @traumaRUs. Major abd surgery, saw a RN the first night to get me OOB to chair (got back by myself), next day saw RN in the morning for 09 meds, no assessment, didnt see anyone again until NOC shift when I called bc IV infiltrated, she came in and told me it was fine (with very obvious edema), left came back and said MD dc'd IVF/PCA. No assessment and never saw her again except once for pain meds. Next day I told MD to dc me, said he couldnt bc of being on the PCA, uhh, its been off since last night. He agrees to dc later. Not one nurse did an assessment much less  look at the incision ever! I dont know what was going on there but the ratios were not working there. The ratios alone are not the answer, there are more factors that need to go into this equation in order to support patients and nurses alike. I dont have much hope for that bc the bottom line is usually money, but overall I think that the ratios do help a little.

Acuity is high everywhere in acute care. I'm sorry for your experience. Nurses still need to be held accountable to best practice and standards. Ratios don't cure subpar performance or lack of management.

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Daisy4RN has 20 years experience and specializes in Travel, Home Health, Med-Surg.

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31 minutes ago, Nurse Beth said:

Acuity is high everywhere in acute care. I'm sorry for your experience. Nurses still need to be held accountable to best practice and standards. Ratios don't cure subpar performance or lack of management.

Exactly, that is why we need more than just ratios. Your hospital sounds like you have got it together!

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traumaRUs has 27 years experience as a MSN, APRN and specializes in Nephrology, Cardiology, ER, ICU.

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On 4/5/2019 at 10:27 AM, Nurse Beth said:

@traumaRUsWow, that is terrible care. You might as well have been home. I'm confused- because you don't have mandated ratios in Illinois...?

Mandated staffing ratios don't help if there are no nurses to fill the positions. (Sorry I should have been more clear)

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amoLucia specializes in LTC.

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Ho hum!

Can't get too enthused for mandated staffing unless it takes into account staffing in facilities other than the hospitals. Like what about us in LTC, skilled, free-standing dialysis, clinics, etc?

I understand how they used to do "the numbers" for staffing. They used to count just about ANYBODY with a nsg license/certificate. All those management/supervisors like staff development, case management, MDS, etc. They all 'counted' into "the numbers" providing care altho I never saw them showering pts after a 'code brown', pushing a med cart, hanging IVS, feeding pts in the DR, alcoholing down a bed for a new admission, etc.

You start adding in all those white lab coated staff into "the numbers" and you have adequate staff providing care. Like baloney!

When they remember to include all the other fields of nsg  (beyond hospital), then maybe I'll become more attentive.

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herring_RN specializes in Critical care, tele, Medical-Surgical.

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On 4/6/2019 at 3:32 PM, Daisy4RN said:

Exactly, that is why we need more than just ratios. Your hospital sounds like you have got it together!

At my hospital the worst staffing was one RN, one LVN, and one CNA for 27 patients on night shift. WE organized with the California Nurses Association mostly for safe staffing.

Since 2005 no nurse at that hospital has been assigned more than five patients.

I used to work a few registry shifts a month at other hospitals. Where the nurses inform a nurse manager or supervisor in writing as soon as they believe staffing is unsafe, And report violations to the DPH they have adequate staffing. 

Where they complain to themselves, but don't police their management they continue working in unsafe conditions. 

At one non-union hospital where staffing was usually safe I arrived to find  that two nurses were to be assigned one patient more than the ratios allowed. In addition due to increased acuity due to multiple patients requiring frequent suctioning, tube feedings, dressing changes, positioning, and diarrhea even more nursing staff was required. Nurses were complaining to their manager. 

I made two copies of the following and asked all staff to sign if they agreed:

"As patient advocates, in accordance with the California Nursing Practice Act, this is to confirm I notified you that, in our professional judgment, today’s assignment is unsafe and places our patients at risk. As a result, the facility is responsible for any adverse effects on patient care. We will, under protest, attempt to carry out the assignment to the best of our abilities."

Specifics minus patient identifiers were added and all nurse, the clerk, an RT and a physician signed in agreement. The shift supervisor was paged to the unit and handed one copy. I promised to make copies and bring them to each person signing it. But the charge nurse, who was to have illegally taken an assignment made copies for all.

The manager took an assignment until an two additional RNs and one LVN were "magically" sent to the unit.

Since then nurses fill out an ADO whenever one or more RNs, in their professional opinion, believe patient care could be unsafe. 

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Here is the first paragraph and link to hospital nurse staffing regulations in California:

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§ 70217. Nursing Service Staff.

(a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system.

No hospital shall assign a licensed nurse to a nursing unit or clinical area unless that hospital determines that the licensed nurse has demonstrated current competence in providing care in that area, and has also received orientation to that hospital's clinical area sufficient to provide competent care to patients in that area. The policies and procedures of the hospital shall contain the hospital's criteria for making this determination.

https://govt.westlaw.com/calregs/Document/I8612C410941F11E29091E6B951DDF6CE?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default) 

 

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SmilingBluEyes has 20 years experience.

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On 4/13/2019 at 12:45 PM, amoLucia said:

Ho hum!

Can't get too enthused for mandated staffing unless it takes into account staffing in facilities other than the hospitals. Like what about us in LTC, skilled, free-standing dialysis, clinics, etc?

I understand how they used to do "the numbers" for staffing. They used to count just about ANYBODY with a nsg license/certificate. All those management/supervisors like staff development, case management, MDS, etc. They all 'counted' into "the numbers" providing care altho I never saw them showering pts after a 'code brown', pushing a med cart, hanging IVS, feeding pts in the DR, alcoholing down a bed for a new admission, etc.

You start adding in all those white lab coated staff into "the numbers" and you have adequate staff providing care. Like baloney!

When they remember to include all the other fields of nsg  (beyond hospital), then maybe I'll become more attentive.

 

Yes, agreed. Having worked outside the hospital, the ratios can be deadly and dangerous. LTC, for example.  It's not  just a matter for hospital nursing.

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 There needs to be more public awareness not just rallying nurses. There needs to be billboards in high traffic areas and online banner ads and campaigns educating the public on the problem, what to do and how to vote to improve this. 

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