staffing by accuity....looking for other opinions

[sandy123]

I work on a busy medsurg-oncology floor on midnights and am wondering how other hospitals deal with the accuity related to demented, detoxing, and confused patients. On my floor midnights generally has 6 or 7 patients to start and generally get atleast one if not 2 admits nightly. Our patients range from chemo to ETOH detox to pneumonia to you name it. Over the last 4 months, we have been transitioning to a staffing by accuity model which focuses on a Braden scale score and "nurse input" regarding how heavy the patient is. Factors such as wound care, tubes in and out, telemetry, etc are left to the nurse to add in. We on midnights are having a hard time getting the management to recognize how big of a factor sundowners, agitation, dementia, detoxing behaviors, etc increase a patient's accuity rating. They tend to minimize the patient who is climbing out of bed from the minute you come on or screaming at the top of their lungs. Does your facility get how much this impacts a patient load and adjust accuity accordingly or is it like this everywhere?

[whipping girl in 07, RN]

When I first moved to my current state and went to work in as an ICU float at my current hospital, we had to fill out an "acuity" form on the front of our flowsheet at the beginning of the shift. It was a 1-5 scale and I could usually make my patients a 4 or 5 pretty easily. This was used to justify our staffing. Unfortunately, the patients who were the most trouble were usually only a 2 or 3 and may qualify us for less staff and the patients who were a 4 or 5 were easier to care for. If the patient was a 2 or 3 we were supposed to be pushing the physicians to transfer them to the regular floor. It made no sense, it was completely pointless and after I'd been there for about a year management finally caught on and quit making us do them.

It's hard to know what someone's going to do on night shift. I've reported off on a completely easy and oriented patient at 6:30 PM only to come back in at 6:30 AM and find that my relief had a horrible night with the patient. And when I worked nights I dealt with the same thing.

You can't just tag a number on a diagnosis/age/medical device/etc, add them all up and come up with an acuity to tell you how many of those patients each nurse should have on a shift. One nurse may handle something with no problems and another may be overwhelmed. Experience of the nurse plays a big part.

[Wise Woman RN]

Staffing by acuity is not cost-effective... LOL LOL LOL You can put in your acuities until you are blue in the face, but if it calls for more nurses, someone will come and change them to make the acuities fit the number of nurses, not vice-versa...

[diane227, LPN, RN]

People have been debating this problem for as long as I have been a nurse and so far as I know, there is no system out there yet that works. No nurse will score the patient the same way, no matter how you train them. In addition, patients change over time. The way they start out at the start of the shift does not tell you how they will be at the end of the shift.

On my unit, as the charge nurse, I am responsible for setting up staffing for the oncoming shift and we have a standard matrix that we go by but I also take into account other issues like number of isolations, total care pts, post ops, confused pts, really heavy pts, pts with very frequent needs or monitoring. We also take into account the bed status of the hospital. If we are the only med surg unit with empty beds, we staff up for admissions. For the most part that works for us. We have a reliable staff that will work overtime and hardly ever call in sick so we don't work short very often. Our staffing ratio is 4:1 or 5:1 but we aim for 4:1. Our unit is a heavy unit and we don't like to have our patients have to wait for things. It was bad when I first got there. Nurses were taking 6-7 patients. But lots of patient and staff complaints so they had to do something about it. The method we use works very well for us.

[carolinapooh, BSN, RN]

First off, if someone told me I'd have the potential to get nine patients (6-7 to start and then possibly 1-2 admits has 7-9 pts written all over it), I'd be out of there like a flash. I'll never complain about six pts on night shift again (not that I ever really have). That alone tells me there's a problem.

That's not staffing by acuity - that's staffing by the seat of your pants before acuity even comes into play. And even from my limited experience I agree with Wise Woman RN - you can tell people what you have all day long, but if they say you only get six RNs (which is all we get on nights, regardless of acuity), they're going to only give you six RNs and they'll MAKE the pt load work - or at least force the charge nurse into it by not giving her the luxury of another RN on the floor.

I don't know what about night shifts makes people think you need fewer RNs just because it's nighttime - because I too have had the experience of an entire floor sundowning (either from dementia or brain mets!) with five RNs - including the charge RN - and 4 of you have seven patients and the charge RN has FIVE. Yeah. And they think we were on Facebook all night.