Staffing Ratios in Acute Care Psych (child/adol) Units

PMHNP10 · May 2, 2005

I work in a psych hospital on a dual unit--we have adolescents on one side and children (up to 12 years) on the other side.
Last evening we had 2-1/2 RN's (one left at 7), and started with 23 patients and got 5 admissions to our crisis stabilization unit, which was closed (insufficient staffing) so they came to us.
We had four techs--two on the children's side and two (usually) on the adoelscent side. But techs can't do meds, call codes, do admissions, take nurse to nurse reports, call the docs for prns, etc.
We were running ourselves ragged; the charge nurse didn't leave until about midnight, and I didn't get out til midnight:45.
We feel we are terribly understaffed but are being told this is a normal/usual staffing ratio.
Days gets an extra nurse. I do see other nurses on other units not having to go nearly as hard as we do, but then, I'm sure they have their busy times too.
So, how many nurses (RN's and LVN's combined) do you have for how many acute care children and adolescents?

I need to come into the psych section more often. First of all, howdy. Second, you are terribly understaffed. Before I came to CA I had no more than 11 patients, which is still pretty understaffed. In CA we have the ratios to protect our licenses. I'm on a 14 bed unit. If full, we get a total of 4 staff--2-3 RNs and 1-2 LPTs (in CA an LPT is an LVN who took an intensive psych course instead of the L&D rotation). By chance are you working at one of the psych facilities within a hospital, or in a freestanding psych hospital?

chris_at_lucas_RN, RN · May 2, 2005

We are in a freestanding psych hospital which is immediately next door to a megahospital that this hospital apparently was once a part of. (Sorry for the dangling participle.)

A funny thing happened since I posted that last bit.

A brand new program manager happened to be walking through our unit around 5 or so, on the way to her own unit. We were up to our knickers in screaming kids, kids throwing things, kids hitting each other, and the pica kid was munching on his third marker, or maybe it was the crayon course, I'm not sure.

She took a look around and said, "this is not right." I told her we had asked for more staff and were told we were fully staffed as is, but if she could get us more staff, I'd kiss her foot.

She said she'd try to do something. I suggested that this would be a good time for our own program manager and the CEO to stop in--I'd heard the CEO had come by earlier. (Here's a good ditz anecdote for you: the yahoo who told us in report about the CEO visiting put it this way: "luckily he came at the one moment when things were peaceful and calm." Yeah, that's the way to make sure you get enough staff. What a dope.)

Another nurse and another tech materialized within 30 minutes. The CEO never bothered to show on the unit again, no loss there for several reasons. Our own program manager is a regular presence--she didn't come back that day, but she had been there before and she has been there since. And she has been so supportive and positive about us, and does seem to know her stuff, that I am pretty certain her earlier statement about us being fully staffed came from higher ups. (The Peter Principle visits .... I don't wanna write what I'm thinking; you get the idea.)

And since then, we have been much better staffed. I thought it would just be when JCAHO was there, but no, they've been gone 5 days now, and each shift I've worked, we've had at least three nurses and four techs. Last night we had four nurses and three techs, which is a genuine luxury and lets us be out on the floor with the kids at times. And we only had 20 patients. It was pretty amazing. We actually get to do therapy. And interact. And (a real treat) we can get to know the kids we are charting on. Helllloooooo!

Let's see how long this lasts. :uhoh3:

PMHNP10 · May 2, 2005

We are in a freestanding psych hospital which is immediately next door to a megahospital that this hospital apparently was once a part of. (Sorry for the dangling participle.)
A funny thing happened since I posted that last bit.
A brand new program manager happened to be walking through our unit around 5 or so, on the way to her own unit. We were up to our knickers in screaming kids, kids throwing things, kids hitting each other, and the pica kid was munching on his third marker, or maybe it was the crayon course, I'm not sure.
She took a look around and said, "this is not right." I told her we had asked for more staff and were told we were fully staffed as is, but if she could get us more staff, I'd kiss her foot.
She said she'd try to do something. I suggested that this would be a good time for our own program manager and the CEO to stop in--I'd heard the CEO had come by earlier. (Here's a good ditz anecdote for you: the yahoo who told us in report about the CEO visiting put it this way: "luckily he came at the one moment when things were peaceful and calm." Yeah, that's the way to make sure you get enough staff. What a dope.)
Another nurse and another tech materialized within 30 minutes. The CEO never bothered to show on the unit again, no loss there for several reasons. Our own program manager is a regular presence--she didn't come back that day, but she had been there before and she has been there since. And she has been so supportive and positive about us, and does seem to know her stuff, that I am pretty certain her earlier statement about us being fully staffed came from higher ups. (The Peter Principle visits .... I don't wanna write what I'm thinking; you get the idea.)
And since then, we have been much better staffed. I thought it would just be when JCAHO was there, but no, they've been gone 5 days now, and each shift I've worked, we've had at least three nurses and four techs. Last night we had four nurses and three techs, which is a genuine luxury and lets us be out on the floor with the kids at times. And we only had 20 patients. It was pretty amazing. We actually get to do therapy. And interact. And (a real treat) we can get to know the kids we are charting on. Helllloooooo!
Let's see how long this lasts.

that is a pretty fortunate thing; it's still too many, but it's much better than previous; I've been spoiled by having safe ratios; I'm so not looking forward to returning to the real world of nursing

spasm · May 16, 2005

I have been trying for some time to find recommendations from a reputable source suggesting appropriate staffing levels (my interest lies with acute adult psych). I have Googled this and searched the ANA site in hope of finding something concrete.....something with numbers! Granted, acuity levels will factor into appropriate staffing levels, but I dumbfounded aobut not being able to find even a minimal starting point. Any suggestions or insight would be truly appreciated.

BTW, your original staffing was reprehensible.

chris_at_lucas_RN, RN · May 16, 2005

I have been trying for some time to find recommendations from a reputable source suggesting appropriate staffing levels (my interest lies with acute adult psych). I have Googled this and searched the ANA site in hope of finding something concrete.....something with numbers! Granted, acuity levels will factor into appropriate staffing levels, but I dumbfounded aobut not being able to find even a minimal starting point. Any suggestions or insight would be truly appreciated.
BTW, your original staffing was reprehensible.

I think there may be a serious problem with the competency of the staffing nurse. (I hate to say that, but it's looking likely.)

Frida, we had two RN's (me for the whole eight hours, two from the crisis unit, but one worked til 7 and the other came on at 7) and five techs. We started the shift with 7 crisis kids (all adolescents) and 19 of our 20 child/adol beds filled as well, so that was 26. We lost two of the crisis kids and admitted 4 more, each carrying a full set of precautions.

Our acuity level statistic is calculated such that each new crisis kiddo amounts to an additional 1.5 acuity points. I stopped counting when I hit 35 points. (A stable "regular" kid with no precautions counts as a half a point.) Plus we had two flaming borderlines (how they love crowds!) and one brain damaged antisocial. Amazingly, we only had one code, and I called it soon enough that nothing bad happened.

Saturday, we had three nurses, no crisis kids, no admissions, no discharges. But the computers went down at 11:30, so we printed out a bunch of stuff for the night shift. No problem there--the supervisor even came and did it, although I was ready and happy to....

Sunday (last night), we had 3 nurses and a fairly full house. The rub there came because the crisis unit was open but they were "too busy" to do their own admission (claimed they had four but when I went to get an admission packet--we don't keep their forms on our unit, the two nurses didn't see all that busy, the kids were in bed and no one seemed to be waiting... but then maybe they took care of that before the Starbucks run?).

Hate to gripe, but the manager is back to "you are fully staffed with two nurses on 3-11" and when I said I think I need to trim off my hours because this is unsafe and too high stress (I like to be busy, but I'm not good at crowd control), she said she wants a staff who is "committed."

I love this lady like a close friend, and I can appreciate being between us and the money grubbers in administration, but I feel taken advantage of. And I feel like as long as we put up with this chronic staffing problem, we will have it.

I mean, aren't there agencies? For Pete's sake, we are right in a huge metroplex!!!!!

And so much for "this ain't right." We are jammed. (And not paid terribly well either--big surprise.)

spasm · May 16, 2005

How about going through the Policy and Procedure manual to see if they have guidelines for staffing? If they do have guidelines and are not following them, then you might be able to first appeal to the 1st in line, 2nd, etc. If this fails, perhaps your organization has a Risk Management department that might be interested in the potential liability risk of a unit which ignores its own staffing policies. A more radical approach might include giving your state regulatory agency a call to voice your concerns...this might be possible with a degree of anonymity.

Or, hit the want ads.

PMHNP10 · May 17, 2005

Hate to gripe, but the manager is back to "you are fully staffed with two nurses on 3-11" and when I said I think I need to trim off my hours because this is unsafe and too high stress (I like to be busy, but I'm not good at crowd control), she said she wants a staff who is "committed."

If she was questioning your committment to you job, she obviously doesn't understand the definition of the word. You are committed because you are committed to wanting SAFE staffing ratios so you can keep the patients safe. Your are also committed to keeping your license safe--because make no mistake about it, it is not.

RHCP fan · May 30, 2005

i am the charge nurse of a 26 bed inpatient adolescent psych unit in chicago, il. usually, i am the only nurse on the unit. generally, it will be myself and four techs for a full census, although at times i am given an lpn to pass meds. the lpn cannot do admissions, discharges, take off orders, call codes, restraints or nurse-to-nurse reports. it is very rare when i actually have another rn to share the load with! so your staffing pattern sounds like a dream come true to me!

PMHNP10 · May 30, 2005

i am the charge nurse of a 26 bed inpatient adolescent psych unit in chicago, il. usually, i am the only nurse on the unit. generally, it will be myself and four techs for a full census, although at times i am given an lpn to pass meds. the lpn cannot do admissions, discharges, take off orders, call codes, restraints or nurse-to-nurse reports. it is very rare when i actually have another rn to share the load with! so your staffing pattern sounds like a dream come true to me!

i'm curious why you keep this job. you are in chicago so i'm sure there are plenty of psych hospitals for all the disgruntled cub fans et al. :chuckle wouldn't you be better off becoming a bartender and have minimal risk getting sued because you are unable to be in 5 places at once? i think i'd rather have 8 acute medical pts than 26 psych pts, and i absolutely refuse to work on a m/s floor. this is fascinating.

RHCP fan · May 30, 2005

Hi, and thanks for the response. Most of the psych hospitals around here are the same. I have been working in this hospital for about three years. Even if I get three admissions, I am at the point where I am able to finish all my work and generally get out on time because I am so used to the work here. I work day shift, by the way. I don't really know of other hospitals that are much better around here. Most are owned by private companies that are for-profit and more inclined to please the stockholders than the staff; administration is interested in admission numbers, not safety or care of the patients. I have been working with my staff for these past years, and we all do support each other. And, speaking to friends who have left and gone to other local hospitals, I am not hearing much difference in their new jobs. It is very difficult to get an RN to stay at these jobs, although many seem to come through orientation. So, we're always short.

Psychrich · Jun 2, 2005

I have been a psych nurse for 11 years and have worked in 6 different states, usually with children and teens. Staffing ratios are not only different from state to state depending usually upon State Medicaid/Medicare regulations, but also hospital regualtions. I have had ratios as low as 9:1 (Pts:RN/Mental Health tech)to 8:3 (in this case it was federally mandated). I do feel that your ratio was low for the census and the acuity of the the time.

As a manager I have always felt that evening shift is the area you should staff up and have your highest staff to patient ratio. This time is when you get most of your admissions and have more behavioral problems. Day shift is where there are usually more ancillary staff to assist.

I hope that your trend does not continue. Psych is an area that is easy to get fried.