Survey: Has your facility implemented nurse to patient ratios?

Published

Here are the results of last months survey question

Has your facility implemented nurse to patient ratios? :

surveyresults01-04.gif

Please feel free to read and post any comments that you have right here in this discussion thread by clicking the "Post Reply" button.

Thanks

Specializes in Community Health Nurse.
Originally posted by zacarias

The ratio is about 4:1 on the Gen Med floor I work on. We do take acuity in mind and sometimes we only have three patients.

Where can I sign up to work at your hospital? :o

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jfjdfsdjfklsdf asd

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We have implemented the CA ratios and we still use acuity.

So, I don't have more than 6 patients. Usually only 3 or 4.

Still have a problem with the break and lunch nurse.

Lots of bugs to work out . . .. . that's the problem with mandation of any kind . . no flexibility.

steph

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4:1 at University Medical Center in Tucson.

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I primarily work ER and it's up to me to call when I need help (solo nurse here). We have 5 beds, I take care of all five, plus triage whoever is in the waiting room based on my own opinion of whether or not the patients are getting good care (5 + patients with common colds, no problem, 2 cardiacs, I need help). I pulled a shift on Med/Surg a couple of nights ago, I had 4 patients, one getting blood, the LPN had 8 patients, we had a CNA to help with vital signs, baths, etc. With the paper work saved for the night RN, I would have liked another nurse...not my choice, though.

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Specializes in Case Management, Acute Care, Missions.

I work on a small observation unit in a major trauma hospital - we only have 7 beds overnight, 2 RN's and a MA/CNA until 1 am. AND they have to be low accuity....(not total care pts)....aslo we are closed weekends (Sat from 1500) and major holidays. I am sooooo blessed!

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4 pts to 1 RN/LPN on med surg floor; 8 pts to 1 RN/CNA on same lfloor days and pms.....and still running from start to shift finish

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Busy regional referral center combined ICU/CCU. If we are full, it is not uncommon to have several nurses with 3 patients each. Patient acuity is measured once a day and only up to the # of beds we have. SO when we start full, transfer 10 out and get 10 in, the new hits aren't classified. We had a nurse pulled the other night and the supervisor cited state regs for the unit the nurse was pulled to. Funny how they don't count our acuity!!!! Is there anyone here who thinks a patient with doppler only blood pressures and is on 2 pressors to maintain that low BP is safe to be 1:3?????

NJ's state regs state staffing by acuity for a unit like mine. It further states at least 1:3 with the ability to go to 1:2 or 1:1 based on acuity. Acuity is left up to the individual hospital to define. In my opinion, ratios are not the be all and end all but they are a wonderful place to start. If the ratio is a maximum patient load of 1:2 in ICU then at least that doppler only BP patient has a fighting chance and the other patient in the assignment won't be ignored like the other 2 were that night. By the way, that nurse with that assignment had to transfer one out and got a train wreck in.

Most State Departments of Health have web sites and you can find the regulations for hospitals and nursing homes on them. I am one of sevral people who have routinely contacted the DOH and nothing has been done.

Administrators tend to be penny wise and pound foolish. They don't understand that turnover of staff and increased length of stay are costing them millions!!! Both situations could be greatly improved with better staffing and safe nurse to patient ratios!!

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We supposedly go by aquity but that never holds up. If you have an empty bed you fill it up despite how many nurses are working. Days you have between 6 to 8 pts, evenings 7 to 9 and nights 8 to 10. Days and evenings you have a unit clerk and two aides, nights usually one aide. You run the whole time and the new nurses usually don't last. Who cares if the pay is ok, it is the work load that gets you.

:o

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In my unit, the neurosurgical ICU, we almost always have a 2:1 ratio unless we happen to have an IABP, then we work one on one.

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For those of you who do work in units that use acuity, how do you measure the acuity factor? Is it strictly by nuring judgement or is there an "objective" system you use??

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Most states require that acuity be the primary tool for assessing ratios, does yours?

Nurse Staffing

New Jersey Hospital Licensing Standards

SUBCHAPTER 6. NURSING PROCEDURES

13:37-6.1 Nursing procedures

Nursing procedures shall be determined by the Nursing Practice Act of this State, subject to the interpretation and revision by the Board of Nursing.

13:37-6.2 Delegation of selected nursing tasks (a) The registered professional nurse is responsible for the nature and quality of all nursing care including the assessment of the nursing needs, the plan of nursing care, the implementation, and the monitoring and evaluation of the plan. The registered professional nurse may delegate selected nursing tasks in the implementation of the nursing regimen to licensed practical nurses and ancillary nursing personnel. Ancillary nursing personnel shall include but not be limited to: aides, assistants, attendants and technicians. (b) In delegating selected nursing tasks to licensed practical nurses or ancillary nursing personnel, the registered professional nurse shall be responsible for exercising that degree of judgment and knowledge reasonably expected to assure that a proper delegation has been made. A registered professional nurse may not delegate the performance of a nursing task to persons who have not been adequately prepared by verifiable training and education. No task may be delegated which is within the scope of nursing practice and requires:

1. The substantial knowledge and skill derived from completion of a nursing education program and the specialized skill, judgment and knowledge of a registered nurse;

2. An understanding of nursing principles necessary to recognize and manage complications which may result in harm to the health and safety of the patient.

© The registered professional nurse shall be responsible for the proper supervision of licensed practical nurses and ancillary nursing personnel to whom such delegation is made. The degree of supervision exercised over licensed practical nurses and ancillary nursing personnel shall be determined by the registered professional nurse based on an evaluation of all factors including:

1. The condition of the patient;

2. The education, skill and training of the licensed practical nurse and ancillary nursing personnel to whom delegation is being made;

3. The nature of the tasks and the activities being delegated;

4. Supervision may require the direct continuing presence or the intermittent observation, direction and occasional physical presence of a registered professional nurse. In all cases, the registered professional nurse shall be available for onsite supervision.

(d) A registered professional nurse shall not delegate the performance of a selected nursing task to any licensed practical nurse who does not hold a current valid license to practice nursing in the State of New Jersey. A registered professional nurse shall not delegate the performance of a selected nursing task to ancillary nursing personnel who have not received verifiable education and have not demonstrated the adequacy of their knowledge, skill and competency to perform the task being delegated.

(e) Nothing contained in this rule is intended to limit the current scope of nursing practice.

(f) Nothing contained in this rule shall limit the authority of a duly licensed physician acting in accordance with N.J.S.A. 45:9-1 et seq.

SUBCHAPTER 17. NURSE STAFFING

8:43G-17.1 Nurse Staffing

(a) The hospital shall have in place a staffing plan that addresses nurse staffing requirements and identifies patient needs, including, at a minimum:

1. A daily staffing schedule that ensures at least one registered professional nurse in charge and assigned exclusively to each patient care unit on each shift;

2. A provision that at least 65 percent of direct patient care hours in inpatient units on a hospital wide average be provided by licensed nursing personnel;

3. A method for assessing each unit's additional nursing needs for each shift, including, at a minimum, objective criteria such as:

Documented skills, training and competency of staff to plan and provide nursing services in the nursing areas where they function;

Patient data base incorporating objective factors such as case mix index, specific or aggregate patient diagnostic classifications or acuity levels, patient profiles, critical pathways or care progression plans, length of stay, and discharge plans;

Operational factors such as unit size, design, and capacity, admission/discharge/transfer index, and support service availability;

Contingency plans to address critical departures from staffing plan, including policies and procedures to regulate closure of available beds if staffing levels fall below specified levels;

Policies and procedures for the reassignment of staff including float and agency staff, and,

1. Ongoing internal institutional evaluation of outcome-based quality indicators related to nursing care to assess and provide a safe and adequate level of patient care including at least:

Patient injury rate;

Medication process errors;

Maintenance of skin integrity;

Nosocomial infection rates;

Hospital-wide patient satisfaction with overall care, including nursing care;

Nursing turnover rate;

Patient satisfaction with pain management; and,

Mix of RNs, LPNS, and unlicensed staff caring for patients.

b. There shall be a registered nurse manager for each patient care unit or units and for surgery, emergency department, and other units, as specified in the hospital organizational plan or policies and procedures.

c. There shall be at least one registered professional nurse in charge and assigned exclusively to each patient care unit on each shift. Additional staff shall be assigned by the hospital as required by the acuity levels.

d. Patient care assignments shall be made on an individual basis by a registered professional nurse and reflect staff competence, skill, and aptitude and patient needs.

e. The hospital shall have in effect a contingency plan for assuring adequate nurse staffing at all times. The plan shall detail policies and procedures to regulate closure of available beds, if actual staffing levels fall below, specified levels.

f. Nurse staffing for all patient care units within the hospital shall also be in accordance with:

N.J.A.C. 8:43g-7.5(a), (b) and © in accordance with N.J.A.C. 8:43g-9.20(a)6 and (i);

N.J.A.C. 8:43g-7.15(D);

N.J.A.C. 8:43g-7.16(a) 2 and 31;

N.J.A.C. 8:43G-7.24(a) 2 and 31;

N.J.A.C. 8:43G-7.27(a)2 and 31;

N.J.A.C. 8:43G-9.4(a)l 1;

N.J.A.C. 8:43G-9.5©, (d), and (e);

N.J.A.C. 8:43G-9.5©, (d) and (e);

N.J.A.C. 8:43G-9.7 (a) and (b);

N.J.A.C. 8:43G-9.7(a) and (b);

N.J.A.C. 8:43G-9.7(a);

N.J.A.C. 8:43G-9.14;

N.J.A.C. 8:43G-9.20(a)6 and ©;

N.J.A.C. 8:43G-9.24;

N.J.A.C. 8:43G-1 1.4(a) and (b);

N.J.A.C. 8:43G-12.3(e), and (g)l through 4;

N.J.A.C. 8:43G-12.5©;

N.J.A.C. 8:43G-12.7(a)

N.J.A.C. 8:43G-12.16© and (d);

N.J.A.C. 8:43G-14.1(a);

N.J.A.C. 8:43G-16.6(a), (b), and

N.J.A.C. 8:43G-19.1(v) and (f)

N.J.A.C. 8:43G-19.3(b)l through 3 and ©

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If there are questions or problems at your health care facility,

call the New Jersey Department of Health & Senior Services (DOHSS).

NJ Department of Health & Senior Services Complaint Hotline for Health Care Facilities...Call 1-800-792-9770

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Delegation

This is a subchapter of the New Jersey Nurse Practice Act.

13:37-6.2 Delegation of selected nursing tasks

The registered professional nurse is responsible for the nature and quality of all nursing care including the assessment of the nursing needs, the plan of nursing care, the implementation, and the monitoring and evaluation of the plan. The registered professional nurse may delegate selected nursing tasks in the implementation of the nursing regimen to licensed practical nurses and ancillary nursing personnel. Ancillary nursing personnel shall include but not be limited to: aides, assistants, attendants and technicians.

In delegating selected nursing tasks to licensed practical nurses or ancillary nursing personnel, the registered professional nurse shall be responsible for exercising that degree of judgment and knowledge reasonably expected to assure that a proper delegation has been made. A registered professional nurse may not delegate the performance of a nursing task to persons who have not been adequately prepared by verifiable training and education. No task may be delegated which is within the scope of nursing practice and requires:

The substantial knowledge and skill derived from completion of a nursing education program and the specialized skill, judgment and knowledge of a registered nurse;

An understanding of nursing principles necessary to recognize and manage complications which may result in harm to the health and safety of the patient.

The registered professional nurse shall be responsible for the proper supervision of licensed practical nurses and ancillary nursing personnel to whom such delegation is made. The degree of supervision exercised over licensed practical nurses and ancillary nursing personnel shall be determined by the registered professional nurse based on an evaluation of all factors including:

The condition of the patient;

The education, skill and training of the licensed practical nurse and ancillary nursing personnel to whom delegation is being made;

The nature of the tasks and the activities being delegated;

Supervision may require the direct continuing presence or the intermittent observation, direction and occasional physical presence of a registered professional nurse. In all cases, the registered professional nurse shall be available for on-site supervision.

A registered professional nurse shall not delegate the performance of a selected nursing task to any licensed practical nurse who does not hold a current valid license to practice nursing in the State of New Jersey. A registered professional nurse shall not delegate the performance of a selected nursing task to ancillary nursing personnel who have not received verifiable education and have not demonstrated the adequacy of their knowledge, skill and competency to perform the task being delegated.

Nothing contained in this rule is intended to limit the current scope of nursing practice.

Nothing contained in this rule shall limit the authority of a duly licensed physician acting in accordance with N.J.S.A. 45:9-1 et seq New Rule, R.1986 d.431, effective October 20 1986. . ."See: 18 N.J.R. 1176(a), 18 N.J.R. 1448(a), 18 N.J.R. 2128(a).

Delegation and UAP Issues

Membership Makes It Happen ! ! ! Join NJSNA Today...On-line or call 1-888-UR-NJSNA

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Frequently Asked Questions

about Workplace Advocacy

Can a hospital take punitive action against nurses who try to organize?

The National Labor Relations Act makes it unlawful for an employer to interfere with, restrain, or coerce employees in the exercise of their right to organize; or to discriminate against an employee with regard to hiring practices, tenure of employment, or any term or condition of employment in order to encourage or discourage membership in a labor organization. This means that an employer cannot express or imply a threat of reprisal for organizing, or promise a benefit for refraining from organizing. Although an employer is prohibited from engaging in certain types of activities to thwart organizing, this does not mean employees will not encounter strong opposition. Employer propaganda and anti-union tactics can be anticipated. An employer has the right to voice its opinions and attitudes about unions and the unionization of its operation, provided its communications and actions carry no direct or implied threats to employees.

What types of organizing activities are permissible in a hospital?

The National Labor Relations Board has stated that nurses have a right to engage in union solicitation during their free time while at work, provided that such activities are conducted outside of patient care areas and are consistent with solicitation opportunities afforded other organizations. There are, therefore, three limitations on union solicitation during the workday: the time during the day when such activities may be conducted; the locations within the hospital; and conformity with solicitation opportunities afforded other organizations.

Can nurses employed in right-to-work states organize?

Not all sociopolitical climates are conducive to collective bargaining. However, the fact that a state has enacted so-called "right-to-work" legislation does not preclude such activities. This type of legislation merely means that a state may prohibit collective bargaining agreements that make union membership a condition of employment. In effect, such laws create a compulsory "open shop" in which a union must represent everyone in the bargaining unit, but no one is compelled to belong to the union. Currently, twenty-one states have enacted right-to-work laws. These states are: Alabama, Arizona, Arkansas, Florida, Georgia, Idaho, Iowa, Kansas, Louisiana, Mississippi, Nebraska, Nevada, North Carolina, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia and Wyoming.

Can nurses be forced to go on strike?

No one can force a bargaining unit to strike. Only unit members themselves can make such a decision. Experience has shown that nurses who have chosen to strike have done so as a last resort. It should also be noted that, if nurses decide to strike, they do not abandon patients on short notice. There are legal safeguards to prevent such actions. Provisions set forth in the 1974 Health Care Amendments to the National Labor Relations Act guarantee continuation of adequate patient care by requiring contract expiration notice, advance strike notice, mandatory mediation, and the option of establishing a board of inquiry prior to work stoppage.

How can nurses determine the best bargaining representation?

As the largest group of health professionals, RNs have long been the target of a variety of unions. State nurses associations first began representing nurses at the bargaining table in the 1940s. State nurses association (SNA) collective bargaining programs have met with considerable success, both in numbers of nurses and the nature of issues addressed in contract negotiations. If nurses are represented by an organization other than a state nurses association, these questions should be considered:

Is the union committed to the goal of service to which nurses subscribe?

How many different groups of employees does the union represent?

Can the union adequately understand and represent nurses' unique needs?

How much control do individual members exercise over bargaining unit activities?

Source: The American Nurse, October 1991.

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SNAs Secure Outstanding Contracts for RNs

State Nurses Associations (SNAs) are recognized trendsetters at the bargaining table, securing outstanding contracts for the nurses they represent.

Economic Gains

As bargaining agents, SNAs have succeeded in winning:

Significant base pay increases

New staff nurse classifications

Additional tenure steps.

Improved differentials.

Staffing Patterns

SNAs have been successful in getting employers:

To limit mandatory overtime.

To offer alternative forms of scheduling.

To designate specific non-nursing functions which nurses will no longer be required to perform.

To establish advisory committees to review staffing issues and to assist in formulating staffing policies.

Quality of Patient Care

SNA-negotiated contracts also address measures to insure quality nursing care, including:

Creation of professional practice and patient care committees.

Regulation of the use of temporary nurses.

Restriction on the use of certain types of personnel.

Creation of "Assignment-Despite-Objection" Forms to document unsafe or poor patient care situations.

Health and Safety

SNAs have negotiated language providing for:

Health and safety committees.

Free hepatitis B vaccine and follow-up procedures to determine whether immunity has been obtained.

AIDS screening free of charge to any nurse exposed to blood or other bodily fluids.

A procedure for informing RNs who may be at risk of exposure to an infectious agent or agents as a result of responsibility for the care of a patient.

Fringe Benefits

While employers have sought to reduce the costs of fringe benefits, SNAs have secured provisions for:

Retention of benefit packages with no change in deductibles or reductions in benefit levels.

Expansion of employee assistance.

Improvements in tuition reimbursement and allowances for educational leave.

Accumulation of sick leave in unlimited amounts.

Source: The American Nurse, October 1991.

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Collective Bargaining Benefits Nurses

How the Bargaining Process Works

While union membership continues to drop in many industries, unionization among health care workers is rising. Nurses are among those employees showing growing interest in and support of collective bargaining activities. A major advantage of coverage under a collective bargaining agreement is the fact that it is a lawfully binding and enforceable contract.

Employee interest in collective bargaining has always met with fierce resistance from employers in all industries. Within the health care industry, opponents of collective bargaining argue that the process creates internal struggles which detract from a hospital's mission to provide high quality services to patients. However, there is concrete evidence that collective bargaining, when used effectively, actually facilitates delivery of the best care and services.

For collective bargaining to occur, a union or employee association must be chosen to represent eligible employees, usually through an electoral process. The following information provides a very basic overview of how collective bargaining works in the private sector.

Understanding the legal framework for collective bargaining

The National Labor Relations Act (NLRA), as amended by the Labor Management Relations Act (Taft-Hartley Act), is the federal law governing labor relations in the private business sector. Section 7 of the NLRA states that employees have the right to self-organize; to form, join, or assist labor organizations; and to bargain collectively through representatives of their own choosing.

Since enactment of the National Labor Relations Act in 1935, employees of private, for-profit health care institutions have been protected in their right to organize for collective bargaining purposes. Under the provisions of the Act, as amended in 1974 (Health Care Amendments), employees of voluntary, not-for-profit health care institutions were also granted the same rights and protections.

Over the years, there has been considerable debate over the composition of bargaining units in the health care industry. After much deliberation, the National Labor Relations Board (NLRB) issued, in 1989, rules on unit composition. Under the rules, eight units (including one limited in its composition. Under the rules, eight units (including one limited in its composition to registered nurses) were deemed appropriate. As expected, employer opposition to the NLRB's rulemaking resulted in litigation challenging and delaying the implementation of this ruling. However, in April 1991, the US Supreme Court, in a unanimous opinion upheld the National Labor Relations Board's rulemaking authority. This ruling is regarded as a significant victory in support of the workplace rights of nurses.

Organizing a collective bargaining unit.

Coupled with a knowledge of the legal framework for collective bargaining, it is important to understand the process for formalizing a bargaining unit.

Organizing Committee: It would be next to impossible for one person to organize an entire hospital nursing staff. Consequently, it is important to identify a core group of nurses who share common issues and concerns and who are supportive of collective bargaining. If possible, this group should be representative of different shifts and practice areas and be well known and respected by the nursing staff and other personnel. These nurses will assume initial responsibility for personally soliciting other supporters and stimulating general interest in organizing activities.

The nature and extent of nurses' issues and concerns are key factors in determining the degree of support for an organizing campaign. Often times, professional and personal concerns are stronger motivating forces for organizing than economic considerations. To conduct an effective campaign, there needs to be a broad base of issues and concerns common to nurses in various departments and units and on different shifts.

Research: Before launching a campaign, it is important to know as much as possible about the history, structure, organization, finances and administration of the hospital as well as other union activity at the facility. Such information is extremely helpful in determining the hospital's probable reaction to organizing efforts. It is equally important to have a clear understanding of hospital personnel policies and other rules and regulations as well as an accurate picture of the treatment of nurses in all areas of the facility with regard to wages, benefits and employment practices.

Planning an organizing campaign should include:

Selection of an organizing committee.

Identification of major campaign issues.

Delineation of specific organizing activities with a projected timetable.

Development of specific strategies for countering employer tactics.

Determination of a system for keeping lines of communication open with nurses.

Structure: In the early stages, attention should focus on the organizing campaign. Once there is a strong indication of support (close to filing a petition for a representation election or during a pre-election campaign), it is time to move toward a more permanent structure and a more formal relationship with a bargaining agent. This phase of the organizing process involves the adoption of bylaws and the election of the officers.

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Any questions concerning workplace advocacy

or collective bargaining should be directed to:

Irma Lupia

Workplace Advocacy

609-883-5335 x 23

TOLL FREE: 1-888-UR-NJSNA

(1-888-876-5762 x 23)

Irma Lupia

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