does your unit have charge nurses?

[MomRN0913]

I have only worked at one facility before starting my new job as a Nurse Manager in a new facility. In my old hospital was an acute care hospital, a "regular" hos[ital. My new place is an LTACH. Here is my question:

At my old facility, the only unit that had a charge nurse in the whole hospital was the MICU which is where I worked most of my career there. And as a charge, we would take a full patient load, and admit patients. They tried ot give us less critical patients, but that didn't always seem to happen. However, all the primary nurse were all very strong nurses who took care of our own problems, talked to our own Dr's and rarely went to the charge. The charge served more for bed flow, assignments and staffing purposes and to communciate with the supervisors. The rest of the units did not have a charge and the primary nurse was responsible for all aspects of patient care.

At my new facility, the LTACH, the averge nurse has 5 patients, sometimes 4. Their acuity varies. Some are vented, sometimes on a dri[, but rarely, and others are walkie talkies in for IV antibiotics. RT does EVERYTHING with the vents, even trach care, CNA's are good and they do blood sugars. It's not too bad. However, there is a charge nurse both shifts who DONT take patients. The charge nurse talks to all the dr's, monitor the labs, starts the drips, takes off orders. I am not happy with it and I am trying to change it. Some of the primary nurses don't even know who the Dr's are, aren't very up to date on their patients and what consultants to call for abnormal labs. And when there isn't a charge on the shift, if they call out or they are too short staffed, the staff doesn't know what to do with itself. It's hard to break, beacause I want the charges ot take a few easy patients. But the staff is so reliant on them that they won't take patients beacuse they have too much going on.

My question is, in your facility, is this your common practice? I guess it's a little tricky because it is not sub-acute, but not acute acute care. They stay for about 3 weeks and can be very sick. But the ratio is nice. What they call "running around crazy" is ridiculous. They don't. I used to run around crazy. They actually are pretty calm most days, working, but not having to run around with chickens with their heads cut off.

Also, how can I break this practice?

[glutton4punishment]

Sounds like you work at my facility. Maybe our definition of "running around crazy" is different. We have 7 patients each, so our charge nurse mans the phones, calls for consults, and provides help when we need it. I love having a charge nurse, b/c there is always someone to support me. There is never enough time in the day.....

[Flo., BSN, RN]

I think you guys are at two different ends of the spectrum. Try to meet them in the middle. We have charges nurses that do not have a pt load. The main purpose is bed flow and resource. That being said they do not do admits, calling mds, lab interpretation, checking off orders except for emergency situation. Personally I find our charges not helpful. They could do more to support the staff.

[jmtndl]

I just left a faciity that eliminated charge nurses, and it was a disaster. They started like you want to...by having the charge nurse take a few "easy" patients. My feeling is that when I take patients they deserve all of my attention...and to not have a nurse distracted by too many interruptions. Example: I was in an intense code where the primary nurse needed my help. In the middle of the code the PCT came and told me that one of my "easy"patients had a blood sugar of 36.The family of the code patient was in the hall and needed support, while the staff was desperately trying to save their loved one's life. And I had a patient I was responsible for with a blood sugar of 36.Nurses are not traditionally overstaffed and underworked. It just seems to me that most managers are not satisfied untill everyone is working as hard as they possibly can trying to do more than can be humanly done in a shift. What is so wrong wth having an extra pair of hands and some calm experience to keep the care running smoothly.If patient care is REALLY first with you, keep your charge nurses.If not, fix what is not broken.

[mentalhealthRN]

I think a charge nurse is needed.....and when they have their own assignment they are not as able to help out. I agree that maybe calling a doc should fall on the primary nurse as they are the one who can best give all the info. Other calls--like callling the pharmacy for a missed med or the IV team when the primary can't get a line, or dietary when the wrong tray was sent, etc. --calls that require knowing minimal details to make the call. But a call to the doc should be the primary. The charge on the medical floor I worked would just pull up and print out all the patients labs and put them on the front of the charts for the primary to deal with and would let the primary know right away if there was something needing attention stat. If in the middle of a long dressing change and another of my pts was requesting a pain med she would take care of it so I wouldn't have to stop. Having her free to help out the rest of staff was helpful.....and I don't think her having an assignment would allow this. She also would help cover pts for lunches sometimes if it was busy and the acuity was high. You need charge nurses......maybe just looking at what they do is what you need. And JMTMDL's post with her being in a code and her pt with a BG of 36 is another reason why the charge needs to not have pts. Helping the rest of the staff is enough if they are acually HELPING like they should IMO.

[BluegrassRN]

In my facility, in every unit, the charge nurse takes patients, with the ED being the one exception. I cannot imagine having a charge nurse who calls the docs and gets orders for patients. How can she possibly know enough about the patient if she is not the primary nurse? We charge nurses take a lighter load typically; the "easier" (though no less acute) patients. All nurses are responsible for their own patients; they call the doc, they give their meds, they hang their own drips, etc. As charge, I typically try to stay ahead of the game on my tasks, and I make sure several times a night I ask everyone if they are doing ok. My nurses give me a good heads up if something is going on with one of their patients, so that I can help them if need be.

If I'm supporting a nurse with a situation (like a code), my tech would know to get another nurse if my patient had a low blood sugar. We cover and support each other. And frankly, our code team would be there and it wouldn't be imperative that I stay in the room the entire time; I could go take care of my low blood sugar and return if need be.

I don't know how you would go about changing the culture of this unit, but good luck. It sounds like change is what needs to happen!

[MomRN0913]

In my facility, in every unit, the charge nurse takes patients, with the ED being the one exception. I cannot imagine having a charge nurse who calls the docs and gets orders for patients. How can she possibly know enough about the patient if she is not the primary nurse? We charge nurses take a lighter load typically; the "easier" (though no less acute) patients. All nurses are responsible for their own patients; they call the doc, they give their meds, they hang their own drips, etc. As charge, I typically try to stay ahead of the game on my tasks, and I make sure several times a night I ask everyone if they are doing ok. My nurses give me a good heads up if something is going on with one of their patients, so that I can help them if need be.

If I'm supporting a nurse with a situation (like a code), my tech would know to get another nurse if my patient had a low blood sugar. We cover and support each other. And frankly, our code team would be there and it wouldn't be imperative that I stay in the room the entire time; I could go take care of my low blood sugar and return if need be.

I don't know how you would go about changing the culture of this unit, but good luck. It sounds like change is what needs to happen!

You seem to understand exactly what I am saying. IF there is a blood sugar of 36 while you are manning the code, another nurse can help with that and give some D50. The nurses in my facility do not take enough responsibility for their own patients. Nurses just dont pass meds and change dressings. They need to be incharge of their patients, know all their systems. I'm not looking to eliminate them all together. I am looking for the primary nurse to take more responsibility for their patients. But with a 5 patient load in a LTACH, the charge can take 2 "easy" patients. ANd if they become "uneasy" the other nurses should be chipping in as a team.

Patient safetly is #1. But i believe it could be achieved with a charge nurse having a light pt load. And yes, this is a budgetary concern. If endless $'s can be spent in healthcare, we would be having a one to one ratio. But they can't be. And cost effectiveness needs to be figured in especially if these nurses want jobs and don't want the facility to close. I am not a manager who would ever make it unsafe or make the nurses overworked. because trust me, these nurses are not overworked. Bad days come due to short staffing. And having the chrage nurses who refuse to take patients on a short staffed day.

I am working on changing the culture. To make the primary nurse stronger so less responsibility is on the charge, therefore the charge could take 2 patients but be able to because the primary nurses can take care of their patients. Makes sense.

[BluegrassRN]

Baby steps is probably a good idea here. Making the changes in phases seems best. Bring in some of your nurses and charges on board, tell them what the end goal is, and ask them how they think you should get there. Ask if they just want to do a cold turkey change, or if implementing the change in phases would be best.

Maybe start with nurses making their own calls to the physicians. Does the charge nurse get report on all the patients? If so, that could be phased out next, combined with the charge taking a patient, then two, then whatever number you expect them to take. Make sure they understand that this is about empowerment: the primary nurses can and should be the ones communicating with the physician, and they should be able to do most of their own tasks. The charge is there for support, sure, but he/she shouldn't be responsible for knowing every single detail about every single patient on the floor. The charge nurse shouldn't be the only one with the skills and knowledge to handle complex patients and communicate with physicians! As a charge, I would hate that. I much prefer to have a qualified staff who can handle most situations most of the time.

Good luck!

[tokmom, BSN, RN]

I'm charge and do not take patients. However I do all admits,discharges,education, work with UR on making sure we get paid. Answer phones, relieve for lunch as needed, do bed flow and minor staffing. I co sign, preceptor and put out fires. I would go over the deep end if I had patients, lol.

If you want to change your practice, have a workable solution ready.

[MomRN0913]

I am going to have to start small. My position here as a nurse manager here is new. There wasn't one before me. I am not your typical nurse manager. I am mostly on the floor, rarely in my office and whenever there is a fire, they run to me to put it out. The patient issues, the family issues, most issues. I actually don't get most of the work done required in management which is causing a problem. FYI people who think nurse managers who sit on their ass in their office all the time, are usually pretty busy on their asses. But I am involved one with my floor/hospital. I take a load off the charges.

And the charges do take report on each patient. They know everything about them. I will start small, the primary nurse will start to call on abnormal labs. We'll see how it goes...