Unsafe staffing with 4:1 ICU ratios 8:1 on floor.

[cmueller]

I really need advice on how to advocate for change.

I work in the SICU of a 350ish bed hospital that does cardiac surgery. We got a new CNO two years ago during a nursing shortage. She gave us a slight pay raise and blocked off rooms on the med surg floors when we did not have staff so that they would only have a 6:1 patient ratio at the most and swore that she would keep us from unsafe staffing.

Two years later, the med surg floors are back to 1:8 and there's a plan to make the ICU patient staff ratio 4:1 with no 1:1 patients (our normal 1:1 patients are fresh, still intubated open hearts, therapeutic hypothermias, CRRT patients, balloon pumps, and Imepellas). We are currently at 3:1 with charge nurses back into staffing and we are feeling a major strain. This is mostly due to staff illness at the moment, but our CNO has been very open about the fact that this is her goal. I can already tell that patient care is suffering. It's manageable when we have less sick patients, but I'm afraid patient acuity will greatly increase as we get further into flu season and we will start having adverse patient outcomes because we've missed something.

There is no law to prevent this from being made our standard of care. Is there anything we can do to start making changes?

[cmueller]

We had a wonderful CNO a few years back that would come in and help if we were desperate and an educational coordinator that will sometimes tech.

[Julius Seizure]

I would leave. As a fellow ICU nurse, that is unsafe. Some hospitals have safe ratios. Mine is one. But I know if one particular hospital in my area wanting to go to 4:1 in the icu. You could not pay me enough to work there.

You could not pay me enough to be a patient there.

[adventure_rn, MSN, NP]

Wow. A strong testament that upper management clearly values the almighty dollar over the safety of their patients. There's no other reason they'd mandate it.

I agree, but how can any reasonable executive think that this will save them money???

With ratios like that, they're bound to have a ton of adverse outcomes and errors, which leads to Joint Commission investigation, which leads to not being eligible to receive Medicare/Medicaid, which leads to the hospital going bankrupt. If they see an increase in CLABSIs/falls/pressure ulcers/surgical site infections because nobody has time to do their jobs safely, then the hospital won't receive any reimbursement for the care. Furthermore, you'd have to account for the potential lawsuits they'd face due to negligence and malpractice.

Not to mention the fact that these types or ratios will lead to a mass exodus, which will lead to an even greater staff shortage, which will become increasingly harder and harder to recover from the worse it gets (not to mention more expensive). There is so much evidence that keeping your nurses happy and reducing turnover is more cost-effective than the cost of constantly recruiting, onboarding, and orienting new people. My friend worked in a NICU that almost shut down for this precise reason. Everyone was quitting because the nurses were taking 6 to 7 patients (for reference, a typical assignment is 1:3 at most since it's an ICU setting and all patients are total care as babies); at the last minute, they canceled everybody's scheduled summer vacation due to being short-staffed, and, *spoiler alert*, even more people quit and the ratios became even more insane.

Seriously, how can a reasonable person (especially a CNO who has presumably worked as a nurse and understands how insane those ratios are) think that this is a good idea?

Baffling.

[umbdude, MSN, APRN]

How about writing an anonymous Op Ed in a large local newspaper detailing how this endangers patients' lives? You could name the hospital, but that risks exposing the staff.

[djh123]

I hope it gets better or you get out of there. On occasion at my previous job (LTC/rehab) I'd have 2 units - 50-ish people - for 4 hours sometimes, sometimes longer. I'd always have a med tech in those situations, but still, it was just ridiculous. I could only do the highest-priority stuff and deal with any emergencies that came up.

[Kallie3006, ADN]

Refuse the assignment, they may fire you but you will still have your license. You accept the assignment, you accept repercussions when something happens and the BON will not care that the ratio is not safe, but they will care that you accepted an unsafe assignment and there for accepted responsibility.

[JKL33]

I agree, but how can any reasonable executive think that this will save them money???

With ratios like that, they're bound to have a ton of adverse outcomes and errors, which leads to Joint Commission investigation, which leads to not being eligible to receive Medicare/Medicaid, which leads to the hospital going bankrupt. If they see an increase in CLABSIs/falls/pressure ulcers/surgical site infections because nobody has time to do their jobs safely, then the hospital won't receive any reimbursement for the care. Furthermore, you'd have to account for the potential lawsuits they'd face due to negligence and malpractice.

They *know* it will save money or will benefit in some other way. If they're big and bad enough their consequences will amount to hand-slapping. It seems like you can kill people and blatantly cover it up and receive "immediate jeopardy" for about 5 minutes.

Not to mention the fact that these types or ratios will lead to a mass exodus, which will lead to an even greater staff shortage, which will become increasingly harder and harder to recover from the worse it gets (not to mention more expensive). There is so much evidence that keeping your nurses happy and reducing turnover is more cost-effective than the cost of constantly recruiting, onboarding, and orienting new people. My friend worked in a NICU that almost shut down for this precise reason. Everyone was quitting because the nurses were taking 6 to 7 patients (for reference, a typical assignment is 1:3 at most since it's an ICU setting and all patients are total care as babies); at the last minute, they canceled everybody's scheduled summer vacation due to being short-staffed, and, *spoiler alert*, even more people quit and the ratios became even more insane.

Now this is interesting. It would seem like common sense but when the opposite is seen with such frequency then it can't not be purposeful.

When things keep steamrolling even though they make zero sense - - well, they do make sense, it's simply that you haven't figured out the rationale/angle yet. This turnover might stress employees at the staff and middle-management levels, but the execs have it figured out and it works into their plans just fine. Their orientations are an assembly-line process just like their patient care - this is for moving people through quickly. There is no investment in individuals because they are throw-aways. Nursing is becoming a series of tasks that sooner or later will not require any sort of expertise to perform - a change that has taken place at a still-accelerating pace.

Turnover is no biggie - and in fact it solves a huge problem of having anyone around who knows enough to gauge/judge any goings on with any kind of perspective.

Control is the name of the game and is first and foremost as far as I can see. Nothing that happens can lead to staff being in any way empowered - - and yes, huge corporations will spend more money to prevent that then they ever would've had to spend to have a normal business relationship with nurses.

We need to smarten up.

Seriously, how can a reasonable person (especially a CNO who has presumably worked as a nurse and understands how insane those ratios are) think that this is a good idea?

I suppose it's easy if someone can be convinced that staff nurses just don't understand the ethics of "resource management" - and that those ethics are somehow different than the ethical principles by which all [real] nurses are bound.

[cmueller]

Thank you all for your comments. So many people threatened to quit that they have backed off on making this normal. Our managers put their foot down. The floors are still over run and I still want to help them in any way I can. I would like to advocate for legislation because if it isn't done now, then nurses will continue to have to deal with these issues.

[BedsideNurse]

That really sucks.

We are seeing this more and more now that hospitals see they can get away with it and nurses put up with it. MA just had a nurse patient ratio law on the ballet and I could hardly find a nurse who supported it where I work. Nearly everyone in ICU I asked (and 1/2 of the nurses on the step down unit) parroted the false information being given out by the hospitals and lobbyist groups. Even worse, the general public was confused from being inundated with untrue scare tactic "vote no" commercials and fliers, including (quite unbelievably) a "vote no" endorsement by the ANA, which is really quite outrageous considering I just read a statement by them imploring that that the importance of safe staffing cannot be underestimated. Well apparently it can, since nursing organizations themselves sabotage our own practice.

I have been in ICU for nearly 20 years and years back 1:1 or 1:2 was the absolute standard of care. Now it's 3 ICU patients, 2 ICU and one step-down, 3 step down and 1 ICU. Or 2 ICU and if a code comes in you have to pick up that too. No secretary, often no tech. This is how it has been the last 3 out of 4 ICU's I've been at. It's horrible but I don't think nursing has the presence of mind to actually fix the problem. Btw: 2 of those 4 hospitals were union hospitals. Union or not, we need set nurse patient ratios, preferably a national law with *no loopholes about acuity* so hospitals can't manipulate the numbers. Literal numbers only!

As far as where you are, I'd try to find another ICU that isn't as punishing. Good luck.

[double00trouble]

Why in the world would nurses vote against staffing ratios!?!?!?!? Is there some tough guy/girl persona or culture in nursing of "I can handle it!" It sure seems like I have seen nurses with that attitude in my short time in the profession.

[TriciaJ, RN]

Why in the world would nurses vote against staffing ratios!?!?!?!? Is there some tough guy/girl persona or culture in nursing of "I can handle it!" It sure seems like I have seen nurses with that attitude in my short time in the profession.

There are a lot of factors, and the previous posts have hit on all of them.

1. Yes, the bean-counters think assembly-line "care" is a wonderful thing. If they get sick, themselves, they will find VIP treatment somewhere. They wouldn't put up with the conditions in their own hospital.

2. The CNO might have had good intentions but she needs to eat, too. CNO jobs aren't growing on trees, there's no way she'll go back to doing patient care and the bean-counters have probably figured she's worth paying to keep her onside.

3. Good luck organizing nurses. You've got the "I'm so good I can handle anything", the "I'm too much of a PROFESSIONAL to unionize", the "I wouldn't want to get into trouble", the "I need the paycheque too much" and the "I'm so glad YOU'RE speaking out; I'm not good at that" crowd.

4. If you were unionized and you did go on strike for better staffing, the media would make it all about undedicated nurses who care more about money than fulfilling their sacred mission and the public would buy it hook, line and sinker.

5. The BON only cares that individual nurses aren't killing anyone; hospital staffing isn't their problem.

6. I'm thinking your best bets would be Joint Commission and any other agencies that regulate hospitals. If you can find some friendly journalists who will interview you anonymously and be trusted to get it right, it may be helpful for the public to know what's really going on.

Good luck. You'll need plenty.

[RNperdiem, RN]

As a staff nurse, the simplest solution is to get another job. If you can enlist the people with power to push back like- nurse managers or attending physicians, then change might be possible.