What is a half a patient?

llg, PhD, RN · Mar 24, 2017

So, doesn't the "Hospital Supervisor" outrank the Charge Nurse? What does your Director say? Does she not want to count the baby at all in the patient count? Who has the authority to make the decision as to whether or not babies are counted in the patient census? That's where you need to start. (I suspect it is the Director.) If you don't get anywhere with the Director, you need to go up the chain of command to the next level with your complaint.

KATNIC · Mar 24, 2017

Yes the Director does out rank all of them but for the moment she is keeping silent.

The CNO doesn't want to be bothered and keeps out of reach from all of us. Every time we speak up and quote the laws in our state-- it falls on deaf ears. We are mocked and written up for speaking up for patient safety.

I love what I do but I fear for my patients and coworkers.

I just never heard about not counting a newborn or counting the newborn as a half of a patient.

llg, PhD, RN · Mar 24, 2017

Theoretically, there is nothing wrong with assigning mathematical values to the workload associated with a patient. Many systems have been developed over the years to estimate the size of the workload on a particular unit so that the correct number of nurses can be assigned to provide the care needed. That's how management decides how many nurses to budget for on a given unit.

For example, an average patient on the average day = 1. A really difficult/busy patient requiring more care/nursing time might equal 1.2 or 1.6 or even 2 points. A patient who had minimal needs would be assigned a number less than 1. These mathematical systems are called "acuity systems" and facilities use them to estimate the amount of nursing hours needed for a particular unit on a particular day based not only on the sheer number of patients, but also on how much nursing time those particular patients need. In this case, the charge nurse was saying that the typical newborn only needs about half as much nursing time as the typical new mom -- and should therefore not count as a full "workload unit" in the calculations. You may or may not agree with that, but the idea of using numbers to represent the quantity of nursing time needed is pretty common people responsible for staffing levels.

I have also used numbers to represent the amount of care that can be expected to be provided by nurses. For example, a typical RN can be represented by a 1. A new orientee might be represented by a 0 if she was too new to be of much help. But an orientee scheduled to come off orientation in just a few days may be counted as half a nurse, or 3/4 of a nurse at times if she can be counted on to contribute to the total amount of work that can be accomplished by the staff that shift.

KATNIC · Mar 25, 2017

Thank you for your reply, but my problem is when we have 2 patients on Magnesium Sulfate and the ratio is 1 RN to 3 patients, two of which must be stable according to Hospital policy. Our problem is when a baby is attached to the mom on Magnesium Sulfate and that mom needs more assistance. So let's say she is 2 points, and the baby now has issues so baby is actually 1.5 points and that nurse has 2 other high acuity patients that are stable so give them each 1 point. Now you only have have another RN w you on the floor with the same situation. So 2 RN are at 5.5 points now your praying something does not happen bec there are only 2 nurses on the floor without a unit secretary and/ or a tech. So call bells are ringing and our unit is locked and the nurses need to buzz visitors in and out of the unit. How is all this justified. Patients are not safe. This is not a regular unit. This is a High Risk unit. The numbers do not add up for justification.

TriciaJ, RN · Mar 25, 2017

If you have a union, you can complete an Unsafe Staffing documentation form for every shift that your staffing is unsafe. If you don't have a union, you can still start documenting. You might have to start the process before your shift, because of course you're aren't going to have any time once things start rolling.

You and your coworkers need to band together and figure out which cages to start rattling. Your hospital admin is certainly not going to help you. And further proof that Magnet status is a naked emperor. They will fudge the numbers to look safe, and throw a nurse under the bus if someone has a bad outcome.

If your hospital has a risk manager, can you and your coworkers request a meeting with that person? You are all between a rock and a hard place. Good luck to you.

Double-Helix, BSN, RN · Mar 27, 2017

In your original post, you state that the "recommended ratios" are 1:4. In your first reply, you state that when you "quote the laws in our state" no one is listening.

The difference between laws and recommendations is significant if you are trying to convince the hospital to give you additional resources. Hospital policy is not law. Recommended staffing ratios are not law. If you do have state laws governing staffing ratios of high risk ante/postpartum patients (this would be very unusual), then you have grounds to report the hospital to your state Department of Health or accrediting body. But, state laws rarely micromanage nurse staffing within hospitals- particularly to such a specific population- and I would be very surprised if there's actual legislation about this situation. More likely, the hospital is guilty of violating it's own policy recommendations. Or rather, they are trying to twist words to make it appear as though they are compliant.

Without a state law or the representation of a nurse's union, you're going to have a hard time making any changes. I would suggest starting by contacting other Magnet institutions who have similar patient populations and investigate how they plan staffing for newborns. I'd also recommend learning who is responsible for updating policies and procedures and see if you can get a committee together to revise your staffing recommendations specifically to include newborns. You may have better luck by advocating for the addition of a nurse tech rather than a change in staffing ratios. The nurse tech may be able to be pulled from the hospital's current staff pool, which would be cost effective. You could also market the proposal from the viewpoint of improving patient satisfaction (and subsequently improved reimbursement). Administration may see this more favorably than "nurses who don't want to work hard" (their perception, not mine). The tech could answer phones, open the door, take vital signs, assist with calculating I&O, toileting, answering call bells, etc. This should help lighten the work load for the RNs so they can pay more attention to the medical/nursing needs.

llg, PhD, RN · Mar 27, 2017

Thank you for your reply, but my problem is when we have 2 patients on Magnesium Sulfate and the ratio is 1 RN to 3 patients, two of which must be stable according to Hospital policy. Our problem is when a baby is attached to the mom on Magnesium Sulfate and that mom needs more assistance. So let's say she is 2 points, and the baby now has issues so baby is actually 1.5 points and that nurse has 2 other high acuity patients that are stable so give them each 1 point. Now you only have have another RN w you on the floor with the same situation. So 2 RN are at 5.5 points now your praying something does not happen bec there are only 2 nurses on the floor without a unit secretary and/ or a tech. So call bells are ringing and our unit is locked and the nurses need to buzz visitors in and out of the unit. How is all this justified. Patients are not safe. This is not a regular unit. This is a High Risk unit. The numbers do not add up for justification.

I was just trying to answer the question asked in your thread title, "What is a half a patient?" Now that you know the answer to that question ... you know "sort'a" how that Charge Nurse was thinking and how the Director might be coming up with her numbers.

I would ask the Director to explain the system she uses to determine the staffing levels for your unit. As she does that, you can find the flaws -- those times in which her numbers don't accurately reflect the workload. That is what is "broken" and needs to be fixed. Understanding her system and speaking her language will help you communicate with her and make your case.

But in the end, it may just come down to politics and money (as it often does). Once you have discussed how staffing levels are determined and done what you can to make your case that you need more nurses, then it is up to the administration to address any problems. If they won't do that, then you may have to decide whether or not it is worth the stress to continue working there or not. If enough people leave and state that unsafte staffing is the reason, someone may eventually listen.

KATNIC · Mar 30, 2017

Thank you for your reply, we do not have a union who can help us. We try to set up meeting with the DON and Nurse Manager, but these meeting are just to pacify us. The meetings have no resolution. The problem is that the nurses making the decisions have absolutely no experience in HIgh RIsk Antepartum. We are all concerned for the safety of the patients with critical issues. We want to save the moms and babies.

You are right, we are all sticking together as a united front to advocate for our patients and our licenses.

KATNIC · Mar 30, 2017

Double-Helix, BSN, RN,

Thank your reply. And your absolutely correct about the recommendations. The hospital changed the MAgnesium Policy due to the fact that the Joint Commission recently visited our hospital. So for the hopsital not to be penalized the Hospital needed to change the policy ASAP--having the Mag assessement be done hrly and use the AWHONN recommendation of 1 RN to 4 stable patients. The DON told us she want 3 people of the floor of all times, in a any combination ( 3 RNs or 2 RNs + 1 Tech or 2 RN + Secretary). Unfortunately, this is not passed on to the Nurse Supervisor or Manager or NIght Management.

We were happy that the JC nusres had OB experience as they knew what to look for. Now that the 40 day grace period is over, the Hospital is violating it's own policy. We are all super exhausted and are concerned for the safety of our patients and oursleves.

I took to this forum to see if any fellow nurses have advice or experience with this kind of situation. Thanks again for your reply.

KATNIC · Mar 30, 2017

llg, BSN, MSN, PhD,

Thank you so much for your informative responses. I do appreciate your explanation and advise. I think you hit the nail on the head, I do not think that the DON is being clear about the system for the staffing. We are a unique unit which is half the problem. I do believe that the DON, Nurse SUpervisor and MAnager each use a different system.

We have requested meetings which go no where. We do come prepared with an agenda and solutions but are are preceived as "Whiners". So we have stepped back and are trying very hard not to "complain".

It is a concern of ours that 'babies" are not being considered a patient when their assessment and charting are twice as much than their mothers'.

I understand the financial portion and you are right. Our manager will have us discharge patients from our census who are going home but are not ready to leave to justify RN:patient ratio--which is a huge concern of ours. Our patients have issues and many discharges have been cancelled because their blood pressures or other issues.

Your right, we are now all facing to leave what we love and have a passion for or stay and jeopardize our patients' safety and our license. We are all aware that the hospital will not back us up if something were to happen. We will be the first to be thrown under the bus, so we all have started documenting and emailing any unsafe staffing associated with acuity on our unit. These emails always go unanswered but at least we have a paper trail.

Thanks again for your advise!

calivianya, BSN, RN · Apr 17, 2017

I know this is a slightly older post, but I will say the only thing that made our staffing change when it got really dangerous was a nurse going to the Joint Commission with documentation of what her shift looked like. If your workload is blatantly unsafe, JCAHO will come down on your facility with a hammer. I work in a 900+ bed regional referral center and we almost lost accreditation last summer because of staffing issues.

I'm talking a night where one of our sister ICU units had multiple four patient assignments, and filled up the morgue because of inability to properly take care of the patients. Every nurse in my unit had a three patient assignment that night.

Our amount of staff RNs has not changed dramatically, but now we usually have several travelers with us every night. We didn't have any travelers at all before that person went to JCAHO.