On the Issue of Hospital Staffing

I can't proclaim to note how all the other hospitals in the USA or world, for that matter, choose to handle the staffing for the floors; I can only comment on how the hospital in which I work handles staffing on my floor. That being said.....

I have just finished reading several posts in other blogs about nursing ratios in the ED. At my hospital, I do not know what the ratio is down in our ED. I do know that on the floor, we are assigned staff based upon the number of patients on the unit. Whether these people are all walkie-talkie or total care people, easily done or complex patients, we get the same number of people for whatever the census is. Included in our staffing concerns are the assistants, nurse manager, unit secretaries, LPN's and RN's. When it comes to a low census day, the first people called off are the non-essential personnel... thus the assistants and unit secretary (which if we were lucky enough to have one, would be called off. we do not have a unit secretary on our unit, do not know why. instead the charge nurse has to handle putting in all of the orders and doing all of the paperwork if the other nurses are not available to do so because the doctors give all of their orders to the charge nurse!). By non-essential, it means those not needed for essential pt care, such as giving meds, etc. Sure sometimes the nurses are called off, but if they need all of the nurses to cover all of the patients, then the nurses will not be called off.

I would love to know why the nurse manager is included in our staffing. She doesn't often work the floor. She might fill in a few minutes now and then if they are in a bind and they need her help right quick, but for the most part, she is in her office or in meetings. She also doesn't count in the staffing for the other departments that she is over either... I don't get that myself. For one thing, she surely isn't ever "called off."

I understand that they have to set limits in order to save money. "They" being the administration. But sometimes these limits are so hindering that the nurses are forced to take 6-7 patients because of circumstances and census control. Maybe you think, well 6-7 patients isn't that bad... what if 5/6 patients ... each have about 30 meds due at 0900, maybe even one has a peg tube and all their meds need to be crushed and put through said peg... one has to go to dialysis and needs weights and other specialized care... heck one is on isolation because they have c diff, and they are stooling every 30 minutes and need extra bottom care so that the stool doesn't eat right through the skin. Surely then another patient on tele monitoring is having an acute episode of afib with rvr, possibly needing transfer to the ICU to get a cardizem drip if the dig doesn't take care of it. The COPD patient is having difficulty breathing and has a hard time remembering to purse-lip breath because... well because they are hypoxic and cannot think of anything but not being able to breath. Oh and that last patient? Came in with chest pain, but tmc's are negative and tele monitoring shows nsr.. all they need is the dr to make rounds and d/c them, and ask you every hour when is the doc getting there because they would really like to go outside and smoke or just go on home.

Of course, these are just examples, but in truth, it really does happen. Prioritizing & time management do have to take place when seeing pt's like this. My question is this... wouldn't it have just been safer to allow the extra staff to come in that day so that we can perform safe pt care? After all, safety is number 1 when caring for patients. People wonder why nurses get burned out so quickly.. have a few days like the above over and over again, and it is obvious. We do the best that we can with what we have. I don't know of a simple solution to the problem unless they somehow came up with staffing quotas for pt problems, much like a drg -- but tailored to the patient and nursing care received.

Now, one thing that I really think should happen in the future is that patients are also billed for specific nursing duties, sure they already getting billed for the supplies, right? I don't know how much it costs to receive that duoderm.. but what about the time it takes for the nurse to cut it to the right size, stand there and hold it against the wound so that it will attach, and monitor it each day to see if 1) it is still intact or 2) it has been a week and needs to be changed, and etc. Doctors get to bill for procedures, why can't nurses? Why can't the patient be billed for insertion of a foley, or insertion of an NG tube? especially the ones who pull out that ng tube several times a shift? I understand that we are not doctors and do not diagnose problems or write orders. We follow the doctors orders and critical pathways for a diagnosis in order to treat the patient and hopefully send them home in the allotted amount of time. All I am saying is that there is the opportunity for nurses to also be money-makers in this profession as well. Just need some good political action on the healthcare forum? Perhaps that could allow nurses to be paid a bit more for the hard work they do and even allow for enough staff to care for patients who might need a little bit more 1:1 attention. May even attract more people into nursing.. who knows?

Finally.. after reading a comment on this topic from a non-medical person who thinks that nursing is well... non-essential. "people come to the hospital to see the doctor" GREAT! just remember that while you are the hospital, it is the nurses who carry out the doctor's orders, give you your medications (for the most part), write up the discharges so you can go home... get you your water in the middle of the night because you are really thirsty etc. It is the nurses who are the eyes and ears of the doctors, so just in case you go into vtach in the middle of the night -- when the doctor's aren't there! -- they can just possibly get in there and save your life. Next time this person goes to the hospital.. I wonder what they would do if the nurse wasn't there to take care of all of their needs.. sure won't be the doctor there giving the meds and wiping their butts if the pt isn't able to do it or watching the cardiac monitor to make sure that ST depression doesn't suddenly flip into an elevation. ok off rant :)