Patient Ratios: Argument Against 

Thanks Losingthedreams

So to combat this issue we have something called “MCOs” or Mandatory Call-Offs. This means that if you have let’s say 6 people on the schedule (so staffed for 20 patients with one nurse as the charge), but we only have 12 patients on the floor, the staffing office would typically MCO one nurse so we would be staffed for 16. On a night like a Friday night we would keep all 6 nurses and later send one home if the census doesn’t increase.

The nice part about these MCOs is that let’s say I have had a particularly bad shit storm of patients for two nights in a row and I REALLY don’t want to work tomorrow night, all I have to do is call in and “request MCO” which means that if the census is low, I’ll be #1 to be called off. If no one requests, the staffers will go in order by who’s turn it is to be called off. They have to go in order. If they were to MCO me and it wasn’t my turn, or they called me off and instead floated an ICU nurse to my floor, all I would have to do is tell my nurse manager and I would get paid for the shift even though I wasn’t there (a part of this is per our union contract).

In low census months like in the summer, we typically get MCO’d once a pay period at the very worst. Low census units like our ICU floor do get MCO’d at a greater rate, so many of those nurses also have part-time jobs to make up for the lost days.

This is how you deal with the change in census that occurs from shift to shift to prevent over or under staffing. By also cross-training your RNs, you can also combat this by having the power to float to understaffed units. Our telemetry nurses can float to ICU and vise versa for example.

I saw this and all I could think of was that point when you’ve been helping a patient with a bedpan every thirty minutes ALL DAMN night and then you see them walking in the AM.

I saw this and all I could think of was that point when you’ve been helping a patient with a bedpan every thirty minutes ALL DAMN night and then you see them walking in the AM.

(via meta-consciousness)


Just an FYI 

I now have to go to my appointment for a cardiac echo and treadmill stress test. Probably not the post I should have worked on prior to this appointment, because I feel SUPER vicariously stressed just thinking about these crazy points you all brought up.

You all must be on bp meds a lot stronger than the ones I’m on.


Patient Ratios: Follow-Up 

Thank you to everyone for reblogging and commenting on the patient ratios post, and also my thanks to those of you who sent me personal messages. Know you are not alone!

I had initially planned to address each of the replies, but because there were so many replies and reblogs I thought I would just do it here instead.

What I have noticed is several themes which I’d love to address and get more feedback on:

1. Unsafe, Fluctuating Staffing
Many of you replied that you that you can take 6-9 patients on a medical-surgical type floor and over 30 in a long-term care or rehab type setting. Granted I do not know what other hospital’s patients are like, but I can’t imagine them being very different than my own. Because so many patient these days are diabetic, medication pass takes longer due to finding Accucheck machines, getting witnesses for insulin, increased patient education, and ensuring you have a snack for your patient. So if all of your 8 or 10 patients have 0730 medications, how can this all take place before the food trays get there?
Working on my floor, we have a 31 bed unit and only 3 Accucheck machines. So if you don’t grab one right at 1945, you aren’t going to get one until after 2100. I would imagine this is not a unique problem to me.

More concerning than the large number of patients is the fluctuating staffing on the night shift. It honestly brings up a lot of questions like:

  • Why be motivated to work the night shift? Sure you will get night shift differential but at what cost?
  • Saying that you can have 20 patients at night “because they all sleep” would show me that not only does management not respect what I do at night, but they are clearly out of touch with floor nursing.
  • A lot of you also mentioned that in addition to these staffing fluctuations, you lose your techs and charge RNs at night. What? So you get more patients, more responsibility, more liability, and less help? I don’t get it.

2. Charting

If you have 8 patients let’s say, and you spent 15 minutes charting on each patient in the course of your 12 hour shift, you would end up charting for 2 hours. I can’t imagine with 8 patients, having only 15 minutes worth of charting apiece while also having 2 hours to spare sitting and charting. And for those of you that still paper chart, it must take much longer to hand write these notes. How can you safely, and responsibly document everything that happens in a 12 hour shift for that many patients? What about those of you with 30+?
Because I am still a new graduate RN, I ascribe to the CYA mentality of charting and I chart EVERYTHING. I mean EVERYTHING. I don’t care if it’s just hourly rounding and the patient is asleep all night, or I walked in to give the patient a glass of water, or I hung the NPO sign on the door, EVERYTHING involving the patient gets a note. Why? Lawsuits of course. If it wasn’t documented it wasn’t done. So even if I have the most stable patient in the universe, I have to prove for my potential legal disposition in ten years that I was there and what exactly I did, and what exactly the patient looked like.
Forget 8 patients, how is this done on 10 patients—or the 30-60 some of you mentioned in LTC?

3. Increased Risk
You have less time to teach, less time to round, less time to chart and CYA. Less time means less likelihood of catching a deteriorating patient. I’m sure all of you who work in these staffing situations would agree that you are at an increased risk of losing your license, of harming a patient or being unable to prevent harm, and increase risk of malpractice. I know in California if I’m found guilty of negligence or neglect the patient or family can come after my personal assets including my home.
What about bedside shift report? This practice has shown to increase patient satisfaction, reduce medication errors by having two RNs verify patient identity at the bedside, etc. How can you do this proven safe practice with 10 patients? Or seven? I know for my four it can take forty-five minutes to find all the nurses and get report on my four patients. Is this practice therefore not done?

I’m left after all of your feedback with more questions I’m afraid. Is there an argument against patient ratios? Is it cost? That doesn’t seem to make sense to me because with less time you may have more readmissions, more complications, increased LOS—which all costs the hospital millions of dollars.
Is it more of the argument of “this is the way nursing has always been done”? That’s never a good argument for anything. We all know patients today are much sicker than they used to be and this increase in acuity needs to be met by better staffing.

I’ve said it once, I’ll say it again. You guys are brave, strong, incredible people for doing what you do as nurses each and every day (and night). I’d love to keep this discussion going and learn more, and maybe then we can start to do something to make a change.

Thank you thank you for all that you do! Feel free to reblog or fanmail or comment here.



Patient Ratios: My Hospital, Somewhere in Southern California 

Before I get to replying on the feedback I got last night and today, I’d like to cover what it’s like at my hospital.

As calarenice pointed out in her reply, we do have unions in CA and my hospital is unionized (some aren’t). Where I work, it doesn’t matter how you feel about the union or unions in general because you are required to join as a part of your hire. Probably something I need to create a new post entirely about another time; I have mixed feelings on the unions.

I work in Telemetry at night. We have 4:1 ratio always, this never fluctuates based on acuity or time of day. One thing that I see a lot of you saying you have is techs and aids, which I imagine are mandatory because how else could you manage such large loads of patients?

On my floor there are no aids. We have a telemetry tech that watches the monitors and our charge nurse who also per our union contract does not take patients. Occasionally she will take patients like if someone has to leave home sick or something, but it’s very rare. If the union gets wind of it they get super pissed and meet with the staff about it.
CNAs do exist of course in my hospital just not on the floor really. We use the CNAs for 1:1’s which if you ask me is a waste of money. Many hospitals use med-student or nursing student volunteers for sitters or patient-safety techs for sitters which cost a fraction of the $24/hr these CNAs get paid. That’s right, $24/hr to sit. I’d rather have some volunteers in our 3 1:1’s and then have a CNA on the floor.

Usually our charge nurse will break the CNAs in the 1:1s so that we can have our vitals taken at 2000, 0000, and 0400.

I work in a very low-socioeconomic area so the patients that come in are very sick with a ton of comorbidities. So we have a ton of total care patients. The charge will try to distribute these evenly so everyone gets one but I’ve had days where I’ve had as many as three totals and one assist patient and like I said, no aids on the floor. So this means coordinating with your other RNs for turning, cleaning, bathing the heavy ones, along with your daily weights. 

What’s the consequence of no CNAs on the floor? We have a TON of falls. Why? Because confused little 80 year old man gets tired of waiting for his RN to help him go to the restroom (because we are stuck with another patient) and tries to go alone and falls. If we ask a doctor for a restraint order they say no (which I agree with) and they usually say no to sitter requests also. IF THEY do say yes, we have to wake up our nurse manager or the CNE at 0300 for approval…even though the doctor gave us an order. Because hey, these people are $24 an hour.

When I was discussing the patient ratio situation with one of our CNAs last week, who has been at the hospital for 20 years, she says it really is a double-edged sword. She said that when there were no ratios, you would have eight patient to an RN let’s say, but there would be three CNAs on the floor, a resource nurse for all the admissions and discharges, and even a separate tech just for daily weights.

More to come later on this issue.



I’m going to address all these responses tomorrow but I need to say three things before I turn in for the night:

1. I have always respected nurses, but damn ladies and gents. I know how bad my nights can get and I have NO idea how you guys can do it with double or triple the patient load, regardless of ancillary help. Wow. Just wow.

2. My mind is completely boggled to be honest. I mean some of the numbers you guys are replying are huge.

3. You are all super heroes.