NR 447 Week 5 Telemetry Staffing Case Analysis Example

One Night Nurse Short at 1500: Pricing Four Staffing Options for a Full Telemetry Unit

Student Name

College of Nursing, Chamberlain University

NR 447: Collaborative Leadership in Healthcare

Instructor Name

Month Day, Year

One Night Nurse Short at 1500: Pricing Four Staffing Options for a Full Telemetry Unit

The Case

The case places me as day charge nurse on a composite 24-bed telemetry unit at 1500 on a Saturday. Every bed is full. The night schedule has five registered nurses and one nursing assistant; at 1455, one of the five night nurses calls in sick. The house supervisor reports that no float nurses are available, the agency list has already been exhausted for the weekend, and no one on our unit's call list has answered. Two patients are high acuity: one on a diltiazem infusion for atrial fibrillation with a rapid ventricular rate and one with a new heart failure exacerbation on an intravenous diuretic, with a potassium of 3.1 being replaced. The emergency department has one patient waiting for a telemetry bed who will come to us when a discharge occurs, and one discharge is expected around 1900.

Two constraints remove the obvious answers. Calling someone in has already failed, and the case states that no one else is available. And the hospital will not close the unit to admissions on a weekend without the administrator on call, who has already said no. The decision is how to cover 24 patients overnight with four nurses and one assistant, or with some other arrangement I can create from the staff already in the building.

Four Options, Priced Alike

Each option is priced in the same four terms: the patient load per night nurse, the acuity each nurse carries, what the night team inherits at 0700, and what patients and families would notice.

Option A, split the patients among four nurses. Load: six patients each. Acuity: two nurses would each carry one of the high-acuity patients plus five others. Inheritance: the day team at 0700 inherits a night where 0400 laboratory draws and 0600 weights are likely to be late. Visible cost: slower call light response all night. Aiken et al. (2002) found that each additional patient per nurse was associated with higher odds of death within 30 days of admission in surgical patients, and a sixth patient on telemetry is exactly the kind of increment that finding describes.

Option B, the night charge nurse takes a full assignment. Load: five nurses with about five patients each, including charge. Acuity: manageable per nurse. Inheritance: no one is free to respond to a rapid response, help with the admission at 1900 or take a break relief; the charge nurse is managing the unit and five patients. Visible cost: a slow response to any emergency.

Option C, ask a day nurse to stay four extra hours, until 2300. Load: five nurses until 2300, then four. Acuity: the admission and the discharge can happen while five are present. Inheritance: the problem moves to 2300 to 0700, which is when the unit is quieter but when a sixth patient per nurse still returns. Cost to staff: a day nurse works sixteen hours with a four-hour tail, which some policies permit and some nurses will decline.

Option D, combine C with a staggered redistribution. A day nurse stays until 2300; at 2300 the night charge nurse takes the three most stable patients, and the remaining 21 patients are split among three nurses at seven each. This option is ruled out on inspection: seven telemetry patients per nurse is well beyond what any of our nurses or our unit's staffing guideline would accept, and the charge nurse would still be carrying patients.

The Choice

I choose Option C, with the night charge nurse taking the three most stable patients at 2300 and the other three nurses taking seven high- and moderate-acuity patients combined into six-patient assignments, arranged so that no nurse carries both high-acuity patients.

The strongest case against my choice is Option A without the extended shift, because it avoids asking anyone to work sixteen hours, and a tired nurse at hour fifteen is a real safety risk. That case is serious. My answer is that the first four hours of the night contain almost all of the unit's predictable workload: the 1900 discharge, the admission that follows, 2000 and 2100 medications, and the potassium replacement on the heart failure patient, which needs monitoring. With five nurses during those hours, the admission and the high-acuity patients can be covered without anyone carrying six. From 2300 to 0700, the unit's workload drops sharply, and six patients per nurse on a quiet unit is safer than six patients per nurse during the admission hour. I also judge that the fatigue risk is bounded: the nurse staying would leave at 2300 rather than working a full double, and only a volunteer would stay.

What I Do for the Nurse Who Pays

The day nurse who agrees to stay carries the heaviest personal cost. Before she agrees, I tell her what the four hours will involve and that she can say no without any consequence. The Code of Ethics for Nurses holds that nurses owe the same duties to themselves as to others, including attention to their own health and safety (American Nurses Association, 2015), so declining has to be a real option rather than a formality. If she agrees, I give her the discharge and the admission, the two tasks that end cleanly by 2300, so that she does not hand over a half-finished problem. I make sure she takes a thirty-minute break between 1830 and 1900, covered by me before I leave, and I ask the house supervisor to authorize a meal voucher. I also document the extension so that it counts toward the unit's record of mandatory overtime, which our manager reviews, and I tell the manager on Monday who stayed. The night nurses taking six patients after 2300 also pay a cost; for them, I ask the house supervisor to round on the unit at 0100 and 0400 and to be the unit's first call for any rapid response.

When I Reassess

The decision is made at 1500 on incomplete information and has to be revisited at 1830, before I leave. At that time I will check three things: whether the 1900 discharge is still happening, whether the diltiazem patient's heart rate has been controlled or is still requiring titration, and whether the sick call has been replaced by anyone answering the call list late. If the discharge is canceled and the admission cannot come, the extended shift may not be needed, and I will release the day nurse at 1900. If the diltiazem patient remains unstable, I will ask the house supervisor to consider transfer to the intensive care unit before the night starts, which would change every assignment. The American Nurses Association (2020) describes staffing as a continuous process that responds to changes in patient needs across a shift, and a plan with no reassessment point would treat a 1500 guess as a 1900 fact.

References

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987-1993. https://doi.org/10.1001/jama.288.16.1987

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.

American Nurses Association. (2020). ANA's principles for nurse staffing (3rd ed.).