Chapter 17
Managers:
Managers must be cognizant of the need to have an ethnically and culturally diverse staff to meet the needs of an increasingly diverse patient population
Why Is Scheduling so Difficult in Nursing?
Doesn't fit traditional business cycle
Erratic and unpredictable health care demand
High level expertise required 24/7
Stress of job requires balanced work-recreation schedule
Staffing mix varies with acuity
Staffing:
Although many organizations now use staffing clerks and computers to assist with staffing, the overall responsibility for scheduling continues to be an important function of first- and middle-level managers.
Centralized Staffing
* Staffing decisions for all units are made by a central office or computer.
* Tends to be fairer to employees, because policies are implemented more consistently and impartially.
* Frees manager to complete other functions.
* Most cost effective, because it maximizes use of human resources organization-wide.
Decentralized Staffing
Staffing is done at unit level, frequently by unit manager.
Allows person who knows the individual unit the best to make staffing decisions for that unit.
Allows staff to take requests directly to their own manager, which gives them increased autonomy and flexibility.
Increases the risk that employee requests may be treated unequally or inconsistently.
Time-consuming for unit manager.
Fair and uniform staffing and scheduling policies must be written and communicated to all staff.
Organizational Staffing Policies
Need policies that address:
Sick leave
Vacations
Holidays
Call-offs for low census
On-call pay
Tardiness and absenteeism
Sample Staffing and Scheduling Options
10- or 12-hour shifts
8-hour shifts
Job sharing
Flex time
Self-scheduling
Part time
Per diem -
Premium pay for weekend only
External registry or agency staffing
Travel nursing
What are the pros and cons of 8-, 10-, and 12-hour shifts?
Agency and Travel Nurses
These nurses are usually directly employed by an external nursing broker and work for premium pay (often 2-3 times that of a regularly employed staff nurse), without benefits.
While such staff provide scheduling relief, especially in response to unanticipated increases in census or patient acuity, their continuous use is expensive and can result
in poor continuity of nursing care.
Per Diem Employees and Float Pools
Some hospitals have created their own internal supplemental staff by hiring per-diem employees and creating float pools.
Flex Time
A system that allows employees to select the time schedules that best meet their personal needs while still meeting work responsibilities.
Self-scheduling
allows employees the opportunity and responsibility to make their own work schedules. What are the limitations of self-scheduling?
Shift Bidding
In shift bidding, the organization sets the opening price for a shift, which may, for example, be at a higher rate of pay than the hourly wage of some nurses, and nurses may bid down the price in order to be assigned the overtime shift.
Generally the organization will choose the nurse to work the shift who bid lowest, but some organizations may deny bids to nurses who work too much overtime.
(Huston, 2006)
Examples of Staffing Standards
Inpatient units: NCH/PPD
Surgery: minutes per case
Emergency departments: total visits
Labor and delivery: number of births
Home health agencies: visits per month
Staffing by Acuity:
Using a Patient Classification System (PCS)
Groupings of patients according to specific characteristics.
Hours of nursing care assigned for each patient classification.
Unique to a specific institution.
Ongoing review critical.
Internal or external forces affecting unit influence classification system.
critical indicator (PCS)
PCS uses broad indicators such as bathing, diet, intravenous fluids and medications, and positioning to categorize patient care activities.
summative task (PCS)
PCS requires the nurse to note the frequency of occurrence of specific activities, treatments, and procedures for each patient.
PCS
At the national level, the use of a PCS(patient classification system) is a condition for participation in Medicare and is required by the Joint Commission for certification.
Literature review shows:
A current review of the literature consistently and overwhelmingly demonstrates that as RN hours decrease in NCHPPD, adverse patient outcomes increase, including increased medication errors and patient falls and decreased patient satisfaction with pain management.
Mandatory Minimum Staffing Ratios
One state (California) has enacted legislation requiring mandatory staffing rates that affect hospitals and long-term care facilities. Under Assembly Bill 394, passed in 1999 and crafted by the California Nurses Association, all hospitals in California had to comply with the minimum staffing ratios by January 1, 2004.
Critics of Staffing Ratios Argue:
The current nursing shortage will make it difficult to fill the slots when the ratios appear.
The ratios may merely serve as a Band-Aid to the greater problems of quality of care.
Numbers alone do not ensure improved patient care because not all registered nurses have equivalent clinical experience and skill levels.
Staffing may actually decline with ratios, because they might be used as the ceiling or as iron-clad criteria if institutions are not willing to make adjustments for patient acuity or RN skill level.
Generational Diversity in Nursing
GENERATION YEAR OF BIRTH
* Silent Generation 1925-1942
* Baby Boomer 1943 to early 1960s
* Generation X Early 1960s to 1980
* Generation Y 1980 to present
Adapted from Hill (2004); McNeese & Crook (2003); Martin (2003)
Identification of Resource Requirements
Accurate definition and quantification of the work of nursing is critical to the identification of appropriate nursing resource requirements.
—Graf, Millar, Feilteau, Coakley, and Erickson, 2003
Closed-Unit Staffing
Closed-unit staffing occurs when the staff members on a unit make a commitment to cover all absences and needed extra help themselves in return for not being pulled from the unit in times of low census.
Fiscal Accountability
Fiscal accountability to the organization for staffing is not incompatible with ethical accountability to patients and staff. It should be possible to stay within a staffing budget and meet the needs of patients and staff.
Mandatory Overtime
Employees are forced to work additional shifts, often under threat of patient abandonment.
Key Concepts:
The manager has both a fiscal and ethical duty to plan for adequate staffing to meet patient care needs.
Key Concepts:
Innovative and creative methods of staffing and scheduling should be explored to avoid understaffing and overstaffing as patient census and acuity fluctuate.
Key Concepts:
Staffing and scheduling policies must not violate labor laws, state or national laws, or union contracts.
Key Concepts:
Workload measurement tools include NCH/PPD, PCS (Patient Classification System), and workload measurement systems. All workload measurement tools should be periodically reviewed to determine if they are a valid and reliable tool for measuring staffing needs in a given organization.
Key Concepts:
Mandatory overtime should be a last resort, not standard operating procedure because an instituion does not have enough staff.
Key Concepts:
Research clearly shows that as RN representation in the skill mix increases, patient outcomes generally improve and adverse incidents decline.
Key Concepts:
Those with staffing responsibility must remain cognizant of mandatory staffing ratios and comply with such mandates.
Key Concepts:
Managers should attempt to have a diverse staff that will meet the cultural and language needs of the patient population
Key Concepts:
Fair and uniform staffing and scheduling policies and procedures must be written and communicated to all staff.