Nursing leadership and management phần 63

17Jones Leadership(F)-ch 17 288 1/14/07 3:49 PM Page 288 Skills for Being an Effective Manager of the organization A centralized system works well in large organizations where management oversees strategy, budget, resources, and process (Sabet, 2005) A centralized system offers management a broader overview and closer control of the entire scheduling and staffing system An obvious disadvantage of the centralized system is that individual considerations are minimized Decentralized In decentralized staffing, the managers of individual nursing units have more control over the budget, resources, and process For example, unit-based staffing and utilization committees can develop schedules Membership consists of the nurse manager and staff members to oversee unit-specific staffing utilization, providing safe patient care on appropriate, efficient, and cost-effective bases Staffing levels would be monitored on an ongoing basis (Texas Nursing, 2001) Under a decentralized scheduling and staffing system, a nursing unit can be accountable for outcomes and would be selfreliant for resources Mixed or Preference Scheduling Mixed staffing combines centralized and decentralized staffing by offering individual units the ability to manage regular schedules with assistance from the central staffing office for shift coverage or other clinical resources for patient activity changes Mixed staffing can accommodate nursing personnel’s need for flexible or preference scheduling Flexible scheduling is one of the advantages of working in health care because many facilities are open 24 hours a day, but this also means some health-care professionals have to work on holidays Flexible scheduling is a strategy aimed at improving retention and offers balance and enhancement between professional and personal-life activities Flexible scheduling can be combined with selfscheduling Self-scheduling offers increased autonomy and job satisfaction Nursing staff is able to enjoy the ability to participate in self-scheduling as well as being able to work shifts that are in 4- to 12hour increments Many organizations now offer flexible schedules to accommodate the needs of both practicing nurses and students (Kimball & O’Neil, 2002), and have thereby improved the work environment hot topic: Shift Bidding Because nursing is a 24/7 business, scheduling modalities are always a topic of discussion In the past, hospitals tried the following: the 12-hour shift, work 32 hours and paid for 40 hours, weekend schedule composed only of two to three 12-hour shifts, and selfscheduling Today with the growth of health-care informatics, shift bidding has become a popular scheduling modality Shift bidding is accomplished by the purchase of a software system The system allows the nurse to access the software program via the Internet anywhere at any time and review available shifts eShift is the trademark of one type of software Shift bidding involves the use of the software system by the staff nurse to bid for extra shifts Both part-time and full-time staff may choose their committed shifts for a month at a time Shift bidding is similar to eBay, as the nurse can bid auctionstyle on available nursing shifts over the Internet Shiftbidding software systems incorporate an overtime rate and a flat fee for the winning shift Shift bidding allows not only part-time or registry nurses to bid for shifts but is also popular among health-care systems where a nurse may choose to work overtime at a system hospital other than the one where she normally works Shift bidding offers flexibility and control to the staff nurse over their schedule and higher rates of pay, which contribute to staff nurse satisfaction The nurse has the opportunity to control her schedule, rate of pay, and in some cases commute to work Shift bidding also affords the staff nurse the opportunity to reverse auction After the self-schedule process, remaining shifts become available for auction Shifts are posted with a maximum hourly rate The lowest bidder wins the shift when the auction closes Shift bidding automates the scheduling system because nurses are tapped from several pools Hospitals save money in recruiting nurses to work overtime, pay less money in overtime costs due to the reduced use of agency nurses, and also reduce vacancy rates for hard-to-fill shifts Times savings are another benefit for nursing management as shift bidding provides a 24-hour self-service process for staff nurses Registry nurses not have to share administrative costs with an agency and can make more money Finally, shift bidding increases the quality of patient care as the system provides more continuity in staffing for units and hospitals 17Jones Leadership(F)-ch 17 1/14/07 3:49 PM Page 289 Staffing and Scheduling SCHEDULING OUTCOMES The implementation of the planned schedule culminates in the daily activities of the patient care team and the subsequent results of that care: the outcomes Daily Staffing Daily staffing, or activation of schedule, is the outcome of the scheduling and staffing system for a specific date and time It dictates who specifically will interact with which patient and when Daily staffing, the implementation of the staffing schedule, is affected by the actual assigned nursing workload to the scheduled nursing staff Daily staffing changes can be warranted for various reasons such as call-ins, patient care needs, patient census changes, and internal and external disasters Often, staffing adjustments are needed hour-to-hour depending on the patient care activities and needs Balancing the staff scheduled and the daily staffing workload is a major challenge to the nurse manager Daily staffing adjustments can be managed by the following options: using other clinical resources and hiring overtime and temporary staffing Examples of clinical resources for making staffing adjustments include STAT, float pool or admitting nurses, and a rapid response team STAT nurses are a pool of nurses, usually with critical-care experience, who respond to crisis situations such as sudden cardiac arrests (“codes”) or traumas or who provide assistance with special procedures (e.g., conscious sedation, transport critically ill patients) (Scalise, 2005) STAT nurses may also be the skin and wound assessment team (Lancellot, 1996) to assist bedside nursing staff with prevention of hospital-acquired pressure ulcers Float pool nurses are experienced generalist or specialized staff available to be assigned as needed to any nursing unit Often, these nurses can work to hours and move on to the next unit in need Some providers have created in-house nursing agency pools to help meet seasonal demands Admitting nurses are an integral part of the patient throughput process in acute-care settings and intake process for home-health care They complete databases, initiate consults (e.g., skin care and pain management) and falls protocols, initiate medical orders, and generally ease the patient’s transition into hospital or home-care settings 289 Rapid response team, also known as the medical emergency team, is a team of clinicians who bring clinical expertise to the patient bedside (Scholle & Mininni, 2006) Similarly, a multidisciplinary system-wide action team (SWAT) coordinated by nursing leadership in response to increasing patient census and acuity has been found to be effective for diagnostic testing and scheduling, expediting the admission process, reducing discharge delays, and staffing to hospital census demands (Tachibana & Hardy, 2001) Temporary/supplemental staffing nurses come from agencies often referred to as “rent-a-nurse” providers, which, although not currently regulated, can apply voluntarily for JCAHO certification Traditionally, these temporary nurses are paid per diem and are reimbursed for traveling expenses Use of temporary staffing personnel has great patient safety implications because, often, credentials and experiences are not easily verified The fatigue factor becomes an issue as, in some cases, agency nurses also work at another institution and temporary staffing for extra income There is a national trend to reduce dependency on temporary staffing options (Kovner et al., 2002; Morse et al., 2005) Overtime Overtime, or extended hours, is defined as continuing to work beyond or before one’s scheduled hours Nurses can work extended hours under mandatory and voluntary overtime scheduled conditions Collective bargaining contracts often address the issue of overtime by setting the terms for mandating or requiring overtime work An example contract (Ohio Nurses Association, 2005) defines mandatory overtime as no nurse will be required to work overtime for a period of more than hours No nurse may be mandated to work more than 16 hours of overtime in any 4-week schedule A nurse will have a minimum of hours off between shifts, when one such shift is a mandated shift Overtime work can leave nurses fatigued and affect their ability to provide adequate clinical judgments and care Gaines and Carter (1989) offer a decisionmaking framework in which to analyze the overtime situation by examining individual rights and responsibilities as a professional nurse Mandatory overtime should not be a “routine” staffing backup plan and should reflect staff nurse input (Shirey, 17Jones Leadership(F)-ch 17 290 1/14/07 3:49 PM Page 290 Skills for Being an Effective Manager 2005) Working long hours has caused nurse illness and injury, fatigue and safety problems, workplace violence, and depression (Mason and Kany, 2005) Major national and state efforts are under way to eliminate mandatory overtime (Unruh, 2005) Currently, because there are no governmental regulations restricting overtime, nurse overtime is not federally limited No state or federal regulations restrict the number of hours a nurse may voluntarily work in 24 hours or in a 7-day period (IOM, 2004, p 388) Several states have laws that protect patients by limiting hospitals’ use of forced overtime In states with these laws, however, nurses can voluntarily work overtime, and the laws not apply in the case of a government-declared state of emergency Jacobsen et al (2002) polled the nursing staff on their opinions about both voluntary and mandatory overtime and identified conditions that influence the nursing staffs’ decisions and perceptions about overtime This study enabled the nursing staff to develop strategies and policies to avoid mandatory overtime and improve staff satisfaction and quality patient care Patient Outcomes The nurse staffing variables used to measure patient outcomes are daily average hours of care, ratio of RNs to average patient census, workload, and skill mix Patient outcomes most generally are based on adverse occurrences such as unit rates of patient falls, pressure ulcers, respiratory and urinary tract infections, and family-patient complaints Other nursing-sensitive indicators for outcomes are RN job satisfaction, RN education and certification, pediatric pain assessment cycle, pediatric intravenous infiltration rate, and patient assault rate Since 1994, a national database program, the National Database of Nursing Quality Indicators (NDNQI), has been available to provide comparative information to health-care facilities for use in quality improvement activities and to develop national data on the relationship between nurse staffing and patient outcomes (NDNQI 7/m, 12/05, www.nursingquality.org) In the Commonwealth of Massachusetts for public disclosure, health-care consumers can go on line to access staffing plans for comparisons with actual staffing numbers when hospitalized (Scalise, 2006) Nursing Workloads Daily staffing is affected by the workload assigned to the scheduled nursing staff, as evident in research studies Carayon and Gürses (2005) identified the assigned workload as the situation-level workload Situation-level workloads are real-time performance obstacles and facilitators that contribute to daily workloads For example, Tucker et al (2002), in a qualitative study, observed 22 nurses in hospitals for a total of 197 hours and documented 120 problems that prevented patient-care task completion The problems ranged from missing or incorrect information, missing or broken equipment, waiting for a resource, and missing or incorrect medications Similarly, Potter et al., (2005) found omissions in patient care due to interruptions in an ethnographic study involving seven staff registered nurses Nurses were frequently interrupted during interventional work such as administrating medications, problem-solving intravenous infusions, and teaching patients Interruptions pose risks for medical errors Daily staffing continues to be influenced by workload predictor/tools More extensive research and development of intensive care unit (ICU)–specific nursing workload predictor/tools are needed to determine the numbers of ICU nurses and their educational backgrounds (Robnett, 2006) All Good Things The staffing and scheduling process incorporates professional nursing standards and accounts for the health-care setting, the care delivery model, patient acuity, and the nursing staff Scheduling and staffing systems can be centralized, decentralized, or mixed The outcomes of scheduling are the daily staffing, patient outcomes, and nursing workloads The challenges faced by nurse managers in providing adequate staffing are the nurse shortage, the advances in patient care technology, the high patient acuity levels, and the health-care industry’s continuous evolution For the appropriate allocation of nursing staff for patient-focused care, staffing is both a process and an outcome (AACNCritical Care, 2001) 17Jones Leadership(F)-ch 17 1/14/07 3:49 PM Page 291 Staffing and Scheduling Let’s Talk Describe staffing as a process with a relationship to scheduling Describe a care delivery model utilized by nursing services NCLEX Questions The nurse manager’s staffing and scheduling goals: A Are consistent with the Principles for Nurse Staffing of the American Nurses Association and other regulatory guidelines B Do not have to be congruent with the mission, vision, values, philosophy, and strategic plan of the organization and its nursing services C Promote patient safety and patient satisfaction D A and C Staffing, according to the Center for American Nurses, refers to: A The monthly work schedule produced for a unit or clinic B The nursing hours per patient per day C The professional skills required for particular job assignments D A nurse’s total years of experience The process of staffing involves: A Assessment of the qualifications and competence of the staff available B Formulation of a strategic staffing plan to meet future needs C Creation of a budget of personnel to provide patient care services D Assigning nurses to the care of specific patients Scheduling variables are defined as: A The number of patients, complexity of patient condition, and nursing care required B The nursing staff members’ competency levels, qualifications, skill range, knowledge or ability, and experience level C The level of supervision required D All of the above 291 An appropriate staffing system incorporates: A B C D Patient needs Staff members’ degrees and credentials A specific ratio of RNs to LPNs The personnel budget Acuity-adapted room models offer the follow- ing: A Transfer of patients to different hospital units as their status improves or worsens B Assistance with the continuity of care C Decreased patient satisfaction D The use of patient room sharing Nurse staff scheduling factors include: A Staff may work one shift or hours prior to the starting time of a different shift or 16 hours straight B 4-week schedules will be posted at least week prior to the beginning of the schedule C Staff should be scheduled to be off duty one out of every four weekends D No nurse will be required to work more than consecutive days without a day off The nurse staffing variables used to measure patient outcomes are: A Nursing hours provided for a patient B Ratios of RNs to nurse assistants C Numbers of units to which a nurse may rotate D Skill mixes Centralized staffing is: A Cyclical B A system in which workdays and time off for personnel are changed monthly C Loose management control of the entire scheduling and staffing system D A system in which individual problems are always taken into consideration 10 Flexible scheduling is: A Difficult to accomplish because health-care facilities are open 24 hours a day B A schedule for health-care professionals that involves no work on holidays C A means to improve staff retention by offering balance and enhancement between professional and personal life activities D Not workable with self-scheduling 17Jones Leadership(F)-ch 17 292 1/14/07 3:49 PM Page 292 Skills for Being an Effective Manager REFERENCES Advocate Good Shepherd Hospital, Barrington, Illinois; 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