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the number and mixture of personnel assigned to work in nursing units at a given time

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staffing

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Goal of staffing

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- to provide an adequate number and mixture of personnel to give proper care to the patients in the nursing units at a particular time - NEEDS TO BE SAFE

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2 Components of staffing

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1. staffing pattern 2. staffing plan

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The number and mix of personnel that should be on duty per each unit per shift per day

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staffing pattern

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Determines the number of nursing personnel that must be hired to delivery nursing care on the nursing units - how many nurses you need

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staffing plan

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why do we have 12 hour shifts at the hospital

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it's cheaper to pay for 2 nurses rather than 3-4 per 24 hours

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T/F: ANA makes laws about nurse staffing

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F- only makes recommendations

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ORganization that started looking at safety and organization of staffing

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AHRQ

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AHRQ Nure Workforce and Nurse Staffing Levels

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- nurse workforce consists of licensed nurses and nursing assistants - both RNs and LPNs licensed by the state - RNs assess pt needs, develop pt care plans, and administer meds and tx -LPNs carry out specified nursing duties under the direction of RNs -Nursing assistants typically carry out non-specialized duties and personal care activities -All provide direct pt care

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Nurse staffing is measured in one of two basic ways:

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1. nursing hours per pt per day 2. nurse to pt ratio

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National Database of Nursing Quality Indicators (NDNQI)

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1. Nursing Hours per Patient Day - RNs vs LPNs vs UAP hours per pt day 2. Nursing Turnover 3. Nosocomial infection 4. Patient falls - more RNs = less falls 5. Patient falls with injury 6. Pressure Ulcer rate - hospital vs community vs unit acquired ulcers; nutrition a big deal 7. Pediatric Pain Assessment, Intervention, Reassessment (AIR) Cycyle 8. Pediatric Peripheral IV Infiltration 9. Psychiatric Physical/Sexual Assault 10. RN Education/Certification 11. RN Survey - job satisfaction scales, practice environment scale (PES) 12. Restraints 13. Staff Mix

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TJC Staffing effectiveness requirements

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TJC just states that staffing must be "safe", but doesn't really have an explicit rule for this - The gov't doesn't tell you what is safe, it just says it needs to be safe

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Patient Safety and Quality: The quality of care that nurses provide is influenced by (5)

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1. individual nurse characteristics such as knowledge and experience 2 Human factors such as fatigue 3. Systems nurses work in, which involve not only staffing levels, but also the needs of all the pts a nurse or nursing staff is responsible for - where do they work? 4. The availability and organization of other staff and support services 5. climate and culture created by leaders in that setting

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Patient Safety and Quality: Safety outcomes include: (2)

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1. rates of errors in care 2. potentially preventable complications in at-risk pts

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Clinical outcomes/endpoints come from where?

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clinical pathways

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Clinical outcomes vary/stay the same for each patient and each population

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Clinical outcomes vary from patient to patient or by clinical population - and they are only as good as the person implementing them - serious errors or complications often lead to poor clinical outcomes

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Clinical outcomes include

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1. mortality 2. length of stay 3. self-care ability 4. adherence to tx plans 5. maintenance or improvement in functional status

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Staffing is a critical human resource issue affecting (3)

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1. cost 2. safety 3. quality How well/poorly managers staff units impact the safety and quality of patient care, financial results, and organizational outcomes such as job satisfaction and retention of RNs

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The major goal of staffing

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Provide the right number of nurses with the right qualifications to delivery high quality, safe, and cost-effective care to a group of pts and their families

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What is the most critical activity of nurse managers?

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staffing

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Role of the manager in staffing

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Recruits, selects, orients, and promotes personnel development to accomplish the goals of the organization

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Factors influencing the difficulty of staffing in nursing (5)

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1. HC doesn't fit the traditional business cycle (it's a 24 hours business) 2. Erratic and unpredictable HC demand - never know when you'll be busy 3. High level expertise required 24-7 4. Stress of job requires balanced work-recreation schedule 5. Staffing mix varies with acuity

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Staffing mix varies with

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acuity

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Fundamental elements impacting staffing (6)

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*Accurately predicting staffing needs is a crucial skill because it enables the manager to avoid staffing crises 1. nurse-patient relationships and decision making 2. work allocation and patient assignments 3. communication between members of the HC team 4. management of the unit or environment of care 5. role of the charge nurse - need to know if it's a free charge or are they taking pts 6. Fair and uniform staffing and scheduling policies must be written and communicated to all staff

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Scheduling and staffing considerations

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1. scheduling (centralized, decentralized, self) 2. determining FTEs 3. Pt care hours

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Centralized Staffing

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- NOT IDEAL - staffing decisions for all units are made by a central office or computer (program or secretary, etc.) - 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

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Pros and cons of centralized staffing

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Pros - tends to be fairer to employees - frees manager to complete other functions - most cost effective Cons - usually not a nurse making decision -doesn't take patient acuity or skill mix into account often

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Decentralized Staffing

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This one is what we want! - Done at unit level by a manager -Allows person who knows the individual unit to make staffing decisions - allows staff to take request directly to their own manager, which gives them increased autonomy and flexibility - increases risk that employee requests may be treated unfairly or inconsistently - time-consuming for unit manager

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Pros and Cons of decentralized staffing

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Pros - allows person who knows the unit to make decisions - allows staff to take requests directly to their own manager - increased autonomy and flexibility Cons - increases risk that employee requests may be treated unfairly or inconsistently -time consuming for manager

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Staff Self-Scheduling

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Very good when it works! - staff schedule themselves - may promote staff autonomy and increase accountability - requires proper management - becoming more complicated because of care delivery changes, decentralization of many activities to patient care units, and readiness of support staff to participate - Problem - very few people want to work holidays

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Pros and Cons of staff self-scheduling

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Pros - may promote staff autonomy and increase accountability Cons -Biggest issue is that people don't want to work holidays - more complicated due to changing nature of health care

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Organizational staffing policies must address (6)

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1. sick leave 2. vacations 3. holidays 4. call-offs for low census 5. on-call pay 6. tardiness and absenteeism

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Full Time Employment

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- staffing position that is equal to 40 hours per week for 52 weeks - If a position requires more coverage than 40 hours a week, the FTE is greater than one

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Fixed vs variable FTE

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Fixed: employees scheduled to work no matter how many patients or acuity Variable: employees who are scheduled according to workload needs

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Patient Care Hours (generally)

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- direct patient care hours and indirect patient care hours - productive and nonproductive patient care hours

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Direct Patient Care Hours

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- all nursing care activities performed in the presence of the patient and/or family - involves patient and includes feeding, bathing, treating and giving medications

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Indirect Patient Care Hours

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- all nursing care activities done away from the patient but on a specific patient's behalf, including all activities that are not direct care - prep for and cleaning up after med administration and treatments, coordination of clinical care, reporting, communications, documentation of care, coffee and lunch breaks

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Productive Hours

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hours worked and available for patient care

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Nonproductive hours

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Hours for benefits such as vacation, sick time, and education time

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Nursing hours of care per patient day (NHPPD)

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reflects only productive nursing time available

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Staffing pattern can be generated by: (3)

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1. Determining the necessary ratio of staff to patients, then calculating nursing hours and total FTEs 2. Determining the nursing care hours needed for a specific patient or patients, then generating the FTEs and staff-to-patient ratio needed to provide that care 3. Using a combination of both methods

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Pros and Cons of 8 hour nursing shifts

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Pros - traditional Cons - longer work week

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Pros and Cons of 10 hour nursing shifts

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Pros - time to complete work - long weekends - extra days off - decreased overtime -cover peak workloads - decreases costs Cons - fatigue - overlap - difficulty finding substitute

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Pros of 12 hour nursing shifts

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Pros - lower staffing requirements - lower cost per patient day (benefits, etc.) - increased knowledge of pts - aility to get new admissions settled - less feeling of being rushed - better continuity of care - possibility for team development - less daily reporting - less time spent in staffing - reduced travel time - lower personal expenses for gas, meals, babysitting

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Cons of 12 hour nursing shifts

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- greater exhaustion at end of work week - increase in tension at end of work week - increase in minor accidents - increase in med errors - home and social life suffer the week worked

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General float pool

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provides organized supplemental staff where needed - these nurses are specifically "float", they may work a different place every shift, just go where they are needed anywhere in the hospital

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Unit-based float pool

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supplies staff to specific unit (not the whole hospital)

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Per diem nurses (prn)

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- hired on daily basis - not guaranteed an assignment - paid a higher hourly wage (no benefits)

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Federal regulations require hospitals certified to participate in Medicare to have

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adequate numbers of RNs, LPNs and other personnel to provide nursing care to all patients as needed - no national staffing law

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T/F : There is a national staffing law

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F -No national staffing law, states are taking steps to ensure that staffing is appropriate to meet patients needs (however, LA doesn't have laws regarding this either)

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Does LA have staffing laws defining safe numbers for nurse to patient ratios, skills mix, etc.?

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No

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T/F: Direct care nurses contribute to development of hospital-wide plans, by unit and shift, that set nurse staffing levels based on patient acuity and needs at any given time, available support staff and other factors

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T

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A specific, legally mandated minimum ratio, varying based on the type of unit

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Nurse-to-patient ratio

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Disclosure of staffing levels

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Hospitals must publicly report nurse-staffing levels so staffing plans can be reviewed by hospital staff, patients, and public or a regulatory body

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T/F: Mandatory nurse to patient ratio is law in California

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T

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Critics of mandatory staffing ratios argue: (4)

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1. the current nursing shortage will make it difficult to fill the slots when ratios appear 2. ratios may merely serve as a Band Aid to the greater problem of quality of care 3. NUMBERS ALONE DO NOT ENSURE IMPROVED PATIENT CARE because not all nurses have equivalent skills and experience 4. Create significant opportunity costs that may restrict employers and payers from responding to market forces

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Mandatory overtime

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- employees are required to work additional shifts, often under threat of pt abandonment - some facilities routinely use mandatory overtime in an effort to keep fewer people on payroll

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Problems with mandatory overtime (4)

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1. nurses who work exhausted represent a risk to public health and patient safety 2. working OT increases the odds of making an error 3. for a long term solution it is neither effective of efficient 4. in short term nurses feel a lack of control and its impact on mood, motivation and productivity, increase stress because nurses are competing with the duties of jobs, family, their health and their pt safety

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a system of classification to evaluate nursing care

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nursing outcomes

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the ratio of required staff hours to actual provided staff hours

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nursing productivity

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time an employee actually works

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productive time

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the implementation of the staffing plan by assigning unit personnel to work specific hours and days

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scheduling

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involves planning for hiring and deploying qualified human resources to meet the needs of a group of patients; it is a primary responsibility of the nursing manager

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staffing

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the conceptual approach of accomplishing the work to be done on a given unit

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staffing plan

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licensing regulations required by the state department of health, usually r/t the min number of professional nurses on a unit at a given time

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staffing regulations

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those full-time equivalent positions that depend on the demand for care, typically staff positions

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variable FTEs

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a report defining the difference bt the actual and projected staffing or budgeting

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variance report

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the amount of work distributed to a person or unit for a given time period

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workload

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