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Overwhelming Response July 28, 2006

Posted by manthey in Academia, Inspiration, Nursing Salons.
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1 comment so far

Note: This post is in response to an email from Gary Saltus, a physician colleague. When I first wrote this post, I left off Gary’s comments, which is a shame because they are so vital to this discussion. Read Gary’s comments, and my complete response, here.

Wow! This whole activity of blogging has already opened more conversations and doors than I had dreamed of. Thanks so much for your thoughtful and insightful comments. I don’t have the grasp on gestalt that you do…..but I definitely get the ‘gist’ of what you are saying. I agree that the transformation has to start with the individual, and then move to groups and teams and that the employing institutions do not yet see the benefit of this kind of staff development.

Throughout my career I’ve been fascinated by how attitudes/behaviors of employees change as institutional and leader values change. I’ve seen so many dramatic changes (both positive and negative) in the lives of patients and nurses that I feel compelled to continue working with these issues.

The issue of not having time to engage in these discussions is really daunting. Also, the separation between professional cultures has erected many barriers to communication I am beginning to see coming down. Another thing that I find very interesting is that the barriers between nurse educators and practice nurses are also beginning to crack. Real light is beginning to shine through. One of the ways I get to see this is thru the monthly gatherings at my home I’ve been doing for the past five years. Attendees vary according to the email lists interests in coming on that evening. It is sort of a blend of the Open Space technology and Socrates Cafe conversation format. I have so enjoyed seeing nurse educators and nurse managers, staff nurses, alternative therapy nurses, public health nurses, etc all sitting around talking about some issue or another in nursing. A retired physician comes whenever he can. And you are right…..it really is about improving Health Care.

Getting Smart about Workload Issues July 21, 2006

Posted by manthey in Leadership.
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1 comment so far

I’ve been thinking a lot about this issue of staffing and time use, and I think we need to develop new terms to express a new way of thinking about these topics.

I’ve expressed my concerns about the universal “staffing mindset” elsewhere, most notably in a speech “Changing the Staffing Mindset.”

We need to be able to pragmatically talk about various workload issues. A set of differentiated situations with clear criteria or standards will make it easier to do this. Some of the factors that need to be considered are: benchmarking statistics, unit culture, interdepartmental cooperation, level of leadership skill at the managerial level, interpersonal relationships among the staff and patient turnover (length of stay). There are probably several others, but those are the one that occur to me immediately.

The differentiation could look something like this:

  • The Under-Budgeted Unit. By all objective comparative measures, this unit falls short of like units in terms of budgeted positions. The staff feels constantly overwhelmed, despite having effective leadership and good teamwork. Quite often units in this category have bed sizes over 30 and rapid turnover of patients. Larger units require a higher staff/patient ratio because of increased indirect time spent in communication and coordination activities.
  • The Understaffed Unit. This unit’s budget is okay, basically similar to that of other like units in other hospitals. However, many positions remain unfilled. This may be due to an overall shortage of nurses, a high turnover rate (perhaps reflecting nurse dissatisfaction with the heavy workload created by empty positions), ineffective leadership, unhealthy interpersonal relations among the staff, or to a myriad of other problems.
  • The Inappropriately Ratioed Unit. On this unit, the FTE budget is fine, unit-based work complexity analysis is needed to determine the correct skill mix based on knowledge and skill requirements of those specific patient populations. Whenever skill mix is driven by dollars rather than acuity, the opportunity for an inappropriate combination of RN/LPN/NA is likely. Skill mix adjustments should be made on basis of findings.
  • The Appropriately Funded, Staffed and Ratioed Unit.Basically budget and staffing are good on this unit, but workload variation causes frequent peak workload situations, lasting from hours to weeks. Intermittent (unpredictable) workload peaks that last hours and occur several times a week should be addressed in two ways:
    1. Nurses need to have permission to decide what to do and what not to do when there is more work to do than time available and additional resources are not feasible.
    2. Peaks that are excessive (too frequent or lasting for days or weeks) need to be addressed through staffing. Many hospitals are offering innovative part-time (such as 4 hour) jobs that specifically cover routine peak workloads. Another approach is to use travel nurses especially when the peak is seasonal or temporary based on remodeling or other types of unit transitions.

The primary solutions for the first three descriptors are usually a leadership or managerial responsibility. These issues need to be addressed in a timely way, supporting the staff using whatever means are available, from travelers to float pool to intensive recruitment/retention actions.

In all four categories, nurses need to learn the strategies of real-world prioritization, they need to be able to draw a bottom-line and consciously decide not only what will be done and in what time frame, but also what won’t be done. The subterfuge is that if a nurse prioritizes well enough, everything can get done. This is simply not true. Everyone (administrators, physicians and nurses) needs to acknowledge that truth.

Intermittent peak workload issues should not be addressed with efforts to add resources. Usually by the time this type of adjustment is made, the peak is over and now everyone is frustrated — the unit that had to send help as well as the unit that didn’t get the help when it was needed. Perhaps being careful to define “peak workload” issues as being materially different than other staffing problems will be a first step to changing the way we think about staffing and workload. We need to stop the “all or none” thinking that results in staff nurses universally feeling like there is never the right amount of staff for the normal workload. I am convinced this “never enough” thinking is what leads to the fear and anger the average staff nurse today experiences regarding staffing.

Rather than expecting additional resources to fix a “peak” we should practice Smart Care (as opposed to Total Care). Smart Care is the result of entrepreneurial thinking. Nurses who practice Smart Care stop trying to do everything. Instead they consistently sort, prioritize and choose the most strategic activities to meet the patients’ goals as well as the medical and nursing goals.