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Getting Smart about Workload Issues July 21, 2006

Posted by manthey in Leadership.
Tags: , ,

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.


1. Using licensure to create role clarity « Marie Manthey’s Nursing Salon - September 26, 2007

[…] Tags: licensure, LPN, ratios, skill mix, Staffing trackback Jean Harry, in reaction to my post of July 28th,  feels that the term “ratios” is troublesome: You can make a ratio out of any two things, but […]

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