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Blast from the Past: Feisty Former Chicagoan (1978) May 13, 2017

Posted by mariemanthey in History, Inspiration, Leadership, Manthey Life Mosaic, Professional Practice, Values.
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Primary Nursing: Hospitals bring back Florence Nightingale

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This article was one of the first in mainstream media about Primary Nursing, Marie Manthey .. and Florence Nightingale!

The picture on page 1 is so wonderful, isn’t it?

Here are some excerpts from the article, which you can see directly via the links at the top of this post.

“We’re not just dealing with inert lumps of flesh that hurt” Davis says. “We’re dealing with people’s emotional well-being, too. And that’s what makes nursing exciting again.”

Chicago Tribune: Sunday, February 2, 1978

by Joan Zyda

Sometime after World War II, the American registered nurse was forced into being less like Florence Nightingale and more like a factory foreman.

The shortage of nurses resulted in assembly-line nursing, which brought with it an assortment of nameless, often uncaring persons who trained for brief periods before being turned loose on patients. They were practical nurses, vocational nurses, technicians, orderlies, nurse’s aides, and nursing assistants.

If you’ve been in a hospital in the lst three decades, you have seen this production line in action. Somebody took your temperature, somebody else gave you a bath, somebody else took your blod pressure, somebody else brought in your food tray, somebody else …

Conducting this “orchestra” was, and still is, the chief duty of the registered nurse in most hospitals. Despite years of learning to care for sick people, she ends up in a supervisory job that takes her out of the mainstream of patient care. If she sees patients at all, it’s only briefly when she gives them a shot or a pill, or if there’s a “problem.”

“The patients are completely perplexed and often get irritable or depressed by this fragmented and impersonal care; it frights and frustrates the doctors; the morale of nurses sinks to an incredible low, resulting in a high turnover rate and absenteeism; and it has caused a decline in patient care at many hospitals,” says Dr. William Shaffrrath, diretor of the National Joint Practice Commission in Chicago.

The commission was set up in 1972 by the American Medical Association and the American Nurses Association to solve the growing dissatisfaction with hospital nursing care.

Teh solution, with which the commission has been shaking the pillars of medicine, is to put the registered nurse back at the patient’s bedside, where she can use her training. Some hospitals have already done this, including Rush-Presbyterian-St. Luke’s Medical Center, University of Chicago Hospitals, Good Samaritan Hospital in Downers Grove, and Evanston Hospital.

“Most nurses we talked to are frustrated. They don’t want to be supervisors,” Schaffrath says. “They prefer hands-on nursing in the Florence Nightingale tradition. They want to walk cot to cot, tending to and cheering on the patients.”

Schaffrath credits Marie Manthey, 42, a fiesty former Chicagoan and now vice president of patient services at Yale-New Haven Hospital in Connecticut, for blowing the whistle on nursing. She has advocated for the “return to the bedside” alternative in articles in several prominent medical journals.

As a registered nurse for 22 years, Manthey has had an inside look at the failings of her profession.

“Registered nurses have become faceless people, and it’s the system’s fault,” she says. “Nursing has become extremely production-oriented with very little concern for human needs. Most nurses are embarrassed about that. They say, almost apologetically, ‘Well, I’m just a staff nurse,’ which equates to, ‘I’m just a housewife.’

“But if nurses got their identity back,” Manthey says, “they’d be a proud people again. Then they’d be saying, ‘Hey, wait a minute. I am a staff nurse. I am an important person.”

“Nurses are supposed to be in the thick of things,” Manthey says firmly.

Manthey has coined her remedy, “Primary Nursing” a system whose main goal is just that — to get the nurse to provide total nursing care to a patient during their hospitalization. That means the same nurse does all the work for a patient from admission to discharge.

“The Nurse and the Patient get to know each other,” Manthey says.

With Primary Nursing, the nurse takes over many tasks she used to assign her aides.. because they’re all relevant to patient care.”

/ end content on front page of article, clip 1of2

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For further content from this article, see clipping number 2, and/or let us know if you’d like us to post further excerpts here.

Isn’t it amazing to look back and remember the days when Nursing was at that factory-process level??

A Labor Day reflection: CHOICE AT WORK! September 1, 2014

Posted by mariemanthey in Inspiration, Values.
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I am one of the lucky ones….I knew nearly all my life that I wanted to be a nurse. When I was 5 years old, I was hospitalized for a month. During that period I truly felt abandoned by my parents and worse yet – when they did come – a very painful procedure was performed on me each time. The only positive moment during my stay was when a nurse named Florence Marie Fisher colored in my coloring book. For reasons only known to God, that meant to me that she cared for me….in the fullest sense of that word care.
I knew from then on that being able to do that for another person was exactly what I wanted my life to be about…..and I’ve never looked back!
What made it full of wonder is that I have been able to learn so much about how to live from my work. A beautiful framework for living came through my work when I was involved in the original development of Primary Nursing. The Primary Nursing framework builds the concepts of Responsibility, Authority and Accountability (RAA) into a dynamic whole that can serve to correctly inform the proper relationship among people….the proper structure for an organization….the proper content of a job description.

When each of those three elements – Responsibility, Authority and Accountability – are viewed in their proper sequence, functionality is enhanced. When Responsibility is legitimately allocated, Authority commensurately delegated and Accountability mechanisms are designed for recognition and education (and not for punishment)….then all aspects of an activity can be optimally functional, and personal relationships can be healthy.

But the most important thing I finally learned (sometime in my mid-forties) is that these same elements are at work in my life. The moment I call my epiphany occurred with a blinding flash of insight…..during which I instantly saw that as long as I blame someone else for whatever is wrong in my life, I am not accepting responsibility for myself. I decided to learn how to change that, and I have never found it necessary to feel victimized by any person or situation or institution again.
What does all this have to do with work? I believe we all have choices every day about all aspects of our work …..and that the choices we consciously (and unconsciously)make have the power to either expand our spirit….or to destroy it. I am continually amazed at how many people tolerate working in dysfunctional systems …..or in toxic workplace cultures.  I know there are many factors operating that may reduce one’s awareness or perception of choices. Nevertheless, I have come to believe that even in the most oppressive environments…consciousness of choice instead of focus on victimization is the key to being able to grow spiritually.
Ultimately, I think the real lesson to be learned is that we have a choice to manage ourselves…..or not. Self management means being aware of the importance of healthy interpersonal relationships. Open communication (no back-biting) functional trust and mutual respect are the three key ingredients to healthy interpersonal relationships. Open communication means taking the time to learn the tactful way to talk about difficult issues with co-workers….it is a skill we can choose to learn. Trust is a choice we need to be willing to risk giving…..because withholding it breeds only more mistrust….and mutual respect requires the judgment to see everyone (at all levels of status and education) as being of equal importance to the overall workplace morale.

And I have learned that morale influences the quality of the product (nursing service) more that any other single or combination of factors. In my world that means that the morale of a nursing unit staff will have more impact on the quality of care patients receive than does any other single or combination of factors. And morale is solely determined by the way staff members treat each other in the context of workplace realities, including the reality of more work to do than time available.
These incredibly valuable lessons came to me from my work experience…..and they dovetail completely with what I have learned in recovery.
Consciousness of choice ….of how to respond to my co-workers….of how to be present in my work…. of my values of integrity and authenticity…all of these and more are the opportunities of learning and growth I have received through my work. And I know that all of this came about because Florence Marie Fisher colored in my coloring book when I was five years old. She created a caring relationship with me…..and permanently influenced my life.
She never knew that. I published a book about Primary Nursing in 1979, and dedicated it to her. The publishers tried to find her, but where unable to. Recently I came across those onion-skin copies of the publisher’s letters to a couple of State Boards of Nursing trying to find her and remembered that they were unsuccessful in locating my Florence Marie Fisher. But I thought to myself that afternoon few months ago……Google! And so I googled her and found her obituary…which also listed her survivors. I have since had the pleasure of meeting her son and grandchildren and telling them about the impact she had….not only on my life…but also on my work, which has in turn influenced the experience of nurses and patients throughout the United States and internationally. Of course they had no idea…..her simple act at work of coloring in my coloring book was a sublime act of co-creation. As nurses we can all find ways to choose to color in a coloring book. It is a choice we have to make, individually, and repeatedly. It is a choice that will not be documented….cannot be charged for….and that has a major impact on the lives of at least two people, the patients we care for and on ourselves. The choice to ‘be with’ the patient, instead of just ‘doing for’ changes the nursing experience for each individual who experiences this choice.

Happy New Year January 2, 2011

Posted by mariemanthey in Professional Practice, Values.
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One of my New Year’s Resolutions is to post on the blog more often and use it for the kind of conversations that promote healthy interactions and pride in our profession.

One way I want to do that is to encourage nurses to reflect deeply on the meaning of our work, as the connection to our deepest values helps energize our work. It is rewarding to an individual nurse to appreciate deeply the privilege we have in alleviating pain and increasing comfort at any and all levels of our patient’s vulnerabilities. Experiencing this intrinsic reward is important for each nurse’s self-care.

Another  goal I have is to keep bringing up certain realities about staffing I call these “hidden truths”  that need to be acknowledged and understood by nurses and by the system.

  • nursing work is never done
  • nursing work is unpredictable
  • nursing work is uncontrollable (it is based on pt. acuity and  MD orders, neither of which nurses will ever legitimately control
  • there is always more work to do than time available.
  • prioritizing involves deciding what NOT TO DO when there is more work to do than time available.  The truth is there has always been and will always be more work to do than time available.

More of my thinking on this topic is in Creative Nursing Journal, Vol 15, Number 2, 2009.  The article is entitled, A Brief Compendium of Curious and Peculiar Aspects of Nursing Resource Management.  It is time for staff nurses to quit driving to work fearing they will be short-staffed and driving home at the end of their shift angry because there wasn’t enough help.

Finally, I encourage you to view this short video. It is meaningful for nurses and people at many different levels of being.

Happy New Year!

http://www.ted.com/talks/brene_brown_on_vulnerability.html

New: A First Salon in Elgin, Ontario, Canada March 16, 2010

Posted by mariemanthey in Nursing Salons, Professional Practice.
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Last month I visited a hospital in Elgin, (near London) Ontario, Canada.  A group of nurses there converted a standard large conference room into a lovely warm living room environment.  They set up comfortable over-sized chairs, used floor and table lamps for warm lighting, and even rented a fireplace. Delicious food was served and the environment was perfect for a Salon.  Nurses from around the region and different walks of nursing were invited.

These Salon experiences are always amazing  to me.   As soon as someone first answers the question, “What’s on your mind about nursing tonight?” the energy starts to flow, issues come forward, and the magic begins. Believe me it is not all sweetness and light. The dark realities, and hard truths about our work are all brought out. And they are not ignored. What happens by the time we  do the around-the-room checkout, is that the incredible, rich and rewarding aspects of nursing return to our consciousness and everyone feels better.

In this case, in addition to the usual issues re. workload and staffing, morale and leadership (etc…) this time, in the presence of many students, there was an open and frank discussion about how senior nurses feel occasionally about being preceptors.

After a serious discussion, both students and older nurses said they now understand each other better. Students caught on that nurses’ unmanageable stress effects everyone and not just them personally.  New approaches to precepting were also discussed. The check out comments reflected a completely different energy than was there earlier.  This is a process that is working. Let’s keep it growing!

HAPPY NEW YEAR January 1, 2009

Posted by mariemanthey in Inspiration, Nursing Salons, Values.
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January One, Two thousand and nine.

What will this year bring?  Despite the economic down turn, which is undoubtedly affecting every single one of us negatively  in some way, there is the paradoxical feeling of HOPE  — for the future, the world, this country, health care and … the nursing profession.

The downturn is scaring new grads who entered school expecting life-long job security; only to find that in some regions low census numbers require staff reductions, lay-offs and empty positions not being filled. Those of us who have lived through these ups and downs  know this is temporary, but that doesn’t help a new grad with 30-50 K in school loan debt.   They need HOPE in the future job market.

HOPE. We all know the health care system is broken. We know we spend too much money on many things and not enough on other things, all because of reimbursement decisions made by someone somewhere. As the changes in the system come down the pike, I pray we as a community of health care workers find a strong voice to help the decision makers use our knowledge and skills to the maximum in order to improve the health of Americans and the humanity with which are sick are cared for.

As readers of this blog know, I am very excited about the potential for Salons to help heal nurses and to strengthen the contribution every nurse makes every day. I think our conversations help us think creatively about how we can better cope with stress and be a positive force for the health of society and to create healthy workplaces.

My personal HOPE for 2009 is that we have an astronomical increase in Salons — that they start up in every corner of the country. That besides purely nursing salons, another type starts up: interdisciplinary salons. First for doctors and nurses. For us to learn about each other as people so that our role relationships on the job can be healthier.

I am asking every who is currently running a Salon, or planning to start one, to please let us know through the blog or email me personally, so I can begin tracking the spread of this idea. My email can be accessed by clicking on my picture on the CHCM website (chcm.com).

We are moving up to four a month here in the Twin Cities.   We have a calendar posted on the University of Minnesota,  STTI chapter website and people can RSVP just by clicking a button. This is still just beginning, but I think we are creating a model that will help others.

2009. Just think of it. A New President. New problems. New solutions. HOPE.


The Latest Salon Report November 2, 2007

Posted by mariemanthey in Academia, Nursing Salons, Values.
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Last night we had our monthly salon at my home. About half the group was new and the other half had been here before. This time only one student nurse came and one fairly new graduate working as a staff nurse and 3 attendees were not nurses, one teaches at health related topics at a local college, one is a retired physician I have known for a long time and the other was a visitor from Iceland who wanted to see how a salon worked. Most of the rest were middle-aged staff nurses and nurse managers from various hospitals around the Twin Cities.

Although many topics were raised during the initial check-in, we ended up focusing on a wide-ranging discussion related to staffing/resource issues, social justice and inequities in the health care system so often part of the every day life of a nurse.

A manager at a local ER told about three patients who died on the floor of the ER vestibule, collapsing as soon as they arrived, having stayed away from care until the last possible moment because they have no insurance.  She also told of a man who cut his leg and waited for a friend to drive him to the ER as he couldn’t afford an ambulance. This man had an arterial bleed and had lost enormous amounts of blood before he arrived. In this ER visits are increasing astronomically while care hours/visit are continuously reduced to increase margins.

A NICU nurse talked about the cost of caring for multiple birth babies (5 or 6) the result of infertility treatments who stay in NICU’s for months. Often staffing throughout their life is 1:1 or 2 nurses/baby. The last group six births resulted eventually in one baby actually living. A nurse manager of a medical ICU talked about the hundreds of thousands of dollars spent during the last few weeks or months of care for catastrophically failing people in their nineties.

The student is now in her public health rotation and wonders why the savings created by keeping people healthy isn’t part of the economic equation.

This may sound like an overall pessimistic evening, but it was far from it. I can’t really explain what happens at a Salon, but we seem to be able to connect with our positive values and experience strength just from knowing each others’ experiences and values.

I am definitely sensing from this discussion and others that have been occurring recently that the “Voice of Nursing” is in the process of become loud enough to be heard. I’m not sure just how this will happen, but I sense a real strengthening of our commitment to make the world a better place coupled with an awareness that we are strong and can be stronger.

I am encouraging all of us to initiate conversations about social justice in all of our professional meetings. Specialty organizations looking for great programs for their meetings could do what the Zeta chapter of Sigma Theta Tau did here last week when three nurse leaders presented brief comments about social justice issues in their workplace. The discussion that ensued was energizing and confidence-building. This concept of social justice has a rippling effect that continues to strengthen with each new discussion.

…About naming and claiming the RN Role September 25, 2007

Posted by mariemanthey in Creative Health Care Management, Professional Practice.
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A recent dialog among Creative Health Care Management (CHCM) consultants resulted in an internal communication I have decided to share with the blog.  As always, your comments are welcome.  (Also…how do you like the new look?)

This communication about Relationship-Based Care started with a question from Mary Koloroutis via email within our company.

From Mary to all Consultants: 

An issue that continues to surface in the RBC Leader Practicum and in some interactions I have with nurse managers and unit practice council members is that as much as they would like to implement a primary nursing model of nursing practice, that the acuity, staffing realities (ratios and schedules), and the geography of the unit, create huge barriers to their getting there.   How are client managers addressing this?

Jayne Felgen, president of CHCM, sent this reply:

From Jayne Felgen to Mary, copied to all consultants:

It IS the HEART of  RBC…accepting a responsibility relationship for the patient’s care throughout their stay on that unit is the ultimate expression of professional practice.

I’m naming it and claiming it! So, the work of the Unit Practice Council is to review current scheduling and assignment practices (Work Complexity Assessment) looking especially for fragmentation reduction opportunities…to make it more likely that the nurse who agrees to perform the admission activities might also chose to be the primary nurse.

So, like an attending physician retains responsibility despite multiple consultants, or her/his day off, so do nurses create an infrastructure in which they claim responsibility for 1-2 patients among their typical assignment. Once those responsibilities are “owned”, the nurses communicate in more deliberate ways, proactively, more precisely…not unlike a parent leaving explicit instructions for the sister who’s caring for the kids while parents have a get-away. When they return, they resume care. While they’re gone, they’ve anticipated every possible need.

Having said that, 100% compliance with this may be impossible, but, we urge them to shoot for it because it’s the right thing to do. And, using Appreciative Inquiry (AI) principles, learn why it worked when it worked, and then do more of that.

Until we accept this responsibility at this level, we’ll continue to ignore the crazy schedules (1 day on, one off, 8-10-12 hour shifts reporting on/off to each other, robbing Peter-to-pay-Paul floating practices, being married to geography rather than relationship, and other craziness that produces high variability and low professional reward/satisfaction in our systems.

I am abundantly clear that we must step up and claim our practice…not by tasks or shifts, but one relationship at a time…nurses, therapists, social workers, pharmacists, etc. It’s the professional v. technical dialog again.

Remembering the Simple Truths June 19, 2007

Posted by manthey in Creative Health Care Management, Values.
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John Nelson — nurse researcher, president of Healthcare Environments and CHCM adjunct faculty —  frequently shares data with us about the outcomes of our work with our clients. One hospital implementing Relationship-Based Care found that a richer skill mix decreased the dollars per Adjusted Patient Day, decreased ventilator-associated pneumonia and decreased patient falls with injury. John would hasten to add that this is a statistical correlation that does not indicate causality, but only a relationship between variables. I think the more we learn how to interpret and correctly discuss this kind of statistic, the better able we are to explain the importance of adequate staffing.

After the “reengineering” of nursing in the nineties (which had nothing to do with nursing, and everything to do with saving money), we lost sight of simple truths and replaced our authentic experience with “grids” which supposedly save money but which in reality wreak havoc with common sense.

Some truths we need to reclaim are:

  • Skill mix should be related to acuity not to a financial goal.
  • Changes in patient census should drive changes in total FTEs.
  • Continuity of assignment increases productivity (having the same patients two days in a row increase productivity by approximately 25%).
  • Use of support staff improves when delegation is based on trust. Working together builds trust, so pairing and partnering leads to the best use of NAs and LPNs.
  • Staff should only be pulled off their home unit when not to do so will have DIRE consequences. It should never be done just “balance the numbers”.
  • Morale of the staff determines quality of care. Morale is a function of how staff members treat each other.

Introducing Relationship-based Care is an excellent way to re-introduce these simple truths and return our profession to “common sense management”.

Using Licensure to Create Role Clarity August 4, 2006

Posted by manthey in Academia, Professional Practice.
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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 it doesn’t give any hint to the complexities or potential affect on the outcomes. There must be a better way to describe how intertwined all of this is. People latch on to ratios because it’s concrete, but it minimizes the important stuff. Staff mix is another area of struggle. Not only in terms of RN/LPN, but mix of RN’s with differing educational preparation. In Vermont, the number of both LPN and ADN programs & graduates outnumber BSN. We are creating new issues on top of those we already have.

I agree that the “ratios” is misleading … and that the variety of entry points into practice is increasingly confusing. We need to analyze work complexity in terms of knowledge and skills needed for safe Nursing Interventions in a particular patient population that are sophisticated enough that also take into account the workplace relationships that impact utilization of support staff. I think that by going back to the basics over and over again (knowledge and skills coupled with effective interpersonal relationships) … rather than trying to differentiate by broad credentialing, we will be able to see the forest for the trees.

For example, when an LPN works as a care pair or a care partner with the same RN over a period of time, his/her contribution to the RN’s workload changes substantially. Likewise, coupling a new AD or BSN with an experienced clinician rather than having them work straight nights significantly increases the speed with which they get on board.

Personally, I like the structural clarity that comes from licensure delineations to guide differentiation … and this leads me to my current absolute conviction that the major difference between RNs (of all types of preparation) and LPNs (and other skilled technicians) lies in the decision-making role. RNs are licensed to make decisions about the amount degree and kind of care patients will receive. Period. No one else has the license to do so. When we step up to the plate and incorporate that in job descriptions, work expectations, nursing education, etc, I think the role of support staff (and appropriate skill mix for any unit) consequently will be clarified. Nursing is a practice profession and RN’s need to be able to combine care giving with care management in order to acquire the complex knowledge about their patient necessary for good decision making

Finally, I guess the diffusion of educational programs (now with the post-baccs, practice doctorates, etc) increases the challenges we will be facing in the coming years. I hope that by focusing on knowledge and skill requirements for patient care, within the structure of licensure healthy workplace cultures, we will have the guidance necessary to maximally utilize the knowledge, skill and talents of every member of the staff. I am optimistic that if we keep focusing on what is right for patient care, what is fundamentally sensible and legally appropriate; we will be able to minimize the confusion of the future challenges to resource utilization.

Getting Smart about Workload Issues July 21, 2006

Posted by manthey in Leadership.
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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.