Nursing Leadership & Management Patricia Kelly-Heidenthal 0-7668-2508-6 Delmar Learning Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Chapter 12 Effective Staffing Delmar Learning Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Objectives Upon completion of this chapter, the reader should be able to:  Discuss utilization of patient classification systems data by the staff nurse and the nurse manager. Develop a staffing pattern for a critical care unit with 10 patients. Evaluate staffing effectiveness on an inpatient unit using two patient outcomes. Compare and contrast models of care delivery. Discuss the role of a case manager versus a unit staff nurse. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Determination of Staffing Needs: Key Concepts Full-time equivalents (FTEs) are a measure of the work commitment of a full-time employee. Hours worked and available for patient care are designated as productive hours. Hours for benefits such as vacation, sick time, and education time are considered nonproductive hours. Direct care is time spent providing hands-on care to patients. Indirect care is time spent on activities that are patient-related but are not done directly to the patient. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Nursing Hours per Patient Day Nursing hours per patient day (NHPPD) is a standard measure that quantifies the nursing time available to each patient by available nursing staff. NHPPD reflects only productive nursing time available. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Patient Classification Systems A patient classification system (PCS) is a measurement tool used to determine the nursing workload for a specific patient or group of patients over a specific period of time.  Patient acuity is the measure of nursing workload that is generated for each patient. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Factor Systems Use units of measure that equate to nursing time Attempt to capture assessment, planning, intervention, and evaluation of patient outcomes along with written documentation processes Are the most popular type of classification system Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Factor Systems Advantages Data readily available for day-to-day operations Provide information against which one can justify changes in staffing requirements Disadvantages Create an ongoing workload for the nurse in classifying patients every day Problems with “classification creep” Do not capture patient needs for psychosocial, environmental, and health management support Calculate nursing time based on a “typical” nurse Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Prototype Systems Allocate nursing time to large patient groups based on an average of similar patients  Advantage Reduction of work for the nurse by not classifying patients daily Disadvantages No ongoing measure of the actual nursing work required by individual patients No ongoing data to monitor the accuracy of the preassigned nursing care requirements Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Next Generation of Classification Systems New models are being developed, e.g., Providence St. Peter Hospital in Olympia, Washington. Models are moving away from tasks to indices of professional components of nursing care and patient outcome. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Utilization of Classification System Data Patient classification data is a valuable source of information for all levels of the organization.  Staff and managers use acuity data on a day-to-day basis to plan staffing for the next 24 hours. In many organizations, a central staffing office monitors the census and acuity on all units and deploys nursing resources to the areas in most need. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Utilization of Classification System Data At the unit level, acuity data is essential in preparing month-end justification for variances in staff utilization. At an organization level, acuity data can be used to cost out nursing services for a specific patient population and global patient types. Acuity data is also used in preparation of the nursing staffing budget for the upcoming fiscal year. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Considerations in Developing a Staffing Pattern Benchmarking is a management tool for seeking out the best practices in one’s industry so as to improve one’s performance. Benchmark planed NHPPD against other organizations with similar patient populations. Few regulatory requirements have related to nurse staffing, but this is changing. Several states are considering legislation to mandate nurse staffing levels in emergency departments and critical care units. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Considerations in Developing a Staffing Pattern Skill mix is the ratio of RN staff to other direct care staff such as LPNs and UAPs. The skill mix of a unit should vary according to the care that is required and the care delivery model being utilized. Staff support Nonnursing staff must be in place to support the operations of the unit or department. Historical information What has worked in the past? Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Establishing a Staffing Pattern A staffing pattern is a plan that articulates how many and what kind of staff are needed by shift and day to staff a unit or department. It can be generated by: Determining the necessary ratio of staff to patients, then calculating nursing hours and total FTEs 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 Using a combination of both methods Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Inpatient Unit An inpatient unit is a hospital unit that is able to provide care to patients 24 hours a day, 7 days a week. Using a staffing plan tool, plot the number and type of staff needed during the week and weekend for 24 hours a day for the number of patients you expect to have.  Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Inpatient Unit Determining the number of FTEs needed to meet the staffing plan: Calculate number of FTEs needed per day Calculate amount of additional staff needed to provide for days off and benefit time  Provide additional FTEs to cover benefit time away from work (vacations, education, orientation, etc.) Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Determining the FTEs Needed to Staff an Episodic Unit Episodic care units are units that see patients for defined episodes of care; dialysis and ambulatory care units are good examples. Start with an assessment of the hours of care required by the patients. Add FTEs to cover days off and benefit time. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Scheduling Scheduling of staff is the responsibility of the nurse manager. There are several issues to consider in scheduling staff. Patient need Measured by the patient classification system Staffing pattern must plan for acuity of patients and support having staff working when work needs to be done Changes when types of patients change, resulting in change in staffing requirements  Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Scheduling Volume Patient volume numbers reviewed for peaks and valleys in the census and patient acuity Scheduling adjusted as necessary Experience and capability of staff Different degrees of knowledge, experience, and critical thinking skills Number of inexperienced staff (add hours) Number of experienced staff Need for staff with special skills Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Scheduling of Staff The nurse manager is responsible for ensuring that appropriate numbers and kinds of staff are on hand to care for the patients being served.  Shift variations 12-hour shifts Weekend programs  Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Scheduling of Staff Impact on patient care Possible disruption of continuity of care Weekend staff should be familiar with patients and recent care events  Financial implications Weekend programs are more expensive than traditional staffing patterns They are a recruitment and retention tool for nursing leadership Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Self-scheduling Self-scheduling is a process whereby staff on a unit collectively decide and implement the monthly work schedule. This process must be done within boundaries: Establish staff committee reporting to nurse manager. Establish roles and responsibilities of committee members. Establish general boundaries. Include and educate unit staff in development of self-scheduling process. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Self-scheduling Educate staff as to the process, their responsibilities, and the impact of their decisions on staffing. Ensure that staff is committed to providing safe staffing on all shifts for their patients. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Evaluation of Staffing Effectiveness Patient outcomes and nurse staffing Studies have found consistent significant relationships between nurse staffing and some patient outcomes. Certain outcomes are affected negatively when nurse staffing or skill mix is inadequate. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Evaluation of Staffing Effectiveness Nurse staffing and nurse outcomes Effect of staffing on nurse performance should also be considered. Track staff’s perception of staffing adequacy. Provide ability for staff to communicate concerns in written and verbal form. Track recommended staffing versus actual staffing. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Models of Care Delivery Care delivery models organize the work of caring for patients. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Total Patient Care In total patient care, the nurse is responsible for the total care for her patient assignment for the shift she is working. The RN is responsible for providing care to several patients during a normal shift. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Total Patient Care Advantages Consistency of one individual caring for patients for an entire shift Patient, nurse, and family can develop a trusting relationship Nurse has more opportunity to observe and monitor patient progress  Disadvantages Nurse may look at the patient on a shift-by-shift basis rather than on a continuum of care Uses a high level of RN nursing hours to deliver care Costlier than other models Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Functional Nursing Functional nursing divides nursing work into functional units that are then assigned to one of the team members. In this model, each care provider is responsible for specific duties or tasks. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Functional Nursing Advantages Care can be delivered to a large number of patients Uses other types of health care workers when there is a shortage of RNs  Disadvantages Lack of continuity of care Patient may feel that care is disjointed Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Team Nursing Team nursing is a care delivery model that assigns staff to teams that are then responsible for a group of patients. A unit is divided into two teams, each led by a registered nurse. The team leader supervises and coordinates all of the care provided by those on the team. Care is divided into the simplest components and then assigned to the care provider with the appropriate level of skills. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Team Nursing A modular nursing delivery system is a kind of team nursing that divides a geographic space into modules of patients with each module having a team of staff led by an RN to care for them. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Team Nursing Advantages Maximizes the role of the registered nurse Nurse is able to get work done through others  Disadvantages Patients often receive fragmented, depersonalized care Communication is complex Shared responsibility and accountability can cause confusion and lack of accountability Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Primary Nursing Primary nursing is a care delivery model that clearly delineates the responsibility and accountability of the RN and places the RN as the primary provider of care to patients. Patients are assigned a primary nurse. The primary nurse is responsible for developing with the patient a plan of care. Other nurses caring for the patient follow this plan of care. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Primary Nursing Nurses and patients are matched according to needs and abilities. The primary nurse has the authority, accountability, and responsibility to provide care for a group of patients. Associate nurses care for the patient when the primary nurse is not working. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Primary Nursing Advantages Patients and families are able to develop a trusting relationship with the nurse. Accountability and responsibility of the nurse developing a plan of care with the patient and family are defined. Such a holistic approach to care, rather than a shift-to-shift focus, facilitates continuity of care. Authority for decision making is given to the nurse at the bedside.  Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Primary Nursing Disadvantages Cost is high due to the higher RN skill mix. The person making assignments needs to be knowledgeable about all the patients and staff to ensure appropriate matching of nurse to patient. Lack of geographical boundaries within the unit may require nursing staff to travel long distances at the unit level to care for their primary patients. Nursing time is often used in functions that could be completed by other staff. Nurse-to-patient ratios must be realistic. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Patient-centered or Patient-focused Care Patient-centered or patient-focused care models are designed to focus on patient needs rather than staff needs. Necessary care and services are decentralized and brought to patients; staff is kept close to patients in decentralized workstations. Care teams are established for a group of patients; within these teams, disciplines collaborate to ensure that patients receive the care they need. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Patient-centered or Patient-focused Care Advantages Most convenient for patients Expedites services to patients  Disadvantages Can be extremely costly to decentralize major services in an organization Some perceive model as a way of reducing RNs and cutting costs in hospitals Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Differentiated Practice Differentiated nursing practice is a care delivery model that sorts the roles, functions, and work of registered nurses according to some identified criteria, commonly education, clinical experience, and competence.  Nursing competencies are generally measured in three arenas: Technical skills Communication skills Management of care or leadership skills Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Differentiated Practice Advantage Nurses are allowed to work in specialized roles for which they were educated, leading to greater career satisfaction.  Disadvantages Nurses who have experience, knowledge, and capability to function beyond their original education may not be recognized. Organizations that have determined minimal educational requirements for RN positions may have difficulty in recruiting staff with the requisite credentials. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Patient Care Redesign Initiative that developed in the 1990s  Emphasis on redesigning how patient care was delivered Motivated by need to reduce costs Most effective when emphasis was on reducing costs while maintaining or improving quality of care Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Care Delivery Management Tools Initiatives to improve care and reduce costs arose in the 1980s and 1990s.  The federal government established diagnosis-related groups (DRGs) as a payment system for hospitals in 1983. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Care Delivery Management Tools In DRGs, the national average length of stay (LOS) for a specific patient type was used to determine payment for that grouping of patients. Hospitals looked to reduce LOS and reduce hospital costs. Clinical pathways and case management surfaced as significant strategies. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Clinical Pathways Clinical pathways are care management tools that outline the expected clinical course and outcomes for a specific patient type. Typically they are pathways that outline the normal course of care for a patient. Pathways are often done by day and for each day expected outcomes are articulated. Patient progress is measured against the expected outcomes. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Clinical Pathways Advantages Very instructive to new staff Save a significant amount of time in the process of care In most cases, improve care and shorten length of stay for the population on the pathway Allow for data collection of variances to the pathway Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Clinical Pathways Disadvantages Some physicians perceive pathways to be cookbook medicine and are reluctant to participate in their development. Development requires a significant amount of work to gain consensus from the various disciplines on the expected plan of care. Pathways are less effective for patient populations that are nonstandard, since they are constantly being modified to reflect individual patient needs. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Case Management Case management is a strategy to improve patient care and reduce hospital costs through coordination of care. Typically a case manager: Is responsible for coordinating care and establishing goals from preadmission through discharge Evaluates the patient’s outcomes daily and compares them to the predicted outcomes articulated in the clinical pathway Works with all the disciplines to facilitate care Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company

Copyright © 2003 Delmar Learning, a Thomson Learning company Case Management In other models, the case management function is provided by the staff nurse at the bedside. The case manager also collects data on patient variances from the clinical pathway and shares this data with the responsible physicians and other disciplines that participate in the clinical pathway. This data is then used to explore opportunities for improvement in the pathway or in hospital systems. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company