STAFFING AND SCHEDULING 221
Medical units usually have the heaviest care needs in the morning hours, when patients’ daily care needs are being met and physicians are making rounds. On skilled nursing and rehabilitation units, care needs are greatest before and immediately after mealtimes and in the evening hours; during other times of the day, patients are often away from the unit and involved in various therapeutic activities.
In contrast with the medical, surgical, critical care, and rehabilitation units that have definite patterns of patient care needs, labor-and-delivery and emergency department areas cannot predict when patient care needs will be most intense. Thus, labor-and-delivery and emergency department areas must rely on block staffing to ensure that adequate nursing staff are available at all times.
Here’s what a nurse manager told a new nurse candidate when asked about the nurse to staff ratio:
“On the surgical step-down floor, we most typically staff at a one-RN-to-four-patient ratio. We also plan to have a charge nurse who is not taking patients to assist staff with extra tasks and needs. On occasion, a nurse may have three patients or five patients. We always work to be flexible, looking at the acuity of the patients and the competencies of the staff who are working. During each shift, we reassess every four hours and as needed to ensure assignments are still appropriate and patient needs haven’t significantly changed, necessitating a reassignment of patients. We also have nurse aides on this floor. They help with vital signs, bed changes, baths, and ambulation. There is most typically one aide for every 8 to 12 patients. Also, a unit clerk answers the phones and greets guests. This team dynamic creates for great patient care.”
Block staffing involves scheduling a set staff mix for every shift. However, there may be trends in peak workload hours in emergency departments, when additional staff (RN, UAP, or secretary) beyond the block staff are necessary. Examples of peak workload hours within the emergency department may be from 6:00 p.m. to 10:00 p.m. to accommodate patient needs after physicians’ offices close, or from 12:00 a.m. to 3:00 a.m. to accommodate alcohol-related injuries. All these needs in patterns of care must be known when staffing requirements and work schedules are established. Data reflecting peak workload times must be continuously monitored to maintain the appropriate levels and mix of staff.
Scheduling Creative and Flexible Staffing Nurse shortages and current restrictions in salary budgets have made creative and flexible staffing patterns necessary and probably everlasting. Combinations of 4-, 6-, 8-, 10-, and 12-hour shifts and schedules that have nurses working six consecutive days of 12-hour shifts with 13 days off, and staffing strategies, such as weekend programs and split shifts, are common.
Flexible staffing patterns can be a major challenge and, in some cases, a mathematical challenge. However, once a schedule is established and agreed to by the nurse manager and the staff, it can become a cyclic schedule for an extended period of time, such as 6 to 12 months. This allows staff members to know their work schedule many months ahead of time.
The use of 8-hour and 12-hour shifts is fairly straightforward. Problems with combined staffing patterns may include:
● The perception that nurses don’t work full-time when they work several days in a row and then are off for several days in a row
● Disruption in continuity of care if split shifts are used (7:00 to 11:00 a.m.; 11:00 a.m. to 3:00 p.m.; 3:00 p.m. to 7:00 p.m.; 7:00 p.m. to 1:00 a.m.; 1:00 a.m. to 7:00 a.m. shifts)
● Immense challenges for nurse managers to communicate with all staff in a timely manner
222 PART 3 • MANAGING RESOURCES
Advantages of using combined staffing patterns are that it:
● Better meets patient care needs during peak workload times ● Improves staff satisfaction ● Maximizes the availability of nurses
Ten-hour shifts provide greater overlap between shifts to permit extra time for nurses to complete their work; for this reason, they may increase salary expenditures. There are a few specialty units in which 10-hour shifts would be cost-efficient: postanesthesia recovery areas, operating departments, and emergency departments are examples.
Self-staffing and Scheduling Some hospitals have instituted self-staffing. This is an empowerment strategy that allows unit staff the authority to use their backup staffing options if the patient workload increases or if unscheduled staff absences occur. Likewise, staff can and must go home early if the patient workload decreases.
Self-scheduling allows the staff to create and manage the schedule. Self-scheduling can be positive for the staff and for the manager, but attention must be paid to balancing unit needs with individual requests (Bailyn, Collins, & Song, 2007). Whether the schedule is determined by the manager or by staff, the schedule can be transparent for all staff by posting it online (also see section on automated scheduling). In this way, the organization can demonstrate fairness in scheduling and leverage staff expertise in an equitable manner.
Shared Schedule A new tool currently in use is a shared schedule. Two people share one full-time schedule by splitting the day of 12 hours into half days of 6.5 hours each, alternating morning and afternoon shift. This allows nurses who might not be able to work the full 12 hours to share the shift.
Open Shift Management Open shift management is an innovative technique to allow an organization’s staff to self- schedule additional shifts (Bantle, 2007). With the schedule posted online, as described above, staff members can select assignments and shifts that fit their expertise and accommodate their personal schedules. This strategy is especially valuable to health care systems with several hos- pitals in which nurses from one hospital can select assignments at any of the others. The organi- zation itself could establish an internal staffing pool (see next section).