I have 5 years management experience in ED and ICU and have recently become the manager of a 28 bed medical surgical unit. Current situation: Typically we have 1 unit clerk, 2 RN's, 2 LVN's, 2 CNA's, and a charge RN (who rarely takes a patient load). Monday through Friday we have a clinical supervisor RN who handles clinical issues, makes the schedules, performs evaluations and assists in the general flow of things.
The usual patient volume on the unit is a total of 14-18 patients. Other than a unit clerk from 6am to 10 pm, Usual assignments on both 12 hour shifts are: charge RN, no patients; 2 LVN's, 4 to 5 pts each, 2 RN's, 4 to 5 pts each; two CNA's who split the patient load. Also, ther is no clear involvement of an RN in every patients care on every shift except at admission. The LVN's work very liberally under a charge RN who does not appear to have much involvement in the care.
My productivity shows I am at least 4 people overstaffed every day. I know that drastic changes will result in extreem upset with the staff. I also have about 5 new RN's (2 with 1 year exp, 3 with less than 6 mos exp). My thoughts are to streamline the unit clerks role by implementing systems to be more organized and teach new tricks to be more supportive (there is a lot of problems currently with this). Then to reduce the amount of re-work in all ways possible (like not having to chart things twice and walk the entire length of the unit for washclothes). Our CNA's are excellent and provide great patient care. I have been meeting the staff and introducing myself in an attempt to form new relationships. I also manage the house supervision group and have great support from them.
My first concern is the RN involvement in each pts care. Secondly, I am overstaffed. I feel a team approach is best and I am thinking of changing the care to a real team approach. My thoughts are:
7a to 7p (75% of addmissions and 68% of discharges occure here)
1 unit clinical supervisor (8-5, mon-fri)
1 Unit Clerk (in at 6am)
1 RN admission, discharge nurse who would be responsible for:
Charge responsibilities when the clinical supervisor is off the unit
Comprehensive admission assessment
Begins standard diagnosis based patient education
Assist in discharges when available
Acts as resource nurse to other staff
Makes admission bed assignments
Each team for 8 to 10 patients:
1 RN-Overall care manager (team leader)
1 LVN-assigned duties like meds, dressing change, focused assessments
1 CNA (shared by 2 teams)-vitals, meals, assist with ADL's
As census drops I would keep a team of 1 RN, 1 LVN for 8-10 pts and another RN to take up to 4 patients with charge responsibilities (keeping the admission nurse as long as the census is at least 14).
7p to 7a would not have the unit supervisor or admission nurse but would have a unit clerk till 11pm and a CNA as long as the census stays above 15
This matrix will keep us close to guidelines (slightly over)
How does this sound? Any suggestions? Any suggestions on getting staff buy-in?
thanks in advance for sharing your thoughts.