An Interesting Thread: Productivity

core0 · Oct 9, 2011

**Disclaimer: I deem this an "interesting thread" only in a sassy jab to my friends in other less interesting threads **
Anyway, perhaps it is the masters classes sinking into my brain but I have been thinking a lot about staffing.
A little background: I have a lot of interest in working with new graduate nurses and helping reduce burn-out when I have completed my MSN. I have noticed that one of the biggest complaints from nurses are staffing ratios. I have discussed this with bosses and managers while I was nursing and was often met with resistance in reference to productivity. It seems there is a delicate balance between increasing staff and keeping productivity.
Recently I asked a co-worker, of whom was complaining about how terrible her night was, what would have made her night easier. She responded with an overwhelming "well of course more staffing would help". I know from experience on this floor that they run 6:1 with one tech. It was often agreed that the patient load was ok if we could have a second tech (like the old days before our hospital ran out of money). It was argued that with two techs there was a decrease in productivity and they wound up sitting around a lot. I understand the knee jerk reaction to call for more staff, but is that really the answer?
Now each hospital is different and I do understand, especially from some of the threads on here, that places ARE painfully understaffed.
How do you feel, related to your personal situation, patient ratios affect productivity? Where is the tipping point on staffing where it negatively affects productivity? How do you encourage productivity when you have adequate staffing?
Tait

They are really using the wrong term. Classically productivity is a measure of efficiency in production. Usually its measured as a ratio of what is produced to what is required to produce it. If you were making Cars its a pretty easy ratio to compute. For nursing not so much

If you look at the product as "nursing" and the number of nurses required to "produce" it you would find the normal view of a hospital toward "productivity". However this misses the entire point. In theory nursing would be most "productive" with one nurse and an infinite number of patients.

In reality productivity should probably be measured in a more complex manner. For example you could start out with the number of nurses plus ancillary staff necessary to complete all nursing tasks in a timely manner. You could then add and respond to any emergencies in a rapid manner. You could then add and accept admissions and other changes in nursing acuity in an appropriate manner. You can see the problem with defining productivity. In reality a well functioning productive nursing unit has to do all of this and more.

So if you want to be able to respond to emergencies and admissions you have to have some inherent unproductive time. Part of the problem is what happens with that unproductive time. If people spend all their time on facebook then the powers that be look to take away that unproductive time by taking away staffing (the only real input they have). If that time is spent on buffing and tuning and making the patient "happier" then thats a different matter.

The current reality is that you are going to have to define productivity with a measurable metric. Whether thats employee satisfaction, patient satisfaction, decrease in adverse events or some other measurement is where the rubber meets the road.

dudette10, MSN, RN · Oct 9, 2011

When a unit is chronically understaffed, people lower their standards and cut corners because they have to. For example, they go without labeling their IV tubing because they have 8000 more important things going on. They take too long to answer call lights because there are too many call lights and not enough staff.
When staffing improves, people are used to meeting those lower, well-established standards. They continue to leave their IV tubing unlabeled. And since it's usually hectic and it usually takes about ten minutes to answer a call light, ten minutes becomes an acceptable amount of time to keep a patient waiting- even when it's not busy.
At that point, someone needs come in, re-set high standards and follow up to make sure they're being implemented. They also need to make sure staffing stays reasonable enough to meet those new standards or it's back to square one.

I agree with everything you've said. As for your second paragraph, do I dare say these two words: work ethic.

Esme12, ASN, BSN, RN · Oct 9, 2011

I wrote something about this in another thread, but I was talking about the time needed for admits and discharges--things that aren't taken into account with ratio staffing. There has to be a better staffing model to use!

You know I have worked with acuity models.....the problem is it just doesn't quite fit. The computer programs at this particular facility that had an "acuity" model......had the model set to the budget and added the acuity but didn't really change the overall ratio's. The thing about data....it can be manipulated to be whatever you are seeking it to say..... :rolleyes:

StrwbryblndRN · Oct 9, 2011

Just too much to do just to keep up with hospital policies, trying to maintain productivity and keep pt safe it not an easy task.

Ruthfarmer · Oct 9, 2011

It never balances fiscally anymore as acuity and the "heaviness" of the patients doesn't translate onto paper. Most budgets are figured on fixed numbers......X amount of staff for X amount of patients. Any variance outside that "number" skews the budget and you go over "allotment". I don't think the patient satisfaction "reimbursement" movement will help because the heaviest patients that require the most care usually can't fill the forms out. PRN"s do save some on not having benefits but that often doesn't defray the costs to go over variance. Some PRN pools utilize "floating help", althought this is usually just for care, and the float "charges " their time spent to the unit which defrays the "cost".
What I really wonder is....does the coporate model really work when the human factor, illness and acuity is thrown a part of the model. I don't think it does. Human illness is unpredictable and the need for how much or how little care is required is diffucult to assess........it typically doesn't translate well onto paper. If cost and budgets can reflect the reality of what it takes to care for patients in not only a timely manner but with how hard it is, I think what is done and how long it takes would in the long run it would be profitable. It has been proven staffing equals positive outcomes, less post op infection, lower pneumonia rates, faster recovery times and less readmittance......all that would lower over all costs and raise reimbursement profit........but it would be an expense at first, and that I'm not sure the CEO's would buy in the long run.....Just my

Bravo!

Flo., BSN, RN · Oct 9, 2011

I think the problem is that management tries to squeeze every ounce of "productivity" out of the nurses. They want to see the nurses running the whole 12 hrs.

I feel it is actually more productive to allow for a few lulls during the day. It allows one to recharge and reprioritize. I think it would also contribute significantly to nurse satisfaction and retention rates.

evolvingrn, BSN, RN · Oct 9, 2011

One thing i have to say is..........all patients are not created equal. a 1:6 ratio may be a breeze one night and a 1:3 ratio may be unmanagable the next. I think productivity is great and that is where a charge nurse comes in ....by directing in downtime work for the techs when things slow down but hands down I think if you want to keep your staff there should be occasional downtime.

Been there,done that, ASN, RN · Oct 9, 2011

When a unit is chronically understaffed, people lower their standards and cut corners because they have to. For example, they go without labeling their IV tubing because they have 8000 more important things going on. They take too long to answer call lights because there are too many call lights and not enough staff.
When staffing improves, people are used to meeting those lower, well-established standards. They continue to leave their IV tubing unlabeled. And since it's usually hectic and it usually takes about ten minutes to answer a call light, ten minutes becomes an acceptable amount of time to keep a patient waiting- even when it's not busy.
At that point, someone needs come in, re-set high standards and follow up to make sure they're being implemented. They also need to make sure staffing stays reasonable enough to meet those new standards or it's back to square one.

Label .... tubing.... bawhahahhah! Change tubing???? on a good day.

ErinS, BSN, RN · Oct 9, 2011

Productivity is something management talks about in the hospital setting, but not something that is really discussed or defined with hospital staff. In the homecare setting there is defined productivity for nursing. Generally nurses are expected to see 5 patients per day.

One of the things that is not being done in nursing is the use of staff at the top of their scope of practice. So we have an RN toileting people. I do not, as a nurse, mind toileting people. But you better believe if I am a manager and looking to save money and reduce staff costs, I do not want to pay a nurse $25 per hour to toilet people, when I could pay an aide $10 per hour.

Unfortunately, as nurses we can not just keep saying 'give us more staff'. We need to be able to reasonably discuss with management how they can save money by making sure they are not paying me to toilet my patients, to insert foley catheters, to answer call lights, and to turn people. They should be paying me to assess, plan, implement, and evaluate. Whatever can be done by an aide, should be done by an aide, what can be done by RT, should be done by RT. Nursing is THE most expensive cost in a hospital, and we should be utilized to our fullest potential. I am not saying that nurses should refuse to ever toilet a patient, but that we need to recognize that there is a better way to use our resources.

VICEDRN, BSN, RN · Oct 10, 2011

I personally scoff at the notion of productivity in a vacuum. I have a previous career as a paralegal behind me and I can tell you I never ran and ran like I do as a nurse. Yet, they look at productivity costs without considering recruiting and training costs for the constant turnover.

TriciaJ, RN · Oct 10, 2011

What is "downtime"? The last place I worked always had little educational projects and other nonsense to do during "downtime". Problem is, they never staffed for "downtime". They staffed for "running around like a fiend all day playing beat-the-clock". I was happy just to get a lunch break. Downtime? That word still makes my blood pressure rise.

Ayvah, RN · Oct 10, 2011

My favorite manager quote was: "I can't justify paying for more staff when you all have so much overtime!"

Great points have already been brought up - people cut corners to get by when understaffed. I agree that people should be having the work ethic to spend any extra time on improving safety and not cutting corners anymore. It has been very rare for me to see nurses sitting around doing nothing. And as was brought up before, having nurses pushed to the limit is not good for productivity as it increases burnout and turnover, and ups the safety risk when there is an emergency. The research shows over and over that nurse patient ratios are critical in mortality rate.

But there is no proper acuity tool out there that can really assess the 'human' factor, as that can change even hourly for patients. My second favorite manager quote is "Our new acuity tool showed that there needs to be more staff per shift, so we are changing the acuity tool" (these are true quotes!)

That is why I advocate for California style CNA/NNOC staffing, because at least that gives some legal ceiling on the number of patients. I never did feel safe when I had 12 patients myself, such as when another nurse was going to lunch.

I've been at hospitals where they tried different tactics such as a resource nurse, or a nurse that goes to each floor and asks what they can do to help, such as a dressing change here or there. But I have found with this method, time is wasted checking for what I can delegate, and explaining what to do. What really helps me far, far more, is having an admissions nurse. Admits that I have to do really mess up my whole shift - they come up in pain and have nothing ordered, and lots of questions, and I have to ask them a million questions myself before I can get them anything, and I'm constantly being interrupted by my other patients needing things. Its demoralizing to not being able to make them comfortable quickly because I'm always being pulled in so many directions, and an admit needs a good solid chunk of time to be able to set up properly.

The other critical thing is a strong charge nurse who knows the patients on the floor well and knows nurse strengths and weaknesses well, so they can properly distribute the patient load.

While there is no perfect solution out there, I think many places yearn for change.