Horribly under staffed unit. What can be done?

quazar · Jan 12, 2017

I'll just be bluntly honest: in both the situations I've personally worked where there was dangerous short staffing, nothing changed it. Absolutely nothing. Not doctors complaining, not sentinel events, not nurses leaving in droves, nothing. Nothing, nothing, nothing. The administration couldn't see the forest for the trees (translation: the almighty dollar) and absolutely would not listen to anything anybody said. I walked away, both times, and never looked back. Both places are still unmitigated disasters. One of them I left 16 years ago and it is STILL an understaffed nightmare.

quazar · Jan 12, 2017

Also, huge sign on bonuses, IMO, are huge red flags to stay away from a unit. One of my former understaffed units is currently offering a huge sign on bonus to work there after a mass exodus of nurses due to unsafe staffing and poor management. Any time I see "sign on bonus" in a job offer, my suspicions reflexively raise now. There has to be a reason a sign on bonus is being offered, and it's usually not a good one.

bear94, BSN, RN · Jan 12, 2017

Also, huge sign on bonuses, IMO, are huge red flags to stay away from a unit. One of my former understaffed units is currently offering a huge sign on bonus to work there after a mass exodus of nurses due to unsafe staffing and poor management. Any time I see "sign on bonus" in a job offer, my suspicions reflexively raise now. There has to be a reason a sign on bonus is being offered, and it's usually not a good one.

I agree with you that sign on bonuses can appear as red flags, especially when not every unit offers them. But how can employers better go about getting staff?

quazar · Jan 12, 2017

I agree with you that sign on bonuses can appear as red flags, especially when not every unit offers them. But how can employers better go about getting staff?

Okay, well let me answer your question with a question: you said your ER is over staffed. Why? What makes the nurses on THAT unit stay and not leave? Why is the ER not understaffed, which is pretty darned miraculous. The ER is doing something right....what is it? I know that in the units where nurses stay and recruit new staff with ease, it comes down to pretty much one factor: management. A good manager can kill a unit or make it thrive. The best units I've worked on were where management did NOT sit in their office all day, but when they could actively take patients and did so on a regular basis. The unit I work on now is like that. One of the units I left was like that for many years (until that manager left and was replaced by the office-only type manager, who effectively killed the unit and the morale within a year).

I often find that the best units have the best managers, and vice versa.

blondy2061h, MSN, RN · Jan 12, 2017

They need to look at what is making these nurses leave besides understaffing. If understaffing is the issue they can fill the gap with agency while they get new nurses oriented and then voila, staffing solved. But it sounds like there is more that's causing a retention issue. Perhaps it's the high acuity of patients. More likely it's overall crappy unity culture and poor management. My guess would be they need to get agency going to get ratios safe immediately, orient new nurses with strong preceptors for a solid orientation period, and look at the manager and charge nurses and make sure they're setting the tone for positive culture. Also, ensure that equipment is in proper functioning order and all supplies needed for patient care is readily available. And communicate with the nurses about the plan of attack! Hopefully these techniques would get a solid group of nurses retained there and improve staffing. It seems like admin actually cares which is a big plus.

HouTx, BSN, MSN, EdD · Jan 12, 2017

... A good manager can kill a unit or make it thrive.
I often find that the best units have the best managers, and vice versa.

AMEN. This says it all.

MikeyT-c-IV · Jan 13, 2017

In addition to the previous suggestions, maybe the overstaffed unit could temporarily float to help the understaffed unit?

And, yes, what the heck is going on with leadership?

dharlow · Jan 13, 2017

I took over a M/S unit years back after being the house sup for the hospital. I was overloaded with LPNs (19) and 3.5 RNs for a 34-bed unit. I was a working manager. I started with surgeons yelling at me from my office do - fast forward 2 years later and they were sitting down and having coffee with me on break. I learned quickly how to interview and hire quality staff and earned their trust and respect slowly but sure. I evened out the RN v. LPN ratio eventually because the 3.5 I had were on burn out mode. One was even a 72 yr old 11p-7a 32 hr a week RN! She rocked! Lead by example I always say. Even if I was having an "office" day and was in business attire, it would not be uncommon to see me relieving nurses if we were being slammed by changing into the set of scrubs stashed in my office or even noting their orders and such so they could take a lunch break. I would also float all over the hospital to start IVs. I also suggested to administration that in lieu of paying agency that we offer incentive that came to light and RNs, LPNs, CNAs would get so much over their base pay to work over their usual 36-hour work week. Plus, if they floated for extra hours then they would get float pay stacked upon the extra pay. Worked. It is still in place today (I moved on to Risk). The percentage of agency went way down but again that was 10+ years ago. My complaints went down and patient satisfaction scores went up. It takes time but is "do-able!."

VANurse2010 · Jan 14, 2017

Okay, well let me answer your question with a question: you said your ER is over staffed. Why? What makes the nurses on THAT unit stay and not leave? Why is the ER not understaffed, which is pretty darned miraculous. The ER is doing something right....what is it? I know that in the units where nurses stay and recruit new staff with ease, it comes down to pretty much one factor: management. A good manager can kill a unit or make it thrive. The best units I've worked on were where management did NOT sit in their office all day, but when they could actively take patients and did so on a regular basis. The unit I work on now is like that. One of the units I left was like that for many years (until that manager left and was replaced by the office-only type manager, who effectively killed the unit and the morale within a year).
I often find that the best units have the best managers, and vice versa.

I sort of agree, but to me a unit where the director is taking patients on the floor is not a functional unit. *that* is a big red flag to me.

quazar · Jan 14, 2017

I sort of agree, but to me a unit where the director is taking patients on the floor is not a functional unit. *that* is a big red flag to me.

I suppose it is different on L&D. My managers who took patients made a point to put themselves on the schedule for an actual shift about once a month. They worked side by side with us, took an assignment, and did everything. It kept morale high for obvious reasons, but also because you knew that any policies that were implemented, your manager had to work within those bounds as well, so she didn't just let any old policy that looked good on paper pass. Not sure how that would work in a med surg/tele environment, but in an environment like L&D it absolutely worked.

brillohead, ADN, RN · Jan 14, 2017

It's definitely a management thing.

Regarding sign-on bonuses, as an existing staffer, I would be FURIOUS if I were busting my butt, picking up extra shifts for months on end, etc., and some newbie came along and got handed Big Cash just for showing up. Where's MY extra cash, huh????

For the longest time, my unit had 3-4 times as many CNAs on day shift as we had on night shift, plus the daytime RNs were only assigned 3-4 patients and we night RNs were assigned 5-6 (and everyone ended up with 6 by the end of the shift because we admit like crazy all night long, but never discharge). That right there was a HUGE management mistake. Why would people want to work on night shift there KNOWING they were being abused by management and all the day-shifters had it easy? (Plus, you can't keep your HCAHPS scores up when you don't have enough hands on deck to answer call lights, provide toileting assistance, etc.)

I like the idea of management working an assigned floor shift once a month (once on days, once on nights).

Let them see what it's like when you have a 500-pound patient who is on Q2H turns and incontinent of urine and feces and you have five other patients (who are also incontinent but under 300 pounds) and there's only one CNA on the unit for all 30+ patients.

Let them see what it's like trying to start IVs on fragile elderly veins because there is no PICC team on at night and the demented patient keeps pulling out the IVs and there are no sitters available so the only option is to take your one CNA off the floor and have him/her babysit the patient. (How are you going to turn and change the 500-pounder all by yourself every two hours now????)

Let them see what it's like running all over the hospital trying to find an IV pole and two IV pumps because you need to start a heparin drip and your unit has no poles or pumps. Or you've got a patient who just came up from the ED who hasn't eaten in almost 24 hours and there are no sandwiches left because they don't stock enough. (How's that HCAHPS score gonna look when all you could offer the patient was graham crackers and applesauce until the kitchen opens in six hours?)

Management NEEDS to be aware of what it's like on the unit on a daily basis, and they NEED to do something about it. More equipment might be expensive, more staff might be expensive, but TURNOVER is VERY COSTLY (and very contagious).