New Med/Surg manager wants your input on staffing matrix

[catalyst]

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 for patients

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.

[KK92RN]

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 for patients

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.

Well i work on a 28 bed trauma, ortho, medsurg floor and we split the floor in to 2 parts. Each side has 14 pts and the staff is set up like this:

1 charge rn

3 lvns or rn's for pt care

1 patient care associate

we also have 2 unit reps most of the time on days but we have a very high turnover for pts. we have a clinical manager and she sometimes helps on the floor but for the most part she has other things that need to be done. the hospital has created a house supervisor position that is for the whole hospital and they take care of the transfers from other places, codes and support for when we need it. the charge nurse oversees all the pts on thier side and signs off on the lvn's charts. sometimes we have other rn's and sometimes we don't. when we do we try to give the rn the one less pt because they can do everything for thier pt( iv pushes, blood, ect) and it works better that way. the hospital created an admit team that consist of 3-4 nursesthat are hospital wide to help with admit and discharges and if it is slow then they can work the floor. all in all it seems to work pretty good. we always get hectic around 4 pm as usual. and staffing doesn't knock us down to 2 charge and 5 for the whole floor until our census is 25.

[PMHNP10]

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

How does this sound? Any suggestions? Any suggestions on getting staff buy-in?

thanks in advance for sharing your thoughts.

I'm trying to get a sense of this, but the "clinical supervisor" seems to be a middle management type of person. Is there any reason this person can't take a pt assignment or function as a charge RN? For example if you have 8 hr shifts and the sup. works FT, schedule an AD (admin. duty) day each week to accomplish the scheduling, evals, and other paperwork. That would consolidate 2 positions into one right there. As for the part I selected above, if I'm correctly comprehending what you are posting, I'm concerned about the possibility of there being one RN responsible for 18 acutely ill patients (or 28 if I understand that is how many beds are on the unit). Either way, that is way way way too many because you'd have the RN be charge and a full patient load of their own (possibly 9+ pts.) and be responsible for the pts the LVN is caring for.

You gotta do what you gotta do, and it's admirable that you are not just going to drop this bomb on them and are seeking input, but from my POV you very well could lose them because from what I'm reading, it appears to be a dangerous situation for them and the patients. I was also thinking maybe you could hire a "clinical supervisor" for the nights, who could do for nights what the day one does (as I suggested above). Perhaps make a promotion from within. That way at least you have 2 RNs on at night as well. Good luck to you.

Man I miss these ratios in CA already and I haven't even left for TX yet.

[nursemary9, BSN, RN]

Hi

I have been nsg. close to 40 yrs.

I have been a manager in the past---I feel too old for that now.

Presently I work Nights--8 hr. shift 40 hr/wk. her weekend off. Staff position.

Certified OCN Nurse.

I work a 34 bed Med/Surg/Onc unit. We're a VERY busy unit.

We have 8 & 12 hr. shifts here.

We routinely get 3 to 5 Admits per night.

We have a unit which is very awkwardly laid out in a U shape.

Our staffing is--on night shift

5 RN's

2 Cna/s

1 Clerk

We don't use Lpn's here.

Our Charge is rotated among us; the Charge gets a full load of patients.

We are not supposed to get more then 7 pt's apiece; bu you know how things go, we often get 8 or 9.

When we have 33 & 34 Pt's we are supposed to have 6 RN's but I've seen that once in 3 yrs.

Day shift has more staff

Still no LPN's, but more RN's & Cna's also 2 clerks;

The unit has a Manager & there is supposed to be a Practice Leader on Day shift--she schedules & does some teaching & coordinating. Not supposed to get a pateinet load, but sometimes has to. Currently that job is vacant.

Tha;s our staffing.

Mary Ann