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 (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.

[barefootlady, ADN, RN]

It sounds like you pushed all of the buttons and came up with numbers, now, who takes care of sudden crisis? Team nursing is a wonderful concept, did it for years, love it, but you have to make sure staff understands the team concept. No real advice here, just see potential for problems.

[meownsmile, BSN, RN]

My facility sounds a lot like yours. We used to do the admissions/discharge nurse thing but that stopped.

Presently,, we have our Nurse Manager that is there most of the time during the day. She works 8-3ish.

Say we have 15 patients on the floor,, we will have 2RN care managers, 2LPN's although i have seen LPN's routinely taking 15 patients depending on scheduling, 2CNA's.

Rn does all daily assessments for her team of patients, IVP to central lines, etc.

LPN does meds/treatments/dressings as well as helps CNA's with ADL's when possible.

CNA's do baths, feeding, toileting etc.

Dishcharges and admissions are done by the RN staff (care managers) that are assigned to the new patients team. We do our own discharges,admission assessments and detailed interview of patient or family, post ops, and all MAR information and calling doctors etc.

LPN will document home meds, surgical history, etc. Subsequent post op checks after the intital check by the RN. Along with daily duties.

CNA's do admission vitals, post op vitals, room setup and room/hospital orientation. Along with daily duties.

I have seen days when each team may end up with 11-12 patients which is boardering unreasonable and dangerous, however i know we cant have staff sitting around waiting. And they try to staff with a 3rd RN if they know it will be a heavy surgical day, she would be assigned a team, splitting the 15 between 3RN's. No more than 2 LPN's, possibly another CNA if a heavy day is expected or patient acuity is REAL bad.

Our nurse manager acts as charge nurse on days, so there is one position you carry that we dont. She will do patient bed assignments, team assignments, make/take calls if needed, and manages the administrative aspects of the floor.

We dont utilize a discharge/admissions nurse. It looks as though the staff you would have in your admissions/discharge position is doing exactly what we do as RN care managers in our team nursing. We usually have one RN with an assignment that acts as resource nurse and if that hasnt been delegated then we usually will put an admission where it "fits" within the mix of patients we have. Our unit clerk will call one of us to the phone or take info and we call admissions back after we have made the assignment.

Getting staff to cooperate with changes is dependant on your staff. Some will work with it and make adjustments, others will have a very difficult time taking on duties they have historically seen as someone elses responsibility.

Actually the RN of the team doing her own discharges and admissions only makes sense. They know the patients presentation, course of treatment since admission, she should have been collaborating with the doctor when he made rounds and knows what other directions he made to the patient that can be incorperated into the discharge instructions or to pass on to the next shift. When you have a discharge/admissions nurse doing just that, there is to much room for communication breakdown between admission and team leader takeover of that patient. Ive worked med/surg for 13 years and have never seen a discharge/admission nurse on our unit.

Things go pretty smoothly this way. Occasionally there is some discrepancy about where the admission should be placed. And we have a "house supervisor" that tends to be a control freak and makes things difficult by "placing" patients all on one team through a shift (you know what we think of her). We have days when we work our behinds off but for the most part it works.

[laurakoko]

Nurse manager, RN team leaders, care managers

sounds like just too much mangement to me!

[SarasotaRN2b]

Because our floor sounds a lot like yours, I thought I would pipe in. We are the first floor to get admissions so we are usually always full. There are times that as soon as we put in a discharge, we are getting beeped by patient placement that we have another admission coming.

Our total unit consists of ~ 44 beds, but because some patients require private rooms due to MRSA, etc., we usually have about 40 beds filled. We divide the unit into the A side and B side with each operating individually.

Each side has a charge nurse who also provides back up support when needed. If for some reason we are short with nurses, the charge will take a patient or two. For days, it is usually 4 patients per nurse. We have both RNs and LPNs. The charge nurse usually oversees the LPNs. We also have two PCAs (CNAs), each having @ 10 pts. There is also a HUC (health unit coordinator) from 7 am to 3:30 am. Usually there is only one HUC from 11 pm to 3:30 am that will cover both A and B sides.

Patient care is very important to this hospital, and it is once in a blue moon that anyone is sent home.

[jmgrn65, RN]

We don't do the team nursing and in my 13 years I haven't done it either. So I can't give advise on that aspect. I will just tell you how we do it. We have a charge nurse, she makes call to the doc's, makes rounds with them (some of them) deal with staffing issues, any problems, makes out the assignment for the next shift, etc. rn take a patient assignment usually 3-5 pts, we get alot of transfer from the icu, LPN's take an assignment just like the RN (chg nurse will do or assign to another any of the things the LPN can't do) Our na's split up the floor, usually the have anywhere form 7-12 patients. night shift the only difference is chg nurse does take patients.

day shift if have 20 patients we would have 5 nurses plus chg nurse and 2 NAs

[jmgrn65, RN]

Oh yeah we have 2unit clerks during m-f one of them works 9-5 the other 7-7, on w/e we only have one, night shift has one.

[General E. Speaking, RN, RN]

I work on a 38 bed Med/Surg floor in Katy, Tx. 10 beds are technically pedi, but if census is down for pedi we use the extra beds for M/S. Our staffing goes like this:

We have a nurse manager Mon-Fri 7-3. She mainly does scheduling, goes to meetings and does customer-service rounds on each patient. After 3 pm and on weekends we have a house supervisor.

One charge nurse per shift 7A-7P who doesn't take patients. Our clerks and tech's work 8 hr shifts. Usually, during the day shift, we have one clerk, 4-5 patients per nurse with 2 tech's on the floor. According to our staffing grid- each nurse can take up to 6 patients each. The pedi nurses are required to take some M/S patients if their census is low- but they only take a max of 4 patients. (If they have 3 pedi's and 1 M/S and get another pedi admission- they give up the M/S patient to another nurse.)

Our hospital is big on nurses "on call". So if we start getting slammed during the day from OR, direct admits, and the ER- we have someone on stand-by. It can get pretty hectic some days. If our census drops drastically during the day- their is usually a staff memeber who will volunteer to leave early (providing, of course, the agency and PRN's have left first)

hope this helps some.