KellyM RN

Talk to any nurse and they will have something to say about the staffing at their hospital or facility. More often than not, that something will be an unflattering depiction best summed up with three words: stretched too thin. Additionally, the COVID 19 pandemic, like a flare up of a chronic disease, has only exacerbated the issue. While the problems addressed here can be frustrating, the goal is to rationally examine the causes of under-staffed hospital units in order to then identify potential solutions. The Problem: Defining Short Staffing What is short staffing? That depends primarily on the defined nurse-to-patient ratios in each hospital and on each unit. Ask any hospital administrator and any nurse at the same hospital to describe the safe, ideal nurse-to-patient ratio on a given unit and they will be give completely different answers. Why is this? One likely reason is the perspective and roles of each side varies greatly. An administrator considers a completely different set of criteria than a nurse would for the same problem. The Fix If nurse-to-patient ratios are the foundation for safe, effective patient care then coming to an agreement on what those ratios should be is paramount. This requires open, honest communication between clinicians and administrators alike. Clearly defined and agreed upon criteria for what adequate staffing on each unit looks like gives everyone a solid foundation with which to start. Nurses are critical to helping define these standards in order to ensure that expectations are realistic. The Problem: Accounting for Census Changes There is no question that patient censuses can fluctuate dramatically in short periods of time. We've all left a shift with adequate staffing only to come back 12 hours later to twice the patients and half the staff. These variabilities are difficult to predict, although not impossible to prepare for. While floating nurses to other units is a commonly used solution, it is a temporary fix and not always seen favorably with floor nurses. Why is floating such a dreaded event? There are many perspectives and reasons although most of these boil down to one common element- the unknown. On any given shift, there is a lot a nurse can know ahead of time and a lot they cannot. We can know our units- where the supply room or code cart is or the policy for various unit specific procedures and processes, on the other hand we can't know our patients, their conditions, or what may happen over the course of a shift until we are there. Floating to new units takes away the piece of the shift we can know. The Fix One option is to give nurses to chance to choose two separate units to work on and then provide full orientations to both units. Allowing nurses the choice of an extra unit gives them some element of control, additionally the orientation gives them the chance to be more comfortable and therefore safe on the unit. Furthermore, this would have the added benefit of reducing potential burn out from being in are place too long. Another option is to hire nurses specifically as float/pool nurses. Setting the expectation at the time of hire for their role and work expectations will allow the hospital and nurse alike to find and fill roles that fit both parties. The Problem: Nursing Burn Out and Turn Over It's a true "chicken or the egg" type question: does short staffing cause nurse burn out or does nurse burn out cause short staffing? There are good arguments for either side, however ultimately addressing both issues is crucial. The Fix Hospital administrators have many parameters they use to measure their hospital's success. There are internal considerations such as patient satisfaction surveys and even employee surveys as well as external influences such as various accreditations that can elevate a hospital's standing. Including safe nurse-to-patient staffing ratios as a unit of measurement for success and then getting "dinged" every time a unit operates without appropriate staffing aligns nursing priorities with administration priorities. This alignment of goals puts everyone on the same page. Which, in turn, helps nurses feel protected by their hospitals leading to a reduction in nurse turn over. All in all, it is mutually beneficial to ensure safe nurse-to-patient ratios. The Best Chance for Change? While short nurse staffing can be difficult problem to address, it is not impossible manage. Ultimately, the best chance for change has everyone working towards the same goals: safe, effective, compassionate care for our patients. What are some of the issues you've found that contribute to under-staffing at your hospital? What are some possible solutions?

Thank you!

Let’s set the scene It’s vitals time- morning medications time- one patient just puked and another fell out of bed time- and you can see down the hall that the surgeons just left Mr. A’s room. You make a mental note to grab the procedure consents when you go in his room for your assessment. You’ve finally handled enough urgencies to get to Mr. A’s room. You show him the consent and repeat for the millionth time in your career, “I know the surgeons discussed the procedure for tomorrow with you. If you don’t have any questions and feel comfortable signing the consent, I have it here for you.” And, then, like clockwork, the patient says “Actually, do you know..” or “I meant to ask..”. It’s a scene that is played out countless times a day in every hospital. However, what we may not always consider is why the patient didn’t get all the information they needed. It is both possible and easy to say that in the moment, yes, these things slip our minds. But the reality may be something else entirely: maybe your patient didn’t hear the surgeon. Why is it important to identify hard of hearing patients? I was born hard of hearing and have the benefit never living in a world I could hear clearly. You might be wondering why I consider that a benefit. I learned from a young age to speak up for myself when someone is mumbling or the TV is too quiet. I learned that in order to be included in the hearing world, I had to advocate for myself constantly. That didn’t come naturally to me, it’s a skill that has taken a lifetime to master, and I still struggle with from time to time. While some patients will advocate for themselves, I’ve found that most of mine do not. They are still firmly in that, “I hear just fine”, phase when in fact, they do not. Why they are in that phase is not for me to determine, however what is up to me, as their nurse, is to make sure they are hearing and comprehending the information everyone on the healthcare team is communicating to them. Just as a translator is used for someone who speaks another language, there are steps we as nurses can take to ensure we are “speaking a language” our hard of hearing patients can understand. How can we help? 1- Reduce surrounding noises Hospitals are not quiet places. The hallways are filled with people talking, machines beeping, computers rolling down hallways, even the patient’s room itself can be noisy (TVs on, family members in person or on speaker phones). All of these can be distracting when someone is trying to concentrate on hearing. Assess the background noises, close the door, turn down the TV, ask people on the phone or in the room to be quiet while you talk to the patient. 2- If your patient wears hearing aids, make sure they are in and turned on I’ll never forget in nursing school at a long term care facility helping a patient put on her hearing aids. Having experience with hearing aids, I knew to check that batteries were in and working. When I checked, the batteries were clearly dead. The patient did not have any batteries and I asked the facility for new ones and they didn’t have any either. I have no idea how long this patient had been wearing these hearing aids (which were essentially ear plugs since the batteries were dead). Moral of the story: make sure that if the patient wears hearing aids that they are in fact wearing them when you are speaking with them (with functioning batteries). If you don’t know how to check batteries and the patient is unable to explain or do it for themselves, ask. 3- Communicate clearly I’m not sure what it is about being told someone is hard of hearing that instantly makes people start screaming but I’m here to tell you: it helps no-one. Additionally, from my experience, over-enunciation, which changes the sounds of the words you are saying, helps no-one. Speak at a solid average, mid-level volume and cadence. Furthermore, communicating is more than the spoken word. While masks are an unfortunate obstacle for the hard of hearing, most of whom use lip reading to communicate, you can still make every effort to make sure they are able to understand you. Facing the patient, getting at eye level, and making eye contact are steps that can help to mitigate the mask issue. 4- Including healthcare team on communication plan We are not always present when doctors, care management, physical/occupational/speech therapy, or others are in our patient’s room so how can we include them in our communication plan? Some kind of signage is a good idea, although it could be considered a patient rights violation to include a “hard of hearing” sign on the door. I once worked on a unit where they used picture codes for different conditions. For example, a cut out of an ear on their door could mean hard of hearing. This would communicate to everyone entering the room to adjust their communication techniques accordingly. Finally Living as a hard of hearing person can be challenging in many ways. Our patients are already going through a difficult time being in the hospital; we can lessen their burden by making sure the entire healthcare team makes every effort to communicate with them effectively. Does anyone have any other tricks or tips they use to communicate with their hard of hearing patients? Or, to notify other members of the healthcare team?