staffing question

[theliman]

Hello all,

I'm hoping those involved in management can shed some light on a frustration I've had with my hospital's staffing decisions (I know I'm not alone here).

I fully understand and accept that hospitals want to make the biggest profit they can. However, it seems that there is a lot of evidence that lower staffing leads to a number of bad outcomes - most of which cost the hospital money. Falls, med errors, extended LOS, etc. Then of course there is nurse dissatisfaction (higher turnover = more money/time to train, more issues with new nurses), which also affects patient (dis)satisfaction.

In my ICU the charge nurse regularly takes patients. If we have an open charge and one nurse with only one patient, they might be sent home 2 hrs early (additional handoff) and if we admit in that window, someone is tripled or the charge takes the patient. We've had numerous nights where all of the units seem to be scrambling, yet we had nurses on "push-back."

I'm trying to understand more of why this is and what is going into these decisions and how hospital finance works. They're already paying us a huge amount in benefits - why send a nurse home early to save $60 when you have so many potential negative consequences? Do these incidents not harm the hospital financially as much as I think? (I can't imagine - think of the cost of one bad fall!) Is staffing only operating to demonstrate concrete, clear savings (nurse hours), while ignoring the much larger effects of low staffing? What's going on?

Thanks!

[SummerGarden, BSN, MSN, RN]

There is something called "productivity" and hospitals have a formula to be used by staffing and leadership to determine appropriate cost effective coverage for various shifts per each department. At times it may seem like it is only leadership/management that is causing the problems (been there done that), but now that I am on the other side, I can tell you that there is more to the story. For example, the people within your own department to include your co-workers and the charge/ANM and people supporting your department such as the House Sup/Staffing/Bed Control and ancillary health care staff on that shift or the prior shift, will make decisions that affects you on your shift.

With that said if you are having staffing problems and are scrambling to cover patients during your shifts, you need to talk to your co-workers (the ones who are not showing up to work or refuse to cover others). Plus, I encourage you to talk to your charge/ANM about staffing needs and unique circumstances to cover patients on your shift. Those in charge on that shift can inform you of the details of which you may not be made aware that will make it impossible to provide additional staff. Also, you may empower your manager to make decisions and justify his/her choices to his/her leadership to provide for additional staff even if it is contrary to the productivity goals for that shift.

Of course, this is not always possible. Some middle managers are not supported by the upper leadership in their department and so cannot make effective supportive decisions. Similarly other ANM/Charge nurses are passive aggressive-shy-please –everybody types that are useless and incompetent so they cannot support you either.

Hopefully, you start to get the support you need. Good luck. :)

[llg, PhD, RN]

Another point ... the day-to-day, hour-to-hour decisions are made on a short-term basis, not on the long term outlook. The middle managers who make such decisions are held accountable for meeting short-term financial targets: so the long-term wisdom of some of the decisions never come into play.

The strategic leadership folks who set those short-term targets don't always look at those long-term considerations, either. They are held accountable by the Board of Directors to meet yearly goals -- and may be more interested in meeting those yearly goals (and keeping their jobs and/or moving up the ladder to a better position elsewhere ... or "hanging in there until retirement" etc.) than the longer term as well. Moving up the ladder, there may be no one whose personal welfare depends upon the long term cost savings or improved outcomes of better staffing. Each person in the decision chain's personal interest may be more closely linked to short-term savings -- saving a nickle in the short term benefits them more than saving a dime in the long run. That's one of the big problems in the health care system.

[theliman]

Thanks to you both. llg, my thinking was definitely in line with your main point. my charge likes to be able to show the manager that they were able to save money by sending someone home, but there's no record or easy, direct tie to an extended LOS or re-admission from poor care. it's all about where the incentives are, and it seems that the highest levels of leadership have to be ok with a more lenient "productivity" rate in the pursuit of cost savings (better outcomes)

mbarnbsn i agree about the "please-everybody" types. we had a charge who refused to triple nurses without a step-down or floor order because she believed she was making a judgment against a doctor's order (since there is still a standing ICU order) and it would make her liable. she is no longer asked to relief charge.

[jrt4]

Speaking as a director of a smaller unit (under 30 beds)... I also want to make the point that the couple hour here and there can save hundreds of thousands of dollars over the long term when you are looking at every shift in every unit. What I am not saying is that we should put patients in jeopardy for bad outcomes... I think there is a balance. With balance comes risk. Most hospitals are non profit...which means they are not in it to make a profit. However, hospitals do have to make enough money to cover costs AND invest in the future. I know nurses hate talking about money when it comes to patient care but unfortunately with the cost of care exceeding with complexity, it is an important factor. I often hear nurses who have been around awhile complaining that things are not what they used to be...which is true...but not necessarily bad. Many patients who are being cared for in ICUs today would have been dead 30 years ago...but now we are keeping them alive with expensive medications, equipment, consults, etc.

I just wanted to mention this because its important to think of costs when making day to day or even hour by hour. But of course...quality should not be undermined to offset cost.

[fifita2010]

I love you. I wonder how as nurses we claim to follow evidenced based practice, but I still deal with interrupted report time, alarm fatigue, constant distractions, you get my drift. I have been sent home early many a time. I have often wondered, what are they saving, like you said, $60. I don't get it either. I was trained that "there is always something to do".They would get their monies worth. Thank you.