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Extra nurses alone won’t help if other factors aren’t working too
Most nurse managers would love to say the biggest concern in the ICU is reducing nurse overstaffing. The sad fact is most units are struggling just to find and keep good nurses, says Kathy Arnold, RN, MS, nurse-manager of adult critical care at Swedish American Health System in Rockford, IL. If a facility has recurrent overstaffing, management isn’t scheduling correctly, or the unit has no patients, Arnold muses.
Staffing-related problems appear to be widespread in critical care. Managers find themselves wrestling daily with patient census and acuity while trying to make adequate staffing assignments. Most appear to be losing the battle.
It’s a battle that can be won, says Justine Medina, RN, MS, a clinical practice specialist with the American Association of Critical Care Nurses (AACCN) in Aliso Viejo, CA.
"People are coming up with solutions," she says. "But they aren’t using terms like staffing" to describe their problems. They’re quite correctly looking at other factors that may be at issue. "The solution isn’t always extra staffing," Medina says.
Yet everyone agrees staffing problems at many hospitals are quite bad, and are likely to get worse. In the next decade, according to projections, hospitals will need many more critical care nurses. Aging baby boomers and higher inpatient acuity levels are going to strain the existing nurse supply. Both factors are a function of managed care.
Meanwhile, hospital financial departments are pressuring CCUs to cut back and meet tough financial targets with fewer resources.
Recent efforts to reorganize CCUs have centered on maximizing existing nurse resources — making do with the same amount or less. (For a report of how one hospital restructured to maximize existing resources, see article, p. 15.) However, a growing body of experts finds fault with the way many nursing administrators are assessing their shortage problems.
Many don’t know what their problems are, yet they tend to blame staffing shortages when the underlying problems may be something else, Medina says. It may not be an actual shortage, but a problem of properly assigning staff each week or distributing patient assignments under fluctuating census and acuity.
Conventional formulas for optimum staffing such as nurse-to-patient ratios or budgeted hours are artificial measures. They fail to reflect what is actually going on with patients in the ICU at a given time, Medina adds.
"Staffing is important, but it’s only one of several factors that contribute to a well-run ICU," observes Joanne R. Duffy, DNSc, CCRN, president of AdviCare, a Burke, VA, health care consulting firm.
In reorganizing your unit, managers should step back and evaluate a series of factors that holistically might be hurting performance, rather than focus solely on nurse shortages. Here’s what some experts suggest:
• Evaluate the unit as a whole, not just the staffing.
The best-performing ICUs are those operating from a set of factors that together influence overall performance, Duffy says. These factors include: Task diversity (the types and volume of different tasks required of each nurse) and nurse staffing (the usual number of nurses assigned to each patient or group of patients and their work schedules). Technological availability (the types and quality of equipment used by nurses) also plays a role, as does the level of caregiver interaction (elements such as leadership, communication with other clinicians, coordination of care, and problem-solving attributes). (See chart, right.)
• Evaluate each of these factors individually and in combination.
For example, most nurses know the importance of patient acuity as a determinant of staffing levels. The more sick patients you have, the greater the need for additional nurses. The number of tasks given to each nurse and their complexity during an eight-hour shift also can make a difference in your coverage.
"Is the nurse expected to do bedside testing? Or is the lab work sent out? Are they expected to work the entire shift alone with the most difficult patients, or are two nurses usually assigned these tasks? These differences don’t only influence the ICU’s overall performance over time, they affect patient outcomes, morbidity, and lengths of stay significantly, Duffy observes.1
• Do your homework.
Evaluate your existing resource management, Medina advises. Ask yourself: What are my staffing levels standards? Have I done competency evaluations on all my nurses? Can I confidently assign appropriate people to patients based on this knowledge? Have I defined my productivity parameters? Do I know what they are? How much or little do my nurses work on a typical day?
Tools to help managers include software programs and research literature. Many managers complain these resources "don’t work, or aren’t right for me, or require too much paperwork," says Medina, who says she fielded dozens of similar nurse manager calls.
• Create a growth environment for nurses.
In the last decade, research has supported claims for giving nurses greater independence in the ICU.
"A decentralized decision-making environment that gives nurses more control over resources contributes to lower burnout and significantly affects workplace errors," says Eileen Lake, RN, MSN, a research associate with the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia.
In the early 1990s, the center conducted a comparison study of hospitals designated as magnet institutions by the American Nurses Association in Washington, DC, with 200 non-magnet facilities. The following characteristics ranked high at magnet facilities:
1) decentralized nurse decision-making,
2) strong positive collaboration between nurses and physicians,
3) a high regard for nurses throughout the institution, and
4) adequacy of resources, including enough RNs to allow for consults, and strong support from non-nursing personnel. [Editor’s note: The decentralized decision-making findings came from related studies.]
• Separate your actual staffing needs from other priorities such as financial targets.
With the frustration of staffing a busy ICU, nurse administrators can easily forget that staffing levels should be based on patient need and not external mandates that include reaching financial targets.
"Many managers don’t have a way to systematically review their patients’ acuity levels," says the AACN’s Medina. One reason is they are placed in a difficult position of staffing for two conflicting purposes: To provide adequate patient coverage and meet financial objectives.
With planning, managers can strike a balance, Medina says. If, for example, a 10-bed ICU has a 70% occupancy on Wednesday and three of those patients are due for discharge on Friday, a manager who usually staffs for 100% occupancy is likely to have more flexibility in nursing assignments, Medina says.
Such ideas are known, but according to nurses they often don’t work due to other unexpected occurrences such as sudden changes in census. Looking ahead in smaller time intervals can help achieve a balance between actual needs and financial targets. Dealing with smaller, more manageable time periods help, Medina concludes.
• Choose long-range planning over short-term results.
If a reorganization plan hopes to succeed, it must include provisions to train and credential nurses, says Arnold. Beleaguered by nurse vacancies and turnover, Arnold has tried to eliminate the hospital’s dependence on registry and agency nurses, which has annually cost the unit about $90,000 per RN.
In recent years, the unit has hired fourth-year nursing students as PCTs (patient-care technicians) and created a professional student nurse associate internship for third-year students. Arnold views the effort as an in-house graduate program not to fill vacant nursing positions, but to mold future nurses according to the hospital’s culture as a means of retention.
The programs haven’t reduced the ongoing need for good ICU nurses, but laid a much-needed groundwork for the future, Arnold says. (The March issue of Critical Care Management will profile Swedish American’s nurse training programs.)
There are no quick fixes to reorganizing for optimum performance. Situations are fluid and don’t allow for easy answers, Medina says. "But in all this, it always comes down to how well do your nurses know their patients, and are you doing the right thing?" These two principles are useful as a starting point.
1. Shortell SM, Zimmerman JE, Rousseau DM, et al. The performance of intensive care units: Does good management make a difference? Med Care 1994; 32:508-525.