Forget stubborn physicians and wildly fluctuating patient volumes. Nurse leaders really do have control over the highs and lows of patient throughput and related staffing problems.
For nurse leaders, it can sometimes feel as though things just happen to their units, things that are beyond their control: Unyielding physicians whose schedules are set in stone; patient flow that fluctuates so widely it's impossible to get staffing right; a sudden rush of patients to the ED that leaves nurses overwhelmed and burned out by the end of their shifts.
But it doesn't have to be that way, says Jennifer Mensik, PhD, RN, NEA-BC, FACHE, former administrator for nursing and patient care at St. Luke's Health System in Idaho, ANA board member, and author of The Nurse Manager's Guide to Innovative Staffing.
"They look at the churn of their patients as if [they] can't control it," Mensik says. In fact, she argues, nurse leaders can, to some degree, control the flow of patients and staff accordingly, if they harness unit-level data to find trends and identify how they change staffing and routines to accommodate those trends.
"We think of staffing as static," Mensik says, but it shouldn't be. "How can we plan better for what we know what we can be expecting?"
Mensik is among the speakers at the upcoming Fostering Innovative Staffing Solutions conference co-hosted by the ANA and the American Nurses Foundation. She'll be leading a session that will encourage attendees to work in groups to "really think outside of the box when we think about staffing."
Among those outside-the-box-ideas: Nurse leaders really do have control over the highs and lows of patient flow and the staffing problems that arise from them.
"Those peaks and valleys don't actually have to exist," she insists. Instead, nurse leaders should ask themselves, "How can we staff differently to make an impact to smooth out variability?"
Mensik concedes that when she tells nurses to find ways to control variability, "They snicker and they laugh a little bit." We can't do it, they say. You don't know my hospital.
But it can be done, Mensik says; all it takes is some new thinking and a willingness to deviate from the status quo. Of course there are some things that nurse leaders can't control, such as who comes into the ED. But there are things that they can control—and therefore, change for the better. Here are three strategies:
1.Schedule discharges: Mensik recalls the staffing issues in her hospital's obstetrics unit. "We had a ton of discharges in the afternoon, and it was really hard. When the census dropped in the evening we had too many nurses," she says. So the unit took control over this problem by scheduling discharges during admissions and scheduling accordingly.
By using a pre-arranged discharge schedule, discharges aren't lumped into the same small window of time, Mensik says. In addition, nurses know upfront who they're discharging and when, allowing them to organize their care and spend a generous amount of time with each patient.
"The nursing staff was really onboard. They weren't rushed with their patient," Mensik says of the change. "The staff nurses loved it." And although one particular hospitalist proved "problematic" because he only wanted to discharge patients in the evening, other physicians worked with nurses to change their rounding patterns.
2. Don't forget about PAs and NPs: "They're still very, very underutilized," Mensik says, adding that nurses don't have to wait for the physician come around at discharge; the PA or NP can discharge patients. Nurse leaders can work with PAs and NPs ahead of time to establish discharge plans with the interdisciplinary team.
3. Revamp the surgical schedule: "Your surgical schedule is artificial," Mensik says, and it can be manipulated to maximize staffing. Mensik says she sees hospitals that can be at 100% capacity on Tuesdays and Wednesdays and at 25% capacity on Saturday night.
"We're burning out the nurses in the middle of the week while at the same time providing the minimum amount of nurses on the weekend," she says, simply to accommodate these "artificial" surgical schedules. "Healthcare is a 24/7 business," Mensik says. She acknowledges that some surgeons have a lot of influence; they like to do certain procedures on certain floors and usually they get their way. "Sit down with those physicians and see what can be done about smoothing that surgery schedule," she says.
Ask them whether they really need to do all surgeries on Monday, Tuesday, and Wednesday. And remind them that errors are more common when hospitals go over capacity.
Alexandra Wilson Pecci is an editor for HealthLeaders.
