25102504 staffing in nursing management

7/31/2019 25102504 Staffing in Nursing Management

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StaffingStaffing is the process of determining and providing the acceptable number and mix ofnursing personnel to produce a desired level of care to meet the patients demand

PurposeThe purpose of all staffing activities is to provide each nursing unit with an appropriateand acceptable number of workers in each category to perform the nursing tasksrequired. Too few or an improper mixture of nursing personnel will adversely affect the

quality and quantity of work performed. Such situation can lead to high rates oabsenteeism and staffs turn-over resulting in low morale and dissatisfaction.

Factors Affecting Staffing1. the type, philosophy, objectives of the hospital and the nursing service.2. the population served or kind of patients served whether pay or charity.3. the number of patients and severity of their illness-knowledge and ability onursing personnel are matched with the actual care needs of patients4. availability and characteristics of the nursing staff, including education, level opreparation, mix of personnel, number and position.5. administrative policies such as rotation, weekends, and holiday off-duties.

6. standards of care desired which should be available and clearly spelled out.7. layout of various nursing units and resources available within the department suchas adequate equipment, supplies, and materials8. budget including the amount allotted to salaries, fringe benefits, suppliesmaterials and equipment9. professional activities and priorities in nonpatient activities like involvement professional organizations, formal educational development, participation in researchand staff development.10. teaching program or the extent of staff involvement in teaching activities.11. expected hours of work per annum of each employee. This is influenced by40 hour week law.12. patterns of work schedule-traditional 5 days per week, 8 hours per day; 4days a week, ten hours per day and three days off; or 3 days of 12 hours per dayand 3 days off per week.

Planning for Staffing and Acting to Resolve Current Nursing ShortagePlanning is the major leadership role in staffing and is often a neglected part of the

staffing process. Because the success of many staffing decisions greatly depends onprevious decisions made in planning and organizing phases, one must consider staffingwhen making other plans. Consideration must be given to the type of patient caremanagement used, the education and knowledge level of the staff to be recruitedbudget constraints, the historical background of staffing needs and availability, and thediversity of the patient population to be served.

Accurate predicting staffing needs is valuable management skill because it enablesthe manager to avoid staffing crises. Managers should know the source of their nursingpool, how many students are currently enrolled in local nursing schools, the usual lengthof employment of new hires, peak staff resignation periods, and times when patientcensus is highest. Analyzing historical patterns, using computers to sort personnestatistics and keeping accurate unit records are example of proactive planning.

Federal moneys for nursing education have increased. The passage of legislationsuch as the 2002 Nurse Reinvestment Act, has encouraged more students to choosenursing as a career and helps students financially to complete their education. It also


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encourages graduate students to complete their studies and assume teaching positionsin nursing schools.

Some experts suggest however, that too much emphasis is placed on recruitingnew nurses to solve the current shortage and that supply could more easily be increasedby bringing unemployed or part-time nurses back to nursing full-time or by enticingnurses back into nursing who are now working in non-nursing position.

Other expert suggests more attention be given to retaining older workers obringing retired nurses back into the workforce. Cyr (2005) agrees, suggesting that while

many nurses retire because they are financially independent, some would considerdelaying retirement if the work environment were altered to support older nurses. Otherssuggest that employer must be able to accommodate aging workers with technologyaimed at reducing physical strain. Other strategies suggested retaining aging nursesinclude flexible scheduling and benefits, continuing education aid and wellness program.

Another short term solution to the current shortage has been the importation offoreign nurses, particularly by developed countries from developing countries. Whilesuch importation can result in positive global economic, social, professionadevelopment, many of the donor countries, who can least afford it, are experiencing asubstantial brain and skills drain.

Long-term solution to a shortage of staff is cross-training. Cross-training involves

giving personnel with varying educational backgrounds and expertise the skillsnecessary to take on tasks normally outside their scope of work and to move betweenunits and function knowledgeable.

However, staffing shortages frequently occur on a day-to-day basis. These occubecause of an increase in patient census, an unexpected increase in client needs or anincrease in staff absenteeism or illness. Health care organizations have used manymethods to deal with an unexpected short supply of staff. Chief among the solutions areclosed-unit staffing, drawing from a central pool of nurses for additional staff, requestingvolunteers to work extra duty, and mandatory overtime.

Closed-unit staffing occurs when the staff members on a unit make a commitmentto cover all absences and needed extra help themselves in return for not being pulledfrom the unit in times of low census. In mandatory overtime, employees are forced towork additional shifts, often under threat of patient abandonment, should they refuse todo so. Some hospitals routinely use mandatory overtime in an effort to keep fewerpeople on the payroll.

A health care worker who is in an exhausted state represents a risk to publichealth and patient safety. Working overtime increases the odds of nurses in makingerrors. While mandatory overtime is neither efficient nor effective in a long term, it hasan even more devastating short-term impact with regard to staff perceptions of a lack ofcontrol and its subsequent impact on mood, motivation, and productivity. Nurses whoare forced to work overtime do so under the stress of competing duties-to their job, theirfamily, their own health, and their patients safety.

However, Manthey suggests that nurses themselves, as well as employingorganizations, need to become smarter about workload issues. She maintains thatintermittent peak workload issues should not be solved by adding personnel but shouldbe solved by prioritizing what can get done in a shift that will meet patient critical needsand learning what is not critical to be done.

Recruiting and Selecting StaffRecruiting


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Recruitment is the process of actively seeking out or attracting applicants foexisting positions. It should be an ongoing process in order to meet demand and provideadequate supply of nurses at any given time.

The nurse manager may be greatly or minimally involved in recruiting interviewingand selecting personnel depending on (a) the size of the institution, (b) the existence ofa separate personnel department, (c) the presence of a nurse recruiter within theorganization, and (d) the use of centralized or decentralized nursing department.

Generally speaking, the more decentralized nursing management and the less

complex personnel department, the greater the involvement of lower-level managers inselecting personnel or individual units or departments. When deciding whether to hire anurse-recruiter or decentralize the responsibility for recruitment, the organization needsto weigh benefits against costs. Costs include more than financial considerations. Foexample, an additional cost to an organization employing a nurse-recruiter might be theeventual loss of interest by managers in the recruiting process. The organization loses imanagers relegate their collective and individual responsibilities to the nurse recruiter.

Recruiting adequate number of nurses is less difficult if the organization is locatedin a progressive community with several schools of nursing and if the organization has agood reputation for quality patient care and fair employment practices.

Because most recruiting methods are expensive, health care organizations often

seek less costly means of recruitment. One of the best ways to maintain an adequateemployee pool is by word of mouth; the recommendation of the organizations ownsatisfied and happy staff. Recruitment, however, is not the key to adequate staffing inthe long term. Retention is and only occurs when the organization is able to create awork environment that makes staff want to stay.

Some turnover, however, is normal and, in fact, desirable. Turnover infuses theorganization with fresh ideas. It also reduces the probability of groupthink, in whicheveryone shares similar thought processes, values, and goals. However, excessive orunnecessary turnover reduces the ability of the organization to produce its end productand is expensive.

Clearly, the manager must recognize the link between retention and recruitmentAtencio and colleagues (2003) suggest that the social climate of the workplace is theprimary initiator of a nurses intent to stay or leave and that this social climate mayreflect either work frustration or work excitement. Similarly, Lynn and Redman (2005)suggest that retention programs must focus on both organizational commitment andwork and professional satisfaction. The middle level manager has the greatest impact inaddressing these concerns and creating a positive social climate.

In addition, the closer the fit between what the nurse is seeking in employmentand what the organization can offer, the greater the chance that the nurse will beretained.

InterviewingAn interview may be defined as a verbal interaction between individuals for a

particular purpose. Although other tools such as testing or reference checks may beused, the interview is frequently accepted as the foundation for hiring. The purpose orgoals of te selection interview are threefold: (a) the interviewer seeks to obtain enoughinformation to determine the applicants suitability for the available position; (b) theapplicant obtains adequate information to make an intelligent decision about acceptingthe job, should it be offered; and (c) the interviewer seeks to conduct the interview insuch a manner that regardless of the interviews result, the applicant will continue tohave respect for and goodwill toward the organization.


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Types of Interview:Unstructured interview requires little planning because the goals for hiring may beunclear, questions are not prepared in advance, and often the interviewer does moretalking than the applicant.

Structured interview requires greater planning time because questions must bedeveloped in advance that address the specific job requirements, information must beoffered about the skills and qualities being sought, examples of the applicants

experience must be achieved, and the willingness or motivation of the applicant to dothe job must be determined. The interviewer who uses a structured format would ask thesame essential questions of all applicants.Limitations of Interviews

The major defect of interview is subjectivity. Most interviewers feel confident thatthey can overcome this subjectivity and view the interview as a reliable selection tool,whereas most interviews still have an element of subjectivity. The applicant, trying tocreate a favorable impression, also may be unduly influenced by the interviewerspersonality.

As a predictor of job performance and overall effectiveness, the structured

interview is much more reliable that the unstructured interview.Overcoming Interview Limitations

Prepare for the InterviewAsselin (2006) suggests that managers should have a complete and cleaunderstanding of the open position before the interviewing candidate. This includesobtaining a copy of the job description and knowing the educational and experientiarequirements for the position. The manager should also create a list of competenciesthat are essential for success on the job as well as the professional valuescharacteristics, and behaviors that are most likely to ensure success in the position.

Use Team ApproachHaving more than one person interview the job applicant reduces individual bias. Staffinvolvement in hiring can be viewed on a continuum from no involvement to a teamapproach, using unit staff for hiring decisions.

Develop A Structured Interview Format for Each Job ClassificationBecause each job has different position requirements, interviews must be structured tofit the position. The same structured interview should be used for all employees applyingfor the same job classification. The structured interview is advantageous because itallows the interviewer to be consistent and prevents the interview from becoming side-

tracked.

Use Scenarios to Determine Decision-Making AbilityIn addition to obtaining answers to a particular set of questions, the interview also shouldbe used to determine the applicants decision-making ability. This can be accomplishedby designing scenarios that require problem-solving and decision-making skills. Thesame set of scenarios should be used with each category of employee

Conduct Multiple InterviewsCandidates should be interviewed more than once on separate days. This preventsapplicants from being accepted or rejected merely because they were having a good or


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Ask questions clearly, but do not verbally or nonverbally indicate the correctanswer. Otherwise, by watching the interviewers eyes and observing other bodylanguage, the astute applicant may learn which answers are desired.

Always appear interested in what the applicant has to say. The applicant shouldnever be interrupted, nor should the interviewers words ever imply criticism of orimpatience with he applicant.

Language should be used that is appropriate for the applicant. Terminology orlanguage that makes applicants feel the interviewer is either talking down to them ortalking over their heads is inappropriate.

A written record of all interviews should be kept. Note taking ensures accuracy andserves as a written record to recall the applicant. Keep note taking or use of achecklist, however, to a minimum so that you do not create an uncomfortable climate

Ten Tips to Boost Interview IQ

1. Practice Good Nonverbal Communication.

2. Dress for the Job or Company

3. Listen

4. Don't Talk Too Much

5. Don't Be Too Familiar

6. Use Appropriate Language

7. Don't Be Cocky

8. Take Care to Answer the Questions

9. Ask Questions

10. Don't Appear Desperate

Interviewing Tips for the Applicants

1. Prepare in advance for the interview.

2. Obtain copies of the philosophy and organization chart of the organization to whichyou are applying.

3. Schedule an appointment for the interview.

4. Dress professionally and conservatively.

5. Practice responses to potential interview questions in advance.

6. Arrive early on the day of the interview.

7. Greet the interviewer formally, and do not sit down before he or she does unlessgiven permission to do so.

8. Shake the interviewers hand upon entering the room and smile.

9. During the interview, sit quietly, be attentive, and take notes only if absolutelynecessary.

10. Do not chew gum, fidget, slouch, or play with your hair, keys, or writing pen.

11. Ask appropriate questions about the organization or the specific job for whichyou are applying.

12. Avoid a what can you do for me? approach, and focus instead on whetheryour unique talents and interests are a fit with the organization.

13. Answer interview questions as honestly and confidently as possible.


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14. Shake the interviewers hand at the close of the interview, and thank him orher for his or her time.

15. Send a brief, typed thank-you note to the interviewer within 24 hours of theinterview.

Interview EvaluationInterviewers should plan post-interview time to evaluate the applicants interview

performance . Interview note should be reviewed as soon as possible and necessarypoints clarified or amplified. Using a form to record the interview evaluation is good ideaThe final question on the interview report form is a recommendation for or against hiringIn answering this question, two aspects must carry the most weight:

The requirements for the job. Regardless of how interesting or friendly people areunless they have the basic skills for the job, they will not be successful at meeting theexpectations of the position. Likewise, those overqualified for a position will usually beunhappy in the job.

Personal bias. Because completely eliminating the personal biases inherent in theinterview is impossible, it is important for the interviewer to examine any negativefeelings that occurred during the interview. Often, the interview discovers that the

negative feelings have no relation to the criteria necessary for success in the position.

SelectionSelection is the process of choosing from among the applicants the best-qualifiedindividual or individuals for a particular job or position. This process involves verifyingthe applicants qualifications, checking his/her work history, and deciding of a goodmatch exists between the applicants qualifications and the organizations expectations.

Educational and Credential RequirementsConsideration should be given to educational requirements and credentials fo

each job category as long as a relationship exists between theses requirements and

success on the job.Reference Checks

All applications should be examined to see if they are complete and to ascertainthat the applicant is qualified for the position. At this point, references are requested,and employment history is verified. According to Asselin (2006), the manager shouldalways be cognizant of red flags in applications such as unexplained gaps inemployment history or frequent changes of employer without acceptable explanationPositions should never be offered until information on the application has been verifiedand references have been checked.

Pre-employment Testing

Pre-employment testing is used only when such testing is directly related to theability to perform a specific job. Although testing is not a stand-alone selection tool, itcan, when coupled with excellent interviewing and reference checking, provideadditional information about a candidate to make the best selection.Physical Examination as a Selection Tool

A medical examination is often a requirement for hiring. This examinationdetermines if the applicant can meet the requirements for a specific job and provides arecord of the physical condition of the applicant at the time of hiring. The physicaexamination also may be used to identify applicants who will potentially have


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unfavorable attendance records or may file excessive future claims against theorganizations health insurance.

Finalizing the SelectionThe closure of pre-employment process is as follows:

1. Follow up with applicants as soon as possible, thanking them for applying andinforming them when they will be notified about a decision.2. Candidates not offered a position should be notified of this as soon as possible

Reasons should be provided when appropriate, and candidate should be told whethetheir application will be considered for future employment or if they should reapply.3. Applicants offered a position should be informed in writing of the benefits, salaryand placement. This avoids misunderstandings later regarding what employees thinkthey were promised by the nurse-recruiter or the interviewer.4. Applicants who accept the job offers should be informed as to pre-employmentprocedures such as physical examinations and supplied with the date to report towork.5. Applicants who are offered positions should be requested to confirm in writing theiintention to accept the position.

PlacementThe astute leader is able to assign a new employee to a position within his or he

sphere of authority where the employee will have a reasonable chance for successNursing units and departments develop subcultures that have their own norms, values,and methods of accomplishing work. It is possible for one person to fit in well with anestablished group, whereas another equally qualified person would never become part ofthis group.

Conversely, proper placement fosters personal growth, provides a motivatingclimate for the employee, maximizes productivity, and increases the probability thatorganizational goals will be met. Managers who are able to match employee strengths tojob requirements facilitate unit functioning, accomplish organizational goals, and meetemployee needs.

IndoctrinationIndoctrination refers to the planned, guided adjustment of an employee to the

organization and the work environment. Although the words induction andorientation are frequently used to describe this function, the indoctrination processincludes three separate phases: induction, orientation, and socialization.

Indoctrination seeks to (a) establish favorable employee attitudes toward theorganization, unit, and department; (b) provide the necessary information and educationfor success in the position; and (c) instill a feeling of belonging and acceptance. Theemployee indoctrination process begins as soon as person has been selected for aposition and continues until the employee has been socialized to the norms and valuesof the work group.Employee Indoctrination Content:

1. Organization history, mission, and philosophy2. Organization service and service area3. Organizational structure, including department heads, with an explanation of thefunctions of the various departments4. Employee responsibilities to the organization5. Organizational responsibilities to the employee


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6. Payroll information, including how increases in pay are earned and when they aregiven (progressive or unionized companies publish pay scales for all employees)7. Rules of conduct8. Tour of the facility and of the assigned department9. Work schedules, staffing and scheduling policies10. When applicable, a discussion of the collective bargaining agreement11. Benefit plans, including life insurance, health insurance, pension, andunemployment

12. Safety and fire programs13. Staff development programs, including in-service and continuing educationfor relicensure.14. Promotion and transfer policies15. Employee appraisal system16. Workload assignments17. Introduction to paperwork/forms used in the organization18. Review of selection in policies and procedures19. Specific legal requirements, such as maintaining a current license, reportingof accidents, and so forth20. Introduction to fellow employees

21. Establishment of a feeling of belonging and acceptance, showing genuineinterest in the new employee

InductionInduction, the first phase of indoctrination, takes place after the employee has

been selected but before performing the job role. The induction process includes alactivities that educate the new employee about the organization and employment andpersonnel policies and procedures.

Employee handbooks, an important part of induction, are usually developed by thepersonnel department. Managers, however, should know what information the employeehandbooks contain and should have input into their development. Most employeehandbooks contain a form that must be signed by the employee, verifying that he or shehas received and read it. The signed form is then placed in the employees personnefile.

The handbook is important because employees cannot assimilate all the inductioninformation at one time, so they need a reference for later. However, providing anemployee with a personnel handbook is not sufficient for real understanding. Theinformation must be followed with discussion by various people during orientation. Themost important link in promoting real understanding of personnel is the first-levemanager.

OrientationOrientation provides information about the activities more specific for the position

The purpose of the orientation process is to make the employee feel like a part of theteam. This will reduce burnout and help new employees become independent morequickly in their new roles.Sample of Line-up of Activities Done in Orientation

- Welcome by personnel department; employee handbooks distributed anddiscussed- General Orientation by staff development- Tour of the Organization- Fire and safety films, body mechanics demonstration


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- Introduction to each unit supervisor- Report to individual units (time with unit supervisor and introduction toassigned preceptor)- General orientation of policies and procedures- CPR recertification- Work with preceptor on shift and unit assigned, gradually assuming greaterresponsibilities- Carry normal workload aster a week. Have at least a 30-minute meeting with

immediate supervisor to discuss progress.

Socialization and ResocializationSocializing new nurses into the healthcare culture will help retain them.- Sandy Keefee, MSN, RN

Role Theory- The phenomenon of socialization has generally focused on this theory- Explains that behaviors that accompany each role are learned socially and by

instruction, observation and trial and error

Socialization

- First occurs during nursing school and after graduation- Because nurse administrators and nursing faculty have found to hold different

values and both this groups assist in socializing the new nurse, there is potential for thenew nurse to develop conflict and frustration.

Resocialization- Occurs when individuals are forced to learn new values, skills, attitudes and socia

rules as a result of changes in the type of work they do, the scope of responsibility theyhold, or in the work setting itself

- Individuals who need resocialization include new graduates leaving school and

entering the work world; experienced nurses who change work settings, either withinthe same organization or in the new organization; and nurses who undertake new roles.- Some employees adapt easily to resocialization, but most experience stress with

the role change.

Overcoming Motivational Deficiencies- Difficulties in socialization and resocialization occurs because of motivationa

deficiencies- There are 2 ways to correct motivational deficiencies: positive and negative

sanctions

Positive Sanctions- Can be used as an interactional or educational process- The reference group sets of norms of behavior and then applies sanctions to

ensure that new members adopt the group norms before acceptance in the group.- Managers should become aware of what role behavior they reward and what new

employee behavior the senior staff is rewarding.

Negative Sanctions- They are like rewards


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- Provide cues that enable the people to evaluate their performance consciously andto modify behavior when needed

- They are often applied in very subtle and covert ways- They should be constructive and not destructive

Employees with unique socialization needs- Managers who provide appropriate socialization assistance for these groups

increase the chance of positive employment outcome

The New Nurse- Reality Shock was coined by Kramer (1974) which described fears and

difficulties in adapting to work setting that are common to new graduate nurses; itoccurs as a result of conflict between a new graduate nurses expectations of thenursing role and the reality of actual role in the work setting

- Four phases of role transition from student nurse to staff nurse:honeymoon phase, shock, recovery and resolution phase.

- Roles of nurse managers in combating reality shock:

Nurse Managers should not rely in anticipatory socialization prepared by nursing

schools. They should be alert for signs and symptoms of the shock phase of role

transition.

They should also ensure that some of the new nurses values are supported andencouraged so that work and academic values can blend.

International Nurses- One solution to current nursing shortage (applicable only to U.S.)- Ryan (2003) suggests that socialization to the professional nursing role is one of

four basic needs that must be addresses if foreign nurses are to adapt successfullyto American workplaces.

-Bola, Driggers, Dunlap, and Ebersole (2003) state that international nurses also

frequently experience culture shock regarding nonverbal communication that mayinterfere with their assimilation.

- Ryan (2003) suggests that using a Cultural Diversity Enhancement Group (CDEG)and a buddy program may assist in socializing these international nurses; includesstaff nurses and management personnel from varied ethnic backgrounds whoagreed to buddy with the international nurses to make them feel welcomed in theorganizational culture.

- Dumpel (2005) says that international nurses need the same socialization as othetransition groups such as mentors and preceptors, support groups and otheorientation programs.

New Managers- Sullivan, Bretschneider, and McCausland (2003) found that many new managers

perceived themselves as lacking basic and introductory managerial skills related tocommunication, conflict resolution, role transitioning, scheduling, budgeting andpayroll management, performance evaluation, and staff counseling which result inmanagement errors.

- The direction a new manager needs comes from several sources withinthe organization which includes:

The new managers immediate superior


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A group of the new mangers peers

A mentor- Role ambiguity- describes the stress that occurs when job expectations areunclear- Role Overload- occurs when the demands of the role are excessive

The Experienced Nurse in the New Position

Transition from expert to novice

- a very difficult role transition- Many nurses transfer or change jobs because they can no longer find their present

job challenging

Transition from familiar to unfamiliar- In the old surroundings, the employee knew everyone and where everything was

located. In the new position, the employee will not be only learning new job skillsbut also be in an unfamiliar environment.

-

Specialized orientation material should be developed and necessary staffdevelopment orientation programs should be provided

Assisting the Experienced Nurse in Role Transition- Managers should not assume that the experienced nurse is aware of the new roles

expected attitudes.- Managers need to support employees during this value resocialization.

Clarifying Role Expectations through Role Models,Preceptors and MentorsIn looking for a role model, I didnt have to go far.- William M. Keane Jr.

Role Model- Defined as someone worthy of imitation- They are experienced, competent employees- One of the exciting aspects of role models is their cumulative effect. The greater

the number of excellent role models available for new employees to emulate, thegreater the possibilities for new employees to perform well.

Preceptor- An experienced nurse who provides knowledge and emotional support, as well as a

clarification of role expectations, on a one-on-one basis- An effective preceptor can role model and adjust teaching to each learner as

needed.

Mentor- Madison (2006) described mentoring as a distinctive interactive relationship

between two individuals, occurring most commonly in a professional setting.- A mentor is able to instill the values and attitudes that accompany each role; often

a role model and visionary for the mentee.- A preceptor is different from a mentor.

PRECEPTOR MENTOR- Usuallyassigned

- Freely choosewho they will


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- Relativelyshortrelationshipwith the personto whom theywere assigned

mentor- Relationship islonger andmore intense

Four phases in mentoring relationships:

1. Initiation occurs when the relationship is established2. Cultivation characterized by coaching, protection and sponsorship as well as

counseling, acceptance and the creation of a sense of competence.3. Separation ---4. Redefinition Both are difficult, as the mentor and mentee may share different

perceptions about whether it is time to separate and what their new relationshipshould be.

Validities and Legalities in HiringHealthcare facilities are more interested in hiring nursing students who canthink critically and organize than those who boast competencies, such as animpressive number of injections given.Lorraine Steefel, RN, MSN, CTN

Given the importance of a decision to hire, it is understandable that humanresources and first- level managers have sought refined methods to evaluate and screenapplicants. A wide variety of pre employment tests are used to determine whichcandidate is best suited for a position.

Testing- It has an impact on selection of employees- If the employees to be hired fail the test in significantly greater percentages than

the overall failure rate, the employer using the test must prove that it is a validindicator of the abilities that are needed to perform the job

3 Forms of Validity in testing:

Content Validity The test recreates or represents significant sample parts of thejob, such as typing tests.

Construct Validity The test identifies a psychological or personality trait that isimportant to successful performance, such as leadership or problem solving abilities.

Criterion-related Validity The test contains elements on which anyone who would

do well on the job perform well or anyone who would do poorly on the job will performpoorly.

Legal Aspects of Pre employment Inquiries

Subject ofInquiry

It may notbediscriminatory toinquire

It may bediscriminatory toinquireabout:


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about:1. Name Whether

applicanthas everworkedunder adifferentname

a. Originalname of anapplicantwhosename hasbeenlegally

changed

b. Theethnicassociationofapplicantsname

2. Age a. If applicant isover theage 18

b. If applicant isunder theage 18 or21 if jobrelated

a.Date ofbirth

b.Date ofhigh schoolgraduation

3.Residence

a.Applicantsplace of residencewhereemployer islocated

a.Previousaddresses

b.Birthplace ofapplicantorapplicantsparents

4. Race orcolor

a.Applicants race orcolor of applicants

skin5.Nationalorigin andancestry

a.Applicants lineage,ancestry,nationalorigin,parentage,ornationality

6. Sexand

a. Sex of applicant


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Familycomposition

b.Dependents ofapplicant

c. MaritalStatus

d. Child-carearrangements

7.Creed orreligion

a.Applicants religiousaffiliation

b.Church,parish, orholidaysobserved

8.Citizenship

a. Whethertheapplicant isa citizen ofthe UnitedStates

b. Whethertheapplicant isin thecountry ona visa thatpermitshim or herto work oris a citizen

a.Whetherapplicant isa citizen ofthe countryother thanthe UnitedStates

9.Language

a.Language

applicantspeaks andor writesfluently, ifjob related

a.Applicants native

language;languagecommonlyused athome

10.References

a. Namesof peoplewilling toprovideprofessional and/or

a. Name ofapplicantspastor orreligiousleader


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characterreferencesof theapplicant

11.Relatives

a. Namesof relativesalreadyemployed

by theemployer

a.Nameand/oraddress ofany relative

of applicant

b.Whom tocontact incase of emergency

12.Organizations

a.Applicantsmembership in anyprofessional, service ortradeorganization

a. All clubsor socialorganizations to whichapplicantbelongs

13. Arrestrecordandconvictions

a.Convictionsif related tojobperformance

a. Numberand kindsof arrests

b.Convictionsunlessrelated tojobperformance

14.Photographs

a.Photographs withapplication,withresume, orbefore

hiring15. HeightandWeight

a.Anyinquiry intoheight andweight ofapplicantexceptwhere abona fideoccupational


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qualification

16.Physicallimitations

a. Whetherapplicanthas theability toperformjob- related

functionswith orwithoutaccomodation

a.Thenature orseverity ofan illnessor theindividuals

physicalcondition

b.Whetherapplicanthas everfiled aworkerscompensation claim

c.Anyrecent orpastoperationsor surgerydates

17.Education

a. Trainingapplicanthasreceived ifrelated tojob underconsideration

b. Highestlevel of educationattained, ifvalidatedthat having

certaineducationalbackground isnecessaryto performthe specificjob

18.Military

a. Whatbranch ofmilitary

a. Type ofmilitarydischarge


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applicantserved in

b. Type ofeducationor trainingreceived inthe military

c. Rank atdischarge

19.FinancialStatus

a.Applicants debts andassets

Hiring A Shared ResponsibilityThe question of who makes the final employment hiring from among screened

candidates is critical. Hiring remains an inexact science despite all the techniques that

have been developed and used. Ideally, the decision is made by the manager to whomthe new employee will report, with the advice and counsel of the human resourcesdepartment. This approach has the advantages that stipulated and necessary credentiarequirements are met, organizational policies and employment laws are followed, andindividuals selected meet the quality standards and conform to its vales and culture.

Patient Care Classification SystemThe patient care classification system is a method of grouping patients according

to the amount and complexity of their nursing care requirements and the nursing timeand skill they require. This assessment can serve in determining the amount of nursingcare required, generally within 24 hours, as well as the category of nursing personnel

who should provide that care.As a result, ofpatient classification systems (PCS), also known as workloadmanagement, or patient acuity tools, were developed in the 1960s. Because othervariables within the system have an impact on nursing care hours, it is usually notpossible to transfer a PCS from one facility to another. Instead, each basic classificationsystem must be modified to specific institution.

Adomat and Hewison (2004) suggest that most PCSs can be classified as robustmeasures for severity of illness. However, they maintain that although they are helpful,they are not accurate tools for determining nurse-patient ratios, and that all PCSmeasurement tools need nursing input if they are to measure nurse-patient needsaccurately.

There are several types of PCS measurement tools. The critical indicatorPCS usesbroad indicators such as bathing, diet, intravenous fluids and medications, andpositioning to categorize patient care activities. The summative task type requires thenurse to note for frequency of occurrence of specific activities, treatments, andprocedures for each patient. For example, a summative task-type PCS might ask thenurse whether a patient required nursing time for teaching, elimination, or hygiene. Bothtypes of PCSs are generally filled out prior to each shift, although the summative tasktype typically has more items to fill out than the critical incident or criterion type.

Once an appropriate PCS is adopted, hours of nursing care must be assigned foreach patient classification. Although an appropriate number of hours of care for eachclassification is generally suggested by companies marketing PCSs, each institution is


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unique and must determine to what degree that classification system must be adaptedto that institution. White (2003) suggests that average length of stay, and practitionerspecialty in defining its patient population. In addition, staff competency, core stafversus visiting staff, and skill mix must be considered (White, 2003).

To develop a workable patient classification system, the nurse manager mustdetermine the following:

1. The number of categories into which the patients should be divided;2. The characteristics of patients in each category;

3. The type and number of care procedures that will be needed by a typical patient ineach category; and4. The time needed to perform these procedures that will be required by a typicapatient in each category.

The number of categories in a patient classification may range from three to fourwhich is the most popular, to five or six. These classes relate to the acuity of illness andcare requirements, whether minimal, moderate, or intensive care. Other factors affectingthe classification system would relate to the patients capability to meet his physicaneeds to ambulate, bathe, feed himself, and other instructional needs includingemotional support.

Patients care classifications have been developed primarily for medical, surgical

pediatrics, and obstetrical patients in acute care facilities.

Classification CategoriesThe various units mat develop their own ways of classifying patient care according

to the acuity of their patients illness. Following is an example of a patient careclassification in the medical-surgical unit.

Level I Self Care or Minimal Care Patient can take a bath on his own, feedhimself, feed and perform his activities of daily living. Falling under this category arepatients about to be discharged, those in non-emergency, those newly admitted, do notexhibit unusual symptoms, and requires little treatment/observation and/or instructionAverage amount of nursing care hours per patient per day is 1.5. Ratio of professionaand non-professional nursing personnel is 55:45.

Level II Moderate Care or Intermediate Care Patients under this level needsome assistance in bathing, feeding, or ambulating for short periods of time. Extremesymptoms of their illness must have subsided of have not yet appeared. Patients mayhave slight emotional needs, with vital signs ordered up to three times per shiftintravenous fluids or blood transfusion; are semi-conscious and exhibiting somepsychosocial or social problems; periodic and treatments, and/or observations and/orinstructions. Average nursing care hours per patient per day is 3 and the ratio oprofessional to non-professional personnel is 60:40.

Level III Total, Complete or Intensive Care Patients under this category arecompletely dependent upon the nursing personnel. They are provided complete bathare fed, may or may not be unconscious, with marked emotional needs, with vital signsmore than three times per shift, may be on continuous oxygen therapy, and with chestor abdominal tubes. They require close observation at least every 30 minutes foimpending hemorrhage, with hypo or hypertension and/or cardiac arrhythmia. Thenursing care hours per patient per day is 6 with a professional to non-professional ratioof 65:35.

Level IV Highly Specialized Critical Care Patients under this level needmaximum nursing care with a ratio of 80 professionals to 20 non-professionals. Patientsneed continuous treatment and observation; with many medications, IV piggy backsvital signs every 15-30 minutes; hourly output. There are significant changes in doctors


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orders and care hours per patient per day may range from 6-9 more, and the ratio ofprofessionals to non-professionals also ranges from 70:30 to 80:20.

Patient Care Classification Using Four Levels ofNursing Care Intensity

Area of Care Category 1 Category 2 Category 3 Category 4Eating Feeds self or

needs little

food

Needs somehelp in

preparingfood tray;may needencouragement

Cannot feedself but is

able to chewand swallow

Cannot feedself and may

havedifficultyswallowing

Grooming Almostentirely self-sufficient

Needs somehelp inbathing, oralhygiene,haircombing,and so forth

Unable to domuch forself

Completelydependent

Excretion Up and tobathroomalone oralmost alone

Needs somehelp ingetting upto bathroomor usingurinal

In bed,needsbedpan orurinalplaced; maybe able topartially turnor lift self

Completelydependent

Area of Care Category 1 Category 2 Category 3 Category 4

Comfort Self-sufficient Needs somehelp withadjustingposition orbed (e.g.,tubes, IVs)

Cannot turnwithouthelp, getdrink, adjustposition ofextremities,and so forth

Completelydependent

GeneralHealth

Good in fordiagnosticprocedure,simple

treatment,or surgicalprocedure(D & C,biopsy,minorfracture)

Mildsymptoms more thanone mild

illness, milddebility,mildemotionalreaction,mildincontinence(not morethan onceper shift)

Acutesymptoms severeemotional

reaction toillness orsurgery,more thanone acuteillness,medical orsurgicalproblem,severe orfrequent

Critically ill may havesevereemotional

reaction


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incontinenceTreatments Simple

supervisedambulation,dangle,simpledressing,test

procedurepreparationnotrequiringmedication,reinforcement of surgicaldressing, x-pad, vitalsigns onceper shift

Anycategory 1treatmentmore thanonce pershift, Foleycatheter

care, I & O;bladderirrigations,sitz baths,compresses,testproceduresrequiringmedicationsor follow-ups, simpleenema forevacuation,vital signsevery 4hours

Anytreatmentmore thantwice pershift,medicatedIVs,

complicateddressings,sterileprocedures,care of tracheostomy, Harrisflush,suctioning,tubefeeding,vital signsmore thanevery 4hours

Anyelaborate ordelicateprocedurerequiringtwo nurses,vital signs

more oftenthan every 2hours

Medications Simple,routine, notneeding pre-evaluationor postevaluation;medicationsno morethan onceper shift

Diabetic,cardiac,hypotensive,hypertensive, diuretic,anticoagulantmedications,prnmedications,more thanonce pershift,medicationsneeding pre-evaluation

or postevaluation

High amountof category2medications;control ofrefractorydiabetes(need to bemonitoredmore thanevery 4hours)

Extensivecategory 3medications;IVs withfrequent,closeobservationandregulation

Teachingandemotionalsupport

Routinefollow-upteaching;patientswith nounusual oradverseemotionalreactions

Initialteaching ofcare of ostomies;newdiabetics;tubes thatwill be inplace for

Moreintensivecategory 2items;teaching ofapprehensive or mildlyresistivepatients;

Teaching ofresistivepatients;care andsupport ofpatients withsevereemotionalreaction


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periods oftime;conditionsrequiringmajorchange ineating,living, or

excretorypractices;patientswith mildadversereactions totheir illness(e.g.,depression,overlydemanding)

care of moderatelyupset orapprehensive patients;confused ordisorientedpatients

Table 2. Categories or levels of care of patients, nursing care hours needed perpatient per day and ratio of professionals to non-professionalsLevels of Care

NCHNeededPer Pt. PerDay

Ratio ofProf. toNon-Prof.

Level I 1.50 55:45Self Care orMinimal Care

Level II 3.0 60:40Moderate orIntermediateCare

Level III 4.5 65:35Total orIntensiveCare

Level IV 6.0 70:30HighlySpecialized orCritical Care

7 or higher 80:20

The Hospital Nursing Service Administration Manual of the Department of Health hasrecommended the following nursing care hours for patients in the various nursing unitsof the hospital.

Table 1. Nursing care hours per patient per day according to classification ofpatients by units.


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Cases/Patients NCH/Pt/day Prof. to Non Prof.Ratio

1. General Medicine 3.5 60:402. Medical 3.4 60:403. Surgical 3.4 60:404. Obstetrics 3.0 60:405. Pediatrics 4.6 70:306. Pathologic Nursery 2.8 55:457. ER/ICU/RR 6.0 70:308. CCU 6.0 80:20

Percentage of Nursing Care HoursThe percentage of nursing care hours at each level of care also depends on the

setting in which the care is being given. For primary hospitals, about 70 percent of theirpatients need minimal care, 25 percent need moderate care. Patients needing intensivecare are given emergency treatment and when their condition becomes stable or whenimmediate treatment is necessary and the hospital has no facilities for this, the patient istransferred to a secondary of tertiary hospital.

In a secondary hospital, 65 percent of the patients need minimal care, 30 percentneed moderate care, and only 5 percent need intensive care. In tertiary hospitals, about30 percent of patients need minimal care; 45 percent need moderate care, 15 percentneed intensive care, while 10 percent will need highly specialized intensive care. Inspecial tertiary hospitals about 10 percent will need minimal care; 25 percent needmoderate care; 45 percent need intensive care; while about 20 percent will need highlyspecialized intensive care.

Table 3. Percentage of patients at various levels of care per type of hospitalPercentage of Patients in Various Levels of CareType of

Hospital

Minimal

Care

Moderate

Care

Intensive

Care

Highly Spl.

Care

PrimaryHospital

70 25 5 -

SecondaryHospital

65 30 5 -

TertiaryHospital

30 45 15 10

Spl. TertiaryHospital

10 25 45 20

Computing for the Number of Nursing Personnel NeededWhen computing for the number of nursing personnel in the various nursing units

of the hospitals, one should ensure that there is sufficient staff to cover all shifts, off-duties, holidays, leaves, absences, and time for staff development programs.

The Forty-Hour Week Law (Republic Act 5901), provides that employees working inhospitals with 100-bed capacity and up will work only 40 hours a week. This also appliesto employees working in agencies with at least one million population. Employeesworking in agencies with less than one hundred-bed capacity or in agencies located incommunities with less than one million population will work forty-eight hours a week andtherefore will get only one off-duty a week.


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There are also benefits that have to be enjoyed by each personnel regardless ofthe working hours per week. The latest is the granting of the three-day special privilegeto government employees by the Civil Service Commission as per Memorandum CircularNo. 6, series of 1996, which may be spent for birthdays, weddings, anniversariesfunerals (mourning), relocation, enrollment or graduation leave, hospitalization, andaccident leaves.

Table 4. Total number of working and non-working days and hours of nursing

personnel per year.Rights and Privileges GivenEach Personnel

Working Hours Per Week

Per Year 40 Hours 48 Hours1. 1. Vacation Leave 15 152. Sick Leave 15 153. Legal Holidays 10 104. Special Holidays 2 25. Special Privileges 3 36. Off-Duties as per R.A. 5901 104 52

7. Continuing Education Program 3 3______ ______Total Non-Working Days Per Year 152 100Total Working Days Per Year 213 265Total Working Hours Per Year 1,704 2,120

Relievers NeededTo compute for relievers needed, the following should be considered:1. Average number of leaves taken each year - - - - - - 15

a. Vacation Leave - - - - - - - - - - - - - - - - - - - - - - - 10b. Sick Leave - - - - - - - - - - - - - - - - - - - - - - - - - - - 5

2. Holidays - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 123. Special Privileges as per CSC MC#6 s.1996 - - - - - - -34. Continuing Education Program for Professionals - - 3

Total Average Leaves 33

It will be noted that although an employee is entitled to 15 days sick leave and 15days vacation leave, 12 holidays, 3 days for continuing education, plus 3 days of speciaprivileges or 48 days total, he or she gets only an average of 33 days leave per year.

To determine the relievers needed, divide 33 (the average number of working daysan employee is absent per year) by the number of working days per year that each

employee serves (whether 213 or 265). This will be 0.15 per person who works 40 hoursper week and 0.12 per person for those working 48 hours per week.

Multiply the computed reliever per person by the computed number of nursingpersonnel. This will give the total number of relievers needed.

Distribution by ShiftsStudies have shown that the morning or day shift needs the most number of

nursing personnel at 45 to 51 percent; for the afternoon shift 34 to 37 percent; and forthe night shift 15 to 18 percent. In the Philippines the distribution usually followed is 45


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percent for the morning shift, 37 percent for the afternoon shift, and 18 shift for thenight shifts.

Staffing FormulaTo compute for the staff needed in the In-Patient units of the hospital the following

steps are considered:1. Categorize the number of patients according to the levels of care needed. Multiplythe total number of patients by the percentage of patients at each level of care

(whether minimal, intermediate, intensive or highly specialized).2. Find the total number of nursing care hours needed by the patients at eachcategory level.

a. Find the number of patients at each level by the average number of nursingcare hours needed per day.

b. Get the sum of the nursing care hours needed at the various levels.3. Find the actual number of nursing care hours needed by the given number ofpatients. Multiply the total nursing care hours needed per day by the total number ofdays in a year.4. Find the actual number of working hours rendered by each nursing personnel peryear. Multiply the number of hours on duty per day by the actual working days per

year.5. Find the total number of nursing personnel needed.

a. Divide the total number of nursing care needed per year by the actuanumber of working hours rendered by an employee per year.

b. Find the number of relievers. Multiply the number of nursing personneneeded by 0.15 (for those working 40 hours per week) or by 0.12 (for thoseworking 48 hours per week).

c. Add the number of relievers to the number of nursing personnel needed.6. Categorize the nursing personnel into professionals and non-professionals. Multiplythe number of nursing personnel according to the ratio of professionals to nonprofessionals.7. Distribute by shifts.

To illustrate:Find the number of nursing personnel needed for 500 patients in a tertiary

hospital.1. Categorize the patients according to level of care needed.

500 (pts) x .30 = 150 patients needing minimal care500 (pts) x .45 = 225 patients needing moderate care500 (pts) x .15 = 75 patients need intensive care500 (pts) x .10 = 50 patients need highly specialized nursing care

5002. Find the number of nursing care hours (NCH) needed by patients at each level of

care per day.150 pts x 1.5 (NCH needed at Level I) = 225 NCH/day

225.5 pts x 3 (NCH needed at Level II) = 675 NCH/day75 pts x 4.5 (NCH needed at Level III) = 337.5 NCH/day50 pts x 6 (NCH needed at Level IV) = 300 NCH/day

Total 1537.5 NCH/day3. Find the total NCH needed by 500 patients per year.

1537.5 x 365 (days/year) = 561,187.50 NCH/year4. Find the actual working hours rendered by each nursing personnel per year.


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8 (hrs/day) x 213 (working days/year) = 1,704 (working hours/year)5. Find the total number of nursing personnel needed.

a. Total NCH per year = 561,187.50 = 329Working hrs/year 1,704

b. Relief x Total Nursing Personnel = 329 x 0.15 = 49c. Total Nursing Personnel needed 329 + 49 = 378

6. Categorize to professional and non-professional personnel. Ratio of professionals tonon-professionals in a tertiary hospital is 65:35.

378 x .65 = 246 professional nurses378 x .35 = 132 nursing attendants

7. Distribute by shifts.246 nurses x .45 = 111 nurses on AM shift246 nurses x .37 = 91 nurses on PM shift246 nurses x .18 = _ 44 _nurses on night shift

Total 246 nurses132 Nursing attendants x .45 = 59 Nursing attendants on AM shift132 Nursing attendants x .37 = 49 Nursing attendants on PM shift132 Nursing attendants x .18 = _ 24 _Nursing attendants on night shift

Total 132 Nursing Attendants

It should be noted that the above personnel are only for the in-patients. Thereforeadditional personnel should be hired for those in supervisory and administrativepositions and for those in special units such as the Operating Room, the Delivery Roomthe Emergency Room, and Out-Patient Department.

A Head Nurse is provided for every nursing unit. Likewise, a Nursing Superior isprovided 1) to cover every shift in each clinical department or area specialty unit; 2) foreach geographical area in hospitals beyond one hundred (100) beds and; 3) for eachfunctional area such as Training, Research, Infection Control, and Locality Management.Managers Responsibilities in Meeting Staffing Needs

The manager must ascertain that adequate numbers and an appropriate mix ofpersonnel are available to meet daily unit needs and organizational goals.

It is important that staffing patterns and scheduling policies must be administered fairlyas well as economicallybecause they both directly affect the daily lives of all personnel.

Leadership Roles and Management Functions Associated withStaffing and SchedulingLEADERSHIP ROLES MANAGEMENT FUNCTIONS1. Identifies creative and flexiblestaffing methods to meet the needs

of the patients, staff and theorganization.2. Is knowledgeable regardingcontemporary methods of schedulingand staffing.3. Assumes a responsibility towardstaffing that builds trust andencourages a team approach.4. Periodically examines the unitstandard of productivity to determineif changes are needed.

1. Provides adequate staffing to meetpatient care needs according to the

philosophy of the organization.2. Uses organizational goals andpatient classification tools tominimize understaffing andoverstaffing as patient census andacuity fluctuate.3. Schedules staff in a fiscallyresponsible manner.4. Develops fair and uniformscheduling policies andcommunicates these clearly to all


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5. Is alert to extraneous factors thathave an impact on staffing.6. Is ethically accountable to patientsand employees for adequate and safestaffing.7. Plans for staffing shortages sopatient care goals will be met.8. Assesses if and how workforce

intergenerational values impactstaffing needs and respondsaccordingly.

staff.5. Ascertains that scheduling policiesare not in violation of local andnational labor laws, organizationalpolicies or union contracts.6. Assumes accountability for qualityand fiscal control of staffing.7. Evaluates scheduling and staffing

procedures and policies on a regularbasis.

Inflexible scheduling is a major contributor to job dissatisfaction and turnover on the partof nurses. Managers should do whatever they can to see that employees feel they havesome control over scheduling, shift options and staffing policies.

The overall responsibility for scheduling continues to be an important function of first-and middle-level managers, although staffing clerks and computers assist with staffing insome organizations. Each organization has different expectations regarding the unitmanagers responsibility in long-range human resource planning and in short-rangeplanning for daily staffing.

Centralized Staffing is where staffing decisions are made by personnel in a central officeor staffing center. Such centers may or may not be staffed by RNs, although someone inauthority would be a nurse when a staffing clerk carries out the day-to-day activity.

Advantages:The managers role is limited to making minor adjustments and providing inputThe manager continues to have ultimate responsibility for seeing that adequatepersonnel are available to meet the needs of the organization.

It is fairer to all employees because policies tend to be employed more consistentlyand impartially.

It allows for the most efficient (cost effective) use of resources since the more unitsthat can be considered together, the easier it is to deal with variations in patientcensus and staffing needs.

Disadvantages:It does not provide as much flexibility for the worker, nor can it account as well fora workers desires or special needs.Managers may be less responsive to personnel budget control if they have limitedresponsibility in scheduling and staffing matters.

Decentralized Staffing is where the unit manager is often responsible for covering alscheduled staff absences, reducing staff during periods of decreased patients or acuityadding staff during periods of high patient census, preparing monthly unit schedules,and preparing holiday and vacation schedules.

Advantages:


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The unit manager understands the needs of the unit and staff intimately, whichleads to increased likelihood that sound staffing decisions will be made.

The staff feels more in control of their work environment because they are able totake personal scheduling requests directly to their immediate supervisor.

It leads to increased autonomy and flexibility, thus, decreasing nurse attrition.Disadvantages:

It carries the risk that employees will be treated unequally or inconsistently.The manager may be viewed as granting rewards or punishments through thestaffing schedule.

It is time consuming for the manager and often promotes more special pleadingthan centralized staffing.

The major difficulty is ensuring high-quality staffing decisions throughout theorganization.

Budreau, Balakrishnan, Titler and Hafner (1999) state that nursing management is

highly decentralized in most hospitals, with considerable variation found in staffingamong patient care units. This means that many nurse-manager have some control ovefactors that affect cost on their specific units.

Managers must also be cognizant of the need to have an ethnicallyand culturallydiverse staff to meet the needs of an increasingly diverse patient population.

unique cultural and linguistic needs of patient population = appropriately diverse staff

Malloch, Deveonport and Hatler (2003) suggest that the importance of providingculturally competent caregivers cannot be overstated since health care congruent withcultural beliefs and values is essential for optimal outcomes.

Nurse-managers must be cognizant of new recommendations and legislationaffecting staffing.

For example: minimum staffing ratiosProponents of legislated minimum staffing ratios say that ratios are neededbecause many hospitals current staffing levels are so low that both RNs andpatients are negativelyaffected.Poor staffing = (-) nurses health & safety + (-) patient outcomes3 Arguments against Staffing Ratios:1. The current nursing shortage will make it difficult to fill the slots when the ratiosappear.2. The ratios may merely serve as a Band-aid to the greater problems of qualitycare.3. Numbers alone do not ensure improved patient care since not all RNs haveequivalent clinical experience and skill levels.

Scheduling OptionsSome of the more frequently used creative staffing and scheduling options include:

10- or 12- hour shiftsThe resultant nurse satisfaction must be weighed against the increased costs because

extending the workday with 10- to 12-hour shifts may require overtime pay.Extending the length of shifts may result in increased judgment errors as nurses

become fatigued.


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Organizations limit the number of consecutive 10- or 12-hour days a nurse can work orthe number of hours that can be worked in a given day.

Premium pay for weekend work

Part-time staffing pool for weekend shifts and holidays

Cyclical staffing, which allows long term knowledge of future work schedulebecause a set staffing pattern is repeated every few weeks

Job sharing

Allowing nurses to exchange hours of work among themselves FlextimeIt is a system that allows employees to select the time schedules that best meet thei

personal needs while still meeting work responsibilities.Most flextime has been possible only for nurses in roles that did not require

continuous coverage. Staff nurses recently have been able to take part in a flextimesystem through prescheduled start times. Variable start times may be longer or shorterthan the normal 8- hour workday.

Units have employees coming and leaving the unit at many different times when ahospital uses flextime. Although flextime staffing creates greater employee choices, itmay be difficult for the manager to coordinate and could easily result in overstaffing or

understaffing. Use of supplemental staffing from outside registries and float poolsAgency nurses or travel nurses are usually directly employed by an external broker

and work for premium pay (2-3 times that of regularly employed staff), without benefits.While such staff provide scheduling relief, especially in response to unanticipated

increases in census or patient acuity, their continuous use is expensive and can result inpoor continuity of care.

Some hospitals have created their own internal supplemental staff by hiringper-diememployees and creating float pools.

Per-diem staff generally has flexibility to choose if and when they want to work. Inexchange for this flexibility, they receive higher rate of pay, but usually no benefits.

Float pools are generally composed of employees who agree to cross train on multipleunits so that they can work additional hours during periods of high census or workershortages. Wing (2001) argues, however, that float pools are adequate for fillingintermittent staffing holes but, like agency or registry staff, are not an answer to theongoing need to alter staffing according to census. It results in lack of staff continuity.

Staff self-schedulingIt was developed in 1960s where it allowed nurses in a unit to work together to

construct their own schedules rather than have schedules created by management.Employees are typically given four to six week schedule worksheets to fill out severa

weeks in advance of when the schedule is to begin.These employees typically have one to two weeks to fill in the blanks on the schedule

following whatever guidelines or requirements are set by the management (i.e., numberof weekend shifts that must be worked, maximum number of consecutive shifts) (Hung2002).

The nurse-manager then reviews the worksheet to make sure all the guidelines orequirements have been met.Points to consider:

Although self-scheduling offers nurses greater control over their work environment, itis not easy to implement. Success depends on the leadership skills of the manager tosupport the staff and demonstrate patience and perseverance throughout theimplementation.


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Shullanberger (2000) found that it provides greater worker participation in decisionmaking but requires greater worker involvement and management flexibility to besuccessful.

It saves management time, improve morale and professionalism and reducespersonnel turnover (Hung, 2002).

Nurses most satisfied with self-scheduling were those who shared responsibility foadequate staffing and those who had developed good negotiating skills.Obviously, all scheduling and staffing patterns, from traditional to creative, have

shortcomings.Therefore, any changes in current policies should be evaluated carefully as they are

implemented.Because all scheduling and staffing patterns have a heavy impact on employees

personal lives, productivity and budgets, it is wise to have a six-month trial of newstaffing and scheduling changes, with an evaluation at the end of that time to determinethe impact on financial cost, retention, productivity, risk management and employee andpatient satisfaction.

Workload Measurement Tools

Requirements for staffing are based on whatever standard unit of measurement forproductivity is used in a given unit.NCH/PPD = Nursing Hours Worked in 24 hours

Patient CensusThis is the simplest formula for calculating nursing care hours per patient day in use andcontinues to be widely used.

In this formula, all nursing and ancillary staff are treated equally for determininghours of nursing care and no differentiation is made for differing acuity levels ofpatients.These two factors alone may result in an incomplete or even inaccurate picture of

nursing care needs.Jennings, Loan, DePaul, Brosch and Hildreth (2001) concur, suggesting that the useof NCH/PPD as a workload measurement tool may be too restrictive, since it maynot present the reality of todays inpatient care settings, where staffing fluctuatesnot only among shifts, but within shifts.

As a result, Patient Classification Systems (PCS), also known as workloadmanagementorpatient acuity tools, were developed in the 1960s.

PCSs group patients according to specific characteristics that measure acuity oillness in an effort to determine both the number and mix of staff needed toadequately care for those patients.It is usually not possible to transfer a PCS from one facility to another because

other variables within the system have an impact on nursing care hours. Insteadeach basic classification system must be modified to fit a specific institution.Seago (2002) suggest that most PCSs can be classified as:

Critical indicatoror criterion type uses broad indicator such as bathing, dietIVF and medications and positioning to categorize patient care activities.

Summative task type requires the nurse to note the frequency of occurrenceof specific activities, treatments and procedures for each patient.

Both type of PCSs are generally filled out prior to each shift although thesummative task type typically has more items to fill out than the critical incident ocriterion type.


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Once an appropriate PCS is adopted, hours of nursing care must be assigned foreach patient classification. Each institution is unique and must determine to whatdegree that classification system must be adapted for them. White (2003suggests that each patient population is different and that each unit must examineclinical profiles of patients, average length of stay and practitioner specialty indefining their patient population. In addition, core staff versus visiting staff andskill mix must be considered.Any classification system has many variables and all systems have their faults. It is

a mistake for managers to think that the PCS will solve all staffing problemsAlthough such systems provide a better definition of problems, it is up to thepeople in the organization to make judgments and use the information obtained bythe system appropriately to solve staffing problems.The middle-level manager must be alert to internal or external forces affecting unitneed that may not be reflected in the organizations PCS. Ex. Sudden increase innursing or medical students using the unit, a lower skill level of new graduates, orcultural and language difficulties of recently hired foreign nurses. Theorganizations classification system may prove to be inaccurate or the hoursallotted for each category or classification of patient may be inadequate. This doesnot imply that unit managers should not be held accountable for the standard unit

of measurement, but rather they must be cognizant of justifiable reasons fovariations.

Some futurists have suggested that eventually workload measurement systems mayreplace acuity-based staffing systems. Workload measurement is a relatively newtechnique that evaluates work performance as well as necessary resource levels (Walsh2003). Thus, it goes beyond patient diagnosis or acuity level, and examines the specificnumber of care hours needed to meet a given populations care needs. Thus, workloadmeasurement systems capture census data, care hours, patient acuity and patienactivities. This tool, while more complicated, holds great promise for better predictingthe nursing resources needed to staff hospitals effectively.Regardless of the workload measurement tool used (NCH/PPD, PCS, workloadmeasurement system, etc), the units of workload measurement that are used need to bereviewed periodically and adjusted as necessary. This is both a leadership role andmanagement responsibility.

Nursing Care Hours, Staffing Mix and Quality CareThe relationship between nursing care hours, staffing mix and quality of care has

occurred in response to the restructuring and reengineering boom that occurred inmany acute care hospitals in 1990s.

Restructuring and reengineering was done to reduce costs, increase efficiencydecrease waste and duplication and reshape the way care was delivered.

Given that health care is labor intensive, cost cutting under restructuring andreengineering often included staffing models that reduced RN representation in thestaffing mix and increased the use of unlicensed assistive personnel (UAP).

This fairly rapid and dramatic shift in both RN care hours and staffing mix providefertile ground for comparative studies that examined the relationship between:Nursing Care Hours + Staffing Mix = Patient Outcomes

As RN hours decrease in NCH/PPD, adverse patient outcomes increase, includingincreased medication errors and patient falls and decreased patient satisfaction withpain management.


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Unit managers must understand the effect that major restructuring and redesign haveon their staffing and scheduling policies as well. As new practice models are introducedthere must be a simultaneous examination of the existing staff mix and patient careassessments to ensure that appropriate changes are made in staffing and schedulingpolicies.

Decreased licensed staff, increasing numbers of unlicensed staff and developing newpractice models have a tremendous impact on patient care assignment methods.

Past practices of relying on part-time staff, responding to staff preferences for work andproviding a variety of shift lengths and shift rotations may no longer be enough. Administrative practices also have saved money in the past by sending people home

when there was low census; they have also floated them to other areas to cover unitneeds, not scheduled staff for consecutive shifts because of staff preferences and hadscheduling policies that were unreasonably accommodating. Patient assignments in the past were often made without attention to patient continuity

and assigned by numbers rather than workload.

Some of these past practices have benefited the staff, and some have been for thebenefit of the organization, but few of them have benefited the patient.

Indeed, assigning a different nurse to care for a patient each day of an already reducedlength of stay may contribute to negative patient outcomes.

Therefore, there must be an honest appraisal of current staffing, scheduling andassignment policies simultaneously as organizations are restructured and new practicemodels are engineered.

Having an adequate number of knowledgeable trained nurses is imperative to attainingdesired patient outcomes.

Ascertaining an appropriate skill mix depends on the patient care setting, acuity ofpatients and other factors.There is no national standard to determine whether staffing decisions are suitable for a

given setting. Manthey (2001) describes several factors that will drive additional new staffing plans in

the coming decade, Work Force 2000:o Increased importation of foreign nurses who must be safely incorporated into the care

delivery systemoOngoing fiscal restraints that result in the need for lean staffingoAnd plentiful, attractive career options for nurses outside the hospital.

Ethical Accountability for Staffing

The manager has ethical accountability both to patients and staff. Their needsshould be met.

Regardless of the difficulties inherent in PCSs and the assignment of nursing carehours, they remain a method for controlling the staffing function of management. As long as managers realize that all systems have weaknesses and as long as they

periodically evaluate the system, managers will be able to initiate the needed change.

It is critical, however, for managers to make every effort to base unit staffing ontheir organizations patient classification system.

It is important for managers to use staff to provide safe and effective careeconomically.


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Managers must increase staffing when patient acuity rises as well as decreasestaffing when acuity is low; to do otherwise is demoralizing to the staff.

Shift staffing based on patient acuity system does, however, allow for moreconsistent staffing and is better able to identify overstaffing and understaffing on amore timely basis.oThis is a fairer method of allocating staff.oThe disadvantage of shift-based staffing is that it is time-consuming and somewha

subjective, because acuity or classification systems leave much to be determined bythe person assigning the acuity levels.

oThe greater the degree of objectivity and accuracy in any system, the longer timerequired to make staffing computations. Perhaps the greatest danger in staffing byacuity is that many organizations are unable to supply the extra staff when thesystem shows unit understaffing. However, the same organization may use theacuity-based staffing system to justify reducing staff on an overstaffed unitTherefore, a staffing classification system can be demotivating if used inconsistentlyor incorrectly.

Employees have the right to expect a reasonable workload. Managers must ensurethat adequate staffing exists to meet the needs of staff and patients.

Managers who constantly expect employees to work extra shifts, stay overtimeand carry unreasonable patient assignments are not being ethically accountable.

Effective managers, however, do not focus totally on numbers of personnel, butlook at all components of productivity; they examine nursing duties, job descriptionspatient care organization, staffing mix, and staff competencies.

Management must work just as hard as the staff in meeting patient needs; andthat the organizations overriding philosophy is based on patient interest and not onfinancial gain.

A leadership challenge for the manager is to develop policies that focus on outcomesrather than constraints or rules that limit responsiveness to individual employee needs.

STAFF DEVELOPMENTThe staffs knowledge level and capabilities are a major factor in determining thenumber of staff required to carry out unit goals.

2 components of staff development:- Education- Training

Early staff development emphasized on:- Orientation

- In-service training

Training vs EducationTraining- An organized method of ensuring that people have knowledge and skills for a

specific purpose and that they have acquired the necessary knowledge to perform theduties of the job.

Education- More formal and broader in scope than training.


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- Designed to develop the person in a broader sense

Responsibilities of the Education DepartmentMost education departments on the organization chart are depicted as having staff oradvisory authority rather than line authority. Likewise, unit manager has no authorityover personnel in the education department.

Because of the ambiguity of overlapping roles and difficulties inherent in line and staff

positions, educating and training employees may be neglected.

It is necessary to delineate and communicate the authority and responsibility for alcomponents of education and training.

Other difficulties are frequent lack of cost-effectiveness evaluation and littleaccountability for the quality and outcomes of the educational activities.

The following suggestions can help overcome the difficulties inherent in a staffdevelopment system in which there is shared authority:

The nursing department must ensure that all parties involve should understandand carry out their responsibilities in that process.

If the nursing department is not directly responsible for the staff developmentdepartment, there must be input from the nursing department in formulating staffdevelopment policies and delineating duties.

An advisory committee should be formed with representatives from aldepartments and all classification of employees receiving training and education.

Accountability for various parts of the staff development program must be clearlycommunicated.

Some method of determining the cost and benefits of various programs should be

used.

Theories of LearningUnderstanding teaching-learning theories allows managers to structure training and useteaching techniques to change employee behavior and improve competence-goal for alstaff development.

Adult learning theory- Pedagogical-Usually ineffective for mature learners because adults have specia

needs.- Adult learners are mature, self-directed people who have learned a great deal from

life experiences and are focused toward solving problems that exist in their immediateenvironment.

PEDAGOGY ANDRAGOGY Characteristics:

- Learner is dependent - learner is self-directed- Learner needs external rewards and punishment - learner is internally motivated- Learners experience is unimportant or limited - learners experiences are

valued- Self-centered - task- or problem-centered


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- Teacher-directed - self-directed

Learning Environment:- Climate is authoritative - climate is relaxed and informal- Competition is encouraged - collaboration- Teacher sets goals - teacher & class sets goals- Decisions are made by teacher - decisions are made by teacher & class- Teacher lectures - students process activities and inquire about

projects- Teacher evaluates - teacher, self, peers evaluate

Obstacles and assets to adult learningOBSTACLES ASSETS- Institutional barriers - high self-motivation- Time - self-directed- Self-confidence - a proven learner- Situational obstacles - knowledge experience reservoir- Special individual obstacles - special individual assets

Social Learning Theory

- Builds on reinforcement theory as part of the motivation to learn and havemany of the same components as the theory of socialization.

- Bandura (1977) suggests that people learn most behavior by direct experienceand observation, and behaviors are retained or not retained based on positiveInvolves four processes:

people learn as a result of the direct experience of the effects of their actions

knowledge is obtained through various experiences

people learn by judgments voiced by others

people evaluate the soundness of the new information by reasoning throughdeductive and inductive reasoning- Soundness of this theory is determined by the effectiveness of role modelspreceptors and mentors.

Anticipated reinforcement

Select and observe a model

Retention process Cognitive process

Behavior is reproduced

Reinforcement of behavior continues

New behavior

Behavior is internalized and attitude change occurs


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Social learning theory process

Other learning theories:- readiness to learn- motivation to learn- reinforcement- task learning- transfer of learning- span of memory- chunking- knowledge of results

Assessing staff development needs

Staff development activities are carried out to:- establish competence- meet new learning needs- satisfy interests the staff may have in learning specific areas

Competence-having the abilities to meet the requirements for a particular role.-state board licensure, national certification and performance review are some methodsused to satisfy competency requirements

The following plan outlines the sequence that should be used in developing aneducational program:

1. identify the desired knowledge or skills the staff should have2. identify the present level of knowledge or skill3. determine the deficit of desired knowledge and skills4. identify the resources available to meet the needs5. make maximum use of available resources6. evaluate and test outcomes after use of resources


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Evaluation of Staff Development ActivitiesEvaluation of staff development consists of more than merely having class participantsfill out an evaluation form at the end of every class session, or assigning a preceptor foreach new employee.

Control- the evaluation phase of the management process, becomes extremely difficultwhen accountability is shared.

Evaluation of the three components of staff development (indoctrination, training andeducation) should include the following four criteria:

1. learners reaction2. behavior change3. organizational impact4. cost-effectiveness

Coaching as a strategyCoaching

-as a means to develop and train employees is a teaching strategy rather

than a learning theory.- Is one person helping the other to reach an optimum level of performance- The emphasis is always on assisting the employee to recognize greate

options, to clarify statements and to grow.

*short-term coaching- effective as a teaching tool for assisting with socialization and for dealing with short-term problems- frequently involves spontaneous teaching opportunities

*long-term coaching- as a tool for career management and in dealing with disciplinary problems is different.

Meeting the Educational Needs of a Culturally Diverse Staff(Seago,2000)- require well-planned learning activities. There should be sufficient

opportunity for small group so that personnel can begin recognizing their own biasesand prejudices.

- This type of learning activity is especially i

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