Avoid short-staffing: Overhire nurses
Do you only hire the exact amount of nurses needed? This short-term solution might seem cost-effective, but it’s a mistake in the long run, argues Chris Lewandowski, RN, nurse manager of the ED at Kennedy Health System in Turnersville, NJ.
"Overhires are nurses hired over and above those approved in the budget. In the long term, they save money," she asserts.
Lewandowski’s ED has not had a nurse resignation for almost a year, which she credits in part to working fully staffed. "However, I have hired five nurses onto staff this year [a 10% increase] due to an increase in budgeted staffing," she says. Members of the nursing staff need to work at safe levels of staffing so that the staff do not feel overwhelmed, she urges.
Overhiring allows a manager to hire someone who might need a little extra time to develop ED skills, because the scheduling needs are not as pressing, notes Lewandowski. "I maintain good relations with the paramedic community, as some of them go on to nursing school and make good candidates for ED positions," she says.
When a nurse from another department floats to the ED, they "roll out the red carpet," says Lewandowski. "They make good candidates because they have demonstrated loyalty to the system and know the processes," she says.
When Lewandowski started at the ED, there was a 35% turnover in nursing staff. "As the performance expectations were made clear and monitored for consistency, some nurses decided that they would be more comfortable in other areas of practice," she says.
Nurses were encouraged to recruit from among their colleagues in other facilities, adds Lewandowski.
Although the vacancies are filled, Lewandowski still interviews for nurses at least once a week. "Interviewing is time-consuming, but it is one of the most important things a manager has to do," she says.
The facility does not have any open positions, but when Lewandowski gets a "lead" on a nurse from any source, she contacts the nurse for an interview. "At least they can be encouraged to join the per-diem pool," she notes.
One "overhire" nurse is carried per shift, says Lewandowski. "I have never gotten into a problem of overscheduling time," she notes. "Leave of absences and vacations provided available shifts for the overhires."
If your ED has "borderline" staffing for your patient volume, add extra staff, urges Diana Contino, RN, MBA, CEN, CCRN, president of Emergency Management Systems, a Monarch Beach, CA-based consulting firm that specializes in staffing issues. "For example, if your ED only saw another five or 10 patients a day and you could add additional nursing, then your facility should try to add the staff now," she says.
Contino offers this scenario to illustrate the point: An ED currently has "clinical hours of care" of 1.8. This is the total of all RN, LPN, and tech hours, which equals 144 hours per day, divided by the total census of 80 patients per day, which equals 1.8 hours of care.
"If you add a nurse 24 hours a day, you have 168 clinical hours divided by an increased census of 91 patients. You still have 1.8 hours of care," says Contino.
The administrative hours of care include the director and unit secretaries, for a total of 208 total hours worked per day, divided by 91 patients seen per day, which equals 2.28 total hours of care, notes Contino. The Emergency Nurses Association recommends 1.57 hours of care for RNs, and 2.3 for all direct patient care providers,1 notes Contino. "These figures exclude the triage nurse, case managers, charge nurses, respiratory and EKG techs, nurse managers, and educators," she adds. "Many EDs are forced to function with fewer hours of care."
Often, an ED can get the additional 11 patients by increasing the education of staff and reducing or eliminating patients who leave without being seen or against medical advice, Contino advises.
Nurses need to start putting the cost of turnover into budgets, which can be done retrospectively to determine a standard, recommends Contino. "The facility needs to look at their costs of recruiting and training," she says. "For example, it takes six months for a new graduate, six months for a manager, and one month for an experienced nurse to be fully functional."
You can retrospectively look at the figures and track them as the new year progresses, she explains.
You also need to lobby for the additional staff and a change of the corporate culture, argues Contino. "That needs to be done instead of spending so much money training new graduates, only to have them leave in a year or two," she says.
The corporate culture of hospitals needs to model the corporate world, with the view that "our employees are our most valuable asset," Contino urges. "If patients only need a physician, they go to their office or their surgicenter. Patients come to the hospital for nursing care, and that is what hospitals are selling."
Reference
1. Emergency Nurses Association. National Emergency Department Benchmark & Staffing Database Guide. Des Plaines, IL; 1999.
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