Staffing for census fluctuations
Budget forecasts and hiring decisions are difficult enough, but shift-to-shift staffing adjustments can be a real nightmare. To manage these fluctuations, our medical center successfully implemented a staffing system.
In the float pool, a group of staff who are hired centrually (not for a specific unit) is assigned to units on a shiftto-shift basis. This unit without walls has a nurse manager, assistant nurse manager, a unit council, newsletter, etc.
has a nurse manager, assistant nurse manager, a unit council, newsletter, etc. Float pool staff are scheduled for 4week periods of time as are other staff, except that the schedule is designed to follow historic census trends as much as possible.
Our float pool consists of 80 registered staff nurses (RNs: 55 of which are full-time equivalents [FTEs]), three licensed practical nurses (LPNs), (2.5 FTEs) and 36 paraprofessional staff (25 FTEs). This unit provides supplemental staff to 15 patient care units whose budgeted FTEs total 850. The patient care units that use the float pool nurses contribute support to the FTEs. The float pool budget pays for the nonproductive component of each FTE.
Float pool RNs and LPNs are hired to support a particular clinical cluster (adult intensive care unit, medical/ surgical units or pediatrics). Float pool nurses orient to all the units in their cluster and to a second cluster of their choice. Paraprofessiional staff orient to all units and perform patient care and clerical work.
Unlike float pool staff, per diem nurses are not guaranteed any regularly scheduled hours and earn no benefits regardless of how many hours they work. They do, however, earn a higher hourly rate of pay and can increase that hourly rate depending on how many hours they work in any quarter of the fiscal year. Currently, nurses working at the 40% level receive an additional $1.25 per hour. This incentive pay increases to $2.00 per hour at the 60% level and $2.75 for those working 80%. Per diem staff must be available for two shifts per month, but most work many more hours. All shifts are subject to cancellation if the census is low. This group of staff determines which units they choose to support and orient only to those units. They are expected to maintain the same level of competence as other staff, and their performance is evaluated in the same manner.
At times, professional nurses are needed; on other occasions, paraprofessional assistance is required. To meet these needs, we maintain a system called the “float.-float.” In this system, regular float pool staff (RNs and paraprofessional staff) who are not assigned to a particular unit that shift respond to a pager and prioritize requests for help as needed. “Float-float” coverage varies depending upon the time of day and the day of the week and may increase or decrease based on the staffing manager’s or administrative supervisor’s discretion.
Perhaps nothing frustrates nurses as much as unit-to-unit floating. Not only are the staff unhappy with the wideopen “float where you’re needed” system, but they also raise serious issues of competency. Yet, some kind of floating system is needed. After considerable deliberation, the Nursing Management Council decided to place patient populations into clusters and restrict floating to those groups only (floating clusters).While patient populations are typically clustered together, our policy requires that nurses float where needed within the duster. Nurses now float outside of their cluster only if they wish to do so and if they are competent to care for that patient population.
Nothing starts a patient’s hospitalization off on the wrong foot more than a harried nurse and a harried admission process. A new role at our hospital-admitting nurse-has been very well received by both patients and staff. Skilled practitioners who are unable to work in a regular staff nurse position fill this role. Some individuals fill this position temporarily; others are permanently assigned. The admitting nurse completes the patient’s admission assessment, orients him or her to the unit and the hospital and begins the initial care plan. Working with the admitting department and the central staffing office, the admitting nurse determines the units most likely to require assistance and prioritizes accordingly. These nurses work weekdays, from 11:00 a.m. until 7:30 p.m., the hours when most of our scheduled admissions occur.
There are, of course, those wonderful days when all these staffing systems rise to the occasion and the shift goes exactly as planned. Then there are other times….When necessary, a nursing management representative visits the units every shift, assesses the workload, problem solves, places patients and redistributes staff. This role is filled by an associate director of nursing (or the staffing manager on the day shift) and an administrative supervisor on off-shifts, weekends and holidays. These individuals carry a pager and are available for troubleshooting throughout the shift.
Effective staff systems can go a long way toward mitigating the effects of the facility’s unpredictability. These successful systems meet the staffing needs, stay within the budget and are accepted by staff.
Copyright Springhouse Corporation May 1997
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