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The Right Way to Staff Your Unit?

I am often greeted by the nursing staff with a, “Good morning!  Today I have five patients.” I often reply with, “And are you doing ok with your five patients?”  You see I try not to get caught up in the numbers. Numbers are important when you are paying your bills and determining a budget. Numbers can get tricky when you are deciding how many staff you need based on this factor alone. I tend to frown at organizations that place caps on their unit purely due to ratios and the number of patients. But this isn’t about that. This is merely a way to help staff your unit and some creative ways to use your resources wisely.

I have a ratio of 40 patients to eight nurses, so every nurse gets five patients and life is good. This could be the answer.  It makes sense based on basic math, but is it the best possible solution for the unit and the team? Chances are it’s not! We all know that every patient brings unique challenges to the plate. For instance, the elderly lady who is requiring placement, does not require many medications, rings her call bell when she needs help and follows all your policies and procedures like a good little patient (I know, I am dreaming here!), is much different than the patient on every two-hour medication, multiple intravenous antibiotics and likes to leave the unit frequently to go for a “walk.” Now divide that based on numbers; and, of course, give the second patient to the nurse who already has four other patients’ like this and the other patient to the nurse who has four other patients the same. Get my point?

It is obvious that patient assignments may contain the same number, yet look very different based on what is going on and how the patient behaves. Along with this, throw in the geographical layout of the unit and go to work. Sounds easy, make an assignment that is fair and will allow all your team to get their work done on time, go off the unit for breaks and punch out on time happy and content. Ok, again I am dreaming here, but we can at least head in that direction. What if we took the eight nurses, gave two nurses the challenging patients on the unit as a team and then divided up the remaining patients to the other six nurses? This could work. Not every day, but it is an idea. Wait, I have another idea, give a nurse one patient per room, buddied with another nurse with the other patient and that way they can team nurse the four or five rooms?

photo-1474546652694-a33dd8161d66My point to all this is simple. Be creative and do what works for the whole unit. Do not let the numbers drive your practice. Learn the variables that affect patient acuity and do something about it. I teach the charge nurse on my area this daily. Do not let numbers drive your decision making. I have had many instances in my clinical practice where six or seven patients were more manageable that three. Acuity is a big piece of this puzzle. I am excited to see that new electronic medical records are beginning to use this strategy to help decisions. What exactly can this look like?

Based on what the nurse charts, the system will assign an acuity number to this. To believe in the system, clinical nurses will review this number and compare it to validate it. Once validated, the numbers will be used when assigning patients to nurses. Scores are associated to each patient where the higher the number means the higher the acuity. You determine a goal acuity number for your staff based on how many care hours per day patients require. You divide the patients up using the scores. Some nurses will have three patients, some five and some only two. The charge nurse may also identify opportunities to pull a nurse from the mix to help resource the unit. Maybe focusing on just medications is why acuity is high. If the acuity is high due to dressings, pull a nurse just for treatments. As the electronic systems become more advanced, decisions can be more meaningful and less objective.

Be open and creative. As we project ahead, we must get smarter at how we provide care. We need to maximize our nursing resources while giving the best care possible. Changing how we do things is a first step. We may not get it right every time, every day; however, we will learn what works and what does not work. Start looking at other factors.  Stop thinking that because all your team has the same number of patients, your assignments are fair. You would not have two people carry a table that was 100 pounds and then have two other people carry one that was 500 pounds. It is basic logic, yet we miss the mark many times. I challenge you to think about the right way to staff your unit!

John Green

John Green, RN, MSN is a Masters-prepared, registered nurse who has worked in healthcare for 20 years. He currently works as the Assistant Director of Nursing at an upstate New York hospital He owns and operates a health and wellness business and is currently a Doctoral Student in Health Care Administration. Read More

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