Foreword:
• Nursing shortages and turnovers seem to be chronic. Even under the most stable conditions, there are times when hospitals need additional nursing staff for scenarios such as epidemic conditions, natural disasters or simply summer vacations. As more baby boomers get older, there will be a need for more nurses to care for them; but not enough people are enrolling and completing nursing school. Several studies indicate that more than 400,000 nurses are needed to meet the 2006 demand projections and another 800,000 by 2020. Therefore, a big gap needs to be addressed; in spite of the fact many nurses continue practicing well into their 60s.
• Other than the fact that nursing is a tough job, retention is particularly difficult for hospitals due to many variables. Hospitals have tough working conditions, often in undesirable locations, and frequent shift changes.
• At one hospital you can see discovered nurses were spending a lot of time on what we call “administrivia” instead of hands on patient care. At another hospital you may find nurses had great difficulty scheduling the use of specialized machines. In both cases the nursing staff felt frustrated with the working environments, which had a negative impact on the patient care. But the number one reason nurses leave a hospital is because of the management under which they work. From a career standpoint, a nurse may be passionate about nursing but may be burned out from the management team or deficits in infrastructure.
• In the health care field, a critical resource is the nursing staff. One value driver in hospitals is the number of nursing hours required to deliver a patient day. If you can reduce the number of nursing hours that support a patient day — without minimizing patient care that must remain as good or better — you can impact multiple areas of performance.
I. Issues involved in workforce shortage:
• Nursing, pharmacy and radiology workforce shortage
• Weak HR department and weak HR process
• Costly outsourcing and budget overrun
• Inadequate staffing
• High turnover/vacancy rate
• Inadequate leadership
• Unhappy and dissatisfied customers (internal and external), for example, nurses, patients and their families;
• Increased workload for others (remaining medical staffs)
• Unionization and threat of litigation from EEOC
• negative impact of shortage of workforce:
a. Injury and sufferings of residents because of low quality care;
b. Deteriorated quality and workplace safety;
c. Additionally, all staff are at risk of exposure to blood-borne pathogens and antibiotic resistant organisms12;
d. Reduced access, long waiting time;
e. Increased stress on remaining providers and increasing dissatisfaction8;
f. Higher costs in response to increased demand;
g. Raised compensation,
h. Increasing the use of overtime pay and
i. Expensive temporary personnel;
j. Closer of rooms or reduction in admissions. Layoffs, ineffective communication and job uncertainty as major causes of poor morale and unproductively. This portray impairs further recruitment.
II. Steps that should be taken to resolve the situation:
A. Managing Permanent nurses/workforce:
1. Understanding the cause-effect relation of workforce shortage:
• Good salary motive is not the only reason for high turnover rates. There are many other issues which are responsible for workforce shortage. Human resource function rises to prominence in transformational management. Each individual has a value to the organization, and that value needs to be maximized like the value of any other asset. Departures, whether preventable or not, represent a financial loss and should be minimized. Successful transformational management requires a great deal more than simply human resources management.
• People are loyal to an organization because it functions well rather than because it pays well or has good benefits. And it must function well before it can pay well or support good benefits. So, human resources management is a critical part of functioning well. As the result, the “HR Department†has expanded from a background support activity to a central part of the organization. The vice president of HR has become the “chief learning officer.†The change in title reflects a doubling or tripling in the investment in training. It also represents a change in mission, from “providing paychecks and background checks†to “ensuring an adequate and loyal associate force.â€
• Therefore we have to ask three questions while evaluating HR function shortage:
o What does this function contribute to overall performance?
o How do we know this function is being performed well?
o How do we improve performance?
• For effective and cost efficient staffing, we need to understand that cause-effect relationship. The main reasons for nursing workforce shortage and high turnover rate are:
o An aging workforce population;
o High retirement eligibility;
o Lack of educational and training opportunities;
o Lack of opportunities for career advancement;
o Difficulty in recruitment of workers and high vacancy rates;
o Difficulty in retention of workers and high turnover rates (lack of available FTE job openings;
o Financial concerns including lower pay as well as lack of benefits;
o Increased work load demand and frustration;
o The misdistribution of health care professionals has left many areas underserved rural areas and inner cities with medically needy and underserved population.
o In urban areas the supply of nurses has been dramatically affected by:
a. Health care shifts;
b. “Downsizing” due to cost containment efforts;
c. Fewer patients in hospitals;
d. reduced budgets and cutbacks for personnel;
e. Layoffs, and
f. The substitution of lesser-trained unlicensed workers for registered nurses;
• Rural shortage the shortage is attributed to:
o Urban areas drawing nurses by offering higher salaries;
o Nurses relocating to urban settings due to family needs;
• Nursing practice environment that contributes to shortage:
o Increasing career options for women (flipping burgers in fast food);
o Poor economic return for a baccalaureate degree;
o Nursing management’s inflexibility, inadequate control over practice; lack of autonomy, arrogant attitude towards nurses. Staff schedules that conflict with outside responsibilities can cause stress and job dissatisfaction12.
o Poor image of nursing (Schneider, 1992; Ludwig, 1998). Ludwig (1998);
o High turnover rate: Turnover of CNA, RNS and LPNs/LVNs are 49%-143%, 28-59% and 27-61% respectively. The most frequent reasons for leaving a job are unrealistic workload and low wages, lack of supervision by licensed nurses–frustration and job dissatisfaction.;
o Payment system: Public finance–80%, including Medicaid (67.6%) and Medicare (9%). A quality LTC is labor and cost intensive. But cost containment in PPS under managed care, limits providers’ ability to retain staffs and deliver optimal quality care.
o Wage and benefits: Wages and benefits are not fair and competitive. Many RNs, LPNs and CNAs are not paid adequately in nursing homes as they get from acute care hospitals. Moreover, many CNAs do not get retirement benefits and get limited health care at higher cost;
o Lack of education, training and supervision.
2. Role of employers in retaining and developing workforce: Setting vision and goal for staffing:
• In addition to compensation and benefit, St. Margaret`s Hospital should envision to provide:
o Improved working conditions,
o Increased teamwork, and
o Lower patient-staff ratios.
• They have to:
o Create a continuous learning environment that enhances skills and rewards initiative and employee contribution;
o Provide customized on-the-job training during working hours to help employees upgrade their skills;
o Support professional training and partner with educational institutions;
o Promote use of information technology which makes nurses life comfortable in managing patients;
o Maximize use of technology to eliminate redundancy and streamline workflow to ensure good working environment;
o Provide adequate pay and benefits–benefit packages that offer cafeteria style options — everything from child care to flex time to adult day care.
o Provide incentives like loan repayment programs. These incentives doesn`t only include financial incentives but also include flexible non-monitory supportive services that encourage a positive workforce, for example:
a. Flexible work hours,
b. Time off from work to attend work-related training,
c. Special privileges such as VIP parking, or
d. Tuition assistance;
e. Helping spouses find work;
f. Providing continuing educational training opportunities,
g. Reducing stress, and
h. Providing on-site child care and transportation services to and from work.
o Maintain mandatory staffing standards–meet mandated ratios of supervisory and direct care staff to residents based on the needs of the residents in the facility;
o Invest in mechanical lift equipment for the safe lifting and movement of residents. A safe resident handling and movement program significantly reduced the rate, severity and cost of injuries to nurses associated with lifting and moving residents;
o Create work environments that accommodate an aging work force–provide new measures of job satisfaction as turnaround rates become less important;
o Provide job sharing and shadowing to build on nurses’ individual strengths.
o Continuously improve workin conditions and promote environments conducive to good car through:
a. Adequate staffing;
b. Enhanced communication between direct care and administrative staff;
c. More time to nurture relationships between staff and residents;
d. Humane salaries;
e. Opportunities for upward mobility, and
f. Greater recognition, respect and understanding for the difficult lives many workers lead;
• Ensuring a good supporting working environment would:
o Promote nursing management’s flexibility,
o Promote adequate control over practice;
o Promote autonomy,
o Remove stress and job dissatisfaction that conflict with outside responsibilities arising out of work overload;
o Thereby motivate nurse tremendously and ensure desired and optimum retention rate;
• They have to understand that the success of any one healthcare facility will depend in part on how successful an institution’s is in addressing the needs of its entire work force. Baby Boomer managers should think like their Gen-X staff and develop new and improved ways of bridging the gap between generations.
3. Does staffing alone can ensure safe and quality care? Role of all stakeholders:
• To prevent abuse and neglects in LTC settings, staffing is very important factor. Staffing crisis can be resolved by changes in our public policies, professional practices, and education as this is influenced by social, economic, and demographic factors, political factors and management philosophies. The government can help chronic and long term care settings like St. Margaret`s Hospital for staffing in following areas. Staffing alone would not do. Revamping HR system, improving the organizational culture and support from, government, advocacy groups are needed. To prevent Abuse and Neglect in Long Term Care Settings, following strategies may help:
o Increase public funding (Medicare and Medicaid ) to achieve adequate staffing goals;
o Set accountability mechanisms in the statutes to assure that public funds are spent to improve staffing levels;
o Coordination between law enforcement, regulatory, adult protection, and nursing home advocacy groups;
o Improve work conditions, through adequate staffing, enhanced communication between direct care and administrative staff, and more time to nurture relationships between staff and residents, humane salaries, opportunities for upward mobility, and greater recognition, respect and understanding for the difficult lives many workers lead;
o Assure compliance with federal requirements concerning hiring of abusive nurse aides;
o Promote environments conducive to good care;
o Assure strict enforcement of mandatory reporting, as well as educate professionals and the public (non-mandatory reporters);
o Keeping national abuse registry by CMS;
o Educational campaign using poster in nursing homes nationwide to better inform residents and family members about how to report abuse;
o Regulating deployment of individuals convicted of abusing residents or child in any of the sates; nursing home’s should have procedure to screen out these individuals;
o Affording due process to nurse aides who have allegedly abused residents;
o Yearly survey by state department of Health (poor care of residents, incompetent staff, a callous attitude by management, or if a facility took too long to correct problems);
o Promoting educational opportunities;
o Supporting professional training of future health care workers;
o Partnering with educational institutions;
o Increasing pay, benefits and flexibility;
o Marketing public health careers;
o Initiating and promoting use of information technology;
o Ensure family like atmosphere with nursing school and affiliation with them (student rotations, internships and job promotional activities) to improve the recruitment and retention of nurses8.
o Mandatory staffing standards in hospitals and nursing homes: Legislation to require nursing homes to meet mandated ratios of supervisory and direct care staff to residents based on the needs of the residents in the facility.
o Investing in mechanical lift equipment for the safe lifting and movement of nursing home residents can cost tens of thousands of dollars, depending on the number of residents in facility. A safe resident handling and movement program significantly reduced the rate, severity and cost of injuries to caregivers associated with lifting and moving residents;
B. Managing Temporary nurses/workforce:
We need to recruit nurses on temporary basis. But we have to keep cost of managing and hiring temporary nurses and save money to redeploy it behind permanent nurses: Few principles of managing temporary nurses at this end are:
• Action for trust boards:
o Monitoring and planning:Receive monthly summary reports of spending on temporary nursing staff which observe variations between wards and which compare use with similar HCOs;
o Controlling demand:
a. Require that the assurance framework includes the HCOs statutory duty of staff welfare and identifies the associated risks and controls;
b. Receive an annual report on the use of temporary staff, including a clear explanation of the reasons for the use of temporary nurses;
• Action for executive directors:
o Monitoring and planning:
a. Receive regular summary reports on the use and cost of temporary nurses by ward.
b. Establish a central budget to cover maternity leave to spread risk across the whole organization.
c. Provide systems that enable ward managers to keep a record of each agency nursing appointment including shift worked, agency nurse’s name, and agency supplier.
d. Review the trust’s safeguards against the risk of fraud in the use of temporary nurses.
e. Require that specific reviews by internal audit are undertaken at least every three years.
o Controlling demand:
a. Prepare a workforce plan that identifies the number of nurses that will be required in the future and address any variance between existing and required numbers and skills;
b. Review and where necessary change nursing establishments;
c. Agree a common methodology for calculating the nursing establishment;
d. Adopt a unique reference number for each post in the organization which can be used to monitor usage of temporary staff against vacancies and track bookings through the system;
e. Achieve compliance with the Improving Working Lives Standard and establish a range of workforce scheduling systems that enable staff to have greater control over the hours they work;
f. Analyze the percentage of the total nursing pay-bill that is associated with bank and agency staff;
g. Read the National Audit Office’s good practice guide on managing attendance and put in place policies and procedures and check regularly that they are achieving ‘good practice’ sickness absence levels;
h. Improve recruitment and retention through the use of seccondment, rotation, family-friendly policies, sabbaticals, flexible hours and flexibility between different nursing roles; and by improving facilities for child care and providing training and development opportunities.
i. Improve the flexibility of the permanent workforce:
j. Consider investing in IT systems to help manage demand for staff e.g. electronic roistering;
k. Generate a culture of sharing staff across wards;
• Action for middle managers:
o Monitoring and planning:
a. Establish ward-level budgets that are linked to cost-centers and owned by local managers. The budgets should be set so that ward managers are aware of the costs they incur through the use of agency nurses.
b. Establish clear accountability for overspending on agency nursing budget and clear responsibility for budget management and monitoring at ward level.
c. Establish separate budgets to assist monitoring of activity levels and to highlight exceptions.
d. Establish clear procedures for authorizing payments to temporary nurses or agencies.
e. Update the register of nurses and remove those who have not worked for six-months, provided that the nurse has not indicated that they only wish to work intermittently;
o Controlling demand:
a. Prepare an up-to–date nursing plan for each specialty, based on an analysis of the numbers and grades needed to deliver the range and volume of services to which the organization is contracted.
b. Monitor staff plans against service needs and establish sufficient flexibility in substantive posts to meet foreseen service demands;
c. Review nurse staffing levels in anticipation of the modernizing potential of Agenda for Change, Connecting for Health, Payment by Results and Patient Choice;
d. Reduce inappropriate demand for temporary staff by addressing the underlying cause of their use and introducing a decision tree;
e. Review establishments annually following the agreement of the local delivery plan and supporting activity/business plans. The reviews should take into account changes in patient dependency, throughput, and changes in technology and workforce design ;
f. Observe variations in sickness absence between similar wards and check that ward managers are competent in implementing local policies;
g. Find out what would improve nurses’ work experience; and conduct exit interviews to find out why people leave;
h. Streamline recruitment procedures to prevent the unnecessary use of agency nurses;
• Action for ward managers:
o Monitoring and planning:
a. Agree and communicate procedures for payment to staff;
b. Make sure that invoices and timesheets are authorized by different people;a. Plan rosters comprehensively: annual leave and study leave should be planned throughout the year by calculating the number of shifts each week that need to be allocated for these purposes. Particular attention is needed to avoid an accumulation of untaken leave at the end of the leave year;
b. Encourage nurses to work flexibly within their knowledge and skills;
c. Minimize the use of agency nurses: vacant posts should never be filled by agency nurses as a matter of routine. Each decision to appoint them should be assessed against other options, for example, altering working patterns or arranging for cross-cover between wards:
• Appointing suppliers:
o Require that the decision whether or not to use NHS Professionals is the subject of a robust evaluation that demonstrates the value for money of the option chosen. Arrangements should be formally reviewed annually and more frequently if problems arise;
o Agree an annual supplies procurement strategy that includes the use of NHS Purchasing and Supply Agency framework agreements for the use of nursing agencies.
o Introduce organization-wide policy that prevents nurses filling a bank shift if they have been absent on sick leave in the previous five days or have a generally poor attendance record.
o When using nursing agencies, only use those on the NHS Purchasing and Supply Agency Framework Agreements to the agreed terms and conditions.
o Require that the standards used in appointing agency nurses are as rigorous as those for recruitment to substantive posts;
o Establish written procedures on the use of agency nurses with user friendly extracts of procedures made available for ward managers;
o Establish one central unit to receive all requests, place orders and receive invoices for agency staff;
o Establish a clear and consistent procedure to validate agency invoices before authorizing payment;
o Require that the nurse manager establishes measures to demonstrate desired performance;
o Establish formal long term contracts with a limited number of agencies to safeguard the organization`s interests;
o Establish a clear escalation policy for covering vacant shifts.
o Ensure that the nurses supplied by agencies are adequately qualified and have been vetted with the same rigor as for a substantive appointment.
o Allow agency nurses to work only if:
a. there are no reservations about standards of competence or performance;
b. they provide their most recent structured appraisal report and are willing to identify their most recent agency nursing employment;
o The appointment would not entail their exceeding their contracted hours (unless the agency nursing employment is within their own organization and time off is given in lieu);
o Give the agency as much notice as possible of future demand.
• Using temporary nursing staff:
o Establish arrangements which, in the event of unsatisfactory performance by an agency nurse, enable the organization to consider whether:
a. The nurse should be employed by them again;
b. The nursing agency should be informed.
o Report all instances of unsatisfactory performance of temporary nursing staff to the relevant supplier and, if relevant, to the Nursing and Midwifery Council and the NHS Purchasing and Supply Agency;
o Provide agencies with induction packs to issue to the temporary nurses;
o Check that all staffs are included in all relevant training and development programs;
o Brief temporary nurses before they commencing their duties.
o Provide feedback to the agency on temporary nurses’ performance, providing an assessment of clinical skills, knowledge, attitude, and relationships.
o Only allow temporary nurses to work unsupervised if deemed competent.
o Document examples of poor performance and send them to the hospital director, chief nurse and the employing agency nurse manager – a formal untoward incident report should be made if appropriate;
o Be alert to the risk of nurses being tired;
• Managing attendance:
o In order to manage absenteeism and thereby reduce the demand for temporary nurses, Organization should agree formal policies with their staff-sides that require action at agreed explicit trigger-points. We can use of the ‘Bradford Index’ (derived from Bradford University School of Management), which is based on a series of triggers based on the formula (S2 x D) where: S represents the number of spells of sickness absence in the previous rolling year; and where D represents the number of days of sickness absence. The formula accentuates the effect of multiple spells of short-term absence in order to recognize the disruption caused by short–term absence;
o Under this methodology:
a. A score of more than 100 [for example, four episodes of absence totaling seven days in the last year – (4x4x7=112)] triggers a formal return-to-work interview that is kept on the nurse’s employment record;
b. A score of more than 500 [for example, eight episodes of absence totaling eight days in the last year – (8x8x8=512)] triggers a referral to the occupational health service and a warning of possible disciplinary action;
c. A score of more than 1,000 [for example, ten episodes of absence totaling ten days in the last year – (10x10x10=1,000)] triggers formal disciplinary action and possible termination of employment on the grounds of ill-health.
C. Preventing Unionization:
If ‘management process’ (HR policy, planning and control systems) work to ensure fairness and just workplace, there will be no question of discrimination, dissatisfaction, unrest, conflicts and their ultimate consequences. Management should adopt following process in resolving conflict and preventing sue by union or stiff penalty by NLRB or EEOC:
• Ensuring open door policy by:
o Withhold their emotion during tension and follow structured ‘due processes’ of mediation.
o Knowing “how to say something†rather than “what to be said‖
Diffusing tension by way of acting or reacting upon a situation that creates concern and,
o Recognizing different behavioral problems of employees rather than judging those on their personal views, stereotype and perceptual concepts;
o Setting mission statement,
o Creating formal structure that favor easy communication,
o stimulating a informal culture and core value by leaders that helps sharing knowledge and networking for getting-doing favor to others
o Invigorating a corporate culture of knowledge sharing and networking that helps mediate and arbitrate dispute at staffs, as well as helps communicate individual and/or collective ‘voice’ (needs and concerns) upwards with ease.
o Improving the way the HCO hire, train, develop, evaluate and compensate and retain people;
o Adequately formalizing and ensuring ‘due process’ by setting clear rules and procedures that ensures, accountability, transparency (internal control), fairness and a just workplace;
o Improving working environment;
• Preventing discrimination and unrest by:
o Doing right things from the very beginning (I mean from hiring);
o Sustain better management by training, evaluating and compensating, and controlling them under clear and strict rules that don’t allow them to discriminate.
o Ensuring due grievance and/or mediation procedure.
o Having a good external and internal fit between company strategies, different elements of HR and planning and control system;
o Ensuring fairness in rewards benefits and discipline, protecting employees from harm
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