Nursing Leadership

Gina is the charge nurse of the 3:00 PM to 11:00 PM shift on the acute care unit where you have worked for 18 months since your graduation. Your supervisor has asked you if you would like to learn the duties of the relief charge nurse. You were thrilled that she approached you for this position. Because it was a relief position, it was permissible for your supervisor to appoint you and not necessary for you to formally apply for the position. One day each week, for the last 2 weeks, you have been working with Gina about the responsibilities of the position. There are several things Gina does that bother you, and you are not sure what you should do. For example, if used supplies were inadvertently not charged to patients at the time of service, Gina admitted she would just charge them to whoever patients she thought were likely to have used them. When you questioned Gina about this, she said, “Well, at the end of the day, the unit needs to make sure that all supplies have been charged for, or the CFO will be after all of us. It is one of the charge nurses’ responsibilities, and I don’t have time to chase everyone down to find the correct patient to charge and besides everyone has insurance and so it does not come out of the patient’s pocket. Most importantly, we must make sure the hospital gets reimbursed or we won’t have our jobs.” In addition, when Gina does the staffing correlation for the upcoming shift, you notice that she fudges a bit and makes sure the night shift is given credit for needing more staff than they need. When questioned, she said, “Oh, we have to take care of each other, better too much staff than not enough.” You think Gina’s actions are unethical, but you do not know what to do about it. It does not directly harm a patient, but you feel uncomfortable about what she is doing and feel it is not the ethical thing to do.

ASSIGNMENT:   You have many options here including doing nothing. Using the MORAL ethical problem-solving model, solve this case and compare your solution with others in your class.

Making Sound Staffing Decisions

You are the staffing coordinator for a small community hospital. It is now 12:30 PM, and your staffing plan for the 3:00 PM to 11:00 PM shift must be completed no later than 1:00 PM. (The union contract stipulates that any “call offs” that must be done for low census must be done at least 2 hours before the shift begins; otherwise, employees will receive a minimum of 4 hours of pay.) You do, however, have the prerogative to call off staff for only half a shift (4 hours). If they are needed for the last half of the shift (7:00 PM to 11:00 PM), you must notify them by 5:00 PM tonight. A local outside registry is available for supplemental staff; however, their cost is two and a half times that of your regular staff, so you must use this resource sparingly. Mandatory overtime is also used but only as a last resort. The current hospital census is 52 patients, although the emergency department (ED) is very busy and has four possible patient admissions. There are also two patients with confirmed discharge orders and three additional potential discharges on the 3:00 PM to 11:00 PM shift. All units have just submitted their patient classification system (PCS) calculations for that shift. You have five units to staff: the intensive care unit (ICU), pediatrics, obstetrics (includes labor, delivery, and postpartum), medical, and surgical departments. The ICU must be staffed with a minimum of a 1:2 nurse–patient ratio. The pediatric unit is generally staffed at a 1:4 nurse–patient ratio and the medical and surgical departments at a 1:6 ratio. In obstetrics, a 1:2 ratio is used for labor and delivery, and a 1:6 ratio is used in postpartum. On reviewing the staffing, you note the following:

Intensive Care Unit Census = 6. Unit capacity = 8. The PCS shows a current patient acuity level requiring 3.2 staff. One of the potential admissions in the ED is a patient who will need cardiac monitoring. One patient, however, will likely be transferred to the medical unit on 3:00 PM to 11:00 PM shift. Four registered nurses (RNs) are assigned for that shift.

Pediatrics Census = 8. Unit capacity = 10. The PCS shows a current acuity level requiring 2.4 staff. There are two RNs and one certified nursing assistant assigned for the 3:00 PM to 11:00 PM shift. There are no anticipated discharges or transfers.

Obstetrics Census = 6. Unit capacity = 8. Three women are in active labor, and three women are in the postpartum unit with their babies. Two RNs are assigned to the obstetrics department for the 3:00 PM to 11:00 PM shift. There are no in-house staff on that shift who have been cross trained for this unit.

Medical Floor Census = 19. Unit capacity = 24. The PCS shows a current acuity level requiring 4.4 staff. There are two RNs, one licensed vocational nurse, and two certified nursing assistants assigned for the 3:00 PM to 11:00 PM shift. Three of the potential ED admissions will come to this floor. Two of the potential patient discharges are on this unit.

Surgical Floor Census = 13. Unit capacity = 18. The PCS shows a current acuity level requiring 3.6 staff. Because of sick calls, you have only one RN and two certified nursing assistants assigned for the 3:00 PM to 11:00 PM shift. Both confirmed patient discharges as well as one of the potential discharges are from this unit.

ASSIGNMENT:   Answer the following questions:

1.  Which units are overstaffed, and which are understaffed?

2.  Of those units that are overstaffed, what will you do with the unneeded staff?

3.  How will you staff units that are understaffed? Will outside registry or mandatory overtime methods be used?

4.  How did staffing mix and PCS acuity levels factor into your decisions, if at all?

5.  What safeguards can you build into the staffing plan for unanticipated admissions or changes in patient acuity during the shift?