Nurse staffing challenges
An ongoing challenge that most healthcare organizations experience is the provision of adequate nursing staff levels to provide safe and effective patient care. Birch (2002) stated the problem most succinctly, that is, having the right number of people with the right skills in the right place at the right time to provide the right services to the right people. A global nursing shortage has further compromized healthcare organizations to meet daily demands for appropriate staffing levels (Kane-Urrabazo, 2006; North et al., 2006). A major challenge faced by Forensic Program management teams is to balance their budgets due to the unpredictability of the forensic patient population, particularly in the context of managing staffing costs where the hospital is not the “gatekeeper” and does not have control over who is admitted and when. In forensic mental health, the justice system, either via the courts, or review boards, determines who is ordered for admission to hospital for assessment or treatment and rehabilitation. Hospitals have little, if any, recourse but to admit these mentally disordered offenders. This typically results in increased levels of staffing with concomitant overtime costs.
Following a series of Canadian provincial and territorial consultation sessions, a recommendation was made to ensure that adequate and appropriate staffing is available to ensure nurses are able to provide high quality patient care in a manner that is safe for the patient and for the nurse (Med-Emerg, Inc., 2006). In an effort to meet this need, a Health Human Resources Capacity and Utilization Project (Provincial Health Human Resources Steering Committee, 2003) identified maximizing existing human resources (and their corresponding skills) by increasing or changing what existing employees do, which can add capacity without necessarily adding people, as a health human resource strategy in use in Ontario.
Historically, the issue of effective human resource utilization has been managed by redeploying nursing staff to wherever the need was greatest. This lead to the development and implementation of float pools. Connor (1961) developed the first staffing pattern that used daily unit transfers (floating) to achieve staffing balance which he called “controlled variable staffing.”Connor (1960) found that his variable staffing pattern cost significantly less than the fixed staffing pattern. With fiscal restraint facing hospitals and healthcare organizations throughout the world, the use of float pools became quite a prevalent cost-saving and efficient staffing strategy (Durkin, 1997; Hall et al., 2003; Hulsey, 1992; Libby & Bolduc, 1994).
However, Pronger (1995) has cautioned that although methods of floating appeared to be cost effective, they were practiced at the expense of the nurse. The literature is replete with evidence of the negative consequences of using centralized float pools where nurses are expected to be able to practice in a variety of clinical areas as generalists without consideration for ensuring safe and effective delivery of services where specialization may be warranted. As Durkin (1997) noted, the old saying of “A nurse is a nurse is a nurse” is no longer tenable due to increased specialization in various clinical domains.
Many of the challenges and consequences for nurses based on the practice of unfettered unit-to-unit floating, include lack of familiarity with the specialty area, physical layout of the unit, unit culture and poor group dynamics among staff, and concerns over competency. Other reasons include receiving a poor reception from unit staff, feeling alienated or lonely on an unfamiliar unit and/or unfriendly staff, lack of appreciation from the staff or nursing administration, and being delegated unpleasant assignments (Banks, Hardy & Meskimen, 1999; Durkin, 1997; Dziuba-Ellis, 2006; Ornstein, 1992). The negative consequences of directing nurses to work in areas where they feel incompetent are varied and numerous. It is not atypical to find staff reacting negatively with an associated sharp decline in morale and job satisfaction (Banks, et al., 1999; Kane-Urrabazo, 2006).
Floating nursing staff has been associated with poor patient outcomes, including increased medication errors and poorer patient care (Durkin, 1997). Several authors have identified a relationship between nurse staffing variables and adverse patient outcomes (American Nurses Association, 2000; McGillis Hall, Doran, & Pink, 2004; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2000; Sovie & Jawad, 2001).
Recognizing the benefits of floating nursing staff to meet the daily demands of appropriate service provision in healthcare organizations, coupled with the increasing specialization of nursing in various clinical domains, required the development of workforce planning strategies and changes in cultural practices (Duffield & O’Brien-Pallas, 2002). As articulated by Dziuba-Ellis (2006), ”the floating of staff in a way ensures nurses work in the areas in which they are familiar and competent can be achieved by limiting the floating of staff to related clinical areas or ‘clusters’(p. 357). The concept of clustering, also referred to as clustered unit floating (CUF), decentralized floating or resource teams, where the nursing staff float between two or three units and have formal orientation to the unit and skills appropriate to the patient populations (McHugh, 1997), has been supported by Durkin (1997) and Pronger (1995).
In contrast to centralized or unclustered float pools, where a nurse is regarded as a generic worker who is able to work with various patient populations and utilize many skill sets (Dechant, 1999), clustered float pools or resource teams recognize nursing expertize, where their specialized skills are recognized and used.
Several authors have identified benefits to utilizing clustered float pools or resource teams, including reductions in agency usage (Dilts-Skaggs & Proto, 2005), improvement in job satisfaction and morale (Pronger, 1995), nurse retention (North et al., 2006), and enhanced patient care (Sochalski, 2004).
Forensic Nursing as a Specialty Area in Mental Health
The literature on float pools is primarily, if not solely, based on acute healthcare organizations. Typically, the focus is on the impact of various staffing options with respect to medical patients and medical outcomes. For example, Dilts-Skaggs and Proto (2005) conducted their study with emergency department nurses. McGillis Hall, Doran, and Pink (2004) investigated the impact of various nurse staffing models on patient falls, medication errors, wound infections and urinary tract infections. Alonso-Echanove et al. (2003) and Robert, Fridkin, Blumberg, Anderson, White, Ray, & Jarvies (2000) looked at blood stream infection rates.
What is clearly absent from the literature is how float pools are utilized in mental health in general and, more specifically, in forensic mental health as a subspecialty of mental health. As noted by Peternelj-Taylor and Bode (2010), forensic nursing has been recognized as a specialty area of nursing practice by the American Nurses Association (ANA) since 1995. The ANA and the International Association of Forensic Nurses (IAFN) published a revised edition of Forensic Nursing: Scope and Standards of Practice in 2009 (American Nurses Association and International Association of Forensic Nurses, 2009). This version includes a description of the inherent roles and responsibilities enacted by forensic nurses. They reported that forensic nursing “has been identified as a multifaceted and complex practice specialty characterized by responsibilities, functions, roles, and skills that have been derived from general nursing practice, yet also developed in accordance with the distinctive practice environments and populations of forensic nursing” (American Nurses Association and International Association of Forensic Nurses, 2009, p. 9). Furthermore, the IAFN & ANA (2009) noted that, “The forensic nurse in psychiatric settings has specialized knowledge and competencies in the assessment, care, and evaluation of individuals with mental disorders as they relate to criminal behavior” (p. 9). Moreover, the IAFN & ANA (2009) added that “the forensic nurse applies principles of forensic psychiatry and nursing to the clinical evaluation for competency and in the assessment and treatment of individuals and groups with crime-related mental disorders” (p. 9). Forensic nursing has been acknowledged by a number of authors, recognizing it as a subspecialty that focuses on nursing practice for people who have come in contact with the legal system and are remanded into custody for assessment for either Fitness to Stand Trial or Criminal Responsibility, or for treatment and rehabilitation if found Not Criminally Responsible for the index offence. This is a complex area of nursing practice which presents many unique challenges, including conflicting philosophies, the roles, mission and terminology of the criminal justice system, and criminogenic factors (Kent-Wilkinson, 2010).
There is the distinct challenge of developing a therapeutic alliance with the patient, which is considered fundamental to every aspect of the nursing process and care of the mentally disordered offender (Peternelj-Taylor, 2010), that encompasses the functional necessities of keeping patients safe while managing their clinical needs and risks (Timmons, 2010). There is a constant need to balance the concepts of risk and violence while providing the forensic patient the opportunity for recovery (Mason, 2002; Webster, Douglas, Eaves, & Hart, 1997). The challenge is to endorse a recovery model of care while the patient remains “in custody.” As Aldred and Drennan (2010) stated, “recovery” must acknowledge the challenge of dual recovery from mental illness and criminal behavior while giving due consideration to the management of risk. Corlett and Miles (2010) also recognized the unique challenges in implementing a recovery philosophy in forensic mental health, such as restrictions placed on mentally disordered offenders by the justice system. These issues are unique to forensic nursing and forensic mental health.
A pilot project
In an effort to address the perennial issue of cost overruns resulting from the unpredictable levels of acuity and degree of dangerousness of admissions to a Forensic Program in a tertiary care facility in Ontario, a forensic float nurse (FFN) pool was created. The FFN pool provided readily available, highly adaptable, skilled forensic nurses to assist in times of unpredictable heavy workloads and/or unplanned staffing shortages. This novel approach in mental health services in forensics provides a nurse-staffing model for the establishment for the safe and efficacious management of short-term crisis situations which may result from unanticipated fluctuations in patient acuity, either resulting from challenging new admissions from the courts or difficult-to-manage patients under the jurisdiction of the Ontario Review Board.
Given its legal obligations to admit patients ordered for detention at the hospital either by the courts or the Ontario Review Board, the Forensic Program does not serve the role as “gatekeeper”. Not having control over who is admitted and when resulted in major challenges for the program management team to provide a balanced budget. A significant contributor to this challenge was the unpredictability of the patient population being served. Mentally disordered offenders typically present with untreated mental illness and are more prone to display highly aggressive and assaultive behavior, which often requires increased nurse staffing levels above and beyond what has been budgeted. Many patients are admitted to the Forensic Program directly from the courts without any identification, psychiatric history, medical history, and are acutely psychiatrically ill. The increase in acuity for forensic patients, often with relatively higher levels of aggression and assaultive behaviors, has been observed for the past few years across the Province of Ontario. This has resulted in an increase in physicians’ orders for Close and Constant Observation and the use of Seclusion as a means of keeping the patients, peers, and staff from harm.
Hospital nursing staff often felt like they were being punished when they were “pulled” from unit to unit because they were pulled from more stable patient populations. Most noteworthy was the challenge Forensic Program staff face when staff from other clinical programs were “pulled” to work shifts in the Forensic Program. These “pulled” staff most often were very reluctant to work in the Forensic Program for the very valid reason that they were unfamiliar with the patient population, the program's policies and procedures, and common practices implemented for the safe management of these patients. There have been several occasions when staff were returned to their home units for these reasons. By remaining in the Forensic Program patient care unit to which they were “pulled,” they would pose a greater risk to patient and staff safety as reported by the “home” unit staff. Some staff refused outright to work in the Forensic Program.
In addition, it was also an established practice at this hospital to accompany all patients with Secure Forensic Service (aka medium secure) Dispositions off the patient care units in an effort to mitigate any increased risk to the public. This required additional staff to accompany patients, for example, to medical appointments and court appearances, and so forth. The hiring of these additional staff often resulted in hiring at overtime rates.
A mitigation strategy proposed to address this perennial staffing and associated fiscal challenge was the introduction of a FFN pool. This provided all Forensic Program patient care units with readily available, highly adaptable, skilled forensic nurses to assist in times of unpredictably heavy workloads and/or unplanned staffing shortages.
In addition to the specialized knowledge and skills expected of forensic nurses, the scope of practice of the FFNs are consistent with the College of Nurses of Ontario (CNO, 2009) Practice Standards, including Accountability, Continuing Competence, Ethics, Knowledge, Knowledge Application, Leadership, and Relationships. Compliance with CNO Documentation Standards are also maintained. The CNO requires nurses to be aware of their competencies through reflective practice. As such, float nurses would be accountable for their practice and should they encounter a situation or patient that they felt they could not care for, then they would be accountable to declare this and collaborate to meet the patients' care needs (for example, seek information, consult, and transfer care if necessary).
FFNs have the designation of Registered Nurse or Registered Practical Nurse. As expected of all nursing staff in the Forensic Program, FFNs provide support, comprehensive and professional nursing care, and pre-crisis and crisis response to patients in the Forensic Program. The FFNs work collaboratively with all members of the multidisciplinary teams across the Forensic Program. FFNs contribute to the ongoing assessment, planning, implementation and evaluation of care to individual forensic patients.
Impact on overtime hours1
The FFN pilot project was implemented in June 2011. A notable decrease in overtime hours was achieved during the fiscal year (2011/12) in which the FFN pool was implemented in comparison with the previous fiscal year (2010/11). As noted in Figure 1, across the Forensic Program (including both the assessment and rehabilitation patient care units), there was an increase in overtime hours by 21% from 2009/10 to 2010/11; however, there was a marked decrease by 47% from 2010/11 to 2011/12.
A breakdown by type of forensic patient care unit (assessment versus rehabilitation) clearly indicated that the major positive impact was on the assessment unit. From 2009/10 to 2010/11, the overtime hours for the assessment unit increased by 32% but decreased by 38% from 2010/11 to 2011/12 following the implementation of the FFN pilot project. For the rehabilitation units, even though there was a decrease in overtime hours by 10% from 2009/10 to 2010/11, there was a further nominal decrease from 2010/11 to 2011/12 by another 9%.
Given that the FFN pool was implemented partway through fiscal year 2011/12 (June 2011), a further analysis was conducted, comparing the first half (April–September) and second half (October–March) of each fiscal year by type of unit (assessment versus rehabilitation). As depicted in Figure 2, for the assessment patient care unit, there was a marked increase by 79% in overtime hours for the first half of the year from 2009/10 to 2010/11 with no change for the rehabilitation units. In contrast, with the FFN pool having been implemented for four months (June to September) in the first half of fiscal year 2011/12, there was a significant decrease in overtime hours by 43% from the first half of 2010/11 compared with the first half of 2011/12. There was a corresponding decrease of 25% for the rehabilitation units for the same time comparison.
With a full 6-month FFN pool implementation in place for the second half of the 2011/12 fiscal year, one would predict an additional decrease in overtime hours. In fact, a further decrease by 49% in overtime hours was obtained for the assessment unit when comparing the second half of 2010/11 to the second half of 2011/12. For the rehabilitation units, a nominal decrease by 7% was observed in overtime hours when comparing the second half of 2010/11 to the second half of 2011/12.
The introduction of a FFN pool provided a creative approach to contributing to the effective management of overtime use by nursing staff, recognizing that this initiative alone does not account for the total number of reduced overtime hours in this pilot study. There is no doubt that there is a multiplicity of factors that also may have affected the outcome. However, it is inevitable that this clustered FFN pool was a significant contributing factor. This finding provides further support for Dziuba-Ellis’ (2006) contention that float pools, clustered float pools in particular, serve as an effective human resource strategy. Based on an overall reduction in overtime by almost 50%, a reduction consistent with results obtained by Dilts-Skaggs and Proto (2005) for emergency department nursing staff, this strategy is certainly worthy of consideration by mental health programs and services, where hospitals cannot exercise control over who is admitted and when.
Although the clustered FFN pool model may be effective in larger forensic programs where nursing staff resources are available to meet demand, smaller programs may have recruitment issues into this specialty area, thereby experiencing a challenge in filling forensic float pool positions. One strategy employed by some mental health facilities is to have psychiatric nursing staff also trained in forensic mental health. This would provide an opportunity to pull staff with this specialized training on an as needed basis without compromising patient and staff safety, work satisfaction, and professional standards.2
Implications for clinical forensic nursing practice
A number of heuristic implications evolve from this pilot study, including the need to evaluate the impact on patient safety and quality of care in conjunction with an overall reduction in overtime costs. A positive outcome with respect to patient safety and quality of care would be predicted based on the published literature which suggests that clustered (decentralized) float pool nurses develop enhanced relationships with staff and patients and enables nurses to attain specialized clinical expertize to treat specific patient populations, thereby promoting safer, high quality care. In addition, forensic program staff satisfaction would be expected to increase because the FFNs are providing assistance as skilled forensic nurse specialists rather than by less familiar generalists.
Finally, in addition to reducing overtime and its concomitant decrease in costs, the introduction of clustered float pools in forensic mental health may also contribute toward the establishment of excellence in care in the safe and efficacious management of short-term crisis situations resulting from unanticipated fluctuations in patient acuity, unexpected staff absences, and enhanced support during crisis codes.
1The current data analyses are based on preliminary data; therefore, only descriptive statistics are provided. Inferential statistical analyses will be applied on additional data being gathered.
2We acknowledge the contribution made by one of the anonymous reviewers for making this observation.
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