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Department: Leadership Q&A

Staffing during budget cuts

Drake, Kirsten DNP, RN, OCN, NEA-BC

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Nursing Management (Springhouse): March 2020 - Volume 51 - Issue 3 - p 56
doi: 10.1097/01.NUMA.0000654868.04675.61
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Q Our organization is altering unit budgets, which will result in a decrease in my unit's hours per patient day (HPPD). I'm not sure how I can staff my unit based on the new goals. Any advice?

As healthcare changes, we're all being challenged to think differently about our HPPD and cost-per-unit targets. Before sharing with your frontline staff, pause and think of some other ways to meet the needs of your patients. This means looking at the total HPPD versus RN HPPD.

A quick reminder that your HPPD is the hours worked divided by the unit census (usually determined at midnight).1 Example: If your 35-bed unit with a census of 33 patients is budgeted for 8.5 HPPD, you can staff 23 total direct care providers for 24 hours (276 hours/33 patients = 8.36 HPPD). Now, let's discuss a couple of staffing ideas that may help you reach your new HPPD.

The first option is adjusting your current staffing matrix. For example, if your HPPD is 8.5 as above and you add another 12-hour employee, you'll end up with 8.72 HPPD worked. So, the adding “one body more” philosophy won't work. Instead, what about partial shifts? Adding 4.5 hours during the 24 hours would get you on target for your budgeted 8.5 HPPD. This requires analysis of your unit's peak times. If you're managing a busy ED, you may not become busy until after 10 a.m., so the traditional 0700 start time isn't a good use of productive time. A surgical unit may see unit admissions around noon after early surgical cases are complete. Scheduling a nurse to assist with admissions from 2 p.m. to 6 p.m. would be helpful.

Our organization had one unit with a nurse scheduled at various times to assist with dressing changes and procedures and another nurse as a circulating person to help as needed. This is a culture shift for nurses not taking the traditional patient load. However, once staff members realize the added hours help them care for their patients, it's much more accepted.

If your unit's culture is more toward keeping the traditional patient assignment, another option is to go old school and implement 8-hour shifts. This isn't a popular idea for many because staff members need to give up having 2 days off a week. A combination of 12- and 8-hour shifts may be more palatable. This method can be difficult when matching 8-hour staff members together to cover a patient assignment. Working off a 4-hour increment matrix model is helpful.

If you're feeling up for the challenge of making a drastic change to your staffing plan, you can do what Froedtert & the Medical College of Wisconsin have done and work a 7/70 plan.2 In this plan, nurses work seven 10-hour days for 7 days straight and then are off for 7 days. When we opened a new unit in 2009, we implemented this staffing plan. It seemed to be successful until the unit's patient population changed. When this occurred, staff members said it was taxing by the sixth and seventh days. A caveat is that we didn't have to change the unit's culture because employees were hired into this model.

Whichever way you split the hours, remember what's going to work best for your HPPD also needs to work for the patient experience on your unit. There's a balance between patient experience and more staffing, but more staff doesn't indicate better outcomes.3 When you're adjusting the HPPD, monitor your patient experience scores to determine if there's a correlation. Lastly, make sure to safeguard your staff members as they consistently work to implement patient experience best practices.

REFERENCES

1. Habasevich B. Managing to nursing HPPD. Mediware. 2012. http://www.mediware.com/rehabilitation/blog/managing-to-nursing-hppd.
2. Maxson-Cooper PA. Empowering nurses through an innovative scheduling model. Nurs Clin North Am. 2011;46(1):59–65.
3. Buhlman N. Nurse staffing and patient-experience outcomes: a close connection. Am Nurse Today. 2016;11(1):49–52.
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