leadership paper

Marissa FowlerPatient care and Appropriate Staffing NUR 3805Dr. KramerFlorida State College at Jacksonville 9/29/2019AbstractIn today’s rapidly changing healthcare environment nurses are struggling to keep up with the demands placed on them every day. There are constantly more policies being implemented more charting being adding and more patients behind those policies and charts. In the fast-paced rhythm of any organization comes staffing ratios and the question of if there is enough hands, skill sets and beds available to handle to fast growing need for patient care in the hospital setting. Poor staffing is a huge concern for healthcare workers on both day and night shift. It is one of the leading causes of patient adverse events and could be avoided if the right steps were taken to look at what is needed to make a change the fractured staffing problem. IntroductionPatient care and staffing ratios important issues in the healthcare system. Appropriate staffing leads to greater patient outcomes and increased employee satisfaction. The American Nurse Association (ANA) points out that safe staffing is essential for nursing as a profession and the healthcare system. With safe staffing ratios, floor nurses can continuously deliver quality care. The ANA continues by explaining staff shortages have been brought about by cost-cutting decisions, an aging population, increased patient complexity and need, and an aging workforce places stress on working conditions (n.d)In 2002, Aiken published a study that found a correlation between higher patient loads and increased risks of adverse events, patient deaths, nurse burn out, and emotional exhaustion (Halm, 2019). Appropriate staffing on the unit endures a time effective match between the amount and type of care and needs of the patient to the skill set and knowledge of the nurse. As the culture shifts from understaffing and unsafe nursing practices positive changes will start to emerge and blossom throughout the organization. This can be seen from the higher patient satisfaction, higher quality of care, and lower nursing turnover rates (Halm, 2019). Patient safety is one of the top priorities in healthcare and that is not possible without the appropriate ratio of nursing staff to patients on the floor at any given time. The current staffing ratios at one facility in town is constantly changing with the influx of patients leaving nurses in the emergency room to care for up to eight or nine patients at a time with at times several having the acuity level of ICU patients. The nurses on the floor can be caring for the maximum allotted patients with no help from a tech or other set of hands to delegate to. The hospital is now planning on overhauling their staffing structures and policies, so their nurses do not feel the strain of heavy patient loads, caregiver burnout, and magnet expansion. Importance of StaffingThe American Association of Critical-Care Nurses confirmed what so many healthcare professionals knew when they said “Staffing, at its most fundamental level, is about patient safety”. There must be match between the patient’s acuity and the nurses’ competencies.The units at the facility in question are often staffed with float nurses and agency nurses. Those nurses are often left with no unit clerk and one or two patient care techs for all the nurses to share especially on night shift. This leaves the nurse to answer the phones at the desk, call lights for both the tech and the nurse, handle the admissions and handle their daily tasks, all while under a time constraint of vitals and medications to administered. When looking at ways to implement safer staffing ratios on the floors, especially at nights at this organization the structure of the team needs to be examined. The unit need to be functioning as one brain and one unit on how they deliver care to the patient. One of the most efficient ways to do this is the Interdisciplinary Team Model of Healthcare. This model allows all disciplinaries of medicine to be involved in the care of each patient while still allowing each member of the team to be heard (Blias &Hayes, 2016). By incorporating this model of care there will an increased amount of learning, a greater sharing of responsibilities, and a decrease in care fragmentation and complications which improves patient care and satisfaction (Blias & Hayes, 2016). By having this model in place, the organization is directly in line with the ANA’s core components of nurse staffing which states that registered nurses or RNs are full partners when working with other healthcare professionals which includes those from other disciplinaries (2012). When choosing the staffing for a unit a nurse manager or bed board for float nurses must look at a variety of factors not just the number of patients in a bed to the number of nurses on the schedule for a given night. “Other considerations include RNs’ competencies, experience, and skill set; staff mix; and previous staffing patterns that have shown to improve care outcomes” (Trossman, 2019). There is also a greater need to look at staffing for the nights, especially at the organization in question. This organization handles the urban core of Jacksonville and is a Level One Trauma Center, where the nights are just a busy as the days but the hospital staff drops to a skeleton crew. “Night shifts tend to not be staffed as well as day shifts, and oftentimes it’s new nurses, who are just learning the job, working those shifts” (Trossman, 2019). Leadership and Change TheoryThe nurse manger must look closely at their staff when making the schedule for their unit. They are expected to be able to know what each member of their team is capable of and how well each one of them work together and what makes that nurse and accessory staff member a leader. As stated in Blias and Hayes (2016), Whitehead, Weiss, and Tappen (2010) a leader has ’integrity, courage, a positive attitude, optimism, perseverance, balance, ability to manage stress, and self-awareness” (pg. 172). By knowing these traits and who possesses which ones the nurse manager can make a strong schedule of workers for the night. This will allow the team to pull on the resources of each other as to not feel as they individually are drowning in the patient load. This also allows the implantation of staffing through float and flex pool more seamless as nurses are aware of their strengthens and weaknesses. If one is weak on venous puncture but is floated to the ICU, that RN can brush up on that skill through watching and learning but their positive attitude and self-awareness lets them be mindful that while they are capable the getting IV access in the patient, someone who works that floor might need to be called to get the blood stick. Many healthcare organizations have used Kurt Lewin’s theory of change to understand how human behavior relates to a change and the pattern of resistance to that change. The model, also known as Lewin’s Force Field Analysis Model, looks at two forces known as the driving and restraining forces and how they affect the change process. The driving force is the force that attempts the change of behavior. The restraining force goes against the driving factor and attempts to undo and resist the change that wants to take place (Blias & Hayes, 2016). In order for the change to be successful the driving force must be stronger than the restraining force and work through the three stages of the model. In the first stage, also known as unfreezing, motivation is established. There is an awareness that there is a need for change. (Blais & Hayes, 2016). Unfreezing involves identifying key parts to the problem and players. Communication about potential “static” forces and problems that may arise move the players into the second stage of the model which is moving. This is where change is planned in detail and information is gathered from more than one source. The last stage is refreezing. This is where the change is solidified and integrated into the belief system of everyone involved (Blias & Hayes, 2016). Application of TheoryUnfreezing Stage:The first step in Lewin’s change theory is identifying the change focus: implementing safer staffing mixes on nursing units at night at a large facility, specifically one dealing with the urban core. Major components of this step are communicating with nursing managers, bed board/nursing resource office (NRO), and staff of the floor. Bozark (2003) maintained that communication was important during the process of change because it gave all involved a “sense of security and trust in all those involved with the proposed change” (pg. 83). By including those on the front lines like the RNS and techs that will be floating or doing overtime or working with new people the more that their voices feel heard and they feel as if they are a part of the change, the less resistant they are going to be. Driving forces for this staffing project would be the possibility for float to get “pick up” bonuses in the future, overtime, better time management and HCAP scores. In this facility some restraining forces might be that float nurses do not get the “short staffed/pick up” bonuses available to the others on the floor, PRN employees not get shift differential or holiday pay, float nurses staffing an entire unit and feeling taken for granted, lack of trust for new individuals, and tension between managers. In this stage managers will talk to their staff about their skill sets, what is expected of them on the floor, ask what they want to see change, and learn their staff and the staffing needs of their unit. Moving Stage:The moving stage represents the actual change including the planning and implementation of the project. Implementation of float staff balancing the par levels to the rest of the hospital will take a few weeks and time from the NRO and float nurse manager. A project of this scale will take a department at a time starting with the staff that is used to and expects to go everywhere in the hospital. The float pool will be the first to align the par levels with what is on trend with last month with patient movement throughout the hospital moving staff based on their experience and skill level where they are the best fit and the most needed. The next phase to the project implementation is take the knowledge of the staffing needs of their unit and relay it to the nursing resource office so everyone is on the same page and expects the same results. There is no lack of communication and resources at 2 am when a nurse is sick and needs a replacement and a Labor and delivery nurse has to float to a cardiovascular intensive care unit. Refreezing stage: In the final stage of the change theory the process of change is frozen, and change is stabilized and integrated into every key player that took part of the process (Blias & Hayes, 2016). Ongoing support for the nurses and support staff on the floor should be ongoing from upper management until the change is deemed solidified and everyone is comfortable with the changes that have been made. Once complete, an evaluation and summary of problems encountered, and praises should be accounted for future references. HealthCare EconomicsBy decreasing the patient to nurse ratios and implementing an interdisciplinary team approach the organization that will implement this change will decrease their duplication of services and decrease the time spent in a fragmented healthcare system. This will save the organization money. While the fee for diagnosis’ will not change the facility will have nurses that confident in their ability to manage their time care for every one of their patients without omission of care. This allows for each admission to be infection free and the hospital to collect on services owed without being penalized. For example, if a patient comes in and acquires a urinary tract infection due to a catheter being placed the whole hospital stay is now for the facility to cover. The staffing ratios and staffing mix on the units will allow for a smoother continuity of care with less hospital funds going to cover the staff in the long term. ConclusionWith any plan of this size and undertaking, it is crucial to have a detailed plan organized and thought out for the highest success rate possible. Using Lewin’s force field analysis model to guide the implementation of ensuring the appropriate staffing ratios through floating and mixing staff at this large Level One Trauma facility located in the urban core will be successful and accepted by everyone involved. Creating united front from the ground workers builds the autonomy and lets everyone know that they are heard. The brainstorming process highlights the driving and resistant forces so they can be fixed which leads to a smoother adoption of change. So many times, nurses want to feel empowered at their organization but end up left with burn out and exhaustion. By using Lewin’s theory, we can help reduce resistance and fear of change and unknown by a well thought out plan and active participation in the change process. ReferencesAppropriate Staffing: Creating a New Narrative and Fresh Approach: AACN spotlights staffing innovations and call for workplace success stories. (2018). AACN Bold Voices, 10(9), 20–21. Retrieved from http://search.ebscohost.com.db08.linccweb.org/login.aspx?direct=true&db=ccm&AN=131287889&site=eds-liveBlais, K., & Hayes, J. S. (2016). Professional nursing practice: concepts and perspectives. Boston: Pearson.Bozak, M., (2003). Using Lewin’s force field analysis in implementing a nursing information system. Computers, Informatics, Nursing, 21(2), pp.80-85.Halm, M. (2019). The Influence of Appropriate Staffing and Healthy Work Environments on Patient and Nurse Outcomes. American Journal of Critical Care, 28(2), 152–156. https://doi-org.db08.linccweb.org/10.4037/ajcc2019938Trossman, S. (2019). Appropriate staffing = safe, quality care. American Nurse Today, 14(9), 1. Retrieved from http://search.ebscohost.com.db08.linccweb.org/login.aspx?direct=true&db=ccm&AN=138801715&site=eds-live