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Part 5 6

  1. 1. PartvManaging l{urnanResources
  2. 2. 18Mobilizing Existing The purpose of this chapter is to discuss an approach to mobilizing existing nursing resources according to levels of expertise, consid- ering work and education experience. Assignment patterns are dis- cussed in terms of organizational variables, nursing resources, and patient care needs. On completion of this chapter, the reader will be able to: 1. Discuss nursing resources as a concept. 2. Differentiate between recruitment and retention activities. 3. Explain factors related to the nursing shortage. 4. Relate competency and relicensure issues to availability of professional nursing resources. 5. Describe a data-based methodology for selecting a nursing as- signment pattern that meets patient care and organizational needs. 5. Propose several solutions to recruitment and retention prob- lems.Trying to understand recruitment and retention problems in nursingtoday is like looking for a straw in the wind and trying to describe itspath. The wind keeps shifting, and a tornadic gust threatens to blowthe whole issue out of our sphere of influence, if not out of nursingsarea of responsibility. Many hospitals have moved in the direction ofnonnursing control of nursing recruitment and retention through theestablishment of human resource departments that control hiring andfiring of all health personnel. Nursing is the focal point for the the delivery of patient care in allhealth care delivery settings. Failure to change or implement new as-signment patterns, such as primary nursing, may be the result of a lack 249
  3. 3. 250 MANAGING HUMAN RESOURCESof understanding of nursing resources and of the appropriate use ofnurses according to experience and expertise.NURSING RESOURCESNursing resources have been defined by Munson, Beckman, Clinton,Kever, and Simms (1) in terms of selected variables all of which haverelevance for care assignment and quality care. Table 18.1 identifiesand explains the various nursing resource components, ranging fromstaff mix and preparation to commitment, stability, availability, andspecial training. This conceptualization provides a broad perspectiveon the components of a nursing resource configuration. These compo-nents are covered in greater detail later in this chapter in the discussionof assignment patterns. iRECRUITMENT, RETENTION, AND TURNOVERHistorically, nursing has experienced high turnover and cyclical short- 6 ! qages. In 1982, discussions of the nursing shortage were especially ramp- ( oant. By 1984, the economy and the advent of prospective payment had 0 cchanged the entire picture of recruitment and retention. Because of the :large number of nurses in the work force, recruitment became an ir- a- k rrl U F.relevant issue, and retention of high-quality, satisfied nurses seemed tobe a possibility for the first time in many years. Recruitment refers to all those activities carried out by a nursing orpersonnel department to attract nurses to a particular work setting forpurposes of interviewing and hiring. Retention activities designed tokeep nurses in the work setting have received less than appropriate at-tention. Dramatic attempts have sometimes been undertaken to recruit o a)regardless of qualifications. The problems that have lead to nursing dshortages and the difficulties of retaining nurses have not been addressed Iron a large scale by nursing and the health care industry. a According to Wolf (2), administrative philosophy and policies con- lrtribute more than any other factors to a high turnover rate, which is cthe direct result of inadequate attention to retention and staff satisfac- .^.o cd !tion. Wolf further describes salary and job conditions as the leading .. bocauses of high turnover. Salaries by and large are simply not at the *A is .o,same level as those of other workers with comparable education in oursociety. In addition, there is little difference in nursing pay scales ac- ;.7 rs acording to level of preparation and experience. Aiken, Blendon, andRogers (3) also cite the limited growth in nurses salaries as a primefactor in retention and turnover difficulties. They further suggest that
  4. 4. iate use of !:= tt. !_ : i. ;iZ:i;i=: ;=i )lt;! i: I=c-cr, Clinton, 1 ! ; 1:t: ! i :2v i i, 2 -=! ; 5 ;E c -o z ! L. c,hich have identifies i ; tI:i li,:-i!:;?l, = t6 oLging frombility, and f- = -,=|ii4i+=:;1 - +; a - i,:7:, i7 ;i ;;v r I -z -c-=a O : cerspective =i= o --se compo- j != 1.: ::;:1 ; ! i=: -. ;€4 C i+t; o Jdiscussion -.; a zEfi*z i ;i t ii;:: i=t a = d) d, &E-.i-a i i?=r7=i=-;E E;: 2?:-+= O ! o A. :i:" ia "=i!i=rr:i1iAiuE=7 itGi-: + 4 !A: ,sa^E,: O [-*. l* n t:!E ! en !^: =: brE":i irJr2.;4-li_3"l; or t: .iJ]-x.c_ o tr cal short- #: f,.= iln ii.=u= al ;ti:i :!:i=z:2-riE;€; ,.(,G-^t=i=7E;= O o rLlly ramp- Oment had o ;E ;E 7;szq irir*=4;:-ai=r;t ;E;Ei;.fi!:*i:E O o z ;use of theme an ir- s e ;C in #!r:3 7=, 11 7A=; ia az "nzi c o . " ?EZ s, .-F .Z: e E.ii=- PA?LQr-:!u2a:LC a ! 0 0 L O o -o ! O ,= E tt 6 E-: :r.= < i t I I d_.r o.j dj { ; tr€ tcli {_..r: o j;eemed to q d ieC jursing or oPFYetting for , b lY o :lsigned to 903-3 o: == I O jpriate at- ,lr oo9^ou o[o recruit *ilho a o .9 .: .99- !^pooEqtr I nursing a a a=.- E E d ci iE Z iE ;E Z o) d. d -i=-! d,d,d. o z o "; cLddressed I - E4cies con- a 3 i) o l t>l .:cwhich is -^::O l6 : I ^ ;EE : ! 5 : =jE . Z i= ! i isatisfac- l t d9 A=.; .= = = = : t e lq leadingrt at the rt bo ^ r :o e -= i= E= = ; n ;E ;i: :a l e = .=-=.=_=-i -^ =, i. E3 ,-f, in our -a 3>Ft{}Ef.e:d ri t =; r d i .;i - O O si za,iZzd,i2;==rn s ! &.=:ales ac- <= ?z L z t € = ; + tc_a a = + ! fi ,i 7 olon, and =E 6 d E o o<a primelest that 251
  5. 5. 252 MANAGING HUMAN RESOURCES in relation to those of other workers, more nursesas nurses incomes rise Johns<become available for hospital employment, and vacancy rates decline. leakage Why do nurses quit their jobs? The following reasons have been ob- I evidenceserved by the authors over time and have been documented in the lit- Over theerature by many others: of nurses enty-five Low salaries and little reward for experience in the 19r Low prestige ing child. Much responsibility and little recognition visualize< Inflexible hours and schedules Variout and VauS Excessive overtime mand for Anger expressed by physicians toward nurses faster th: Gap between education and practice higher ac Lack of autonomy delivery < Too much work Rose (7. Quantity of assignments interferes with quality tional tur The supp Frequent reassignment to unfamiliar units the emph Assignment to units not compatible with skills simply d< Poor physician-nurse relationships sired. Mo Incompetent and unsupportive supervisors lection o. Lack of opportunity for advancement professior are no lor There may be other contributing factors, but these issues appear over Aiken (.and over again in the literature. Equal pay for equal work is no doubt nursesp: incomes aa major influencing variable, as the gap between nurses and physicians responseincomes has widened dramatically over the last several years (3). in relativr control ov ceived sh<THE PERCEIVED NURSING SHORTAGE sonnel is s could be <In recent years, much attention has been focused on the critical shortage Beyers (of nurses, particularly in hospitals. For the following reasons, it is dif- and careeficult to understand why a shortage is perceived to exist (if, indeed, one as opposedoes any more): agency. Te not be cot One fin:1. There has been an overall decline in the growth of hospitals over the the vast nr past three decades. Since 1950, the ratio of hospital beds to population are opport has dropped by one-third (a). settings th2. Since 1950, the general hospital occupancy rate has declined signif- ing admin icantly (4). ploring su3. Since 1950, the nations output of nurses has doubled (5). model cou
  6. 6. MOBILIZING EXISTING RESOURCES 253ore nurses Johnson and Vaughn (6) find no statistical evidence of significant:s decline. leakage from the profession. On the contrary, they observe that most: been ob- evidence provided to support a shortage is based on anecdotal material. in the lit- Over the last 10 to l5 years, there has been steady growth in the supply ofnurses. There has also been an increase ofnewly licensed nurses. Sev- enty-five percent of all nurses are employed, an increase from 55 percent in the 1960s. Even though nurses may vacate positions temporarily dur- ing childbirth, they do return. The current supply of nurses should be visualized as a dynamic, constantly changing, constantly growing entity. Various reasons are cited for the perceived shortage of nurses. Johnson and Vaughn (6) call attention to the high probability that employee de- mand for nurses has been increasing and continues to increase at a rate faster than the supply of nurses is increasing. This may be due to the higher acuity rate in all settings and the technological revolution in the delivery of care. Rose (7) describes the problem as one of intensity of annual institu- tional turnover, which ranges from 35 percent to 60 percent nationwide. The supply of nurses is also influenced by payment mechanisms. With the emphasis on cost containment, government ceilings on care costs simply do not allow for the number of nursing positions needed or de- sired. Moreover, the womens movement continues to influence the se- lection of nursing as a career, as women may increasingly choose professions in medicine, law, dentistry, the sciences, or the ministry and are no longer bound to those in teaching or nursing.ppear over Aiken (3) equates the perceived shortage to the dramatic increase ins no doubt nursesparticipation in temporary service agencies to maximize theirphysicians incomes and control their working hours. Agencies have proliferated inrs (3). response to the increased need for temporary services and the decline in relative income for nurses. In addition, nurses wish to have more control over their working hours. One often forgotten reason for the per- ceived shortage is that the differential cost of a nurse over other per- sonnel is so small that hospitals may be substituting nurses in jobs that could be done by nonnurses.:al shortage Beyers (8) believes that not enough attention is paid to job promotionrs, ir is dif- and career advancement, which provide functional turnover patterns,.ndeed, one as opposed to the dysfunctional turnover when employees leave the agency. Temporary vacancies exist with functional tumover that should not be counted or depicted as a nursing shortage.lls over the One final rcason for the pcrceived shortage is thc incomplete usc of the vast nursing expertise in schools of nursing around the country. Thcre population are opportunrties for facultir practice in acutc, long-term, and home carc se ttings that could be attraitive to schools of nursing, but, to date, nurs-ined signif- ing administrators and educators have not taken the initiative in ex- ploring such options. A contract for scrvices or a shared consultation). model could be developed in most settings.
  7. 7. 262 MANAGING HUMAN eE9QrrRqES _ 9. Sta3. Interest in flexible hours with more leisure time and social oppor- Nur tunities (21). 10. Mic4. Need for role transition guidance (22). Reli soci Perhaps most important is the element of support services. Nurses 1l. Claare more satisfied and more likely to stay in organizations where support are adequate and they do not have to carry out extensive non- 12. Joh tionnursing tasks. 13. Horr U.rp PublSUMMARY 14. Shu. JourThe nurse administrator should support the competency of nurses by 15. Betzbuilding on the educational preparation appropriate for their assigned Marrroles and by using assignment patterns selected through data-based de- 16. Eliolcisions. Such an approach to using nursing resources differs from that high t 3(1(found in traditional nursing texts. The availability of nursing personnel, 17. Carkcoupled with organizalional and patient characteristics, should dictate primnursing assignment patterns. Selection of any model without considering Junethese variables usually is a contributing factor in dissatisfaction and 18. Shukhigh nurse turnover. Servi 19. Friss pensiREFERENCES Decer 20. Duxb Joum L Munson, F.C., Beckman, J.S., Clinton, J., Kever, C., and Simms, L.M. Nursing 21. Vik, ] Assignment Patterns. Ann Arbor, Mi.: Health Administration Press, 1980. The J, 2. Wolf, G.A. Nursing turnover: some causes and solutions. Nursing Outlook, April 1981, 29(4), 233-236. 22. Dear, hospi 3. Aiken, L.H., Blendon, R.J., and Rogers, D.E. The shortage of hospital nurses: 1982, a new perspe ctle. American J ournal of N ursing, September 1981, 8 1 (9), 1612- 1618. 4. American Hospital Association. Hospital Statistics: Data from the American Hospital Associtttion 1979 Annual Suwey. Chicago: American Hospital As- sociation,1980. BIBLIO 5. U.S. Department of Health and Human Services, Division of Health Profes- sions Analysis. Supply of Manpower in Selected Health Occupations, 1950- Hofmann, 1990. DHHS publication no. (HRA) 80-35. Washington, D.C.: Government reducti< Printing Office, 1980. tI (11-r 6. Johnson, W.L. and Vaughn, J.C. Supply and demand relations and the Munson, I shortage of nurses. Nursing and Heabh Care, November 1982, 3(9),497-507 . search, . 7. Rose, M.A. Factors affecting nurse supply and demand: an exploration. The Weisman, Iournal of Nursing Administration, February 1982, 12(2), 3l-34. Journal 8. Beyers, M., Mullner, R., Byre, C.S., and Whitehead, S.F. Results of the nursing personnel survey, part 2: RN vacancies and turnover. Journal of Nursing Administration, May 1983, 13(5), 26-31.
  8. 8. MOBILIZINC EXISTING RESOURCES 261 in the same hospital. Shukla (14) found that on matched units, where nurses had similar educational backgrounds and experience, differences in quality of care between primary and team nursing disappeared. Thisen by the raised the question as to what makes the real difference in quality and satisfaction: the competency of the nurse or the nursing assignment pat-Ig the care tcrn. Betz (15) also found that nurses were not always more satisfied withvolved in primary nursing. Betz compared three team nursing units with threeers for a primary nursing units over a year and discovered that primary nurses were less satisfied than team nurses, depending on educational level.nners for a Primary nurses had difficulty delegating responsibility, utilizing per- sonnel, and setting priorities. B.S.N.s showed the greatest drop in sat-nsible for a isfaction when moved to team nursing.stay on a In the long-term care setting, Eliopoulos (16) explores the use of the registered nurse in a professional manner. She believes it is an unrealistic)ommon goal in long-term care to increase the ratio of registered nurses, in lightrf nursing of the number of tasks that can be delegated to nurse assistants. Herit common preferred approach is the team assignment pattern.)lvement In a large research hospital survey, Carlsen and Malley (17) determinedvolvement that neither team nor primary nursing afforded sufficient opportunities)atients for self-fulfillment, decision making, or independent judgment. Neitherns (CCC) system provides sufficient opportunities to meet self-actualization needs.;C) The need for primary nurses to be superwised was an unexpected finding.dof In dealing with high turnover, the nurse administrator must not as-rift sume that primary nursing is the answer. Jumping on the primary nurseNursing As- bandwagon may be possible only if qualified baccalaureate-prepareds, 1980, p.5. nurses are available for the primary nurse role. Shukla (18) suggestedacting other that when nurse competency is controlled, the primary nursing structureve or simplv does not provide more direct care than does the team or the modular structure. On the contrary, the primary nursing structure provides the least amount of direct care, suggesting that the competency of the nurs- ing staff may have a greater impact than the structure. An additional finding in Shuklas work was that the modular structure is most pro-ve way to ductive. Registered nurses did not perform as many nonprofessional oruate high indirect care tasks. Modular nursing has been defined as a miniteam,t for con- as it provides the features of both team and primary nursing assignmentoss units. patterns. The R.N. works in a subunit, or module, with an L.P.N. or aideand R.N./ but does not follow the same patients if they are transferred to another subunit. Other important issues in dealing with turnover problems are pur- ported to be:e, but its 1. The propensity to leave the organization (19).;ing units 2. Inadequate information about leavers and stayers (20).
  9. 9. 260 MANAGING HUMAN RESOURCESTABLE I8.3Elements of the Nursing Assignment Pattern in the nursesVariable Name Basis for t ariable Definition in qualNursing care integration (NCI) The proportion of total care given by the raised person providing the most care satisfarCare management integration The number of persons managing the care tern.(cMr) process at a given time BetzPlan-do integration (PDI) The proportion of care givers involved in primar the planning of care primarNursing care continuity (NCC) The average number of care givers for a patient over a seven-day period rvere leCare management continuily The average number of care planners for a Primar(CMC) patient over a seven-day period sonnel,Care management continuity Whether a care planner is responsible for a isfactioacross settings (CMCI) patient before or after patients stay on a In th unit registerNursing coordination (NC) An index that records the most common goal in pattern of on-unit coordination of nursing of the r care activities for a patient preferrtCare-cure coordination (CCC) Two indexes that record the most commonPatient services coordination pattern of the. nurses direct involvement Inal,(PSC) and the proactiveness" of that involvement that nei in coordinating other inputs to patients for self- care requirements from physicians (CCC) system and from other professionals (PSC) The neeIntershift coordination (ISC) An index that records the method of In der communication by which intershift coordination is achieved sume th bandwaSOURCE: F. Munson, J. Beckman, J. Clinton, C. Kever, and L.M. Simms, Nursing Assigwnent Pattens LIsers Manual. Ann Arbor, Mi.: Health Administration Press, 1980, p. 5. nurses i"Proactiye: taking the initiative in coordination activities, for example, contacting other that wh personnel, making referrals, problem solving. Reactire.not initiating: a passive or simply does no cooperative response to coordination initiatives from others. structur least an ing staftImplications finding ductive.This study has several implications. By providing an effective way to indirectacquire a data base, the nursing administrator can better evaluate high as it procost assignment patterns, can select a particular component for con- patternscentrated study, or can more logically make comparisons across units. but doesThis study further suggests the need to view staff satisfaction and R.N./ subunit.L.P.N. ratios as important aspects of nursing resources. Other ported tImplication for Turutover ProblemsPrimary nursing may be a better system for organizing care, but its 1. The peffectiveness is not uniform for all types of nurses, even on nursing units 2. Inade
  10. 10. MOBILIZING EXISTING BEIQUBQES 259 TABLE I8.2 Hospitaloutcomes Central Elements of the "y"9 |1.g.l-:4}tt"11 !!t"_c!!!9" Contirtuitv Coordination Nursing care Nursing care Nursing coordination integration (NCI) conrinuity (NCc) (NC) Care management Care management Care-care coordination integration (CMI) continuity (cMC) (ccc) Plan-do integration Care management Patient services Patient (PDI) continuity across coordination (PSC) care qua lity settings (CMCI)outcomes Additional integration, continuity, and coordination variables were conceptualizedro complete the profile. Note on Table 18.3 the elements Person nel+ satisfaction of integration, care management, continuity across settings, and the co- outcomes ordination elements of care-cure, patienl services, and intershift coor- dination. - Cost of care By collecting specific data, a nursing unit can determine the type of- outcomes assignment pattern actually in use. It is also possible to look at patient(Reprinted characteristics and consider which elements of the nursing assignment,on, Joanne pattern are most closely related to the needs of the patients. For example,M. Simms, a patient with high psychosocial support needs may benefit tremen-)80.) dously from a high level of nursing care integration, that is, care provided by a single person. By contrast, the patient with multiple and complexwhich the care requirements may benefit from the care of several specialists.ere devel- Based on nursing resources, it is also possible for a unit to consider(13) were whether it is appropriate to move toward greatcr care management in-/eness, ac- tegration, a different level of care management continuity, or a differentdeveloped type of intershift coordination. In summary, the elements of a nursings, nursing assignment pattern can be prioritized in order of importance according to the availability and competence of the nursing resources.ized: care A great advantage in using this approach is the opportunity to lookt includes for the weak and strong points in organizational support. For example,ulation of it is difficult to have high levels of care management continuity whenrventions, nurse staffing or scheduling systems provide a constant rotation of theof nursing nursing staff within a hospital. Scheduling and staffing policy are in- a nursing tricately related to nursing assignment pattern decisions. The findings in the Michigan study suggest a betler way to look atnagement assignment patterns. The identification of the key elements of the nursingssignment assignment patlern lead to the development of data collection instru-llans. In a ments specific to three variables: patient characteristics, nursing rc-rf the hall sources, and organizational support. The study further demonstratedr. Nursing that this kind of infcrrmation can bc quantified and displayed in a format, patterns, lhat can be used to defend an existing pattern or a change to a newlumber of pattern.
  11. 11. 258 MANAGING HUMAN RESOURCES I nfluencing Professtonal Nursing Quality standards Hospital TABLE factors: judgments and unit for nursing empirical structu re process: outcomes: Central research that esta bilsh and policy: rtt"s!! re lations: Nursinp integrat T-----*---t Care mz Patient I I Comprehensiveness I integrat characteristics l- Connective Nursing I Accountability I PIan-dottursinc resources propostlons Assignment -+l Patient | | pattern I Continuity i ! care (PDD I i L-.>j quality Organizational I i Coordination I I support L__________.1 outcomes J i f--------- r Addit | Schedulinc I concept i ^sturiinc i i Personnel p_- of integr t---r----- +----- --------.1 satisfaction outcomes ordinati I Dailv allocations I rl I dinatior t---l L-_:_-______-l | - Cost of care By co outcomes assignmFIGURE 18.1 Nursing assignment pattern conceptual framework. (Reprintedfrom Nursing Assignment Pattenls (Jsers Manual, by Fred C. Munson, Joanne characteSchultz Beckman, Jacqueline Clinton, Carolyn Kever, and Lillian M. Simms, pattern iby permission of Health Administration Press, Ann Arb<tr, Mi., O 19S0.) a patien dously fr the organization. Figure 18.1 shows the framework within which the by a sinl definition of the elements of a nursing assignment pattern were devel- care reql oped. Four quality attributes identified by Horn and parker (13) were Basedused as the basis for the conceptual framework: comprehensiveness, ac- whethercountability, continuity, and coordination. Instruments were developed tegratior to measure the influencing factors of patient characteristics, nursing type of irresources, and organizational support. assignm( within [he nursing process, two basic activities are recognized: care to the avgiving and care planning, or management. Care management includes A greaassessment of patient requirements for nursing care, formulation of for the wnursing diagnosis, stating outcomes of care and nursing interventions, it is diffiand evaluation. care giving refers only to the implementation of nursing nurse stainterventions. Table 18.2 highlights the four central elements of a nursing nursing sassignment pattern. tricately These elements vary across assignment patterns. Care management The finintegration (cMI) would be relatively high in a functional assignment assignmeipattern and in a primary nursing pattern where one person plans. In a assignmeteam assignment pattern in which the team changes sides of the hall ments spevery week, care management continuity (CMC) would be lower. Nursing sources, icare integration (NCI) would be high in most primary nursing patterns, that this Ilower in team, and lowest in functional, with the greatest number of that cancare givers. pattern.
  12. 12. MoBILIZINc EXISTING RESoURCES 257I settings.d division could functionally assign tasks within the team itself, with less concern:n evolved for the number of personnel rendering direct care to an individual pa-,d a redis- tient. In functional nursing, the picture of variation is less clear, for few:luded the nursing departments now identify with this structure. Yet one can rec-nsed prac- ognize this structure in hospitals, where there is a separate specialiston getting for activities such as discharge planning, patient education, medications time and administration, and so on.asks-cat-ortance to;kill levels. A NEW APPROACH TO NURSING ASSIGNMENTients care PATTERNS[ed within The purpose of a recent two-year study at the University of Michiganre basis of was to develop useful tools for nurses in management and clinical prac- personnel tice who are faced with nursing assignment pattern decisions. The pro-m nursing ject included (1) development of instruments to measure nursing as-iary work- signment patterns, patient characteristics, nursing resources, andhe diverse organizational support; and (2) the publication of a nursing assignmented nurses. users manual (1); decisions This demonstration project collected data in four hospitals. Prelim-:am leader inary work was essential to the quality of the project and included::mbers.[or nursing l. Development of a conceptual framework within which the definitionrg requires of the elements of a nursing pattern could be developed.lager-per- 2. Literature review of about 270 items selected for their potential con-s aide ac- tribution to an understanding of the linkage between patient char-atient and acteristics, nursing resources, and organizational support and ap-I practical propriate nursing assignment patterns.:ontinuum 3. Development of connective propositions from the literature review nurse. De- that could translate the data into appropriatc recommendations for: giver and a units nursing assignment pattern.ather thaning assign- 4. Development of the instruments..nd no one In developing the essential instmments, the study group found it useful1e pattern, to go beyond the traditional nursing assignment patterns (functional,he primary team, or primary) and to think of three major dimensions in any nurse plans and utilization pattern: patient characteristics, nursing resources, and or-scharge or ganizational support.rsing unit.lnagement Conceptual Frameworkrder mightlch patient The pattern of nursing assignmcnt on any patient unit may be seen as:am leader a link between problems, as presented by different patient populations, and purpose, as expressed bv professional standards and purposes of
  13. 13. 256 MANAGING HUMAN RESoURcESof the use of nursing personnel in providing care in hospital settings.One type of assignment pattern focuses on specialization and division could frof labor, or functional nursing. This type of assignment pattern evolved lor thein response to political and economic factors that demanded a redis- tient. Irtribution of registered nurses during World War II and included the nursingcreation of new nursing personnel categories such as the licensed prac- ognize 1tical nurse and the nurses aide. Functional nursing focuses on getting for actir.the greatest amount of task work done at the least cost in time and administraining. This pattern is accomplished by assigning specific tasks-cat-egorized or ordered according to degree of difficulty and importance topatient well-being-to nursing personnel with corresponding skill levels. A NEWThe use of multiple personnel to provide elements of a patients care PATTErequires a level of coordination and decision making best handled withina formal unit structure with a well-defined hierarchy. The purl Following the focus on specific technical excellence as the basis of rvas to dtassignment patterns was an emphasis on integrating nursing personnel tice whoof varying skill levels into a democratic, close-knit team. Team nursing ject inclrrepresents another way of adjusting care to the influx of auxiliary work- signmeners and was created to improve patient care by utilizing the diverse organizatskills of team members under the close guidance of registered nurses. users meThis pattern shifted much of the authority for making nursing decisions This deto a lower level in the nursing hierarchy: the registered nurse team leader inary worwho assumes responsibility for care given by other team members. The most recent pattern to develop places the responsibility for nursing 1. Develccare management within the direct care giver. Primary nursing requires of the ,that the registered nurses activities change from care manager-per- 2. Literatsonnel organizer to care manager-care implementer. Nurses aide ac- tributitivities are refocused away from direct contact with the patient and acteristoward equipment and supplies. The services of the licensed practical propri:nurse are not used in this pattern or fall somewhere on a continuumfrom direct patient care to direct assistance to the registered nurse. De- 3. Develocisions in the care process are usually made by a single care giver and that coare facilitated through horizontal consultation with peers, rather than a unitswith line authority. Primary nursing has been the basic nursing assign- -1. Develolment pattern used in community health nursing. Each assignment pattern has had its day of popularity, and no one In devekbest way has emerged for all settings.Indeed, within the same pattern, to go beycthere is no clear description of nursing responsibility. Within the primary ieam, or pnursing pattern, the time duration in which a primary nurse plans and utilizationgives care to a patient might span hospital admission to discharge or sanizationbe limited to a patients length of stay on a particular nursing unit.Within a given day, primary nurse responsibility for care management Conceptuimay vary from 8 to 24 hours. In team nursing, the team leader mightcarefully match patient needs to team member skills so that each patient The pattenmust cope with only a limited number of personnel; or the team leader alink betw and purpor
  14. 14. MoBrLrzrQl>(EuNE BqgouRCES 255 competent in their assigned roles. However, these assigned roles cannot be determined in educational settings away from the work environment. The technological revolution has created a situation in which educationle past 10 is far behind practice. Nurse administrators are the professionals in thedecreased best position to see the needs of the patients and the organization.lant under Johnson (12) describes competency by the standards of the state ofill become New Jersey as "being functionally able to perform duties of an assigned: questions role. The functions are performed having drawn conclusion for this ac-f nursing? tion from a sound knowledge of related sciences. The judgments madeork? What are based on a logical assessment of a given situation. Both deductive;e workers and inductive reasoning are imperative to competent practice."sing prac- The licensed practical nursing role is a dependent role. For minimal- level competency in todays dynamic health care system, the practical onal nurs- nurse should be prepared at the associate degree level. Registered nursesnursing is should be prepared at the baccalaureate level and have studied super-red knowl- vision and management. As nurse administrators conduct job and nurs-Lvioral sci- ing staff analyses, they need to have competent nurses and nurse as-ndividuals sistants in order to develop assignment patterns designed for quality, es or who cost-effective care delivery.vention or:red nurse It is no longer acceptable to deny the legal accountability of the professional nurse by creating such titles as primary or team leader or practical modular nurse. Prospective payment legislation demands a quantifi-oerformed cation of nursing services. The first unknown to be defined in the equa-cr dentist.o minimal tion is nurse. The nurse administrator has the best key to solving theprofession, following:ference in n * assignment pattern : quality care)s, contro-N.s. Inev- education The assignment pattern is easy to identify once a clear decision has been frequently made about n (nurse).ent would Institutional licensure is greatly feared as the antithesis of independentement for professional licensure. If nurses do not assume responsibility for practice as defined in most state practice acts, it may be only a matter of time a trained before institutional licensure takes over as a method of competency;sion with maintenance for relicensure. Nurse administrators must create practicetability to environments that address the best use of nurses, associate degreestitutions through doctorate. Nursing assignment patterns based on the creationlities, and of new titles without attention to the competence of the participantsls for who lack credibility.r the basicrrs, beforent pattern TRADITIONAL ASSIGNMENT PATTERNSrncerning During the last three decades, an extensive literature has developed onnurses be the subject of nursing assignment patterns, reflecting the importance
  15. 15. 254 IVIANAC!G Iu I44N &E!9 U 3e El compelCOMPETENCY AND RELICENSURE be dete The tecThe pool of employed nurses has steadily increased over the past 10years, and the proportion of inactive nurses has substantially decreased is far br(a).If a clear identification of nursing services is really important under best poprospective payment, perhaps an analysis of nursing jobs will become Johns New Jeias mandatory as continuing education is in many states. Some questionsto be answered in such analysis include: What is the work of nursing? role. ThWhat should it be? Who should be doing which parts of the work? What tion fro. are basrwill be the competencies of the workers? How will the nurse workers and indrmaintain competency according to their level of expertise? Most states have health occupation legislation covering nursing prac- The litice and licensure provisions that specifically address professional nurs- level cor nurse sh,ing. In the state of Michigan, for example, the practice of nursing is should bdefined as "the systematic application of substantial specialized knowl- vision aredge and skill derived from the biological, physical, and behavioral sci-ences, to the care, treatment, counsel, and health teaching of individuals ing staff sistants iwho are experiencing changes in the normal health processes or who cost-effecrequire assistance in the maintenance of health and the prevention ormanagement of illness, injury, or disability" (9). The registered nurse It is nr professioengages in the practice of nursing; the practice of licensed practicalnursing is considered a subfield of the practice of nursing performed modular cation ofonly under the supervision of a registered nurse, physician, or dentist.Incompetence means a departure from or failure to conform to minimal tion is ne followingstandards of acceptable and prevailing practice for the health profession,whether or not actual injury to an individual occurs. Although the laws in most states clearly describe the difference inlevels of competency between registered and practical nurses, contro-versy continues to iage about substitution of L.P.N.s for R.N.s. Inev-itably, nursing must come to grips with the idea of a standard education The assigrfor a professional activity. Although "B.S.N. or equivalent" is frequently made aboused to state a position requirement, no personnel department would Instituti professionrever argue for an M.D. or equivalent as the minimum requirement fora physicians appointment. as defined Over the years, nursing has evolved from the services of a trained before insnurse who learned skills at the bedside to those of a profession with maintenarstandards of education and practice and recognized accountability to environm,the public. Credentialing at graduation from accredited institutions through drsuggests that minimal criteria with respect to faculty, facilities, and of new tit.program have been met. Nurse administrators set the standards for who lack credilwill do what in nursing in their settings. They need to consider the basiceducational competency of the participants, among other factors, beforedeciding on a particular organizational structure or assignment pattern TRADITI(10). Fragmented, irreler,ant discussions prevail nationwide concerning During thecompetencies for registered nurses (11). It is important that nurses be the subjecl
  16. 16. !!QB4rzre EXIIIING 3Eq9!4cEq _ _z03 9. State of Michigan Public Health Code, Article 15, Occupations Part 172,oppor- Nursing. 1978. 10. Michigan Nurses Association Task Force. Position Paper on Competency for Relicensure of Michigan Nurses. East Lansing, Mi.: Michigan Nurses As- sociation, 1978.Nurses 11. Clayton, G.M. Identification of professional competencies, in N.L. Chaska, ed. The Nursing Profession. New York: McGraw-Hill, 1983.;upport 12. Johnson, H. Maintaining competency: a call for collaboration. lssrzes, Na-ue non- tional Council of State Boards of Nursing, Summer 1983,4(2),3. 13. Horn, B.J. and Parker, J.C. Reorganization of Nursing Resources in Hospitals. Unpublished manuscript. Ann Arbor, Mi.: University of Michigan School of Public Health, 1975. 14. Shukla, R.K. Primary nursing? Two conditions determine the choice. The Journal of Nursing Administration, November 1982, f 2Q1),12-15.rses by 15, Betz, M. Some hidden costs of primary nursing. Nursing and Heakh Care,;signed March 1981, 11(3), 150-154.sed de- 16. Eliopoulos, C. Nurse staffing in long-term care facilties: the case against arm that high ratio of RNs. The Journal of Nursing Administration, October 1983, /3(r0), 29-31.sonnel, 17. Carlsen, R.H. and Malley, J.D. Job satisfaction of staff registered nurses indictate primary and team nursing delivery systems. Research in Nursing and Health,;idering June 1981, 4(2), 251-260.on and 18. Shukla, R.K. Nursing care structures and productivity. Hospiteil and Health S ent ic es Admini s trat iorz, November/Deccmber 19 82, 27 (6), 45-5 8. 19. Friss, L. Why RNs quit: the need for management reappraisal of the "pro- pensity to leave." Hospital and Health Services Administration, November/ December 1982, 27(6), 28-44. 20. Duxbury, M. and Armstrong, G.D. Calculating nurse turnover indices.The Journal of Nursing Administration, March 1982, 12(3), 18-24.Nursing1980. 21. Vik, A.G. and Mackay, R.C. How does the l2-hour shift affect patient care? The Joutnal of Nursing Administration, January 1982, 12(l), 11-14.)utlook, 22. Dear, M.R., Celentano, D.D., Weisman, C.S., and Keen, M.F. Evaluating a hospital nursing internship. The Joumal of Nursing Administration, Novembernurses: 1982 , 1 201,), 16-20 .t, 1612-nericanital As- BIBLIOGRAPHY Profes- 1950- Hofmann, P.B. Accurate measurement of nursing turnover: the first step in its nment reduction. The J ournal of N ursing Administration, November/December 1 98 l, 1 t (t t-12) , 37 -39 . nd the Munson, F. and Clinton, J. Defining nursing assignment patterns. Nursing Re- 7-507. search, July/August 1979, 27(4), 243-249. >n. The Weisman, C.S. Recruit from within: hospital nurse retention in the l980s.The Journal of Nursing Administration, May t982, 12(5),24-31. rursing tursing
  17. 17. 19 istrato staffinl Nurs pretati,Stafnng and Schefuling compol cation. personl entailsYvonne M. Abdoo on pati signme A gre staffing The purpose of this chapter is to discuss requirements and consid- describ erations in nurse staffing and scheduling. The evolution of nurse (l) asse staffing is briefly explained, and current state-of-the-art systems are described. Various scheduling methodologies and trends in Nurse st sound ra workday length are explored. On completion of this chapter, the required reader will be able to: patients number l. Describe the trends in the development of patient classification and kin< systems in nursing. week. . . 2. State four work measurement methods that have been utilized public tl to measure nursing activity times. and the 3. Identify at least five factors related to physical surroundings and professional nursing practice that could affect nursing The p activity times. tifiable, 4. Describe the advantages and disadvantages of: must in a. Cyclical scheduling. needs (p to meet b. Block scheduling. gorithm c. Float, or supplemental, nurse staffing. sonal flr d. A 10-hour workday and a 4-day workweek. variable e. A l2-hour workday and a 3-day workweek. Devia f. Centralized versus decentralized scheduling. proach , 5. Discuss the physiological effects of shift rotation and cisions 1 the implications for nurse staffing. its comlOne of the most critical issues confronting nursing service administratorstoday is nurse staffing. Staffing policies and needs affect the nursing THE Edepartment budget, staff productivity, quality of care provided to clients,nursing staff morale, and even turnover. At the same time, nurse staffing Nurse strequirements are affected by overall hospital policies and by nearly every publisheother department in the organization, including admitting, lab, x-ray, on the udietary, and the like. Thus, it is essential that nursing service admin- the deve264 a hospitr
  18. 18. slAl l,lN{;ANl}:i( lnrt)lrilN(, .l/ 272 MANA(;tN(;tttlMAN l{lis()tllt(t,s Itctcttctlo rt grtl:trrl ;,l,rrr,,r Pt,rtcclrttc wirs n()l s.trr lry rrrrlsinl. pr.r:,orrnr.lof nursing carc rcquircrncnts. llris schcnra rcsults in 3u, ol ti I , pt-rssiblc as citlrtrcsstttli;rl ot rlt:.itlrlrlt.l[rc wotlt sccltttrrcrlrrrtl l)ir((w(11.ri(.1basic classification configurations, cach with its own mean nursing timc by othcr kirrrls ol plior itits" ( I ).and variance to reflect the nursing work load of medical patients and Improvcntcttl irtttl trlirrr,rttcttts in dctcrmirri-rtiorr ol nrrrsirrg irctivilyanother 81 means and variances for surgical patients.Intravenous ther- times can ottl.y occur il thc rrurse has a basic unclcr-starnclirrg ol wolltapy, catheter care, dressing care, and isolation are included in a special measuremcnt principlcs so that effective collabroratiorr witlt irrclr-rstlitrIprocedures section, since these activities have been found to reflect a engineers will occur. Four basic work mcasurcntcnt tcclrniclucs lrirvthigh amount o[ nursing time. been utilized in nursing studies to determine thc timc involvccl irr rrtrrsirrli activities (22):WORK MEASUREMENT IN NURSING 1. Time study and task frequency 2. Work sampling of nurse activityThe determination of the amount of nursing time required by each pa- 3. Continuous observation of nurses performing activiticstient for every shift is an essential but by no means simple component 4. Self-reporting of nurse activity.of a staffing methodology. Nursing has relied primarily upon industrialengineers and engineering work measurement techniques to quantify Difficulties encountered by nursing in using industrial-basccl w,rl<nursing actions, but there are often problems with the values obtained measurement methods to measure nursing practice are as follows:For example, many of the allocated time values for patient care dealonly with technical tasks. Difficulties in quantifying nursing times can 1. Many of the allotted time values deal with technical tasks, sirr.t,rlrt,be attributed to several causes: industrial engineer or observer does not recognize thc assr.ssrrrt,rrr, evaluation, and psychosocial aspects of the nurse-paticnl torr llrt t .1. The industrial engineer or nonnurse observer does not recognize the Thus, a patient who requires technical tasks could very likcl.y bc r.irlr.rl assessment, evaluation, and psychosocial aspects of the nurse-patient in a higher category than one who requires psychosocial or- tcirt.lrinli contact, and the nurse often does not convey these components of activities. professional nursing practice to the industrial engineer, due to the 2. In developing a patient classification system, some nursing clcltirr.t- nurses unfamiliarity with work measurement techniques. ments borrow the nursing times from the classification systcrrrs ol2. It is often difficult to differentiate between the start and completion others. It is important to realize that the times for one agcncy nt:rv of a nursing activity. For example, while giving a patient a bath, the not be accurate for another, since the nursing policies and proccclrrr.t,s, nurse interacts with the patient. How much of the time spent with unit architecture, experience of the nurse, and methocls o[ irrrplt the patient should be allocated to the technical task of bath giving menting the work can vary from agency to agency. and how much to assessment and interaction? 3. Many systems employ the mean time for a task without any corrsitl3. Although often referred to as time-study or efficiency experts, in- eration of the variance. Abdoo and colleagues (23) havc fburrcl tlr.t dustrial engineers cannot easily measure the time spent in assessment nursing tasks often vary widely with who performs thc activity irnrl and interaction. Measurement of repetitious, technical tasks can the method utilized. For example, report time on oruc stucliccl trrrit readily be done, but determination of times involving professional ranged from 15 to 90 minutes, with a mean of 30 minr-rtcs. judgment and skills is much more difficult. 4. The educational and experience background ol thc obscrvcc is rltt not considered, nor is a differcntiation made among thc lcvcls ol l{.N., Hudsons dissertation, summarized in Aydelottc (1), presents "criteria L.P.N., and nurse assistant or aide.that support the classification of nursing work as nonrepctitive. He also 5. Mosl stuclics ckr rrol corrsiclcr:examines questions relating to variations in task prediction time, t<-rprocedure development, and 1o thc inccntivc problcm. Hudson found it er. Thc it1-r;-rl-oltriirlrtttss ttl lht rtursing irrtclvtrrliorr ort ulling lrl tlrt.difficult to encourage inclivicluals to contplctc task zrssignmcnts withir-r Iirttr ol ittltt vctrl iorr.the time predictcd lirr tlrcir- acconrplislrnrcnt. l-Ic concluclccl thart a tzrshs b.llrc stall irrg, silrrrtlior;rl llrc littrtol tlrtslrrtll,(ovt.1 , r1(l(1 , ()rtime variation was cluc rrot orrly to tlrc irrclivirlrrirlit.y ol tlrc p:tticnt itrttl slr IislactoliIy slr Iltt I)his c1;nclition ltrrt trlso lo llrtirrrlivitltrlrlily ol tltc tttttsc, lttt tottccltt ol t. Wlrtllrtrprintiu,, lrrrrt liorr;rl, or lt.:rrrr rrtrlr,inli ,;r., rrr r.llr.r l.nursirrg 1-rllrt litt, irrrrl llrtplttontrivrtl ttoliotr ol lrorv l<t lrttlot ttt it. Acl-
  19. 19. st Atrtil N(; AND SqIIEDUIING_ 273272 MANAGING HUMAN RESOURCES herence to a present pran or proccdun- w:rs .r sccn by nursing personnelof nursing care requirements. This schema results in 3o, or 81, possible as either essential or dcsirzibrc. Thc wr.kbasic classification configurations, each with its own mean nursing time scclu.,,."urrJfuce were set by other kinds of prioritics,, (l).and variance to reflect the nursing work load of medical patients and Improvement and refincmcnts in dctcrn-riertionanother 81 means and variances for surgical patients.Intravenous ther- times can only occur if rhe nurse has a of nursing activity basicapy, catheter care, dressing care, and isolation are included in a special measurement principles so that eflectivc "na".rturriing of work collaborati", *iir, industriarprocedures section, since these activities have been found to reflect a engineers will occur. Four basic workhigh amount of nursing time. mcasurcment techniques havc been utilized in nursing studies to deterrnine the time irrrir"a in nursing activities (22):WORK MEASUREMENT IN NURSING 1. Time study and task frequency 2. Work sampling o[ nurse activitvThe determination of the amount of nursing time required by each pa- 3. Continuous observation of .rt-r.r", perfbrmingtient for every shift is an essential but by no means simple component activities 4. Self-reporting of nurse activity.of a staffing methodology. Nursing has relied primarily upon industrialengineers and engineering work measurement techniques to quantify Difficulties encountered by nursing innursing actions, but there are often problems with the values obtained. using industrial-based w<_rrk measurement methods to measure nursingFor example, many of the allocated time values for patient care deal p.J.ti." u." ., follo*s:only with technical tasks. Difficulties in quantifying nursing times can 1 Many of the allotted time values deal withbe attributed to several causes: industrial engineer or observer d""r ,rot technical tasks, since thc recognize the asscssmcnt, evaluarion, and psychosocial urp".r,l. The industrial engineer or nonnurse observer does not recognize the of the conracr. assessment, evaluation, and psychosocial aspects of the nurse-patient Thus, a patient whorequire. t".ii..t ";;_p;;r tasks could very likcr.y bc r.tccr category thin one who requir", pry.hosoiial contact, and the nurse often does not convey these components of professional nursing practice to the industrial engineer, due to the ff*:Ll* ,,,. r"u.hiug nurses unfamiliarity with work measurement techniques. 2 In developing a patient classification system, somc nur.sirrg rlt.rrr.r_ ments borrow the nursing times from2. It is often difficult to differentiate between the start and completion others It is imporrant to realize that the crassifi.u,i.r,,ror,t.rrrs .r of a nursing activity. For example, while giving a patient a bath, the the ,i;;"r".:;,,.i,,*,,,,,.u ,,,,,u not be accurate for another, since the nurse interacts with the patient. How much of the time spent with nursing unit architecture, experience of the nurse, policics ^rrtr the patient should be allocated to the technical task of bath giving and and how much to assessment and interaction? menting the work can vary from agency to agcncy. rctrr,rrs,r irrrr,. rrx.t.rrrrr.s, 3 Many systems employ the mean time for u3. Although often referred to as time-study or efficiency experts, in- eration of the variance. Abdoo and colrcagucs *irr,,,,,, ;rrrt,rr:.itl ,,,1t dustrial engineers cannot easily measure the time spent in assessment (z.r) irrru,.r,,,,,,,r rr,,,t nursing tasks oftenvary widely with who and interaction. Measurement of repetitious, technical tasks can pcr-lirr.rrs rlrr.;rr rrrr. ;rrrtl the method utilized nor readily be done, but determination of times involving professional judgment and skills is much more difficult. ranged from l5 to 90 minutes, with "*u-pl", a"p,rrr tirrrtrrr t)rt,:.rr rrrr,,rr ,rrir orr"r,,,,l 3O 4 The educational and experience backglrurrrl .l rrrrrrrtr.r, rlrt.,lr,,r,r r{,(. r,)lr(., Hudsons dissertation, summarized in Aydelotte (l), prcscnts "criteria not considered, nor is a differentiationir,,,r,irr(),,,, L.P.N., antl nurst, assislanl or aidc. rr,,. l,.r,rr., ,r ri.N.,that support the classification of nursing work as nonrepctitivc. Hc alsoexamines questions rclating to variations in task prcdiction tinrc, to 5. M<tsl slutlits rlo rrol corrsiclcr:procedure dcvelopmcnt, ancl to thc inccntivc prt.rblcnr. llrrclsorr lbtrncl it it.llrt. :rp;lr.olrr.irrlt, ol lltt. nutsiltg ttllr.t.r,t,trlt()n 1r{ r til Iilt,, ;rl lltt,difficult to cnc<-rt.rlagc: irrrlivitlurrls to corrrplr:lt: lask rrssigrrrrrcrrls within Iirttt. ol inl(.1 r.(.nIiorIthctin-rcprccliclttl lirlllrtillrtrotttplislttrrrrrt.llttorrtlrrtltrl llrll irllrsks ll.llrt sl;rllrrr1, .,rlr:rtr.r ;rt llrtlilrrtol lltt,s,lrrrlt (.rtintc varilrliorr r,virs tlrrtrrol orrly lo tlrtintlivitlrrlrlilv ol llrtpirlitlrl lrrrrl slrlisl;rr lot rlr ,.l,rll, rl) I ln{lr.t , otlri. , r"r,lili,,rr lrrrl ,rlqr l, llr,. i,r,li*,i,ltr,,litr, ,l llt, rrrrr..,. lr,.r, rrrr,,.rrl rrl