INR Features

Hospital populations have changed a great deal over the last few years. Shorter hospital stays, out-patient procedures replacing acute care and changes in insurance contracts are just a few of the reasons why many hospitals now need fewer acute care beds. Smaller hospitals can also be affected by retirement, illness or death of doctors in the community.

Jennie Edmundson Hospital in Council Bluffs saw a sharp decline in their inpatient population in 2004. The average daily census was frequently one-half to two-thirds less than the year before. Other hospitals of similar size and smaller rural hospitals have experienced the same decline. Fewer patients means less revenue and presents many challenges for a hospital administration. One of the largest challenges involved staffing. While the staffing issues involved all hospital employees, this article will focus on nursing staff only.

In the past Jennie Edmundson had an Outpatient Department, Surgery Department, Women and Children's Health Unit, Psychiatric Health Unit, Telemetry Unit, Intensive Care Unit, Utilization Review Department, Emergency Room, two Medical-Surgical units and a few other small areas that require nursing staff. Because of the changes in patient needs the hospital developed a response that would maintain quality care without decreasing services and retain enough staff to accommodate an increase in patient census, should that happen. The units experiencing the biggest change were the Medical-Surgical units and the Telemetry Unit.

Following are some of the major strategies instituted by the hospital to adapt to the decreased number of patients:

• The two medical-surgical units, one designated for orthopedic patients and one designated for oncology patients, were combined into one unit. The two units were caring for a little more than half of their usual number of patients and this allowed for more efficient use of staff and facilities. Other units were also combined under one manager which eliminated several management positions.
• Open positions were filled with in-house staff. Nurses floated off of their regular unit more often to fill staffing needs.
• Nursing staff took low census days off on a rotation basis.
• Many nurses were cross-trained to work in other areas. For example, operating nurses trained to also work in post-anesthesia and the outpatient department.
• Some units, such as surgery, have a changed the way shifts are scheduled and these nurses will be rebidding for their positions related to scheduled shifts.
• Both eight hour and twelve hour shifts have continued to be used, and sometimes even four hour shifts are assigned. However, with more stable patient numbers they are considering a requirement that all staff work twelve hour shifts.
• The number of nurses in the Options Program has been reduced to only a few. The Options staff consisted of nurses who earned a higher hourly wage, had no benefits, and were not guaranteed any number of hours. They also were not a part of the bargaining unit contract. Many of these nurses took other jobs because they were the first to be called to take time off.
• The matrix determining the nurse to patient ratio on the inpatient units has been changed several times and staffing is evaluated at four hour intervals.
• The hospital administration hired a group of consultants to evaluate and make recommendations for the best use of our staff and facilities. These recommendations are currently being implemented.
• An early retirement program was offered to nurses 62 years old and older.

There are eleven hospitals in the Council Bluffs - Omaha metro area. There are also several home health agencies, hospice programs, dialysis centers, insurance companies, physician's clinics, nursing homes and temporary staffing companies all competing to hire nurses. There are also numerous small hospitals in the outlying communities. This means that Jennie Edmundson must provide competitive salaries and benefits in order to retain nursing staff.

Jennie Edmundson nurses are a part of a bargaining unit and the president of that unit meets with the director of Human Resources once a month. This has facilitated communication from administration to staff and also provides vital feedback from staff to administration.

There are always consequences to making so many changes in a relatively short period of time. Some things have worked well, while others have had to be reworked to maintain quality and safe patient care. Some of the results of the changes made are as follows:

• With staff needing to function in unfamiliar areas and taking extra time off there has been a high level of stress and feeling of insecurity. This has caused the loss of some nurses to other facilities.
• Some nurses took a second part-time job which makes scheduling more difficult.
• Many of the nurses drive 30 to 90 miles to work and didn't want to drive that far for a four hour shift. It is also difficult for them to be on call unless they stay at the hospital.
• There is a general feeling of uncertainty related to working with a different patient population and not always feeling sure of what is expected of you. Nurses tend to build up a support system amongst the group with whom they work. Frequent floating to other units has caused a disruption in those relationships and contributes to that feeling of insecurity.
• As the hospital moves toward twelve hour shifts another burden is placed on many nurses who have worked eight hour shifts for many years and will have difficulty changing child care arrangements and family routines.
• Many nurses have used up their vacation and holiday time in order to be paid for the low census days they have taken.

To meet the staffing needs created by yet another change in the number of acute care patients the hospital has begun advertising positions and put into place a plan for recruiting nurses. With the rapid discovery of new medical techniques, medications and treatments there is no accurate way of predicting whether the number of patients requiring acute beds will decrease, increase, or stay the same. Therefore, staffing issues must continually be reevaluated and changes made to accommodate the number and type of patients that require acute care.

Changing Times Require Flexible Nurses

In the last few years medical facilities have had to adapt to an unprecedented number of changes in short periods of time. Today's nurse must constantly be able to adjust to changes in the type of patients she/he cares for, be open to learning new procedures, new documentation methods, new medication regimes and changing nurse to patient ratios. What was learned a short time ago may no longer be correct. What was considered safe patient care a short time ago may no longer be valid. New discoveries are being made every day and every facility must institute changes rapidly to provide the best patient care possible. This entails almost constant inservice education and communication from management to staff. It also requires nurses to be able to adapt to constant change and have the ability to learn and put into practice new information on an almost daily basis. The old saying of "We've always done it this way" or "We've never done it this way" is no longer valid. These things make our jobs more stressful but also more challenging. The most important goal in this entire process must be in the care of the patient. Nurses must continue to demand safe patient care and continually evaluate what safe patient care is. There must be an ongoing communication with administration in order to meet the needs of the individual patient who is in our care. Despite a continually changing knowledge base we must keep our focus on the patient who places his or her trust in the facility and its staff from the moment he or she enters the door.

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