ORGANIZING

Staffing and Scheduling

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Staffing

• Process of determining and providing the acceptable number and mix of nursing personnel to produce a desired level of care to meet the patient's demand.

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Factors Affecting Staffing

• The type, philosophy, and objectives of the hospital and the nursing service;

• The population served and the kind of patient served, whether pay or charity;

• The number of patients and severity of their illness

• Availability and characteristics of the nursing staff, including education, level of preparation, mix of personnel, number and positions.

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• Administrative policies.• Standards of care desired which

should be available and clearly spelled out.

• Layout of the various nursing units and resources available within the department

• Budget

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• Professional activities and priorities in non-patient activities

• Teaching program or the extent of staff involvement in teaching activities.

• Expected hours of work per annum of each employee. This is influenced by the 40=hour week law; and

• Patterns of work schedule – traditional 5 days per week, 8 hours per day; 4 days a week, ten hours per day and three days off; or 3 ½ days of 12 hours per day and 3 ½ days-off per week.

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PATIENT CARE CLASSIFICATION SYSTEM• A method of grouping patients

according to the amount of complexity of their nursing care requirements and the nursing time and skill they require.

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Requirements • The number of categories into

which the patients should be divided;

• The characteristics of patients in each category;

• The type and number of care procedures that will be needed by a typical patient in each category; and

• The time needed to perform these procedures that will be required by a typical patient in each category.MJCN2014

Classification Categories

• Level I – Self Care or Minimal Care

Average amt of NCH/pt/day = 1.5

Ratio of Prof to NonProf = 55:45

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Classification CategoriesLevel I-Self

Care or Minimal Care-NCH 1.5/pt/day- Ratio 55:45

-Can take a bath on his own; feed himself; perform his own ADL. -For discharge pt; non-emergency, newly admitted don’t exhibit unusual s/s; - requires little treatment and observation

Level II – Moderate Care or

Intermediate Care

-NCH 3/pt- Ratio 60:40

-Need some assistance in bathing, feeding, ambulating for short period.-Extreme s/s of illness must have subsided or have not yet appeared-May have slight emotional needs-v/s taking ordered 3x/shift; with IVF/BT; are semi-conscious and exhibiting some psychosocial or social problems;- periodic treatments and/or observations and /instructions

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• Level II – Moderate Care or Intermediate Care

Average NCH/pt/day = 3

Ration or Prof to NonProf = 60:$0

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Classification CategoriesLevel III –

Total, Complete or

Intensive Care

-NCM 6hrs/pt/day-Ratio 65:35

-Patient are completely dependent upon the nursing personnel.-They are provided complete bath, are fed, may or may not be unconscious, with marked emotional needs; with v/s monitoring more than 3x/shift-Maybe on continuous oxygen therapy, with chest or abdominal tubes-They require close observation at least every 30 minutes for impending hemorrhage, with hypo or hypertension and/ or cardiac arrhythmia

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• Level III – Total, Complete or Intensive Care

Average NCH/pt/day = 6

Ratio of Prof to NonProf = 65:35

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Classification CategoriesLevel IV- Highly

Specialized Critical Care

-NCH 6-9 or more /pt/day- Ratio 70:30 or 80:20

-Need maximum level of nursing care with a ratio of 80 professionals to 20 non-professionals.-Needs continuous treatment and observation-With many medications, IV piggy backs; v/s monitoring every 15-30 minutes; hourly output.-There are significant changes in doctor’s orders

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• Level IV – Highly Specialized Critical Care

Average NCH/pt/day = 6-9 hours

Ratio of Prof to NonProf = 70:30 or 80:30

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Categories of Level of Care of Patients: Nursing Care Hours/Pt/Day & Ratio of Prof-Non Prof

Levels of Care NCH Needed Per Pt./Day

Ratio of Prof to Non-Prof

Level I – Self-Care or Minimal Care

1.50 5:45

Level II Moderate or Intermediate

Care

3.0 60:40

Level III Total or Intensive Care

4.5 65:35

Level IV Highly Specialized or Critical Care

6.07 or higher

70:3080:20

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Percentage of Nursing Care Hours

Type of Hospital

Minimal Care

Moderate Care

Intensive Care

Highly Spcl Care

Primary Hosp 70 25 5 -

Secondary Hosp

65 30 5 -

Tertiary Hosp 30 45 15 10

Spcl tertiary Hosp

10 25 45 20

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Nursing Care hours per patient/day according to classification of patients per units

Cases/Patients NCH/Pt/Day Prof to Non Prof Ratio

1. General Medicine 3.5 60:40

2. Medical 3.4 60:40

3. Surgical 3.4 60:40

4. Obstetrics 3.0 60:40

5. Pediatrics 4.6 70:30

6. Pathologic Nursery 2.8 55:45

7. ER/ICU/RR 6.0 70:30

8. CCU 6.0 80:20MJCN2014

Computing for the number of Nursing Personnel Needed• Consider sufficient staff to cover all

shifts, off-duties, holidays, leaves, absences and time for staff development programs.

• R.A. 5901 – Forty-Hour Week Law

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Total No. working-Non working days & hours of nursing personnel per year

Rights & Privileges Given Each Personnel Per Year

Working Hours Per Week

40 hours 48 hours

1. Vacation Leave2. Sick Leave3. Legal Holidays4. Special Holidays5. Special Privileges6. Off-Duties as per R.A. 59017. Continuing Education Program Total Non-working Days per year Total working days per year Total working hours per year

15151023

1043

152213

1,704

15151023

523

100265

2,120

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Relievers Needed

- To compute for relievers needed, the following should be considered;

1. Average number of leaves taken each year------ 15

a. vacation 15

b. sick leave 5

2. Holidays -----------------------------------------------------12

3. Special Privileges as per CSC MC#6 s. 1996-------3

4. Continuing Educ. Prog. For professionals------------3

Total Average Leave-------33

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To determine the relievers needed- divide 33 by number of working days per year each employee served (whether 213 or 265)

- result will be 0.15 per persons works for 40 hour/week

- result will be 0.12 per persons works for 48 hour/week

- multiply the computed reliever per person by the computed number of nsg personnel

- this will give you the total number of relievers

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Distribution by Shifts

• 45% AM shift, 37 % PM and 18 % night

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Staffing Formula

To illustrate: Find the number of nursing according to levels of care needed.

1. Categorize the patients according to levels of care needed

250 pts x 0.30 = 75 pts needing minimal care

250 pts x 0.45 = 112.5 pts needing moderate care

250 pts x 0.15 = 37.5 pts needed intensive care

250 pts x 0.01 = 25 pts need highly specialized 250 nsg care

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2. Find the number of nursing care hours (NCH) needed by patients at each level of care per day.

75 pts x 1.5 (NCH needed at Level I) = 112.5 MCH/day

112.5 pts x 3 (NCH needed at Level II) = 337.5 NCH/day

37.5 pts x 4.5 (NCH needed at Level II) = 168.75 NCH/day

25 pts x 6 (NCH needed at Level IV) = 150 NCH/day

Total 768.75 NCH/day

3. Find the total NCH needed by 250 patients per year.

768.75 x 365 (days/yr) = 280,593.75 NCH/year

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4. Find the actual working hours rendered by each nursing personnel per year.

8 (hrs/day) x 213 (working days/year) = 1,704 (working hours/year)

5. Find the total number of nursing personnel needed.

a. Total NCH per year = 280,593.75 = 165

Working hrs/year 1,704

b. relief x total nsg. Personnel = 165 x 0.15 = 25

c. total nursing personnel needed 165 + 25 = 190

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6. Categorize to professional and non-professional personnel ratio of prof to non-prof in a tertiary hospital is 65:35

190 x .65 = 134 professional nurses

190 x .35 = 66 nursing attendants

7. Distribute by shifts

124 nurses x .45 = 56 nurses on AM shift

124 nurses x .37 = 46 nurses on PM shift

124 nurses x .18 = 22 nurses on night shift

Total 124 nurses

66 nsg attendants x .45 = 30 nsg. attendants on AM shift

66 nsg attendants x .37 = 24 nsg attendants on PM shift

66 nsg attendents x .18 = 12 nursing attendants on noc

Total = 66 nursing attendantsMJCN2014

Placement

• Advantages

– Fosters personal growth

– Provides motivating climate for the employee

– Maximizes productivity

– Organizational goals have better chances of being met.

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• Results of Inappropriate placement–Frustration–Poor quality of work–Reduced organizational

efficiency–Rapid turn-over–Poor image of the agency

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Factors to consider

• Inherent in the employee

• Past experience and training

• Culture of the clientele

• Decision-making skills

• Communication skills

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Advantages of proper placement• Adapt faster

• Feet are lighter

• A lot happier

• Felt confident when supervised

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Scheduling

• A timetable showing planned work days and shifts for nursing personnel.

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Factors considered in Making Schedules• Different levels of the nursing staff;

• Adequate coverage for 24 hours, seven days a week;

• Staggered vacations and holidays;

• Weekends and long stretches of consecutive working days;

• Evening and night shifts; and

• Floating.MJCN2014

Assessing a scheduling system• Ability to cover the needs of the

unit.

• Quality to enhance the nursing personnel’s knowledge, training and experience.

• Fairness to the staff

• Stability

• Flexibility

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Types of Scheduling

• Centralized Schedule

• Decentralized Schedule

• Cyclical Schedule

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Advantages of Cyclical Schedule• It is fair to all

• It saves time

• Enables the employee to plan ahead for their personal needs

• Scheduled leave are more stable

• Productivity is improved.

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Rotating Work Shifts

• Common in most hospitals.

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Assessing a Scheduling System

1. Ability to cover the needs of the unit

2. quality to enhance the nursing personnel's knowledge, training and experience

3. fairness to the staff – fair share of weekends, holiday offs, rotation patters for the whole year including assignment to “difficult” or “light” or “undesirable” units or shifts

4. stability – the schedule must be harmonized with their family or social activities of the nurse staff

5. flexibility – ability to handle changes brought by emergency leaves.

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Make a schedule in a weekly or monthly basis and do cycle system with the staff under the area assigned for fairness and flexibility.

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A one-week cyclical schedule

Personnel S M T W T F S

7/3 Headnurse/Senior Nurse x x

Staff Nurse x x

Nsg. Att. x x

3/11 Staff Nurse x x

Nsg. Att. x x

11/7 Staff Nurse x x

Nsg. Att. x x

Gen. Rel. 3/11; 11/7 S. nurse 3/11 3/11 11/7 x x 3/11 11/7

N. Att. 3/11 11/7 x 7/3 3/11 11/7 x

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Organizing Patient Care

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• What is our focus……

• Why are we here…….

• ….patients now more than ever need reassurance that they are indeed the focus of the healthcare team - Joan Shinkus Clark

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Traditional Modes of Care Delivery

• Total Patient Care

• Functional Nursing

• Team and Modular Nursing

• Primary Nursing

• Case Management

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• Care delivery modalities (modes) affect autonomy and job satisfaction.

• Direct pt care functions are actually caring for pt.

• Indirect pt care functions are like being able to self schedule, charting

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Total Patient Care• Total patient care - nurses assume total

responsibility for meeting all needs of assigned patients during their time on duty– ICU – Form of primary nursing

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Functional Method• Functional nursing - work assignment by

functions or tasks, such as passing medicine, doing dressing changes, giving baths, or taking vital signs

• Assignment by function.

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Team Nursing• Team nursing - a team of RNs, and aides

under the supervision of one nurse, called the team leader

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Primary Nursing

• Primary nursing is an approach in which a nurse has responsibility and accountability for the continuous guidance of specific clients from hospital admission through discharge

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Case Management• Case management in acute care hospital

nursing has been defined as a system of client care delivery that focuses on the achievement of client outcomes within effective and appropriate time frames and resources

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CASE MANAGEMENT SERVICE AREAS

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Category

Service Setting

Acute Orthopedics, cardiovascular, critical care, high-risk perinatal, oncology, emergency department

Subacute Skilled nursing centers, rehabilitation units

Ambulatory Physician's office, clinics

Long-term care Nursing homes, group homes, assisted-living facilities

Insurance companies

Health maintenance organizations (HMOs), preferred provider organizations (PPOs), workers' compensation, Medicaid, Medicare

Community Nurse-managed centers, home health agencies, urgent care centers, schools, rural settings

Disease Management

• Common high-cost, high-resource utilization diseases

• Population-based health care– Covered lives

• Continuous health improvement

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Job descriptions

• It is a written statements, found in policy manuals that describe the duties and functions of the various jobs within the organization.

• They outline the scope of authority, responsibility, and accountability involved in each position.

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Job descriptions

• It should provide

1. the broad general guidelines under which the individual will function

2. the basis for performance evaluation of the person working in that role

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Contents of a Job Description

• 1. Identifying Data

• 2. Job Summary

• 3. Qualification Requirements

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Uses of Job Description

• 1. For recruitment and selection of qualified personnel

• 2. To orient new employees to their jobs

• 3. For job placement, transfer or dismissal

• 4. As an aid in evaluating the performance of an employee

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Uses of Job Description

• 5. For budgetary purposes

• 6. For determining departmental functions and relationships to help define the organizational structure

• 7. To serve as channel of communication.

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Uses of Job Description

• 8. For classifying levels of nursing functions according to skill levels required.

• 9. To identify training needs

• 10. As basis for staffing

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Developing Job descriptions

• Contents– Identifying data– Job summary– Qualification requirements– Job relationships– Specific and actual functions and

activities

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Uses of Job Description

• For recruitment and selection of qualified applicants

• To orient new employees to their jobs

• For job placement, transfer or dismissal

• As an aid in evaluating the performance of an employee

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• For budgetary purposes;• For determining departmental

functions and relationships to help define the organizational structure;

• For classifying levels of nursing functions according to skill levels required;

• To identify training needs;• As basis for staffing; and• To serve as channel of

communication.MJCN2014

DISCIPLINE

MEANINGThe word “discipline” is derived

from the Latin word “disciplina”, which means teaching, learning and growing.

TYPES OF DISCIPLINE

1. Self controlled discipline 2. Enforced Discipline

INDISCIPLINE:- Indiscipline means disorderliness, insubordination and not following the rules and regulation of an organization.

Causes of indiscipline:-

• Non-placement of the right person on the right job

• Undesirable behaviour of senior officials.

• Faulty evaluation of persons and situations by executives leads of favoritism.

• Lack of upward communication.• Leadership which is weak, flexible,

incompetent and distrustful.

• Defective supervision and an absence of good supervisors who know good techniques, who are in a position to appreciate critically the efforts or their subordinates.

• Lack of properly drawn rules and regulations.• Workers’ personal problems, their fears,

apprehensions, hopes and aspirations; and their lack of confidence in and their inability to adjust with their superior and equals.

• Worker’s reactions to rigidity and multiplicity of rules and their improper interpretation.

• Intolerably bad working conditions.

• Inborn tendencies to flout rules.• Absence of enlightened, sympathetic

and scientific management.• Errors of judgement on the part of the

supervisor or the top management.• Improper co-ordination, delegation of

authority and fixing of responsibility.• Discrimination based on caste, colour,

creed, sex, language, and place in matters of selection, promotion, transfer, placement and discrimination in imposing penalties and handling out rewards.

APPROACHES TO DISCIPLINE:-The different approaches to

discipline include;• Human relation approach: In human

relation approach the employee is. helped to correct his deviations

• Human resources approach: Under the human resources approach, the employee is treated as resource and the act of indiscipline are dealt by considering the failure in the area of development, maintenance and utilization of human resources.

• Group discipline approach: The group as a whole sets the standards of discipline, and punishments for the deviations. The individual employees are awarded punishments for their violation under the group discipline approach.

• Leadership approach: In this approach, every supervisor administers the rules of discipline and guides, trains and controls the subordinates regarding disciplinary rules.

• Judicial approach: In judicial approach, indisciplinary cases are dealt on the basis of legislation and court decisions.

The Industrial Employment Act, 1946, to a certain extent, prescribed the correct procedure that should be followed before awarding punishment to an employee in India.

PRINCIPLES FOR MAINTENANCE OF DISCIPLINE:-

The most important principles to be observed in the maintenance of discipline have been outlined by Yoder, Heneman, Turnbull and Harold Stone. They are:

All the rules should be framed in co-operation and collaboration with the representatives of employees.

All the rules should be appraised at frequent and regular interval to ensure that they are, and continue to be, appropriate, sensible and useful.

Cont.. Rules should vary with changes in the working conditions of employees.

Rules should be uniformly enforced if they are to be effective.

Penalties for any violation of any rules should be clearly stated in advance.

A disciplinary policy should have as its objectives the prevention of any infringement rather than the simple administration of penalties; however it should be preventive rather than punitive.

Extreme caution should be exercised to ensure that infringements are not encouraged.

If violations of a particular rule are fairly frequent, the circumstances surrounding them should be carefully investigated and studied in order to discover the cause or causes of such violations.

Recidivism must be expected. Some offenders would almost certainly violate rules more often than others. These cases should be carefully considered so that their causes may be discovered.

Definite and precise provisions for appeal and review of all disciplinary actions should be expressly mentioned in the employees’ handbook or collective agreements.

ASPECTS OF DISCIPLINE:-

Positive aspect: Employees believe in and support discipline and adhere to the rules, regulations and desired standards of behaviour. Discipline takes the form of positive support and reinforcement for approved actions and its aim is to help the individual in moulding his behaviour and developing him in a corrective and supportive manner. This type of approach is called positive approach or constructive discipline or self-discipline.

Positive discipline takes place whenever the organizational climate is marked by aspect such as payment of adequate remuneration and incentives, appreciation of performance and reinforcement of approved personnel behaviour or actions etc.

which will motivate employees to adhere to certain rules and regulations or exercise self-control and work to the maximum possible extent.

Negative aspect: Employees sometimes do not believe in and support discipline. As such, they do not adhere to rules, regulations and desired standards of behaviour. As such, disciplinary programme forces and constraints the employees to obey orders and function in accordance with set rules and regulations through warnings, penalties and other forms of punishment. This approach to discipline is called negative approach or corrective approach or punitive approach.

• This approach is also called autocratic approach as the subordinates are given no role in formulating the rules and they are not told why they are punished. Punishment, penalties, demotions and transfers provide or establish a climate which demotivate and delead the employees.

The highest level and most effective form of discipline is self-discipline.

Ideally, all employees should have adequate self-control and should be self-directed in their pursuit of organizational goals.

Definition:

Self discipline is best defined as the ability to regulate ones conduct by principle and sound judgment, rather than by impulse, desire, or social custom.

Self discipline can be considered a type of selective training, creating new habits of thought, action, and speech toward improving yourself and reaching goals.

The Five Pillars of self discipline

Acceptance

Willpower

Hard work

Industry

Persistence.

If you take the first letters of each word you get the acronym “A WHIP”- since many people associate self discipline with whipping themselves into shape.

To be self disciplined:

• Get yourself organized• Don’t constantly seek to be entertained • Be on time • Keep your word • Do the most difficult tasks first• Finish what you start• Accept correction • Practice self denial • Welcome responsibility

Health Care Education Associates (1987) identified four factors that must be present to foster a climate of self-discipline.

• Employee awareness and understanding of rules and regulations that govern behaviour- The rules and regulation must be clearly written and communicated. Young and Hayne (1988) stated that the most common reason for unsatisfactory work performance is that the employee thinks they are performing satisfactorily. In other words the employee does not know there is a problem.

• There must exist an atmosphere of mutual trust- Manager must believe that employees are capable of and actively seeking self-discipline. Likewise employees must perceive the manager as honest and trustworthy. Employees lack the security for self-discipline if they do not trust their manager’s motives.

• Formal authority must be used judiciously- Approximately one-half of grievance cases appealed before an arbitrator by labour unions involved disciplinary action. In about one-half of those cases, management either reversed or modified its decision when the individual’s appeal was upheld.

• Employees should identify with the goals of the organization- When the employees accept the goals and objectives of an organization, they are more likely to accept the standards of conduct deemed acceptable by the organization.

DICIPLINARY PROCEDURE:-

The following steps should be taken into consideration:

• Accurate statement of the problem- The first step is to ascertain the problem by seeking answer to the following questions:– Does this case call for a disciplinary action?– What exactly is the nature of the violation or offence?– Under what condition did it occur?– Which individual or individuals were involved in it?– When or how often, did the violation occur?

• Collecting facts bearing on the case- Before any action is taken in a case, it is essential to gather all the facts about it. A thorough examination of the case should be made within the stipulated time limit.

• Selection of tentative penalties- The kind of penalty to be imposed for an offence should be determined beforehand.

• Choice of Penalty- When a decision has been taken to impose a penalty, the punishment to be awarded should be such as would prevent a recurrence of the offence.

• Application of the Penalty- The application of the penalty involves a positive and assured attitude on the part of the management. If the disciplinary action is a simple reprimand, the executive should calmly and quickly dispose of the matter.

• Follow-up on disciplinary action- The ultimate purpose of disciplinary action is to maintain discipline, to ensure productivity, and avoid a repetition of the offence. A disciplinary action should, therefore, be evaluated in terms of its effectiveness after it has been taken.

BASIC INGREDIENT FOR A DISCIPLINARY ACTION:-

The principle ingredients of a sound disciplinary system are:Location of responsibility Proper formulation and communication of rulesRules and regulations should be reasonableEqual treatmentDisciplinary action should be taken in Private Importance of promptness in taking Disciplinary action

Innocence is presumedGet the facts Action should be taken in cool atmosphere: Natural justiceAfter a disciplinary action has been taken the Supervisor should treat his subordinate in a normal mannerDon’t back down when you are rightNegative Motivation should be handled in a positive manner

TYPES OF PUNISHMENT:-

When the delinquent employee is going to be punished, the type of punishment should be a commensurate with the severity of the omission or misconduct.

Different types of punishment resulting from various types of omission or misconduct are as follows:– Oral warnings– Written warnings– Loss of privileges and fines– Punitive suspension– Withholding of increments– Demotion– Termination

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