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Article review 2025 acuity staffing · Nurse Leadership Dumpster Fire

• speaker-0: Good morning, Teresa. speaker-1: Good morning, Cindy. How are you? speaker-0: I'm good. good to see you. Hm. You two. We haven't seen each other in two weeks. It's too long. We need our teleport machine. speaker-1: It's good to see you. I know. Have you figured that out yet? speaker-0: No. Hopefully I will do that next. speaker-1: Yeah. speaker-0: Doesn't destroy our planet. Just kidding. ⁓ Okay, so audience, we are going to be doing an article review today. so I just went to that AONL Nurse Leadership Conference a couple months ago. And Teresa found this article. It's actually a white paper that AONL put out. ⁓ and for those that don't know, AONL stands for American Organization for Nurse Leaders, and it's a great organization. ⁓ to network and get resources for nurse leadership. They have all kinds of cool things there. Like ⁓ they have ⁓ competencies for nurse leadership that are very helpful to make sure that your leaders have the right training and skill sets to be able to do all the things that they need to do. ⁓ but this one, what was this one called, Teresa? ⁓ speaker-1: I actually forgot the title of it. I have it right in front of me though. It well this is called twenty twenty five trends in Nurse Scheduling. Yeah. And the reason I wanted to talk about it was because I like how it talks about doing staffing and scheduling as with your s with your areas based off of acuity, not ratios. Yeah. So I wanted to talk about that and like brainstorm how do we do this and how do we feasibly make this happen. speaker-0: It's definitely been a big common topic in healthcare, at least in nursing, I've been hearing a lot lately. Like in our own facility, they keep talking about how they don't want us to refer to our staffing as ratios, like nurse to patient ratios. They want us to refer to it as nursing hours per patient day, which in my head I still have a little bit of a hard time differentiating that. But I think if you're truly doing it on acuity, then that may change the required nursing hours. But if you're just looking at ⁓ the number of patients and the number of staff, it's not that different from ratios, from my understanding. Do you have a different thought about that? speaker-1: ⁓ no, it's it really isn't. It's just a different way of looking at it. So kind of the but at the end of the day, instead of like, ⁓ we're a four to one ratio and you get four patients no matter what, we're it's taking and looking at how sick are the patients they're giving you. Yeah. And I like that concept because you should be considering how much time does it take to do these tasks. ⁓ but then That has to be done probably the day of. And then planning wise, you would have to look at like, okay, ⁓ most of the time are when we no matter what, like over time, we were kind of talking about how do I make sure I have a schedule enough nurses and schedule enough staff to cover these needs. At the end of the day, that's the tricky part. So a couple of things this article talks about is. different technology, different software. ⁓ and then the big one is the float pools. It it has an ⁓ yeah, and ⁓ every hospital I've worked at does have a float pool. And so I thought that was kind of interesting. ⁓ and the the article goes into about like balancing flexibility, efficiency, and staff satisfaction. Mm-hmm. speaker-0: Mm, yeah. And by the way, ⁓ for those listening, this article was actually like a a big survey that they put out to nurse leaders. So they were questioning how nurse leaders are currently doing staffing. So whether they're using ⁓ nurse to patient ratio based staffing or acuity-based staffing, they talked about the difference between centralized scheduling and decentralized scheduling. And then they talked about which ⁓ which leaders are using apps for scheduling. So that there's or and they talked about self scheduling versus, you know, one person doing it and which ones are using apps and then a little bit about AI technology and how you can use that for your staffing. ⁓ so there's a lot of options out there on the table right now and I think you're gonna see a lot of different things depending on the facility you're at and how big it is and how how much how many resources they have. ⁓ because some of these products are very cool, but I imagine they're very expensive. In fact, when I was at that conference, Teresa, there was a company there that would track like they would take all of the nurse sorry, nurse staffing skill sets and training and competencies that the nurses had. And then it would also ca it had like real-time tracking of the patients in beds and what their diagnosis was, and it would give it like an acuity score and it would tell you exactly what your NHPPD should be for that day on every single unit. And it was meant to be utilized for house supervisors to take away the the thought that it's, you know, not that it's like a biased decision. So it makes it more of a factual database decision. Which I know we have had many conversations about that in our leadership days working with our house supervisors. ⁓ but I mean, the technology was so complex and widespread that I was like, I can't even imagine like my facility right now buying this. I mean, it'd be so cool, but you know, like we we're still doing scheduling on Excel spreadsheets. So speaker-1: Actually this talks about ⁓ technology and scheduling and actually a lot of people use spreadsheets still. Yeah. According to this article. speaker-0: Crazy because I don't like it. Like, I I find it really hard. You know, we complained, we used a program in Salt Lake called Accustaff, which a lot of VAs use. I know it's not a VA-specific program, but a lot of VAs do use it. And ⁓ I didn't like it at when we used it, but now, like going back to just using a spreadsheet, I'm like, God, I really wish we had Acu Staff here. Like, this is crazy. Like, even for me to just be like, how many staff are on the unit today? Like an accu staff, you could turn off if somebody was in patient care. So it didn't go into your count. So like if you had somebody that was working on a project or was like don't going to an RCA or doing training, you could turn that off so that they didn't go into your staffing count. And there's no way to do that with a regular Excel sheet. It's just how many bodies are there? And I can't, you know, if I don't know intimately what's going on on the unit, I can't tell. if somebody's there to do patient care or they're there for something else. speaker-1: Yeah. That's crazy. Yeah. So I I wanted to talk about this because it's like this at the end of the day, if we start to shift our thinking towards more acuity of patients rather than just you take everybody takes the same amount of patients, I think patient care will be improved and our outcomes will be better. And if you're taking like that program you were talking about and you take all of their skill sets too, which is actually something we did do. We considered our skill sets. We were kind of talking about that even before we started the podcast today. ⁓ how we we did, we organized, we had a list and whoever had all of their competencies done and all of their skills done, we had two of those people on every shift. So no matter what, there was somebody available to take anything that came. speaker-0: Yeah, because I think when we looked back at like 'cause we'd both worked on this unit as staff and so we knew what the what the routine was and we were saying how on average we might have two really sick patients on the unit, you know, maybe one. We didn't have we wouldn't we weren't such a busy ICU that every patient was in there was like really that critical, but you might have on average one to two critical patients. And the rest of them are like a pretty straightforward, they're not in an acute, you know, they're not they still should be in an ICU bed, but they're not like actively crumping or running multiple devices. So we were like, okay, you we need to have a minimum of two. So you have one person who can take a really sick patient and you have one person who can charge. ⁓ so you're right. What that's how we did our scheduling. But I think, you know, we did that based off of just our own pattern recognition of saying this is typical. And there were times there was going to be outliers for that. And we would try to have to adjust. And you might call in overtime if you have ⁓ you know, extra like more sick patients than usual, or we might move things around in real time if we see that trend happening. But I just think how much more efficient it could have been if we had a program like that to help us really look at the accurate trends of what were happening. ⁓ And to have that, you know, I remember having conversations with our executive leadership. They used to not want us to have a crash bed in the ICU. Do you remember that? Mm-hmm. And I remember trying to explain that if we weren't gonna have an open crash bed in the ICU, you know, it takes I mean, best case scenario, it takes an hour to move a patient from one unit to another, even if everyone's got their ducks in a row. And so But that's like even best case scenario. So even with that, you're looking at if you have a patient who's crashing on one of the other units in the hospital and they need to move up to the ICU for a higher level of care and we don't have beds first. That has to assume that there is a patient who can leave. We have to get that patient out. We have to try to disinfect the room as best as we can, turn it over, and then move that other patient up there. Meanwhile, you have somebody has to be down on that unit, managing that patient to keep them from crumping. speaker-1: Yeah. speaker-0: And it was like, and I was like, this is really dangerous. So, you know, I'm I remember saying things like, if that's the risk that you want to take as our executive leadership team, then that's on you. But I am I'm doing my due diligence to explain the potential risk of doing that. ⁓ and having that data though would have been very easy to say, this is why we should not do that, because this is how often that happens. speaker-1: Yeah. And actually shortly after that, we started that bed management system to where they could track how ⁓ long it took to get a room turned over. Right. And that was part of that process. And I think once they realized how long it actually takes to get rooms turned over, I think that was when they were kind of like, ⁓ okay. Yeah. Cause now you actually have data to point to to say this. ⁓ some of the other things we also did to help identify the reason we needed like staffing the way we needed it in the ICU and yada yada yada. We started I started tracking how much time our ICU nurses were off the floor ⁓ doing different things. You remember that? Yeah. My identify hospital resources. speaker-0: Yeah, the ICU manager that I'm working with right now in this facility does the same thing because they're ⁓ this this ICU has less acute patients than we did in s and ⁓ when you and I were together. And so I think it happens even more that people are leaving the unit. ⁓ that they're floating all the time. ⁓ and so they are also doing that tracking, which you're right, is very helpful. And, you know, our situation, I think our executive leadership is a little bit more familiar with managing higher acuity patients and bed flow than when in in previous positions where people were coming from like very different kinds of backgrounds like mental health or community care and didn't have as much acute knowledge of inpatient. ⁓ so I don't feel like we have to have that fight as often here, but it's still very useful for other people to understand, you know, when you're like asking like, ⁓ Those guys are just sitting around doing nothing. It's like, well, not really. Let me show you what they're actually doing. speaker-1: Yeah. ⁓ so some of the key findings from this article and the the review, it I I'm gonna just talk about them because they're listed right here, but staff safety is the number one ⁓ work first priority. So fifty two percent of nurse leaders rank staff safety as their top priority above scheduling efficiency. Mm-hmm. and technology adapt adoption. Sorry, words are hard words are hard. And then the other one was ⁓ well So okay, they have a lack of nurse input ⁓ undermining scheduling as a technology option. So I don't know if that made sense. Forty five percent of nurse leaders say that the top barrier to successful scheduling software adoption is the lack of nurse involvement in the decision making. That's what speaker-0: Yeah, yeah. speaker-1: And then a cute bigger. speaker-0: Talking about frontline staff in particular, like like what we're talking about right now, where you had somebody in executive leadership who has a com a background in a completely different area is making a decision about how you're staffing your unit without really a full understanding. And they're not necessarily using their s ⁓ smees, their ⁓ things to to guide those decisions. speaker-1: Yeah, subject medic. ⁓ yeah, or they and when you do like kind of come up against them, they think you're being a barrier versus you're trying to explain, which can happen and and it's of no fault of people. It's just trying to remind all of us as nurse leaders that to trust the people that are giving us that information. And you can trust but verify. You can just ask for data and supporting documentation. But it's important to remember that like if you haven't worked in that area, you might need to trust that they know how to how To manage their area. Yep. ⁓ the other thing, the other three key findings was acuity based scheduling drives higher satisfaction. Only 37% of organizations they evaluated used acuity based schedule ⁓ staffing and scheduling. And then equitable scheduling boosts retention and more morale. ⁓ and that one is tricky because that's what makes a lot of nurses have be sad that they and leave their jobs is is scheduling. And then decentralized scheduling limits visibility and efficiency. Meaning ⁓ like when we were just each unit is doing their own little thing. Yeah. speaker-0: There's a lack of a big picture. Yeah. So a double edged sword, because if you're centralized, you're efficient and you're you have the big picture in in in your mindset, but you don't necessarily know what's happening on the ground level. And so you're making decisions that are going to be affecting people and you might be missing what's happening in real time when you make those decisions. speaker-1: And it says sixty-five percent of healthcare facilities rely on decentralized s ⁓ scheduling methods while units enjoy local control. Decentralized scheduling impairs system wide visibility, creating duplicate efforts and creating workload imbalances across departments. So and and you see that with with the decentralized. You get some units where they're they don't their ratio shouldn't be two to one, and it is. Yeah. And then other areas there's four or five to one. Mm-hmm. And they're working their butts off. Yeah. And that that part can I c I can see that. So it's speaker-0: very much vary on the leader who's running that unit. And so if your leaders are not in alignment of how we're going to handle staffing, then that's where you can get that dis and that's going to create discontent. And that's what you're talking about, the equality, I'm guessing, the equitable staffing is that, you know, if if you're like, ⁓ we're we're always floating a nurse to telemetry, the telemetry consistently has like these, you know, like really nice ratios and the workload feels harder when you go there and then another unit is getting six to one patients and they're, you know, just going crazy, then yeah, you're gonna have some discontent and some dissatisfaction for sure. speaker-1: ⁓ one other thing that talking about the type of scheduling used, so sixty eight percent of organizations support self-scheduling. Many still rely on outdated methods such as spreadsheets, which was about twenty-nine percent, or a desktop only access, which was twenty-seven percent. So it's kinda wild. A a lot of facilities are actually still doing the spreadsheet method. speaker-0: Yeah. Which we were talking about before that my facility is using Excel spreadsheets and I find it I hate it. Yeah. So and I know that the apps are really nice. I staff want to be able to schedule from home and access and ⁓ you know, I think some facilities have more flexibility than others in doing that. You know, we ran into there was a firewall. with our ⁓ safety and IT issue that didn't allow us to do that. And so the only way to to access that was to have like a redundancy of scheduling where you have like a program that's accessible to all staff through something like Google Sheets. And then we would have to retranslate that into the staffing program we had at our facility. So it created double work, but it also there was no other way to make it better for the work life ⁓ access to the frontline staff. And so I think we ended up doing it. But I would say our staffing system was quite cumbersome. And that's why in the end we had to sort of ask for the frontline staff to, you know, lead it because it was like I it would take up all of my time if I it does if I was the only one doing it. speaker-1: You see about how much FTE it takes to manage a schedule? Is there one to three on average? One to three FTE on average to manage scheduling. speaker-0: That's crazy. And I know have you ever seen that be like one person's job? It's it's always a collateral duty. speaker-1: And it's it takes a lot of time and it really truly does take a lot of time. Yeah. It's I saw that I can't remember what page it was on. I want to say ⁓ gosh, I can't remember. One to three FT. ⁓ here it is. It's on page fourteen of the article and How nurse scheduling gets done. It's that section. And then in one of these things, it talks about for the centralized staffing office, how many resources support scheduling? 23% have one to three FTE. 60% have no idea because they're just using collateral duties. Yes. ⁓ there's ⁓ and then the others, there's one that eight percent have 10 plus FTE working on scheduling. That's correct. speaker-0: Mm-hmm. I don't even care that. speaker-1: I don't know. speaker-0: Where is this organization? I wanna go talk to them. It's speaker-1: I know, I'm like, what is going on? speaker-0: ⁓ what did you think about the use of float pools and ⁓ like what what makes a float pool helpful? How do we underutilize float pools? Like what could we be doing differently? speaker-1: Mm. I don't know, I couldn't. I'm not sure what I don't think I had a thought on that. I I really what my thought was was from what I got gathered on this is like they're I don't know. I I think they're helpful. Every time I've ever seen them, I liked it. ⁓ seventy-two percent of respondents had a centralized swivel pool. speaker-0: It seemed like the facility you came from before we were working together, they had multiple float pools, didn't they? Like they had like a regular frontline staff float pool and they like an ICU float pool. And that seemed like a really nice system. So that you had because I think that's a challenge with managing a float pool is if you're trying to get everyone competent for every floor, it it's really difficult to keep everybody able to do everything. And so it was nice at that facility where they had, you know, an ICU float float pool that focused only on critical care patients and then another float pool that could do the lower acuity. the f smaller facilities that I've been to, you know, you might have one or two patients who can go to the ICU or patients, staff who can go to the ICU or or the ER, but then the majority of them can't. And so that means your highest acuity floors just don't get any help. And that was, I feel like, an issue we had and and because like when we would do our staffing methodology, I remember I would hi I would overcalculate our NHP P D because I knew that I had to be able to take like sort of the worst case scenarios. But even though I knew that wasn't going to be a regular occurrence, I had to be able to prepare for those and then ⁓ And then I knew we were gonna float, but that was o optimal because there was no way for me to staff up with other people. There was no way for me to get other resources outside of our own unit. speaker-1: That's true. it did say that most people do prefer ⁓ like skill set type float pools. Like forty-eight percent of them said they ha were their float pools were organized by care setting type, like med surge float pool, ICU float pool. ⁓ seventeen percent had an enterprise-wide float pool. Yeah. ⁓ so more had the float pool I came from style versus the one that we have at the VA. However I feel like float pool, like for my experience, the float pool managers can still manage the same all of the float pools, yeah, but have like this pool of people are for this section. Yeah. And I think if I understand correctly, I think we are trying to lean more towards that. Unfortunately, what if the needs, for example, one of our ICU nurses did go to float pool eventually. And ⁓ sorry. ⁓ and what happened was they ended up speaker-0: Do that. Yeah. speaker-1: not working in the ICU because they weren't needed very often and then they they lost their skill sets. speaker-0: That's such a big challenge. You know, we've talked about cross-cut cross training other units. And, you know, it's like, how do you make sure that that person keeps that skill set up? It takes so much planning to be able to do that. So you're always trying to balance like the cost and the reward. You know, if we're gonna train all the step down nurses to be able to go up to ICU, those staff have to be able to go work on that unit like probably once a month to not lose that skill set. And so that means the managers. have to be able to collaborate and trade staff purposefully. Otherwise, if they're waiting for the opportunity, the opportunity may never come. And so then they're not going to be ready. And then when you need that person, you're not going to have a person. So it's I mean, yeah, I think the the summary of this discussion is it's not an easy task to do. speaker-1: That's literally what we're finding. Basically you need computers and apps or you have to have like three people working all the time to make this all work. speaker-0: It's yes, it's crazy. So like yeah, I think what I what I feel like the what I'm getting to in my head is that even though the apps and the technology are expensive, we probably should really be looking at the cost of that versus the cost of the effort we're putting into it and how many hours, how many man hours it's taking, or how many missed opportunities are we having because we're not doing the up the extra things to make it work. more effectively and make sure that thus the patients really are and truly do have the safest staffing. ⁓ so I mean all that to say that everyone is still I think what I came away from that conference, the general consensus is that nurse leaders all still feel like they're struggling to keep their units staffed. They're they're having trouble having enough staff to do it. And so then complicate that with these w the way that we do scheduling and patient assignments, you know, it's it's something that we do need to keep working on. And I think if your facility has the budget and you can get these apps, I'd highly recommend looking into it. I would be doing it if I if I could. speaker-1: Yeah. Yeah, I think at the end of the day it the amount of effort it requires is worth the money. speaker-0: And I think you're right, you know, that staff satisfaction piece is huge. When we sort of went when we started in our management position and we were like, what are we gonna have to do to keep the staff here? A big portion of that was the equitable staffing, ⁓ because there was ⁓ just lots and lots of rotations, everyone was having to flip days and nights and weekends, and and there was a dissatisfaction over that. And so we had to implement some seniority incentives. I've also seen the flip side though where the s senior nurses always get this the shifts that they want and the f and the newer staff always get the crappy shifts and then you're always turning over your new staff. And so you have this like small team of of experienced nurses who get what they want every time and then nobody ever moves into the next tier. So it's it's such a delicate balance of trying to keep those things in perspective. speaker-1: And it's tricky to find the right the the right balance for everybody. Yeah. It's that keeps people safe. Cause you can't also have all of your experienced staff on the same shifts all the time. They need to be everywhere. That's the other part. You can't have a full s every Friday night has to always be your new kids. That's dangerous. Yes. So how do you like balance that part too for patient safety? So speaker-0: And I remember having to like ask for crazy things. So, you know, many managers I think struggle with getting your staff to work weekend nights. And we had the opposite problem where all of our staff wanted to work on the weekend nights. They all liked working together and they had a little system. And so I had to be like, if you're on a night shift, you have to sign up for three shifts that are between Tuesday and Thursday because now our midweek shifts are looking dangerous because I don't have enough senior staff on those shifts. So we had to like incentivize it a different way or create those rules, which was, you know, interesting. speaker-1: Then you can always do like set schedules for some people. That's an incentive that you can offer those hard to fill shifts. Yeah. ⁓ but you can't always do that either. But what what we did at the U or at one of the places yeah, so it was at the U what we did on one of our ICUs is take those hard to ⁓ fill fill shifts. Yeah. And get people to do we did contracts. So like We would do a three month contract, you would be on this set set schedule, and then we would reevaluate the needs of the unit later. So if that was no longer ⁓ a need, then you can't have that set schedule anymore. You have to go back to the normal scheduling. But it and then it that did increase satisfaction. And then we didn't have a lot of those options. So there would be a lottery of who got the options to do the the set schedule. That way, so say we only need three sets of set schedules to kind of fill those gaps in. And it can't be all new kids and it can't be this. So then you do who's interested? Mm-hmm. Get that and then you put ⁓ in a lottery and then you just do a random generation and then if they want to, then you only do it for a short period of time and then reevaluate. speaker-0: So I love the contract idea though, because like when you say when I hear you say, let's make a set schedule, like I immediately get panicky because I'm worried about creating something you can't take back. Cause it's hard to give incentives and then take them away. So whenever I'm looking at giving an incentive, I really have to be like, Can I continue this incentive for a really long period of time? But like having the contract or having it be like only just a s a set so it's not really a set schedule, it's like a set schedule agreement for a period of time. And then try again. If you liked it, you can you can try to get it back again. But that gives other people the opportunity. So it remains equitable. So that's that's a cool concept. speaker-1: For based off the needs that the unit has. Yeah, that's how we did it. And I've tried I brought that up with other people when they do the same thing, they always cringe when because you're right. Like you can't offer everybody a set schedule and keep everything safe all the time. It would never work, but you can in small batches and with like a basic contract with the employee. ⁓ and you'd probably have to run that through your legal department to make sure that like the contract is correct. But it could be a simple thing of like, hey, ⁓ as a manager, I'm offering you this type of schedule for this length of time. They also when they do this at schedules, if they're taking time off, they are there was something in how they had their time off requirements. They had to do something specific with it that we added in there so that they weren't if we're offering you this, you can't take a whole bunch of time off in the middle of it or whatever. speaker-0: Yeah. And I will say, you know, for those listening, if you're like, ⁓ that's a good idea, if you work in an area that has a union, you need to make sure that you run any contracts or any agreements like this through your union first. ⁓ just ⁓ from past experience, you can get in trouble if you haven't included your union if you're looking at making a change like this. So just putting that out there too. speaker-1: At the end of the day, what we've discovered is we we get it. It's challenging. Scheduling is challenging. Making sure you are doing ratio versus acuities and ⁓ you know, making your staff happy and reducing burnout, all of the things, it's all complex and scheduling is hard. speaker-0: Yeah. But if you're interested to see what other people are doing and what the trends are, you should go check out this report off of AONL. We'll put the link in the comments. And ⁓ there are some tips in there and I think also it does describe a lot of the why behind why you would put the effort into some of these different options. And ⁓ remember that y when you have an objective and you don't know how to get there, I think trying to Go back to that innovation mindset and, you know, maybe bring in some other people to help have a discussion, say what are other people's experiences they have. If you have a shared governance group, that's a great place to talk about staffing systems. We I have several shared governance teams at my hospital that do their staffing programs and they figure out how they're going to do their self scheduling. So ⁓ anyway, those are just some ideas. So Yeah. Good discussion, Teresa. speaker-1: Thanks. It was fun. I wanted to talk about this article for a while. speaker-0: Yes. Well, there we go. Hopefully that was helpful to some folks out there. All right. Have a great day. speaker-1: You two, bye.