Perinatal Quality Collaborative of North Carolina (PQCNC)

Trust in a New Staffing Model

Mary Cascio MSN, RN, NEA-BC, RNC-OB
October 2019

1 This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication
represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Disclosures

I have no actual or potential conflict of interest or

financial disclosure in relation to this presentation.

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Objective
• By the end of this presentation, learners will be able to share ideas surrounding staffing decisions
based on the ability to obtain actual data from their own units to identify trends and gaps in
coverage for nurses.

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 Is this your OB unit?

OB ED
Med Surg • Increasing volumes and patient
Palliative Care acuity makes standard 12 hour shifts
Care during starting at 7a and 7p obsolete!
Pregnancy

Intensive • Can you imagine a flexible staffing

Survivor Care for that allows for less nurses on a low
Services

Birth Moms and

their Fetus
census Sunday night and more
nurses by the end of the week when
we all get busy?

Overflow
OB PACU Couplet • Thinking ahead, can we make a
Care staffing model that allows for July,
August, and September surges???
Long Term
OB OR High Risk
Care

4 © Mary Cascio 2014

 Guidelines for
Professional Registered
Nurse Staffing
for Perinatal Units

Did you know you can promote quality care by

planning nurse staffing for your perinatal unit

Did you know this is available from the

leading authority in perinatal nursing:
AWHONN

Do you use it?

Can we afford to implement?
Can we afford not to?

Association of Women’s Health, Obstetric and Neonatal Nurses. (2010). Guidelines for
professional registered nurse staffing for perinatal units. Washington, DC.
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Recommendations
for Staffing

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 Manual Processes
Labor and Birth

A
1 RN to 1 Mom

B
1 RN to 2 Moms
(or a Mom/Baby Couplet )

C
1 RN to 3 Moms or Babies

Antepartum

B
1 RN to 2-3 Moms

C
1 RN to 3-4 Moms
Examples of our data collection
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 Where we were and where we are going

Have (Flat)

18
Need (Flexible)
16
14 18
17
12 16
15
14
10 13
12
11
8 10
9
8
6 7
6
0 9 18 3 1221 6 15 0 9 18 3 1221 6 15 0 9 18 5
4
Sun Mon Tue Wed Thur Fri Sat 3
2
1
Approved Headcount Acuity at 75th%ile 0
0 9 18 3 1221 6 15 0 9 18 3 1221 6 15 0 9 18
Sun Mon Tue Wed Thur Fri Sat
Proposed Headcount Acuity at 75th%ile

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How did we get staff buy in?

Wakeman, C. (2010). Reality-based leadership.

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10
0
1
2
3
4
5
6
7
8
9
10
11
12
13
15
16
17
18
19
20
21

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12/11/2016 0:00
12/11/2016 6:00
12/11/2016 12:00
12/11/2016 18:00
12/12/2016 0:00
12/12/2016 6:00
12/12/2016 12:00
12/12/2016 18:00
12/13/2016 0:00
12/13/2016 6:00
12/13/2016 12:00
12/13/2016 18:00
12/14/2016 0:00
12/14/2016 6:00
12/14/2016 12:00
12/14/2016 18:00
12/15/2016 0:00
12/15/2016 6:00
12/15/2016 12:00
12/15/2016 18:00
12/16/2016 0:00
12/16/2016 6:00
12/16/2016 12:00
12/16/2016 18:00
12/17/2016 0:00
12/17/2016 6:00
12/17/2016 12:00
12/17/2016 18:00
PPE 12/24/16

12/18/2016 0:00
12/18/2016 6:00
12/18/2016 12:00
12/18/2016 18:00
12/19/2016 0:00
12/19/2016 6:00
12/19/2016 12:00
12/19/2016 18:00
12/20/2016 0:00
Actual Staffing December 2016

12/20/2016 6:00
12/20/2016 12:00
12/20/2016 18:00
12/21/2016 0:00
12/21/2016 6:00
12/21/2016 12:00
12/21/2016 18:00
Have
Need

12/22/2016 0:00
12/22/2016 6:00
12/22/2016 12:00
Min Staffing

12/22/2016 18:00
12/23/2016 0:00
11
0
1
2
3
4
5
6
7
8
9
11
12
13
14
15
16
17
18
19
20
21

10
2/5/2017 0:00
2/5/2017 6:00
2/5/2017 12:00
2/5/2017 18:00
2/6/2017 0:00
2/6/2017 6:00
2/6/2017 12:00
2/6/2017 18:00
2/7/2017 0:00
2/7/2017 6:00
2/7/2017 12:00
2/7/2017 18:00
2/8/2017 0:00
2/8/2017 6:00
2/8/2017 12:00
2/8/2017 18:00
2/9/2017 0:00
2/9/2017 6:00
2/9/2017 12:00
2/9/2017 18:00
2/10/2017 0:00
2/10/2017 6:00
2/10/2017 12:00
2/10/2017 18:00
2/11/2017 0:00
2/11/2017 6:00
2/11/2017 12:00
2/11/2017 18:00
2/12/2017 0:00
2/12/2017 6:00
2/12/2017 12:00
2/12/2017 18:00
PPE 2/18/17

2/13/2017 0:00
2/13/2017 6:00
2/13/2017 12:00
2/13/2017 18:00
2/14/2017 0:00
2/14/2017 6:00
2/14/2017 12:00
2/14/2017 18:00
2/15/2017 0:00
2/15/2017 6:00
Actual Staffing February 2017

2/15/2017 12:00
2/15/2017 18:00
2/16/2017 0:00
2/16/2017 6:00
2/16/2017 12:00
2/16/2017 18:00
2/17/2017 0:00
2/17/2017 6:00
2/17/2017 12:00
2/17/2017 18:00
Have
Need

2/18/2017 0:00
2/18/2017 6:00
Min Staff

2/18/2017 12:00
2/18/2017 18:00
2/19/2017 0:00
Survey Results
• Initial Survey was administered on 9/29/16
• Follow-up Survey was administered on 2/24/17

Before After

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Sustaining and Improving
What staff overwhelmingly wanted in the Stay Interviews:
More staff, less call

Call shifts required: was 3 in 6 weeks, now 1 in 6 weeks

Call Back: 43.5% less over Dec-Feb compared to same time period in 2016 and 2017

Employee Comments
• Offer permanent start-up times for shifts.

• Sign-up time is stressful.

• Offer 8 hour shifts.

• “I am thankful that our work environment has greatly improved.”

• “I LOVE it. I hope everyone else does too.”

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What now?

• Can we transition to an
electronic process based on
arrival and departure times for
patients in our units?

• What is the correct nurse to

patient ratio to accommodate
our volumes and acuity?

• Can we accommodate 8 / 9 / 10
hour shifts to fit the needs of our
nurses?

Internet images: Creative Commons

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Approach
• Categorize months as Low, Mid or High based on births/encounters
– Low= February, March, May and November
– Mid= January, April, June and December
– High= July, August, September and October

• Display RN needs by hour of day (blue lines) by day of week

• Display RN haves by hour of day (orange lines) by day of week

• Identify opportunities to better align RN needs with RN haves

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Seasonal staffing explained

High volume staffing (July-Aug-Sept-Oct)

Call / Travelers / Staffing Bonuses

Mid volume staffing (Jan-Apr-June-Dec)

Call / Staffing Bonuses

Low volume staffing (Feb-Mar-May-Nov)

No Call!

16 © Mary Cascio 2019

 Seasonal Scheduling
• Feb-Mar-May-Nov • Jan-Apr-June-Dec • July-Aug-Sept-Oct

8.4 to 10.6 8.7 to 10.8 10.6 to 13

10.5 to 13.8 10.1 to 14.8 12.5 to 17.3

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Sample Staffing Sheets
• Low Volume Thursday • High Volume Thursday

13 > 15 > 13 RNs 15 > 18 > 15 RNs

Includes one 8 hour shift and Includes two 8 hours shifts

one 10 hour shift and one 10 hour shift

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Building Trust

• More staff and less call

• Nurses ability to speak up and

provide staffing suggestions

• Revisions to the schedule

• Offering and acceptance of a

Critical Staffing Bonus versus
Travel Nurses

Internet image: Creative Commons=Trust

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References
Association of Women’s Health, Obstetric and Neonatal Nurses. (2010). Guidelines for professional
registered nurse staffing for perinatal units. Washington, DC.
Jones, T.L., Hamilton, P., & Murry, N. (2015). Unfinished nursing care, missed care and implicitly
rationed care. State of the science review. International Journal of Nursing Studies, 52(6),
1121-1137. doi:10.1016/j.ijnurstu.2015.02.012.
Longo, J., Wright, M.E., Woods, M., & Raviotta, G. (2015). A Survey Study of Horizontal Violence
and Women’s and Children’s Nursing. Poster presentation at Academy of Neonatal Nursing,
2016.
Prestia, A. S. (2016). Existential Authenticity: Caring Strategies for Living Leadership Presence.
International Journal for Human Caring, 20(1), 8–11. Retrieved from
http://search.ebscohost.com.ahecproxy.ncahec.net/login.aspx?direct=true&db=ccm&AN=11846
4873
Simpson, K.R., Lyndon, A., & Ruhl, C. (2016). Consequences of inadequate staffing include missed
care, potential failure to rescue, and job stress and dissatisfaction. Journal of Obstetric,
Gynecologic, & Neonatal Nursing, 45(4), 481-490. doi:10.1016/j.jogn.2016.02.011.
Wakeman, C. (2017). No ego.
Wakeman, C. (2010). Reality-based leadership.

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