EP - Exemplary Professional Practice

EP11 How guidelines such as the ANA Principles of Nurse Staffing (American Nurses Association, 2005), standards for scheduling, delegation, and from nursing specialty organizations and/or state-mandated requirements are incorporated into staffing and scheduling processes.

Jersey City Medical Centers (JCMC) staffing and scheduling process is influenced by the American Nurses Association Staffing Principles, 2005. The American Nurses Association identifies nine principles under three categories as guidelines for nurse staffing. The three categories:

  • Patient Care Unit Related
  • Staff Related
  • Institution/Organization Related

The patient care unit related issues incorporates that staffing levels be, based on the intensity of the patient population and the associated roles and responsibilities of the nursing staff. Factors which must be taken into consideration include: Number of patients to be cared for, levels of intensity/acuity of the patients being cared for, geography of the environment and available technology and the level of experience of the nurses providing the care. When considering specific patient needs, the following should be taken into account: age functional ability, communication skills, cultural and linguistic diversities, severity and urgency of admitting condition, scheduled procedure(s), ability to meet health care requisites, availability of social support and other specific needs identified by the nurse. Unit functions necessary to support the delivery of quality patient care must also be taken into consideration:

  • Unit governance
  • Involvement in quality measurement activities
  • Development of critical pathways
  • Evaluations of practice outcomes

Staff related issues involve having well-defined competencies for each nursing staff member. Nursing staff must be supported both at the operational level and the nurse executive level. Experienced RNs should be readily available to those staff members with less proficiency. The following should be taken into account when determining staffing:

  • Experience with the population being served
  • Level of experience
  • Education and preparation, including certification
  • Language capabilities
  • Tenure on the unit
  • Level of control of the practice environment
  • Degree of involvement in quality initiatives, measure of immersion in activities such as nursing research, measure of involvement in interdisciplinary and collaborative activities regarding patient needs and the number and competencies of clinical and non-clinical support staff the RN must collaborate with and supervise.

Institutional and Organizational related issues should reflect a supportive environment which places value on the registered nurse, and displays a commitment to filling budgeted positions in a timely manner as displayed in table comparison. The organization must have documented competencies for all nursing staff, to include agency, supplemental or traveling nurses. Staff should be cross-trained when floating between units to insure competency. The organization should provide:

  • Effective and efficient support services to reduce the nurses time away from the patients
  • Access to timely and accurate relevant information which involves patient care
  • Sufficient orientation and preparation including preceptors and expert nurses to insure competency
  • Preparation specific to technology used in providing patient care
  • Necessary time to collaborate with and supervise other staff
  • Support in ethical decision-making
  • Sufficient opportunity for care coordination and arranging for continuing patient care and patient/family education
  • Adequate time for coordination and supervision of assistive personnel
  • Processes to facilitate transition during work redesign if necessary
  • The right for the staff to report unsafe conditions or inappropriate staffing without personal consequence
  • A logical method for determining staffing levels and skill mix

Jersey City Medical Center strives to ensure that staffing plans and scheduling model after the ANA Staffing Principles, 2005. Ongoing support to staff nurses in the categories of Patient Care Related Unit, Staff Related, and Institution/Organization Related enable nurses to develop and collaborate with other healthcare team members to deliver safe, optimal, individualized patient care. Delivery of comprehensive care also entails the delegation of patient care tasks by the RN. The RN delegates to unlicensed personnel, such as the Patient Care Technician, and retains the accountability of the task outcome, which is in line with the ANA Principle of Delegation, 2005. The responsibility of delegating tasks by the RN is done with the guidance of the ANA Principles of Delegation, 2005. The ANA Delegation Principles are the following:

  • The RN may delegate elements of care but does not delegate the nursing process itself
  • The RN has the duty to answer for personal actions relating to the nursing process
  • The RN takes into account the knowledge and skills of any individual to whom the RN may delegate elements of care
  • The decision of whether or not to delegate or assign is based upon the RNs judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated
  • The RN delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures
  • The RN uses critical thinking and professional judgment when following The Five Rights of Delegation:
    1. Right task
    2. Right circumstances
    3. Right person
    4. Right directions and communication
    5. Right supervision and evaluation (NCSBN 1995)
  • The RN recognizes that there is a relational aspect to delegation and that communication is culturally appropriate and the person receiving the communication is treated respectfully

Resource materials are made available to support RNs involved in the staffing process. Available resources include the current ANA Nursing Scope and Standards of Practice, as well as Principles of Delegation.

In addition to using the ANA Staffing Principles, 2005 for the staffing and scheduling process, JCMC specialty units also uses guidelines from their nursing specialty organizations. For instance, the Emergency Department uses the Emergency Nurses Association (ENA) and the Labor and Delivery Unit uses the Association of Womens Health, Obstetrics, and Neonatal Nurses (AWOHNNs) staffing standards in guiding staffing and scheduling plans.

The Nurse Manager, Michele Lopez MSN, RN, CEN evaluates staffing and Productivity Reports on a regular basis to make certain the delivery of safe, efficient, optimal and cost effective emergency care is being provided by her department. (Refer to Reference EP8-A1 for further detail on Productivity Reports). Ms. Lopez considers various aspects such as, patient acuity and volume, nursing time and care provided, length of stay, skill mix, and non-productive time. Nurses have access to the Emergency Department Staffing Guideline, which provides a baseline for Emergency Nursing staff for the day, evening, and night shifts. (See ED Treatment and Staffing Guideline in Reference EP11-A) The Emergency Department nurses work 12 hour shifts with the availability of flexible working hours to respond to the rapidly changing emergency care environment. The ENA staffing guidelines were considered when developing the Emergency Department Staffing Guidelines. An example of this is the Emergency Department nurse staffing plan, which consists of having 11 RNs available during the day and night shift and five addition RNs during the11am to11pm shift. It is recommended, in the ENA Staffing Guidelines, that there should be a minimum of two RNs whose responsibility is to provide care in the Emergency Department at all times. The Emergency Department provides overlap coverage of five RNs during peak patient volume time of 11am to 11pm. This provides patients, seen in the Emergency Department, with safe nursing care.

The Labor and Delivery Nurse Manager, Lillian Reyes BSN, RN refers to the AWHONNs recommendation to staff the unit appropriately. The classification of patients and clinical situations are also considered when developing staffing for this high risk unit. Ms. Reyes staffs her shifts with four nurses for a unit capacity of eight Labor and Delivery patients. A Charge RN and a Triage RN are also available. In addition, in the Mother Baby Unit, 25% of the Antepartum RNs are cross trained to care for Labor and Delivery patients, and 100% of the Postpartum RNs are cross trained to care for the Antepartum patients. Furthermore, Ms. Reyes has increased her RN staff to six on Tuesday, Wednesday, and Thursdays to be available to provide safe efficient care to potential patients from the High Risk Outpatient Clinic, as well as increased patient volumes during these days. To further provide safe quality care, a one to one RN to patient ratio is provided, as recommended by AWHONN, when:

  • Initial dose of Magnesium Sulfate therapy for the first hour
  • Antihypertensive intravenous management is initiated
  • During a labor with medical complications or obstetrical complications

AORNs recommendations are also incorporated in the Operating Room. Kelly Loo BSN, RN, CGRNA assures a staffing plan that provides safe optimum patient care delivery in the Operating Room. Every procedure requires at least one RN per operating suite in addition to an RN or a Surgical Operating Room Technician who fulfills the scrub responsibility. The Operating Room also has a Charge RN who facilitates, oversees, plans, and directs the nursing care of every patient undergoing procedures. (See Staffing and Call Coverage for the OR in Reference EP11-B).