1. Raso, Rosanne RN, CNAA, MS

Article Content

Q It's budget time again and the edict is that we cut staff. Without appearing uncooperative, how can I prove to the administration that I can't do with less staff?


Making the case for exempting certain staff, such as frontline nursing at the point of care, must be based on empirical data with a focus on what's essential for safe, high-quality patient care. Administrators won't knowingly jeopardize patient care during the budget process; however, it's your job as part of the team to provide an analysis that demonstrates in good faith where you can and can't make reductions. One way to accomplish this is to develop comparative trends and patterns to help make decisions by analyzing unit volume and activity for at least 2 years, including admissions, transfers, and discharges. Keep in mind that discharges drive hospital revenue, so the more discharges you have, the more revenue you're contributing to the bottom line.


Another important factor to consider is your unit's length of stay (LOS) because keeping down LOS allows a unit to have more throughput or discharges. How does your LOS compare to benchmarks and other units? Have there been any program changes, new patient clusters, or new treatments requiring more staff time? What's the NCHPPD (nursing care hours per patient day) you're providing, and how does it compare to other units and industry standards? What are the minimum staffing patterns that can't be compromised, whether regulated or unregulated? Look at what you're spending on temporary staffing and overtime because you may be able to convert this expense to staff or per diem positions, which may save money. Can you minimize the use of 1:1 observation through frequent rounding, alternatives, and/or stricter criteria and save money there? Can you save money by converting the use of reusable or reprocessed supplies, or by avoiding rental charges or changing linen use practices? Also look at your clinical outcomes and how they tie into hospital revenue. Nursing surveillance prevents complications, which is essential to quality as well as cost avoidance.


Remember, any cuts you can make will help the bottom line, so don't just say no way to cuts. You can show that nursing is part of the team by being willing to perform the necessary analysis and make difficult decisions when it comes to reducing expenses.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Q I'm a newly hired manager to a unit that had the same leader for over 20 years, and I'm finding that many standards of care, practice, and employment policies weren't appropriately administered. How can I make changes when staff members are always saying, "This was never a problem before, so why is it now?"


My best advice is to let the changes come from your staff. First, you must establish credibility and trust by supporting your staff, collaborating, making "quick wins," role modeling leadership (not dictatorship), and setting the tone for going from great to greatest. Don't speak negatively about the past, because putting staff on the defensive won't position you for growth and improvement. Your role is to facilitate and coach staff members; you can't make change without their engagement.


Show staff your unit data and outcomes, and set measurable and achievable goals. Use established standards, regulations, and hospital policies to guide expectations. Having third-party expectations starts to take the pressure off you and put it on your staff because it's truly about them, with your leadership of course. Provide education and utilize the support of instructors, quality staff, and/or clinical nurse specialists. Set up unit councils to address goals and engage staff. Measure and celebrate success all the time, and make sure individuals and the team are recognized during rounds, in newsletters, and in meetings. Send handwritten thank-you notes to staff in appreciation of great work or ideas. And have short daily huddles to keep the spirit and values alive.


Change is always hard and takes time. I like to follow Jayne Felgen's I2E2 model, a focused model that cements lasting change when all four phases-inspiration, infrastructure, education, and evidence-are consistently addressed.1 Your staff members will welcome change when it makes them feel proud of their work and accomplishments, and it isn't just something you made them do.




1. Felgen J. I2E2: Leading Lasting Change. Minneapolis, Minn: Creative Health Care Management; 2007. [Context Link]