Provide TWO examples, with supporting evidence, from different practice setting when input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate for a change in patient acuity, patient population, resources, or redesign of care.

Example One - Input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate for a change in patient acuity, patient population, resources, or redesign of care.

In the first quarter of 2012, the nursing staff of the Ambulatory Procedures Center (APC) held a staff meeting to discuss standardizing staffing within APC to ensure all patients receive the same standard of care 24 hours a day. It was identified that if an APC nurse was called in for an emergency procedure by the Nursing Supervisor or GI physician outside of regular hours, the on call APC nurse assessed the need for more support during the procedure, and would then call another APC staff member for assistance. All APC nurses felt as though there was a potential hazard when working alone or with another nursing staff member from the hospital with little to no GI experience. The complexities of cases the APC RNs were called in for necessitated a redesign of care to use two APC nurses and/or tech instead of utilizing a clinical nurse from a medical surgical unit that is not familiar with APC and could prove to have potential patient safety issues to include:

• delay in emergent care
• potential or worsening of bleeding
• airway maintenance with endoscopy scope
• ​sedation reversal
• assisting GI physician/anticipating his/her needs.

Following the standards of evidence-based practice through the Society of Gastroenterology Nurses and Associates (SGNA) and their Standards of Clinical Nursing Practice and Role Delineations, the APC nursing staff proposed a change to their schedule to add another APC nurse or technician on call Monday through Friday from 1600-0700.
This proposal was presented to Donna Fulmer, MSN, RN, CPAN, NE-BC, then Director of Perioperative Services, who reviewed with the Chief Nursing Officer and was given approval to implement.
The APC Hospital Unit Coordinator (HUC) created an electronic on call sheet and submitted the form as a Just Do It (JDI).

The shared governance structure and process at FF Thompson Hospital was effective in implementing change to proactively benefit patient safety and standardize care in the APC on weekday off-shifts.
The APC nursing staff and technicians were surveyed approximately 19 months after the on-call change occurred. There was a 100% completion rate on the survey.

Results

The APC nursing staff felt they spent less time at the hospital when called in and working alongside a fellow APC staff member, and felt much safer working with a second GI RN or technician.
The entire APC staff and Nursing Administration were involved in the change.

Input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate for a change in patient acuity, patient population, resources, or redesign of care. 

In June of 2013, a neighboring hospital in Geneva, NY closed their maternity unit, which managed about 500 deliveries a year. The OB providers from Geneva transferred their practice to a third hospital, Newark-Wayne, which is about 20 miles north of Geneva. This resulted in a marked increase in volume at Thompson Health from 2013-2014, as many patients lived closer to us than to the hospital in Newark.
 
The change in volume was quick, and unanticipated. The increase resulted in a rise in overtime and call-back time. Staff were worn out, and feeling the strain. The Director consulted with staff, as she did not want to "jump the gun" with hiring until it was known if this was a trend that would be sustained. The size of the Birthing Center is such that having an unneeded staff member working, even a few shifts per pay period, substantially affects productivity. In those instances, staff were kept home on call and either used paid time off or elected not to be paid, obviously not a staff satisfier.
 
A premium pay incentive was put in place to offer extra money to staff who worked more than their budgeted shifts during the first several months of the surge in volume. As it became clearer that this was a sustained trend, staff were consulted as to what their current needs were. They concluded: 

1. Increase the hours of the Charge role to 12 hours per day from 8 hours per day
2. Increase the OB tech role from one tech to two techs on the day shift to support the nurses. The additional position will also allow one tech to scrub on all scheduled cesarean sections, improving their competency in the operating room.
3. Increase the night RN core staffing from three nurses to four nurses to insure safe care and reduce call-back time.

 
The change in the charge role was accomplished by re-arranging existing positions. One additional full time day shift RN was added by combining existing Full Time Equivalents (FTE). The Director, with the support of the CNO, advocated for the new tech and RN positions with the Productivity Review Committee in May, 2014 (see Exhibits EP9.1 and EP9.2). Based on the data presented, all four positions were approved.
 
The unit is in the process of interviewing for and filling those positions. Both tech positions are filled, and in training. Data regarding outpatient, observation, and delivery census was trended over several months. It was identified that the additional day shift position would be used to provide a fifth nurse on the day shift on Tuesdays, Thursdays, and Friday, based on volume. The first of the night nurses hired will be utilized to provide the fourth nurse on Thursday, Friday, and Saturday. 

Exhibit EP9.1 Night RN and tech request
Exhibit EP9.2 Night RN and tech request_June3 2014