1. Strategic Change SYSTEMS ISSUE OF MANDATORY DOWN STAFFING AT THE CHESTER COUNTY HOSPITAL

2. The Issue  Patient census is down at The Chester County Hospital (TCCH)  Staff is being mandated not to come into work and be on-call  Differing processes on determining who is to be down staffed

3. Patient Census is Down  Less patients are coming to the Emergency Department and even less are being admitted to the hospital  The Cardiovascular Unit (CVU) is closed during the filming of a movie for about 2 weeks.  The hospital is performing less cardiothorasic surgeries  Other small units are being closed during low patient census

4. Down Staffing  Down staffing occurs when nurses and other staff members are placed on- call  When the nurse in on-call they may be phoned at any time and told to come in to work.  At times there may be 2-4 nurses placed on-call for a single unit  During times when the CVU is closed those nurses are being displaced to other units.  If there is not a need on other units the CVU nurses are mandated to be on-call

5. Who is Placed On-Call  The nursing supervisor is in charge of staffing and patient placement at TCCH  They work in three different shifts throughout the day  It is there job to determine what units patients are admitted to after the ED  They also determine what staff members are placed on-call  Different supervisors use different techniques in determining what staff members are placed on call  Nurses feel as though the process is unfair and certain staff members are being mandated to take on-call more often than others  When a staff member is placed on call if often takes place an hour and a half prior to a shift

6. Change Theory  Lewin’s Theory  The unfreezing stage: Identify, diagnose and motivate  The moving stage: Gather information and identify a solution  The refreezing stage: Change is established

7. The Unfreezing Stage  Staff nurses have identified being mandated to take on-call as an issue that needs changing.  They feel as though a fair solution to low patient census and staffing has not been found.  Facilitators:  Most nurses are affected and want change to occur  Barriers:  Poor communication between staff nurses and management.

8. The Moving Stage  A few nurses from individual units will be nominated to involve themselves in developing a hospital wide low census down staffing protocol.  An assistant nursing supervisor position will be created to allow for calls to nurses for down staffing to be sooner and more efficient.  When there are multiple nurses placed on-call some may be cancelled  Barriers:  lack of agreement between different unit nurses.  Lack of funds to create the assistant position  Risks:  Staff losing funds  Top management rejecting developed protocol  Benefits:  Staff being down staffed equally  No nurse loses more funds than another

9. The Refreezing Stage  Developed protocol is put into place and used by every nursing supervisor during every shift  The assistant nursing supervisor allows for staffing of shifts to be known at least three hours before its start.  Nursing staff feels a sense of fairness with down staffing during times of low census and do  The facilities budgets are still maintained during these times.  Facilitators:  A set protocol creates homeostasis.  Nurse development leads to higher satisfaction.  Barriers:  Lack of top management approval  Risks:  Using more funds than available to innovate the change  Possibility of not using protocol  Benefits:  Higher nurse satisfaction scores on National Database of Nursing Quality Indicators (NDNQI)