Have back-up plan to call in nurses

Efficiency requires being prepared for the worst

Despite the best planning for emergency department (ED) staffing, there will always be "crunch" times when additional nursing support is needed.

"You need an effective `Plan B' in place for those times," says Robert Herr, MD, MBA, FACEP, former corporate chairman of emergency medicine for FHP International and currently a Salt Lake City-based consultant in ED human resources management.

Here are some solutions:

· Part-time staff.

It's often difficult to bring in part-time nursing staff. "This is most evident around holiday times when many of your part-time employees will not be available," says Herr.

One potential solution is to provide child care during part-time nurses' night shifts, recommends Herr. "A large enough hospital might find it pays for itself, since the leading reason nurses can't come to work is their child care responsibility."

· Agency nurses.

Since orientation is necessary, this can be expensive for the short term. "Agency nurses require somebody to orient them, which can decrease your efficiency because they don't know where anything is," says Herr. "They're most helpful in a pinch when you anticipate busy volume over the holidays, and your staff is about to revolt, and you know you'll be down three or four nurses the next week."

If the agency nurses will work in the ED for a week or longer, the investment in orientation is paid back. "They're expensive in the short run," notes Herr. "On the other hand, they usually have a good attitude and can actually improve morale because they tend to interrupt negative thinking and circular reasoning of staff and can offer some refreshing new perspectives."

· ICU staff.

Having ICU nurses come to the ED to help during busy shifts can be beneficial. "They are very valuable nurses to have in the ED, and many have been ED nurses in the past," says Herr. "It also improves relations with the ICU because it helps the floor nurses understand why patients need to be moved up to the ICU quickly, which can erode their resistance to taking report."

ICU nurses also might be grateful to have the extra hours. "When the ICU is not busy, nurses are often asked to go home, and this gives them an alternative to doing that," he says.

Prepare to reciprocate

However, the ICU may expect the favor to be returned, Herr notes. "Out of 30 ED nurses, a few probably won't mind going to the ICU once in awhile, so you can make it voluntary to minimize complaints."

· Permanent ED nursing staff.

This option should be your last resort, and using it too often is a mistake, Herr emphasizes. "In the short run, it may help a crisis, but it's a bad habit to get into because your full-time staff need their rest," he says. "I've never heard of a nurse being reluctant to come in if there is a true disaster or mass casualty, but you shouldn't be calling them in otherwise."

If you make that mistake too often, your nursing staff will burn out, he warns. "You'll end up losing them, or they won't be able to relax because they don't know when the phone is going to ring, which encourages full-time staff to leave town on their days off," says Herr.

Even meetings and mandatory education can be handled while nurses are working their shift during slow times, Herr advises. "Take advantage of their time during slow shifts and allow self-study courses or watching videos - with a little extra effort, any talk can be videotaped."

If it becomes absolutely necessary to call in your regular staff, rotate that duty, says Janet Johnson, RN, BSHA, CEN, CFRN, ED director at Central Peninsula General Hospital in Soldotna, AK.

"Some of our full-timers were feeling stressed during the flu season because their name was on the top of the schedule, so they were always called first. So, we flipped it around and made a reverse list, with the per diem people at the top, then the part-timers, to give the full-timers a break."