So far we have talked about the advantages and disadvantages of each approach. Nevertheless, it is important to think about how the chosen scenario would be implemented. We propose the following steps for the implementation:
1. Measurement of the nurses’ motivation: the main reason why this research was done is because the medical manager had the feeling that there were more nurses than needed and their motivation decreased when there was not a lot of workload. The first step we suggest is to measure the motivation of the nurses using questionnaires. This will allow us to later know how the change of the methodology affects the nurses.
8.1. GENERAL DISCUSSION 65 2. Month test: before finally deciding if this methodology change is to be implemented, a real life test should be carried out to see how it would work. We suggest to do a test during one month. For that, some preparation needs to be done, in which a steering team formed by the main stakeholders (medical manager, the head of the nurses and a leader nurse) has to motivate the nurses to try it. Even though we have introduced this methodology change at a tactical level, it is possible to make a test with the 85% capacity scenario -if chosen- and plan it at the operational off-line level. In case of choosing the 85% capacity scenario, it would only be necessary to reduce the amount of nurses that work during the specified month. We propose to perform the test during August for two reasons. The first one is that it is a month with less workload, which can be useful to reduce the stress that this test can cause or to be able to better handle possible obstacles that might appear. The second reason is because some nurses might be looking forward to have more summer vacations if they are not needed during the test. If the test is carried out during August, a total of 51.8 FTE are needed per week: 16.8 FTE for the Thorax unit and 35 FTE for the General unit. The calculations for these numbers can be found in the Appendix D.
3. Measurement of the test performance: once the test finishes, it is of high relevance to see how many corrections at the on-line operational level are needed. This means to investigate how many times there has been a shortage of nurses and extra nurses have been called. Furthermore, it is also important to analyze how adjusted the pool of nurses has been to the activity.
4. Measurement of the nurses’ motivation after the test: once the test month finishes, it is important to measure the motivation of the nurses again to be able to see how this change has affected them and what they think about it.
5. Decision making: If the given feedback (test performance and nurse motivation) is positive, the test can be extended one more month. In case of having performed the test during August, it can continue during September. The positive aspect of continuing in September is that it is a good moment to introduce a new system, because a period starts again after summer and people might have fresh courage to carry it out. Moreover, the new methodology would be tested in a month of more workload. If the extended test has positive outcomes, then the change can be implemented at the tactical level. In the case the feedback is negative, then we recommend to refuse using the chosen scenario. This change may not be palatable to the nurses because this means that the amount of nurses needed in the ICD is reduced. Thus, they can be afraid of being fired. Nevertheless, it is necessary that the steering team motivates them to perform the test. In the sequel, we present motivation arguments:
r The test (and maybe change) is carried out in order to have a better alignment between
nurses and number of beds occupied. This leads to a more evenly spread workload, which implies that nurses will have a more constant work pace.
r If with the current staffing methodology extra nurses are needed when unexpected events
happen, with the new scenario, which contemplates less nurses, it is more likely that even more extra nurses will be needed. The extra hours worked are better paid and this can motivate the nurses.
r Nurses may fear to be fired with this change. However, by natural cause maybe some
nurses leave, some retire, others are pregnant... so it is possible that, at the end of the year, no more nurses are hired but also none are fired.
r It is possible that instead of firing nurses, they can be allocated to other departments
of the hospital in which they are needed.
It is of relevance to motivate and involve the nurses in the test, because they can have a negative idea about such change, generated by the fear of being fired or because they do not understand the reason for changing. If they are reluctant to it, this will be reflected in the questionnaires performed after the test. Nonetheless, it is important to separate the concepts of how they felt with the new methodology regarding the day-to-day work (workload, work pace...) and what their fears and thoughts are about the new methodology.