Jeni Williams

One of the biggest, most expensive labor challenges that hospitals face is filling open nursing shifts that result from unexpected call-ins, particularly on weekends, when nurses who have the weekend off are not enthusiastic about covering for their coworkers.

In 2008, call-ins accounted for 5.2 percent of the total 17 percent for all RN deficit demands (defined as reasons for vacant shifts, e.g., unexpected absences/call-ins at 5.2 percent, vacation/PTO at 6.8 percent, LOA/Family Medical Leave Act [FMLA]/Intermittent FMLA at 5 percent). During the same year, 5.2 percent of hospitals surveyed reported that they responded to deficit demands through the use of overtime pay; 5.5 percent relied on agency nurses to fill staff vacancies, and 2.1 percent used traveling nurses to fill open shifts (Suby, C., 2008 PSS™ Annual Survey of Hours, Labor Management Institute).

"Unexpected call-ins from nurses are a huge problem for hospitals," says ChrysMarie Suby, president/CEO of the Labor Management Institute, Bloomington, Minn. "Often, the shifts left vacant when nurses call off from work are filled by staff who work overtime or agency nurses, both of which add significant expense per shift."

Unexpected call-ins have become particularly challenging for hospitals since intermittent leave under the Family Medical Leave Act (FMLA)-such as leave taken on an occasional basis for medical appointments related to a serious health condition, or leave taken several days at a time for treatment of a health condition or to care for a family member who has a serious health condition-became an option for employees. Many human resources departments have experienced turnover in specialists who are skilled in the management of intermittent FMLA, Suby says.

"Consequently, the expectation to manage intermittent FMLA has been pushed onto nurse managers, who oftentimes have not been given instruction in how to manage intermittent FMLA," Suby says. "This presents challenges when a nurse manager is trying to figure out whether a "call-in" qualifies as intermittent FMLA or a standard call-in, and when to attribute those call-ins to the unit's budgeted nonproductive time."

Intermittent FMLA is one of the leading sources of overtime for nursing units, Suby says. When the number of call-ins is high, the unit suffers financially, and nurse satisfaction levels take a hit. Additionally, when overtime percentages are high, patient safety has the potential to be affected as well (ibid, and "Identifying Root Sources of Overtime," Perspectives in Staffing and Scheduling, March/April 2007).

Strategies for Reducing Nurse Call-ins

An overtime percentage of less than 5 percent is considered a reasonable response to fluctuating workload volumes or deficit demands, according to the Labor Management Institute. Overtime usage of 5 to 7.9 percent is considered a sign of financial bleeding; overtime usage of 8 percent or higher is a sign of financial hemorrhaging (ibid).

There are a number of strategies hospitals can employ to reduce the number of call-ins on nursing units.

Absenteeism/attendance policy enforcement. Ensure that nurse managers are aware of attendance requirements and the way in which absences affect their budgets-and that staff are held accountable to attendance policies.

Close monitoring of FMLA. It takes managers time to learn how to relate call-ins to their budgeted nonproductive time, Suby says. "For example, say a unit is budgeted for a 10 percent nonproductive replacement value, and let's say, for example, that this amounts to about four budgeted FTEs per year. Well, when you convert four FTEs to hours-for example, four FTEs times 2,080 hours equals 8,320 hours per year-and you divide this by 364 days in a fiscal year, this comes out to 23 hours per day for total paid benefit absences. If you're dealing with 12-hour shifts, this essentially gives the manager one 12-hour person and one eight-hour person can be gone (on intermittent FMLA or LOA) each day. But a lot of times, nurse managers are thinking about their budgeted nonproductive time in terms of shifts, so they allow one RN and one non-RN to be gone per shift per day-double their allocation. If they have not otherwise addressed the replacement factor and they don't have a good strategy for using their per-diem casuals and part-time people, then when they've given up more time off than what they are budgeting for their only recourse for covering absences becomes overtime or agency staffing."

Suby recommends that hospitals provide basic budgeting and management courses for all nurse managers. Such classes would help managers translate their budgets into scheduling requirements for their working direct and indirect caregivers and their non-productive/benefit budget and help managers develop strategies to cover absences.

Weekend makeup for weekend call-ins. Requiring nurses to make up the assigned weekend days they have missed by working another weekend shift will promote a sense of fairness throughout the unit. However, watch for patterns of abuse on the weekdays, as Mondays and Fridays often becomes the days of highest call-ins as employees try to pair them with their weekends off.

Allow for flexible scheduling and staffing. "We've found that 12-hour shifts work very well for young staff and in teaching institutions, but in community and rural hospitals many senior nurses are finding they can't cope with 12-hours shifts-complaining they are just too exhausting to cope with. If nurse managers have an understanding of this, they can take a particularly busy 12-hour shift and divide it into two six-hour segments. But they should define these six-hour shifts as 'shifts of need' by associating them to what the shift is designed to do (for example, the 7 a.m. to 12 p.m. "rapid admit nurse" shift, or the 11 a.m. to 7 p.m. admission, discharge, transfer [ADT] shift). If you set a shift between 11 a.m. and 5 p.m. and the bulk of the work is done from 7 a.m. to 11 a.m., staffs are going to be very resentful of the nurses who come in at 11 a.m."

Decentralize accountability for staffing. There should be some resources that are shared centrally among nursing units, such as a resource or float pool.

Place limitations on overtime. "When the manager has overcommitted for vacation or paid time off and is under resourced to cover the replacement of that time, overtime goes up. What we've found in our research is the higher the overtime over 5 percent, the greater the job dissatisfaction, and the more unsafe the conditions become for patients as measured by increased med errors and patient falls" ("ADT, ALOS, OT % Compared to Med Errors and Patient Falls," Perspectives in Staffing and Scheduling, January/February 2008;).

Encourage all nurses to receive flu shots. "Educate nurses on the importance of flu shots as a preventive measure to protect their health as well as the health of their family members. Because nurses are exposed to the majority of viruses, the better prepared they are to handle this exposure helps to reduce their own risk of personal illness-and, therefore, their call-ins." Another strategy for protecting nurses' health: Encourage participation in health and wellness activities.

Offer bonuses for perfect attendance. How much should the bonus be to be effective? Consider that when hospitals replace a nurse who has called in sick with a nurse working overtime or an agency nurse, the replacement cost could run as high as $54 an hour, or $432 per eight-hour shift; if the benefit sick time given to the nurse who is ill equals $288 (based on $36/RN hour), the total cost to the unit of replacing one nurse for a single eight-hour shift would be $720 and 12-hour shifts are running $1080 (2008 National Average Rates of Pay and Overtime for RN's in the United States, Bureau of Labor Statistics,

"Providing a perfect-attendance bonus of $500 is far less than the hospital would pay if the nurse were to call in sick," Suby says. Consult with your payroll staff before offering it to the staff to ensure your organization's payroll system could support such a bonus. Alternatives to cash bonuses are to award gift cards for perfect attendance (which may be less cumbersome than cash bonuses from a payroll standpoint).

Publication Date: Thursday, October 01, 2009