How should hospitals plan cover for absence so work does not stop?

It is 6.40 am in a general hospital. Two staff-nurses on the night shift have not yet been relieved, because the morning nurses from the hostel bus are stuck behind a flooded underpass. The ward has twenty-eight beds. Four patients are on intravenous drugs due at seven. The charge-nurse has a drug-round to start, an OT-list to prepare and a phone that keeps ringing.

Hospitals cannot close a shift because someone is absent. Wards, casualty, labour-room, laboratory and pharmacy-counter run through the night and on public holidays. Planning cover for absence in such a place is a clinical safety matter as well as an HR one. This article sets out a workable method.

• Nursing: staff-nurses by unit (ICU, ward, labour-room, OT), with a float-pool for peaks.
• Doctors: duty-doctors in casualty, RMOs in wards, consultants on call, locums for gaps.
• Diagnostics: phlebotomist, X-ray and CT-scan radiographers, sonography reporting-slot, laboratory technicians.
• Pharmacy: pharmacists at the counter and the indent desk, with a narcotics key-register.
• Support: ward-attendants, porters, housekeeping, ambulance drivers, oxygen cylinder handlers.
• Front office: reception, billing-desk, discharge desk.

Each group needs its own rule. A porter can be borrowed from another floor within minutes. A theatre scrub-nurse cannot. Mark in your roster which absences are fillable from inside the group, which need a named outside person, and which force a change in the day's work.

1. 1

   Rung one: the same unit

   The charge-nurse or duty manager checks whether the shift can run safely with an adjusted allocation and a short overtime request.

2. 2

   Rung two: the float-pool

   A nurse trained in more than one unit moves in. Keep a list of float staff, their skills and the units they have worked in the last month.

3. 3

   Rung three: the off-duty list

   Staff who have agreed to be called, in turn, with a recorded extra payment or a day off in lieu.

4. 4

   Rung four: locum or external help

   For doctors, a locum from a pre-agreed list. For nurses, an external person only through an approved route with credentials checked.

5. 5

   Rung five: reduce the work

   The nursing superintendent and the medical director decide together to hold admissions, defer elective cases, or divert. This must be a recorded decision.

Write the ladder on one page and display it in every nursing station. A night manager who knows the ladder does not have to improvise.

Cover is easier when gaps are seen early. At each shift change, the outgoing charge-nurse reports bed-census, patient-load, critical cases and staff short for the next shift. The duty manager reads all reports and moves float staff before the handover is complete. A late discovery at 7 am costs more than an early discovery at 5 am.

Unit and shift:
Bed-census (occupied, vacant, reserved):
Patient-load (critical, step-down, stable):
Staff present by role:
Staff absent and reason:
Short for the next shift (role, number):
Cover arranged (float-pool, off-duty call, locum):
Called by and at what time:
Issues that need the duty manager:
Charge-nurse signature:

The charge-nurse fills the sheet. The duty manager collects them at each shift change. The nursing superintendent reviews the week's sheets every Monday to see which units are always short.

Duty-doctor gaps are riskier because they affect decisions at the bedside. Maintain a locum list with registration details, speciality, last worked date and rate. Test their orientation with a one-page ward note. Casualty needs a named second call. Consultant absence should be handled by the head of department with a recorded alternate for the OPD-roster and ward-round.

An absent phlebotomist leaves sample-collection rounds undone, so the morning ward-round has no reports. An absent radiographer stalls the CT-scan queue and the casualty trolley waits. An absent ambulance driver leaves a transfer on hold with oxygen running down. Name a second person for each of these seats. Put the second name on the roster itself, beside the first, so the duty manager does not search for it. Store the cylinder-change schedule and the crash-cart check in the same place. Staff who cover must know where those lists live.

Labour-room and OT staff deserve a note of their own. A delivery cannot wait for a replacement, and a theatre list cannot start without a scrub-nurse. For both, keep one named on-call nurse who lives within thirty minutes of the hospital, and pay that on-call time fairly.

The hospital types and specialities hub explains the pressures that differ across types of hospital. For rules on leave, rotation and swaps, see the attendance, shift and leave process page and how cancer hospitals set up theirs. To bring your own roster to us, use the requirements form.