Appropriate nurse staffing has been an issue facing nurse managers for decades. It requires a sensitive touch due to the variable dynamics of healthcare. According to a report by the U.S. Department of Health and Human Services published in 1981:
Nurse staffing problems are perennial and universal. The history of nursing can be said to be, in large part, a history of attempts to respond to patient care needs with an appropriate organization and allocation of nurse staffing resources. The choice, however, of optimal strategies for the provision of patient care is complicated by underlying natural forces that give rise to an erratic flow of patients through hospital facilities and by concomitant uncertainty as to expected demands (U.S. Department of Health, 1981, p. 1).
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Many hospitals utilize the average nursing hours per patient day (NHPPD) and the average number of patients admitted to the facility at midnight equation to decide how many nurses to staff. This can be calculated by dividing the average total number of hours worked by nurses in a 24 hour period by the average number of patients at midnight. It is an easy tool for hospitals to use because it allows staffing and financial planners to have concrete formulas and allows hospitals to better predict estimated nursing costs. As a nurse this is not the best staffing method because not all patients or shifts are the same. This formula also does not take into account nurses in positions that are not directly related to bedside patient care such as the nurse manager or the education specialist. These positions while important and necessary create a misrepresentation of actual direct patient care when factored into NHPPD calculations. This staffing method allows for little flexibility to adapt to various patient needs or increased nurse workload.
Another method hospitals use to determine nurse staffing is nurse to patient ratio. In this method each department establishes a minimum ratio of nurses to patients based on the unit’s average patient acuity. For example, if the Intensive Care Unit’s ratio is 1:2, then the Progressive Care Unit would be 1:4, and Medical/Surgical 1:7. These ratios are based off of the premise that medical patients require less nursing time then an intensive care patient. This method is easy to apply because if there are 12 patients in the intensive care unit then six nurses are needed. Unfortunately nurse staffing is not a “one size fits all” situation; staffing is a complex problem that involves numerous variables and nurse to patient ratios are often seen by staffing planners as the maximum number of nurses needed to care for the number of patients in each unit. It does not take into account patient acuity, nursing experience, or increased nurse workload as a result. Inappropriate staffing can play a detrimental role on patient safety and satisfaction as well as nurse satisfaction and retention. Nurse to patient ratios do not guarantee that staffing will be sufficient enough to provide patient safety and quality of care and prevent adverse outcomes.
Historically, staffing in hospitals has been based on opinion and tradition, not evidence (Douglas, 2011). Nurse staffing should be based on total patient workload and must factor in admits, transfers, and discharges. Staffing should not be based solely on midnight patient census because it is not a true accounting of total nurse workload or patient need (Beswick, Hill, & Anderson, 2010). Historical methods of staffing such as NHPPD and nurse-patient ratio are outdated and do not provide the best means of ensuring patient safety and satisfaction, staff satisfaction and retention nor do they improve financial cost & reimbursement. Proposed solutions to the staffing conundrum have been debated for years; however conflicting research and study limitations have made selecting and implementing the best staffing approach difficult if not impossible for nurse managers. In addition, the significance of quality nursing care on patient safety, outcome, and cost savings has been misunderstood and undervalued for decades. This paper proposes that Health Information Technology (HIT) and electronic data mining, utilized in conjunction with the wisdom of expert nurses, have the potential to provide a new and more accurate method to ensure appropriate evidence based nurse staffing. Technology should be utilized fully to assist in assessing patient needs, expenditure of time to fulfill those needs, and the appropriate staffing to ensure safety, satisfaction, and financial viability of the healthcare institution. It is also imperative that understanding of the economic value of nursing be promoted and a model that calculates the direct cost of nursing care be created to bolster the argument of the positive financial impact of appropriate nurse staffing.
What is appropriate nurse staffing? According to the American Nurses Association, appropriate nurse staffing is:
A match of registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation. The provision of appropriate nurse staffing is necessary to reach safe, quality outcomes; it is achieved by dynamic, multifaceted decision making processes that must take into account a wide range of variables (Weston, Brewer, & Peterson, 2012, p. 248).
Research has shown that nurse staffing is one of the most important variables influencing patient, staff, and organizational outcomes (MacPhee, Ellis, & McCutcheon, 2006). The influence staffing has over preventing tragic events such as patient deaths, adverse events such as pressure ulcers and falls, and also on the rate of contracting nosocomial infections is well documented. According to MacPhee, Ellis, & McCutcheon, five major American studies dating from 1998 to 2004 reported that reduced nurse staffing levels were significantly associated with increased patient mortality (2006). Needleman et al. found that the risk of patient death increased with increasing exposure to shifts in which registered nurse hours were eight hours or more below target staffing levels or when there was high patient turnover (2011). It was estimated that risk of death increased by 2% for each below-target shift and 4% for each high-turnover shift to which a patient was exposed. Staffing models such as NHHPD and nurse to patient ratio do not account for the effect of admissions, discharges, and transfers on nurse workload (Beswick, Hill, & Anderson, 2010; Needleman et al, 2011). These findings reinforce the need to match staffing with patient need and projected nurse workload on a shift by shift basis.
Staffing also impacts the work environment, nurse satisfaction, rate of burnout, and rising health care costs (Weston, Brewer, & Peterson, 2012). Studies on staff and organizational outcomes found decreased nurse staffing levels increased job dissatisfaction, absenteeism, and staff turnover while also increasing patient length of stay and overall cost of care (MacPhee, Ellis, & McCutcheon, 2006). In fact one study found that the cost of decreasing patient ratios from 1:8 to 1:4 is $136,000 per life saved and could save 72,000 lives annually (Rothberg, Abraham, Lindenauer, & Rose, 2005). Beswick, Hill, & Anderson recommend that direct nursing care be assigned a monetary value and be billed separately from room charges to more accurately reflect the realities of nursing workload and the economic impact of nurses on patient care (2010). Nursing care should be moved from the cost side of the balance sheet to the revenue side so it can finally be recognized for the value it brings to healthcare organizations in an era of payment for quality (Weston, Brewer, & Peterson, 2012). Appropriate nurse staffing is an evidence-based way to improve quality of care and prevent adverse events which are costly to healthcare facilities due to financial penalties from payors, legal costs, and payouts to patients and families after a preventable event occurs (Weston, Brewer, & Peterson, 2012).
Evidence supporting the association between nurse staffing and patient outcomes has met resistance due to previous study designs. Past studies have been cross-sectional, used inexact hospital-level data, and did not account for differences in patients’ requirements for care (Lucero, Ji, de Cordova, & Stone, 2011). Differing research results and limitations of previous studies makes it difficult for nurse managers to understand and apply findings to unit-level staffing decisions. An article by Spetz, Donaldson, Aydin, & Brown addressed this issue (2008). The researchers reviewed the data sets used in multiple studies and found that vast differences in results can occur depending on the data set used in the study, unit level versus payroll data. This is due to the fact that payroll data does not differentiate between direct and indirect nursing care hours. They also found that differing study results can be attributed to the use of different staffing methods between facilities and the resulting difficulty comparing them to each other.
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NHPPD calculations and nurse to patient ratios are difficult to adapt to every situation and the number of variables involved in the decision making process makes clear-cut evidence based formulas difficult to construct. According to Harper, health information technology (HIT) is a tool that can be utilized to help sort through the myriad of variables to create an evidence based staffing model (2012). It provides a means to calculate nursing intensity by electronically identifying how nurses spend their time and which variables are most closely related to nursing intensity (Harper, 2012). Clinical data can be pulled in real time from the electronic medical record (EMR) to help calculate patient needs and the appropriate staffing levels (Harper, 2012). Health Information Technology may be a credible solution to the staffing problem because of its ability to track patient’s requirements for nursing care and nurse’s responsiveness to those needs in real time (Lucero, Ji, de Cordova, & Stone, 2011). HIT has the potential to reduce costs, improve efficiency, enhance quality of care, and improve patient safety by utilizing data mining and business analytics to reengineer processes (Harper, 2012).
The nurse manager is responsible for assuring the effectiveness of the nursing workforce in delivering safe, quality patient care. Technology today plays a huge role in healthcare delivery and can provide the nurse manager with tools through which philosophy, policies, and practices can be reflected and operationalized (Douglas, 2011). It may be the key to staffing success by helping to achieve optimum workforce management and maximum financial return. Healthcare technology should be embraced by the nurse manager to improve the ability to allocate the right resources to the right situations to support the best possible quality of care, patient safety, and financial outcomes of the facility.
The nurse manager’s first step in implementing new technology is identifying the desired outcomes. These could be: improving the efficiency and effectiveness of scheduling, facilitating evidence-based decision making, and standardizing the collection of data for monitoring, managing, and improving staffing practices. The second step is encouraging staff buy-in. In order to assure the successful implementation of any new process, the nurse manager should educate the staff, share goals, set expectations, inspire participation, and establish momentum for the changes that will be occurring. Staffers who are included and kept well informed will understand and hopefully appreciate the value of the change and feel more personal responsibility for the success of the new endeavor. This is especially true if the technology improves processes for those affected by the change. A good way to inspire cooperation is by establishing a committee to help identify outcomes and system requirements and to give those who will be affected a voice. Once staff buy-in has been initiated, the third step, finding an appropriate technology solution, can begin.
The forth step is implementing the selected technology solution. Continued education throughout the implementation process is imperative. Staffers should be reminded of why the change is important and their role in achieving it. Training of end users should include tying the program features and functions to the goals previously established and linking staffing decisions to the evidence to help increase interest and support adoption. Making the change process fun can help sustain the change. Putting posters in the break room and giving away buttons and goodies at meetings can increase interest and inspire the desire to succeed. The last step is cementing the change. Good communication and listening are important to ensure that the change is adopted fully and staffers do not fall back into more familiar patterns and practices. Answering questions, acknowledging feedback, and fixing program problems will help. It is also important for the nurse manager to continue monitoring pertinent staffing research and literature to ensure that practices and policies are updated as necessary and that the technology does not become outdated.
How will new technology and processes be evaluated for effectiveness? The following are questions the nurse manager should ask after implementation: Has there been a decrease in near misses and sentinel events? Are we more appropriately staffed or are we still having short staffed shifts? Are our patients and nurses reporting increased satisfaction? Have we decreased the cost of overtime payments and contracted labor? Have we increased the financial stability of the facility and lowered our costs? If the answers to these questions are positive then the initiative was a success. If not, processes and program functions need to be assessed and refined.
Despite the continued focus on what is appropriate nurse staffing, it must be remembered that the ultimate goal is not just to identify better staffing patterns but a method for providing the best possible patient care (Weston, Brewer, & Peterson, 2012). If Healthcare Information Technology is to be the key to success for the future of nurse staffing it must be remembered that it is only a tool. Any staffing process must also utilize expert professional nurses to assist in making staffing decisions and allow them to override the chosen model when it does not support the best interests of the patient, staff, and hospital (Douglas, 2010). Expert nurses are able to consider numerable factors, combine them with evidence, observations, and wisdom from experience to quickly provide the most accurate accounting of staffing needs (Douglas, 2010). This invaluable resource should not be negated by the use of inflexible staffing plans or increased use of technology.
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