Staffing and Scheduling
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This document summarizes research on the relationship between nurse staffing levels and patient outcomes. It identifies several influential studies that found associations between higher nurse staffing levels and lower mortality rates, failure to rescue rates, and nosocomial infection rates. The document also discusses different approaches to establishing minimum nurse staffing standards and ratios. It concludes that simply requiring more nurses may not improve patient care without also enhancing working conditions and support for nurses.
Staffing and Scheduling
- 1. Staffing and Scheduling Musa Abu Sbeih Director of Nursing Affairs Ibn Sina Hospital 1st Line Manager Leadership and Management Course January 2009
- 2. Review research on the relationship between staffing and quality of car Identify ways to measure nurse staffing Present data on hospital staffing Identify basic elements of staffing and scheduling Explore staffing-related policy options for ensuring quality of care Assess the potential impact of minimum nurse staffing ratios What Next Objectives
- 4. “The idea of requiring more nurses at the bedside won’t necessarily make them go there. The issue is more complex than that. If we do get nurses to the bedside, we need to keep them there by providing the appropriate resources, such as staff and technology, so that working conditions best support their daily needs.” White, K.M., April, 2006. Nursing Management, pg 24.
- 5. Research on nurse staffing has changed in recent years • In the 1990s: – INC said there was insufficient evidence to determine whether nurse staffing changes were detrimental (1996) – ANA said there was insufficient scientific evidence to establish ratios (1999)
- 6. The newest research shows that nurse staffing is important • Evidence suggests that an increase in nurse staffing is related to decreases in: – risk-adjusted mortality – nosocomial infection rates – thrombosis and pulmonary complications in surgical patients – pressure ulcers – readmission rates – failure to rescue
- 7. The Most Influential Studies • Aiken, Clarke, et al. (2002) – Journal of the American Medical Association (2002) • Surveyed nurses about staffing and work environment in Pennsylvania, linked surveys to discharge data • Poor nurse staffing associated with higher: –30-day mortality –Failure to rescue – Journal of the American Medical Association (2003) • Same data as 2002 paper • Hospitals with more baccalaureate-educated RNs had lower: –30-day mortality –Failure to rescue
- 8. The most influential studies • Kovner and Gergen (2002) – Health Services Research (2002) • National data on hospitals, 1990-1996 • Poor nurse staffing increased pneumonia rates – Journal of Nursing Scholarship (1998) • Focus on postsurgical events • Poor RN staffing raised rates of: – Pneumonia – Urinary tract infection – Thrombosis – Pulmonary compromise
- 9. How do nurses feel about staffing? ANA’s 2001 survey • 56% of nurses say their time for direct patient care has decreased • 75% say quality of nursing care has declined in their work setting in the past 2 years • Inadequate staffing is the top reason for the decline in quality of nursing care
- 10. Patient-to-Nurse Ratios Important in Nurse Retention (Aiken et al. JAMA 2002) • Higher burnout and greater job dissatisfaction—precursors of turnover— are strongly related to patient-to-nurse ratios. • An increase of one patient per nurse increases the probability of: high levels of burnout by 23 percent job dissatisfaction by 15 percent
- 11. Nursing Staff & Mortality Rate Nurse Staffing and Mortality Following Common Surgical Procedures Aiken et al. JAMA 2002 • 7 percent increase in mortality for every patient added to the average hospital- wide nurse workload • 7 percent increase in failure-to-rescue patients with complications
- 12. Nursing Education Variation in Nurses’ Education and its Consequences Aiken et al., JAMA 2002 • Each 10 percent increase in proportion of nurses with BSNs was associated with a 5 percent decline in mortality following common surgical procedures • Each 10 percent increase in BSN was associated with 5 percent decline in failure to rescue
- 14. Nurse staffing also affects job satisfaction • High workload and poor staffing ratios are associated with: – Nurse burnout – Low job satisfaction – Increased nurse stress • Nurse stress is related to: – Adverse patient events – Nurse injuries – Quality of care – Patient satisfaction
- 15. The research has limits • Data on hospitals do not recognize different staffing on different units • Studies at the nursing unit level involve primary data collection and are costly • Single-year studies cannot prove a causal relationships • No study identifies the “ideal” staffing ratio
- 18. Approaches to Staffing Standards • Patient acuity/patient classification systems • Fixed ratios • Formula-based ratios • Skill-mix requirements
- 19. Patient Acuity/patient Classification Systems • Inputs: number of patients, acuity of illness • Output: appropriate staffing levels • Widely marketed systems and home- grown systems • Problems: – Systems best for long-term, not short- term, prediction – Difficulty of staffing up if necessary – Enforcement – hard to monitor
- 20. Fixed Ratios • Fixed, specific nurse-to-patient ratios are mandated • Problems: – Minimum staffing could become average staffing – Hospitals could eliminate ancillary and support staff – Loss of flexibility and innovation
- 21. Formula-based ratios • Nurse workload = function of: – RN staff expertise – Patient acuity, work intensity – Support staff, MD availability – Unit physical layout • Problems: – Defining the function – Establishing new staffing ratios every week/month/year
- 22. Skill-mix Requirements • Hospitals must have a minimum fixed ratio of Staff Nurse (RN) relative to all staff • Problems: – What is the appropriate ratio? – Minimum ratio could become average – Total staffing may not be adequate – Loss of flexibility and innovation
- 23. There are Many Ways to Measure Nurse Staffing • Nurse-to-patient ratios – Legislation calls for these – Nurses think about staffing in these terms • Skill mix • Hours per patient day (HPPD) – Administrative data uses this term – Easy to measure with some public data sources – Hard to relate to skill mix or nurse-to-patient ratios • Full-time equivalent employment (FTE) – Can use to approximate HPPD – Inaccurate measure of hours worked
- 24. Scheduling/Staffing • FTE (40 Hours Worked / 40 Total Hours = 1.0 FTE; 20 Hrs / 40 Hrs = 0.5 FTE) • Hours / Week & Days/Week (Each day = One 8 hour shift) FTE Hours / Week Days / Week 0.1 FTE 4 1/2 0.2 FTE 8 1 0.3 FTE 12 1 1/2 0.4 FTE 16 2 0.5 FTE 20 2 1/2 0.6 FTE 24 3 0.7 FTE 28 3 1/2 0.8 FTE 32 4 0.9 FTE 36 4 1/2
- 25. FTEs Number of FTEs required to staff the following situation -- SAT SUN MON TUES WED THURS FRI Staff Required 1 1 1 1 1 1 1 8 Hour Shifts (Excluding Sick, Vacation & Holiday (SVH) = 7 Shifts x 8 Hours = 56 Hours / 40 Hours = 1.4 FTEs 40 Hours / 8 Hours = 5 Hours 7 Shifts / 5 = 1.4 FTEs
- 26. Nonproductive Time Sick, Vacation & Holiday Time (SVH) or Paid Time Off (PTO) Percentage of time a Full-time employee will be off due to SVH or PTO assuming the employee takes 34 SVH/PTO days per year 34 Days x 8 hour shifts = 272 Hours / 2080 Total Hours = 0.1307 x 100 = 13.1 % 5 Days/Week x 52 Weeks = 260 Total Days Paid 34 Days / 260 Paid Days = 13.1%
- 27. Total FTEs Total FTEs Required Total FTEs (1 employee per day (8 hour shift) x 7 days = 1.4 FTEs x 0.13% Nonproductive time = 0.182 FTEs 1.4 FTEs + 0.182 FTEs = 1.582 FTEs
- 28. Building/Analyzing FTE Requests Total Budgeted Staff FTEs (8-Hour Shifts) 13% SVH SAT SUN MON TUE S WED THUR S FRI Total # Shifts FTEs w/out SVH (Prod.) # shifts/5 FTEs with SVH (Total) x 1.13 % Day 4 5 5 5 5 5 4 33.0 6.60 7.46 Eve 3 3 3 3 3 3 3 21.0 4.20 4.75 Night 2 2 2 2 2 2 2 14.0 2.80 3.16 Total 9 10 10 10 10 10 9 68.0 13.60 15.37
- 29. Building/Analyzing FTE Requests Total Budgeted Staff FTEs (12-Hour Shifts) 13% SVH SAT SUN MON TUES WED THUR S FRI Total # Shifts FTEs w/out SVH (Prod.) # shifts/3.33 3 FTEs with SVH (Total) x 1.13 % Day 4 5 5 5 5 5 4 33.0 9.91 11.2 Night 3 3 3 3 3 3 3 21.0 21.00 6.31 Total 7 8 8 8 8 8 7 54.0 16.20 18.33 Comparing 12-Hour Total Shifts w/o SVH = 16.2 and 8-Hour Total Shifts w/o SVH = 13.6 16.2 Shifts – 13.6 Shifts = 2.6 / 13.6 = 0.1912 x 100 = 19% difference (Showing 8-Hour Shifts are more cost-effective than 12-Hour Shifts)
- 30. Hours Per Unit of Service Hours Per Unit of Service (H/UOS) (Average number of hours of both direct and indirect nursing care supplied in a 24 hour period) Industry Standard (Formula for Dailey H/UOS) Total Number of Staff x Hours Worked (= Productive Hours) Unit of Service in 24 Hours •Example – 2600 productive hours worked by direct care providers divided by 500 Patient Days = 5.2 HPPD •Number of Staff on Duty per Day (8-Hour Day, 30-Day Month) 2600 / 30 = 86.67 Hrs/Day 86.67 / 8 Hours = 10.8 Staff per Day
- 31. Staffing Costs • Full-time Employee with OR 4.5 hourly rate (excluding SVH + Fringe Benefits) – 4.5 x 2080 = OR 9360(Or OR 4.5 X 8 Hours = OR 36/Day) – OR 36/Day x 260 Days = OR 9360 • Full-time time Employee Costs – Full-time employee is paid 260 days/year but works 226 days (34 days of SVH taken) Salary = $27,040 + $3000 Fringe Benefits • OR 9360 + OR 600 = OR 9860 • OR 9860/ 226 = OR 43.63/Day • 0.5 FTEs = most expensive, decreasing costs 0.6 FTEs to 0.9 FTEs, 0.1 FTEs to 0.4 FTEs least expensive
- 32. How should the minimum ratios be evaluated? • Overall framework • Data sources • Recommendations
- 33. There are many factors to include in an evaluation • Patient outcomes – Draw from current nurse-sensitive outcomes literature – Major forthcoming study by Buerhaus & Needleman, ongoing work by Kovner, Aiken • Nurse outcomes – Satisfaction with job – Disability, injuries on the job – Organizational culture (Aiken) • Unit-specific analyses will have more power to measure success/failure
- 34. What next? • More nurses lead to better patient outcomes • Legislative approaches have potential pitfalls • To improve nurse staffing: – Budgets need money to pay more staff – More nurses are needed in the labor market
- 35. Solution Solutions to nurse shortage and patient safety concerns • Transform work environment of nurses to support rather than deter nurses from providing the best possible care: Budget enough positions, administrative support, good nurse- physician relations, career advancement options
- 36. Solution Increase work flexibility and personal choice Increase public investment in nurse education Capital investments in labor-saving, error preventing and decision making technologies
- 37. Evidence-based work environment Attributes associated with good patient and nurse outcomes • Staffing adequacy • Good doctor-nurse relationships • Administrative support for nursing care • Career support of nurses
- 38. References Finkler, S.A., & Kovner, C.T. (2000). Financial management for nurse managers and executives (2nd ed.). Philadelphia, PA: Saunders. Gullatte, M.M. (2005). Nurse management: Principles and practice. Pittsburgh, PA: Oncology Nursing Society. Henderson, E. (2003). Budgeting: Part one. Nursing Management, 10(1), 33- 37. Henderson, E. (2003). Budgeting: Part two. Nursing Management, 10(2), 32- 36. Lehmann-Spitzer, R. (1994). Nursing management desk reference concepts, skills and strategies. Philadelphia: Saunders. Marrelli, T.M. (2004). The nurse manager’s survival guide (3rd ed.). St. Louis, MO: Mosby. Schmidt, D.Y. (1999). Financial and operational skills for the nurse manager. Nursing Administration Quarterly, 23(4), 16-28.