Staffing and Scheduling



Staffing and Scheduling


Susan Sportsman




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This chapter explores research regarding the relationship between nurse staffing and various nurse and patient outcomes. It discusses the interrelationship between the personnel budget and the staffing plan. Measures for evaluating unit productivity and the impact of various staffing and scheduling strategies on overall nursing satisfaction and continuity of patient care are discussed. These key points are critical to nurse managers’ ability to deliver safe and effective care in their areas of responsibility while maintaining a high degree of employee satisfaction on the unit. Understanding the impact of nurse-sensitive indicators on patient outcomes helps nurse managers control the unit’s labor expenses. Their ability to use this information and communicate about staffing to employees is critical to effectively managing productive services and being a valuable member of the leadership team.



Objectives



• Evaluate the impact of patient and hospital factors, nurse characteristics, nurse staffing, and other organizational factors that influence nurse and patient outcomes.


• Integrate current research into principles to effectively manage nurse staffing.


• Analyze activity reports to determine the effectiveness of a unit’s productivity.


• Examine personal scheduling needs in relation to patients’ requirements for continuity of care and positive outcomes, as well as the nurse manager’s need to create a schedule that is balanced and fair for all team members.


• Relate floating, mandatory overtime, and the use of supplemental agency staff to nurse satisfaction and patient care outcomes.



Terms To Know































The Challenge



The inpatient general surgical units of a large regional medical center total 54 beds, and the surgical trauma intensive care unit (STICU) has 16 beds. The organization was faced with severe capacity constraints as it prepared to begin a master site facility plan that would result in an additional 120 beds over the next 3 years. There was a particular void in service, because there was no step-down unit for surgical patients. The coronary care unit (CCU), medical intensive care unit (MICU), and cardiovascular intensive care unit (CVICU) all have step-down units to which they can transfer patients and free up beds for truly critical patients. Beds that were already filled with general surgery patients were targeted to be the step-down unit for the STICU.


The challenge to develop the surgical step-down unit included the identification of the appropriate number of step-down beds needed by considering the volume of patients in STICU that could be transferred to the surgical step-down unit. Admission and discharge criteria for this step-down unit needed to be developed and approved by the medical staff. New equipment needs also had to be identified. The staff competencies necessary to provide appropriate care to these patients had to be considered and education plans developed. In addition, a staffing plan had to be outlined. Communication to the nursing staff was critical—some feared that they would lose their jobs because the critical care staff would assume their positions.


What do you think you would do if you were this nurse?




Introduction


Healthcare costs are escalating at a furious pace, and revenues continue to decelerate. Healthcare organizations have recognized that controlling labor costs is critical for overall cost reduction. Because nursing salaries constitute some of the major drivers of labor costs in a healthcare organization, nurse leaders are increasingly challenged to tightly manage both staffing and scheduling within their assigned cost centers. Staffing, which involves planning for hiring and deploying qualified human resources to meet the needs of a group of patients, is a primary responsibility of the nurse manager. It is also a major way in which a nurse in that role can influence quality of care. Scheduling, on the other hand, is a function of implementing the staffing plan by assigning unit personnel to work specific hours and days of the week.


Nurse managers must make skilled staffing and scheduling decisions to ensure that safe and cost-effective care is provided by the appropriate level of caregiver. No matter what the practice setting—acute care, home care, or long-term care—there is an increased focus on manager accountability for establishing and monitoring effective and efficient staffing systems.



The Staffing Process


AHRQ Nurse Staffing Model


Because of the emphasis on patient safety and ensuring positive patient outcomes in health care, research to define the “best practices” of staffing has been a high priority in the past 15 years. Consistently over that period, the research suggests that increasing the numbers of registered nurses results in many positive benefits to patients, such as a reduction in hospital-related mortality and failure to rescue, both nurses-sensitive outcomes (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). None of these studies demonstrated a causal relationship. Further, hospitals with an overall commitment to high-quality care through sufficient staffing also invested in other actions that improve quality (Kane et al., 2007).


The results of the meta-analysis by Kane et al. (2007) is published in an Agency for Healthcare Research and Quality (AHRQ) report “Nursing Staffing and Quality of Patient Care” (www.ahrq.gov/clinic/tp/nursesttp.htm). Based on the relevant research, the authors developed a conceptual framework (Figure 14-1) illustrating the complex relationships between nurse staffing and the quality of patient care. The framework considers the impact of patient and hospital factors, nurse staffing, nurse characteristics, nurse outcomes, medical care, and organizational factors on patient outcomes. Hyun, Bakken, Douglas, and Stone (2008) suggest that although data available to decide how to effectively allocate scarce nursing resources in practice are still limited, existing principles, frameworks, and guidelines provide a foundation for evidence-based nurse staffing. So, despite the complex relationships apparent in the AHRQ framework, it can be useful not only for further research but also for nurse managers to develop “best practices” for staffing.


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FIGURE 14-1 Conceptual framework of nurse staffing and patient outcomes.


Patient Factors


The acuity or severity of patients’ conditions, influenced by their age, primary diagnosis, co-morbidity and treatment stage, is a key component in determining the staffing required for safe care. However, the dynamic nature of patient care often makes it difficult to quantify the care needs of patients at any given time.


Patient classification systems have been developed in an effort to give nurse managers the tools and language to describe the acuity of patients on their unit. “Sicker” patients receive higher classification scores, indicating that more nursing resources are required to provide patient care. Nurse managers use the classification data to adjust the unit’s staffing plan for a given time or to quantify acuity trends over longer periods as they forecast their staffing needs during the budget process.



Patient Classification Types


Two basic types of patient classification systems exist: prototype and factor. A prototype evaluation system is considered both subjective and descriptive. It classifies patients into broad categories and uses these categories to predict patient care needs. The relative intensity measures (RIMs) system is a prototype system. This system classifies patient care needs based on their diagnosis-related group (DRG). The data are then fed to a decision support system that integrates clinical and financial information.


A factor evaluation system is considered more objective than a prototype evaluation system. It gives each task, thought process, and patient care activity a time or rating. These associations are then summed to determine the hours of direct care required, or they are weighted for each patient. Each intervention is given a name and a definition and is further specified to incorporate a list of all associated interventional activities. The list of interventions is comprehensive and applicable to inpatient, outpatient, home care, and long-term care patients.


Typically, organizations use a combination of systems. Some patient types with a single healthcare focus, such as maternal deliveries or outpatient surgical patients, would be appropriately classified with a prototype system. Patients with more complex care needs and a less predictable disease course, such as those with pneumonia or stroke, are more appropriately evaluated with a factor system.


Numerous potential problems exist with patient classification systems. The issue most often raised by administrators relates to the questionable reliability and validity of the data collected through a self-reporting mechanism. Another concern with patient classification data relates to the inability of the organization to meet the prescribed staffing levels outlined by the patient classification system. Administrators worry that they risk potential liability if they do not follow the staffing recommendations of the patient classification system. If the classification data indicate that six caregivers are needed for the upcoming shift but the organization can provide only five caregivers, what are the potential consequences for the organization if an untoward event occurs?


Concern over the accuracy of biased data and the inability to meet predicted staffing levels outlined by the patient classification systems has caused many healthcare organizations to abandon patient classification as a mechanism for determining appropriate staffing levels. Staff morale is at risk when acuity models indicate one level is necessary and the organization cannot increase staffing to meet those needs. Likewise, staff morale is at risk without acuity models when it is clear to staff that patient needs exceed care capacity. A truer approach is to measure and monitor patient outcomes and participate in national databases that monitor staffing effectiveness. For example, the National Database of Nursing Quality Indicators® (NDNQI®) provides a benchmarking report comparing “like” participating organizations and units around the country.



National Database of Nursing Quality Indicators®


The NDNQI® (www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality.aspx) is the only national nursing database that provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level. This large, longitudinal database is built upon the 1994 American Nurses Association (ANA) Patient Safety and Quality Initiative. This initiative involved a series of pilot studies across the United States to identify nurse-sensitive indicators to use in evaluating patient care quality. These nurse-sensitive indicators include both structures of care and care processes, which in turn influence care outcomes. Nurse-sensitive indicators are distinct and specific to nursing and different from medical indicators of care quality (Montalvo, 2009).


Data for the NDNQI® database are collected for eight types of units: critical care, step-down, medical, surgical, combined medical-surgical, rehabilitation, pediatric, and psychiatric. RN survey data are collected for all hospital unit types including outpatient and interventional units (Dunton, Gajewski, Klaus, & Pierson, 2007). Hospitals may join the NDNQI® project, submitting data regarding nurse-sensitive indicators. Hospitals can benchmark (or compare) their own data against other similar hospitals and participate in the ongoing research on nurse-sensitive data. Table 14-1 outlines the nurse-sensitive indicators included in the NDNQI® project.



TABLE 14-1


NURSE-SENSITIVE INDICATORS INCLUDED IN THE NDNQI® PROJECT

































































INDICATOR SUB-INDICATORS MEASURE(S)
 1. Nursing Hours per Patient Day*†
Structure
 2. Patient Falls*†   Process & Outcome
 3. Patient Falls with Injury*† a. Injury Level Process & Outcome
 4. Pediatric Pain Assessment, Intervention, Reassessment (AIR) Cycle   Process
 5. Pediatric Peripheral Intravenous Infiltration Rate   Outcome
 6. Pressure Ulcer Prevalence*
Process & Outcome
 7. Psychiatric Physical/Sexual Assault Rate   Outcome
 8. Restraint Prevalence†   Outcome
 9. RN Education/Certification   Structure
10. RN Satisfaction Survey Options*‡
Process & Outcome
11. Skill Mix: Percent of total nursing hours supplied by Agency Staff*†
Structure
12. Voluntary Nurse Turnover†   Structure
13. Nurse Vacancy Rate   Structure

   Outcome


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*Original American Nurses Association (ANA) nursing-sensitive indicator.


†National Quality Forum (NQF)–endorsed nursing-sensitive indicator “NQF-15.”


‡The RN survey is annual, whereas the other indicators are quarterly.


From Montalvo, I. (September 2007). The National Database of Nursing Quality Indicators™ (NDNQI®). OJIN: The Online Journal of Issues in Nursing, 12(3), 2.


A component of the NDNQI® database is the hours per patient day (HPPD) required to provide the necessary care for patients on the unit. This figure may include the HPPD of total nursing care provided or the HPPD of RN care provided. The NDNQI® project reports a number of findings related to the HPPD required by patients. For example, Dunton, et al. (2007) suggest that:



Nurse managers may also use clinical or human resource indicators other than those identified by NDNQI® to evaluate the effectiveness of the staffing and quality of patient care. Box 14-1 identifies some of these indicators.



BOX 14-1   Other Indicators of Staffing Effectiveness





Nurse Staffing


Over the past 10 years, as the evidence regarding nurse-sensitive indicators has grown, there has been significant controversy regarding the level of nurse staff required for various groups of patients, primarily in acute care hospitals. In 2008, the ANA polled more than 10,000 nurses nationally to determine their perceptions of the impact of staffing levels on their work environment. Of the nurse respondents, 73% did not believe the staffing on their unit or shift was sufficient and 59.8% said they knew of someone who left direct care because of concerns about safe staffing. Of the 51.9% of respondents who were considering leaving their current position, 46% cited inadequate staffing as the reason. Almost 52% of the respondents said that they thought the quality of nursing care on their unit had declined in the past year, and 48.2% would not feel confident having someone close to them receiving care in the facility where they work (American Nurses Association [ANA], 2008).


The recognition that the number of nurses providing care to patients is associated with better patient outcomes in acute care leads to a discussion regarding the best model to ensure sufficient staffing. Two major approaches have been put forward. The first requires a specific number of patients cared for by one nurse per shift (mandated nurse-patient ratios). Legislation to mandate specific nurse-patient ratios was implemented in California in 1999 (Keepnews, 2007).


The second approach requires the development of a staffing plan, which holds hospitals accountable for projecting the nursing needs on each unit for a period of time, typically for 6 months or a year. Hospitals are also responsible for monitoring the extent to which actual staffing matches the staffing plans, making revisions as necessary. These plans often require that direct care nurses are part of the nurse staffing committee to ensure that safe nurse-to-patient ratios are based on patient needs and other related criteria. The first legislation mandating such a committee was passed by the Texas state legislature in 2002. As of October 2008, seven states had some sort of legislation requiring a nursing staffing plan in acute care hospitals (Haebler, 2008).


Those who support a specified nurse-patient ratio based on the type of unit (e.g., ICU, medical-surgical) believe this approach will require hospitals to either find sufficient numbers of nurses to meet the ratio or shut down units. Those who prefer the nurse staffing plan approach believe that use of a staffing plan is built on nursing judgment that will allow staffing to be flexible, depending on patient acuity, nurse experience, configuration of the unit, and other factors. The ANA has developed a website (http://safestaffingsaveslives.org/) devoted specifically to staffing. This website, Safe Staffing Saves Lives, includes the principles of safe staffing developed by ANA that apply to all clinical care settings (Box 14-2). Review the website for more information.



BOX 14-2


Ana Principles for Nurse Staffing






Copyright © 2008 by American Nurses Association. Principles for nurse staffing. Washington, DC. Reprinted with permission of the American Nurses Association. All rights reserved.



24-Hour Staffing


Most of the research regarding safe staffing has been done in acute care hospitals or long-term care facilities. As a result, these findings must be applied to other healthcare settings with some caution. In addition, there has been little research regarding the differences in staffing in any clinical environment during off-peak hours (nights and weekends). Despite the fact that hospital activity is at its peak from 7 am to 7 pm weekdays, when maximum resources are available in the nurse’s work environment, this time represents only 36% of the time that nurses work in acute care or long-term care. During the remaining 64% of the time, nurses work in off-peak environments with (1) scaled-back ancillary personnel, (2) fewer (often less-experienced) staff, (3) minimal supervision, and (4) strained communication with on-call healthcare providers (Hamilton, Eschiti, Hernandez, & Neill, 2007).


The problems identified by Hamilton et al. (2007) are corroborated in other studies. Researchers have associated weekends and nights with increased mortality in hospitals for more than 25 diagnoses/patient groups. For example, Becker (2007) found acute myocardial infarction more likely to result in death among Medicaid patients admitted on weekends and Goldfarb and Rowan (2000) reported mortality after night discharge from ICU to a general unit to be 2.5 times greater compared with discharge during the day. Peberdy et al. (2008) found lower survival rates from inpatient cardiology units at nights and on weekends, even after adjusting for potentially confounding factors. Although the reasons for the differences in risk in off-peak hours are under investigation, nurse managers must be cognizant of these differences and staff during off-peak times in a prudent manner to minimize patient risk.



External Factors Influencing Staffing


An important source for guidance in projecting staffing requirements is the licensing regulations of the state, typically through the department of health, which often reflect legislation discussed earlier. Staffing regulations or recommendations can relate to the minimum number of professional nurses required on a unit at a given time or to the amount of minimum staffing in an extended-care facility or prison.


However, it is important to note that licensing standards and staffing regulations by state departments of health are not the only regulatory bodies that affect staffing plans. There are a number of national organizations with missions related to continuous improvement in the safety and quality of health care provided to the public. The Joint Commission (TJC) is an example of this type of organization. TJC works to support performance improvement in healthcare organizations through establishing standards and survey accreditation processes. To comply with the 2008 TJC patient care standards related to staffing, for example, an institution must provide an adequate number and mix of staff consistent with the hospital’s staffing plan to meet the care, treatment, and service needs of the patients. TJC is not prescriptive as to what constitutes “adequate” staffing. However, in response to increasing public concerns about patient care safety and quality, TJC correlates an organization’s clinical outcome data with its staffing patterns to determine the effectiveness of the overall staffing plan.


During the TJC accreditation process, the surveyor reviews the staffing plans developed by the nurse manager for any obvious staffing deficiencies—for example, a shift or series of shifts in which the unit staffing plan is not met. The surveyor also interviews staff nurses outside of the presence of nurse managers to inquire about staff perceptions of the units’ staffing adequacy. Surveyors may review the staffing effectiveness data for that unit as it compares with any variations from the staffing plan to identify quality-of-care concerns. Nurse managers are well advised to prepare a balanced staffing plan that supports a unit’s unique patient care needs and the scrutiny of TJC survey process. They also should post this staffing plan and compliance reports for staff to see on a routine basis. In some states, this posting is required.


Additional regulatory agencies that provide accreditation services similar to those provided by TJC include the American Osteopathic Association (AOA), the Center for Accreditation of Rehabilitation Facilities (CARF), the Accreditation Association for Ambulatory Health Care (AAAHC), the Det Norske Veritas (DNV), the National Committee for Quality Assurance in Behavioral Health, and the Community Health Accreditation Program. Other groups are emerging.


Consumer expectations may also play a role in the development and implementation of the staffing plans. Exceeding the expectations of consumers for care and services is a major strategy for maintaining and improving the long-term viability of any healthcare organization. Recognizing that the patient expects to receive high-quality nursing care that is delivered promptly and efficiently by nurses who are satisfied with their workload has a significant influence on the development of a staffing plan.


Organizational policies and clear expectations communicated to staff are essential to manage high and low volume as well as changes in acuity. Proposed personnel budgets and staffing plans that cannot flex up or down when patient acuity or volumes change put the nurse manager in a position in which patient safety may not be maintained and financial obligations cannot be met. In addition, there must be mechanisms in place and internally publicized that allow staff to ask for additional help as needed. Patient, staff, and physician satisfaction; service and care improvement; and patient safety improvement are all outcomes of a solid staffing plan. Nurse managers are obligated to consider these variables when preparing the personnel budget.

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Aug 7, 2016 | Posted by in NURSING | Comments Off on Staffing and Scheduling

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