Chapter 21

Staffing and Scheduling

Sharon Eck Birmingham, Beth Pickard and Lori Carson

evolve.elsevier.com/Huber/leadership/

Nurse staffing methodology should be an orderly, systematic process, based upon sound rationale, applied to determine the number and kind of nursing personnel required to provide nursing care of a predetermined standard to a group of patients in a particular setting. The end result is prediction of the kind and number of staff required to give care to patients. This prediction of the number and kinds of personnel to give patients nursing care 24 hours a day, 7 days a week…is no small task. The aim is to provide, at a reasonable cost to the general public the agency serves, a standard of nursing care acceptable to its clientele and the nursing staff serving it

(Aydelotte, 1973, p. 3)

Nurse staffing methodology eloquently articulated by Aydelotte in the early 1970s continues as a critical issue affecting the quality, safety, and cost of U.S. health care today (Aiken et al., 2002; Aiken et al., 2003; Blegen & Goode, 1998; Hinshaw, 2006; Institute of Medicine [IOM], 2004; Kane et al., 2007a, b; Kovner & Gergen, 1998; Litvak et al., 2005; Needleman et al., 2002; Needleman et al., 2006; Needleman et al., 2011; Unruh, 2008). Nursing is essential in the delivery of health care to society. Nursing’s Social Policy Statement reflects the societal contract for the provision of safe and quality nursing care and services for all people in every health care setting (American Nurses Association [ANA], 2010a). The major goal of staffing management is to provide the right number of nursing staff with the right qualifications to deliver safe, high-quality and cost-effective nursing care to a group of patients and their families as evidenced by positive clinical outcomes, satisfaction with care, and progression across the care continuum (Eck Birmingham, 2010; Warner, 2006).

Staffing management is one of the most critical yet highly complex and time-consuming activities for nurse leaders at every level of the health care organization today (Abdoo, 2000; Sullivan et al., 2003). How well or poorly nursing leaders execute staff management impacts the safety and quality of patient care, financial results, and organizational outcomes, such as job satisfaction and retention of registered nurses (RNs) (Beyers, 2000). The purpose of this chapter is to assist students and nursing leaders at all levels to understand the complex issues associated with staffing management in patient care. A framework for staffing management is presented, and critical components of the staffing management plan are described. New evidence that fosters an understanding of the effects of RN fatigue, independent of staffing, on quality is presented. Technology tools for frontline nursing leaders to foster the alignment of roles and accountability for staffing management are discussed. Additionally, the IOM (2010) report on the future of nursing articulates many recommendations to strengthen the advancement of evidenced-based staffing and they are explored here.

DEFINITIONS

Staffing terminology in nursing is multifaceted and often confusing, with a specific set of terms used. The most common staffing terms are defined in Box 21-1. Staffing strategies reflect the hospital’s mission, and annual strategic goals and are executed to meet the staffing management plan of an organization. Chief nursing officers are accountable to establish and translate staffing management strategies for the overall patient care divisions. The nurse managers accountable for a patient care unit or area execute the staffing management strategies, to yield an optimal health experience and clinical outcomes for patients and their families; a healthy, satisfying work environment; and cost-effective staffing model for the organization. Nursing leaders at all levels are challenged to clearly identify the leadership roles that are accountable for staffing management and adopt technologies that provide the real-time tools to execute, measure, and achieve the desired outcomes.

BOX 21-1

Staffing Terminology

Human Resources Staffing Strategy

A set of actions undertaken to determine human resources needs, recruit and select qualified applicants, and meet the needs of the organization (Fried & Johnson, 2002).

Nurse Staffing Management Plan

A structured approach to the process of identifying and allocating unit-based personnel resources in the most effective and efficient manner (Kirby & Wiczai, 1985; Nash et al., 2000).

Nurse Staffing

Staffing refers to the process of assessing and allocating the direct care nursing staff on a shift to a patient care unit.

Skill Mix

Skill mix is the proportion of direct-care RNs to total direct care nursing staff; expressed as a percentage of RNs to total nursing staff (Unruh, 2003). For example, a medical surgical patient care unit may have a skill mix of 60% RNs and 40% unlicensed assistive personnel (UAP). A skill mix ratio is typically budgeted for at the patient care unit level, but must also be examined at the shift level during the scheduling process.

Staffing Pattern

A staffing pattern lists the total number of direct care staff by skill level scheduled for each day and each shift. For example, for a 12-hour day shift for a pediatric unit on Mondays, there may be six RNs and two UAP for direct care. An additional RN assigned to care for children being admitted or discharged may be scheduled from 3 to 6 pm, during this peak time where children are returning from the operating room or going home.

Scheduling

Scheduling is the process of assigning individual personnel to work specific hours, days, or shifts and in a specific unit or area over a specified period of time (Barnum & Mallard, 1989).

Staffing Effectiveness

Staffing effectiveness is an evaluation of the effect of nurse staffing on quality patient, financial, and organizational outcomes.

Nurse-to-Patient Ratio

The RN-to-patient ratio reflects the actual patient care assignment or a state-mandated regulatory requirement for an RN-to-patient assignment. The number of RNs assigned to care for a certain number of patients is stated as a ratio. For example, 1:2 is a common ratio for one RN to care for two patients in an intensive care unit and may be changed based on the condition of the patients.

Skill Level

Skill level is the licensure (e.g., RN, LPN, LVN) or certification (e.g., UAP, NA) of a direct care staff member.

Nursing Workload

Workload is defined as the intensity (in terms of effort required) of the work a nurse performs within a given period (Unruh, 2008). Because so many variables affect workload, there are efforts to better explicate and measure workload, such as nursing intensity (Moore & Hastings, 2006) and nurse dose (Brooten & Youngblut, 2006; Huber, 2008).

Nursing Direct-Care Hours

Direct-care hours is the number of nursing staff hours that are assigned to provide direct care to a patient or groups of patients for a specified period; the most common direct-care staff include the RN, LPN/LVN, and UAP. The hours are typically calculated per patient day or nursing hours per patient day (NHPPD).

Average Daily Census

The average daily census (ADC) is calculated by dividing the number of patients cared for per day over a certain period by the number of days in a period. It may be an actual ADC or a budgeted ADC.

Admission, Discharges, and Transfers

Admission, discharges, and transfers (ADT) refers to the patients who are admitted, discharged, and transferred. The ADT factor has also been referred to as a churn or turnover of patients. ADT is associated with increased care or workload to meet the standard of care for the patient, and with safe and effective RN-to-RN communication or handoff regarding the patient condition and plan of care.

Average Length of Stay

Average length of stay is the average number of days the patient is in the hospital. It is determined by dividing the total number of patient days by the total number of admissions.

Data from Finkler SA, Kovner CT, and Jones CB: Financial management for nurse managers and executives, 3rd edition, Philadelphia, 2007, Saunders.

FRAMEWORK FOR STAFFING MANAGEMENT

Staffing management is complex and challenging because of the numerous dependencies and interrelated organizational processes. A conceptual framework provides logic and order to complex processes for administrators and scientists to consider (Edwardson, 2007). A conceptual framework for staffing management is proposed and illustrated in Figure 21-1.

This conceptual framework is adapted from Donabedian’s (1966) framework for the evaluation of quality of care: relating various structures (e.g., hospital characteristics) that impact various processes (e.g., actual staffing) and subsequently influence various outcomes (e.g., patient quality, patient satisfaction, and staff satisfaction). Multiple staffing studies have adapted this framework to organize the variables of interest (Cho, 2001; Eck, 1999; Edwardson, 2007; Kane et al., 2007a, b; Mark et al., 2007; Mark et al., 2004). In the proposed framework, structures represent the various nursing strategies, both internal and external to the organization, which directly influence an organization’s ability to effectively manage processes for staffing. The processes are a series of defined stages with outputs that directly affect subsequent stages of staffing. Finally, the outcomes of staffing management are multidimensional and measured in terms of organizational outcomes including patient, fiscal, and staff outcomes. The staffing management framework is not intended to address all possible variables but, instead, is intended to provide a guide for nursing leaders to assess staffing management in their organizations.

STRATEGIES INFLUENCING STAFFING MANAGEMENT

It is important for all nursing leaders to remain current on both the internal and external influences affecting staffing management. Briefly presented are (1) professional resources and recommendations, (2) nursing care delivery models, (3) state legislative mandates, (4) The Joint Commission (TJC) regulation, and (5) nurse union agreements.

American Nurses Association Principles for Nurse Staffing

The American Nurses Association (ANA) has published guiding documents that serve as resources to understand the complex staffing issues associated with creating a nursing unit schedule, an organization-wide staffing plan, or meeting staffing legislation. Principles for Nurse Staffing (ANA, 1999) was developed by an appointed expert panel to guide nurse staffing. The nine principles are organized into three categories pertaining to the patient care unit, the staff, and the organization (ANA, 1999). The nine principles capture the complexity of nurse staffing and offer an excellent guide for dialogue among nursing leaders. Principles related to the patient care unit are the following (ANA, 1999, p. 2):

A Appropriate staffing levels for a patient care unit reflect analysis of individual and aggregate patient needs.

B There is a critical need to either retire or seriously question the usefulness of the concept of nursing hours per patient day (HPPD).

C Unit functions necessary to support delivery of quality patient care must also be considered in determining staffing levels.

A The specific needs of various patient populations should determine the appropriate clinical competencies required of the nurse practicing in that area.

B Registered nurses must have nursing management support and representation at both the operational level and the executive level.

C Clinical support from experienced RNs should be readily available to those RNs with less proficiency.

A Organizational policy should reflect an organizational climate that values registered nurses and other employees as strategic assets and exhibit a true commitment to filling budgeted positions in a timely manner.

B All institutions should have documented competencies for nursing staff, including agency or supplemental and traveling RNs, for those activities that they have been authorized to perform.

C Organizational policies should recognize the myriad needs of both patients and nursing staff.

These principles reflect values of the patient, nurses, work environment, and outcomes at the unit or practice level. The ANA recommends a professional model in which the staffing factors taken into account include the number of patients, acuity levels of patients, contextual issues such as unit geography and technology availability, and the level of preparation, experience, and competency of caregivers. The demand for this work was evident when the published principles were rapidly integrated and adopted into health care organizational policies, collective bargaining language, and state staffing legislation.

As the nursing shortage intensified, the ANA (2005) responded with an updated Utilization Guide for the ANA Principles for Nurse Staffing. This report highlighted several policy perspectives: (1) the value of direct-care nurses’ input into an organization’s staffing plan; (2) the value of direct-care nurses’ input into the selection and implementation of patient classification or acuity systems; and (3) the value of both the clinically skilled and experienced RN who is familiar with the specific patients and nursing staff rendering their professional judgment regarding staffing decisions. This guide is an excellent document relevant for all nursing leaders and staffing committees for dialogue and planning.

Patient Acuity

Technology advancements foster adoption of the ANA staffing principles for annual budgeting and in everyday practice. Unfortunately, most patient classification systems aimed at adjusting staffing for acuity have been plagued with an inability to accurately and reliably measure patient care variability. Further, they have lacked organizational credibility and added burden to the direct care nurse. In recent years, health care reform and meaningful use legislation (HITECH act) has catapulted the advancement of health information technology to widespread adoption of electronic medical records (EMR) in the United States (www.hipaasurvivalguide.com/hitech-act-summary.php). These advances additionally offer nursing leaders technologies that leverage the automated patient assessment information entered into the patient EMR by nurses to generate accurate measurements of patient acuity (Eck Birmingham et al., 2011). The electronic patient assessment information is translated into not only workload information at the patient level, but also standardized outcomes of care (Moorhead et al., 2008) that may assist the nurse and care team in tracking patient progression to the anticipated Medicare Severity Diagnosis Related Groups (MS-DRGs) and length of stay (Eck Birmingham, 2010). The objective patient acuity information generated as a by-product of routine clinical documentation allows frontline charge nurses to make informed patient care assignment decisions. From the chief nurse’s perspective, new acuity technologies help build the business case for acuity-adjusted staffing for both improved quality and cost outcomes (Dent & Bradshaw, 2012).

Nursing Care Delivery Models

Nursing care delivery models significantly influence staffing management. A nursing care delivery model “is defined as a method of organizing and delivering nursing care in order to achieve desired patient outcomes” (Deutschendorf, 2010, p. 444). Examples of nursing care delivery models include patient-focused care, team nursing, private duty nursing, total patient care, functional nursing, primary nursing, and various combinations.

Manthey (1990) and Person (2004) described the four fundamental elements of any nursing care delivery model as follows: (1) nurse/patient relationship and decision making; (2) work allocation and patient assignments; (3) communication among members of the health team; and (4) management of the unit or environment of care. Translating the nursing care delivery model’s elements and inherent values to staffing management is a key role for nursing leaders (ANA, 2004). One common element among care models is the value of the nurse and patient/family relationship. Patient assignment technology offers charge nurses access to real-time data in order to match the right nurse (i.e., competency, expertise) with the right patient and provide continuity of care during an episode of care. A second common trend is the evolving role of the charge nurse as the frontline leader with responsibility to coordinate patient flow with expert communication among health care team members. Increasingly a charge nurse is appointed as a resource, managing patient flow and supporting novice nurses, and thus does not assume a direct care assignment.

Three nursing care delivery models, relationship-based care, the synergy model, and case management are briefly described next and depict how each model influences staffing management. Relationship-based care (RBC) is a common model used in care delivery (Koloroutis, 2004). Person (2004) articulated continuity of care as central to the RBC model, and this model also integrates Jean Watson’s theory of caring (Watson, 2002).

The synergy model for patient care is presented by the American Association of Critical-Care Nurses (Hardin & Kaplow, 2005). The core concept of the model is also based on the nurse-patient relationship and acknowledges that the needs or characteristics of the patients and families drive the competencies of the nurse. Synergy, or optimum outcomes, results when the needs and characteristics of the patient clinical unit, or system, are matched with a nurse’s competencies (Kaplow & Reed, 2008). Patient assignment technology may assist in defining, and therefore aligning, patient needs with the nurse’s abilities, a concept central to the model.

A third example is case management, defined by the Case Management Society of America (CMSA) as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes” (CMSA, 2012, p. 1). Case management can be coupled with demand management to best coordinate care and resources to achieve positive patient outcomes, transitions of care coordination, and hospital reimbursement (Pickard & Warner, 2007).

Complementing these models, the American Association of Colleges of Nursing (AACN) has recommended a new professional nurse role, the clinical nurse leader (CNL), into current care delivery models (AACN, 2003, 2007). The CNL role integrates various aspects of previous roles known in nursing, such as the case manager and clinical nurse specialist. The CNL vision statement is as follows: “The CNL champions innovations that improve patient outcomes, ensure quality care and reduce healthcare costs. The CNL integrates emerging nursing science into practice and leads this effort to enhance patient care. A recognized leader in all settings, the CNL is an advocate for reforming the healthcare delivery system and putting best practices into action” (AACN, 2003, p. 2).

The staffing management plan should reflect the values and roles established in the care delivery model that will ultimately influence the patient and organizational outcomes. Both the care delivery model and staffing plan within the context of patient populations in the health care organization are critical to the overall annual strategic plan for nursing.

American Organization of Nurse Executives

The American Organization of Nurse Executives (AONE), a subsidiary of the American Hospital Association, is a national organization whose mission is to represent nurse leaders. More than a decade ago, this key leadership group published Staffing Management and Methods: Tools and Techniques for Nurse Leaders (AONE, 2000), which presents an introduction to evolving staffing measures. It has a chapter dedicated to staffing management approaches in each of four hospital types: the large academic medical center, an integrated health care system, a small community hospital, and a rural hospital setting. The final chapter discusses how various innovations in information systems support nurse staffing.

More recently, AONE’s 2008 Legislative Agenda for public policy and advocacy included several key points relevant to staffing management. The policy agenda aims to: “Develop, evaluate and support legislation that will foster the nurse executive’s leadership role in the management of the care environment, especially in areas related to staffing, information technology and patient care services” (AONE, 2008, p. 1). The agenda does not support mandates, such as overtime or staffing ratios, and recommends working with state and federal legislators to shape policies that promote flexibility and recognize the volatility of the patient care environment.

Staffing Recommendations by Professional Organizations

Several professional nursing specialty organizations have published position statements for nurse staffing to offer evidence-based guidelines for specialty practice. Nursing leaders in specialty practice should encourage identification and discussion of the position statement during the annual staffing plan review. For example, the National Association of Neonatal Nurses (1999a, b) has a staffing position statement and recommended staffing ratios that are also described in the “Guidelines for Perinatal Care” (American Academy of Pediatrics [AAP] & the American College of Obstetricians and Gynecologists [ACOG], 2007). The ratios delineate care provided for women and newborns in the antepartum, intrapartum, and postpartum settings, as well as the newborn nursery. In recently revised guidelines, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN, 2010) describes the specific staffing recommendations for women in the various stages of normal labor and labor with complications.

Similarly, the Association of periOperative Registered Nurses (AORN, 2005) has a position paper addressing key staffing issues in the operating room (OR), and the Emergency Nurses Association (ENA, 2003), has published recommendations for staffing. Finally, the American Academy of Ambulatory Care Nursing (AAACN, 2005) has published an annotated bibliography summarizing the ambulatory nurse staffing literature. Haas and Hastings (2001) have outlined the methods for determining staffing requirements, skill mix, and productivity in the ambulatory care setting. Adoption of staffing recommendations in clinical settings by the relevant professional organizations is endorsed in the Principles of Nurse Staffing and frequently seen written into the staffing plans.