There are typically three categories of staff in nursing units or outpatient clinics:

1. Licensed practical or vocational nurses (LPN/LVN). The scope of the LPN/LVN role is determined by the state in which they practice. They may perform various technical skills, including medication administration, under the direction and supervision of a registered nurse.

2. Unlicensed assistive personnel (UAP). These staff have a wide range of individual job titles (e.g., patient care assistant, nursing technician, medical assistant, medical aide, orderly, nursing assistant, unit secretary, unit clerk). They may have certification, but are not licensed by the state, and their work must be directly delegated and supervised.

3. Registered nurses. RNs work in a variety of settings where they provide direct care, and supervise the care delivered by LPNs/LVNs and UAP.

In determining the staffing for a unit, hospital administrators, nursing directors, and managers must first decide how many people with each skill set (RN, LPN, UAP) must be hired to meet the needs of a specific population. Many factors are involved in staffing decisions, especially when determining the allocation of staff for each unit. The most time consuming tends to be the type of unit. Nursing units typically classify patients by their diagnosis or condition and their degree of illness or their acuity level. In acute care, there are typically four designations: critical care, progressive care (also known as SAC or step-down), medical-surgical units, and long-term care or rehabilitation. In addition to the level, the number of hours the unit or clinic is open will determine how many staff in each skill mix are needed. Ideally, these calculations should be performed annually, as needs of the organization and patient population change. Outpatient clinics rely on number of patient encounters (how many office visits are done) in a day, which varies dramatically by the type of provider.

Hospitals are reimbursed at different rates depending on the level of care, to account for the varying care needs of the patients on each different unit. However, the patient must meet the criteria to be in that level of care and must be coded appropriately. This is often referred to as accommodation coding. This process can cause hospital-wide problems if patients are placed in higher levels of care, but the hospital cannot get reimbursement for the more expensive bed.

The next most important factor in allocation is the number of patients on the unit. Because reimbursement is determined by the number of occupied beds, it is important to have enough staff to care for patients—but not too many. Conversely, too few staff requires utilizing on-call staff or floating staff from other units.

After staff is hired, the manager must create a schedule of when each person will work. Often employee preference is taken into account, but managers must balance not only skill mix (licensed versus unlicensed), but also experience levels of the nurses. It is important to have adequate resources available for new nurses or those with limited experience in a particular unit.

Reallocation of staff occurs on a unit level shift by shift. Managers and charge nurses may choose to alter staffing plans based on the needs on the unit at a specific time. They may choose to census manage (CM) a nurse due to low admission rates or bring in an on-call nurse when volumes exceed expectations or if a staff member calls in sick. They might also decide to reallocate staff to different areas of the hospital Æ depending on overall needs.

Typically, nurse staffing is determined by hours of care (HOC) per patient day, which are determined by multiplying the number of nurses by the number of hours each nurse works and dividing by the total number of patients. These hours roughly translate to patient ratios, or the number of patients assigned to an individual nurse during the shift. This model of nursing staffing does not allow accommodation for the individual needs of the patient or the demands placed on the nurse during the shift (O’Brien-Pallas, Irvine, Peereboom, & Murray, 1997; Upenieks, Kotlerman, Akhavan, Esser, & Ngo, 2007). Aiken et al. (2002) and Needleman et al. (2002) found that adverse patient events, such as falls, cardiac arrest, hospital-acquired infections, and development of pressure ulcers increased when nurses had higher workloads.