Staffing and Scheduling 1 One of the most critical issues confronting nurse executives today is nurse staffing. The major goal of staffing and scheduling systems is to identify the need for and provide the number and type of personnel required to deliver care. 2 1
Staffing is a human resources function that is targeted at creating the personnel and favorable work conditions for optimal productivity and the professional practice of nursing. Staffing and scheduling are complex, multifaceted responsibilities that are central to nursing efforts to effectively integrate organizations and systems. 3 " Staffing and scheduling affect the jobs, positions, workload, personal lives, and morale of nurses. Staffing and scheduling decisions impact the organization or unit's financial management plan, impinge on productivity, and affect patient outcomes. Staffing and scheduling are both frustrating and time-absorbing for nurse managers. 4 2
Issues of safety and quality of client care may arise due to specific staffing and scheduling. "Staffing policies and needs affect the nursing department budget, staff productivity, quality of care provided to clients, nursing staff morale, and even nurse retention. 5 Regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have a standard that calls for a sufficient number of qualified registered nurses( RNS) to be on duty at all times to give clients nursing care that requires the specialized skill and judgment of an RN. 6 3
DEFINITION OF TERMS Staffing: is defined as human resources planning to fill positions in an organization with qualified personnel. Nurse staffing has three main components: Planning. Scheduling. Allocation. 7 Planning refers to determining the number of nursing personnel needed over a long term period. Scheduling is assigning nursing staff for specific time periods by shift. Allocation refers to making adjusted assignments or reallocations on a daily or shift-by-shift basis. 8 4
The staffing plan is a written plan that specifies the number and classification type of staff personnel who are needed to implement a care delivery model for each unit on a shift-by-shift basis. Short-term plans involve filling existing positions. Long-term plans are concerned with determining the gap between the present and a desired future human resources status. 9 A staffing strategy is a set of actions undertaken to determine the organization's future human resources needs, recruit qualified applicants, and select the best of the applicants as new employees. Staffing activities need to mesh with other organizational strategies and the mission. 10 5
Scheduling: is defined as the ongoing implementation of the staffing pattern by assigning individual personnel to work specific hours, days, or shifts and in a specific unit or area. Scheduling generally means the actual preparing of work hour assignments according to the staffing plan and mix. Staff mix is defined as the skill level of individuals delivering the required care. Staff mix in nursing includes RNs, LPNs, nursing assistants, and unlicensed assistive personnel. 11 Skill mix: is the proportion of RNs to total nursing staff. It is usually expressed as RN/ total nursing personnel. Nursing resources: refers to the number and types of employees designated to provide nursing services to clients. -There are many ways to distribute resources within any organization. - Workload is defined as the volume of work for a unit or department. - Nursing workload is defined as the nursing care needs of clients. It refers to the nursing resources required for delivering nursing services to individuals or groups of clients. 12 6
Nursing workload is a measurement of the nursing work activities and the dependence of the clients on nursing care. Thus both direct and indirect nursing care activities are a part of nursing workload Nursing workload in a hospital is a function of two variables: Number of patient days Hours of nursing care required per patient day. Workload is the use of time, and time is the basis of nursing workload measurement. 13 Acuity is defined as the severity of illness or client condition. Acuity can translate into volume (census, visits, or encounters) or severity or intensity. Nursing intensity is defined as both the amount of care and the complexity of care needed by patients in hospitals. 14 7
Average Patient Length of Stay in Pennsylvania Hospitals, 1991-2000 9 8 7 6 5 4 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 15 Nurse staffing intensity which is expressed as the ratio of RNs to patient census in hospitals, has been associated with lower mortality in hospitals. e.g (1 RN : 10 patients). "The real driver of nurse staffing is patient demand for care... 16 8
Prescott (1991) identified four major dimensions to nursing intensity (Box 33.1) Severity of illness Client dependency on nursing. Complexity of nursing care. Time the four components are related to each other and have been combined into a 10-item for nursing intensity scale, called the Patient Intensity Nursing Index (PINI). 17 Severity of illness: The medical condition and how ill the person is in relationship to abnormality and instability of physiological parameters: Client dependency: need for assistance with activities of daily living. Complexity of nursing care. Time: The hours of direct and indirect care received by a client. 18 9
Staffing and scheduling are a fine balance of competing interests and needs. There are predetermined standards, budget constraints, personal preferences, legal aspects, and individuals to please. Staffing and scheduling are two aspects of the allocation of scarce and expensive personnel resources. 19 To increase the chance of successful and appropriate allocation of resources, the administrative function of planning is involved in staffing and scheduling. The planning may be simple or complex. It may be as simple as deciding what is wanted,(e.g.. an all-rn staff). And then as complex as determining what must be done to obtain it (e.g. budgeting.. recruitment, and retention). 20 10
Staffing methodology needs to be based on quantifiable and measurable data. The following three variables are central to the staffing methodology (Abdoo, 2000): 1. Assessment of patient needs for care (patient classification) 2. Assessment of required nursing time to meet needs (workload determination) 3. An algorithm that uses the first two variables 21 Principles for Nurse Staffing: Using an expert panel, the ANA (1999) identified nine principles to guide nurse staffing, grouped into three categories of : (1) patient care unit-related, (2) staff-related, and (3) institution/organization-related. The nine principles are as follows: 22 11
I. Patient care unit-related: Appropriate staffing levels for a patient are unit reflect analysis of individual and aggregate patient needs. There is a critical need to either retire or seriously question the usefulness of the concept of nursing hours per patient day (HPPD). Unit functions necessary to support delivery of quality patient care must also be considered in determining staffing levels. 23 hours per patient day (HPPD). The average number of hours worked per patient day by all employees in a given cost center and employee classification during the reporting period; determined by dividing the hours worked (by such employees) by the total patient days of care provided during the reporting period 24 12
II. Staff-related: The specific needs of various patient populations should determine the appropriate clinical competencies required of the nurse practicing in that area Registered nurses must have nursing management support and representation at both the operational level and the executive level Clinical support from experienced RNs should be readily available to those RNs with less proficiency. 25 III. Institution/Organization-Related 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 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 Organizational policies should recognize the myriad needs of both patients and nursing staff. (ANA, 1999, p. 2) 26 13
STAFFING AND SCHEDULING DECISIONS To determine appropriate staffing, the ANA (1999) presented a matrix for staffing decision making composed of the following four critical factors: The number of patients, including elements of patient characteristics and the number of patients for whom care is being provided. The levels of intensity of the unit and care, including individual patient intensity; across the unit intensity; variability of care; admissions, discharges and transfers; and volume 27 Contextual issues, including architecture, geography of the environment, available technology, and same unit or cluster of patients. Level of expertise and preparation of those providing care, including learning curve; staff consistency, continuity and cohesion; cross training; control over practice; involvement in qualityimprovement activities; professional expectations; preparation; and experience 28 14
Thus decisions about appropriate staffing levels for any patient care unit need to reflect the analysis of both individual and aggregate patient needs, as well as unit functions necessary to support quality patient care delivery. Staffing and scheduling decisions contain unique factors, depending on the care delivery setting. For example, staffing an operating room requires different considerations based on schedule, space, time, coordination of personnel, and special skills or equipment needs. 29 The following four elements are essential to a staffing program (Ramey,1973):. A statement of philosophy for the unit, department, and institution that defines values and beliefs. Objectives-general for the department and specific for each unit. Job descriptions for each type and level of personnel. A determination of the frequency with which nursing care is to be provided and who will provide it. 30 15
STAFFING METHODS: The common denominator for identifying and measuring activities for quality and quantity is the unit of service The unit of service is a volume measure and may be patient days, treatments, visits, encounters, births, operations, exercise sessions, or client contact. Time is measured in "hours per... "-for example, hours per patient day (HPPD). 31 Research indicates that HPPD alone is insufficient for either accurate staffing and scheduling projections or for monitoring and controlling labor budgets. This is because many factors affect time requirements, and averages do not describe or account well for outlier cases. 32 16
Two general methods of nurse staffing are the traditional fixed staffing and controlled variable staffing. - With fixed staffing, staffing is built around a fixed projected maximum workload requirement, and the plan is based on maximum workload conditions. - With variable staffing, units are staffed below maximum workload conditions and staff then supplemented as needed. 33 Supplementation may be done by using supplemental staffing agencies. Kirk (1988) listed a semiflexible system as a third type of nurse staffing system. In this system, about 10% to 15% of staff members are fixed, whereas the rest are flexible and the volume is adjusted to match the need. 34 17
STEPSIN DEVELOPINGA STAFFING PATTERN: Ramey (1973) suggested the following eleven steps for developing hospital staffing patterns (Page 720): e.g Select criteria to classify clients into severity of illness categories. Record all direct and indirect activities Average the number of minutes required to accomplish each nursing activity to equal an average performance time. Calculate the total number of nursing hours needed annually for the unit. Note the skill level of personnel required to perform each nursing activity per severity of illness category. 35 An ideal measure of nursing staff adequacy should indicate the volume of nurses of a certain skill level that is necessary for the given volume of patients given the intensity of nursing care required for those patients during their stay: # of RNs # of patient days X intensity of RN care for those patient days 36 18
SCHEDULING: The daily work schedule is a short-range plan for human resource management. It establishes the needed human resources for a unit or area. The number of shifts per day and the number of FTEs (Full Time Equivalents) need to be calculated, and this information needs to be converted into the specific positions needed. 37 Each unit or organization needs to develop guidelines and scheduling policies to maintain order and fairness. Types of time- scheduling system: Block: is fixed until revised yearly Unstructured: is created weekly and fluctuates based on staff s needs. Skeleton: starts with a basic skeleton staffing and fixes only a portion of the schedule, usually weekends. Cyclical: sets a pattern for each staff person s day on and days off. Shifts are rotated. A master: is a cyclical repetitive schedule, covering an entire area for a long period such as a 4 week block. 38 19
Computerized nurse scheduling may be used to integrate patient classification,workload calculations, staffing and scheduling. Self- scheduling: once the number of nurses needed per shift for the timeframe is determined, nurses sign up for any shifts they want to work, within guidelines and contractual bounds. An upper limit is placed on the number allowed to sign up in each time block In case of conflict, adjustments are made based on consensus. 39 PATIENT CLASSIFICATION SYSTEMS Prototype systems: Factor Systems: Computerized real-time factor systems: 40 20
Prototype systems: are based on average care times for groups of clients defined by broad categories and typical characteristics. Categories are hierarchical (such as low-mediumhigh) according to the amount of care required. Clients are classified by being compared with the described prototype. Prototypes are often called subjective systems whose reliability is questioned. 41 Factor systems: use critical indicators to describe individual elements of direct care requirements. For example, time-and-motion studies may be conducted to derive those elements of the job that are critical to work accomplishment. Factor systems are heavily based on tasks and specific activities. Their ability to capture the full scope of the nursing process is questioned. 42 21
Computerized Real-Time Factor: Actual times of all direct and indirect nursing care activities are recorded These time computations and acuity ratings are automatically calculated and updated in real time. If all activities are documented,the computer captures actual activity performed for the client, rapidly and automatically calculates data, and determines acuity and staffing while avoiding subjectivity and information delay. 43 In some systems, nursing diagnoses, interventions, and outcomes form the basis of the care activities documentation. 44 22
RN Staffing, Patient Outcomes, and Ratios: Agency for Healthcare Research and Quality (AHRQ), Reviewed 26 studies on the relationship between nurse staffing levels and measures of patient safety. These studies found that "lower nurse-to-patient ratios were associated with higher rates of nonfatal adverse outcomes, both at the hospital and nursing unit levels. 45 (HRSA), (HCFA), (AHRQ), (NINR), jointly sponsored a study titled Nurse Staffing and Patient Outcomes in Hospitals. This study found "strong and consistent relationships between nurse staffing variables and important patient outcomes in acute care hospital inpatient units in the following areas:. Next slide. 46 23
Medical Patients Urinary tract infections Pneumonia Shock Upper gastro intestinal bleeding Length of stay Major Surgical Patients Failure to rescue (defined as the death rate among patients with sepsis. pneumonia. Shock, upper gastrointestinal bleeding, or deep vein thrombosis. 47 For example, in hospitals with high RN staffing, medical patients had lower rates of five adverse patient outcomes: Urinary tract infections Pneumonia Shock Upper gastro intestinal bleeding Length of stay 48 24
Specifically, "three Agency for Healthcare Research and Quality (AHRQ) funded studies found a significant correlation between lower nurse staffing levels and higher rates of pneumonia". 49 Curtin (2003) concluded that research indicates that RN staffing has a real and measurable impact on patient outcomes, medical errors, length of stay, nurse turnover, and patient mortality. She noted that researchers are now providing the information needed to help determine what is appropriate staffing. 50 25
Ratios : are important, -a consensus seems to be emerging supporting a range of from 4 to 6 patients per nurse in most hospital inpatient settings, with no more than one to two patients per nurse in high-acuity settings. However, ratios must be modified by: the nurses level of experience, the patients' characteristics (e.g.. Acuity level or debility), and the quality of clinical interaction between and among physicians, nurses, and administrators. 51 26