staffing and scheduling in healthcare institutions

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.

39. QUESTIONS?
sbeih68@yahoo.com