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Objectives Upon completion of this chapter, the reader should be able to: Calculate full-time equivalents (FTEs) needed to staff a typical inpatient nursing unit Analyze the impact of patient volume and work intensity on the demand for nursing care Discuss appropriate units of service used to measure nursing need by unit type

Objectives Critique organizational, regulatory, staff, and patient dynamics underlying development of a staffing plan Analyze scheduling issues that impact the matching of nursing resources to patient needs Compare and contrast models of care delivery and their impact on patient outcomes

Determination of Staffing Needs Patient census was historically used to determine staffing needs Has proven to be inaccurate, since patient care needs vary greatly Better matching of patient needs to nursing resources is now an important financial quest in health care institutions

Core Concepts Full-time equivalent (FTE) is a measure of the work commitment of an employee who works 5 days a week or 40 hours per week for 52 weeks per year; some agencies consider 36 hours (three 12-hour shifts) full time FTE hours are a total of all paid time

Core Concepts Productive hours Hours worked and available for patient care Nonproductive hours Benefit time such as vacation, sick time, and education time Direct care Time spent with hands-on care to patients Indirect care Time spent with activities that support patient care

Units of Service A variety of volume measures used to reflect different types of patient encounters as indicators of nursing workload Used in budget negotiations to project nursing needs of patients and to assure adequate resources for safe patient care

Nursing Hours per Patient Day (NHPPD) A standard measure that quantifies the nursing time available to each patient by available nursing staff NHPPD reflects only productive nursing time available based on: Midnight census Past unit needs Expected practice trends National benchmarks Budget negotiations

Patient Classification Systems Patient classification system (PCS) A measurement tool used to determine the nursing workload for a specific patient or group of patients over a specific period of time Patient acuity The measure of nursing workload that is generated for each patient

Patient Classification Systems Nurse intensity A measure of the amount and complexity of nursing care needed by a patient Patient turnover A measure reflecting patient admission, transfer, and discharge

Factor Classification Systems Use units of measure that equate to nursing time Attempt to capture assessment, planning, intervention, and evaluation of patient outcomes along with written documentation processes Are the most popular type of classification system

Factor Classification Systems Advantages Data readily available for day-to-day operations Provide information against which one can justify changes in staffing requirements Disadvantages Create an ongoing workload for the nurse in classifying patients every day Problems with “classification creep” Do not capture patient needs for psychosocial, environmental, and health management support Calculate nursing time based on a “typical” nurse

Prototype Systems Allocate nursing time to large patient groups based on an average of similar patients Advantage Reduction of work for the nurse by not classifying patients daily Disadvantages No ongoing measure of the actual nursing work required by individual patients No ongoing data to monitor the accuracy of the preassigned nursing care requirements

Utilization of Classification System Data Can be utilized by staff and managers for planning nursing care over the next 24 hours Essential for preparing month-end justification for variances in staff utilization Used to cost out nursing services for specific patient populations and global patient types Information useful in negotiating payment rates with third-party payers Used in preparing the budget

Considerations in Developing a Staffing Plan Benchmarking A tool used to compare productivity across facilities to establish performance goals Does not always reflect quality of care indicators that can link quality patient care outcomes to productivity measures Can be helpful in establishing a starting point for a staffing pattern

Considerations in Developing a Staffing Plan Regulatory requirements One controversial issue is nurse staffing levels Mandated nurse staffing plans are enacted by law The Joint Commission does not regulate staffing levels Does assess staffing effectiveness Requires organizations to monitor four of twenty-one specified indicators

Considerations in Developing a Staffing Plan Skill mix The percentage of RN staff to other direct care staff Should vary according to the care that is required and the care delivery model utilized Staff support The supports in place for the operation of the unit or department (a systematic process to deliver medications, patient transport services, secretarial services, etc.)

Establishing a Staffing Plan Articulates how many and what kind of staff are needed by shift and day to staff a unit or department Two ways of development Determine the ratio of staff to patients; nursing hours and total FTEs are then calculated Determine the nursing care hours needed for a specific patient or patients and then generating the staff-to-patient ratio needed to provide the care

Inpatient Unit An inpatient unit is a hospital unit that is able to provide care to patients 24 hours a day, 7 days a week Using data from all your sources, you can build a staffing pattern that will meet the needs of the patients, the staff, and the organization Average daily census The total numbers of patients at census time, usually midnight, over a period of time, e.g., weekly, monthly or yearly, and dividing by the number of days in the time period

Determining the FTEs Needed to Staff an Episodic Unit Episodic care units Units that see patients for defined episodes of care Examples are dialysis and ambulatory care units Start with an assessment of the hours of care required by the patients Add FTEs to cover days off and benefit time

Scheduling Scheduling of staff is the responsibility of the nurse manager The manager must ensure that the schedule places the appropriate staff on each day and shift for safe, effective care

Considerations for Staffing The patient type and acuity The higher the patient acuity, the more consistent the staffing needs are across shifts The experience of the staff Novice nurses take longer to accomplish the same task than an experienced nurse An experienced RN can handle more workload and higher acuity patients Good staffing requires putting the patient first

Scheduling Volume Patient volume numbers reviewed for peaks and valleys in the census and patient acuity Scheduling adjustments are necessary Experience and capability of staff Different degrees of knowledge, experience, and critical thinking skills Number of inexperienced staff (add hours) Number of experienced staff Need for staff with special skills

Shift Variations Traditional staffing patterns Generally 8-hour shifts Start times may vary by organization or nursing unit Shift variations occur to meet the needs of patients and the staff 12-hour shifts Weekend programs

Concerns for Scheduling Impact on patient care Possible disruption of continuity of care Weekend staff should be familiar with patients and recent care events Financial implications Weekend programs are more expensive than traditional staffing patterns They are a recruitment and retention tool for nursing leadership

Self-Scheduling A process in which unit staff take leadership in creating and monitoring the work schedule while working within defined guidelines Increasing staff control over their schedule is a major factor in nurse job satisfaction and retention Has been associated with sick time usage

Implementing Self-Scheduling Form a committee made up of unit staff who report to the manager Define the roles and responsibilities of each committee member Establish generic boundaries regarding fairness, fiscal responsibility, evaluation of the self-scheduling process, and the approval process Educate the staff

Evaluation of Staffing Effectiveness Patient outcomes and nurse staffing Studies have found consistent significant relationships between nurse staffing and some patient outcomes Certain outcomes are affected negatively when nurse staffing or skill mix is inadequate

Evaluation of Staffing Effectiveness Nurse staffing and nurse outcomes Effect of staffing on nurse performance should also be considered Track staff’s perception of staffing adequacy Provide ability for staff to communicate concerns in written and verbal form Track recommended staffing versus actual staffing

Models of Care Delivery Care delivery models Organize the work of caring for patients The decision for which care delivery model is used is based on the needs of the patients and availability of competent staff Managers have the responsibility to implement models and evaluate the outcomes in their areas

Total Patient Care Total patient care The nurse is responsible for the total care for his or her patient assignment for the shift he or she is working

Total Patient Care Advantages Consistency of one individual caring for patients an entire shift Enables development of patient and family trust Provides a higher number of RN hours of care than other models The nurse has more opportunity to monitor progress of the patient

Total Patient Care Disadvantages Utilizes a high number of RN staffing More costly than other models

Functional Nursing Divides nursing work into functional roles that are then assigned to one of the team members In this model, each care provider is responsible for specific duties or tasks Technical rather than professional nursing care often results Decision making usually at the level of the charge nurse

Functional Nursing Advantages Care can be delivered to a large number of patients Uses other types of health care workers when there is a shortage of RNs Disadvantages Lack of continuity of care Patient may feel that care is disjointed

Team Nursing A care delivery model that assigns staff to teams that are then responsible for a group of patients A unit is divided into two or more teams, each led by a registered nurse The team leader supervises and coordinates all of the care provided by those on the team Care is divided into the simplest components and then assigned to the care provider with the appropriate level of skills

Team Nursing Modular nursing delivery system A kind of team nursing that divides a geographic space into modules of patients, with each module having a team of staff led by an RN to care for them Useful with decentralized nursing stations

Team Nursing Advantages Maximizes the role of the registered nurse Nurse is able to get work done through others Disadvantages Patients often receive fragmented, depersonalized care Communication is complex Shared responsibility and accountability can cause confusion and lack of accountability

Primary Nursing Clearly delineates the responsibility and accountability of the RN Places the RN as the primary provider of care to patients Patients are assigned a primary nurse The primary nurse is responsible for developing with the patient a plan of care Other nurses caring for the patient follow this plan of care Patients are assigned to their primary nurse regardless of geographic location

Primary Nursing Advantages Patients and families are able to develop a trusting relationship with the nurse Accountability and responsibility of the nurse developing a plan of care with the patient and family are defined Facilitates continuity of care Authority for decision making is given to the nurse at the bedside

Primary Nursing Disadvantages Cost is high due to the higher RN skill mix The person making assignments needs to be knowledgeable about all the patients and staff to ensure appropriate matching of nurse to patient Lack of geographical boundaries within the unit may require nursing staff to travel long distances at the unit level to care for their primary patients Nursing time is often used in functions that could be completed by other staff Nurse-to-patient ratios must be realistic

Patient-Centered or Patient-Focused Care Designed to focus on patient needs rather than staff needs All patient services are decentralized to the patient area Care teams are established for a group of patients The care team includes all disciplines Disciplines collaborate to ensure that patients receive the care they need

Patient-Centered or Patient-Focused Care Advantages Most convenient for patients Expedites services to patients Disadvantages Can be extremely costly to decentralize major services in an organization Some perceive model as a way of reducing RNs and cutting costs in hospitals

Patient Care Redesign Initiative that developed in the 1990s to redesign how patient care was delivered Motivated by need to reduce costs Goals are to make care more patient-centered and not caregiver-centered Reduces the number of caregivers a patient has to interface with, thus increasing patient satisfaction

Care Delivery Management Tools Work flow analysis A tool used to determine what activities are value- added Determines how to streamline or eliminate those activities that do not contribute to improved patient outcomes Value-added The customer is willing to pay for this activity Activity must be done right the first time Activity must somehow change the product or service in some desirable manner

Care Delivery Management Tools In diagnosis-related groups (DRGs) the national average length of stay (LOS) for a specific patient type was used to determine payment for that grouping of patients Hospitals looked to reduce LOS and reduce hospital costs Clinical pathways and case management surfaced as significant strategies

Clinical Pathways Clinical pathways Care management tools that outline the expected clinical course and outcomes for a specific patient type Should be evidence-based Pathways include expected outcomes specified for each day of care Patient progress is measured against the expected outcomes

Clinical Pathways Advantages Very instructive to new staff Save a significant amount of time in the process of care In most cases, improved care and shortened lengths of stay for the population on the pathway are the results Allow for data collection of variances to the pathway

Clinical Pathways Disadvantages Some physicians perceive pathways to be cookbook medicine and are reluctant to participate in their development Development requires a significant amount of work to gain consensus from the various disciplines on the expected plan of care Pathways are less effective for patient populations that are nonstandard, since they are constantly being modified to reflect individual patient needs

Case Management A strategy to improve patient care and reduce hospital costs through coordination of care Typically a case manager: Is responsible for coordinating care and establishing goals from preadmission through discharge Evaluates the patient’s outcomes daily and compares them to the predicted outcomes articulated in the clinical pathway Works with all the disciplines to facilitate care

Case Management In other models, the case management function is provided by the staff nurse at the bedside The case manager also collects data on patient variances from the clinical pathway Shares this data with the responsible physicians and other disciplines that participate in the clinical pathway This data is then used to explore opportunities for improvement in the pathway or in hospital systems

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