Nurse staffing within healthcare organizations is one of the most challenging and complex issues facing management today. Research from the past two decades definitely proves a strong relationship between adequate staffing levels and improved patient outcomes, safety and satisfaction. However, despite all the research that has been done, achieving appropriate staffing levels is still every healthcare administrator’s nightmare.
To that end, every nurse should have a basic understanding of:
- The staffing process and its related terms;
- How their unit or organization performs these functions; and
- How to be actively involved in the solution.
Here are three practical thoughts for your consideration.
1. Staffing vs. Scheduling
There are several factors that need to be taken into consideration when dealing with the challenges of nurse staffing. First and foremost, it is important to understand the terms used, especially the difference between “staffing” and “scheduling.”
“Staffing” and “scheduling” are two words that are frequently used interchangeably. However, they do not mean the same thing. The American Nurses Association (ANA) defines appropriate nurse staffing as “a match of registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation.” In other words, “staffing” is the process of finding the right nurse for the job.
When it comes to the way organizations staff their facility, one of two methods will be used: centralized staffing or decentralized staffing.
- Centralized Staffing: A staffing model in which one unit (e.g., the human resources department) is exclusively responsible for staffing all units, including call-in, call-off and float staff.
- Decentralized Staffing: A staffing model in which unit managers, leaders, directors, etc. are responsible for determining the level of staffing needed for their unit before and during the shift.
“Scheduling,” on the other hand, “consists of assigning shifts and rest to nurses for each day, on a time schedule, taking in account legal and collective constraints, and individual wishes (National Institutes of Health). In essence, “scheduling” is about making sure an organization’s nurses show up to the right place at the right time. Many healthcare organizations choose to draft their nursing schedules one, three or six months in advance.
2. Staffing Models
Another important item to consider when contemplating nurse staffing challenges at your healthcare facility is the different staffing models. There are three staffing models and they are typically used in combination to fit a unit’s particular dynamics. The three models are: budget-based staffing; nurse-patient ratio staffing; and patient acuity staffing.
Budget-Based Staffing: In the budget-based staffing model, nursing staff are allocated according to nursing hours per patient day (aka the average number of hours needed to care for each patient on a given unit). While this staffing model provides a terrific overview of the staff needed for each shift, it fails to account for any special considerations.
Nurse-Patient Ratio Staffing: In the nurse-patient ratio staffing model, staffing levels are determined by the number of nurses per the number of patients or patient days (e.g., one nurse cannot provide care to more than five patients per shift). While California is the only state to have laws on the books that strictly enforce nurse-patient ratios, most healthcare facilities do their best to abide by best practices.
Patient Acuity Staffing: In the patient acuity staffing model, the needs of a unit’s patient population are used to determine each shift’s staffing requirements. If not administered properly, this model runs the risk of undermining the full scope of the nursing practice. However, when done correctly, it creates an environment that fosters the best possible outcomes for patient success and clinician retention.
3. State and Federal Regulations
State and federal staffing requirements are the third thing to consider when developing a solution to nurse staffing shortages. The argument for better staffing ratios has led to federal and, in some cases, state regulatory requirements. It is important that healthcare facilities comply with these requirements, since failure to comply can result in penalties. Medicare and Medicaid have their requirements, yet they are based on having “adequate” numbers of licensed professionals for proper care. This, of course, is open to a wide range of interpretation. So, it is important to know your state’s specific requirements.
According to the ANA, the following states have enacted legislation around staffing:
- CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT and WA have enacted legislation or adopted regulations to address staffing;
- CT, IL, NV, OH, OR, TX and WA require hospitals to have staffing committees responsible for plans (nurse-driven ratios) and staffing policy;
- IL, NJ, NY, RI and VT require some form of disclosure and/or public reporting; and
- CA is the only state that stipulates in law and regulations a required minimum nurse-to-patient ratio to be maintained at all times by a unit.
Implement a Staffing Plan
If your state does not require staffing committees and plans, it is a great idea to form a strong committee at your facility. This committee can provide a collaborative approach to your staffing challenges, overseeing the process and providing input on unit scheduling, policies and procedures.
It is important to remember that staffing plans need to be unit- and shift-specific, taking into consideration patient acuity, available support staff, technology and the care delivery model. These types of plans will help reduce variability, building standardization of care into the unit and foster more effective communication.
Staffing Impacts Patient Outcomes
With pressure building to decrease costs, researchers have already shown the impact of staffing on patient outcomes. As a direct care nurse, you should know how your care is being measured and how the combined patient outcomes of your organization’s nursing units are being measured. Check unit outcomes as the relate to nurse staffing. In many cases, this data is used to justify improved staffing levels.
Today, no one should doubt that nurse staffing affects patient outcomes. Staffing and scheduling are complicated processes that need to involve not only the managers but the direct-care RNs as well. With their wealth of knowledge about clinical care, these nurses can provide invaluable knowledge that can improve care, processes and quality. Remember, as a direct-care nurse, you’re not “just a nurse.”
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Last Modified: Katy Konkelby