Staffing and Scheduling Flashcards
what is staffing
- A comprehensive, dynamic process necessary to ensure that patients receive optimal levels of care.
- Aligns patient needs, nurse abilities, and workload with available technology and includes collaboration with other disciplines
- Culture of the work environment is an important consideration.
- Safety of clients is priority.
what is scheduling
- A function of implementing the staffing plan by assigning unit personnel to work specific hours and specific days of the week.
- Depends on the historical census in a particular unit, as well as its anticipated volume.
- Schedules may be developed 1 to 3 months in advance.
The staffing process
Developing a Staffing Budget
Calculation of Full-Time Equivalents
Impact of Staffing on Patient Outcomes
Theoretical Framework for Nursing Staffing
Models for Nurse Staffing
Nurse–Patient Ratios
Alternative to the Nurse–Patient Ratio Staffing
Tools to Estimate the Number of Nurses Needed
DEVELOPING A STAFFING BUDGET
When developing a staffing budget, nurse managers consider the services offered on the unit as well as organizational plans to provide new or expanded services.
Nurse managers must understand the nature of the work in their area of responsibility to define the units of service (UOS) and to project the volume of work that will be performed by their cost center during the upcoming year.
To develop an adequate staffing or personnel budget, you must consider:
the workload and units of service provided.
Workload: Amount of work performed by a nursing unit or cost center. Measured in terms of the UOS defined by the cost center
Units of Service (UOS): Productivity targets, such as nursing hours per patient day (HPPD) or hours per visit for emergency departments or clinics. UOS multiplied by the volume for a clinical area determines the number of staff needed in each period
Full-time equivalents
To achieve a balanced staffing plan, managers must:
Determine the correct combination of full-time and part-time positions needed and understand how to allocate budgeted FTEs into full-time and part-time positions to meet the staffing requirements
Consider the effect of productive (paid) and nonproductive hours when projecting the FTE needs
Compare the number of employees being paid for any specific day to the number providing care (direct vs indirect hours)
Nurses must be replaced when they are off duty and accessing their paid benefit for time off. Benefit time includes hours paid to an employee for:
- Vacation, holiday, personal, or sick time
- Some organizations consider attending orientation or continuing-education activities
The nurse manager must be competent in finances, information technology, and automation of staffing and scheduling programs.
impact of staffing on patient outcomes: nurse education
More BSN-prepared Nurses. Literature shows large reductions in patient deaths.
impact of staffing on patient outcomes: overtime
No more than 12 hours per shift.
impact of staffing on patient outcomes: nurse fatigue
*Involve nurses in designing work schedules that implement a “regular and predictable schedule that allows nurses to plan.”
*Stop using mandatory overtime.
*Encourage “frequent, uninterrupted rest breaks during work shifts.”
*Adopt official policies that give RNs the “right to accept or reject a work assignment. Policies should indicate that there will be no retaliation or negative consequences for rejecting the assignment.”
*Encourage nurses to be proactive about managing their health and rest.
*Specific Recommendations for Nurses
*Work no more than 40 hours in a 7-day period and limit work shifts to 12 hours in a 24-hour period, including on-call hours worked.
Adequate nursing care has been associated with a decrease in:
Falls
Medication errors
Hospital-acquired infections
Mortality rates
Additionally, nurse retention and job satisfaction have been shown to improve patient satisfaction in acute care hospitals and nursing homes.
Nursing Intellectual Capital (NIC) Theory (2009) by Cavell, is derived from the Intellectual Capital Theory developed in business and accounting.
Shows relationship among knowledge at all levels in an organization and improves the organization’s performance
Is based on organizational investment in learning about hiring and retaining qualified employees
Explores the relationship between nursing staffing, nursing knowledge, and variables within the work environment and their influence on patient and organizational outcomes.
two types of models for nurse staffing
Fixed Staff vs Flexible Staff
Centralized vs Decentralized Staffing
fixed staffing vs flexible staffing
Fixed Staffing
It is built on a set number of nurses for a particular unit or shift
It results in unalterable nurse-to-patient staffing ratio
Changes in severity of patient conditions, volume, or procedural requirements are not considered.
Flexible
It considers the variations in staffing needs on a shift-to-shift basis.
It is more responsive to the complex healthcare environment.
It is more difficult to develop.
The nurse-to-patient ratio approach assigns a minimum or fixed number of nursing staff per occupied bed.
The needs can be anticipated and met with a set roster.
It assumes that patients have similar requirements for care and the average is stable across patient groups.
Additional staffing requirements may be deployed when demand increases
ALTERNATIVE TO THE NURSE–PATIENT RATIO STAFFING
There has been a discussion regarding the effectiveness of nurse–patient ratios over other staffing models.
Labor unions have focused on the approach to capture the necessary workforce on a unit.
The American Nurses Association (ANA) has opted to support the nurse staffing committee to ensure safe staffing.
- Nurse-led groups that create unit-level staffing plans based on a patient population’s acuity and needs, matched with staff’s skills and experience.
The ANA has advocated for passage of a Registered Nurse Safe Staffing Act in the U.S. Congress.
5 principles of nurse staffing
- health care consumer
- interprofessional teams
- workplace culture
- practice environment
- evaluation
tools to estimate the number of nurses needed
Patient Classification Systems
Budget-Based Staffing
PATIENT CLASSIFICATION SYSTEMS
tool to estimate number of nurses needed
The acuity or severity of patients’ conditions is a key component in determining the staffing required for safe care.
- It is influenced by their age, primary diagnosis, comorbidities, severity of illness, treatment stage, socioeconomic status, ability to provide self-care, anticipated length of stay, and family or caregivers.
- Care needs cannot be quantified because of the dynamic nature of patient care.
Nurse managers use the data to adjust the unit’s staffing plan for a given time or to quantify acuity trends over longer periods to forecast their staffing needs during the budget process
types of patient classification systems
prototype or factor
prototype patient classification systems
An older approach that considers both subjective and descriptive.
Patients are classified into categories that predict patient care needs.
The relative intensity measures (RIMs) system classifies patient care needs based on their diagnosis-related group (DRG).
An electronic decision support system then integrates clinical and financial information from the data.
exs: maternal deliveries or outpatient surgery
factor patient classification systems
It is an objective evaluation system.
It gives each task, thought process, and patient care activity a time or rating.
The associations are summed to determine the hours of direct care required or are weighted for each patient.
Exs: complex and less predictable: pneumonia or stoke
BUDGET-BASED STAFFING
Budget-based staffing requires the staffing plan for the year to be developed in concert with the personnel budget.
The nursing leadership and the personnel department project the number of nursing hours per patient day (HPPD) needed annually.
- Use historical data and national benchmarks from nursing units with similar characteristics.
The nursing hours are calculated and compared with the budget.
- If the hours are higher than identified during a particular period, the nurse manager is expected to reduce staffing to meet the set budget.
- When the census and needs of the patients remain high throughout the period, the unit may go over budget.
Direct Care Hours
Hours worked by nursing staff who have direct patient care responsibilities for greater than 50% of the shift in activities.
- The activities may include:
- Medication administration and nursing treatments
- Admissions, discharge, and transfer activities
- Patient teaching and communication
- Coordination of patient care and nursing rounds
- Documentation time
- Treatment planning
The staff counted in the staffing matrix (a tool to assist in deciding what level of each staff group (RN, LPN/LVN, CNA)) is needed based on the patient census.
Direct care providers are replaced if they call in sick and the hours worked are charged to the unit cost center.
Indirect Care Hours
Hours that unit-based staff worked on or off the unit/department.
This includes:
In-service education time
Orientation hours
Staff meeting time
Committee meeting time or work Shared governance meetings or activities
Unit-related project work (quality assurance/quality improvement (QA/QI) and standards development)
Fixed Hours
Hours required to support the department activity or volume, such as management staff, or unit-based educators.
Additional hours include productive hours (hours worked) and non-paid but not worked.
When nurses’ benefits cover non-working hours the time paid is referred as Nonproductive hours. (Watkins, 2020).
It includes vacation, holiday, Family Medical Leave Act, jury duty, and educational professional leave.
WHY SAFE STAFFING MATTERS
Organizational policies and clear expectations communicated to staff are essential to manage high and low volume as well as changes in acuity.
Patient safety may not be maintained, and financial obligations cannot be met when personnel budgets and staffing plans cannot flex up or down when patient acuity or volumes change.
Mechanisms must be in place and internally publicized to allow staff to ask for additional help.
COMPLEX FACTORS IN HEALTH CARE INFLUENCING PATIENT OUTCOMES
Missed Care
Hospital-Acquired Conditions
National Database of Nursing Quality Indicators as Evidence of Staffing Effectiveness
Nurse Overtime
what is missed care
Missed nursing care means that care is delayed, partially completed, or not completed at all.
A significant amount of nursing care processes are missed in hospitals, which includes nursing care responsibilities such as:
Assessment (44%)
Interventions and basic care (73%)
Planning (71%)
It is associated with poor patient care experiences, health outcomes, and nurse ethical distress and burnout.
The processes are prevalent and foretell certain patient outcomes that include:
Higher occurrence of infections and falls
New-onset delirium
Pneumonia
Medication variances
Increased length of stay
Delayed discharge
Increased pain and discomfort
hospital-acquired conditions
Hospital-acquired conditions (HACs) represent a failure of the hospital system to provide safe care.
The Hospital-Acquired Condition Reduction Program (HACRP) was established by the Affordable Care Act in 2013 to reduce the rates of HACs and improve patient safety.
25% of hospitals with the highest rates of HACs were penalized with a 1% reduction in Medicare payment rates for inpatient care by the Centers for Medicare & Medicaid Services (CMS).
nurse overtime
One component in evaluating the effectiveness of the staffing process
NDNQI opportunity to compare effectiveness in specific nursing service unit
Comprehensive national nursing database
18 Quality indicators to use for benchmarking
overtime vs mandatory overtime
Overtime
Requesting staff to stay on duty after their shift ends to fill staffing vacancies.
Staff experience no employment consequences for refusing to work overtime.
Nurses may work in more than one employment setting to increase their income.
Mandatory
Requiring staff to stay on duty after their shift ends to fill staffing vacancies.
Unionized settings and some state nurses’ associations that use workplace advocacy strategies to improve the work environment have developed legislation prohibiting mandatory overtime.
Seen as a risk to both patients and nurses, it is opposed by ANA and other nursing organizations
NEGATIVE CONSEQUENCES OF OVERTIME
Tired and overworked nurses are more likely to have compromised clinical judgment abilities and technical skills because of fatigue.
The ANA recommends legislation to limit the number of hours required to work.
Individual nurses must consider their responsibilities for patient safety when working voluntarily.
SUPPLEMENTAL STAFF AND FLOAT POOLS
Organizations may use supplemental staff (travel nurses) to fill temporary staff vacancies
Nurses may be used to fill unanticipated staff vacancies, which involves “floating” from one clinical unit to another
ORGANIZATIONAL FACTORS THAT Affect Staffing Plans
Organizational factors affecting staffing plans include issues such as the types of clinical units, the duration of the shift, and the extent to which shifts are rotated.
These factors are typically addressed in:
- Structure and philosophy of the nursing service department
- Organizational staffing policies
- Organizational supports
- Services offered
things to consider with scheduling
Constructing the Schedule
Centralized Scheduling
Decentralized Scheduling
Staff Self-Scheduling
Variables Affecting Staffing Schedules
CONSTRUCTING THE SCHEDULE
Mechanisms are in place for staff to use in requesting days off and to know when the final schedule will be posted.
- The written policies and procedures must be followed by the nurse managers to ensure compliance with state and federal labor laws relative to scheduling.
Schedules are constructed for a predetermined block of time based on organizational policy using the staffing matrix for each unit.
- The nurse manager or unit staff may prepare the schedule in a decentralized fashion through a self-scheduling method.
Centralized staffing coordinators may oversee the schedules prepared for the patient care units.
centralized staffing
A single department is responsible for staffing in all units, including call-in staff, call-off staff, and float staff.
Making use of all the available resources reduces the burden of staffing for unit leaders.
decentralized staffing
Unit leaders (e.g., nurse managers and charge nurses) determine the level of staffing needed before and during the shift.
Familiarity with the needs of the unit and background and expertise of the nurses allows for customization and optimization of staffing.
centralized staffing advantages vs disadvantages
Advantages
The staffing coordinator is aware of:
Abilities, qualifications, and availability of supplemental personnel needed to complete the schedule
Each unit’s personnel budget and the constraints it may impose on the schedule
Disadvantages
The staffing coordinator has limited knowledge of changing patient acuity needs or other activities on the unit.
- A mechanism to share unit-specific knowledge with the respective manager can resolve this disadvantage.
decentralized staffing advantages vs disadvantages
Advantages
Managers are:
Accountable for submitting a schedule in alignment with the established staffing plan
Responsible for maintaining unit productivity in line with the personnel budget
Disadvantages
Managers cannot understand the “big picture” related to staffing across multiple patient care units.
Requests for time off are approved in isolation.
Each manager’s decisions will be felt in aggregate as a “staffing shortage” across multiple units.
STAFF SELF-SCHEDULING
Self-scheduling is successful when everyone’s personal schedule is balanced with the unit’s patient care needs.
The process:
Promotes staff autonomy
Increases staff accountability
Enhances team communication, problem solving, and negotiating skills
challenges to staff self-scheduling
The professional nursing staff cannot work in isolation when creating a schedule.
Readiness of support staff to participate is critical, as resource utilization and cost containment are major points of concern.
Flexible scheduling or self-scheduling needs to be responsibly managed.
The patient care needs are the focus for building a schedule.
Unit standards for a staffing plan are established.
A negotiated schedule meeting the needs of staff and patients is the expected and ultimate outcome.
VARIABLES AFFECTING STAFFING SCHEDULES
Hours of operation
Shift rotations
Weekend rotations
Approved benefit time for the schedule period—for example, vacations and holidays
Approved leaves of absence/short-term disability
Approved seminar, orientation, and continuing education time
Scheduled meetings for the schedule period
Current filled positions and current staffing vacancies
Number of part-time employees
Unanticipated Scheduling Variables
Call-outs
Compassion Leaves
Jury Duty
Emergent need for Leave of Absence
EVALUATING UNIT STAFFING and Productivity
Managers must justify staffing
Provide productivity reports
Average daily census projects potential workload
Percentage of occupancy
Average length of stay
Nursing productivity
TIPS FOR STAFFING AND SCHEDULING
Know state laws and voluntary accreditation (professional society and institutional) standards for staffing.
Evaluate organizational policies for congruence with accreditation and state licensing expectations.
Integrate ongoing research regarding the impact of numerous factors on patient outcomes into staffing plans.
Identify current demands for staff and anticipate externally imposed changes, such as services offered and availability of RNs and LPNs/LVNs.
Value the various responses to short staffing from the manager, staff, and patient perspectives.
Recognize the complexity of staffing issues and how they relate to staff satisfaction, community perception, budget, and accreditation standards.
