Monday September 16th 2019

Optimal staffing

New resource aims to help RNs implement evidence-based staffing plans

When it comes to achieving quality care, better patient outcomes and financial stability, optimal staffing should be viewed as a necessity and not a nice, but impossible, dream — particularly as health care reforms and new regulations take hold.

That is a key message reflected in a new, comprehensive document commissioned by the American Nurses Association and developed by Avalere Health, LLC, in collaboration with nurse and policy experts.

Although the white paper, “Optimal Nurse Staffing to Improve Quality of Care and Patient Outcomes,” focuses more on acute care hospitals, nurses in all settings and at all levels can use this resource to advocate for and implement sound, evidence-based staffing plans. It is the first in a series of papers aimed at addressing the value of nursing care and services.

“The evidence from hundreds of studies — and the white paper — make it clear that there is a relationship between staffing and patient outcomes,” said Matthew McHugh, PhD, JD, MPH, RN, FAAN, a nursing outcomes and policy researcher and associate professor at the University of Pennsylvania School of Nursing. “If there are not enough nurses at the bedside, bad things are likely to happen.”

The white paper highlights published studies that demonstrate how appropriate nurse staffing helps to achieve both clinical and economic improvements, from reducing medication and other errors to shortening patients’ length of stay.

Yet there continues to be significant variations in staffing from one hospital to the next, because there are not enough budgeted positions, according to McHugh, a Pennsylvania State Nurses Association member who helped develop the paper. And members of the public generally are unaware of these variations.

Matthew McHugh

“They wouldn’t expect that if they go to one hospital they will get lots of attention, and then go to another [in their community] and not get an equal level of care,” he said.

To ensure optimal staffing and equitable, quality care throughout the nation, RNs must continue to build the business case for optimal nurse staffing.

“It’s a good investment in terms of the bottom line that pays dividends with regard to positive patient outcomes, better overall care, and in avoiding penalties, such as those associated with preventable readmissions,” McHugh said.

A closer look

“I, like many other nursing professionals, view safe staffing like air and water; it has to be there,” said Kathy Baker, PhD, RN, NE-BC, the nursing director of patient care support and emergency services at Virginia Commonwealth University Medical Center and Health System. “But because of the complex environment in health care today, we need to be more sophisticated in how we look at staffing. In the ’90s, it was a matter of getting more bodies at the bedside. Now, it’s not just about the numbers, but rather linking it to all the variables.” Those variables include patient acuity, experience of staff, staffing mix and the changing needs of patients over time.

Further, while she said every organization is interested in staffing and scheduling, no one really has “owned” it.

“The white paper fuels this dialogue and offers a very positive staffing framework,” said Baker, a Virginia Nurses Association member who lent her expertise to ANA’s 2014 Staffing Summit discussion and review of the document. (The framework is built on ANA’s Principles for Nurse Staffing.)

The white paper, in part, examines the various forces that have impacted discussions about staffing and health care, from Affordable Care Act provisions and Institute of Medicine reports to changing demographics.

It specifically notes that existing staffing systems are often antiquated and lack flexibility to adjust to factors, such as patient complexity, a rise in admissions, discharges and transfers, and the physical layout of the unit. It further addresses efforts by ANA and other organizations to promote federal regulation and legislation promoting flexible staffing plans, as well as ANA activities to support transparency and public reporting of staffing data.

Making it work

Flexible staffing models, forecasting technology and routine discussions about staffing levels are three key factors that can bolster care at health care facilities.  Two hospitals that have engaged in these strategies, and are featured in the white paper, are Midland Memorial Hospital in Texas and Mayo Clinic Hospital in Phoenix, AZ.

In 2008, Midland Memorial Hospital created a Nurse Staffing Advisory Council to help improve staffing and address concerns that the hospital might fall short of meeting its mission to provide quality care, according to Bob Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE, senior vice president and chief operating officer at Midland.

The advisory council, made up of 60 percent frontline nurses, nursing leadership and executive staff subsequently worked together to implement several strategies to address staffing and positively influence patient care.

One important change involved implementing a comprehensive, electronic patient-classification acuity system that could more accurately forecast staffing needs, said Dent, an ANA and Texas Nurses Association member. Previously, staffing decisions were being made with data that did not necessarily reflect up-to-date changes in patients’ conditions, for example. So managers were constantly reacting to short-staffing situations.

The new system further was validated by nurses on the units to ensure that it did reflect staffing needs based on the ability to meet patients’ needs on every shift. And nurses and leadership set the budgeted positions for nurse staffing at the 50th percentile of the National Database of Nursing Quality Indicators® benchmark.  Using the 50th percentile in the all-hospital database for nursing hours per patient day is only used to procure positions needed in the budget. These resources are then assigned to patients based on their acuity level.

Midland also decided to eliminate the use of outside nurse staffing agencies, and instead created a roughly 100-member resource team-float pool to fill in for staff vacations, sick calls and when the patient census or acuity rises. The hospital still uses some travelers to meet patient needs, and nurse managers can hire ahead of the turnover curve.

Another vital factor in strengthening staffing and care is Midland’s shared governance system.

“We have unit-based councils, and nurses can make decisions on staffing for what works for them, such as bringing in a nurse who only handles admissions and discharges, or staggering shifts in the ER so staffing is higher when more patients tend to come in for emergency care,” Dent said. “That’s the power of unit-based councils.”

Midland also implemented fatigue management guidelines, and leaders conduct spot checks to ensure they are being followed, Dent said. The guidelines, for example, specify that nurses cannot work more than 12.5 hours a day, no more than three 12-hour shifts in a row and no more than 60 hours in any seven-day period. Nurses and administrators also routinely meet to address nursing retention and turnover, as well as other staffing-related issues formally and informally.

Lessons learned in Arizona

Like other hospitals across the nation, the Mayo Clinic Hospital in Arizona was expecting a greater shift from inpatient to outpatient care in 2012 based on the implementation of ACA provisions.

Kathleen Matson

“But our census didn’t drop as we anticipated,” said Kathleen Matson, MSN, MHA, RN, NE-BC, nursing administrator of nursing resources at Mayo. “So nurses and other employees were working more overtime. But it came at a cost — we had an uptick in injuries and nurses felt burnt out. We also noticed that some of the drivers affecting patient satisfaction — like the length of time it took for someone to answer their call light — were affected.

“We realized we needed to right-size our workforce.”

Mayo brought in temporary nurses to bridge the gap and then immediately hired staff for an additional 20 FTEs, according to Matson.

Mayo leaders also made improvements to their patient classification-acuity system to ensure it would more accurately forecast staffing needs based on patient needs. The system has 21 indicators that determine patients’ level of care, including looking at the number of medications they receive, their ability to perform ADLs, and need for 1:1 monitoring.

“We have the ability to run our classification system and then flex our staffing by the hour,” said Matson, an Arizona Nurses Association member. For example, Mayo can bring in more staff mid-shift if a unit that was staffed for 30 patients suddenly admits four more patients.

Additionally, Mayo nurse managers, supervisors and team leaders meet at least three times a day to address staffing concerns, and there is a built-in ability to share staff.

“Every nurse must meet core competencies, and processes are standardized from unit to unit,” Matson said.  “We also have an inpatient float pool to help us manage just-in-time and scheduled absences, and we engage in targeted recruiting for those areas of nursing — such as ICU and oncology — where we may have ongoing needs.”

Parting words

Nurse experts understand that financial resources are not limitless, and that staffing mix and experience are crucial considerations.

“At VCU Medical Center, we want all our nurses and allied health staff to safely and effectively care for patients, and we want to allow them to practice at the top of their scope of practice,” Baker said. “To optimally staff, we need to look at patients’ needs over time on a unit, and have the ability to have the right nurses in the right places at the right times. And sometimes that means reorganizing, and not adding, staff.”

Dent emphasized that having not only the appropriate number of nurses, but also well-rested nurses, is a moral and ethical responsibility shared by all within health care.

“And we in nurse leadership have to be able to defend our budgets [for optimal staffing],” Dent said. “We need to be able to tell our boards of trustees and other administrators: “If we want to be able to deliver quality care to our community, then here is the staffing we need and here is the evidence [that supports that decision].”

To learn more or obtain the white paper, go to

— Susan Trossman is the senior reporter for The American Nurse.

More from category

Stepping into a culture of safety
Stepping into a culture of safety

Onboarding programs help retain nurses, strengthen patient care Retaining newly hired, competent nurses — whether new [Read More]

Higher education
Higher education

Learning what it means to provide spiritual care Providing spiritual care may seem as ethereal as the term implies. It [Read More]

A challenging road
A challenging road

Nurses discuss complexities, ways to address rural health care Registered nurse Sharon Webster, manager of the Hannibal [Read More]

Without a home
Without a home

Nurses offer care, hope to those in need Tent cities — generally unsanctioned encampments for homeless individuals [Read More]

Optimal Staffing
Optimal Staffing

New resource aims to help RNs implement evidence-based staffing plans When it comes to achieving quality care, better [Read More]