Case Objectives

• Understand the context for nurse staffing plans and the processes that hospitals use to design them.
• Describe the licensing and regulatory constraints that shape staffing plans.
• Appreciate system capacities for covering sudden changes and overload situations.

Case & Commentary: Part 1

A 68-year-old man was admitted to the intensive care unit (ICU) with chronic obstructive pulmonary disease (COPD) exacerbation and atrial fibrillation with rapid ventricular response. He was markedly short of breath despite use of accessory muscles and was only able to speak in short sentences. He was alert and oriented but frail, and providers were concerned that he might tire and ultimately require mechanical ventilation.

In the ICU that evening, two nurses scheduled to work had called in sick. There was only one patient care assistant scheduled on this weekend shift. Due to the short staffing and inability to locate a last-minute replacement, each existing nurse was assigned three patients rather than the usual two.

In this case, due to a shortage of nurses in the ICU, each nurse present had to take care of more patients than usual. Nurse researchers have long explored the relationship between registered nurse staffing, skill mix, and hospitalized patient outcomes (1-3), a line of inquiry that took on additional momentum with the publication of a 1996 Institute of Medicine (IOM) report on nurse staffing in hospitals.(4) Seminal studies then demonstrated that increases in the number of RNs caring for patients, as well as their education and experience, resulted in fewer complications, lower morbidity, fewer medication errors, and lower costs.(5-8)

Although some efforts to standardize nurse staffing ratios had begun prior to the 1996 IOM report, the increased evidence after 1996 linking ratios to outcomes created substantial momentum in the policy arena. In 1999, the American Nurses Association (ANA) introduced a nursing quality report card and the Principles for Nurse Staffing.(8,9) In 2003, another key IOM report prioritized increased nurse staffing as a key mechanism to decrease medical errors.(10) In 2004, building on the work of the California Nursing Outcomes Coalition (CalNOC), the National Database for Nursing Quality Indicators (NDNQI), and research reports, the National Quality Forum (NQF) introduced the 15 nursing-sensitive quality measures that included hours of nursing care and RN staff mix.(11) As of July 2009, 12 states (CA, CT, IL, ME, NV, NJ, OH, OR, RI, TX, VT, WA) and the District of Columbia have passed legislation or regulations to address nurse staffing, and 15 states (CA, CT, IL, MD, MN, MO, NH, NJ, NY, OR, PA, RI, TX, WA, WV) also restrict mandatory overtime.(12,13)

Although these laws and regulations create some external constraints, individual organizations retain considerable flexibility in their staffing strategies. Developing these hospital staffing plans requires a complex dance involving nurse leaders, staff nurses, physicians, hospital administrators, financial officers, regulators, patients, and families. This dance is guided by the ANA Principles of Safe Nurse Staffing.(12) Staffing plans are developed annually by nurse leaders and presented to hospital administrators to review, negotiate, and approve based on numerous indicators, including patient volume/acuity, regulatory standards, external and internal benchmarks, and nursing skill mix and experience.

Once the annual budget is approved, each nursing care unit develops monthly staffing and scheduling templates to ensure adequate nurse staffing. This monthly plan uses past experiences to estimate the number of nurses needed to fully staff each unit. Even after the plan is developed, it is reassessed frequently (sometimes every hour) based on the acuity of patients and the competency of nursing staff. Not only do patients have differing needs, but nurses have different experiences, competencies, and organizational skills. Both the ANA and the American Organization of Nurse Executives (AONE) (12,14) support evidence-based nurse–patient ratios. Specifically, these organizations feel that staffing patterns should not be mandated or standardized, but determined, created, and monitored (i) with input from direct care RNs and based on (ii) number of patients and acuity; (iii) number of admissions, discharges, and transfers each shift; (iv) RN experience; (v) factors such as orientation to unit, support staff, physical design of unit, vacancy, and turnover; and (vi) RN ratios benchmarked with specialty and hospital organizations. The Labor Management Institute (15) and the National Database for Nursing Quality Indicators (16) are both recognized as valid and reliable sources for guiding staffing ratios. The standard rule of thumb is to have a nurse–patient ratio of 1:4-5 on medical–surgical units, 1:3-4 on intermediate units, and 1:2 in ICUs.

State nurse licensure boards, The Joint Commission, and Centers for Medicare & Medicaid Services (CMS) all have standards designed to help ensure adequate nurse staffing. Each of these regulatory bodies and appraisers works to ensure that hospital systems adhere to the ANA guidelines (12) and provide the necessary financial support to staff their units safely.

According to the 2003 IOM report "Keeping Patients Safe" (10), it is vital that we empower staff nurses to regulate their own unit work flow. In the case presented, RN shortages could have been addressed by closing the unit to new admissions or by considering the transfer of a more stable patient to an intermediate level of care unit. The decision not to take transfers and admissions must be made in collaboration with and supported by physician staff and must be based on predetermined admission/discharge /transfer triage guidelines. If it is deemed appropriate to hold all new admissions, alternative solutions must be offered to care for the new patients. These alternative solutions require clinician teamwork and strict adherence to handoff communication protocols. Many times, the patient awaiting admission or transfer remains in the original point of entry (such as the emergency department) and does not receive the level of care needed (e.g., in the ICU). In these situations, the ICU RN ratio is maintained at the expense of the ratio in the unit at the point of entry. This conundrum is commonplace and is best addressed with an internal resource pool that creates the capacity for nurses to "float" to units where they are needed.

In this specific case, it appears that the nursing staff members were not supported in making difficult decisions that would protect the patient and themselves. If "holes" in nurse staffing are allowed to remain unfilled at times like these, my guess is that such failures are a regular feature of this hospital, like many others. Ill calls and other unplanned absences are a regular feature of every hospital. Accordingly, nurse leaders and their designees must develop strategies to deal with these absences to ensure patient safety. It is the responsibility of the board of trustees and senior leaders to empower the Chief Nurse to design safe nurse staffing patterns and to provide the resources to carry out these plans.

To navigate this complex, dynamic system requires real-time, redundant decision-making processes. In this area, best practices include the following: First, a centralized staffing office that assists the nurse leaders in adjusting the daily predicted budgeted staff vs. the actual, and maintains the data to justify staffing alterations. Second, a Shift Coordinator who has a hospital-wide perspective and can reallocate or adjust RN staffing in real time, minute to minute if necessary. It is important to mitigate the stressors of short staffing on a shift to shift basis. The practicing nurse needs to focus on the care of patients. The empowered Shift Coordinator is best placed to understand the overall hospital activity and hence is better able to problem-solve with physicians, patients, and other stakeholders in real time to maximize safety. Third, an internal resource pool of RNs available and incentivized to provide the ability to flex up or down to accommodate variations in acuity and/or volume.(12)

Internal resource pool budgets are based primarily on the expected nonproductive hours of nurses. For example, a nursing unit can estimate the expected number of hours of vacation, education, and unplanned absences for a year and plan the replacement hours needed to cover. Nonproductive hours expected for each unit can be averaged on a yearly basis, and resource pool nurses can be hired to replace these hours. Each unit's hours can then be tallied, and an internal pool leader can hire nurses to cover this time.

These strategies allow hospitals to customize staffing to meet both patient and nurse needs, decrease time spent by nurse leaders in managing unplanned events, instill trust in nurses that leadership supports safe patient care, improve nurse retention, and provide accountability for the efficient and effective use of valuable resources.

Case & Commentary: Part 2

The nurse assigned to the new admission reviewed and implemented the initial physician orders as the patient was stabilized on a diltiazem drip for his atrial fibrillation. His respiratory status also stabilized, and he avoided the need for noninvasive ventilatory support and intubation and began to transition to intermittent, rather than continuous, nebulizer treatments.

Within 30 minutes of his arrival in the ICU, a second patient was transferred from the overflowing emergency department with hemodynamic instability from a massive pulmonary embolism. Since the patient with COPD just admitted appeared to be improving rapidly, and the other nurses were caring for more critically ill patients, the same nurse "volunteered" to admit the new patient. While she was tending to the orders for the new admission and discussing the vasopressor medications being ordered with pharmacy, her patient with COPD began urgently asking for help to use the bathroom. Rather than using the bedpan, the patient insisted on getting up and going to the bathroom. The nurse quickly assisted the patient to the toilet and then called for a patient care assistant to transfer the patient back to his hospital bed when he was ready to do so. The nurse then hurriedly returned to the bedside of the acutely ill patient with the pulmonary embolism.

Approximately 5 minutes later, the patient care assistant arrived at the COPD patient's bathroom and found him slumped on the floor, unresponsive and cyanotic with his oxygen detached from his face. A code blue was called but, despite extensive resuscitation attempts, the previously "stable" ICU patient was pronounced dead.

While we are not provided with details regarding the physiologic causes of this tragic outcome—it is possible that it was unrelated to the staffing—the case highlights the tensions involved in determining appropriate nurse staffing ratios and policies that exist or need to exist to ensure patient safety. The solutions are multifaceted, and all solutions begin with the nursing culture of the organization and the unit.

Commonly Used but Inadequate Options

The previous discussion focused on policies at the hospital level to ensure adequate staffing on each unit. But even in hospitals with such staffing policies, situations will arise in which nurses find themselves being stretched to the limits. How should nurses and the systems in which they operate respond?

The first option for this staff nurse was to discuss with the nurse manager or charge nurse his or her specific concerns about caring for three ICU patients and collaboratively establish a new plan of care for all patients during that shift. An appropriate leadership intervention would have been to validate the staff nurse's concerns and develop a solution. Solutions that are commonly used include: (i) reassigning a nurse from another comparable unit where acuity is lower, (ii) reprioritizing and readjusting the workload of all nurses on the shift, and (iii) having nursing management personnel extend their hours of work into the shift or come in early to help. In my view, while these actions appear to solve the problem at hand, these "fix-the-bridge-as-you-walk-on-it" solutions are not sustainable. When invoked routinely, they cause increased stress, emotional and physical fatigue, and compromised patient safety. Staff nurses who endure such shortages shift after shift do feel that care is unsafe.(9) A second option is to refuse transfers from the emergency department to the unit until a secondary plan can be created. Again, while this ameliorates the situation in the ICU, it often exacerbates staffing problems in the emergency department. Over time, if overcrowding in any venue of care persists, all care providers become overtaxed and anxious. Disrespect for one another begins to flourish, and patient care can become secondary to unit and caregiver needs. Other inadequate options are (i) mandatory or voluntary overtime and (ii) returning to work on an on-call basis but still working the next day. This translates to working 16-24 hours at one time. Robust research has demonstrated that these strategies are associated with poorer patient outcomes.(10)

Best Practice Options

The best approach to unplanned staffing deficits is to proactively define the action steps to take prior to the crisis. This action plan is defined by the approach articulated in Part 1. Nurse unit leaders must anticipate changing staffing needs and assess at least 4-8 hours prior to the next shift if staffing ratios and patient needs can be met. If unpredictable events occur, staff nurses must feel empowered to voice concerns and collaborate with nurse leaders, shift coordinators, and physicians to make decisions that protect patients first. This commentary has expressed both proactive and just-in-time approaches to making patients safe.

The budgeted staffing ratios must be planned with staff nurse input and support, and their decision making must be respected. Danger points for shortages of staff are weekend shifts and times of high emergency department census. Nursing leadership must proactively design incentives for nurses to work on weekends and plan for adjusting staffing levels when volume increases before the problem actually occurs.

Chief Nursing Officers (CNOs) must constantly balance the financial management of nurse staffing against the needs of patients. As budgets tighten, it is vital that nurse leaders maintain RN ratios when census is high and decrease RN staffing when census is low. The flexibility of a resource pool and keen daily budget management enable the CNO and other nurse leaders to follow budgeted staffing plans and instill trust and confidence in the staff nurses that patient care ratios will be protected. When RN ratios are adhered to, patients receive safe, quality care and nurses are recruited and retained. It is not rocket science.

Take-Home Points

Best practices in dealing with nurse staffing ratios include:

• Conduct failure mode effect analysis on nurse staffing for each unit in order to develop strategies and options to use when staffing levels are not adequate.
• Create an internal resource pool for flexibility and census adjustments.
• Communicate all action plans to staff nurses on the unit plus interdisciplinary and administrative stakeholders.
• Empower staff nurses to identify solutions for staffing issues. Administer annual nurse satisfaction survey such as NDNQI to measure and assess if staffing plan is safe and adequate according to nursing staff. Annually involve staff nurses in staffing decisions made for budgetary purposes.
• Benchmark staffing ratios annually with other facilities and correlate with patient outcomes, adverse events, and root causes. Provide data about quality outcomes as evidence to assist in determining future staffing needs. Evaluate patient satisfaction feedback closely and correlate with nurse staffing plan.

Victoria Rich, PhD, RN Chief Nurse, PENN Medicine Associate Professor of Nursing Administration

University of Pennsylvania School of Nursing

Faculty Disclosure: Dr. Rich has declared that neither she, nor any immediate member of her family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, her commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

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10. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment for Nurses. Washington, DC: National Academies Press; 2004. ISBN: 9780309090674.

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13. Nationwide State Legislative Agenda, 2008-2009 Reports. Silver Spring, MD: American Nurses Association; 2009. [Available at]

14. AONE Policy Statement on Mandated Staffing Ratios. Washington, DC: American Organization of Nurse Executives (AONE); 2005. [Available at]

15. Perspectives on Staffing and Scheduling. Phoenix, AZ: Labor Management Institute; 2006.[Available at]

16. The National Database. Silver Spring, MD: American Nurses Association; 2009. [Available at]