STAFFING STAFFING is one of the major functions of the nurse manager.

The nurse manager should always see to it that safe staffing is provided on all shifts for the patients care plan together with all personnel on a round-the-clock basis. Objectivity in deciding the type and number of personnel needed in providing adequate and quality patient care is an on-going responsibility of the nurse manager. The staffing process requires a thorough delineation, measurement, and review of staffing pattern. Responsible staffing does not concern only the nurse manager. Staff members should understand that their responsibilities and decisions have effects on the process. The nurse manager should remember that each staffing plan cannot be done by a simple worker/patient ratio or formula.

STAFFING DEFINED Staffing

process of determining and providing the acceptable number and mix of personnel to produce a desired level of care to meet the patients demand for care (Rowland and Rowland, 1992)

a systematic approach to the problem of selecting, training, motivating, and retaining professional and non-professional personnel in any organization (Basavanthappa, 2000)

PHILOSOPHY OF STAFFING IN NURSING Nurse administrators of a hospitals nursing department might adopt the following staffing philosophy. Nurse administrators believe that 1. It is possible to match employees knowledge and skills to patient care needs in a manner that optimizes job satisfaction and care quality. 2. The technical and humanistic care needs of critically ill patients are so complex that all aspects of that care should be provided by professional nurses. 3. The health teaching and rehabilitation needs of chronically ill patients are so complex that direct care for these patients should be provided by professional and technical nurses.

4. Patient assessment, work quantification, and job analysis should be used to determine the number of personnel in each category to be assigned to care for patients of each type. 5. A master staffing plan and policies to implement the plan in all units should be developed centrally by the nursing service heads and staff of the hospital. 6. Staffing should be administered at the unit level by the head nurse, so that selected plan details, such as shift-start time, number of staff assigned on holidays, and number of employees assigned to each shift can be modified to accommodate the units workload and workflow.

STAFFING METHODOLOGY Nursing staffing methodology should satisfy the following criteria: 1. It should be observed in an orderly manner. 2. It should follow a systematic process. 3. It should be based upon sound rationale.
4. It should be applied to determine the number and kind of nursing personnel required to

provide nursing care of a predetermined standard to a group of patients in a particular setting. (Aydelotte, Ibid.)

FACTORS AFFECTING STAFFING Factors that affect staffing include 1. The type, philosophy, and objectives of the hospital and the nursing service; 2. The population served or the kind of patients served whether pay or charity;
3. The number of patients and severity of their illness knowledge and ability of nursing

personnel are matched with the actual care needs of the patient; 4. Availability and characteristics of the nursing staff, including education, level of preparation, mix of personnel, number, and position; 5. Administrative policies such as rotation, weekends, and holiday off-duties; 6. Standards of care desired which should be available and clearly spelled out. Institutions may utilize the Standards of Nursing Practice; PRCs Standards of Safe Nursing Practice and/or the hospitals themselves may formulate/develop their own standards; 7. Layout the various nursing units and resources available within the department such as adequate equipment, supplies, and materials;

8. Budget including the amount allotted to salaries, fringe benefits, supplies, materials, and equipment; 9. Professional activities and priorities in non-patient activities like involvement in professional organizations, formal educational development, participation in research, and staff development. 10. Teaching program or the extent of staff involvement in teaching activities; 11. Expected hours of work per annum of each employee. This is influenced by the 40-hour week law; and 12. Patterns of work schedule traditional 5 days per week, 8 hours per day; 4 days a week, ten hours per day and three days off; or 3 days of 12 hours per day and 3 days off per week.

The Hospital Nursing Service Administration Manual of the Department of Health has recommended the following nursing care hours for patients in the various nursing units of a hospital.

Table1. Nursing care hours per patient per day according to classification of patients per units. Cases/Patients 1. General Medicine 2. Medical 3. Surgical 4. Obstetrics 5. Pediatrics 6. Pathologic Nursery 7. ER/ICU/RR 8. CCU NCH/Pt/Day 3.5 3.4 3.4 3.0 4.6 2.8 6.0 6.0 Prof. to Non Prof. Ratio 60:40 60:40 60:40 60:40 70:30 55:45 70:30 80:20

PATIENT CARE CLASSIFICATION SYSTEM

a method of grouping patients according to the amount and complexity of their nursing care requirements and the nursing time and skill they require an assessment that can serve in determining the amount of nursing care required, generally within 24 hours, as well as the category of nursing personnel who should provide that care

To develop a workable patient classification system, the nurse manager must determine the following:

1. the number of categories into which patients should be divided; 2. the characteristics of patients in each category; 3. the type and number of care procedures that will be needed by a typical patient in each category; and 4. the time needed to perform these procedures that will be required by a typical patient in each category.

The number of categories in a patient classification may range from three to four, which is the most popular, to five or six. These classes relate to the acuity of illness and care requirements, whether minimal, moderate, or intensive care. Other factors affecting the classification system would relate to the patients capability to meet his physical needs and other instructional needs including emotional support.

CLASSIFICATION CATEGORIES Various units may develop their own ways of classifying patient care according to the acuity of their patients illnesses. Following is an example of a patient care classification in the medical-surgical unit. LEVEL I Self Care or Minimal Care Patient can take a bath on his own, feed himself, feed and perform his ADLs. PATIENTS: Patients for discharge, Non-emergency, Newly Admitted, Do not exhibit unusual symptoms and require little treatment/observation and/or instruction NCH/Pt/Day: 1.5 PROF to NON PROF. RATIO: 55:45

LEVEL II Moderate Care or Intermediate Care Patients need some assistance in ADLs for short periods of time. PATIENTS: Extreme symptoms of illness have subsided or not yet appeared, Slight emotional needs, V/S ordered up to three times per shift, IV or BT, semi-conscious and exhibiting some psychosocial or social problems, periodic treatments, and/or observations and/or instructions NCH/Pt/Day: 3 PROF to NON PROF RATIO: 60:40

LEVEL III Total, Complete, or Intensive Care Patients are completely dependent upon nursing personnel. PATIENTS: Provided with complete bath, are fed, may or may not be unconscious, with marked emotional needs, V/S more than 3 times/shift, may be on continuous oxygen therapy, require close observation (at least every 30 minutes for impending haemorrhage), etc. NCH/Pt/Day: 6 PROF to NON PROF RATIO: 65:35

LEVEL IV Highly Specialized Critical Care Patients need maximum level of care. PATIENTS: continuous treatment and observation, with many medications, IV Piggy Backs, V/S every 15-30 minutes, hourly output, significant changes in doctors orders NCH/Pt/Day: 6-9 or more PROF to NON PROF RATIO: 70:30 or 80:20 . Table2. Categories or levels of care of patients, nursing care hours, needed per patient per day, and ratio of professionals to non-professionals Levels of Care Level I Self Care or Minimal Care Level II Moderate Care or Intermediate Care Level III Total or Intensive Care Level IV Highly Specialized or Critical Care NCH Needed Per Pt. Per Day 1.50 3.0 Ratio of Prof. to Non-Prof.

55:45 60:40

4.5 6.0 7 or higher

65:35 70:30 80:20

PERCENTAGE OF NURSING CARE HOURS depends on the nursing care hours at each level of care and on the setting in which the care is being given

Table 3. Percentage of patients at various levels of care per type of hospital Type of Hospital Primary Hospital Secondary Hospital Tertiary Hospital 30 Special Tertiary Hospital 10 45 25 15 45 10 20 Percentage of Patients in Various Levels of Care Minimal Care Moderate Care Intensive Care 70 65 25 30 5 5 Highly Spl. Care _ _

COMPUTING FOR THE NUMBER OF NURSING PERSONNEL NEEDED Nurse managers need to ensure that there is sufficient staff to cover all shifts, off-duties, holidays, leaves, absences, and time for staff development programs when computing for number of personnel in the various nursing units of hospitals.

Forty-Hour Week Law (Republic Act 5901) employees working in hospitals with 100-bed capacity and up will work only 40 hours a week applies to employees working in agencies with at least one million population if working in agencies with less than one hundred-bed capacity or agencies located in communities with less than a million population, 48 hours a week with only 1 day-off
three-day special privilege for government employees for birthdays, weddings, enrolment,

graduation leave, hospitalization, accident leaves (Civil Service Commission Memorandum Circular No. 6, series of 1996)

Table 4. Total Number of working and non-working days and hour of nursing personnel per year. Rights and Privileges Given Each Personnel per Year Working Hours Per Week 40 Hours 15 15 10 2 3 104 3 -----152 213 1,704 48 Hours 15 15 10 2 3 52 3 -----100 265 2,120

1. 2. 3. 4. 5. 6. 7.

Vacation Leave Sick Leave Legal Holidays Special Holidays Special Privileges Off-Duties as per R.A. 5901 Continuing Education Program

Total Non-Working Days Per Year Total Working Days Per Year Total Working Hours Per Year

RELIEVERS NEEDED To compute for relievers needed, the following should be considered: 1. Average number of leaves taken each year a. Vacation Leave b. Sick Leave 2. Holidays 3. Special Privileges as per CSC MC#6 s.1996 4. Continuing Education Program 15 10 5 12 3 3

Total Average Leaves

33 (Average Number of Absences/Year)

To determine the relievers needed:

1. Divide 33 by the Number of Working Days per Year (213/33 or 265/33) 40NCH = 0.15 per person; 48NCH = 0.12 per person 2. Multiply the computed reliever per person by the computed number of nursing personnel. 3. Result = Total Number of Relievers Needed

DISTRIBUTION BY SHIFTS (Philippine Setting) Morning Shift: 45% Afternoon Shift: 37% Night Shift: 18%

STAFFING FORMULA To compute for the staff needed in In-Patient units of a hospital, the following steps are considered: 1. Categorize the number of patients according to the levels of care needed. Multiply the total number of patients by the percentage of patients at each level of care (whether minimal, intermediate, intensive, or highly specialized).

2. Find the total number of nursing care hours needed by the patients at each category

level.
a. Find the number of patients at each level by the average number of nursing care

hours needed per day. b. Get the sum of the nursing care hours needed at the various levels.

3. Find the actual number of nursing care hours needed by the given number of patients.

Multiply the total nursing care hours per day by the total number of days in a year.

4. Find the actual number of working hours rendered by each nursing personnel per year. Multiply the number of hours on duty per day by the actual working days per year.

5. Find the total number of nursing personnel needed. a. Divide the total number of nursing care needed per year by the actual number of working hours rendered by an employee per year. b. Find the number of relievers. Multiply the number of nursing personnel needed by 0.15 (for those working 40 hours per week) or by 0.12 (for those working 48 hours per week).
c. Add the number of relievers to the number of nursing personnel needed.

6. Categorize the nursing personnel into professionals and non-professionals. Multiply the number of nursing personnel according to the ratio of professionals to nonprofessionals.

7. Distribute by shifts.

Example:

Find the number of personnel needed for 250 patients in a tertiary hospital.

1. Categorize the patients according to the levels of care needed. 250 (pts) x .30 = 75 patients needing minimal care

250 (pts) x .45 = 112.5 patients needing moderate care 250 (pts) x .15 = 37.5 250 (pts) x .01 = 25 250 2. Find the number of nursing care hours (NCH) needed by patients at each level of care per day. 75 pts x 1.5 NCH Level I = 112.5 NCH/day patients needing intensive care patients needing highly specialized nursing care

112.5 pts x 3 NCH Level II = 337.5 NCH/day 37.5 pts x 4.5 NCH Level III = 168.75 NCH/day

25 pts x 6 NCH Level IV

= 150 NCH/day

Total = 768.75 NCH/day 3. Find the total NCH needed by 250 patients per year.

768.75 x 365 (days/year) = 280,593.75 NCH/year 4. Find the actual working hours rendered by each nursing personnel per year. 8 (hrs/day) x 213 (working days/year) = 1,704 (working hours/year)

5.

Find the total number of nursing personnel needed.

a. Total NCH/year = 280,593.75 = 165

Working hours/yr

1,704

b. Relief x Total Nsg. Personnel = 165 x 0.15 = 25 c. Total Nursing Personnel Needed 165 + 25 = 190

6. Categorize to professional and non-professional personnel. Ratio of Prof. to Non Prof. in a tertiary hospital is 65:35. 190 x .65 = 124 Professional Nurses 190 x .35 = 66 Nursing Attendants 7. Distribute by shifts. 124 nurses x .45 = 56 nurses on AM shift 124 nurses x .37 = 46 nurses on PM shift 124 nurses x .18 = 22 nurses on Night shift Total 124 nurses 66 nursing attendants x .45 = 30 nursing attendants on AM shift 66 nursing attendants x. 37 = 24 nursing attendants on PM shift 66 nursing attendants x .18 = 12 nursing attendants on Night shift Total 66 nursing attendants

Note: Above personnel are only for in-patients Additional personnel should be hired for those in supervisory and administrative positions and for those in special units (OR, DR, ER, OPD). A Head Nurse is provided for each unit. A Nurse Supervisor is provided: 1) to cover every shift in each clinical department or area specialty unit 2) for each geographical area in hospitals beyond one hundred (100) beds and; 3) for each functional area such as Training, Research, Infection Control, and Locality Management Additional staff should be provided for roomed-in babies for bathing, changing of diapers, etc. Additional staff are needed for hospitals which are also wellness centers to provide health education classes both at in- and out-patient units.

References: Leadership and Management in Nursing 1st Edition by Carlito Asperas (2005) Nursing Administration by BT Basavanthappa (2000) Nursing Management Towards Quality Care 3rd Edition by Lydia Venzon and Jennifer Nagtalon (2006)