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NinePrinciplesforImprovedNurseStaffing
BobDent,DNP,MBA,RN,NEABC,CENP,FACHE
NursEcon.201533(1):4144,66.

AbstractandIntroduction
Introduction

Duringthe81stlegislativesessioninthestateofTexas,thelegislaturefound(a)researchsupportingadequatenursestaffingis
directlyrelatedtopositivepatientoutcomesandnursesatisfactionand(b)nursesatisfactionandpatientsafetycanbeadversely
affectedwhennursesworkexcessivehours.Toprotectpatients,supporttheretentionofnurses,andpromoteadequatestaffing,
legislationwasestablishedtopromotesharedgovernancerelatedtonursestaffingdecisions(HealthandSafetyCode,2009).
ResearchandevidenceregardingnursestaffingwerereviewedbyleadersatMidlandMemorialHospital(MMH),a464bed
hospitalinMidland,TX.Muchofthisreviewoccurredin2013.ItwasevidentfromthereviewoftheliteraturethatMMHshould
allowformoreflexibilityinnursestaffingtoachieveoptimaloutcomeswithpatientsatisfactionandnursesensitivequality
indicators.TheNationalDatabaseofNursesensitiveQualityIndicators(NDNQI)(PressGaneyAssociates,2014)wasusedasa
benchmarkingtooltoattainnursingresourcesonly.NDNQIisaprogramoriginallyoftheAmericanNursesAssociation(ANA)and
wasadministeredonbehalfoftheANAbyTheUniversityofKansasSchoolofNursing.NDNQIwasacquiredbyPressGaney
Associatesin2014.AspartofMMH'sexecutivestaff,theseniorvicepresident/chiefoperatingofficer(COO)reviewedthe
evidencewiththenursingdirectorsandwiththenursestaffingadvisorycouncil(NSAC).
Onceasharedvisionforstaffingwasestablished,theCOOmetwithmembersoftheexecutivestaff,inparticularthechief
executiveofficerandchieffinancialofficer,toreviewthevisionfornursestaffingandthedesiredoutcomes.Abudgetwas
establishedandsupportedbymembersoftheNSACandexecutivestaff.TheCOOthendefendedthestaffingbudgetthrough
presentationstotheMMHFinanceCommittee,BoardofTrustees,andBoardofDirectors.Thebudgetwasapprovedeffective
October1,2013forthenewfiscalyear(Dent,Armstead,&Evans,2014).NursestaffingatMMHperformedmostlybelowthe
NDNQI50thpercentileforRNhoursperpatientday(RNHPPD)asnotedinFigure1.

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Figure1.

RNHoursperPatientDay(RNHPPD).ComparedbyNDNQIAllHospitalDatabase

NinePrinciplesofNurseStaffingatMMH
1.TheNSACwillmeetatleastquarterlyandreviewnursestaffingalongwithnursesensitiveoutcomesincludinganypatient
grievancesassociatedwithnursestaffing.
2.BudgetnursingresourcesandreconcilethepositioncontrolorhiringplancreatedonanNDNQI50thpercentilefor
RNHPPD.
3.Forecastturnoveratapredeterminedrateandprehiringintoonboardingpositions.
4.Maintainaninternalresourceteam.
5.Budgettheuseoftemporarytravelernursesduringanidentifiedpeakcensustimeperiod,DecemberthroughApril.
6.Nursesselfschedulewithinanelectronicstaffingandschedulingsystemusingpredictivevolumepatterns.
7.AssignmentsareacuitybasedusingapatientclassificationsystemmappedfromtheelectronichealthrecordwithNursing
OutcomesClassification.
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8.MinimumstaffingidentifiedtobetheNDNQI25thpercentileforRNHPPDandmaximumstaffingidentifiedattheNDNQI
75thpercentileforRNHPPD.
9.Assurenursingstaffpracticewithinafatiguemanagementguideline.
Afterthebudgetwasapproved,theCOOheldanursestaffingconferenceandinvitedmembersoftheNSAC,nursingdirectors,
clinicalmanagers,andeducators.Duringthishalfdayconference,thenursestaffingbudgetwasshared.Rationaleforthebudget
includinghowevidenceandsciencewasincorporatedintonursestaffingandtheprinciplesfornursestaffingwereshared.This
conferenceallowedforbettercommunicationaboutnursestaffingamongalargergroup.Inadditiontotheconference,theCOO,
alongwiththechiefnursingofficerandthechiefhumanresourcesofficer,metwitheachnursingdirectorseparatelyin1hour
meetingstoreconcilethepositioncontrol,orhiringplan,andestablisharecruitmentandretentionplan,asneeded.These1hour
positioncontrolreconciliationmeetingsprovideformanyopportunitiesfortheteamtoidentifycontinuingeducationneeds,
retentionissues,andotherstaffingrelatedconcerns.Itcannotbeemphasizedenoughhowimportantleadershipand
communicationaretoimprovednursestaffing.EachofthenineprinciplesofnursestaffingatMMHwillbereviewedinbrief.

NurseStaffingAdvisoryCouncil
TheNSACisacouncilwithinMMH'ssharedgovernancestructure.Thecouncil'smembershipismadeupof60%frontlinenursing
stafffromeachnursingdivisionand40%leadership.Othermembersofthiscouncilincluderepresentativesfrominfectioncontrol
andqualitymanagement.ThecochairsareanelectedfrontlineRNandanursingdirector.Thechiefnursingofficer(CNO)isa
valuablepartofthiscouncil.Thecouncilmeetsatleastquarterly.ThepurposeoftheNSACistoaddressnursestaffingneeds
groundedinethicalpracticesandfacilitateprofessionalpracticeandaccountability.TheCNOprovidesareporttothegoverning
bodyofMMHtwiceperyearwithinformationrelatedtothenursestaffingplaninclusiveofRNHPPDandnursesensitive
outcomes.TheaccountabilitiesofNSACinclude,butmaynotbelimitedto:
Reviewandimprovethewrittennursestaffingplantoincludetheminimumstaffingplanandthesurgemanagementplan.
Considercriticalstaffingfactorsindeterminingstaffinglevels.
Considernursesensitiveoutcomesinevaluatingtheadequacyofstaffing(e.g.,catheterassociatedurinarytract
infections,centrallineassociatedbloodstreaminfections,fallswithinjuries,healthcareacquiredpressureulcers).
Facilitatetimelyandeffectiveidentificationofconcernsabouttheadequacyofstaffing.
Assurethefatiguemanagementplanisinplaceandmonitoredregularly.
Assuretheselfschedulingpolicyisinplaceandismonitoredandevaluatedregularly.
Explorestaffingtechnologiesthatmayimprovestaffeffectiveness.
Addressstaffingcomplaintsorgrievancesmadebypatientsand/orvisitors.
ReviewandselectTheDAISYFoundationawardeesbasedonnominationssubmitted.

PositionControl
Thepositioncontrolistheallocationofnursingresourcesforeachunit.TheseresourcesarecalculatedattheNDNQI50th
percentileforRNHPPD.AtMMH,thisiscalculatedattheaveragedailycensusand9%nonproductivetimeplanned.
Forexample,theNDNQI50thpercentileforRNHPPDforthemedicalunitis5.88.Anaveragedailycensus(ADC)of38patients
isplanned,alongwith9%nonproductivetimebasedonhistoricdata(indicatedinthebelowcalculationas0.91).Asthisunit
schedulesnursesin12hourshifts,thetotalhoursperyearforeachRNfulltimeequivalent(FTE)is1,872.Thisisanimportant
factorbecausemostfinancialofficerscalculateFTEsusing2,080hoursperyear.Using2,080mayshortthenumberofresources
neededtoprovidecoverage.Therefore,thecalculationisasfollows:

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Thenursingdirectorsmayuseanycombinationoffulltime(FT)(0.9),parttime(PT)(0.6),orasneeded(PRN)(0.3)FTEsto
makeupthetotalRNFTEsneededfortheirunit.Asthebenchmarkdataorvolumesmaychange,thesedataarereviewedat
leastannuallywiththeCNO,humanresources,andnursingdirectorstoassuretheyhaveadequateresourcesfortheirunit.

OnboardingPositions
Onboardingpositionsareplannedusingapredeterminedturnovertarget.Thistargetmaybeestablishedusingadirectedgoalor
usinghistoricalturnoverdata.DuetotherobusteconomyinMidland,a16%annualizedturnoverwasplanned.Usingthe
previousmedicalunitexample,thecalculationforonboardingpositionsisasfollows:

Recognizingeachnewhirewillexperienceupto18weeksofnewemployeeexperienceororientation,thecalculationis:

Therefore,ifaunitiscompletelyhiredandhastheonboardingpositionsinorientation,thetimetofillavacantpositionismuch
less.ThenursingdirectorsaregiventheflexibilityandautonomytousetheseonboardingpositionstohireexperiencedRNs,
newgraduatesintoaresidencyprogram,ornursingstudentsintonurseinternpositions.Inallcases,theseonboardingpositions
areamoreproactiveprocessofprocuringtherequisitenursestaffingresources.Itisbettertobeinfrontofthenursestaffing
resourcesthanitistoreacttoturnover.

InternalResourceTeam
TheresourceteamincludesRNswhoworkaminimumnumberofhourspermonthandapredeterminednumberofholidays.
Oncethenurses(FT,PT,andPRN)oneachunitschedulethemselves,opportunitiesareavailablefornursesintheresource
teamtopickupwherethereisdemand.

TravelNurses
EachyearfromDecemberintoAprilthefollowingyear,thecensusatMMHincreasestocapacity.Thisleavesagapbetweenthe
budgetedADCandthecapacityofeachnursingunit.Therefore,duringthistimeanagencyiscontractedfortemporarynurses.
AtMMH,thetravelnursebudgetisbasedontheminimumstaffingplanwhichisestablishedattheNDNQI25thpercentile(tobe
discussedindetaillater).Continuingtousethemedicalunitexample,twotravelnursesareplannedfromDecembertoAprilor
upto26weeks.Travelernursesareassignedtolikedivisions.Forexample,thetwotravelersidentifiedformedicalareaddedto
thetotalneedsofothermedicalsurgicallikeunitsincludingpostsurgical,orthopedics/neurology,oncology,pediatrics,and
obstetrics/gynecologyunits.Thetravelnursesforcriticalcarealsoareutilizedintheemergencydepartment.

Selfscheduling
Usinganelectronicschedulingandstaffingsystemwithpredictivevolumeneeds,nursesselfschedulein4weektimeframes.The
unitbasedsharedgovernancecouncilsreviewtheirvolumesbydayofweekandhourofdaytopredeterminestaffingneeds.
Thoseneedsarethennotedintheelectronicsystemandstaffschedulethemselves.Thetraditionaltimesof7:00p.m.7:00a.m.
and7:00a.m.7:00p.m.maynotworkforeachunit.Usingtheresourcesallocatedfromabove,theremaybeothershiftsneeded
suchas5:00a.m.5:00p.m.or9:00a.m.9:00p.m.Byallocatingthenursingresourcestodemandassuresproductivityison
targetwhilenursestafffeeltheyhavemorestaffifneeded.Theclinicalmanagerreviewsandapprovesthefinalschedulebefore
beingpublished.Theremaybetimeswhentheclinicalmanagernegotiateswiththestafftohavetherightnumbersofnursing
staffoneachday.
Oncethescheduleispublished,opportunitiesareidentifiedfornursestosignupforvolunteerovertimeandtheinternalresource
teamtosignupforshifts.

AcuitybasedAssignments
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Nurse'sdocumentintheelectronichealthrecord,whichismappedtoapatientclassificationsystemusingNursingOutcome
Classification(Mosby,Inc.,2008).Eachpatientisassignedanacuityallowingforacuitybasedassignments.Nomoreistherea
staffing"matrix."EachunithasanallocationofnursingFTEswithFT,PT,andPRNstaffwhoselfschedulethemselvesbased
onthedemandoftheunitandareassignedbyacuity.Recognizingnotallpatientsarethesame,onenurseonthemedicalunit
mayhavefiveorsixpatientswhileanothercolleaguemayhavethreeorfour.

MinimumStaffingPlan
Theminimumstaffingplanisthelowestacceptablenumberofnursingstaffforprovidingcare.MMHdeterminedthistobethe
NDNQI25thpercentile.Iftheunitisstaffedbelowthisguideline,otherresourcesareavailabletoassistwithnursingcare
includingtheclinicalmanager(s),nursingdirector,educator,carecoordinator,housesupervisor,orothercompetentnurse.A
nursestaffingvariancereportismaintainedintheclinicaloperationsdepartmentforanyunitnotmeetingtheminimumstaffing
planalongwiththeresourcestobringstaffingbackuptotheplannedneed.
Ifasurgeinpatientvolumeordecreasedstaffingresourcesoccur,MMHimplementsasurgemanagementplanthatmayinclude
theadministratoroncalltocallforaninternaldisaster.Thisinternaldisastercallsforanincidentcommandcentertobeopened
usingtheHospitalIncidentCommandSystemusingallbranchesofthesystemasneeded.Weexpeditethroughputinitiatives
andreallocatenursingresourcesfromacrossthehospitaluntilthedesirednursestaffingisachieved.Theuseofthesurge
managementisrare.Therefore,tabletopdrillsarecompletedperiodicallytoassureleadersandstaffunderstandthepurposeand
processesforprocuringtherightnursestaffingresources

FatigueManagementGuidelines
LeadersatMMHwereearlyadoptersofFatigueManagementGuidelines.Theseguidelinesprovideastrategythatrecognizes
andmanagesthepotentialnegativeconsequencesofsleepdeprivationandsustainedworkhoursonpatientoutcomesandstaff
wellbeing.Professionalnursesareresponsibleandaccountableforindividualpracticeandunderstandingtheconsequencesof
fatigueinpreservingintegrityandsafety.Whiletheguidelinesareindepth,thefatiguemanagementprinciplesfornursesare:
Donotworkmorethan12.5hoursperday.
Donotworkmorethanthree12hourshiftsinarow.
Donotworkmorethan60hoursinany7dayperiod.
Guardrailshavebeenbuiltintotheelectronicselfschedulingsystemtoprotectagainstschedulingoutsideoftheseguidelines.
Membersofthenursingleadershipteam,NSAC,andunitbasedcouncilsreviewadherencetothepolicyregularlyanddiscuss
withanynursewhofallsoutsidetheseguidelines.

Summary
Nursestaffingiscomplex.Nurseleadershavetakenmanyinitiativestoincorporateevidenceandscientificdataintonurse
staffing.Eachunitisuniqueparticulartopatientpopulations,acuitiesofthepatients,skillmixofnurses,educationand
competencyofthenurses,amongothervariablestoconsiderinmakingassignments.Understandingthesevariables,theclinical
managers,staffedmostly24hoursperday,7daysperweek,havethepowerandautonomytomakeappropriatenursestaffing
assignments.Nursingleadersmustunderstanddatadrivennursestaffingplanstocommunicateclearlyandbudgetappropriately
fornursingresources.Moreresearchandsharingofevidencebasedorbestpracticesinnursestaffingneedstobecompleted
andsharedwiththenursingcommunity.

Sidebar
ExecutiveSummary

Nursestaffingiscomplex.
Nursingleadershavetakenmanyinitiativestoincorporateevidenceandscientificdataintonursestaffing.

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MidlandMemorialHospital(Texas)developednineprinciplestoimprovenursestaffing.
TheprinciplesincludebudgetingnursingresourcesandreconcilingthepositioncontrolorhiringplancreatedonaNational
DatabaseofNurseSensitiveQualityIndicators50thpercentileforregisterednursehoursperpatientday.
Nursingleadersmustunderstanddatadrivennursestaffingplanstocommunicateclearlyandbudgetappropriatelyfor
nursingresources.
References

1.Dent,R.L.,Armstead,C.,&Evans,B.(2014).Threestructuresforahealthyworkenvironment.AACNAdvancedCritical
Care,25(2),94100.
2.HealthandSafetyCode.(2009).Healthandsafetycode.Retrievedfrom
http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.257.htm
3.Mosby,Inc.(2008).Nursingoutcomeclassification(NOC).St.Louis,MO:Elsevier,Inc.
4.PressGaneyAssociates.(2014).AboutNDNQI.Retrievedfromhttp://www.nursingquality.org/AboutNDNQI#getstarted
NursEcon.201533(1):4144,66.2015JannettiPublications,Inc.
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