Staffing Powepoint

Nursing Leadership
& Management
Patricia Kelly-Heidenthal
0-7668-2508-6
Delmar Learning
Copyright 2003 Delmar Learning, a Thomson Learning company
Chapter 12
Effective Staffing
Delmar Learning
Objectives
Upon completion of this chapter, the reader should be

able to:
Discuss utilization of patient classification systems data by
the staff nurse and the nurse manager.
Develop a staffing pattern for a critical care unit with 10
patients.
Evaluate staffing effectiveness on an inpatient unit using
two patient outcomes.
Compare and contrast models of care delivery.
Discuss the role of a case manager versus a unit staff nurse.
Chapter 12
Determination of Staffing Needs: Key

Concepts
Full-time equivalents (FTEs) are a measure of the work

commitment of a full-time employee.
Hours worked and available for patient care are
designated as productive hours.
Hours for benefits such as vacation, sick time, and
education time are considered nonproductive hours.
Direct care is time spent providing hands-on care to
patients.
Indirect care is time spent on activities that are patientrelated but are not done directly to the patient.
Chapter 12
Nursing Hours per Patient Day
Nursing hours per patient day (NHPPD) is a standard

measure that quantifies the nursing time available to
each patient by available nursing staff.
NHPPD reflects only productive nursing time
available.
Chapter 12
Patient Classification Systems
A patient classification system (PCS) is a

measurement tool used to determine the nursing
workload for a specific patient or group of patients
over a specific period of time.
Patient acuity is the measure of nursing workload that
is generated for each patient.
Chapter 12
Factor Systems
Use units of measure that equate to nursing time

Attempt to capture assessment, planning, intervention,
and evaluation of patient outcomes along with written
documentation processes
Are the most popular type of classification system
Chapter 12
Factor Systems
Advantages
Data readily available for day-to-day operations
Provide information against which one can justify changes in
staffing requirements
Disadvantages
Create an ongoing workload for the nurse in classifying
patients every day
Problems with classification creep
Do not capture patient needs for psychosocial, environmental,
and health management support
Calculate nursing time based on a typical nurse
Chapter 12
Prototype Systems
Allocate nursing time to large patient groups based on

an average of similar patients
Advantage
Reduction of work for the nurse by not classifying patients
daily
Disadvantages
No ongoing measure of the actual nursing work required by
individual patients
No ongoing data to monitor the accuracy of the preassigned
nursing care requirements
Chapter 12
Next Generation of Classification

Systems
New models are being developed, e.g., Providence St.

Peter Hospital in Olympia, Washington.
Models are moving away from tasks to indices of
professional components of nursing care and patient
outcome.
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Utilization of Classification System Data
Patient classification data is a valuable source of

information for all levels of the organization.
Staff and managers use acuity data on a day-to-day
basis to plan staffing for the next 24 hours.
In many organizations, a central staffing office
monitors the census and acuity on all units and
deploys nursing resources to the areas in most need.
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11
Utilization of Classification System Data
At the unit level, acuity data is essential in preparing

month-end justification for variances in staff
utilization.
At an organization level, acuity data can be used to
cost out nursing services for a specific patient
population and global patient types.
Acuity data is also used in preparation of the nursing
staffing budget for the upcoming fiscal year.
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12
Considerations in Developing a Staffing

Pattern
Benchmarking is a management tool for seeking out

the best practices in ones industry so as to improve
ones performance. Benchmark planed NHPPD
against other organizations with similar patient
populations.
Few regulatory requirements have related to nurse
staffing, but this is changing. Several states are
considering legislation to mandate nurse staffing
levels in emergency departments and critical care
units.
Chapter 12
13
Considerations in Developing a Staffing

Pattern
Skill mix is the ratio of RN staff to other direct care

staff such as LPNs and UAPs. The skill mix of a unit
should vary according to the care that is required and
the care delivery model being utilized.
Staff support
Nonnursing staff must be in place to support the operations
of the unit or department.
Historical information
What has worked in the past?
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14
Establishing a Staffing Pattern
A staffing pattern is a plan that articulates how many

and what kind of staff are needed by shift and day to
staff a unit or department.
It can be generated by:
Determining the necessary ratio of staff to patients, then
calculating nursing hours and total FTEs
Determining the nursing care hours needed for a specific
patient or patients, then generating the FTEs and staff-topatient ratio needed to provide that care
Using a combination of both methods
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Inpatient Unit
An inpatient unit is a hospital unit that is able to

provide care to patients 24 hours a day, 7 days a week.
Using a staffing plan tool, plot the number and type of
staff needed during the week and weekend for 24
hours a day for the number of patients you expect to
have.
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Inpatient Unit
Determining the number of FTEs needed to meet the

staffing plan:
Calculate number of FTEs needed per day
Calculate amount of additional staff needed to provide for
days off and benefit time
Provide additional FTEs to cover benefit time away from
work (vacations, education, orientation, etc.)
Chapter 12
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Determining the FTEs Needed to Staff an

Episodic Unit
Episodic care units are units that see patients for

defined episodes of care; dialysis and ambulatory care
units are good examples.
Start with an assessment of the hours of care required
by the patients.
Add FTEs to cover days off and benefit time.
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Scheduling
Scheduling of staff is the responsibility of the nurse

manager. There are several issues to consider in
scheduling staff.
Patient need
Measured by the patient classification system
Staffing pattern must plan for acuity of patients and support
having staff working when work needs to be done
Changes when types of patients change, resulting in change
in staffing requirements
Chapter 12
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Scheduling
Volume
Patient volume numbers reviewed for peaks and valleys in
the census and patient acuity
Scheduling adjusted as necessary
Experience and capability of staff

Different degrees of knowledge, experience, and critical
thinking skills
Number of inexperienced staff (add hours)
Number of experienced staff
Need for staff with special skills
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Scheduling of Staff
The nurse manager is responsible for ensuring that

appropriate numbers and kinds of staff are on hand to
care for the patients being served.
Shift variations
12-hour shifts
Weekend programs
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Scheduling of Staff
Impact on patient care

Possible disruption of continuity of care
Weekend staff should be familiar with patients and recent
care events
Financial implications
Weekend programs are more expensive than traditional
staffing patterns
They are a recruitment and retention tool for nursing
leadership
Chapter 12
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Self-scheduling
Self-scheduling is a process whereby staff on a unit

collectively decide and implement the monthly work
schedule. This process must be done within
boundaries:
Establish staff committee reporting to nurse manager.

Establish roles and responsibilities of committee members.
Establish general boundaries.
Include and educate unit staff in development of selfscheduling process.
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Self-scheduling
Educate staff as to the process, their responsibilities, and the
impact of their decisions on staffing.
Ensure that staff is committed to providing safe staffing on
all shifts for their patients.
Chapter 12
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Evaluation of Staffing Effectiveness
Patient outcomes and nurse staffing

Studies have found consistent significant relationships
between nurse staffing and some patient outcomes.
Certain outcomes are affected negatively when nurse
staffing or skill mix is inadequate.
Chapter 12
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Evaluation of Staffing Effectiveness
Nurse staffing and nurse outcomes

Effect of staffing on nurse performance should also be
considered.
Track staffs perception of staffing adequacy.
Provide ability for staff to communicate concerns in written
and verbal form.
Track recommended staffing versus actual staffing.
Chapter 12
26
Models of Care Delivery
Care delivery models organize the work of caring for

patients.
Chapter 12
27
Total Patient Care
In total patient care, the nurse is responsible for the

total care for her patient assignment for the shift she is
working. The RN is responsible for providing care to
several patients during a normal shift.
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28
Total Patient Care
Advantages
Consistency of one individual caring for patients for an entire
shift
Patient, nurse, and family can develop a trusting relationship
Nurse has more opportunity to observe and monitor patient
progress
Disadvantages
Nurse may look at the patient on a shift-by-shift basis rather
than on a continuum of care
Uses a high level of RN nursing hours to deliver care
Costlier than other models
Chapter 12
29
Functional Nursing
Functional nursing divides nursing work into

functional units that are then assigned to one of the
team members. In this model, each care provider is
responsible for specific duties or tasks.
Chapter 12
30
Functional Nursing
Advantages
Care can be delivered to a large number of patients
Uses other types of health care workers when there is a
shortage of RNs
Disadvantages
Lack of continuity of care
Patient may feel that care is disjointed
Chapter 12
31
Team Nursing
Team nursing is a care delivery model that assigns

staff to teams that are then responsible for a group of
patients. A unit is divided into two teams, each led by
a registered nurse. The team leader supervises and
coordinates all of the care provided by those on the
team. Care is divided into the simplest components
and then assigned to the care provider with the
appropriate level of skills.
Chapter 12
32
Team Nursing
A modular nursing delivery system is a kind of team

nursing that divides a geographic space into modules
of patients with each module having a team of staff
led by an RN to care for them.
Chapter 12
33
Team Nursing
Advantages
Maximizes the role of the registered nurse
Nurse is able to get work done through others
Disadvantages
Patients often receive fragmented, depersonalized care
Communication is complex
Shared responsibility and accountability can cause
confusion and lack of accountability
Chapter 12
34
Primary Nursing
Primary nursing is a care delivery model that clearly

delineates the responsibility and accountability of the
RN and places the RN as the primary provider of care
to patients.
Patients are assigned a primary nurse.
The primary nurse is responsible for developing with
the patient a plan of care.
Other nurses caring for the patient follow this plan of
care.
Chapter 12
35
Primary Nursing
Nurses and patients are matched according to needs

and abilities.
The primary nurse has the authority, accountability,
and responsibility to provide care for a group of
patients.
Associate nurses care for the patient when the primary
nurse is not working.
Chapter 12
36
Primary Nursing
Advantages
Patients and families are able to develop a trusting
relationship with the nurse.
Accountability and responsibility of the nurse developing a
plan of care with the patient and family are defined.
Such a holistic approach to care, rather than a shift-to-shift
focus, facilitates continuity of care.
Authority for decision making is given to the nurse at the
bedside.
Chapter 12
37
Primary Nursing
Disadvantages
Cost is high due to the higher RN skill mix.
The person making assignments needs to be knowledgeable
about all the patients and staff to ensure appropriate
matching of nurse to patient.
Lack of geographical boundaries within the unit may
require nursing staff to travel long distances at the unit level
to care for their primary patients.
Nursing time is often used in functions that could be
completed by other staff.
Nurse-to-patient ratios must be realistic.
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38
Patient-centered or Patient-focused Care
Patient-centered or patient-focused care models are

designed to focus on patient needs rather than staff
needs.
Necessary care and services are decentralized and
brought to patients; staff is kept close to patients in
decentralized workstations.
Care teams are established for a group of patients;
within these teams, disciplines collaborate to ensure
that patients receive the care they need.
Chapter 12
39
Patient-centered or Patient-focused Care
Advantages
Most convenient for patients
Expedites services to patients
Disadvantages
Can be extremely costly to decentralize major services in an
organization
Some perceive model as a way of reducing RNs and cutting
costs in hospitals
Chapter 12
40
Differentiated Practice
Differentiated nursing practice is a care delivery

model that sorts the roles, functions, and work of
registered nurses according to some identified criteria,
commonly education, clinical experience, and
competence.
Nursing competencies are generally measured in three
arenas:
Technical skills
Communication skills
Management of care or leadership skills
Chapter 12
41
Differentiated Practice
Advantage
Nurses are allowed to work in specialized roles for which
they were educated, leading to greater career satisfaction.
Disadvantages
Nurses who have experience, knowledge, and capability to
function beyond their original education may not be
recognized.
Organizations that have determined minimal educational
requirements for RN positions may have difficulty in
recruiting staff with the requisite credentials.
Chapter 12
42
Patient Care Redesign
Initiative that developed in the 1990s

Emphasis on redesigning how patient care was
delivered
Motivated by need to reduce costs
Most effective when emphasis was on reducing costs
while maintaining or improving quality of care
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43
Care Delivery Management Tools
Initiatives to improve care and reduce costs arose in

the 1980s and 1990s.
The federal government established diagnosis-related
groups (DRGs) as a payment system for hospitals in
1983.
Chapter 12
44
Care Delivery Management Tools
In DRGs, the national average length of stay (LOS)

for a specific patient type was used to determine
payment for that grouping of patients.
Hospitals looked to reduce LOS and reduce hospital
costs.
Clinical pathways and case management surfaced as
significant strategies.
Chapter 12
45
Clinical Pathways
Clinical pathways are care management tools that

outline the expected clinical course and outcomes for
a specific patient type. Typically they are pathways
that outline the normal course of care for a patient.
Pathways are often done by day and for each day
expected outcomes are articulated.
Patient progress is measured against the expected
outcomes.
Chapter 12
46
Clinical Pathways
Advantages
Very instructive to new staff
Save a significant amount of time in the process of care
In most cases, improve care and shorten length of stay for
the population on the pathway
Allow for data collection of variances to the pathway
Chapter 12
47
Clinical Pathways
Disadvantages
Some physicians perceive pathways to be cookbook
medicine and are reluctant to participate in their
development.
Development requires a significant amount of work to gain
consensus from the various disciplines on the expected plan
of care.
Pathways are less effective for patient populations that are
nonstandard, since they are constantly being modified to
reflect individual patient needs.
Chapter 12
48
Case Management
Case management is a strategy to improve patient care

and reduce hospital costs through coordination of
care.
Typically a case manager:
Is responsible for coordinating care and establishing goals
from preadmission through discharge
Evaluates the patients outcomes daily and compares them
to the predicted outcomes articulated in the clinical pathway
Works with all the disciplines to facilitate care
Chapter 12
49
Case Management
In other models, the case management function is

provided by the staff nurse at the bedside.
The case manager also collects data on patient
variances from the clinical pathway and shares this
data with the responsible physicians and other
disciplines that participate in the clinical pathway.
This data is then used to explore opportunities for
improvement in the pathway or in hospital systems.
Chapter 12
50

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Nursing Leadership

Upon completion of this chapter, the reader should be

Copyright 2003 Delmar Learning, a Thomson Learning company

Determination of Staffing Needs: Key

Full-time equivalents (FTEs) are a measure of the work

Copyright 2003 Delmar Learning, a Thomson Learning company

Nursing Hours per Patient Day

Nursing hours per patient day (NHPPD) is a standard

Copyright 2003 Delmar Learning, a Thomson Learning company

Patient Classification Systems

A patient classification system (PCS) is a

Copyright 2003 Delmar Learning, a Thomson Learning company

Use units of measure that equate to nursing time

Copyright 2003 Delmar Learning, a Thomson Learning company

Copyright 2003 Delmar Learning, a Thomson Learning company

Allocate nursing time to large patient groups based on

Copyright 2003 Delmar Learning, a Thomson Learning company

Next Generation of Classification

New models are being developed, e.g., Providence St.

Copyright 2003 Delmar Learning, a Thomson Learning company

Utilization of Classification System Data

Patient classification data is a valuable source of

Copyright 2003 Delmar Learning, a Thomson Learning company

Utilization of Classification System Data

At the unit level, acuity data is essential in preparing

Copyright 2003 Delmar Learning, a Thomson Learning company

Considerations in Developing a Staffing

Benchmarking is a management tool for seeking out

Copyright 2003 Delmar Learning, a Thomson Learning company

Considerations in Developing a Staffing

Skill mix is the ratio of RN staff to other direct care

Copyright 2003 Delmar Learning, a Thomson Learning company

Establishing a Staffing Pattern

A staffing pattern is a plan that articulates how many

Copyright 2003 Delmar Learning, a Thomson Learning company

An inpatient unit is a hospital unit that is able to

Copyright 2003 Delmar Learning, a Thomson Learning company

Determining the number of FTEs needed to meet the

Copyright 2003 Delmar Learning, a Thomson Learning company

Determining the FTEs Needed to Staff an

Episodic care units are units that see patients for

Copyright 2003 Delmar Learning, a Thomson Learning company

Scheduling of staff is the responsibility of the nurse

Copyright 2003 Delmar Learning, a Thomson Learning company

Experience and capability of staff

Copyright 2003 Delmar Learning, a Thomson Learning company

The nurse manager is responsible for ensuring that

Copyright 2003 Delmar Learning, a Thomson Learning company

Impact on patient care

Copyright 2003 Delmar Learning, a Thomson Learning company

Self-scheduling is a process whereby staff on a unit

Establish staff committee reporting to nurse manager.

Copyright 2003 Delmar Learning, a Thomson Learning company

Copyright 2003 Delmar Learning, a Thomson Learning company

Evaluation of Staffing Effectiveness

Patient outcomes and nurse staffing

Copyright 2003 Delmar Learning, a Thomson Learning company

Evaluation of Staffing Effectiveness

Nurse staffing and nurse outcomes

Copyright 2003 Delmar Learning, a Thomson Learning company

Models of Care Delivery

Care delivery models organize the work of caring for

Copyright 2003 Delmar Learning, a Thomson Learning company

Total Patient Care