16Jones Leadership(F)-ch 16 1/14/07 3:48 PM Page 278 This page has been left intentionally blank 17Jones Leadership(F)-ch 17 1/14/07 3:49 PM Page 279 chapter 17 Staffing and Scheduling BARBARA SHELDEN CZERWINSKI, PHD, RN, CNAA, BC, FAAN CHAPTER MOTIVATION “No system can endure that does not march.” Florence Nightingale (Ulrich, 1992) CHAPTER MOTIVES ■ ■ Describe staffing as a process with a relationship to scheduling Describe various care delivery models and staffing and scheduling systems utilized by nursing services 279 17Jones Leadership(F)-ch 17 280 1/14/07 3:49 PM Page 280 Skills for Being an Effective Manager T he nurse manager’s staffing and scheduling goals are to assure the presence of adequate, responsible, qualified, and competent personnel who will provide quality nursing care services in a timely manner and consistent with the Principles for Nurse Staffing of the American Nurses Association (ANA) (1999) Additional goals in staffing and scheduling include sustaining congruence with the mission, vision, values, philosophy, and strategic plan of the organization and its nursing services and maintaining compliance with regulatory guidelines Overarching objectives in providing nursing care services include patient safety and patient satisfaction This chapter will discuss the staffing process with relationship to staffing plan, care delivery models, staffing and scheduling systems, and scheduling outcomes Background The late 1990s brought with them a nursing workforce shortage, which has had a significant effect on nursing care delivery systems A widespread nursing shortage in the United States translated into demanding and less attractive work environments (Kimball & O’Neill, 2002) Compounding the nursing workforce shortage were the alarming findings by the Institute of Medicine (IOM) in 2000, 2001, and 2004 Based on the IOM quality chasm trilogy series, which provided strong evidence for the need for safer patient care environments in the healthcare delivery system, a redesign of health-care processes became imperative (IOM, 2000, 2001, 2004) To redesign health-care processes, local, state, consumer, professional, and regulatory organizations joined to seek solutions The redesign would include plans regarding nurse staffing The IOM reports identified nursing as a pillar of quality and patient safety that must be strengthened to keep patients safe and retain nurses Transformation of the work environment of nurses requires improving staffing adequacy, administrative support, and good nurse-physician relations (IOM, 2004) Staffing and resource adequacy are systemcentered measurements advocated by the National Quality Forum (NQF) in conjunction with other nurse-sensitive performance measures to achieve an environment of safety (Kurtzman & Kizer, 2005) NQF is a unique public-private partnership of more than 170 organizations, including the ANA Examples of measurable nursing-sensitive outcomes are satisfaction, burnout, intent to leave, and costs Examples of patient-sensitive outcomes affected by nursing care are mortality, failure to rescue, complications, satisfaction, and costs Nurse staffing influences nursing and patient-sensitive outcomes Staffing In 1999, the ANA published Principles for Nurse Staffing, which emphasized the nursing work environment to provide safe patient care Subsequently, the ANA advocated a work environment that supports nurses in providing the best possible patient care by budgeting enough positions, administrative support, good nurse-physician relations, career advancement options, work flexibility, and personal choice in scheduling (ANA, 1999) Staffing, according to the Center for American Nurses (The American Nurse, 2006), refers to job assignments Job assignments include the following: the volume of work assigned to individuals, the professional skills required for particular job assignments, the duration of experience in a particular job category, and work schedules The process of staffing begins with an assessment of the current staffing situation The assessment includes the qualifications and competence of the staff available (ANA, 2004) The next step is to formulate a plan to meet future needs The staffing process culminates with a schedule (organized plan) of personnel to provide patient care services Scheduling variables are defined as: The number of patients, complexity of patient condition, and nursing care required The physical environment in which nursing care is to be provided The nursing staff members’ competency lev- els, qualifications, skill range, knowledge or ability, experience level The level of supervision required Availability of nursing staff members for the assignment of responsibilities Appropriate allocation of nursing staff for patient-focused care (American Association of Colleges of Nursing [AACN]-Critical Care, 2001) or 17Jones Leadership(F)-ch 17 1/14/07 3:49 PM Page 281 Staffing and Scheduling patient-centered and essential patient safe care (Bleich & Hewlett, 2004) is the desired goal of nursing staffing levels The ANA Principles for Nurse Staffing (1999) offer standards to incorporate and balance the needs of patients, nurses, and organizations committed to positive patient outcomes The principles recognize that providing nursing care services can be multivariate and complex The ANCC Magnet Recognition Program (2004) is an example of a quality recognition organization that has incorporated the ANA Principles for Nurse Staffing as a program foundation The ANA patient care unit-related principle of “appropriate staffing levels for a patient care unit reflect analysis of individual and aggregate patient needs” (ANA, 1999) is aligned with current research findings Appropriate staffing concentrates on a higher proportion of patient care hours provided by registered nurses as compared with patient care provided by licensed practical nurses or unlicensed personnel for better patient outcomes An appropriate staffing system incorporates patient needs, staff member skill sets, and staff mixes (ANCC, 2004) The 2004 University HealthSystem Consortium Nursing Work Environment Benchmarking Survey (2005) of 59 academic medical centers found better patient outcomes and improved nurse satisfaction when registered nurses deliver a higher proportion of care Another nursing quality recognition program, the Texas Nurses Association Nurse-Friendly Hospital Criteria (TNA, 2005), has incorporated the ANA principle of staff-related “clinical support from experienced RNs should be readily available to those RNs with less proficiency” (ANA, 1999) TNA Nurse-Friendly Hospital Criteria are 12 essential elements identified as an ideal practice environment for nurses One of the essential elements is “nurse orientation.” The facility must demonstrate that it has a nurse-specific orientation program that considers the education, experience, and identified strengths and weaknesses of the nurse being oriented (TNA, 2005) The ANCC Magnet Recognition Program (2004), a quality-focused organization, advocates that the organization has a function and productive system of shared decision making among the nursing staff members An example of a shared decisionmaking process is a decentralized nurse staffing and scheduling system that provides staffing throughout 281 Practice Proof 17-1 A University HealthSystem Consortium study consisted of eight performance issues that identified staffing targets using benchmark data (UHC, 2005) The measures used were as follows: worked hours at or near organization target, reduction in vacancy and turnover, reduction in agency use, and increased nurse satisfaction Evidence suggests that better patient outcomes result when a higher proportion of care hours are provided by registered nurses as compared with care provided by licensed practical nurses or nursing assistants Inadequate staffing also leads to nurse dissatisfaction, burnout, and turnover (Gallant & Lanning 2001) Research suggests that patient safety is affected not only by nurse staffing levels but also by nurses’ education levels (Aiken, et al., 2002) The UHC study looked at these elements: How staffing effectiveness is monitored and reported The retention and recruitment plans of Human Resources to decrease turnover and vacancy rates The monitoring system in place for nurses working over 60 hours per week and the amount of overtime worked How the centralized scheduling office obtains a broad overview of staffing needs The type of supplemental staffing or flex pools used to reduce or eliminate agency use and manage behindthe-scenes staffing work (recordkeeping, calls for time off, etc.) Question: what factors discussed in this chapter might affect staffing? the nursing operations of the organization The organization’s personnel policies and programs need to reflect minimal rotating shifts and creative and flexible staffing models The staffing system adapts and flexes internal and external factors such as staff illness, shift changes in workload, and other uncontrollable variables Trending data are to be used to formulate the staffing plan and to acquire necessary resources to make staffing adjustments in response to fluctuating patient workload and acuity (e.g., agency staff, float pool staff, overtime) In contrast to appropriate staffing is inadequate staffing Inadequate staffing came to the forefront of the nursing profession in the early 21st century with such national published and publicized reports as the IOM (2000, 2001, and 2004) In response to the nursing shortage, nurse working condition studies reported nurses’ dissatisfaction with inadequate staffing conditions (Unruh, 2005) For exam- 17Jones Leadership(F)-ch 17 282 1/14/07 3:49 PM Page 282 Skills for Being an Effective Manager STAFFING PLAN Healthcare Setting Care Delivery Models Patient Acuity Nursing Staff SCHEDULING & STAFFING SYSTEMS Centralized Decentralized Mixed SCHEDULING OUTCOMES Daily Staffing Patient Outcomes Nursing Workloads ©B.S Czerwinkski FIGURE 17-1 Staffing process ple, inadequate staffing conditions are reported in acute-care (Aiken et al., 2002) and long-stay nursing home (Horn et al., 2005) studies as well as in national nursing (Stanton & Rutherford, 2004) and health-care standardization organization (JCAHO, 2004) studies The goal of nursing care is to provide patientcentered and essential patient-safe care (Bleich & Hewlett, 2004) The purpose of nurse staffing is to ensure patient care needs are met The staffing process starts with a staffing plan and ends with positive patient outcomes and acceptable nursing workloads (Fig 17-1) STAFFING PROCESS The staffing process is the linear incorporation of the staffing plan, the scheduling and staffing system, and the scheduling outcomes into a systematic flowing process The following discussion describes the various components of each step of the process, beginning with the staffing plan Staffing Plan The staffing plan consists of four different elements that must be addressed: the health-care setting, care delivery model, patient acuity, and nursing staff They are then incorporated into the next step in the process, the scheduling and staffing system A staffing plan can also be referred to as the staffing matrix Health-Care Setting The health-care setting is where the patient care services are provided It is the first consideration in developing the staffing plan Geographical location and architectural design of the health-care facility will determine the accessibility of the nursing staff to the patient, which has ramifications regarding the work allocation and provision of the patient care services Specific examples in the development of the staffing plan are the consideration of the location of the patient care supplies in relation to the point-of-use at the bedside and the walking distances between the patient bedside and the nursing station The impact of the design of the health-care setting on system metrics was addressed by Gabow et al (2005) This study illustrated that nursing turnover and vacancy rates are influenced by efficiency, workforce development, and architectural effects on the work environment Care Delivery Models Care delivery models, also referred to as nursing care delivery systems or patient care delivery models, can vary from one nursing unit to another, depending on the type of patients, the care requirements, and available resources The focus of care delivery models is on the patient and how nursing care services are developed and provided Nurse clinical decision making, work allocation (workload), communication, and management are included in care delivery models The choice of model used is dependent on these factors, combined with the differing social and economic forces (Tiedeman & Lookinland, 2004) A care delivery model needs to address four components: Patient needs Patient population demographics Number of nursing staff members Ratio of nurses serving various roles and levels (ANCC Magnet, 2004, p 46) ... goals in staffing and scheduling include sustaining congruence with the mission, vision, values, philosophy, and strategic plan of the organization and its nursing services and maintaining compliance... organization’s personnel policies and programs need to reflect minimal rotating shifts and creative and flexible staffing models The staffing system adapts and flexes internal and external factors such... well as in national nursing (Stanton & Rutherford, 2004) and health-care standardization organization (JCAHO, 2004) studies The goal of nursing care is to provide patientcentered and essential patient-safe