Question

The topic of discussion for this week is how to manage the nursing skill mix. Identify nurse staffing models, then compare and contrast these models on the basis of skills, costs and benefits, anticipated trade-offs, and any other aspects you choose.

Answer 1

Traditionally, hospitals have focused on productivity (hours per unit of service, such as patient day) to determine staffing levels. However, this approach creates unintended incentives to reduce the number of staff members on the floor, which then limits the time spent on patient care.

Optimizing the nursing skill mix enables hospitals to lower their costs (see Exhibit), but it also does much more: It allows registered nurses (RNs) to practice at the top of their license (for example, by spending more time on patient education), which generally leads to higher job satisfaction. And higher satisfaction often lowers staff turnover, resulting in additional cost savings. Patients benefit as well, because increased staff time at the bedside correlates with improved outcomes.

Hospitals must find ways to provide high-quality care despite these challenges. After working with multiple healthcare systems in the US, UK, and elsewhere, we have found that one of the best ways hospitals can achieve this goal is by optimizing the nursing skill mix – they maximize patient care time by using lower-paid staff to perform less complex tasks, freeing up the more highly qualified staff to focus on tasks only they are qualified to undertake. For example, helping patients walk does not require a fully trained RN. That task can be performed by unlicensed staff members as long as they are given the right training.

This skill mix shift results in the same number of hours with the patient, but at a lower total cost without sacrificing top quality care. By optimizing the nursing skill mix around both patient needs and total cost, hospitals can deliver safe, effective, high-quality care in a fiscally responsible manner

Many countries have introduced new models for staffing hospital units with nursing staff in response to shortages of qualified nurses and changes in patient care needs. These include changes in the mix of qualified and unqualified nurses within the hospital workforce, the mix of nurses with different qualifications and different levels of experience, and the way in which nursing staff are allocated to hospital units and to individual patients receiving care on each hospital unit. We identified 15 relevant studies that were considered to be of an appropriate design to be included in this review.

It appears that certain changes to hospital nurse staffing, particularly the introduction of specialist nursing roles and specialist support staff, may improve patient outcomes. The introduction of staffing models such as primary nursing and self-scheduling may reduce the number of staff resignations. However, the research in relation to these topics is limited and the findings should be treated with caution.

Staffing models

Staffing levels can be determined in several ways, but none is sufficient on its own.

Budget-based staffing

Commonly, the number of nursing hours per patient day (HPPD) or nursing hours divided by total patient days is used to determine staffing levels based on national or regional benchmarks. On a medical unit, total patient days reflects the average number of patients for a 24-hour period. Nursing hours refers to the total number of hours worked by all nurses on that unit for a given time period. This staffing model provides a snapshot of the overall day and shift, without concern for “churn” within the shift.

Staffing by nurse-patient ratio

The nurse-patient ratio model is based solely on the number of patients on a unit. A pure nurse-patient ratio approach to staffing might not take into account individual patient needs or nursing judgment. A hospital might use this model in conjunction with HPPD, where HPPD is converted to a ratio.

Be aware that although a nursing unit can stop admitting patients if it hits the maximum nurse-patient ratio, the hospital’s emergency department (ED) can’t stop accepting patients. Federal laws require hospitals to provide medical screening for patients who present to the ED. However, ED patients who need to be admitted to the hospital may have to remain in the ED if additional staff aren’t available on the unit. With a ratio-only staffing model, the minimum staffing level would then become the maximum staffing level

Scope of nursing practice

The scope of nursing practice must be considered when determining staffing needs. According to the American Nurses Association, the scope of nursing practice includes:

• assessment
• nursing diagnosis
• outcomes identification
• planning
• implementation
• coordination of care
• health teaching and health promotion
• consultation
• prescriptive authority and treatment (for advanced practice registered nurses)
• evaluation