The nurse staffing challenge

By 2030, just twenty years from now, all the baby boomers will have crossed over into the elderly category. Average annual medical expenditures for Americans age 65 and older are more than three times that of the working age group. Aging boomers are driving demand for medical care. For example, the cancer incidence report published online in the Journal of Clinical Oncology (April 29, 2009) concluded that the aging of America will drive a 45 percent increase in the total number of annual cancer cases in the U.S. from 1.6 million to 2.3 million over the next two decades.

Not coincidentally, as America ages, the incidence of chronic disease is going up. By 2020, the number of Americans with one or more chronic conditions will climb to about 157 million; by 2030, to 170 million. Average medical expenditures for people with one chronic condition are twice that of those with none; for those with five or more chronic conditions, 14 times greater.

Thus, demographics are driving ever greater demand for medical care. Moreover, if fully implemented, healthcare reform could extend coverage to more than 32 million uninsured Americans by 2014. As the experience of Massachusetts underscores, expanding coverage increases demand.

Conservative estimates forecast a national shortage of registered nurses of 340,000 by 2020. More and more older people needing more care, more and more people with chronic conditions needing more care, and coverage expanding to more and more of the uninsured - plus a shortage of nurses to care for them. This is the rock and the hard place between which hospitals are caught. Hospitals are challenged to dramatically improve productivity. They must find ways to optimize the efficiency of nurse staffing.

Now more than ever, no hospital can afford persistent patterns of over-staffing. Yet under-staffing undermines quality, puts patient safety at risk, diminishes patient satisfaction, and erodes nurse morale. How can hospitals strike the right balance?

Hospital administrators and nurses have a shared interest in smoothing out patterns of under- and over-staffing. Getting nurse staffing right is a challenge. Even getting agreement on how to get it right is no easy accomplishment. Rigid staffing ratios imposed uniformly on all hospitals from the outside - by legislative mandate as in California or in labor contracts as proposed by the Minnesota Nurses Association in Minneapolis-St. Paul - are arbitrary and costly. Hospital-specific staffing ratios often formulated by internal committees of nurse managers and hospital administrators far removed from the front lines of patient care are abstract.

There is another way. Hospitals in metro areas such as Phoenix and Chicago are collaborating with nurses to staff according to defined levels of patient acuity. Staffing and scheduling decisions are now based on the documented complexity of the patients' conditions in each unit and the intensity of the services they will need during the next shift.

Patient classification or acuity systems identify for the nurses and unit managers the baseline level of care for the "typical" or standard patient on their specific unit. Studies are performed to ensure that all activities that surround a standard patient are included in the baseline workload and acuity values. These systems also identify a unique set of additional services and procedures that are associated with the higher acuity patients along with level of effort each adds to the overall required patient care. In the routine process of nursing documentation, acuity can then be derived as an automated calculation of the amount of time each individual patient requires. Staffing and scheduling software systems can then utilize the resulting patient classifications to automatically calculate the optimal staffing for every unit and shift. Your hospital can allocate available staff based on individual patient care needs, not just based on census. Acuity tools can also take into consideration the activities surrounding the admit, discharge, and transfer process. These often overlooked tasks typically generate large amounts of "uncounted" nursing and clerical workload.

Thus, with software designed to determine the correct number and skill mix of nurses that should be scheduled to provide the appropriate patient care based on the intensity of patients' medical needs and to balance workload taking into consideration the amount of nursing time required to care for them, staffing and scheduling systems can bring nursing supply and patient demand into balance. Unit-specific staffing can be based not just on the number of patients but on the quantified amount of care individual patients require.

Hospitals are dynamic places. A unit can get unexpected admissions and transfers in the middle of a shift. Patients get sicker. That makes it impossible to maintain absolute nurse-patient ratios perfectly. But hospitals adopting acuity-based staffing, and automating the process within their staffing and scheduling systems, are achieving success in moderating both under- and over-staffing with best-performing units routinely staffing their shifts at 95 percent to 105 percent of optimal staffing levels based on the quantified needs of their patients.
Looking ahead to the challenge looming on the near horizon, hospitals and nurses have to take action. Acuity-based staffing and scheduling is a way forward. Now, more than ever, no hospital can afford persistent patterns of over-staffing. Yet, under-staffing undermines quality, puts patient safety at risk, diminishes patient satisfaction, and erodes nurse morale. How can hospitals strike the right balance?