Efficiency in Nurse Staffing Practices
By Jennifer Decker Arevalo, contributor
For nurses, wasteful and inefficient scheduling practices in health care is as much a problem in delivering quality patient care and controlling medical costs, as the workforce shortage, according to a recent joint health care study, Managing Unnecessary Variability in Patient Demand to Reduce Nursing Stress and Improve Patient Safety.
The authors, who are experts in health care management and quality improvement from Boston University, Vanderbilt University, Children’s Hospital Boston and the Institute for Healthcare Improvement, maintain that hospital managers should consider alternative nurse staffing strategies in addition to recruitment.
“Because we are not making rapid enough progress needed to replace the large number of older, and soon to be retiring registered nurses, we must anticipate a future in which there will not be enough RNs available to provide adequate or safe staffing,” said Peter Buerhaus, RN, Ph.D., senior associate dean of research at Vanderbilt University School of Nursing in Nashville, Tennessee, in a May 24, 2005 joint press release from Boston University in Massachusetts. “Thus, we need to be sure that management is doing all that is possible to reduce the load on nurses and use nursing resources wisely in times of scarcity.”
One way to accomplish this is by limiting the variability in the health care delivery process so as to correctly utilize the existing workforce. According to the investigators, the “variability in the daily patient census is a combination of the natural [uncontrollable] variability contributed to by the emergency department and the artificial [potentially controllable] peaks and valleys of patient flow into the hospital from elective admissions.”
Variability has a direct impact on hospital nurses. Most hospitals now calculate nursing staff based on average patient demand. However, peaks in demand create stress for nurses and affect quality of care. The Management of Variability Program at Boston University states that nurses who are required to care for more patients than they can adequately handle has the same effect as nurses in short supply. More importantly, the program’s research indicates that inadequate staffing levels (greater than a 1:4 ratio) increase the mortality rate by 7 percent. Studies have found that nurses who work shifts lasting longer than 12.5 hours are three times more likely to make an error. Conversely, valleys in demand mean that nurses are underutilized, thereby wasting time, money and resources.
Likewise, the American Nurses Association Health Care Agenda 2005 report states that “improving the work environment ultimately rests on nurse staffing levels that are based on the development and assessment of staffing systems that will determine safe and appropriate staffing levels and skill mix that are linked to patient outcomes.”
The authors believe that if artificial variability is reduced, then many of the peaks and valleys will dissipate and what remains is primarily patient- and disease-driven. By addressing variability in “flow,” hospitals can improve staff and patient satisfaction, patient safety and revenue, as outlined by the Institute for Healthcare Improvement.
At Boston Medical Center, radical changes in the management of the center’s operating room reduced artificial variability and had a positive impact on staff. Asking specialists to rearrange their OR schedule for elective surgeries, separating urgent/emergent surgical flow from elective admissions, eliminating “block” scheduling (where surgeons “own” a specific period of OR time), and dedicating one OR to urgent/emergent care resulted in a 30-minute reduction in nurse hours/patient day. Since overtime hours and daily variation in nurse staffing were also reduced, workforce morale increased.
“Proper staffing ratios do matter, but proper attention to the technical aspects of patient flow and controllable aspects of demand can also contribute greatly to smoothing the flow of work for nurses…” said Donald Berwick, M.D., MPP, president and CEO of the Institute for Healthcare Improvement in the joint press release from Boston University. “Scheduling elective surgical and medical care more scientifically improved both safety and work life.”
“The new system has made operations a lot smoother,” said Mary Fingliss, RN, OR charge nurse, at the Menino Pavilion at Boston Medical Center in the September 2004 issue of MedCenter News. “It’s definitely a less stressful environment. The surgeons are generally happier because they can get their cases through in a reasonable amount of time and their cases aren’t bumped or delayed. And the patients are happier because they don’t have to wait for their surgeries.”
The American Nurses Association’s recently published Health Care Agenda 2005 summarizes the importance of efficiency in nurse staffing practices best: “Efforts to dramatically improve the work environment for registered nurses are essential to sustaining the current nursing workforce; enhancing the success of recruitment programs; and more importantly, improving patient outcomes and overall satisfaction.”
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