Appropriate Nurse Staffing

Position Statement on Principles
for Determining Nurse Staffing
Adopted July 18, 2005

Iowa Organization Nurse Leaders and Iowa Nurses Association in a collaborative effort to address appropriate nurse staffing have developed this position statement.

In any health care setting appropriate nurse staffing can only be achieved through a decision making process in which nurses themselves evaluate and res pond to the drivers of patient care intensity. This evaluation and res ponse must be made in light of the nursing organization’s capacity to provide professional services. The com ponents of appropriate staffing include the hours of nursing care and the appropriate mix of professional and non-professional providers.

1. Authority and accountability for all nurse staffing decisions within the organization must rest with the nurse executive who will work in direct collaboration with the clinical direct care professionals in each specialty. Expertise in nursing is a foundation of appropriate staffing decisions.
2. An effective system of appropriate staffing strives to match patient care requirements with nursing care resources each shift, each day. Patient care needs must determine the level of staffing.
3. The daily determination of appropriate staffing requires objective information concerning patient care needs, skills of available staff, and budgeted resources, coupled with expert clinical judgment about the specific patient care requirements on any particular day. Appropriate staffing requires mechanisms to increase staffing in res ponse to greater care requirements and to decrease staffing in res ponse to reduced care requirements. Further required is a collaboration approach to managing patient flow within the organization when the demand for patient admissions exceeds the available nursing resources.
4. The nursing standards, developed by the nationally recognized professional nursing associations to address appropriate staffing, must be considered in developing staffing plans within organizations.
5. Clinical Nurses recognize the prerequisites to providing a meaningful voice in determining appropriate staffing include an awareness of the fiscal realities of the current health care environment, and a willingness to play an active role in assuring the efficient and effective use of resources through the pursuit of improved approaches to patient care.
6. The continuous pursuit of evidence-based best practices is an obligation of the profession. Benchmarking with other organizations must be an ongoing comprehensive endeavor in determining appropriate staffing. Comparisons of multiple variables, in addition to “hours of care”, should be considered in a broader organizational context.
7. Ongoing evaluation of outcomes is also a necessary element in insuring the provision of quality care. At a minimum, this should include collection and analysis of data related to nurse sensitive outcomes such as length of stay and rates for urinary tract infection, pressure injury, post-operative infections, and pneumonia (ANA 2000) and their correlation with other patient care trends.
8. All organizations must evaluate staffing as it relates to patient safety, actual or potential adverse patient outcomes, and quality of work life.

Key Drivers of Intensity of Patient Care Requirements:

1. The acuity, complexity and case mix of the patient situation are the primary determinants of patient care requirements.
2. There is a direct relationship between the length of stay in the acute setting and the intensity of care requirements. For every day the length of stay is decreased, nursing workload is increased by greater than 27% (The Advisory Board, 2002)
3. Intensity of patient care is increased by admissions, discharges and transfers in a given day, the greater the intensity. Midnight census does not accurately reflect nursing workload.

Key Drivers of the Capacity of the Nursing Organization to Provide Patient Care:

1. The experience/expertise of the nurse directly influences individual capacity to provide patient care. Generally, the greater the expertise of the nurse, the greater the capacity to manage, both in terms of the number and complexity of patients.
2. The support systems available to nurses in the practice setting directly impact the capacity to provide professional services within the organization. Nurses whose work is supported by effective housekeeping, pharmacy, food and supply systems, as examples, have a greater capacity to provide professional services than those who are forced to spend time compensating for inadequate support.
3. The effectiveness of the system of care, particularly documentation and other non-direct care requirements, directly impacts the capacity of the nursing organization to provide professional services. Cumbersome systems that pull nurses away from the patient detract from the capacity to provide patient care.
4. The geography and unit design in which nurses practice influence the capacity to provide professional services. The ability to readily visualize and access patients enhances capacity. The demand for larger and more private patient care spaces (essential to meeting the expectations of today’s active consumer,) detracts from the capacity of the nursing organization to provide rofessional services.

Reference: Wisconsin Organization Nurse Executives, Guiding Principles in Determining Appropriate Nurse Staffing, November 2004

 July 18, 2005