Managing healthcare professionals in today’s market is a constant balancing act between resources and needs. In the staffing schedule, nurse managers must balance legal requirements for nurse-to-patient ratios, the need for experienced charge staff on the floor, budgetary restrictions from the C-suite, and the individual needs and preferences of each RN. It can be a frustrating task, but a solid staffing plan or matrix can make it just a bit easier.
What’s a Nurse Staffing Plan?
A nurse staffing plan (sometimes referred to as a staffing grid) is a document that managers use to determine when and where they need to schedule team members. It usually incorporates the following:
- Expected number and type of patients
- Number of professionals needed to meet the demands of the patients
- Types of nurses and other employees required for regulatory compliance
Staffing plans may be based on historical patient admission numbers. They also typically take into account any regulatory requirements, patient populations, environmental factors, and staff education. Healthcare business analysts or leadership teams use a combination of software and statistical analysis skills to develop forecasting numbers for this purpose.
3 Types of Staffing Models
The American Nurses Association (ANA) explains that there are three models by which nurse staffing is organized:
Nursing staff is decided based on the number of nursing hours per patient day (HPPD) or nursing hours divided by total patient days.
2) Nurse-to-Patient Ratio
This is based solely on the number of patients on a unit and usually doesn’t account for the patients’ needs. However, this can be combined with the HPPD model when HPPD is used as a ratio.
3) Patient Acuity
This considers the level of care that will be provided, based on each patient’s needs. When done well, it should account for the scope of nursing and the time needed for nurses to maintain standards of practice.
Benefits of Nurse Staffing Plans
The purpose of nurse staffing plans is to ensure the appropriate number of trained clinical staff are present at all times.
According to the ANA, federal regulations make some demands on nurse staffing. For example, hospitals that participate in Medicare must have an "adequate" number of RNs and LPNs to cover patient needs. It's not specific language, which means that many states, such as California, have laws requiring specific nurse-to-patient ratios. Staffing plans help keep facilities compliant with those requirements.
Jennifer Wilson, a retired RN, says staffing plans also provide guidance for managers trying to balance facility and patient needs with the preferences of staff.
“It helps to have a document to fall back on when deciding some of these things,” Wilson says. “Do you give a nurse a requested day off? A staffing plan helps you understand if you can or not. It’s like a best guess on if you need that nurse that day.”
Zach Smith, RN, BSN, and vice president of Nursing at NurseGrid, agrees with this benefit.
“A nurse’s schedule is one of the most personal parts of their job,” he says. “For a scheduler, getting the schedule right is the difference between a very angry or very satisfied staff.”
How Do You Make a Staffing Plan That’s Built to Last?
Smith points out that staffing plans may be created by business analysts or the CFO of larger hospitals. But he recommends that executives — or anyone creating these plans — work with departments to help them better manage staffing numbers based on the census.
In fact, nurse managers are the ones who typically have to integrate the theoretical plan with very real scheduling quandaries, so their input is essential.
Case Example: San Diego's Sharp Memorial Hospital
In 2015, charge nurses working in the progressive care unit (PCU) at San Diego’s Sharp Memorial Hospital voiced concerns that shifts were consistently understaffed. Specifically, the existing staffing model only allowed for one or two nursing assistants to be present per shift — which meant one assistant could end up supporting as many as 13 nurses and serving upwards of 32 patients at a time. Because their assistants were stretched so thin, the nurses weren’t always able to delegate tasks or get the help they needed. Ultimately, these staffing issues created a vicious cycle that resulted in increased numbers of patient falls and hospital-acquired infections, as well as increased numbers of reported staff injuries.
In an effort to address the problem, four members of the PCU team were selected to participate in the Clinical Scene Investigator (CSI) Academy offered by the American Association of Critical-Care Nurses (AACN). During the training program, the nurses were given the chance to redesign their staffing matrix to make it more balanced and teamwork-focused. The new model called for four assistants and 11 nurses to be present during day shifts, and three assistants to support 10 nurses during night shifts. The new staffing plan also put a cap on the number of patients each assistant could work with during a given shift. Rather than seeing up to 32 patients, the new model capped out at 12.
As a result of the new staffing plan, the facility saw a marked reduction in patient falls and staff injuries.
Other Elements of Successful Staffing Plans
According to the Oregon Nurses Association, other elements to consider when creating solid staffing plans include:
- Historic trends in admissions
- How long it takes nurses to perform clinical tasks
- How long tasks unrelated to direct patient care may take, including breaks, meals, communication to coordinate care, and charting
- Data regarding quality measures and incidents, such as patient falls or medication errors
- Legal requirements for nurse staffing in the state
The ANA notes that having an understanding of historical patient census data isn’t enough to build staffing plans that work long-term. Nurse managers and executives must also understand how the stability and complexity of care of a given patient population translates to staffing needs.
4 Signs That Your Team Is in Need of a New Staffing System
Staffing and scheduling aren’t the same thing. The schedule can change on a regular basis — perhaps even weekly — but staffing plans should follow a regular template with numbers that move up and down according to estimated needs. That doesn’t mean facilities can work from the same plan forever. Staffing plans should be reevaluated periodically to ensure that they still meet organizational, staff, and patient needs.
Here are four signs that your team is in need of a new staffing plan or system:
1) You’re scrambling regularly to staff up to immediate needs.
If you’re doing the staffing shuffle on a regular basis, either your schedule isn’t following the plan or the plan is no longer working. Smith says that if staffing plans are successful and departments work consistently within them, nurse managers avoid crisis staffing situations when census spikes.
In fact, the constant ebb and flow is why automated staffing plans and scheduling solutions exist. This type of software aims to plan proactively, reducing the chances that nurses will deal with stressful staffing shortages.
2) Errors or negative outcomes are increasing in frequency.
An increase in medication errors, patient falls, or negative outcomes can be a sign that a department is understaffed. These might also be signs of other issues, including staff in need of training or incomplete or inappropriate SOPs. (Review our Risk Management Guide to learn how to prevent and handle an incident.)
Nurse managers should consider all root causes when error rates climb. Talk to nurses on the unit to find out where problems might be. If they say they’re overburdened with patient care and can't provide excellent treatment to everyone, nurse managers need to escalate this and request a change to the staffing plan.
3) Your staff is complaining — a lot.
While you can’t always accommodate your staff's requests for more help, consistent complaints may signal a serious problem with your staffing plans.
Because plans are based on historical trends and analysis, they can sometimes move out of alignment with reality. A single understaffed shift can — and will — happen. But nurse managers should always compare their staffing plan to current needs and report consistent skews to leadership. Analysts may need to update the plan to take into account new data about patient populations.
4) There isn’t enough work.
On the flip side, if staff doesn’t have enough work to keep them busy during shifts, the plan might be leading you to oversaturate the schedule.
Again, a single shift that falls far outside the forecast is an outlier. Nurse managers must act within that shift to use resources appropriately, either assigning nurses other work that needs to be done or sending people home. When nurse managers see a trend that has shifts regularly overscheduled, they should approach leadership about an update to the staffing plan.
Ultimately, staffing plans should be a cooperative effort. Good data and strong analytical skills help ensure these plans are useful for nurse managers who must create daily schedules. But nurses must also feel comfortable pushing back when reality veers away from the plan.