Staffing in the Hospital

Abstract

Nowadays, the US healthcare system is experiencing a great challenge with nurse staffing. The paper is focused on a greater workload and the insufficient number of nurses to provide the appropriate service as the main reasons for the staffing challenges. In addition, there is a problem with hospitals hiring temporary nurses in order to solve the situation. Hospitals have great problems with restricted budgets and through staffing, they try to reduce the costs. However, such decision has negative implications for both nurses and patients. If there are not enough workers to tend to the patient, nurses have difficulties because due to the high number of patients and work, and lack of staff, they cannot express empathy and compassion for the patients in order to provide the appropriate service. The solutions applied to the described challenge were the fixed and flexible staffing models. However, they have their own limitations, which means they are not effective enough to solve the problem. Thus, the nurse staffing challenges can be solved through the incorporation of the qualitative factors in the staffing plan, consideration of the underlying reasons for staff turnover, and reduction of the cost problem not through the staffing issues, but through the promotion of the technological advances.

Introduction

Nowadays, there is a great problem with the nurse staffing. Due to the problems with budget and financial resources, hospitals tend to provide cost-savings through the nurse staffing that in the end has negative consequences. Hospitals that have lower nurse staffing levels showed a correlation with increased rates of negative patient results such as urinary tract infections, cardiac arrest, shock, and pneumonia. At the same time, the staffing problem provokes challenges with appropriate service to patients that require one to one care. Due to the staffing problems, nurses simply cannot physically spend the needed time with patients. Evidently, there is a great need to improve the situation in order to increase the positive outcomes for both the nurses, and the patients. Therefore, the nurse staffing challenge can be solved through the incorporation of the qualitative factors in the staffing plan, consideration of the underlying reasons for staff turnover, and reduction of the cost problem not through the staffing issues, but through the promotion of the technological advances.

Problems with Staffing

In modern conditions, hospitals experience serious challenges with nurse staffing. Nurses are crucial stakeholders in the healthcare industry. Nonetheless, this work has many challenges as it is a highly demanding profession. Staffing is an issue of personal and professional concern nowadays (API Healthcare Corporation, 2016). However, the strong workload of nurses in the hospital is a critical challenge for the US healthcare system. Nurses have problems with greater workloads due to four reasons, which are “increased demand for nurses, inadequate supply of nurses, reduced staffing and increased overtime, and reduction in patient length of stay” (API Healthcare Corporation, 2016). Specifically, the need for nurses is rising as the population is aging. From 2000 to 2020, the US population is expected to increase by 18%, but the over-65 population, with more healthcare needs, is going to increase by 54% (Carayon & Gurses, 2008). In addition, the nurses’ supply is not sufficient when meeting the current demand, while it is expected that this shortage will increase even more, with the future being at rise and nursing schools being unable to withstand the rising education demand. When the nursing shortage appears, the workload increases for those that are already employed (Carayon & Gurses, 2008). Additionally, “in response to increasing health care costs since the 1990s, hospitals reduced their nursing staffs and implemented mandatory overtime policies to meet unexpectedly high demands, which significantly increased nursing workloads” (Carayon & Gurses, 2008). Finally, the rising cost pressure forced healthcare organizations to decrease the length of stay. Thus, the adequacy of nurse staffing in the hospital due to the increasing patient acuity is a challenging issue that provokes a great number of arguments about the patients’ safety, well-being, and care quality.

The use of temporary or supplemental nurses in order to provide the support to the short-term nurse staffing shortage is perceived negatively. Temporary nurses include nurses who are hired by nurses who work permanently and who moved from permanent units, internal hospital per diem pools and external agencies (Aiken, Xue, Clarke, & Sloane, 2007). According to one research, 67% of hospital staff states that their units use more temporary or agency staff than what is best for patient care (Aiken et al., 2007). The research also showed that “56% of hospitals used agency per diem or traveling nurses in 2001 … 75% of participating hospitals used supplemental nurses” (Aiken et al., 2007). The main problem is that such practice leads to negative outcomes. The relation between non-permanent nurses use and negative outcomes, involving needlestick injuries to nurses, medication errors, and infection, were researched in several studies. Therefore, issues associated with staffing levels are quite complex and demand detailed insight.

Currently, supplemental nurses play a great role in the nurse staffing. According to a research that analyzed data from Pennsylvania, more non-permanent nurses were found in a clinic where staffing and other sources adequacy were rated lower, which makes sense since temporary nurses are hired specifically to compensate for shortfalls of permanent staff (Aiken et al., 2007). “After controlling for adequacy of staffing and resources, higher levels of nonpermanent staff were actually associated with lower levels of such events, suggesting that resource adequacy is the deeper underlying problem and that nonpermanent or supplemental nurses may mitigate or compensate for nurse staffing deficiencies” (Aiken et al., 2007). Thus, in case the staffing is inadequate, nurses contend it threatens the safety and health of patients, leads to greater care complexity, and affects their safety and health through raising the injury rate and fatigue. At the same time, there is other evidence of the staffing problems’ negative influence.

Specifically, adequate nursing staffing is a critical issue for the patient’s well-being and safety. Inappropriate nurse staffing levels strongly affect the general mortality, respiratory infection, medication mistakes, and heart attack rate. According to one research, the risk for the patient to die during thirty days after admission escalated by seven percent in regard to each patient the nurse has to handle (CNA HealthPro, 2009). In addition, the research points out that “54 percent of nurses in adult medical units and emergency rooms do not have sufficient time and overtime has increased during the past year with 43 percent of all RNs working extra hours because the unit is short staffed or busy” (CNA HealthPro, 2009). In 20% of the researched cases, low staffing negatively affects the unit discharge, transfers and admission (CNA HealthPro, 2009). Additionally, staffing problems deplete morale, provoking higher levels of staff turnover and absenteeism. Thus, it leads to serious consequences.

Another research also found adverse outcomes of the high nursing workload. Moreover, it adversely influences the nursing job satisfaction and in the end leads to high turnover and nursing shortage (Carayon & Gurses, 2008). Also, the work system factors and expectations lead to the increase in the nurses’ workload because they are expected to do nonprofessional issues such as performing, coordinating, or ordering ancillary services, transporting patients, housekeeping duties, delivering and receiving food trays (Carayon & Gurses, 2008). Additionally, 39% of respondents reportedly planned to leave work within a year due to the work demands. Immense nursing workload increases the chances of dissatisfaction with work and burnout that leads to high nurse turnover (Carayon & Gurses, 2008). At the same time, the staffing problem can also be expressed through inadequate scheduling.

Ensuring open shifts and managing staff scheduling is a great challenge for healthcare organizations. It is rather difficult to match nursing personnel with patients while meeting theit needs, satisfying staff, and minimizing costs. The first issue is the management of the staffing process from the top down with limited involvement of employee (API Healthcare Corporation, 2016). The top-down approach provides nurses with very little insight or input in the staffing process. Specifically, due to the restricted participation in the schedule shaping process, the personnel cannot express their own position and participate in the problem-solving. As a result, the staffing weight and scheduling tasks fall squarely on the managers’ shoulders (API Healthcare Corporation, 2016). The staff knows the preferences and availability better than managers do and through providing them with the control over the chosen shifts, it is possible to reach a good work and satisfaction balance and to raise the autonomy sense (API Healthcare Corporation, 2016). Nonetheless, this is not the only challenge.

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The other problem is staffing in silos with a lack of consideration of matching staff with patient needs. When every unit only concentrates on its own staffing needs, there is no chance to build the staffing strategy that advantages the entire organization. The transparency difficulties in hospital represent many challenges for staff that is available in one unit and that has to move to the other unit in order to fix the problem with the lack of staffing (API Healthcare Corporation, 2016). It means that while the nurse is being sent home for the low census in one unit, the other nurse will experience extra work due to the staffing needs in the other unit. It leads to the raised costs and the staff satisfaction decrease. The next issue is the problem with standardized staffing policies (API Healthcare Corporation, 2016). The main point is that policies concerning incentive programs, holiday schedules, and over time have to be consistent across the whole organization. The staff appreciates being treated equitably and fairly and inconsistent staffing and performance can provoke perceived or actual inequalities (API Healthcare Corporation, 2016). Therefore, the staffing problem is expressed through many challenges.

In general, the situation with staffing is quite complex. Nurse staffing levels are influenced by different external factors including general economic state, immigration policies, nursing school capacities, and cyclical shortages of registered nurses (CNA HealthPro, 2009). Industry analysts predict the nursing shortage problem shall increase within the next decade due to the economic improvement and many nurses reaching the retirement age (CNA HealthPro, 2009). Nonetheless, due to the healthcare organization’s diversity and the nurse staffing issues complexity, a single solution for all organizations simply does not work. The efficient staffing model has to consider such variables as nurses’ education regarding the needed unit, specialized training, experience, skills, unit layout, and ancillary report in determining the appropriate number and patient acuity (CNA HealthPro, 2009). Therefore, to avoid negative outcomes it is critical to consider many issues.

Caring for Patients

In general, the establishment of the nurse-patient relationship is a conscious effort on the part of the nurse in caring for a patient. It is an agreement between the patient and the nurse to work together for the patient’s good (Sheldon & Foust, 2014). While the nurse accepts responsibility for setting the relationship’s aim and structure, the nurse uses the patient-centered approach to create the relationship and meet the needs of the patient (Sheldon & Foust, 2014). Nurses have to shape relationships with patients based on the concepts of confidentiality, genuineness, trust, empathy, and respect (Sheldon & Foust, 2014). It is critical for nurses to support patients with such emotions. However, in case of staffing challenges, such service is difficult to provide. Moreover, in case there is no one to handle the patients, nurses are not able to provide the required amount of time due to staffing issues.

There are several critical emotions that have to be expressed by nurses toward the patient. One of them is being genuine. The ability to be oneself within the professional role perspective is called genuineness (Sheldon & Foust, 2014). In addition, nurses have to treat a considerable number of patients, while some them might have values and behaviors that are rather different from the nurses’ ones. The other way to express genuineness it to express interest in the patient using daily nursing care (Sheldon & Foust, 2014). Another critical issue is empathy and compassion. Compassion is the feeling of deep sympathy or desire to realize the experience of another person in addition to the desire to relieve their suffering (Sheldon & Foust, 2014). Patient can develop such symptoms as social challenges, including family concerns and financial community, psychological symptoms, e.g. relationship and mood issues, and physical symptoms such as nausea, breath shortness, and pain.

At the same time, empathy is the educated compassion or the intellectual realization of the other person’s emotional state. It can be described as the desire of nurse to realize what the patients experience from their own perspective (Sheldon & Foust, 2014). The empathy helps nurses to see the world from the patient’s perspective without experiencing emotional concern (Sheldon & Foust, 2014). Such intellectual realization provides nurses with the ability to detect the patient’s concerns in a more clear and specific way. There is a whole spectrum of empathy and professional compassion in nursing. Evidently, all these issues are critical for the appropriate care services for the patient. Nonetheless, in case of the caregiver it is physically impossible to provide such service level due to the staffing problem (Sheldon & Foust, 2014). Therefore, due to the staffing problems, it is difficult to provide the patients with the appropriate services, including emotional aspect, particularly empathy and compassion.

In addition, nurse staffing problems and the patient outcomes are closely interconnected, and there is many pieces of evidence to support this claim. Specifically, one of the studies stated “Many participants mentioned their concerns about providing safe care under current staffing conditions. There were numerous comments about budgetary limitations and what nurses considered safe compared with actual routine staffing circumstances” (Simpson, Lyndon, Wilson, & Ruhl, 2012). It means that nurses realized the inadequacy of the provided service but could not do anything about it due to the managerial position. Another problem is the staffing of small-volume perinatal units (Simpson et al., 2012). This challenge was often mentioned by the research participants, but the small-volume perinatal units staffing became a specific challenge that was prevalent throughout the research. Around 58% of the US perinatal services have less than 1000 births per year and 37% have less than 500 births annually (Simpson et al., 2012). The problems associated with the need to respond to emergency cases and the amount of in-house resources were explained as professional demand among nurses who possess high qualifications in perinatal care and these requirements are present all the time, despite the fact that there are no perinatal patients sometimes. However, this is not the only evidence.

In fact, it is possible to provide many examples that prove the signification association between patient outcomes and the nurse staffing issue. Researching the lowest mortality rates in magnet hospitals in comparison to the non-Magnet hospitals indicated that there were improved outcomes in the Magnet hospitals due to nurses’ experience, improved relationships with physicians, increased control during their practice, and more autonomy (Cheung, Aiken, Clarke, & Sloane, 2008). In the other study of AIDS units, the difference in nurse and patient outcomes were contrasted between healthcare organizations focused on AIDS patients. It was found that lower death rates were related to the lower nurse burnout (Cheung et al., 2008). Nurses gained a great support in the decision making process, while the staffing was organized in an appropriate way so that nurses had the ability to take part in the observation activities, which in turn assisted in early prevention of complications and detection of mistakes (Cheung et al., 2008). Another research proved the connection between patient mortality, nurse job dissatisfaction, nurse burnout levels, and staffing ratios (Cheung et al., 2008). In 186 hospitals from Pennsylvania it was discovered that patients’ mortality raised by 7% for every additional patient added to the nurse workload beyond the four patient baselines (Cheung et al., 2008). Moreover, every additional patient per nurse not only raised the burnout odds by 23%, but also raised the odds of job dissatisfaction by 15% (Cheung et al., 2008). These results provided the support for the initiatives advocating the minimum staffing ratio establishment in the US.

There is also other evidence. The next research provided information regarding the higher nurse staffing correlation with pneumonia developed in the hospital, cardiac arrest, failure to rescue, reduced rate of hospital-related mortality and other negative cases (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Greater RN hours aspect of the direct, patient care were related to the decreased risk of shorter stay lengths and hospital-related deaths (Kane et al., 2007). More overtime hours were related to the rise in hospital-related bloodstream infections, shock, nosocomial infections, and mortality (Kane et al., 2007). Therefore, it is possible to see numerous evidence of the negative impact of staffing problems on patients’ outcomes.

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Hospital Budget

Budgets assist as standards to evaluate, monitor, and plan the performance of the health care system. Budgets account for the income gained as compared to the expenses needed to provide the service (Kelly, 2010). It is critical because the healthcare organizations measure multiple key indicators of general performance. They are usually developed for a twelve-month period and are monitored monthly (Kelly, 2010). Short- or long-term budgets can be developed based on the organizational planning process. In order to prepare the budget, organizations gather foundation elements that impact the organization, including patient demographic and marketing information such as income, sex, race, age, competitive analysis, history, goals, strategic plans and regulatory influences (Kelly, 2010). Consequently, the budget is a critical part of the hospital’s operation and it has a strong relation to the nurse staffing.

There is a strong association between hospital budget and nurse staffing. In a time of the restricted health care funding and rising health care costs, hospitals are forced to restructure work environments trying to deliver health care services at low cost without lowering the care quality (Thungjaroenkul, Cummings, & Embleton, 2007). As a result of an increase in attention to costs and restructuration, a lot of hospitals decided to downsize the general labor pool, including some full-time nursing positions, provoking serious adverse effects for nurses and patients (Thungjaroenkul et al., 2007). Attempts to promote the operational efficiency provoked changes in nurse staffing issues, reducing the number of registered nurses and replacing them with the unlicensed assistive personnel. A great cost reduction is possible through efficient staff management. Raising the hours’ proportion provided by the registered nurses would yield cost saving due to avoiding heat and reducing adverse consequences (Thungjaroenkul et al., 2007). In addition, it is possible to promote the cost reduction through the registered nurses’ caring activities increase. Despite the fact that increasing number of registered nurses was positively associated with increasing hospital expenditures, it did not considerably affect the hospital’s profits.

On the opposite, the high number of non-registered nurses led to greater hospital expenditures and caused the profits’ reduction. From the business perspective, more experienced employees raise the organizational labor expenditures (Thungjaroenkul et al., 2007). Nonetheless, in healthcare, a great reduction in general costs is possible by increasing the number of experienced nurses. It was stressed that hospitals with highly qualified nursing staff had lower non-personnel costs (Thungjaroenkul et al., 2007). The results help to consider the possibility that nurses are significant resources for the healthcare organization among more competitive markets. Moreover, higher nurse staffing level leads to better organizations’ performance (Thungjaroenkul et al., 2007). Therefore, the hospital budget and nurse staffing are strongly correlated.

Applied Strategies for Staffing Improvement

The strategies applied to the staffing problem were fixed and flexible staffing models. In case of the fixed staffing models, such methods as the fixed mandated staffing ratios and grids use are usually based on the set number of nurses for a specific unit. In addition, the analyzed models have difficulties with taking into consideration the hour-to-hour changes (Avalere Health LLC, 2015). The grid approach mostly relies on the fixed number of nurses for a specific shift or unit. The main challenge is that “other variables that impact the need for nursing staff such as severity of patient condition, complexity of care, nursing skill level, skill mix of staff, and actual or projected change in census are given little or no consideration in this type of staffing plan” (Avalere Health LLC, 2015). Many issues have to be considered. Thus, this method has its limitations.

At the same time, in case of the flexible staffing models, the nurses’ number and the nurse-to-patient’ ratio is performed upward or downward to consider the units’ level factors involving patient condition and census fluctuation, just as the needed level of nursing skill and care acuity complexity. Therefore, this method presents more calculation challenges (Avalere Health LLC, 2015). In addition, it needs the evaluation of all factors in a continuous way that can also be quite difficult to perform. Similarly, this method is not efficient enough for managing the nurse staffing challenge. Nonetheless, it is critical to analyze possible solutions with better efficiency.

The change theory of Kurt Lewin plays a critical role in nursing and can be applied to find a solution regarding nurse staffing. This is a theorized three-stage change model. This theory provides three main concepts, namely equilibrium, restraining forces and driving forces (Sarayreh, Khudir, & Barakat, 2013). The driving forces are aimed at pushing in the direction that provokes changes. It means to push the person in the desired direction and provoke the shift in equilibrium towards the needed change. The driving forces are restrained by the focus center, hindering change to push the patient in the opposite direction. They cause the equilibrium shift that opposes the changes (Sarayreh et al., 2013). Equilibrium is the state of no changes between the two mentioned forces. Accordingly, this theory can be used for the solutions implication.

The theory represents three stages, namely refreezing, unfreezing, and change. The unfreezing stage can be explained as the process, which includes a model of representation for providing people with the ability to leave the old methods that seem to be ineffective. Specifically, at this stage, the new policies regarding nurse staffing are represented as changing patterns for old mechanisms. It is critical to handle the individual resistance and groups, conformity strains (Sarayreh et al., 2013). There are three methods that provoke the unfreezing achievement. The first one is to provoke the driving forces, which in turn will direct the behavior from the current situation. The other proposition is to reduce the restraining forces that hold back the shift of the existing equilibrium. The third issue is to find the mentioned two-method combination (Sarayreh et al., 2013). The change stage that also means the movement to a new level includes the process of change in behavior, feeling, thoughts, or all of the above, which is more productive. At this stage, as managers, employees and politicians realize, the importance of change and their position is transformed into something new. The last stage established the change as the new habit and it turns the standard operating procedure (Sarayreh et al., 2013). This stage helps to apply the chosen solution for all levels and for all stakeholders. Thus, the change theory helps to implement new solutions to the nurse staffing problem and to move on from the old patterns of changes.

Interventions

To provide the appropriate recommendation regarding nursing staffing it is critical to develop a specific philosophy. Specifically, it has to be based on the understanding that it is possible to match the skills and knowledge of the staff with the patient care needs in a way that optimizes job satisfaction and the care quality. In addition, the humanistic and technical care needs of the patients have to be provided in an inappropriate way by the professional nurses. The solutions have to be found through the perspective of patient-centered care and the inclusion of nurses’ interests in staffing decision making.

Therefore, one of the interventions can be the qualitative factors’ involvement in the staffing plan. Formal staffing plans propose a flexible alternative to focus nurse-patient ratios (CNA, 2009). It is critical for written plans to be focused not only on the numbers, but to provide the patients with conditions, where they are carried out by nurses with the needed experience and skills. Supported by a predetermined and written strategy, the organization can more easily address nursing shortages and ensure that decisions in regard to staffing reflect such issues as unit turnover, involving transfers, discharges, and admissions, the level of employees and patients’ satisfaction, available sources, access to support staff and medical personnel, staff qualifications, skills, training and education mix, daily census and patient population trends, and patient diagnosis, special needs and acuity (CNA, 2009). The unexpected issue can be the lack of understanding of all mentioned issues from the managerial perspective.

The next solution is to address the underlying reasons for staff turnover. Unfavorable working conditions and low wages always affect the nurses’ decision to work with other organizations. The healthcare organizations have to propose fair and competitive compensation and benefits for nurses with the required experience and education, apply the critical information and ergonomic technologies that are directed at the harm risk reduction and workflow improvement, improve the nursing employment from the ethnicity, age, and gender perspective in order to reduce the nursing shortage influence, restrict the obligatory overtime use in case of emergency situations, and reduce the paperwork that takes time of nurses from their patients care (CNA, 2009). The unexpected aspect can be a lack of places for nurse employment due to the increased desire to participate in such employment proposition.

In addition, in order to change the situation with nurse staffing, it is critical to reduce the cost problem, not through the staffing issues but by promoting the technological advances. Specifically, the electronic healthcare information has to assist in reducing the general health care costs and to improve the patient equality (Bernanke, 2009). In addition to the redundancies and error reduction, a higher level of patient confidence and satisfaction in care delivery setting has to be realized, serving to improve the patient outcomes. Leveraging IT and gaining access to the electronic health information can decrease the portion of the care costs for a number of chronic conditions (Bernanke, 2009). Nowadays, IT is understood to be a critical part of the successful change. The main issue is that it is important to search for other alternatives in cost reduction in case of a limited budget, but to avoid cost-savings through the staffing as it will only bring negative consequences for both nurses and patients (Bernanke, 2009). The unexpected element is that it can be challenging to apply and using such technological advantages among the staff.

Conclusion

Overall, nurse staffing is a great challenge of the US health care system. Nowadays, there is a great workload with the patients and not enough nurses to provide the appropriate service. Additionally, the situation becomes more difficult with hospitals hiring temporary nurses in order to solve the situation. Hospitals experience difficulties with a restricted budget and through staffing, so they try to reduce the costs. Nonetheless, such decisions impose negative implications for both the nurses and the patients. Specifically, nurses experience great fatigue and dissatisfaction with work, while patients experience negative outcomes for their health and well-being. In addition, hospitals that have lower nurse staffing levels showed a correlation to increased rates of negative patient results such as urinary tract infections, cardiac arrest, shock, and pneumonia. Very often, nurses are demanded to provide the one to one care to the patient, but it is almost impossible due to the high number of patients, heavy workload, and the lack of staff. Moreover, nurses have to express empathy and compassion for the patients in order to provide the appropriate service. However, it is also challenging due to the lack of time and great workload. Therefore, all mentioned consequences and effects are serious and they cannot be ignored. The applied solutions to the challenge under consideration were flexible and fixed staffing models. Nevertheless, they have their own limitations, which means they are not effective enough to solve the problem. For better solutions implication it is critical to realize the Lewin theory of change that helps to implement new solutions and to move from old patterns. As a result, the nurse staffing can be solved through the incorporation of the qualitative factors in the staffing plan, consideration of the underlying reasons for staff turnover, and reduction of the cost problem not through the staffing issues, but through the promotion of the technological advances. Thus, nurse staffing problem is a serious challenge and the currently applied methods are not effective enough. It is critical to look for new solutions and alternatives in managing the hospital costs and representing the appropriate staffing due to the negative consequences of the staffing challenges both for patients and nurses.