Assessing – and addressing – nurse staffing levels

To address workforce challenges, you need the full picture. Consider these approaches for assessing nurse staffing levels.

Staffing shortages continue to challenge healthcare provider organizations nationwide, making employee issues a top priority for leaders. Nurse staffing levels can affect quality of patient care and outcomes and contribute to provider burnout and stress. The workforce challenges plaguing the industry show no signs of slowing, as many experienced nurses and other clinicians leave the workforce as part of the Great Resignation phenomenon.¹

It has become paramount for leaders to better understand nurse staffing levels and determine the appropriate staffing needed to keep patients and clinicians safe. Following are considerations for a workforce staffing approach with an emphasis on nurses, as an increasing number are thinking about leaving the field.²

Review compliance standards

Many states have laws related to staffing, such as requirements for nurse-to-patient ratios. Daily monitoring is necessary for organizations to make sure they are compliant. Statutory requirements also can serve as general guidance for hospitals regarding appropriate nurse staffing levels to best meet patient and community needs.

Nurture relationships

Meaningful relationships among nurses and their peers, between nurses and other clinicians, and between nurses and executive leadership are critical in efforts to retain and recruit clinical staff. Emphasizing positive relationships helps nurses feel more valued and supported – and less likely to leave the organization.

Executive rounding on nursing units is one effective way to build engagement between front-line nurses and the C-suite. Rounding gives nurses an opportunity to share their concerns with executives, which can lead to meaningful improvements. Executives can also show support by ensuring nurses who move into leadership roles receive adequate training in areas such as finance, budgetary planning, full-time equivalent calculations, and patient perception versus nurse-to-patient ratios, so those nurses in leadership feel confident supporting the front-line nurses they manage.

Hospitals that haven’t already done so should consider establishing relationships with local college and university nursing programs. These relationships often lead to a pipeline of student nurses, provide opportunities to introduce students to the organization and its culture, and help nursing students establish professional contacts with other nurses.

Get creative

As healthcare leaders work to retain existing nurses and recruit new staff, organizations can turn to creative solutions to meet their daily staffing needs. Though some have associated costs, the return on investment – in the form of retaining valued staff and potentially decreasing the use of costly contract labor and overtime – often outweighs the costs.

Self-scheduling allows staff to provide input on their schedules and provides leaders with a better understanding of core needs per day.
Per diem and part-time staff allow for greater flexibility, as nurses can pick up additional shifts without the hospital incurring overtime expenses.
Job sharing is well suited for nurses who want to work only a couple of shifts per week.
On-site childcare for well and sick children can be especially attractive to nurses with young children.
Sleeping arrangements and meal vouchers show appreciation for staff and concern for their physical and emotional well-being.
Paid time off (PTO) accrual – versus placing caps on PTO days – is attractive to nurses who might not have been able to take time off work for vacation due to their extreme workloads.
“Legacy nurses” – or nurses with decades of experience, many who might now be retired – often are willing to come back to the hospital to pick up shifts or provide training for new nurses. Welcoming back these experienced nurses can help new nurses get up to speed more quickly without overburdening the existing workforce.

Although these strategies can be considered in both inpatient and ambulatory settings, hospitals might want to consider additional ideas for addressing employee retention, recruitment, and well-being in ambulatory care settings, including outpatient clinics:

Consider shared community partnerships such as integrating clinical nursing staff from ambulatory settings into hospital settings to expand their training or entering into agreements for hospitals and affiliated clinics to share nurses.
Make use of legacy nurses who are experienced in ambulatory care settings and interested in additional shifts.
Offer more opportunities for nurses to work per diem. Ambulatory care nurses already are more likely to work per diem, and this allows them to pick up extra shifts.
Determine whether an outpatient clinic has medical assistants that can be trained as certified nursing assistants for the inpatient setting.
Use a team model approach in which licensed vocational nurses from clinic settings and registered nurses work together to provide care in the inpatient setting.

Conduct ongoing staffing analyses

Rather than waiting until the hospital is facing a staffing crisis, conducting a staffing analysis on an ongoing basis – and regularly evaluating patient outcomes compared to nurse staffing levels – is ideal.

A hospital’s human resources department is a good place to start collecting data to aid in a staffing analysis. Data points that can be assessed include:

Turnover rates. Reviewing turnover trends can help in planning for workforce needs.
Compensation. Conducting a market evaluation by service area is helpful, as pay typically is an important consideration when clinicians are deciding where to work.
Anticipated retirements. Review this incrementally and proactively conduct replacement planning, including factoring in the time it will take to train new staff members who will replace the retirees.
Difficult-to-fill positions. Some specialty positions are historically more difficult to hire for than others because of the extra training needed to provide care.
Vacancy rates. Tracking vacancy rates over time by department and how long it typically takes to fill those vacancies is valuable.
Sick calls. Hospitals should have a good idea about how many accumulated hours of nonproductive time is spent replacing staff members who call in sick, and they should have a structured procedure in place to minimize disruptions when it happens.
PTO hours. It’s helpful for hospitals to know how many accumulated hours of nonproductive time is spent when staff members are on vacation. Consider analyzing the data by department and determine each department’s plans for filling in for staff members who are out on PTO.
Workforce injuries. Analyzing injuries received on the job can be a good indicator that nurse staffing levels are inadequate.

Perform an integrated audit

Incorporating an effective audit approach using automation and data to assess progress, identify barriers, and validate compliance can provide further value to workforce staffing assessment efforts. Organizations can conduct a broad staffing audit or a more focused audit on a topic such as labor budget, staffing variances, contract labor use, employee engagement, or safety events.

A first step is to thoughtfully consider who should make up the audit team. An integrated approach, in which a clinical auditor with a nursing background teams up with individuals in the organization who have finance, legal, project management, or data analytics backgrounds, for example, can result in a more robust audit. In addition, compliance and auditing professionals should be included in the process.

Next, determine which auditing tools – whether manual or automated – will be most effective in capturing the data needed to effectively analyze nurse staffing levels. Examples of staffing analytics tools include automated software, labor productivity spreadsheets, hours per patient day variance reports, and staffing grid calculators.

Financial systems and their data captures can provide additional tools for a staffing audit. Examples of information they can provide include payroll system exports, departmental ledger reports, workforce budgeting with variance capture, and productive labor costs versus nonproductive labor costs.

Finally, don’t forget data from employee engagement surveys. The information gleaned from these can provide some of the greatest insight into whether employees are happy at work in the organization – or plan to leave.

Consider an independent assessment

Labor expenses are a top line item for most hospitals’ budgets, making the biggest impact on an organization’s bottom line. Having the right people and processes in place to audit and continuously monitor the organization’s staffing policies is essential in today’s climate. In addition to the numerous strategies listed, organizations might consider partnering with specialists in this area, who can provide an independent assessment to identify gaps and opportunities.

¹ David Weldon, “The Great Resignation’s Toll on Healthcare,” HealthLeaders, March 16, 2022, https://www.healthleadersmedia.com/human-resources/great-resignations-toll-healthcare
² Chris Jackson, “American Healthcare Workers Persevering, but Remain Stressed,” USA Today-Ipsos survey, Feb. 22, 2022, https://www.ipsos.com/en-us/news-polls/usa-today-ipsos-healthcare-workers-covid19-poll-022222