DNP 835 Module 6 Staffing, Productivity and Resources Example

Minutes, Hours and Skill Mix: Staffing and Productivity for Acute Care for Elders Protocols on a Medical Unit

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 835: Strategic Leadership and Business Management

Instructor Name

Month Day, Year

Minutes, Hours and Skill Mix: Staffing and Productivity for Acute Care for Elders Protocols on a Medical Unit

New clinical protocols take time, and time is staff. A project that asks nurses to walk patients three times a day, toilet them on a schedule, screen for delirium and join daily interdisciplinary rounds without adjusting staffing is likely to fail quietly as the work is squeezed out by other demands. This paper works through what the acute care for elders protocols mean for staffing and productivity on 5 West. It estimates the added workload, considers skill mix in light of evidence on staffing and mortality, proposes a staffing adjustment, and sets productivity measures that support the change.

Current Staffing and Productivity

5 West has an average daily census of 27 and is staffed on 12-hour shifts with seven registered nurses and four nursing assistants by day and six registered nurses and three nursing assistants at night, including a charge nurse on each shift. That staffing produces about 6.7 registered nurse hours and 3.1 nursing assistant hours per patient day. The hospital measures productivity as worked hours per unit of service against a budgeted target, and the unit has run at 98% to 104% of target over the past year.

The target was set years ago, before the unit's patients became older and more dependent, and has not been revisited since.

What the Protocols Add

The project team timed each new task on a sample of patients. For the roughly 60% of patients aged 70 and older, assisted walking three times a day adds about 30 minutes per patient per day, scheduled toileting every two to three hours while awake adds about 20 minutes, daily delirium screening and prevention measures add about 10 minutes, and participation in interdisciplinary rounds adds about 3 minutes per patient for the nurse. Across about 16 older patients a day, that is roughly 17 hours of added care per day, most of it mobility and toileting that do not require a registered nurse.

Without additional staff, this work competes with medication administration, assessments and admissions, and it is the kind of care most likely to be missed. Missed nursing care, required care that is omitted in whole or in part or delayed, results from decisions nurses make about priorities under pressure, shaped by the environment and by nurses' own values (Kalisch et al., 2009). Mobility is typically sacrificed first because its harms are delayed and invisible.

Skill Mix Considerations

Because most added work is mobility and toileting, a tempting response would be to add nursing assistants while reducing registered nurse hours to hold costs flat. Evidence argues against that. In a longitudinal study of acute hospital wards, each day a patient experienced registered nurse staffing below the ward mean was associated with a 3% increase in the hazard of death, days with high admissions per registered nurse carried additional risk, and while low nursing assistant staffing was associated with higher mortality, so was high nursing assistant staffing; the authors judged that adding nursing assistants was not a safe substitute when registered nurses were in short supply (Griffiths et al., 2019). Similarly, a large study found that each shift spent on a unit running well short of its registered nurse staffing target raised a patient's risk of death (Needleman et al., 2011).

The staffing proposal therefore adds capacity for mobility without reducing registered nurse hours.

The Staffing Proposal

The proposal adds a mobility technician, a nursing assistant role trained in safe mobility and fall prevention, for 12 hours a day, seven days a week, adding about 0.44 hours per patient day at a cost of about $78,000 a year. The technician carries out scheduled walks and toileting for older patients according to each patient's plan, documents activity and alerts the nurse to changes. Registered nurse staffing stays at current levels, and the half-time geriatric clinical nurse specialist supports protocols and teaching. Because the project's business case already includes the specialist but not the technician, the proposal revises the budget and notes that the technician's cost is partly offset by expected reductions in sitter use for patients at risk of falls, which averaged 2.1 sitter shifts a day last year.

Productivity Measures That Support the Change

If 5 West continues to be judged solely against its current worked hours target, the added technician will make the unit look less productive. The proposal asks finance to adjust the target to include the technician hours as part of the approved care model, and to add outcome measures to the unit's productivity review: falls, delirium incidence, length of stay and discharges home. Productivity would then be judged on value, outcomes relative to hours, rather than hours alone. The nurse manager will also track whether mobility sessions are completed as planned, since unfinished sessions would show that staffing is still insufficient.

Monitoring After Go-Live

Staffing plans rest on estimates, so the first months after go-live will test them. The nurse manager will review daily whether the mobility technician completed scheduled sessions, whether registered nurses reported being pulled into mobility work, and whether sitter use fell as expected. If older patients on the unit exceed the estimated 60% share, or if sessions go unfinished on busy days, the manager will bring data to the sponsor to adjust the technician's hours or add weekend coverage. Staff will be asked monthly, in a short pulse survey, whether the protocols are feasible within their assignments, since nurses' judgment of workload is an early warning of missed care.

Conclusion

Acute care for elders protocols add roughly 17 hours of care a day on 5 West, mostly mobility and toileting, work that is likely to be missed if staffing does not change. Evidence that lower registered nurse staffing and heavier registered nurse workloads track with more deaths, together with the finding that aides are no safe replacement for registered nurses, supports adding a mobility technician while holding registered nurse hours. Adjusting productivity targets and adding outcome measures ensures that the unit is judged on the value of its care, not only its hours.

References

Griffiths, P., Maruotti, A., Recio Saucedo, A., Redfern, O. C., Ball, J. E., Briggs, J., Dall'Ora, C., Schmidt, P. E., & Smith, G. B. (2019). Nurse staffing, nursing assistants and hospital mortality: Retrospective longitudinal cohort study. BMJ Quality & Safety, 28(8), 609-617. https://doi.org/10.1136/bmjqs-2018-008043

Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509-1517. https://doi.org/10.1111/j.1365-2648.2009.05027.x

Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037-1045. https://doi.org/10.1056/NEJMsa1001025