One Nurse or Two Assistants: A Staffing Decision for a Composite Medical-Surgical Unit, Priced and Weighed Against the Evidence
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Master of Science in Nursing Program, Aspen University
N522: Modern Organizations and Health Care
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One Nurse or Two Assistants: A Staffing Decision for a Composite Medical-Surgical Unit, Priced and Weighed Against the Evidence
Staffing decisions are where organizational priorities become visible. Every choice about how many nurses to schedule, and with what mix of licensed and unlicensed staff, affects patient outcomes, staff well-being, and the budget. This paper analyzes a staffing decision facing a composite medical-surgical unit, compares three options by cost and by the evidence linking staffing to outcomes, and recommends one.
The Unit and the Decision
Unit 5 West is a composite 32-bed medical-surgical unit in a 280-bed hospital. On nights, five RNs care for an average of 30 patients, a ratio of six patients per nurse, supported by two nursing assistants. Over the past year the unit's rate of rapid response calls on nights has been higher than on days, falls with injury have increased, and night RN turnover reached 26 percent. The chief nursing officer has approved new funds equal to roughly $225,000 a year and asked the unit's director to choose among three options.
Option A adds one RN on every night shift, reducing the ratio to five patients per nurse. Option B keeps five RNs and adds the equivalent of two nursing assistants on every night shift. Option C makes no position change and uses the funds for overtime and incentive shifts to fill vacancies.
The Cost of Each Option
Covering one additional position on every 12-hour night shift requires about 4,380 hours a year, which, divided by a standard 2,080-hour work year, comes to roughly 2.1 full-time equivalents. At an estimated $105,000 per RN full-time equivalent including benefits, Option A costs about $220,000. At an estimated $52,000 per nursing assistant full-time equivalent, Option B requires two positions, or about 4.2 full-time equivalents, costing about $218,000. Option C spends the same funds on premium pay, which at time-and-a-half buys fewer hours than new positions would, and relies on the same tired staff working more shifts.
The costs of A and B are nearly identical. The decision therefore turns on which option buys better outcomes, and on costs the budget does not show, such as turnover, length of stay, and adverse events.
What the Evidence Says
Research consistently links RN staffing to patient outcomes. Aiken et al. (2002) linked workload to outcomes across 168 Pennsylvania hospitals: for surgical patients, each one-patient increase in the average nurse's assignment carried 7 percent higher odds of 30-day death and 7 percent higher odds of failure to rescue, while for the nurses themselves it carried 23 percent higher odds of burnout. In a study of nearly 200,000 admissions in one academic hospital, each understaffed shift, meaning RN hours at least 8 short of the unit's target, added to a patient's risk of dying, as was each shift with high patient turnover (Needleman et al., 2011).
Skill mix matters as well. Across hospitals in six European countries, each 10-point drop in the percentage of professional nurses among all nursing personnel was associated with an 11 percent increase in the odds of death, along with lower patient ratings of care (Aiken et al., 2017). Adding assistants in place of nurses is not a neutral substitution; the evidence suggests it trades licensed judgment for hands, and patients pay the difference.
Weighing the Options
Option A directly addresses the variable most consistently linked to mortality and failure to rescue: the number of patients per RN. It also addresses the night unit's specific signals. More rapid response calls suggest late recognition of deterioration, which depends on RN assessment time. Higher turnover suggests workload strain, which the burnout evidence links to patient load.
Option B would help with tasks such as turning, toileting, and feeding, which could reduce some falls, but it would dilute the unit's skill mix at night, when fewer physicians and resources are available and nurses' judgment matters most. Option C would fill some gaps but depends on overtime, which increases fatigue and error risk and does nothing to address the turnover that created the vacancies.
Option A has limits too. Reducing the ratio from six to five helps only if the new positions are filled; if recruitment fails, the unit may end up relying on overtime anyway. And falls may need targeted interventions beyond staffing, such as scheduled toileting rounds, which can be assigned to the existing assistants.
Costs the Budget Does Not Show
The budget comparison treats the options as equal in cost, but their indirect effects differ. Replacing a night RN who leaves costs the hospital recruitment, orientation, and months of reduced productivity, and at a 26 percent turnover rate the unit is replacing roughly one in four night nurses every year. If a lower patient load reduces burnout, as the evidence suggests, even a modest drop in turnover would offset part of Option A's cost. Adverse events carry costs as well: a fall with injury or a failure to rescue lengthens the stay, may not be reimbursed, and can lead to a claim. Option C carries a hidden cost in the opposite direction, since overtime-dependent units tend to lose more staff to fatigue. A leader presenting this decision should show these indirect effects alongside the direct cost, so the chief nursing officer sees the full price of each choice.
Recommendation and Measures
The recommendation is Option A: add one RN on every night shift, reducing the ratio to five patients per nurse, and assign the existing nursing assistants to structured rounding for fall-risk patients. The unit director should post the positions immediately, offer a retention incentive for current night nurses, and report to the chief nursing officer quarterly on night rapid response calls, falls with injury, failure-to-rescue events, night RN turnover, overtime hours, and nurse-reported workload. If the measures do not improve within a year, the unit should examine whether other factors, such as patient acuity or admission timing, are driving the night-shift problems.
Conclusion
Unit 5 West's staffing decision compares options that cost nearly the same but differ in what they buy. The research linking RN staffing and skill mix to mortality, failure to rescue, and nurse burnout supports adding an RN rather than substituting assistants or relying on overtime. The recommendation is a quality and safety decision expressed in budget terms, which is how staffing decisions should be made.
References
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987-1993. https://doi.org/10.1001/jama.288.16.1987
Aiken, L. H., Sloane, D., Griffiths, P., Rafferty, A. M., Bruyneel, L., McHugh, M., Maier, C. B., Moreno-Casbas, T., Ball, J. E., Ausserhofer, D., & Sermeus, W. (2017). Nursing skill mix in European hospitals: Cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Quality & Safety, 26(7), 559-568. https://doi.org/10.1136/bmjqs-2016-005567
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
How this N 522 Module 7 example is structured
N522 Module 7 typically brings quality, safety and staffing decisions into the written work. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example defines a real decision with a budget, prices each option with stated assumptions, weighs the options against major staffing studies, acknowledges the limits of the recommendation and closes with measures.
N522 Module 7 questions, answered
What does N522 Module 7 usually ask for?
The module typically focuses on quality, safety and staffing decisions, often asking you to analyze a staffing or safety decision in an organization and support your recommendation with evidence and costs. Aspen does not publish module deliverables, so your classroom's instructions govern.
What did Aiken's 2002 staffing study find?
Among surgical patients in Pennsylvania hospitals, each additional patient per nurse was associated with a 7 percent increase in the odds of 30-day mortality and of failure to rescue, and a 23 percent increase in the odds of nurse burnout.
Does replacing nurses with assistants save lives or cost them?
Evidence from European hospitals found that each 10-point reduction in the share of professional nurses among nursing staff was associated with an 11 percent increase in the odds of death, suggesting that substituting assistants for nurses carries risk.
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