I. Patient Care Unit Related

There is a critical need to either retire or seriously question the usefulness of the concept of nursing HPPD. It is becoming increasingly clear that when determining nursing hours of care one size (or formula) does not fit all. In fact, staffing is most appropriate and meaningful when it is predicated on a measure of unit intensity that takes into consideration the aggregate population of patients and the associated roles and responsibilities of nursing staff. Such a unit of measure must be operationalized to take into consideration the totality of the patients for whom care is being provided. It must not be predicated on a simple quantification of the needs of the "average" patients but must also include the "outliers." The following critical factors must be considered in the determination of appropriate staffing (see Table I):

  • Number of patients;
  • Levels of intensity of the patients for whom care is being provided;
  • Contextual issues including architecture and geography of the environment and available technology; and,
  • Level of preparation and experience of those providing care.

Appropriate staffing levels for a patient care unit reflect analysis of individual and aggregate patient needs. The following specific patient physical and psychosocial considerations should be taken into account:

  • age and functional ability
  • communication skills
  • cultural and linguistic diversities
  • severity and urgency of admitting condition
  • scheduled procedure(s)
  • ability to meet health care requisites
  • availability of social supports
  • other specific needs identified by the patient and by the registered nurse

Unit functions necessary to support delivery of quality patient care must also be considered in determining staffing levels:

  • unit governance
  • involvement in quality measurement activities
  • development of critical pathways
  • evaluation of practice outcomes

 

TABLE I
Matrix for Staffing Decision-Making
Items Elements/Definitions
Patients Patient characteristics and number of patients for whom care is being provided
Intensity of unit and care Individual patient intensity; across the unit intensity (taking into account the heterogeneity of settings); variability of care; admissions, discharges and transfers; volume
Context Architecture (geographic dispersion of patients, size and layout of individual patient rooms, arrangement of entire patient care unit(s), and so forth); technology (beepers, cellular phones, computers); same unit or cluster of patients
Expertise Learning curve for individuals and groups of nurses; staff consistency, continuity and cohesion; cross-training; control of practice; involvment in quality improvement activities; professional expectations; preparation and experience