Evidence-based Standards for Measuring Nurse Staffing and Performance

Key Implications for Decision Makers

Variations in nursing productivity/utilization and staffing patterns are frequently observed between, as well as within, hospitals. Decision makers are challenged to maximize productivity/utilization and minimize staffing costs, while ensuring the quality of care. Recommendations from this study inform decision-making on these important issues within hospital cardiac and cardiovascular units.

  • Nursing unit productivity/utilization levels should target 85 percent, plus or minus five percent. Levels higher than this lead to higher costs, poorer patient care, and poorer nurse outcomes.
  • Maximum productivity/utilization is 93 percent (because seven percent of the shift is made up of paid, mandatory breaks). Units where nurses frequently work at or beyond maximum productivity/utilization must urgently reduce productivity/utilization and implement acceptable standards.
  • Productivity/Utilization targets can be met by enhancing nurse autonomy, reducing emotional exhaustion, and having enough staff to cope with rapidly changing patient conditions.
  • Overall costs are reduced when experienced nurses are retained. Retention is more likely when there is job security, when nurses can work to their full scope of practice, and when productivity/utilization levels are below 83 percent.
  • Retention strategies must address the physical and mental health of nurses, balancing the efforts and rewards associated with work, nurse autonomy, full scope of practice, managerial relationships, innovative work schedules, hiring more nurses into full-time permanent positions, and reasonable nurse-to-patient ratios based on targeted productivity/utilization standards. These will minimize the effect of persistently high job demands and reduce absenteeism and the use of overtime.
  • Investment is needed for infrastructure to collect data that will monitor and improve care delivery processes and measurement of performance outcomes. Data that should be routinely captured, but are not yet, include valid workload measurement; environmental complexity; patient nursing diagnoses and OMAHA ratings of knowledge, behaviour, and status; nurse and patient SF-12 health status; nurse to patient ratios; and productivity/utilization.

Executive Summary

Policy makers and hospital administrators are seeking evidence to support nursing staffing decisions that includes both the volume and mix of nurses required to provide efficient and effective care. The principal objective of this study was to examine the interrelationships between variables thought to influence patient, nurse, and system outcomes. The results provide quality, evidence-based standards for adjusted ranges of nursing productivity/utilization and for staffing levels for patients receiving cardiac and cardiovascular nursing care.

Although hospitals have little control over patient severity and complexity, organizations can manage nurse characteristics, system characteristics and behaviours, and environmental factors that influence patient, nurse, and system outcomes. Numerous findings provide important evidence to guide policy and management decisions related to the deployment and use of nursing personnel. These findings suggest that organizations can implement many strategies to improve the cost and quality of care.

In the past, actions to minimize expenses have focused on reducing the cost of inputs, the number of nurses, and the skill level. The findings of this study suggest that to actually reduce the cost and improve the quality of patient care, organizations will benefit from 1) hiring experienced, full-time, baccalaureate-prepared nurses; 2) staffing enough nurses to meet workload demands; and 3) creating work environments that foster nurses' mental and physical health, safety, security, and satisfaction. The evidence supports the need for a significant change in the way organizations view costs and suggests that the emphasis on cost of inputs should shift to the cost of outputs and the quality of care.

The study found nursing productivity/utilization should be kept at 85 percent, plus or minus five percent. When rates rise above 80%, costs increase and quality of care decreases. Patient health is more likely to be improved at discharge if productivity/utilization levels are below 80 percent and if patients are cared for by nurses who work less overtime. When productivity/utilization levels are kept below 80 percent, nurses are more likely to be satisfied with their jobs and absenteeism is reduced, and nurses are less likely to want to leave their jobs when productivity/utilization is less than 83 percent.

Costs are lower when hospitals maintain productivity/utilization levels below 90% and implement strategies to improve nurse health and incentives to retain experienced nurses. Autonomy can be enhanced by balancing the number of patients assigned to each nurse and each nursing unit, and emotional exhaustion is less likely when nurses are satisfied, mentally and physically healthy, and feel that they receive appropriate rewards for their efforts. Nurses are more likely to be physically healthy when there are good relationships with the physicians on the unit, and these relationships tend to improve when nurses' autonomy and decision-making abilities are respected.

Aggression- and violence-free workplaces are key to enabling nurses to do their nursing interventions on time. There also needs to be enough nursing staff to deal with the rapidly changing conditions in hospitalized patients, so that nurses have enough time to complete patient care.

Patient care is improved when units are staffed with degree-prepared nurses and when nurses can work to their full scope of practice. This not only improves job satisfaction, but nurses are also less likely to leave their jobs.

Patients' health behaviour improves when nurses have a satisfying work environment, secure employment, and when unit productivity/utilization does not exceed 88 percent. Enhanced nurse autonomy, full-time employment, and fewer shift changes are shown to improve patients' knowledge about their conditions when they are discharged.