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HRA-232-79-0150 AVAILABLE from National Technical DOCUMENT RESUME ED 198 384 CE 028 108 AUTHOR Young, ,john P.: And Others 'TITLE Factors Affecting Nurse StaffiYig in Acute Care Hospitals:A Review and Critique ofthk:: Literature. Nurse Pl. nninq Information Series 17. INSTITUTION Public Health Service (DHHS) ,lockvilie, Md. Div.or Nursing. FEPOR'l NO DHEW-PUB-HRA-81-10: HR1,-0501301 PUB CATE Jan 81 CONTRACT HRA-232-79-0150 NOTE 298p. AVAILABLE FROM National Technical Information Fervice, 3265 Port Royal Pd., Springfield, VA 22161. EDFS PRIG' MF01/FC12 Plus Postage. DESCRIPTORS Bibliographies: Environmental Influences; Facilities: Hospitals: Influences: Labor Needs: Literature Reviews: Medical Services: Needs; *Nurses; *Nursing: Nursing Eth.7ation: Patients: *Personnel Needs: Program Design; Program Development: *Res,earchNeOF; *Staff Role: *Staff Utilization: Synthesis TDENTIFIEPS *Intensive Care Nursing ABSTRACT A critical review of literature onfactors affecting nurse staffing in acute carehospitals, with particular regard for the consequences of a movement from teamnursing to primary nursing care,. was conducted. Theliterature search revealed a need for more research on the philosophy of nursing andnursing goals and policy as they relate to nurse staffing methodologies.Personnel and patient factors (especially education, staffing patterns,and the use of part-time and agency personnel) have beenexamined more or less rigorouslY. Care requirements as required bypatient classification systems have also received intensive study.Nursing service organization, unit management, scheduling, and themodified work week are among management factorsthat have received descriptive treatment in literature. However, study of theinterrelationships of these factors have largely been ignored. Teamnursing, the Loeb Center system, unit assignment, and primary nursing care areamong the organizational modes of nursing that have beenexamined. Unit design, the use of computers as it affectsnursing schedules, and the unit dose system are among the few environmentalfactors to affect nursing care discussed in literature.(Seventy-one pages of references are appended.) (MN) ********************************************************************** Reproductions supplied by EDRS are the best that canbe made from the original document. *********************************************************************** D N 4 Factors Affecting a Nurse Staffing in Acute Care Hospitals A Review and Critique of the Literature John P. Young Phyllis Giovannetti Dana Lewison Mary L. Thorns Developed under contract number HRA 232-78-0150 January 1981 U.S. Department of Health and Human Services Public Health Service Health Resources Administration Bureau of Health Professions Division of Nursing Hyattsville, Maryland 20782 S DEPARTEAENT OF HEALTH EDUCATION & WELFARE DHEW Publication No. HRA 81-10 NATIONAL INST1TUTE OF EDUCATION HRP 0501801 *rISDOCilMETNIT HAS BEEN REPRO- oHcED ExAC TT Y AS RECEIVED F POPO THE PERSON OR ORGANIZATIONORIGIN A Ti N c ,I T P O I N T S OFVIEWO P O P I N I O N S TTAT ED DO NOT NECESSARILY REPRE- SF NT 0E-CIAL NATiONAt INSTI TUTE OF 4-1 E Du( AT ION POSITION OP POLIO Y FOREWORD Over the past two decades, much has been written on nurse staffing ru.:thodologies. The continuing search for rational methods of respondinc: effectively to changing patient care reeds in the acute care setting has led to an evolution of more or less formal techniques for patient assessment, classification, and the allocation of nursing staff based on quantified predictions cf required care activities. The value of such procedures was recognized recently by the Joint Commission on Accreditation of Hospitals, which mandated the use of patient classi- fication systems as a means for determining appropriate use of nursing resources. Many questions, however, remain unanswered--questions relating to productivity, quality, and costs. Attempts to implement and evaluate the variety of staffing methodologies that currently exist are con- founded by the myriad operational and environmental fLctors that influence the provision of nursing care activities. Moreover, the emergence of primary nursing care as a potentially moreeffective organizational mode than either functional or team nursing has created uncertainties as to the manner and extent to which such an organiza- tional mode can be implemented in specific settings. As a comprehensive sourcebook of the literature on nursestaffing methodologies, this document should provide an excellent guide for future research it this area. The most recent literature on important input, operational, and environmental factors that affect staffing is reviewed and criticized. Deficiencies in research and evaluation are highlighted and numerous areas for further research are suggested. The nursingCbmponentof the National Health Planning Information Center provides health planners with a centralized, comprehensive source of information on nurse manpowerplanning to facilitate an improved health care delivery system in the United States. The component acquires, screens, synthesizes, disseminates,and makes available specialized documentary material on nursing, as well as methodological information on a wide variety of topics relevantto health planning and resources development. 4--fte-v" o Eleanor Elliott Director Division of Nursing PREFACE This ri-.graph, published as part -' the Nurse Planning Information Series, is intended to provide a sourcebook of the litera- ture on factors affecting nurse staffing in acute care hospitals. Recent articles and -eports on a number of important input, opera- tional, and environmental factors affecting staffing are reviewed and critiqued..This information should be valuable to all those concerned with the effective provision of nursing ca and will be of interest to researchers, educators, administrators, and practi- tionePs-ETIke. Numerous areas for further investigation are sug- gested and the_importance of methodologically sound E,..dies for evaluating the impact of various staffing innovation, emphasized. This document represents a component of a larger project entitled "Evaluation of Staffing Patterns in Hospitals," funded under Contract No. HRA 232-78-0150. A supplemental document, entitled "A Compar- ative Study of Team and Primary Nursing Care on Two Surgical Inpatient Units of a Teaching Hospital," describes research efforts that evaluated the impact of primary nursing as carried out at the Johns Hopkins Hospital. The authors wish to thank their project officer, Ms.Patricia A. Delman for her guidance throughout the preparation of this mono- graph. The invaluable advice and assistance of Dr. Eugene Levine and Ms. Virginia Saba are gratefully acknowledged. Thanks are also due to Dr. Myrtle K. Aydelotte, Dr. Carol A. Lindeman, and Dr.Gloria G. Mayer, Advisory Committee to the project, for their manyuseful suggestions on the content of this review. Finally, the authors extend their sincere thanks to Ms. Renate Wilson for hereditorial advice. TABLE OF CO-ITENTS Foreword Preface Chapter 1 Introduction 1 Chapter 2 The Conceptual Framework 11 Chapter 3 Methods of Review 25 Chapter 4 l nput Factors : Personnel 35 Educational Preparation of Nurses 35 Nurse Staffing Patterns 48 The Use of Part-time and Agency Personnel 59 Chapter 5 Input Factors: Patient Care Requirements 69 Chapter 6 Operational Factors: Management 87 Nursing Service Organization 87 Unit Management 93 Scheduling 104 The Modified Workweek 111 Chapter 7 Operational Factors :Organizational Modes of Nursing 123 Team Nursing, the Loeb Center System, and Unit Assignment 124 Primary Nursing Care 141 Chapter 8 Environmental Factors 181 Unit Design 181 The Use of Computers 191 The Unit Dose System 201 Chapter 9 Summary and Recommendations 213 Appendix A Literature Citations :Alphabetical Index 223 Appendix B Literature Citations :Index by Subject Area 255 Appendix C Secondary References 291 -vii- Chapter 1 INTRODUCTION Nurse staffing problems are perennial and universal.The history of nursing can be said to be, in large part, a historyof attempts to respond to patient care needs with an appropriate organization and allocation of nurse staffing resources.The choice, however, of optimal strategies for the provision of patient care is complicated by underlying natural forces that give rise to anerratic flow of patients through hospital facilities and by concomitant uncer- tainty as to expected demands. The essentially stochastic nature of demand for acute care was recognized by Balintfy (1960, 1962) and Flagle (1960), who argued that, from a theoretical point of view, everyindividual in a popu- lation has a small but finite chance of becoming ill orhaving an accident on a given day; and that such events areintrinsically random and independent, if one disregards epidemicsand catas- trophes.Under these conditions, one would expect thenumber of unscheduled arrivals to acute care hospitalinpatient units during a limited period of time, such as a day, to bedistributed according to the well-known Poisson probability distribution. Young (1962a) verified these findings and showedthat, as a rough approximation, the Poisson distribution could indeedbe used to predict the number of admissions per day of bothscheduled and unscheduled patients, and could also be used todescribe the daily bed occupancy for most inpatient units in an acute carefacility. To some extent, nursing service administratorshave long known that they are dealing with uncertainty in a systemdominated by chance factors.Attempts to cope with this state of
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