A Health System Risk Management member recently asked for information on tracking nurse-to-patient ratios in the emergency department (ED).
ECRI responded that there is growing evidence that the links between staffing ratios and quality of care have created a need to track and calculate safe staffing levels. However, no one approach has been found to be completely effective (for example, the authors of a study in Health Research and Educational Trust concluded that there is no single measure that can be recommended for nurse staffing).
According to a 2016 study in PLOS One, adequate calculation of required full time staff in the ED represents "a particular challenge" and there is "no gold standard." But the authors presented methodology based on priority levels and takes into account workload fluctuations that can present an objective measure and offer a "valuable contribution" for planning human resources in the ED.
Generally, there are numerous factors that must be taken into account when considering staffing ratios, including the cognitive workload on the nurses, the nurses' level of experience, and patient factors. One way to gather the most accurate information is to interview unit leaders. The authors of a study published in the Journal of Nursing Administration said this may be the most effective way to track staffing levels. Using such a method can be more efficient than surveying nurses since it allows for clarification—for example, a unit leader can easily explain their staffing grid or provide a photocopy of their staffing list. Unit leaders should be approached in a nonconfrontational manner, the authors said. Many organizations use nurse surveys to gather information, but the authors cautioned that they can only be conducted in units where there are no major labor conflicts. Other downsides of nurse surveys are the cost and the potential for response fatigue. If a survey is used, the authors said, they must be analyzed to make sure all shifts are properly represented.
An analysis from the Journal of Emergency Nursing found that a calculation of hours per patient visit was the most frequently used method for determining staffing in the ED. This method requires dividing the number of actual paid hours by the total number of ED visits to calculate the number of staff hours per year. The authors pointed out that this type of system fails to take a few critical factors into consideration, including patient acuity, length of stay, and nursing workload. The authors discussed a tool that may be more accurate for calculating annual needs. It incorporates key variables of patient volume, patient acuity, nursing interventions and activities, skill mix, and ED length of stay to determine the direct needs in an emergency department. There is also a chart in the article that can show how to use the tool to facilitate the calculation of the number of full-time equivalent nurses needed. The authors say that the tool can be used to determine staffing needs in the ED as well as for monitoring staffing indicators.
Another tool was reviewed by the Nursing Times in 2015. This tool uses data collected at least twice year (for example, in January and June) by nurses who gather information on each patient in their wards from Monday to Friday for at least 20 days. The authors found the tool to be valid and said it can help determine baseline decisions for staffing needs. Still, they said, there should be some sort of secondary measure—surveys or external measures—to ensure the ratio is accurate.
Many tools are flawed, and these flaws must be taken into account. For example, a tool may allocate five minutes for a nurse to perform a given task, when in actuality such a task takes seven minutes to complete. Over time, this will add up and impact staffing needs. Thus it is important to consider staffing needs on a case-by-case basis.
The following additional resources may provide more information.