Description
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Topic: Staffing Shortages
o Description: Healthcare systems often struggle with staffing shortages,
leading
to increased workloads for existing staff and potential impacts on patient
care.
o Interventions: Recruitment campaigns, training programs, flexible
scheduling.
o Keywords: Nurse-to-patient ratio, healthcare recruitment, workload.
Create a 3-5 page annotated bibliography and summary based on your
research related to best practices addressing a current health care problem
or issue.
1- Write a brief overview of the selected health care problem or issue. In your
overview:
• Summarize the health care problem or issue.
• Describe the professional relevance of this topic.
• Describe any professional experience you have with this topic.
2- Identify peer-reviewed articles relevant to this health care issue or problem.
• Conduct a search for scholarly or academic peer-reviewed literature related to
the topic and describe the criteria you used to search for articles, including the
names of the databases you used. You will select four current scholarly or
academic peer-reviewed journal articles published during the past 3–5 years that
relate to your topic.
• Locate appropriate references. Pertaining to the US healthcare system.
• Use keywords related to the health care problem or issue you are researching to
select relevant articles.
3- Assess the credibility and explain relevance of the information sources you find.
• Determine if the source is from an academic peer-reviewed journal.
• Determine if the publication is current.
• Determine if information in the academic peer-reviewed journal article is still
relevant.
4- Analyze academic peer-reviewed journal articles using the annotated
bibliography organizational format. Provide a rationale for inclusion of each
selected article. The purpose of an annotated bibliography is to document a list of
references along with key information about each one. The detail about the
reference is the annotation. Developing this annotated bibliography will create a
foundation of knowledge about the selected topic. In your annotated
bibliography:
• Identify the purpose of the article.
• Summarize the information.
• Provide rationale for inclusion of each article.
• Include the conclusions and findings of the article.
• Write your annotated bibliography in a paragraph form. The annotated
bibliography should be approximately 150 words (1–3 paragraphs) in length.
• List the full reference for the source in APA format (author, date, title, publisher,
et cetera) and use APA format for the annotated bibliography.
• Make sure the references are listed in alphabetical order, are double-spaced, and
use hanging indents.
5- Summarize what you have learned while developing an annotated bibliography.
• Summarize what you learned from your research in a separate paragraph or two
at the end of the paper.
• List the main points you learned from your research.
• Summarize the main contributions of the sources you chose and how they
enhanced your knowledge about the topic.
❖ Describe any professional experience you have with this topic.
• Working under staff is dangerous for the staff member as well as for the patient.
You cannot provide an efficient customer service while meeting the needs of
more patients than you are humanly capable of.
Your assessment should also meet the following requirements:
•
•
•
•
•
•
•
Length: 3–5 typed, double-spaced pages, not including the title page and
reference page.
Font and font size: Times New Roman, 12 point.
APA tutorial: Use the APA Style Paper Tutorial [DOCX] for guidance.
Written communication: Write clearly and logically, with correct use of spelling,
grammar, punctuation, and mechanics.
Content: Provide a title page and reference page following APA style.
References: Use at least four scholarly or academic peer-reviewed journal
articles.
APA format: Follow current APA guidelines for in-text citation of outside
sources in the body of your paper and also on the reference page.
Competencies Measured:
By successfully completing this assessment, you will demonstrate your proficiency in
the following course competencies and scoring guide criteria:
•
Competency 2: Apply scholarly information through critical thinking to solve
problems in the field of health care.
Assess the credibility and relevance of information sources.
Analyze academic peer-reviewed journal articles using the annotated bibliography
organizational format.
Summarize what was learned from developing an annotated bibliography.
• Competency 4: Write for a specific audience, in appropriate tone and style, in
accordance with Capella’s writing standards.
Apply academic peer reviewed journal articles relevant to the health care problem or
issue being researched.
Produce text with minimal grammatical, usage, spelling, and mechanical errors.
Integrate into text appropriate use of scholarly sources, evidence, and citation style.
Topic: Staffing Shortages
o Description: Healthcare systems often struggle with staffing shortages,
leading
to increased workloads for existing staff and potential impacts on patient
care.
o Interventions: Recruitment campaigns, training programs, flexible
scheduling.
o Keywords: Nurse-to-patient ratio, healthcare recruitment, workload.
Create a 3-5 page annotated bibliography and summary based on your
research related to best practices addressing a current health care problem
or issue.
1- Write a brief overview of the selected health care problem or issue. In your
overview:
• Summarize the health care problem or issue.
• Describe the professional relevance of this topic.
• Describe any professional experience you have with this topic.
2- Identify peer-reviewed articles relevant to this health care issue or problem.
• Conduct a search for scholarly or academic peer-reviewed literature related to
the topic and describe the criteria you used to search for articles, including the
names of the databases you used. You will select four current scholarly or
academic peer-reviewed journal articles published during the past 3–5 years that
relate to your topic.
• Locate appropriate references. Pertaining to the US healthcare system.
• Use keywords related to the health care problem or issue you are researching to
select relevant articles.
3- Assess the credibility and explain relevance of the information sources you find.
• Determine if the source is from an academic peer-reviewed journal.
• Determine if the publication is current.
• Determine if information in the academic peer-reviewed journal article is still
relevant.
4- Analyze academic peer-reviewed journal articles using the annotated
bibliography organizational format. Provide a rationale for inclusion of each
selected article. The purpose of an annotated bibliography is to document a list of
references along with key information about each one. The detail about the
reference is the annotation. Developing this annotated bibliography will create a
foundation of knowledge about the selected topic. In your annotated
bibliography:
• Identify the purpose of the article.
• Summarize the information.
• Provide rationale for inclusion of each article.
• Include the conclusions and findings of the article.
• Write your annotated bibliography in a paragraph form. The annotated
bibliography should be approximately 150 words (1–3 paragraphs) in length.
• List the full reference for the source in APA format (author, date, title, publisher,
et cetera) and use APA format for the annotated bibliography.
• Make sure the references are listed in alphabetical order, are double-spaced, and
use hanging indents.
5- Summarize what you have learned while developing an annotated bibliography.
• Summarize what you learned from your research in a separate paragraph or two
at the end of the paper.
• List the main points you learned from your research.
• Summarize the main contributions of the sources you chose and how they
enhanced your knowledge about the topic.
❖ Describe any professional experience you have with this topic.
• Working under staff is dangerous for the staff member as well as for the patient.
You cannot provide an efficient customer service while meeting the needs of
more patients than you are humanly capable of.
Your assessment should also meet the following requirements:
•
•
•
•
•
•
•
Length: 3–5 typed, double-spaced pages, not including the title page and
reference page.
Font and font size: Times New Roman, 12 point.
APA tutorial: Use the APA Style Paper Tutorial [DOCX] for guidance.
Written communication: Write clearly and logically, with correct use of spelling,
grammar, punctuation, and mechanics.
Content: Provide a title page and reference page following APA style.
References: Use at least four scholarly or academic peer-reviewed journal
articles.
APA format: Follow current APA guidelines for in-text citation of outside
sources in the body of your paper and also on the reference page.
Competencies Measured:
By successfully completing this assessment, you will demonstrate your proficiency in
the following course competencies and scoring guide criteria:
•
Competency 2: Apply scholarly information through critical thinking to solve
problems in the field of health care.
Assess the credibility and relevance of information sources.
Analyze academic peer-reviewed journal articles using the annotated bibliography
organizational format.
Summarize what was learned from developing an annotated bibliography.
• Competency 4: Write for a specific audience, in appropriate tone and style, in
accordance with Capella’s writing standards.
Apply academic peer reviewed journal articles relevant to the health care problem or
issue being researched.
Produce text with minimal grammatical, usage, spelling, and mechanical errors.
Integrate into text appropriate use of scholarly sources, evidence, and citation style.
EDITORIAL
Nurse staffing and patient safety in
acute hospitals: Cassandra calls again?
Peter Griffiths , Chiara Dall’Ora
NIHR Applied Research
Collaboration (Wessex),
University of Southampton,
Southampton, UK
Correspondence to
Professor Peter Griffiths, NIHR
Applied Research Collaboration
(Wessex), University of
Southampton, Southampton,
Hampshire, UK;
peter.griffiths@soton.ac.uk
Accepted 8 November 2022
Published Online First
6 December 2022
► http://dx.doi.org/10.1136/
bmjqs-2022-015291
© Author(s) (or their
employer(s)) 2023. No
commercial re-use. See rights
and permissions. Published by
BMJ.
To cite: Griffiths P, Dall’Ora C.
BMJ Qual Saf
2023;32:241–243.
The risk of adverse patient outcomes,
including death, is lower in hospitals that
provide more registered nurses to care
for patients on inpatient wards. The association has been demonstrated in a body
of evidence comprising several hundred
studies, involving hundreds of hospitals and
millions of patients from around the world.
The association has been shown at hospital
level in large cross-sectional studies and in
a growing number of longitudinal studies
examining the effect of variation in staffing
experienced by individuals.1–3 In the context
of such an extensive body of evidence, one
might ask what could possibly be left to
discover?
In this issue of BMJ Quality and Safety,
Zaranko and colleagues contributed some
important new evidence.4 Their findings
highlight further the potential consequences
of the nursing shortages being experienced
in many countries. Using data from 53
inpatient wards from three hospitals in the
English National Health Service (NHS), the
study focused on team size and composition, linking daily staffing rosters to patient
outcomes. Adding an additional registered
nurse to the average ward team on a shift
reduced the odds of a patient death on that
day by 9.6%. Adding more senior nurses (as
measured by pay grade) had a larger effect
than adding more junior registered nurses,
whereas increases in assistant staff (healthcare support workers) and agency employed
registered nurses were not associated with
reduced mortality.
These findings support those of other
studies that have used varied designs and
taken different approaches to exploring
team composition. A systematic review of
63 mainly cross-sectional studies found that
a nursing team with a higher proportion of
registered nurses was associated with lower
mortality and other adverse outcomes.5
Others using more sophisticated longitudinal
designs have found beneficial effects from
higher assistant staffing,6 while research
published by our team in BMJ Quality
and Safety in recent years has pointed to
complex non-
linear relationships between
assistant staffing and quality, with possible
interactions between assistant staffing and
registered nurse staffing levels.7 8 In general,
this research all supports the same conclusion. Support staff are important members
of the team, but they are not effective substitutes for registered nurses when it comes to
maintaining patient safety. Without sufficient registered nurses to supervise support
staff, benefits are not realised and harm can
occur. Similarly, agency staff are not effective substitutes, with other studies indicating possible harms arising from heavy
reliance on temporary staff.9 Zaranko et al
go beyond the existing research in showing
the additional benefits of more senior registered nurses.
These findings are important because they
highlight the importance of skill mix. Strategies that focus exclusively on increasing
numbers to address staff shortages may be
harmful if they lead to a dilution of skill mix
or a reduced number of highly skilled staff,
although such strategies are still advocated.
Zaranko et al’s new study is also important
simply because it offers more diversity to
the methods used to demonstrate associations between nurse staffing and patient
outcomes. Although many regard evidence
that staffing levels and skill mix influence
outcomes as statements of the obvious,
questions about causal inference remain for
others, with some senior figures, including
health policy makers, appearing to dismiss
the causal connection.10 Despite the close
alignment between staffing and outcome
data in Zaranko et al’s research, this is an
observational study, as is almost all other
research on this topic. This research is
novel in the way that daily staffing levels
are associated with daily outcomes with
direct linkage between patient outcomes
and team composition. The fact that similar
findings come from diverse study designs
Griffiths P, Dall’Ora C. BMJ Qual Saf 2023;32:241–243. doi:10.1136/bmjqs-2022-015578
241
Editorial
lend increasing weight to a causal interpretation and the
absence of experimental studies can no longer be used to
dismiss evidence such as this as ‘merely showing an association’. Much like the denials of evidence for a causal
association between lung cancer and smoking, maintained by senior figures in the tobacco industry well after
the epidemiological evidence was clear, the proposition
that staffing levels have no causal influence on patient
outcomes seems increasingly absurd.
However, acting on the evidence is more difficult.
In Greek mythology, Cassandra was a Trojan priestess
and prophet, whose true prophecies were fated to be
ignored. Similarly, the evidence on nurse staffing and
patient outcomes has, in many respects, been effectively ignored by policy makers and those in charge
of planning workforce requirements. Outright denial
is rare, but effective action has not been taken, with
inertia seemingly fuelled by a false belief that the
consequences of predicted staff shortages could be
averted. In the UK, a growing shortage of registered
nurses is underpinned by a persistent failure to provide
enough training capacity for the projected demand, in
part supported by an assumption that demand could
be reduced by using more support staff.11 Enquiries
into failings in hospital care have revealed inadequate
nurse staffing as a core factor,12 13 with low registered nurse staffing ‘enabled’ by use of support staff
as a cheaper alternative. The NHS in England uses
a benchmarking approach that equates productivity
with care hours per patient day from registered and
assistant staff combined, compounding the impression
of a degree of equivalence and seemingly oblivious to
the evidence that links skill mix and registered nurse
staffing levels to the quality and safety of care. As we
note below, there is even some evidence indicating that
reducing skill mix reduces productivity.
So, why has the substantive body of research on nurse
staffing led to so little action? In part, it might be due to
national and local decision makers being affected by the
normalcy bias, a cognitive bias that leads people to simply
ignore warnings of imminent threat.14 Perceptions about
limitations of the evidence base have clearly inhibited decisive action in some circumstances. In developing guidance
on safe staffing for England in 2014, the National Institute for Health and Care Excellence noted that evidence
was of insufficient quality to inform decision-making. Yet
many system changes are implemented in health services
with far weaker evidence. For example, while electronic
medical records seem an obvious necessity in modern
healthcare, evidence of clinical or economic benefits from
their implementation is sparse and often contradictory.15
The assumption that future changes in care delivery
will dramatically alter the demand for staff has often
underpinned optimistic appraisals that demand for staff
can be reduced. Technology is often offered as the solution to workforce shortages but evidence to support such
claims is scant and, in many cases, it appears that workload is increased.16 Healthcare is labour intensive and
242
likely to remain so for the foreseeable future. Extraordinary advances in health technology in the modern era
have created opportunities to improve care outcomes but
rarely do they remove the need for people to support the
delivery of care. Improved modes of treatment alongside
better housing conditions and a growing awareness of the
adverse effects of simply being in hospital for a period
of recovery have enabled hospitals to operate with fewer
beds relative to activity but increased acuity of patients
means that more nurses are required to safely staff each
bed.
In many countries, a shortage in supply of registered nurses provides a seemingly compelling case
to search for alternatives and innovation should not
be ruled out, provided it is supported by evidence.
What is less clear, as in the case of perennial failures of
workforce planning in the UK, is whether those who
control the policy levers, be they government departments commissioning training or those setting wages
and working conditions, have ever fully committed to
solving the registered nursing shortage with the one
evidence-based solution we already know of—more
registered nurses. It is unclear why this is the case. In
part, local decision makers may feel powerless in the
face of system supply issues or the pressure of finance
directors to control costs. Certainly, any significant
increase in the number of registered nurses appears
to be potentially expensive for the simple reason that
registered nurses are such a large proportion of the
hospital workforce, and hence, the pay bill.
If the costs of expanding the registered nurse workforce could be a major factor inhibiting action, close
attention has to be paid to the economics of nurse
staffing and the relevant evidence. Generically, there is
evidence that spending on healthcare gives a positive
return on investment through increased population
health, keeping more people economically active, in
addition to the immediate contribution of the spending
power of workers in this labour-intensive sector of
the economy.17 Government spend on healthcare can
therefore make a significant contribution to economic
growth. A position of principle that society simply
cannot afford the additional expense of investing in
nurse staffing must therefore be questioned and should
never be taken as a given. Is nurse staffing the best
investment to make in healthcare? In truth, that is a
hard question to answer, although evidence indicates
a possibility that increases in registered nurse staffing
in acute hospitals may be cost-effective at a level that
makes it a strong candidate for investment, and there
is more evidence that a shift towards a more skilled
nursing workforce could be cost neutral because of
improved patient outcomes and more efficient use
of beds.8 18–20 More research into the economics of
nurse staffing and approaches to determining staffing
requirements (a field distinguished by a staggering
volume of outputs but remarkably little progress21) is
certainly needed, but that should not obscure the fact
Griffiths P, Dall’Ora C. BMJ Qual Saf 2023;32:241–243. doi:10.1136/bmjqs-2022-015578
Editorial
that the current evidence provides some clear priorities for action.
In the 1990s, a compelling case was made by the
evidence-based practice movement that implementing
interventions that were already known to be effective
was likely to provide a better return on investment
than the discovery of novel treatments. Zaranko et
al’s study contributes to a body of evidence that reinforces the same point about staffing health services.
Investment in training registered nurses, including
continuing professional education and developing a
cadre of experienced and skilled senior clinical nurses,
is an evidence-based solution that is likely to provide
good returns. Perhaps it is time to stop looking for
alternatives. It is certainly time to stop implementing
solutions that are likely to be ineffective.
Cassandra prophesised the fall of Troy. With many
now fearing the collapse of the publicly funded NHS
in the UK in the face of staffing shortages that have
been predicted for some time, the message of this
research is that you cannot deliver safe modern healthcare without enough registered nurses, including
senior experienced clinical nurses, on hospital wards.
It is time that those able to make decisions at a local
and national level listened and acted.
Twitter Peter Griffiths @workforcesoton and Chiara Dall’Ora
@ora_dall
Contributors PG and CD both drafted the manuscript,
reviewed it and revised it. Both approved the final version.
Funding This study was funded by NIHR Applied Research
Collaboration (Wessex).
Competing interests Both PG and CD receive funding from
the National Institute for Health Research for research projects
related to nurse staffing.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Commissioned; internally peer
reviewed.
ORCID iDs
Peter Griffiths http://orcid.org/0000-0003-2439-2857
Chiara Dall’Ora http://orcid.org/0000-0002-6858-3535
REFERENCES
1 Dall’Ora C, Saville C, Rubbo B, et al. Nurse staffing levels and
patient outcomes: a systematic review of longitudinal studies.
Int J Nurs Stud 2022;134:104311.
2 Kane RL, Shamliyan TA, Mueller C, et al. The association
of registered nurse staffing levels and patient outcomes:
systematic review and meta-analysis. Med Care
2007;45:1195–204.
3 Shekelle PG. Nurse-patient ratios as a patient safety strategy: a
systematic review. Ann Intern Med 2013;158:404–9.
4 Zaranko B, Sanford NJ, Kelly E, et al. Nurse staffing
and inpatient mortality in the english national health
Griffiths P, Dall’Ora C. BMJ Qual Saf 2023;32:241–243. doi:10.1136/bmjqs-2022-015578
service: a retrospective longitudinal study. BMJ Qual Saf
2023;32:254–63.
5 Twigg DE, Kutzer Y, Jacob E, et al. A quantitative systematic
review of the association between nurse skill mix and nursing-
sensitive patient outcomes in the acute care setting. J Adv Nurs
2019;75:3404–23.
6 Needleman J, Liu J, Shang J, et al. Association of registered
nurse and nursing support staffing with inpatient hospital
mortality. BMJ Qual Saf 2020;29:10–18.
7 Griffiths P, Maruotti A, Recio Saucedo A, et al. Nurse staffing,
nursing assistants and hospital mortality: retrospective
longitudinal cohort study. BMJ Qual Saf 2019;28:609–17.
8 Griffiths P, Ball J, Bloor K, et al. Nurse staffing levels, missed
vital signs and mortality in hospitals: retrospective longitudinal
observational study. Health Services and Delivery Research
2018;6:1–120.
9 Dall’Ora C, Maruotti A, Griffiths P. Temporary staffing
and patient death in acute care hospitals: a retrospective
longitudinal study. J Nurs Scholarsh 2020;52:210–6.
10 Cayton H. Mandating staffing levels is not the answer to
reducing poor care. Health Service Journal 2012.
11 Buchan J, Gershlick B, Charlesworth A. Falling short: the NHS
workforce challenge. London: The Health Foundation, 2019.
12 The Mid Staffordshire NHS Foundation Trust Inquiry chaired
by Robert Francis QC. Independent inquiry into care provided
by mid Staffordshire NHS Foundation trust January 2005 –
March 2009. London: The Stationary Office, 2010.
13 Keogh B. Review into the quality of care and treatment
provided by 14 Hospital trusts in England: overview report:
NHS, 2013.
14 Drabek TE. Human system responses to disaster: An inventory
of sociological findings: Springer Science & Business Media,
2012.
15 Reis ZSN, Maia TA, Marcolino MS, et al. Is there evidence
of cost benefits of electronic medical records, Standards, or
Interoperability in hospital information systems? overview of
systematic reviews. JMIR Med Inform 2017;5:e26.
16 Priestman W, Sridharan S, Vigne H. What to expect from
electronic patient record system implementation; lessons
learned from published evidence. Journal of Innovation in
Health Informatics 2018;25:13.
17 Reeves A, Basu S, McKee M, et al. Does investment in the
health sector promote or inhibit economic growth? Global
Health 2013;9:43.
18 Griffiths P, Saville C, Ball JE, et al. Beyond ratios flexible and resilient nurse staffing options to deliver
cost-effective hospital care and address staff shortages: A
simulation and economic modelling study. Int J Nurs Stud
2021;117:103901.
19 Twigg DE, Myers H, Duffield C, et al. Is there an economic
case for investing in nursing care–what does the literature tell
us? J Adv Nurs 2015;71:975–90.
20 Needleman J, Buerhaus PI, Stewart M, et al. Nurse staffing
in hospitals: is there a business case for quality? Health Aff
2006;25:204–11.
21 Griffiths P, Saville C, Ball J, et al. Nursing workload, nurse
staffing methodologies and tools: a systematic scoping review
and discussion. Int J Nurs Stud 2020;103:103487.
243
© 2023 Author(s) (or their employer(s)) 2023. No commercial re-use. See
rights and permissions. Published by BMJ.
International Journal of Nursing Studies 117 (2021) 103901
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
Beyond ratios – flexible and resilient nurse staffing options to deliver
cost-effective hospital care and address staff shortages: A simulation
and economic modelling study
Peter Griffiths a,b,c,∗, Christina Saville a,b, Jane E. Ball a,b, Jeremy Jones a, Thomas Monks d , On
behalf of the Safer Nursing Care Tool study team
a
Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
National Institute for Health Research Applied Research Collaboration (Wessex), Southampton, UK
c
Portsmouth Hospitals University NHS Trust, Portsmouth, UK
d
University of Exeter Medical School, Exeter, UK
b
article info
abstract
Article history:
Received 2 November 2020
Received in revised form 25 January 2021
Accepted 4 February 2021
Background: In the face of pressure to contain costs and make best use of scarce nurses, flexible staff
deployment (floating staff between units and temporary hires) guided by a patient classification system
may appear an efficient approach to meeting variable demand for care in hospitals.
Objectives: We modelled the cost-effectiveness of different approaches to planning baseline numbers of
nurses to roster on general medical/surgical units while using flexible staff to respond to fluctuating demand.
Design and setting: We developed an agent-based simulation, where hospital inpatient units move between being understaffed, adequately staffed or overstaffed as staff supply and demand (as measured by
the Safer Nursing Care Tool patient classification system) varies. Staffing shortfalls are addressed by floating staff from overstaffed units or hiring temporary staff. We compared a standard staffing plan (baseline
rosters set to match average demand) with a higher baseline ‘resilient’ plan set to match higher than
average demand, and a low baseline ‘flexible’ plan. We varied assumptions about temporary staff availability and estimated the effect of unresolved low staffing on length of stay and death, calculating cost
per life saved.
Results: Staffing plans with higher baseline rosters led to higher costs but improved outcomes. Cost savings from lower baseline staff mainly arose because shifts were left understaffed and much of the staff
cost saving was offset by costs from longer patient stays. With limited temporary staff available, changing
from low baseline flexible plan to the standard plan cost £13,117 per life saved and changing from the
standard plan to the higher baseline ‘resilient’ plan cost £8,653 per life saved.
Although adverse outcomes from low baseline staffing reduced when more temporary staff were available, higher baselines were even more cost-effective because the saving on staff costs also reduced. With
unlimited temporary staff, changing from low baseline plan to the standard cost £4,520 per life saved
and changing from the standard plan to the higher baseline cost £3,693 per life saved.
Conclusion: Shift-by-shift measurement of patient demand can guide flexible staff deployment, but the
baseline number of staff rostered must be sufficient. Higher baseline rosters are more resilient in the
face of variation and appear cost-effective. Staffing plans that minimise the number of nurses rostered in
advance are likely to harm patients because temporary staff may not be available at short notice. Such
plans, which rely heavily on flexible deployments, do not represent an efficient or effective use of nurses.
Study registration: ISRCTN 12307968
Tweetable abstract: Economic simulation model of hospital units shows low baseline staff levels with
high use of flexible staff are not cost-effective and don’t solve nursing shortages.
© 2021 The Author(s). Published by Elsevier Ltd.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
Keywords:
Costs and cost analysis
Computer simulation
Cost savings
Health care economics and organizations
Hospital information systems
Nursing staff
Hospital
Patient classification systems
Personnel staffing and scheduling
Nursing administration research
Operations research
Patient safety
Quality of health care
Safer Nursing Care Tool
Workload
∗
Corresponding author at: Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.
E-mail address: peter.griffi[email protected] (P. Griffiths).
https://doi.org/10.1016/j.ijnurstu.2021.103901
0020-7489/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
2
P. Griffiths, C. Saville, J.E. Ball et al. / International Journal of Nursing Studies 117 (2021) 103901
What is already known about the topic?
• Because nursing is the largest staff group, accounting for
a significant proportion of hospitasl’ variable costs, nurse
staffing is frequently the target of cost containment measures
• Staffing decisions need to address both the baseline staff
establishment to roster, and how best to respond to fluctuating demand as patient census and care needs vary
• Flexible deployment of staff, including floating staff and
using temporary hires, has the potential to reduce expenditure while meeting varying patient need, but high use of
temporary staff may be associated with adverse outcomes.
What this paper adds
• Low baseline staff rosters that rely heavily on flexible staff
provide cost savings largely because units are often left
short staffed, leading adverse patient outcomes and increased non-staff costs.
• A staffing plan set to meet average demand is cost effective compared to a plan with a lower baseline.
• A staffing plan with a higher baseline, set to meet demand
90% of the time, is more resilient in the face of variation
and may still be highly cost effective
1. Introduction
In the face of pressure to contain costs and to use nursing staff,
who are in short supply, as efficiently as possible, it is important
to understand how best to plan staffing on hospital units. Key decisions relate to
