NH Staffing Toolkit July 2010

Toolkit contents will allow reader to:
1. Describe the events leading to the development of the Nurse
Staffing Committee initiative.
2. Describe the role of the Chief Nursing Officer (CNO) in implementing a Nurse Staffing Committee.
3. Describe the duties of the staffing committee.
4. Describe the role of direct care nurses in implementing a
Nurse Staffing Committee
5. Describe the yearly review of the facility wide nursing services staffing plan.

• 2009 Legislation drafted by New Hampshire Nurses’
Association (NHNA) in response to:
– Increasing calls from nurses re: staffing concerns
– Concern about consequences of legislatively mandated patient/nurse ratios, e.g., access to care impacted due to closure of units and hospitals
– Lobbyist representing another states’ collective bargaining organization filed to lobby in NH

• Dialogue between NHNA, NH Hospital Association and NH Organization of Nurse Leaders
• Led to withdrawal of legislation in favor of:
– Voluntary, non-legislative approach to safe staffing
– Influencing practice verses being dictated to
• Nurse Staffing Steering Committee formed:
– Survey
– Development of “tools” based upon results

• Ratios: legislative mandating of staffing minimums
– Fixed – each nurse “must have” only so many patients
– Shift – the shift average meets the minimum (some nurses may have more, some less)
– Puts nursing decisions in the hands of legislators
– Significant recruitment strategy for unions
• traditional focus on staffing – “the nurse as worker” verses
• the nurse as critical thinker delivering quality care

• Staffing Committees:
– Clinical decision making is essential for professional practice
– Provides a framework for evidence based staffing
– Requires:
• Education – both staff nurses and nurse leaders
• Processes in place
– Two options:
• Legislative mandate (the drafted legislation proposed this)
• Robust voluntary plan

• “Direct patient care” – care provided by a nurse with direct responsibility to carry out medical regimens or nursing care for one or more patients.
• “Nursing care unit” - hospital or facility unit, including operating room or other patient care area, in which nursing care is provided to patients who have been admitted to the facility.
• “Nurse” – a person who is licensed to practice as a registered or licensed practical nurse under RSA 328 of the
Nurse Practice Act

• “Chief Nursing Officer” (CNO) – designated nurse executive with accountability for nursing practice within the facility
• “Nurse Staffing Committee” – Standing Committee responsible for establishing staffing guidelines
• “Staffing Guidelines” – Established pattern of assigning nursing hours to patient needs, also referred to as a staffing matrix, staffing plan

Administrative Representatives
Chief Nursing Officer
Clinical directors/nurse managers
Off shift nursing supervisor
Human Resources representative
Finance representative (CFO designee)
Direct Care Nurse Representatives
Critical Care RN/Step Down/Telemtery
Med-Surg RN
Peri Operative RN
Labor/Delivery/Post Partum/NICU
Resource/Float Pool RN

• Surveys
– Pencil and paper
– Online
– Utilize committee members to design
• Unit specific staff meetings
• Open staff forums
• Open office hours
• Solicit emails from nurses
• Unit rounds
• Post drafts online for nurses to review and respond to
• Ask members of committee to hold unit meetings to discuss plan development
• Seek suggestions from
Public Relations,
Communications or
Human Resources

• Provide mechanism for collaboration
• Establish minimum staffing guidelines
• Meet patient needs
• Provide healthy work environment
• Recognize evidence-based standards

Structure of the Staffing Committee includes:
• Not more than 13 members
• At least 50% direct care nurses
• Representation by shift and specialty
• Designated term of service
• Time and resources to participate
• Access to periodic quality evaluation tools
• Meeting minutes accessible to all staff
• Led by CNO or designee

Function of the Staffing Committee is to establish staffing guidelines which consider:
• Individual patient needs
• Aggregate patient needs
• Qualification and competencies of nurses
• Availability of equipment and technology
• Requirements for equipment and technology
• Geographic environment
• Patient safety
• Evidence based standards
• Care delivery models
• Available resources
• Emergency plans

• Review existing staffing guidelines for all units
• Review current evidence based staffing standards
• Offer revisions to staffing guidelines based on annual review
• Annually review staffing guidelines using indicators
– Patient satisfaction
– Nurse satisfaction
– Quality measures
– Fiscal measures

Offer recommendations for nurse staffing guidelines that:
– Are cost effective
– Ensure competent staff
– Ensure specialized skills
– Meet patient needs
– Consides complexity of care
– Consider patient assessment
– Consider patient acuity
– Consider patient census
– Consider volume of patient admissions/discharges/ transfer
– Adjust staffing based on patient needs

• Facility shall provide access to the staffing guidelines to all direct care staff
– Paper copy available in nursing department
– Electronic document
• Facility shall provide access to the staffing guidelines to patients and their families