International Proceedings of Social and Behavioral Sciences, 2014
Vol. 2, No.1, 63-73
URL: http://www.pakinsight.com/?ic=projournal&journal=IPSBS
NURSE STAFFING: A CONCEPT ANALYSIS
Ying Liu
Faculty of Nursing, Chulalongkorn University Bangkok, Thailand, School of Nursing, Dalian
Medical University, Dalian city, China
Yupin Aungsuroch
Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand
Ping Jiang
School of Nursing, Dalian Medical University, Dalian city, China
Feng Ge Wang
The People’s Hospital of Baoan, Shenzhen city, China
ABSTRACT
This study aims to undertake a concept analysis of nurse staffing. Research studies show that nurse
staffing would have a significant impact on nurse, patient and hospital outcomes. However, a
theoretical definition of what exactly “nurse staffing” means is not clear. Therefore, Walker and
Avant's approach of concept analysis is used. Dictionaries, books, theses/dissertations, research
articles from Cumulative Index to Nursing and Allied Health Literature (CINAHL), Science direct,
PubMed, and Google Scholar databases were applied to search concept analysis topics in the
process. The result shows that the main attributes of nurse staffing are (1) nurses’ quantity and (2)
nurses’ quality. The antecedents of nurse staffing include demand factors and supply factors. The
consequences of nurse staffing have an essential impact on nurse, patient, and hospital outcomes.
This analysis provides nurse managers with a new perspective to look at nurse staffing, which does
not only consider the number of nurses, but also the qualification of nurses. These results may
further influence health policy makers to consider both quantity and quality of the global nursing
shortage.
What is already known about this topic?
-Nurse staffing significantly impacts nurse, patient, and hospital outcomes.
What this paper adds?
-The attributes of nurse staffing include two main attributes, which are nurses’ quantity and
nurses’ quality.
-The demand and supply model is used to explain the factors influencing the antecedents of nurse
staffing within the current global situation.
-The conceptual model of nurse staffing gives the health policy maker a clear picture of the
attributes, antecedents, consequences, and empirical indicators pertaining to nurse staffing.
© 2014 Pak Publishing Group. All Rights Reserved.
KEYWORDS: Concept analysis, Nurse staffing, Outcome, Attribute, Antecedent, Consequence,
Case, Empirical indicator
INTRODUCTION
In the examination of the global health workforce crisis, World Health Report stated that the
most critical issue facing health care systems nowadays is the shortage of the people who make
them work (World Health Organization, 2003). In 2006, the World Health Organization (WHO)
devoted the whole World Health Report to analyzing the negative impact of human resource
shortages on global health care (World Health Organization, 2006). Based on these estimates, it
foresees that there are 57 countries with critical shortages equivalent to a global deficit of 2.4
million doctors, nurses, and midwives.
In health care organizations, nurses are the major profession. A nursing shortage is being
experienced across virtually all westernized healthcare systems, including the USA (World Health
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Organization, 2008) and Canada (Spurgeon, 2000), with the same situation existing in far eastern
countries such as China. According to the WHO report (World Health Organization, 2008), close to
a million professional nurses will be needed by 2020 in the United States of America. In China,
according to the Chinese national nursing career development outline (Ministry of Public Health,
2012), at the end of the 2015, 2,860,000 nurses are needed due to an increasing demand of the
population. Until 2011, there were 2,233,000 registered nurses in China. Thus, there are still
627,000 vacant nursing positions that need filling in order to achieve the minimum required
number of registered nurses (RNs).
An increasing body of evidence indicates that adequate nurse staffing is required for patient
safety and to justify nursing resource allocations. Several staffing variables are found that are
associated with nurse, patient, and hospital outcomes. For example, the empirical studies support
the idea that adequate nurse staffing is related to a nurse‟s positive perception of job satisfaction
(Davidson et al., 1997; Shaver and Lacey, 2003; Dunn et al., 2005) and reduced nurses‟ burnout
(Aiken et al., 2002; Sheward et al., 2005). Moreover, nurse staffing variables have also been
reported to influence patients‟ mortality (West et al., 2009), pressure ulcers (Yang, 2003), failureto-rescue (Halm et al., 2005), and patient satisfaction (Seago et al., 2006; Tervo-Heikkinen et al.,
2008). Furthermore, it is found that nurse staffing variables significantly impact hospital outcomes,
such as nurse-assessed quality nursing care (Rafferty et al., 2007), personal cost per patient day
(Thungjaroenkul et al., 2008), and a patient‟s length of stay (LOS) (Tschannen and Kalisch, 2009).
In the empirical staffing research, some authors used the term skill mix, while some authors used
patient to nurse ratio or hours per patient day (HPPD). In addition, the term full time equivalent
(FTE), nurses‟ education, nurses‟ experience, and nurses‟ perceived staff adequacy are also found
in nurse staffing studies. Manojlovich and Sidani stated that the majority of staffing studies “gave
little explanation for why a specific staffing variable was chosen over others” (Manojlovich et al.,
2011). Since the definition of nurse staffing is not clear, the theoretical definition of nurse staffing
should be determined through conceptualizing the attributes of this concept. Then, the empirical
indicators that reflect these concept attributes would be beneficial for measuring this concept.
Therefore, the aim of this analysis is to determine the attributes, antecedences, consequences, and
empirical indicators of nurse staffing by using Walker and Avant‟s concept analysis process.
METHODS
This paper defines the attributes of nurses staffing using the eight-step Walker and Avant
process of concept analysis method: (1) select a concept; (2) determine the purpose of the analysis;
(3) identify all uses of the concept; (4) determine the defining attributes; (5) construct a model case;
(6) construct a borderline, related, and contrary case; (7) Identify antecedents and consequences;
and (8) Define empirical referents. The main objectives of the concept analysis process are to
identify the attributes and provide researchers with a precise definition of the concept. Thus, this
analysis could provide the conceptualized definition and the aforementioned concept analysis
process contents of nurse staffing. Dictionaries, books, theses/dissertations and research articles,
which cover the year from 1994 to 2014, were reviewed. A total of 51 articles were used for this
analysis.
RESULT
In accordance with Walker and Avant‟s concept analysis process (Walker and Avant, 2005),
the results of the definitions, attributes, case descriptions, antecedents, consequences, and empirical
referents related to nurse staffing have been written in this part.
A. Definitions Related to Nurse Staffing
1) Dictionary Definitions of Nurse
“Nurse staffing” does not appear in dictionaries as one term. Since the word “staffing” does
not appear in the following dictionary, the word “nurse” was first reviewed.
According to Collins English Dictionary & Thesaurus‟s description, nurse is “a person, often a
woman, who is trained to tend the sick and infirm, assist doctors” (Summers and Holmes, 2006).
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Cambridge dictionary of American English states nurse is “a person trained to care for people who
are sick or not able to care for themselves because of injury or old age, and who may also help
doctors in treating people” (Landau, 2000). Similarly, the New Oxford American Dictionary
defines the word “nurse” as “a person trained to care for the sick or infirm, esp. in a hospital”
(Jewell and Abate, 2001). Moreover, Merriam-Webster's Collegiate Dictionary defines nurse as a
noun in two ways “one that look after, fosters, or advises” and “a person who is skilled or trained in
caring for the sick or infirm especially under the supervision of a physician” (Merriam-Webster's
Collegiate Dictionary, 1998).
2) The Definitions of Staffing
The business dictionary defines staffing as “the selection and training of individuals for
specific job functions, and charging them with the associated responsibilities” (Business
Dictionary). In the management discipline, Heneman III et al. (2011) defines staffing as the process
of deploying, acquiring, and retaining a workforce of sufficient quantity and quality to create
positive impacts on the organization‟s effectiveness. In the science industry, Plott et al. defines
staffing as the accurate number of people with the available abilities and skills to support factory
events and operations (Plott et al., 2006).
3) Literature Definition of Nurse Staffing
In literature cited here, the following research has discussed nurse staffing. For example,
Douglass (1988) and Sullivan and Decker (1997) define nurse staffing as a process of determining
and allocating an appropriate amount and mix of nursing personnel to fulfill positions in nursing
organizations and units. Similarly, Yoder-Wise mentions nurse staffing as “the function of planning
for hiring and allocating qualified nurses‟ resources to meet the needs of patients for care and
services” (Yoder-Wise, 2003). Sullivan and Decker define nurse staffing as providing suitable
numbers and categories of nurses in order to make nursing care efficient and effective (Sullivan and
Decker, 2005). Nurse staffing is also defined as “the process used to determine and deploy the
acceptable number and skill mix of personnel needed to meet the care needs of patients in a
program, unit or healthcare setting” (Canadian Health Services Research Foundation, 2006).
Similarly, nurse staffing refers to “the number and type of workers employed by an agency to
provide nursing care to the persons served by the agency” (Fitzpatrick and Wallace, 2006). In
addition, Nantsupawat defines nurse staffing as the number of patients cared for by one nurse in a
nursing unit (Nantsupawat, 2010).
B. Attributes or Characteristics of Nurse Staffing
Walker and Avant define attributes as the characteristics that appear in a concept repeatedly,
and help researchers differentiate the occurrence of a specific phenomenon from a similar one
(Walker and Avant, 2005).
From the aforementioned definitions, two main characteristics of nurse staffing are
synthesized: nurses‟ quantity and nurses‟ quality. Nurses‟ quantity refers to the adequate number of
nurses that provide nursing care. Nurses‟ quality refers to nurses‟ skills to provide the nursing care,
such as type/category or skill mix of nurses.
C. Cases Description and Analysis for Nurse Staffing
The model case, borderline case, related case, and contrary case are demonstrated in this
analysis. Walker and Avant (2005) state that (1) a model case demonstrates “all defining attributes
of the concept” (p.69); (2) a borderline case contains “most of the defining attributes of the concept
being examined but not all of them” (p.70); (3) a related case demonstrates “ideas that are very
similar to the main concept but that differ from them when examined closely” (p.71); and (4) a
contrary case is a “clear example of not the concept”(p.71). Examples of each of the three types of
cases are provided below.
1) Model Case
Hospital A was a remarkable hospital. It attracted competent nurses to work there. The nurse to
patient ratio was 1:4. According to the number of patients in one unit, twelve RNs worked as full65
International Proceedings of Social and Behavioral Sciences, 2014, 2(1): 63-73
time workers (40 hours per week, 52 weeks one year). Three RNs worked as part-time workers (20
hours per week, 52 weeks one year). Additionally, two licensed practical nurses (LPNs), under an
RN‟s supervision, worked as full-time workers. The human resource department manager
calculated FTE for RNs in this unit was 40×52×12+20×52×3=28080. The FTE for LPNs was
40×52×2=4160. Additionally, nurses‟ tasks were allocated according to nurses‟ work experience
and educational background. HPPD was documented electronically according to the type of nurses,
such as RNS or LPNS. In addition, from the hospital survey, it also found that nurses reported that
this hospital did have enough nurses to provide qualified patient care.
This model case illustrates the successful achievement of all the attributes of the nurse staffing
concept. First, nurses‟ tasks were allocated regarding their education and experience. The
categories of nurses in this ward included both RNs and LPNs. Therefore, the nurse staffing
attribute of nurses‟ quality was achieved. Second, FTE was used to measure nursing workforce in
the ward. HPPD, nurse-patient ratio, and nurse perceived staffing adequacy were included in this
case as well. Thus, the attribute of nurses‟ quantity did exist.
2) Borderline Case
Hospital B was a tertiary general hospital. The nurse to patient ratio was 1:6. Additionally, the
nursing tasks were allocated according to nurse work experience and educational background as
well. In one inpatient ward, three LPNs were under RNs supervision. Moreover, by using the
hospital documentation system, HPPD was documented according to the type of nurses.
In this case, not all nurse staffing attributes appeared. The attribute of nurses‟ quality was
included, since the nurses‟ education, nurses‟ experience, and skill mix were mentioned in this
case. However, the attribute of nurses‟ quantity was lacking because FTE and nurse perceived
staffing adequacy were not recorded in the case.
3) Related Case
Hospital C was a tertiary general hospital. This hospital recruited nurses from the formal
nursing schools. New nurses took part in the department rotation during the beginning of three
years‟ work in order to get a variety of work experience. In one unit, the RN to LPN ratio was 5:1.
According to the number of patients in this unit, eight RNs worked as full time workers (40 hours
per week, 52 weeks one year). Two RNs worked as part time workers (20 hours per week, 52
weeks one year). Additionally, two LPNs were supervised by a RN and worked as full time
workers. The human resource department manager calculated the FTE for RNs in this unit as
40×52×8+20×52×3=19760. The FTE for LPNs was 40×52×2=4160. HPPD was documented
electronically regarding the type of nurses, such as RNS or LPNS. In addition, this unit also used the
HPPD system and the nurse to patient ratio was 1:8. Since there were enough nurses working in
this unit, the average number of LOS was seven days. This related case illustrated the successful
achievement of all attributes of the nurse dose concept, which includes the attributes of purity,
amount, frequency, and duration. Nurses‟ education and experience reflected the purity attribute.
The FTE was described as the amount attribute. The HPPD and nurse to patient ratio represented
the frequency attribute. The LOS was used to explain the duration attribute.
4) Contrary Case
In one private clinic, RNs tasks were allocated depending on how many patients visited the
clinic. The clinic manager did not calculate the nurse workforce requirement by using FTE. Thus,
nurses had flexible work schedules in accordance with the actual clinic situation.
In this case, all attributes of nurse staffing had absented. First, neither nurses‟ education,
nurses‟ experience, or skill mix were introduced. Therefore, the attribute of nurses‟ quality was not
maintained. Second, FTE, HPPD, nurse to patient ratio, or nurse perceived staffing adequacy were
not mentioned in this case as well, thus causing the attribute of nurses‟ quantity to be lacking.
D. Antecedents of Nurse Staffing
“Antecedents are those events or incidents that must occur prior to the occurrence of the
concept” (Walker and Avant, 2005). Sources show that the factors that influence nurse staffing can
be divided into two groups: demand factors and supply factors.
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1) Demand Factors Influence Nurse Staffing
The following factors are related to the demand side: (1) the increasing aging population with a
shift from hospital to home care service (Booth, 2002; Oulton, 2006), (2) spreading of infectious
disease, such as HIV/AIDS and tuberculosis (Oulton, 2006), (3) patient diagnosis or conditions
(Pay et al., 1996).
A) The Increasing Aging Population with a Shift from Hospital to Home Care Service
Several researchers have stated that an increasing aging population causes an increase in the
number of nurses (Booth, 2002; McCatheon, 2006; Oulton, 2006). Since advances in science and
medicine result in a decreased death rate and an increased life expectancy (Guo, 2008), people live
longer than before. For example, in the United States, the recent census reports that nearly 35
million individuals were 65 and older, approximately one in eight Americans. By 2030, one in five
Americans will be older than 65 (Himes, 2002). Similarly, in China, the older adult population is
143 million, comprising 20% of the older adult population in the world (Wang, 2004). It is
estimated that the older adult population in China is increasing at a rate of 3.2% per year; therefore,
by 2020, the proportion of older adults will be increased to 16% (China Sustainable Development
Insituition, 2000) and by 2040, older adults will comprise over 27% of the national population in
China (Populiation Council, 2005). Under this situation, more nurses will be required to provide
nursing service for the aging population.
B) Infectious Disease, Such As HIV/AIDS and Tuberculosis
According to the literature reviewed, it has been mentioned that infectious diseases, such as
HIV/AIDS and tuberculosis cases, will increase the need of nurses as well (Oulton, 2006), since the
number of people living with those infectious diseases has increased dramatically. For example, the
number of people living with HIV rose from an estimated 29.5 million in 2001 to 33 million in
2007 (United Nations, 2008). In addition, the tuberculosis incidence rate increased its distribution
from 1.35 million in 2004 to 18 million in 2006. In 2006, there were an estimated 1.7 million
deaths due to tuberculosis and 14.4 million people were infected with the disease (United Nations,
2008). Therefore, more nurses with specialized training in taking care of infectious disease patients
are needed as well.
C) Patient Diagnosis or Conditions
Patient diagnosis or conditions also influenced nurse staffing. For example, Pay et al. (1996)
surveyed 12 home care agencies in Massachusetts to report the home health resource use in patients
with different diagnoses. The results found that, during a period of one year, AIDS patients
required 33.3 home visits, infants and pregnant women required 25.1 home visits, and medicalsurgical patients required a mean of 8.1 home visits. Additionally, Brooten et al. (2001) conducted
randomized clinical trials to provide prenatal care and home follow-up to women with high-risk
pregnancies. Women with progestational diabetes required the highest mean number of contacts
(M=109.8, SD=47.86), followed by women with chronic hypertension (M=99.8, SD=29.65),
women at risk of preterm labor (M=84.5, SD=33.65), women with gestational diabetes (M=64.5,
SD=27.09), and women with diagnosed preterm labor (M=54.8, SD=20.99). Therefore, the
allocation of nurses should also consider the patients‟ diagnoses or conditions.
2) Supply Factors Influence Nurse Staffing
Factors that influence nurse staffing on the supply side include the following aspects: (1)
legislation (Spetz et al., 2000); and (2) work environment factors (Booth, 2002; Goodin, 2003;
McCatheon, 2006; Oulton, 2006; American Association of Colleges of Nursing, 2009).
A) Legislation
Legislation is one of the factors that influence nurse staffing. According to Spetz, Seago,
Coffman, Roseneff, and O'Neil‟s report (Spetz et al., 2000), in order to maintain patient safety, the
California legislation requires a ratio of one nurse to six medical surgical patients, one to four
pediatric patients, one to four mother-baby couples, one to two laboring patients, and one to one for
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trauma patients. However, in other countries, this ratio may vary according to each country‟s
situation.
B) Work Environment Factors
A good working environment attracts and retains nurses to continue working at the current
place. Censullo (2008) explained that a reputation of having a poor working environment serves as
a deterrent to new recruits and disheartens even tenured nurses. Turnover at an organizational level
is seen to be a major contributor to the number of nurses (Gauci-Borda and Norman, 1997).
According to many sources, working environment has been found to significantly influence
nurses‟ intention to leave (Gardner et al., 2007; Hwang and Chang, 2009), which further
contributes to turnover (Davidson et al., 1997). In addition, other factors in the work setting, such
as job satisfaction (Shields and Ward, 2001; Larrabee et al., 2003) and workload (Aiken et al.,
2002) are also found to impact a nurse‟s intention to leave. Thus, work environment factors have a
correlating relationship with the number of nurses.
E. Consequences of Nurse Staffing
“Consequences are those events or incidents that occur as a result of the occurrence of the
concept” (Walker and Avant, 2005). The effect of nurse staffing would be on nurse outcomes,
patient outcomes, and hospital outcomes.
1) Nurse Staffing Impact on Nurse Outcomes
Research points out several studies that show that nurse staffing significantly influences nurse
job satisfaction, nurse burnout, intention to leave, nurse assessed quality of care, or adverse nurse
events. For example, Sheward et al. (2005) divided nurse to patient ratio into four levels, which
account as 0-4, 5-8, 9-12, to 13 or greater. When numbers of patients to nurses increase, risk of
emotional exhaustion (OR=0.57, 0.67, 0.80 to 1.00, P<0.01) and dissatisfaction with one‟s current
job (OR=0.70, 0.75, 0.84 to 1.00, P<0.01) increase as well. The consistent result is also supported
by Aiken et al. (2002), Aiken et al. (2007), Aiken et al. (2008), and Rafferty et al. (2007). In
addition, the increase of patients to nurses also impacts a nurse‟s intention to leave (Aiken et al.,
2007; Cho et al., 2009) and nurse-assessed quality of care (Rafferty et al., 2007; Aiken et al.,
2008).
In addition, other nurse staffing indicators, such as nurses perceived adequate staffing and a
nurse‟s experience are also found to impact nurse outcomes. For example, Cho et al. (2009)
research findings show that when nurses perceive adequate staffing, they are less likely to be
dissatisfied with their job, they tend to have low burnout, and have less intention to leave.
Gunnarsdottir et al. (2009) also found that nurse perceived adequate staffing is a predictor of nurse
job satisfaction, burnout, and nurse-assessed quality of care. Tervo-Heikkinen et al. (2009) states
that adequate staffing negatively influences adverse events for nurses (p = 0.004, b1 =-0.870, R2 =
24.6%). Halm et al. (2005) found that with every one year increase of employment, a nurse`s risk
of high emotional exhaustion will be increased by 5.2% (p = 0.01) and job dissatisfaction will be
increased by 6.8% (p = 0.03). Moreover, various nurse staffing indicators have been found to
influence nurse needle stick injuries. For example, Patrician et al. (2011) reported that factors of a
lower RNs skill mix, a lower percentage of experienced staff, and fewer HPPD associated with
needle stick occurrences on working shifts.
2) Nurse Staffing Impact on Patient Outcomes
According to the related research, it is found that nurse staffing influences several patient
outcomes, such as mortality (West et al., 2009), pressure ulcers (Yang, 2003), failure-to-rescue
(Halm et al., 2005), and patient satisfaction (Seago et al., 2006; Tervo-Heikkinen et al., 2008).
For example, Aiken et al. (2002) determined the association of patient-to-nurse ratio with
patient mortality, failure-to-rescue (deaths following complications). After adjusting for patient and
hospital characteristics (size, teaching status, and technology), each additional patient per nurse was
associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in
the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% CI, 1.02-1.11)
increase in the odds of failure-to-rescue.
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In addition, various nurse staffing indicators have been found to influence patient satisfaction.
For instance, Tervo-Heikkinen et al. (2009) studied about patient satisfaction and the ratio and
structure of nurse staffing inpatient wards at four Finland university hospitals among 4045 patients.
The result showed that all six nurse staffing indicators significantly influenced some parts of the
patient satisfaction scores. These six nurse staffing indicators were skill mix (proportion of RNs out
of all nurses), patient-to-RN ratio in the day shift and in all shifts, patient load per RN, RN hours
per patient load, and working years in the same ward. The result showed that both staffing level
indicators and the patient-to-RN ratio in the day shift and in all shifts, were linearly connected to all
the sum scores, including the total satisfaction indicator. Quadratic correlation showed that when
the patient-to-RN ratio in the day shift increased to more than 8 patients per RN, satisfaction began
to decrease. Patient load per RN (month) was also statistically significant to the sum scores of
treatment, respect, and care of patient, participating in one‟s own care, adequate information, and
no problems with care, as well as the total satisfaction indicator (p ranged from <.001 to .012, b
ranged from −.312 to −.439 and R2 ranged from 18.0% to 38.3%). RN hours per patient load
positively influenced all satisfaction variables except social and physical welfare during the
hospitalization (p ranged from <.000 to .039). The regression coefficients (b) ranged from 3.961 to
6.084 and the total variance (R2 %) ranged from 12.6% to 34.1%.
In addition, Kane et al. (2007) systematic review with meta-analysis‟s report gave the
conclusion that an increasing in RN staffing has an impact on lowering hospital related mortality in
intensive care units (ICUs), surgical, and medical patients. The odds ratios for an additional full
time equivalent per patient day are 0.91, 0.84, and 0.94 with 95% confidence interval (CI),
respectively. An increase of 1 RN per patient day causes a decreased odds ratio of hospital acquired
pneumonia, unplanned extubation, respiratory failure, and cardiac arrest in ICUs and a lower risk of
failure-to-rescue for surgical patients at 0.70, 0.49, 0.40, 0.72, and 0.84 with 95% confidence
interval (CI), respectively.
3) Nurse Staffing Impact on Hospital Outcomes
In health care setting, patients‟ costs and length of stay are important to hospital management.
Therefore, since nurse staffing influences these variables, they are classified as hospital outcomes.
Thungjaroenkul et al. (2008) studied the effect of nurse staffing on the cost of care in adult
intensive care units at a 1400-bed university hospital in Thailand. The result indicates that a higher
average ratio of RNs to patients influenced an increased personal cost per patient day (HC) (b =
10.92, p <0.001) and the average ratio of RNs to other nursing staff positively impacted the HC (b
= 8.07, p<0.001).
Tschannen and Kalisch (2009) explored the predictor of nurse staffing variables to patient
length of stay (LOS). Three staffing variables were selected (HPPD, skill mix, and nursing
expertise) through surveys and administrative forms. The overall model accounted for 40.3% of the
variation noted by the deviation from expected LOS (p < .0001). Patients with a higher HPPD
value were discharged sooner than expected by their DRG (b = 2.459, p = .05).
F. Empirical Referents of Nurse Staffing
“Empirical referents are classes or categories of actual phenomena that by their existence or
presence demonstrate the occurrence of the concept itself” (Walker and Avant, 2005). The defining
attributes of the nurse staffing concept are abstract, so it needs empirical referents in order to make
the concept measurable. From previous explanation, nurse staffing included the attributes of (1)
nurses‟ quantity and (2) nurses‟ quality. The following section examines these referents in detail.
1) Empirical Indicators for Nurses’ Quantity
From literature review, four staffing variables served as empirical indicators for nurse staffing
quantity: HPPD, the nurse–patient ratio, FTE, and nurse perceived staffing adequacy. HPPD refers
to the number of hours of paid nurse time relative to the number of patient days (Finkler and
Kovner, 2000). For this indicator, some countries‟ systems measure it based on patient diversity,
complexity, and nursing tasks required (Twigg and Duffield, 2009). In addition, it can be measured
by categorizing total nursing HPPD, RN HPPD, or no-RN HPPD (Choi and Staggs, 2014). The
formula to measure this indictor is [the hours of day shift × the number of all kinds of nurse
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personnel (registered nurses, technical nurses, practical nurses, and nurse aids) +the hours of
evening shift × the number of all kinds of nurse personal+ the hours of night shift × the number of
all kinds of nurse personnel] ÷ the number of patients at the time of 24:00 (Chitpakdee, 2006). The
nurse–patient ratio refers to the number of patients who are assigned to any one nurse in a nursing
unit for a particular shift (Manojlovich and Sidani, 2008). It can be measured by the item “How
many patients did you take care of in the last shift” (Aiken et al., 2002). FTE represents “fifty-two
40-hour work weeks of five 8-hour days, or 2,080 hours, the typical annual paid work time for a
full-time employee” (Fitzpatrick and Wallace, 2006). Therefore, each personnel FTE can be
calculated by the formula of FTE =40 hours per week×(52weeks－vacation weeks). Nurse
perceived staffing adequacy describes nurse perception of an adequate number of nurses providing
quality patient care (Lake, 2002). It can be measured by the item “Enough registered nurses to
provide quality patient care” (Lake, 2002).
2) Empirical Indicators for Nurses’ Quality
From the literature reviewed, three empirical indicators are used for interpreting the attribute of
nurses‟ quality: nurses‟ education, nurses‟ experience, and skill mix. (1) Nurses‟ education refers to
the “highest degree achieved”. (2) Nurses‟ experience are the years of experience within one‟s
current position, such as RN or LPN. (3) Skill mix, sometimes named as staffing mix, is defined as
„proportion of RNs, LPNs, and unit assistive personnel (UAPs) working on the unit for each
patient‟ (Tschannen and Kalisch, 2009). These empirical indicators can be measured by the
following questions: “What is your education level?” “How long have you worked as a nurse?”
“Which type of license do you have?” or “What is your position at work?”
DISCUSSION
This analysis gives nurses a more fundamental perspective on characteristics of nurse staffing.
The current global nursing shortage situation is not only related to the number of nurses, but also to
the qualification of nurses in dealing with complex diseases or an increasing in the aging
population. Thus, this article summarizes the main attributes of nurse staffing, including nurses‟
quantity and nurses‟ quality. In order to bring relief to the global nursing shortage situation, the
health care managers should consider recruiting more nurses along with providing continuing
nursing education to enhance clinical nurses‟ abilities. Many kinds of these cases are illustrated in
this analysis to describe the understood phenomena related to nurse staffing in the clinical setting.
Based on the demand and supply model, the antecedents of nurse staffing are analyzed under the
current global situation. For instance, with the increasing of the aging population and infectious
disease, health policy makers should provide specific training programs for clinical nurses in order
to enhance and update their knowledge and skills. In addition, the consequences of the nurse
staffing concept show the significant impact of nurse staffing on various outcomes. It can help
nurse practitioners to conduct the meta-analysis or to construct hypotheses in order to further
conduct research that produce more effective outcomes. Moreover, with respect to empirical
references, all of the indicators representing nurses‟ quality and nurses‟ quantity are illustrated.
This analysis provides the concrete information along with a linkage of various nurse staffing
indicators.
The conceptual model of nurse staffing (Fig.1) clarifies how antecedents, concept and
consequences of nurse staffing are related to each other. The findings of this analysis can be used to
provide service training for clinical nurses. This will ensure that nurses clearly understand the
nurse staffing concept. In addition, this model may further convince policy makers and clinical
nurse mangers to stipulate the nurse to patient ratio, the full time equivalent, and hire higher
educated nurses in order to achieve better nurse outcomes, excellent patient outcomes, and
expected hospital outcomes.
70
International Proceedings of Social and Behavioral Sciences, 2014, 2(1): 63-73
ACKNOWLEDGEMENTS
This research is supported by the 90th Anniversary of Chulalongkorn University,
Rachadapisek Sompote Fund. This research is under the support of the Liaoning Province
Education Science "Twelfth Five" plan research project (JG13DB196).
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