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As the manager, you have been asked to provide an RN staffing plan for a 40-bed in-patient nursing unit with an Average Daily Census of 40

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As the manager, you have been asked to provide an RN staffing plan for a 40-bed in-patient nursing unit with an Average Daily Census of 40. The proposed staffing ratio is 1:6 (1 nurse for each 6 patients per shift). Using the Nursing Hours Per Patient Day (NHPPD) methodology, calculate the number of FTEs needed to staff the unit for a 14-day pay period. Use the information in the Welch and Smith (2020) article to assist with your analysis.

Nursing Hours per Patient Day (NHPPD) is a measure used to track nursing care. Patient acuity refers to the amount of safe and effective care that is needed based on a patient’s clinical needs. More severe patients’ clinical needs result in increased staff numbers and hours required to provide care for these patients. It is important for nurses to understand how patient acuity impacts NHPPD. The articles in this Activity provide different perspectives and solutions to staffing. In your Assessment, you will examine the effects of NHPPD and patient acuity necessary for developing a staffing plan that addresses patients’ clinical needs.

1. Convert Nurse Patient Ratio to NHPPD.
2. Determine the nursing unit annual volume in patient days.
3. Determine total NHPPD for the previous year.
4. Determine number of FTEs needed to staff the unit.
5. Explain why the unit uses a particular staffing ratio and how that ratio is determined.
6. Explain whether other units in the same facility would have the same staffing ratio or different staffing ratios. Justify your response.
7.  
8.  
9. Based on the FTEs you calculated in Part I, calculate the salary cost for each nurse FTE using the hourly wage multiplied by 2,080 (number of hours worked per year), then add 30% to cover benefits. Use the following to make your calculations: RN salary: $32.50 per hour + 30% for benefits = $42.25 per hour.
10. 1. Determine the salary per year for one RN FTE.
    2. Calculate the total salary costs for the entire RN staff to determine your initial professional staff budget for the entire year.
    3. Explain the importance of budgeting when making staffing decisions.

Guest Editorial JONA Volume 47, Number 10, p 471 Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved. Measuring Patient Acuity Implications for Nurse Staffing and Assignment John M. Welton, PhD, RN, FAAN One of the more enduring traditions in nursing is to set staffing based on the midnight census. One of the main flaws of this approach is the underlying assumption that any point in the day, ostensibly midnight, can predict nursing care needs for patients in hospitals for the rest of the shift or following day. This may have worked 50 years ago when care was much simpler and patients were much more stable. In the fast and furious 21st century version of healthcare, the nursing component in acute care is very dynamic and subject to a myriad of patient and unit level conditions that can vary from moment to moment. Another important factor to consider is the acuity of each patient and the overall acuity mix in an inpatient unit. This ties to the overall demand and need for nursing care, as well as the patient care burden for each nurse within a shift assignment. Patients are Bsicker[ today because hospital lengths of stay are shorter and care is compressed and more intense. For example, patients newly admitted to a hospital require more care, are at Author Affiliation: Professor, College of Nursing, University of Colorado, Aurora. The author declares no conflicts of interest. Correspondence: Dr Welton, College of Nursing, University of Colorado, Education 2 North, Room 4325, Mail Stop C288-18, 13120 E 19th Ave, Aurora, CO 80045 (John. Welton@ucdenver.edu). DOI: 10.1097/NNA.0000000000000516 a higher risk for clinical instability in the 1st few hours of admission, and may require more frequent assessments, treatments, or care coordination if the patients need further tests or procedures. How do nurse managers and charge nurses approach assigning nurses to patients? Too little nursing care can result in poor clinical outcomes, and too much nursing care can result in higher costs. Frequent measurement of patient acuity is needed for both nurse staffing and nurse-to-patient assignments to keep up with the real-time needs of inpatient care. In this issue of the Journal, Dr Amy Garcia1 provides findings from a study that used nursing acuity measures linked to patient care outcomes. The key finding from 28 739 nursing assessments for 405 patients with heart failure treated at a single hospital showed wide variety in the acuity and associated needs for nursing care. Overall, acuity decreased from admission scores and then increased at discharge. Garcia also found that patients who had longer lengths of stay had higher nursing acuity scores on admission and throughout hospitalization. These clinical indicators can be used to develop new predictive models to identify at-risk patients and make adjustments for staffing and assignment. The acuity system was based on a standardized nursing language, Nursing Outcome Classification (NOC), and linked to nurse assessment and other relevant clinical data and reported frequently during the shift.2 Systems such as the one used in the study provide timely information about the patient condition and overall acuity mix in an inpatient unit to aid in decision-making. One key benefit to this data-rich approach is the elimination of the burden for nurses to collect additional data to support nurse staffing and assignments. The NOC scores were directly linked to nurses" assessments and other clinical data. The findings of this study demonstrate that nursing care can be measured at the individual patient level and can identify each nurse caring for each patient to optimize staffing and assignments. Future systems can use these data to develop data-driven approaches to staffing and assignment and can also be used to develop new predictive models to identify patient risk and measure nursing care performance in a nearYreal-time manner. Perhaps, it is time to retire the midnight census. REFERENCES 1. Garcia A. Variability in acuity in acute care. J Nurs Adm. 2017;47(10). 2. Birmingham SE, Nell K, Abe N. Determining Staffing Needs Based on Patient Outcomes Versus Nursing Interventions. In: Cowen PS, Moorhead S, eds. Current Issues in Nursing. 8th ed. St. Louis, MO: Mosby; 2010:391-404. JONA Vol. 47, No. 10 October 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 471 Understanding FTEs and Nursing Hours Per Patient Day Teresa D. Welch, EdD, MSN, RN, NEA-BC, and Todd Smith, PhD, MBA, MSHA, RN, NEA-BC The personnel budget is the largest line item on a hospital’s general budget and often consumes the majority of an organization’s ?nancial resources. It is also the most challenging to develop and dif?cult to manage. This article provides a detailed, step-by-step guide to understanding how to develop a hospital’s unitlevel personnel budget. The intent of the article is to provide new or aspiring nurse managers within the acute care setting with a basic understanding of ?nancial concepts required to manage the personnel budget, and to serve as a training resource for supervisors placing new managers into positions with ?nancial responsibilities. B udgeting processes are not unique to nursing or health care.1 Every business, every home, and every individual has a budget, however formal or informal it may be, to plan income and cash flow against expenditures. A well-planned budget is time consuming and resource intensive. As the largest line item on a hospital’s general budget,2 the personnel budget consumes most of an organization’s financial resources. It is also the most challenging to develop and difficult to manage.2 Historically, first-level managers in nursing have been selected on the merit of their strong interpersonal skills and clinical expertise, oftentimes without the requisite business preparation necessary for the upcoming role.3,4 Although nursing schools are charged with preparing the next generation of nurses for professional nursing practice, one specific to the profession of nursing and health care, they are not generally taught the language of, and skills comprised in, business.5,6 When nurses initially enter the hierarchy of formal leadership as first-level managers, they are typically responsible for the daily operations of the unit. This generally includes the responsibility of understanding and using financial concepts to maintain productivity standards, and to calculate nursing hours per patient day based on unit of service (UOS) and productive and nonproductive hours, all essential functions of the nurse manger’s role.3,4 The immediacy of these expectations place new managers in a position of learning an entirely new language unique to finance, in addition to acclimating themselves to their new role. Oftentimes, they are provided with very little to no formal training in regard to the financial aspects of www.nurseleader.com their new position.5,6 Therefore, it is important for first-level managers, and superiors responsible for placing new managers, to understand the necessity of learning and acquiring skills related to finance so that they may adequately perform in their new roles and clearly articulate and defend patient care needs.3,4 In this article, we provide a detailed, step-by-step guide to understanding a hospital’s unit-level personnel budget. The intent of the article is to provide new or aspiring nurse managers within the acute care setting with a basic understanding of the financial concepts required to manage the personnel budget and to serve as a training resource for supervisors placing new managers into a new position with financial responsibilities. KEY POINTS As the largest line item on a hospital’s general budget, the personnel budget consumes most of an organization’s ?nancial resources. The ?rst-level manager is the most knowledgeable about departmental needs and uniquely positioned to negotiate ?nancial requirements to meet and maintain ef?cient and high-quality patient care. Financial competency for the ?rst-level manager is critical to organizational success. April 2020 157 PERSONNEL (SALARY) BUDGET A unit’s personnel budget projects the applicable salary expenses that will be charged to the department over a given budget period.1,5,6 Prior to beginning work on a new personnel budget, you will need to establish several key facts: first, determine the UOS and expected volume for the department, and next, determine the nursing workload (nurse–patient ratio) and skill mix. The personnel budget includes productive as well as nonproductive full-time equivalents (FTEs) and the annualized hours and salary dollars for each employee.1,5,6 Elements of the personnel budget will be discussed in detail below with examples provided to support the reader’s understanding of the concepts presented. UNIT OF SERVICE The UOS, or patient days, is a linear measure of activity that defines the workload within each department. On most in-patient nursing units, the UOS is determined by the number of in-patients admitted to an in-patient bed at the midnight census.2,6 However, the UOS may differ depending on the type of service a department provides. See Table 1 for examples of the UOS for other departments. AVERAGE DAILY CENSUS The average daily census (ADC) represents the volume in the department. It is the number of admitted in-patients (UOS) at midnight on any given day.5 To clearly document workload based on the ADC, one must review midnight census numbers (the ADC) across the previous 12-month period. Next, one must calculate the mode or most frequent midnight census number (again, from the ADC). Although referred to as the average daily census, the mode derived from the previous 12 months of data is typically the most reliable number on which to base core staffing numbers and the personnel budget. Using the most frequent midnight census will minimize wide fluctuations in volume and subsequently make flexible staffing decisions easier to manage. NURSING WORKLOAD AND SKILL MIX Nursing workload is defined as “the time taken to carry out ‘direct’ and ‘indirect’ care, as well as other activities such as ward and organization management.”7 (p.247) Workload for the adult in-patient acute-care settings is usually measured through patient classification systems and based on acuity metrics or workload management systems that use algorithms embedded within the electronic documentation systems. The purpose of nursing workload measurement or patient classification systems is to ensure that the most efficient number and skill mix of workers are appropriately matched to the amount of work that must be accomplished to efficiently meet clinical expectations.7 Skill mix 158 April 2020 Table 1. Unit of Service by Department Unit of Service by Department In-patient nursing Laboratory Midnight census Number of tests run OR OR time (minutes) ED Patient visits per day Radiology Dietary Maintenance Number of diagnostic exams Number of patient meals served Work list ED, emergency department; OR, operating room. breakdown is the percentage of staff within each job category and is determined by the patient care model, type of unit, patient acuity, and hospital policy.6-8 FULL TIME EQUIVALENT One FTE is defined as 2080 worked hours in 1 year or 80 worked hours in a 14-day pay period.2,6 It’s important to remember that 1 person who is working 40 hours per week, or 80 hours every 2 weeks (the typical pay period), is considered full-time. In other words, 1 FTE = 10 8-hour shifts, or, 80 hours every 2 weeks, or 2080 hours a year. With that said, we must also consider the individual who works within an organization that defines full-time status 3 12-hour shifts, or 36 hours each week or 6 12-hour shifts, 72 hours every per pay period (Table 2). The definition of full time has not changed, but the organization has made the decision to adopt 12-hour shifts as their primary shift. Rather than 2080 hours as previously described, the full-time employee will work 1872 hours as a fulltime employee. The principles of calculating FTEs remains the same. After all, FTEs are a reflection of hours, not people. Stay focused on the hours. It’s also important to note that employees are only paid for actual hours worked. Likewise, benefits are based upon actual hours worked; 2080 hours versus 1872. Additionally, for budgetary purposes, make sure that you understand how the personnel budget was calculated and whether it was based on the 2080 rule of full-time equivalents. Example #1: As the manager, you have been asked to provide a staffing plan for an in-patient unit that requires 1 RN each day for each shift. RNs only work 8-hour shifts. How many FTEs will be required to provide coverage across the 14-day pay period? Calculations: One ful l-time nurse works 40 hours per week or 80 hours per pay period. www.nurseleader.com Table 2. The Full-Time Equivalent by Hours and Shifts Biweekly Weekly FTE Shifts Hours Shifts Hours Annualized Comments 2080 Full time 1.0 5 40 10 80 0.9 4.5 36 9 72 0.8 4 32 8 64 0.7 3.5 28 7 56 0.6 3 24 6 48 0.5 2.5 20 5 40 0.4 2 16 4 32 0.3 1.5 12 3 24 0.2 1 8 2 16 0.1 0.5 4 1 8 Also considered full time by most $0.5 FTE is typically eligible for bene?ts 1040 Based on an 8-hour work day. Bene?ts are based on worked hours. Combine the calculated FTEs needed to provide coverage for each of the 14 days in the pay period: 1.4 FTEs will provide 1 RN for one 8-hour shift across 14 days. o One full-time FTE (1.0) = ten 8-hour shifts. o A part-time FTE (0.4) = four 8-hour shifts. You will need to provide coverage for 3 shifts. You just calculated FTE requirements to provide 1 RN across the pay period for 1 shift. If it takes 1.4 FTEs to provide 1 RN for one 8-hour shift for 14 days, simply multiply 1.4 FTEs by the three 8-hour shifts: 1.4 × 3 = 4.2 FTEs. o One shift is 8 hours a day × 5 shifts (or 5 days) = 40 hours (1.0 FTE) o One shift is 8 hours a day × 10 shifts (or 10 days) = 80 hours (1.0 FTE) o 80 hours / 10 shifts per 2-week period = 8 hours or 0.1 FTE o One full-time FTE (1.0) will only cover 10 of the 14 days within the pay period. o Four days or shifts are left without coverage. o Shift = 8 hours; 8 hours × 4 = 32 hours without coverage. o 32 hours / 80 hours (1 FTE) = 0.4 FTE Table 3. Sample 14-Day Schedule Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa D D D D D D D D D D N N N N N N N N E E Employee FTE Sue 1.0 Brad 0.7 Cindy 0.7 N N N Carol 0.5 E E E Jan 0.5 David 0.4 Joe 0.4 7 Employees 4.2 FTEs N E E D E E N E E N E E D D E D One RN per day per shift across the pay period D, day shift; E, evening shift; N, night shift. www.nurseleader.com April 2020 159 Table 4. NHPPD Based on Staf?ng Ratios Nurse-toPatient Ratio 24 Hours/Day Nursing Hours Per Patient Day 1:1 24 ÷ 1 24 1:2 24 ÷ 2 12 1:3 24 ÷ 3 8 1:4 24 ÷ 4 6 1:5 24 ÷ 5 4.8 1:6 24 ÷ 6 4 You may also consider calculating the required FTEs by hours. FTEs are, after all, a representation of hours. One FTE = 80 hours The 14-day pay period = 336 hours 336 hours / 80 (1.0 FTE) = 4.2 FTEs See Table 2. Full-Time Equivalents by Hours and Shifts. TWELVE-HOUR SHIFTS When working with schedules that require 12-hour shifts, remember to concentrate on the hours that the FTE represents to build the schedule. The required number of FTEs will remain the same, but the number of required shifts will differ based on 8- or 12-hour shifts. 14 days × 24 hours = 336 hours 336 hours / 1.0 FTE (80 hour) = 4.2 FTEs o 336 hours / 8-hour shift = forty-two 8-hour shifts o 336 hours / 12-hour shift = twenty-eight 12-hour shifts Table 3 provides an example of a 14-day pay period with 1 RN per shift, per day. Notice that the schedule requires 4.2 FTEs to cover all shifts, 24/7, for 2 weeks. In this example, a combination of full-time and part-time employees are working on the schedule for a total of 7 employees who collectively work the 4.2 FTEs or 336 hours (4.2 FTEs × 80 hours = 336 hours). Remember, 1.0 FTE does not necessarily mean 1 individual. One FTE may mean 1 person scheduled to work ten 8-hour shifts or 10 people scheduled to work one 8-hour shift each pay period. As the hiring and scheduling manager, consider that an individual hired part time as a 0.5 FTE, who is scheduled to work 40 hours per pay period, is typically not capitated at 5 shifts or 40 hours per pay period. This individual can often work more hours in a 2-week period to cover vacation and sick time for other 160 April 2020 employees, or for census fluctuations, without incurring the additional expense of overtime pay. However, if the individual is hired into a 0.5 FTE position, he/she cannot be scheduled for less than their assigned FTE. Example #2: As the manager, you have been asked to provide a staffing plan for a 40-bed in-patient nursing unit with an ADC of 40. The proposed staffing ratio is 1:6 (1 nurse for each 6 patients per shift). How many FTE’s will be needed to staff the unit for the 14 day pay-period? Calculations: 40-bed unit with 1:6 nurse-to-patient ratio o 40 patients / 6 nurses = 6.66 patients per nurse The FTEs required to cover 14 (8-hour) shifts across the pay period = 1.4 FTEs (see Example 1, Calculating FTEs, for 1 shift for 8 hours for 2 weeks) You have 3 (8-hour) shifts per day across the 2-week pay period 3 shifts × 1.4 FTEs per shift = 4.2 FTEs for the 2-week pay period (24/7 coverage) Note: The 4.2 FTEs provide the unit with 1 nurse for each shift for the entire 2-week period. Because we have a 1:6 nurse-to-patient ratio, we need 6 nurses per shift. o 4.2 × 6.66 = 27.9 FTEs to fully staff the unit. When calculating FTEs, never round the decimal points. FTEs are tied to salaries, and small decimal points (e.g., 0.2) could mean thousands of additional dollars applied to the personnel budget on an annualized budget. POSITION CONTROL The position control report is a master list of all approved and budgeted FTEs, organized by job category, for a unit. The report provides current FTEs and vacant FTEs for all job categories on the unit, giving the manager a quick summary of FTE status. The position control report is used daily by managers to determine how many total FTEs by position (i.e., job type) are needed to maintain adequate staffing on the unit. Changes to the report typically occur through additional hires, terminations, or transfers into the unit. As a unit census fluctuates, nurse managers are required to make an educated guess as to how many FTEs will be needed to cover departmental needs. Typically, this decision is determined by the ADC. It is also wise to consider patient acuity levels when adjusting staffing numbers on the position control report. NURSING HOURS PER PATIENT DAY Nursing hours per patient day (NHPPD) is a measurement of the average number of hours needed to care for each patient on a given unit. Unlike the ADC, which is a linear measurement of patient volume at the www.nurseleader.com midnight census, NHPPD takes into consideration work flow processes, geography, patient acuity, patient population, service line type, and any other factors that may influence workflow processes having an impact on the workload of nurses providing direct patient care. All variables should be considered when negotiating the budgeted NHPPD for departmental personnel budgets (Table 4). Benchmarking, or comparing “like units” across facilities for best practices, is a valuable resource when negotiating NHPPD. The nurse manager should be involved with all personnel budget discussions involving his/her unit and have an opportunity to question the manager of the comparison unit to determ...