Creating safe and effective nursing schedules can be frustrating for nurse managers and bedside nursing staff. There is little training available to nurse managers on translating their budget into caregivers at the bedside while providing enough time off to prevent employee burnout. Nursing schedules posted alongside an overtime sign-up sheet to fill in the holes were common even before COVID.
This post will discuss a simple formula and some budget concepts that can empower and educate all stakeholders in the staffing and scheduling process by increasing transparency, awareness, and understanding of available scheduling capacity. This greater awareness and understanding of scheduling capacity will enable nurse managers and leaders to identify scheduling scenarios that are likely to lead to increased burnout and moral injury risks.
The formula will provide valuable insights to nurse managers and their leadership by quickly and easily modeling, quantifying, and predicting the impact of resource variances on scheduling capacity.
We will also cover how you can determine if your facility uses the flawed nursing budget process that creates a shortfall in expected resources and increases your risk of understaffing and burnout.
If you’re a bedside nurse, this post will provide you with information that should help you better understand how the scheduling process works. We will also discuss questions and information that you can take back to your nurse manager that can help to improve scheduling on your unit.
Budget Basics for Care-Centric Scheduling
If you haven’t already, I recommend that you read through my earlier posts, Flawed Nursing Budget Process Increases Understaffing Risk and Nursing Budget Flaw Impact on Understaffing at the Hospital and Regional Levels. These posts cover basic budget terminology and concepts, explain how a flawed nursing budget process creates a shortfall in expected patient care resources, and provide a couple of examples of calculating the resources needed for staffing a unit.
Think of your budget as a box of a finite number of hours per week that you can assign to either a patient care shift or a non-patient care shift. We can represent these hours as a pie chart:
Orientation has an asterisk beside it because it is a special case. From a patient care and productivity perspective, an orientee may be providing patient care and may have a portion of their time counted in the patient care hours for productivity. However, from a scheduling perspective, an orientee is not fully productive and cannot provide shift coverage for another fully productive employee.
FTEs temporarily assigned to work on another unit, such as a COVID unit, are also a special case. We will discuss this in more detail below when we get into the care-centric scheduling calculations.
Now, let’s take a look at one of the units from an earlier post:
In the example above, we calculated that we would need to schedule 1008 hours of RN time per week to provide a 1:4 nurse-to-patient ratio for a budgeted average census of 24 patients. We accomplished this by scheduling six nurses working 12-hour shifts for the day and night shifts. Dividing 1008 hours by 40 hours per FTE equals 25.2 Direct Care or Productive FTEs.
We now need to calculate the number of additional Replacement or Non-Productive FTEs that we need to hire to provide coverage when an employee is assigned to a non-patient care shift. Our Direct Care, or Productive FTEs, will comprise 85% of our total FTE hours, and the remaining 15% of our total FTE hours will be our Replacement or Non-Productive FTEs. We will take care not to use the incorrect formula described in my Flawed Nursing Budget Process Increases Understaffing Risk post.
According to Professor William Ward, we should divide the 25.20 Direct Care FTEs by the Direct Care percentage of 85% to determine Total FTEs. Subtracting the 25.20 Direct Care FTEs from the 29.65 Total FTEs gives us 4.45 Replacement FTEs.
Direct Care FTEs / Direct Care % = Total FTEs
25.20 / .85 = 29.65 Total FTEs
Total FTEs – Direct Care FTEs = Replacement FTEs
29.65 – 25.20 = 4.45 Replacement FTEs
When we divide the 4.45 Replacement FTEs by 29.65 Total FTEs, we get the desired 15% Replacement FTEs.
Replacement FTEs / Total FTEs = Replacement FTE Percentage
4.45 / 29.65 = 15.00%
Using a table, we can better visualize the breakout of Direct Care (Productive) and Replacement (Non-Productive) FTEs and hours:
[table id=1 /]
Care-Centric Scheduling Calculations
A schedule posted along with an overtime sign-up sheet is often an indicator that the nurse manager hasn’t been provided the tools, data, and education needed to determine how much non-patient care time they can schedule while leaving enough resources for patient care. Employees will often submit their time off requests weeks to months in advance. Managers will frequently approve time-off requests before scheduling patient care shifts or opening up the schedule to employee self-scheduling.
Time off guidelines such as “X% of staff can be scheduled off per week” or “Y number of staff can be scheduled off per week” are ineffective and often inaccurate. Available replacement (non-productive) time can and should be calculated each time before a nurse manager sits down to approve time-off requests and create the schedule.
For this care-centric scheduling calculation, you’ll need your FTE budget information if you’re a nurse manager for this exercise. Specifically, you need the following information from your budget or position control:
- Total Budgeted FTEs
- Vacant FTEs
- Budgeted Patient Care FTEs: these may be referred to as productive, direct care, or core FTEs.
- Budgeted Non-Patient Care FTEs: these may be referred to as non-productive, indirect, or replacement FTEs
- Budgeted Replacement (Non-Productive) Percentage: for most units, this should be somewhere around 15%, give or take a few percentage points.
First, you’ll want to do a quick check to see if your facility is using the flawed replacement FTE budget formula. You can do this by calculating your actual Budgeted Replacement (Non-Productive) Percentage and comparing it to the budgeted percentage stated by finance or your leadership:
Budgeted Replacement (Non-Productive) FTEs / Total Budgeted FTEs = Budgeted Replacement (Non-Productive) Percentage
Suppose your leadership told you that your budget has 15% replacement (or non-productive) time in it, but you calculate a different value. In that case, that should be a red flag that someone needs to double-check the methodology being used to calculate those replacement FTEs.
Looking at the table of FTEs and hours above, we can see that we must have 1008 nursing hours (25.20 FTEs) scheduled per week for our budgeted census of 24 patients to provide a 1:4 nurse-to-patient ratio. We can also see that our budget provides us with 178 hours for non-patient care shifts, and that’s enough time for nearly 15 12-hour non-patient care shifts per week.
One thing that often doesn’t get mentioned about budgets is that they are a best-case scenario that assumes that you are fully hired and don’t have any employees on leave or orientation. Units very rarely find themselves in this situation, especially since COVID arrived.
Our mock unit is fairly small from an FTE perspective, so let’s see what happens once we have two 0.9 FTE vacant positions as well as two 0.9 FTE nurses on orientation. To review, we’re going to be using the following pieces of data:
- Total Budgeted FTEs: 29.65
- Vacant FTEs: 0.9 x 2 = 1.8
- Orientation FTEs: 0.9 x 2 = 1.8
- Budgeted Direct Care (Productive) FTEs: 25.20
With the above data elements, the formula for this scenario looks like this:
Total Budgeted FTEs – Vacant FTEs – Orientation FTEs – Budgeted Direct Care (Productive) FTEs =
Available Replacement (Non-Productive) FTEs
29.65 – 1.8 – 1.8 – 25.20 = 0.85 Available Replacement (Non-Productive) FTEs
0.85 FTEs x 40 hours/FTE = 34 Available Replacement (Non-Productive) Hours
The calculation is “care-centric” because it treats the patient care resources as required for scheduling patient care shifts. This simple formula allows us to model the scheduling capacity of the unit reasonably. It shows the nurse manager how many hours are available to schedule for non-patient care shifts while preserving the hours needed to schedule for the desired budgeted level of care for the budgeted average patient volume.
We can see that we only have 34 hours available each week to schedule non-patient care shifts after considering the vacant and orientation FTEs. That’s the equivalent of only 2.8 12-hour shifts. These 34 hours will have to be used to cover all of the following:
- Scheduled Time Off
- Unscheduled Time Off
- Education Time
- Any Leave Time
It’s not practical to run a nursing unit that can grant less than 3 12-hour shifts for all of the above items. But, this formula provides the nurse manager with data and information that they can use to inform their scheduling decisions better. Since budgeted FTE hours are finite, the nurse manager can now know that scheduling more than 34 hours of non-patient care time per week will mean pulling shifts away from patient care. This formula allows the nurse manager to quickly assess how their scheduling decisions will impact their final schedule.
The Care-Centric Scheduling Formula
The example above doesn’t cover all scenarios that can impact scheduling capacity. Let’s take a look at the full formula:
Filled FTEs – Budgeted Direct Care (Productive) FTEs – Orientation FTEs – Leave FTEs – Reallocated FTEs = Available Replacement (Non-Productive) FTEs
That looks a little different than the formula above. Let’s review each element in the formula:
- Filled FTEs: This is your Total Budgeted FTEs – Vacant FTEs
- Budgeted Direct Care (Productive) FTEs: These are your budgeted patient care FTEs
- Orientation FTEs: These are the FTEs for employees that are on orientation and are not fully productive and therefore, cannot replace a fully productive employee for a shift.
- Leave FTEs: These are FTEs that are on medical leave, military leave, or any other sort of leave supported by your institution.
- Reallocated FTEs: These are FTEs that have been temporarily assigned to work all of their shifts on another unit, such as a COVID unit.
Some hospitals are temporarily assigning employees from their home units to COVID units on a semi-permanent basis. While these nurses may still be employees of your unit, if their temporary reallocation to the COVID unit will remove them from your unit’s schedule, we must consider that when evaluating scheduling capacity.
Let’s expand the previous example also to include a 0.9 FTE RN on medical leave and a 0.9 FTE RN temporarily reallocated to a COVID unit and use the following values in the expanded formula:
- Filled FTEs: 29.65 – 1.8 = 27.85
- Budgeted Direct Care (Productive) FTEs: 25.20
- Orientation FTEs: 1.8
- Leave FTEs: 0.9
- Reallocated FTEs: 0.9
Filled FTEs – Budgeted Direct Care (Productive) FTEs – Orientation FTEs – Leave FTEs – Reallocated FTEs = Available Replacement (Non-Productive) FTEs
27.85 – 25.20 – 1.8 – 0.9 – 0.9 = -0.95
Available Replacement (Non-Productive) FTEs x 40 hours/FTE = Available Replacement (Non-Productive) Hours
-0.95 FTEs x 40 hours/FTE = -38 hours
Using the formula above, we can see that we have a negative replacement (non-productive) time scenario. Even if the nurse manager approved no time off and there were no call-ins for unscheduled time off, this unit would still be short-staffed on the schedule by approximately three 12-hour shifts per week.
The care-centric calculations can also be used for LPNs, CNAs, and any other patient care staff included in your budget.
With this information, the nurse manager can know that each non-patient care shift scheduled above the Available Replacement (Non-Productive) Hours will remove another shift from patient care.
Possible Applications for Care-Centric Scheduling Calculation Data
Now that we can quickly assess scheduling capacity, let’s explore some potential scenarios for using this information.
In 2020, AONL, ANA, and HFMA published a joint report titled The Business of Caring: Promoting Optimal Allocation of Nursing Resources. In this report, they identified five action steps to improve the allocation of nursing resources[1]Begley, R., Cipriano, P. F., & Nelson, T. (2020). Common ground: AONL, ANA, and HFMA Outcomes-Based Staffing Report Provides Guidance, Insights. Nurse Leader, 18(3), 216–219. … Continue reading:
- Pioneer creative nurse staffing approaches. Optimize staffing using evidence-based approaches to help organizations make informed decisions, enhance workforce utilization, and improve outcomes.
- Assess the impacts of new technology on all phases of care before, during, and after implementation. In some cases, improvements in certain outcomes may come at the expense of other elements of the care episode.
- Work toward joint accountability. Addressing long-term challenges requires fierce collaboration, starting in the C-suite and diffusing throughout the organization.
- Agree on shared principles. Workplace stresses on nurses and finance professionals have ripple effects ont he entire healthcare organization. These systemic stresses translate to principles for allocating appropriate nursing resources for patient care.
- Promote interprofessional collaboration. The key to delivering high-value health care is collaboration among clinicians, health care administrators, and finance leaders. Interprofessional collaboration is predicated on relationship building. When finance and nursing professionals achieve a shared understanding of value and build solid working relationships that reflect insight into their respective workplace stresses, all health care team members, the organization – and most importantly, patients – will reap the benefits.
The data from the Care-Centric Scheduling Calculation can help support many of the recommendations in the report.
When combined with other financial, scheduling, staffing, quality, safety, and productivity data, the care-centric scheduling calculation data becomes a vital component of a data-driven, evidence-based approach to workforce management. Schedules are the foundation for daily staffing operations. Quickly assessing the ability of available resources to provide the desired budgeted baseline scheduling can inform the nurse manager and nursing leadership of problem areas weeks in advance. For example, if a nurse manager learns that three 0.9 RNs are expected to go on medical leave in 3 months, they can quickly assess the impact on their scheduling capacity and begin exploring options for supplementing staff. This information provides the nurse manager, administration, and finance with a simple, measurable metric to help inform collaboration and decisions on resource allocation, hiring, recruitment, and retention activities for units with resource shortages.
The care-centric scheduling calculation considers the additional dimension of an FTE’s ability to be scheduled for patient care. This information is often not included on standard position control reports that finance and nursing leadership may be reviewing.
Care-centric scheduling calculation data can also help to foster collaboration, transparency, and accountability at all levels.
The nurse manager can use the data to provide a transparent assessment of scheduling capacity for their staff. Nurse managers can have frank conversations with staff regarding how much time off and other non-patient care time the nurse manager can reasonably grant. This information may allow for negotiation with the team on the timing of vacation requests to help support patient care delivery on the unit.
The care-centric calculation provides the nurse manager with a valuable assessment of their scheduling capacity. Nurse managers can use this information to help facilitate conversations between them, their leadership, and finance regarding resource needs and allocation.
Cohorts of units in the same service line can aggregate their data to see if resource sharing between their teams can help alleviate severely understaffed periods on their schedules.
Suppose you’re a bedside nurse on a unit struggling with understaffing. In that case, you can use the information in this post and the posts in my Demystifying Understaffing series to facilitate discussions between you and your nurse manager. Your manager may not be aware of the flawed budget methodology, and it’s also likely that they have not received adequate tools and training for effectively managing their budget to create safe and effective schedules.
Key questions that you may want to ask include:
- What is the unit’s stated budgeted replacement or non-productive percentage?
- According to William J Ward, Jr., professor of Health Policy and Management at Johns Hopkins and author of Healthcare Budgeting and Financial Management, 2nd edition, budgeting approximately 15% of your total hours for non-patient care time is a good starting point for many units. [2]Ward, W. J., Jr. (2015). Health care budgeting and financial management, 2nd edition (2nd ed.). Praeger.
- What is the unit’s actual calculated replacement or non-productive percentage?
- This is calculated by dividing the Budgeted Replacement FTEs by the Total Budgeted FTEs. If this percentage differs from the stated budgeted replacement or non-productive percentage, the nurse manager and finance need to investigate whether they are using a flawed nursing budget process.
- How much non-patient care time can be scheduled each month without pulling shifts away from the bedside?
- As mentioned earlier, time off guidelines such as “X% of staff can be scheduled off per week” or “Y number of staff can be scheduled off per week” are ineffective and often wrong. Available replacement (non-productive) time can and should be calculated each time before a nurse manager sits down to approve time-off requests and create the next schedule.
Finally, the care-centric scheduling calculations can assist nursing directors, CNOs, and other healthcare executives in better understanding scheduling capacity so that they can establish benchmarks and thresholds for acceptable vs. unacceptable scheduling capacity levels.
Opportunities for Nursing Informatics Professionals
The ANA’s Nursing Informatics Scope and Standards of Practice, 2nd Edition defines nursing informatics as follows:
Nursing informatics (NI) is the specialty that integrates nursing science with multiple information and analytical sciences* to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. NI supports nurses, consumers, patients, the interprofessional healthcare team, and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology.
The nursing informatics specialty and its constituent members contribute to achieving the goal of improving the health of populations, communities, groups, families, and individuals. Supporting activities include, but are not limited to, the identification of issues and the design, development, and implementation of effective informatics solutions and technologies within the clinical, administrative, educational, and research domains of practice.[3]American Nurses Association. (2021). Nursing informatics: Scope and standards of practice (3rd ed.). American Nurses Association, Nursing Knowledge Center.
If we can’t measure it, we can’t improve it. Given the right data, Informatics nurses well versed in staffing and scheduling operations and finance can proactively identify units at risk for staffing problems due to inadequate schedules and guide nursing and finance leadership on the root causes of the identified issues. Given the many quality, safety, and financial metrics negatively affected by understaffing[4]Shin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), 273–282. … Continue reading, even minor improvements in staffing and scheduling could reap significant rewards for patients, patient care staff, and facilities.
The data-driven Care-Centric Nurse Scheduling approach creates new opportunities for developing and implementing information structures, information processes, and effective informatics solutions and technology focused on improving the clinical and administrative domains of practice.
To accomplish this, we need nursing informatics professionals who
- Understand the theory and math behind nursing FTE budgets, schedule creation, and the resulting impact on daily staffing operations.
- Know how to operationalize a nursing FTE budget to create safe and effective schedules.
- Understand how resource variances will impact nursing care delivery and financial and productivity metrics.
- Understand how predicted impacts to nursing care delivery can flow through to affect employee and patient satisfaction, employee recruitement and retention efforts, quality and safety metrics, and financial performance of the unit and facility.
- Are adept at data analysis and recognizing trends and patterns in financial, scheduling, staffing, quality, safety, and productivity data that warrant further investigation.
A Call to Arms to Combat Understaffing, Burnout, and Moral Injury
My proposal above aims to address a small part of the understaffing and burnout problem.
News reports and social media continue to publish story after story on understaffing, burnout, moral injury, and the negative impact that understaffing is having on the availability and quality of healthcare services.
We need to prepare for the possibility that we will experience additional waves of COVID. Bold and innovative healthcare leaders are needed to brainstorm ideas and initiatives that can stabilize nursing in the short term and position nursing for the growth that will be needed to replenish our healthcare system.
I welcome thoughts, feedback, and ideas regarding my posts and would love to connect with anyone else that is interested in or working on exploring solutions to the staffing challenges healthcare is experiencing.
If your facility is struggling with understaffing, I may be able to help.
You can reach me on Twitter at @In4maticsNurse and on LinkedIn.
References
| ↑1 | Begley, R., Cipriano, P. F., & Nelson, T. (2020). Common ground: AONL, ANA, and HFMA Outcomes-Based Staffing Report Provides Guidance, Insights. Nurse Leader, 18(3), 216–219. https://doi.org/10.1016/j.mnl.2020.04.007 |
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| ↑2 | Ward, W. J., Jr. (2015). Health care budgeting and financial management, 2nd edition (2nd ed.). Praeger. |
| ↑3 | American Nurses Association. (2021). Nursing informatics: Scope and standards of practice (3rd ed.). American Nurses Association, Nursing Knowledge Center. |
| ↑4 | Shin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), 273–282. https://doi.org/10.1016/j.outlook.2017.12.002 |
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