In the Fall of 2021, the Maryland Hospital Association launched the Task Force On Maryland’s Future Health Workforce to address the growing healthcare workforce crisis in the state. The Task Force reported a 25% RN vacancy rate, an expected shortfall of 13,800 RN and 9,200 LPN positions by 2035, and that 62% of nurses have considered leaving the profession due to understaffing and burnout.Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. … Continue reading We should commend the Maryland Hospital Association for its systemic and interdisciplinary approach to identifying the problems and developing innovative and creative recommendations to address long-standing and recently developed issues in nurse staffing. However, the task force should dig deeper to identify significant root cause contributors to their workforce problems. They have also overlooked issues that could undermine the effectiveness and success of some of their recommendations.
In this blog post, we’ll review the impact of Maryland’s 25% RN vacancy rate on staffing capacity for our model unit and facility to understand better the effect that it is having at the bedside. We will discuss potential roadblocks for some of the identified strategies and additional considerations not covered by the report that could undermine the effectiveness and success of key initiatives. The report contains some recommendations that will likely take months to years to implement and produce results. We will explore some ideas on how nursing informatics can assist nursing and finance leaders with tools and techniques we can use now to support nurse staffing and facilitate the report’s goals.
Maryland Health Care Workforce Crisis Analysis and Recommendations
In August 2022, the Maryland Hospital Association released its 2022 State of Maryland’s Health Care Workforce Report. They reported that “…Maryland hospitals [are facing] the most critical staffing shortage in recent history, with one in every four nurse positions vacant. High staff turnover, shifting care delivery models, and an insufficient nursing pipeline is reaching an unsustainable point that stretches bedside care incredibly thin and further strains the workforce across the care continuum.” Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. … Continue reading The multidisciplinary task force did a great job of identifying problems and developing creative and innovative approaches to addressing them.
The task force identified three key challenges contributing to the healthcare workforce shortage:
- High Staff Turnover
- Shifting Care Delivery Models
- Insufficient Nursing Pipeline
The tasks force grouped the action items to address the above issues into four high-level recommendations:
- Expand Marylands Workforce Pipeline
- Remove Barriers to Health Care Education
- Retain the Health Care Work Force
- Leverage Talent with New Care Models
The report urges improving the long-neglected nursing education pipeline while also recommending innovative team-based approaches to staffing that leverage allied health professionals such as medical assistants to decrease the workload of RNs while getting more eyes and hands on patients. It recognizes the need for improved physical and psychological safety for healthcare workers and the need to improve diversity, equity, and inclusion. The report also suggests “…[leveraging] technology to alleviate administrative burden, predict adverse events, and boost workflow efficiencies.” Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. … Continue reading
The above are some highlights from the report. There are many great ideas in the report, and I recommend that everyone take the time to read through the report’s details, as plans for addressing the staffing crisis in other states will likely contain similar suggestions.
Nursing Budget Basics
To adequately assess the impact of a 25% vacancy rate on staffing, we must evaluate it within the context of budgeted resources and how they are utilized.
A nursing budget is a plan for determining the employee hours needed to deliver the desired level of patient care, such as a nurse-to-patient ratio or nursing hours per patient day (NHPPD) target, for a given volume of patients, often defined by an expected average daily census. The employee hours in the budget are typically expressed in full-time equivalents (FTEs), where 1.0 FTE represents an employee working 40 hours a week for 52 weeks for 2080 hours a year.Jones, C., Finkler, S. A., Kovner, C. T., & Mose, J. (2018). Financial Management for Nurse Managers and Executives (5th ed.). Saunders.
Productive time is the time spent by staff participating in direct patient care.
Replacement or Non-productive time is time paid to staff for benefits such as PTO (paid time off), sick time, vacation, holiday time, and education time.
Nursing Budget Calculations Review
We will use the FTE values from the TNIB Medical Center Mock Stepdown Unit from my Nursing Budget Flaw Impact on Understaffing at the Hospital and Regional Levels blog post for this discussion.
Your nursing budget should contain the following information:
- Direct Care FTEs: The FTEs needed to provide direct patient care.
- Replacement FTEs: The FTEs needed for all non-patient care activities. They may also be called non-productive FTEs.
- Total FTEs: The sum of your direct care and replacement FTEs.
- Direct Care Percentage: Direct Care FTEs divided by Total FTEs. A number around 85% is a good starting point for many budgets.Ward, W. J., Jr. (2015). Health care budgeting and financial management, 2nd edition (2nd ed.). Praeger.
- Replacement Percentage: Replacement FTEs divided by Total FTEs. Allocating 85% of FTEs for direct care leaves 15% for replacement.
Determining direct care FTEs is pretty straightforward. By mapping out the resources needed to deliver the desired level of patient care for a given volume of patients during a week, we can easily calculate the resources required to accomplish this.
We then must calculate the additional replacement/non-productive resources needed to provide coverage for time off, education, and other non-patient care activities that we expect our staff to be scheduled for. We’ll use 15% for our replacement/non-productive percentage:
Direct Care FTEs / Direct Care % = Total FTEs
42.50 / .85 = 50.00 Total FTEs
Total FTEs – Direct Care FTEs = Replacement FTEs
50.00 – 42.50 = 7.50 Replacement FTEs
When we divide the 7.50 Replacement FTEs by 50.00 Total FTEs, we get the desired 15% of Total FTEs as Replacement FTEs.
Replacement FTEs / Total FTEs = Replacement FTE Percentage
7.50 / 50.00 = 15.00%
Replacement FTEs x 40 = Replacement Hours per week
7.5 x 40 = 300
300 / 12 = 25 12-hour replacement shifts per week
Scheduling to the unit’s budgeted assumptions requires 2000 FTE hours per week, 1700 hours for patient care, and 300 hours for replacement/non-productive time. Remember that the budget above represents a best-case scenario where the unit is fully hired and has no one on orientation or leave.
Care-Centric Modeling of Staffing with a 25% RN Vacancy Rate
By utilizing care-centric modeling and assuming that the nurse manager will assign available resources to patient care first, we can see how severe a 25% RN vacancy rate is at the bedside:
Since we don’t know the actual or average budgeted replacement (non-productive) percentage for Maryland hospitals, I’ve calculated the replacement percentage variances from 15% to 25%.
One corollary in care-centric modeling is subtracting your vacancy percentage from your budgeted replacement percentage will give you your available replacement percentage before considering employees on leave, orientation, or some other status that prevents them from replacing productive employees. You can see this by comparing the Replacement % and Available Replacement FTE % columns above.
42.5 FTEs representing 1700 hours of direct care time are required for the desired budgeted level of care each week. For our unit budgeted for 50 RN FTEs with 15% of total hours budgeted for replacement, a 25% vacancy rate leaves us with only 37.50 FTEs available for scheduling.
Our unit is 5 FTEs or 200 hours short of the resources needed to schedule the desired budgeted level of care for each week. That translates into a shortage of nearly 17 12-hour shifts per week or 25 8-hour shifts per week for just this one unit. This shortage is also before taking into account scheduled and unscheduled time off, education, orientation, and leave. Each shift scheduled for these activities will create another unfilled shift at the bedside.
Increasing the replacement percentage to 25% gives the unit enough FTE hours for patient care before considering employees on leave, orientation, or some other status that prevents them from replacing productive employees. The unit is more short-staffed at 25% budgeted replacement than at 15% due to the higher volume of replacement/non-productive shifts expected to be used.
When these results are replicated across an entire facility, the results are shocking.
If we apply the above scenario to our mock medical center, which consists of 10 model units, we can see just how severe the shortage at the bedside is.
The shortages across the facility quickly balloon to a weekly deficit of 50 FTEs (2,000 hours) needed to provide the desired budgeted level of care at average patient volume and a 15% replacement factor. A shortfall of 50 FTEs translates into a deficit of nearly 170 12-hour or 250 8-hour shifts every week.
Even with a 25% replacement factor, our facility would only have enough resources for patient care at average patient volume before considering scheduled and unscheduled time off, orientation, education, and leave.
These severe shortages for the examples above represent best-case scenarios at average patient volumes.
It also means that this facility cannot provide time off and education to employees. Every shift scheduled for time off, education, or other non-patient care capacities will require pulling a shift away from the bedside.
If this facility experiences higher than budgeted patient volumes, the shortages will be even more extreme as there are no additional resources to step in for the additional staffing needed.
Also, we have only considered the RN vacancies in this blog post. Maryland is experiencing severe shortages across many patient care and allied health positions. Using care-centric modeling, one can better understand the depth and severity of the need in Maryland when considering the combined impact shortages of LPNs, RNs, Respiratory Therapists, and Nursing Assistive Personnel are having on patient care.
The MHA also reported these shocking statistics:Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. … Continue reading
- 62% of surveyed Maryland Board of Nursing licensees and certificate holders thought about leaving nursing recently, with nearly 40% of respondents stating feeling overworked, burned out, and unappreciated was the #1 reason.
- A growing shortfall of 13,800 RNs and 9,200 LPNs by 2035.
- RN supply was adequate to meet about 91% of demand in 2021 but is projected to meet only 80% of expected demand by 2035
Without immediate and significant mitigation efforts, these severely understaffed units and facilities are at high risk for a dangerous positive feedback loop where understaffing, burnout, moral injury, and turnover continue to worsen.
When evaluating staffing issues, it is essential to assess the foundation that creates the workforce: the nursing FTE budget and how the budgeted resources are allocated.
Of note is that Maryland hospitals operate under a capped budget system in an effort to decrease overall healthcare costs. The MHA report notes that the capped budgets hinder their ability to provide competitive wages for recruitment and retention. Maryland’s budget system is a fascinating experiment in controlling healthcare costs at a regional level. If you’d like to learn more about it, look at these Vox and Health Affairs articles.
Nurse Staffing Information Structures
Interrelated mathematical models and information structures drive nursing budgets, staffing, and scheduling. The nursing budget is the foundation for nurse staffing. The budget defines the resources needed to provide the desired level of patient care, allow employees time off to recharge, and cover for education required to support patient care and maintain workforce competency.
In the Nurse Staffing Information Structures model, we have the following structures and relationships:
- Budget: Defines the resources needed to provide the desired level of patient care for a given volume of patients. It also determines the resources required to provide coverage for time off and education. The budget is the primary input for Position Control.
- Position Control: Creates a framework for all jobs and positions. Positions filled by employees become the primary input for Scheduling.
- Scheduling: Initially allocates employees’ FTE hours to specific patient care and non-patient care shifts. The schedule becomes the primary input for Staffing.
- Staffing: Near-term adjustment and reallocation of available resources, ideally considering patient volume, patient workload/acuity, and the skills and experience of available staff. The patient care delivered by staffing becomes a significant input for patient outcomes; quality, safety, and financial metrics; and various reports.
- Patient Outcomes, Metrics, & Reports: These are the results affected by operationalizing the budget and allocating the available nursing resources to patient care and non-patient care shifts.
Problems at one information structure layer will impact other layers in the structure. Mistakes in the budget layer will impact all information structures above it. If a nurse manager schedules more replacement/non-productive shifts than they have resources to cover, the unit will likely be short-staffed, which could negatively impact patient outcomes; quality, safety, and financial metrics; and other reports.
Assessing the Nursing Workforce Foundation: The Nursing FTE Budget
Maryland hospitals need to evaluate whether they are using the flawed nursing budget process identified and explained by Willam Ward in his book Health Care Budgeting and Financial Management, 2nd edition. Any hospital using this inadequate budget methodology will have a 2-6% shortfall in FTEs needed to meet their budget assumptions for patient care, time off, and education. Managers should also add the shortfall percentage (FTE Variance % below) to their vacancy rate if they use this budget process.
My research continues to suggest that this budget methodology is widespread in healthcare. So far, I’ve identified the error in over 30 sources spanning 39 years. I have found the calculation error in journal articles, textbooks, conference presentations, white papers, nurse manager workshops, and materials from consultants. I’ve verified that one of the largest US health systems uses this budget methodology. As a result of the math error, this health system needs over 2,000 more RNs than they realize to meet its budget assumptions for patient care, time off, and education. There are also four high-profile professional organizations in healthcare that have been promoting this budget methodology in their workshops for nurse managers and other healthcare leaders.
This flawed budget process has worked its way into our conventional wisdom and is an excellent example of the “garbage in, garbage out” concept where “nonsense (garbage) input data produces nonsense output.” Wikipedia contributors. (2022, October 2). Garbage in, garbage out. Wikipedia, The Free Encyclopedia. https://en.wikipedia.org/w/index.php?title=Garbage_in,_garbage_out&oldid=1113657649 We cannot expect incorrect formulas to generate correct FTE values.
Additionally, many facilities and health systems have nursing positions they cannot fill even before they learn that they need more positions than initially thought. Some of these positions have been vacant for many months. For this reason, we must leverage data to manage our scarce available resources more efficiently and determine more realistic budget goals that can deliver adequate resources for safe patient care, time off, and education.
Tunnel Vision: There’s More to Nurse Staffing than Just Staffing
Much of the discussion around the nurse staffing crisis is focused on the patient care element of nursing. What often gets overlooked in these discussions and in the nursing literature is the importance of the non-patient care aspects of the nursing budget in supporting nursing care delivery.
In order to avoid burnout, there must be enough resources to allow employees to take time off to destress and recharge their batteries.Ward, W. J., Jr. (2015). Health care budgeting and financial management, 2nd edition (2nd ed.). Praeger. This means that there must be more FTEs available than are needed for patient care.
Education and orientation time will also be critical components of stabilizing nursing. The increase in nursing turnoverNursing Solutions, Inc. (2022). 2022 NSI National Health Care Retention & RN Staffing … Continue reading has contributed to a significant decrease in nurse tenure at facilities.Johnston Thayer, Joe Zillmer, Neil Sandberg, Anna R. Miller, Paul Nagel, Alissa MacGibbon. (2022). ‘The New Nurse’ Is the New Normal. … Continue reading We must also consider that with the baby boomer nurses retiring, we will be losing “…more than 2 million years of nursing experience each year between 2020-2030.”Buerhaus, P. I. (2021). Current Nursing Shortages Could Have Long-Lasting Consequences: Time to Change Our Present Course. Nursing Economic$, 39(5), 247–250. … Continue reading We must recognize the importance of education and orientation and how it supports nursing care delivery. In order to provide orientation and education time, we must have more FTEs than are needed for just patient care and time off.
We need a more holistic view of the nursing budget process and a greater understanding of the importance of replacement time and how it supports nursing care delivery, the mental health of our caregivers, and the education needed to ensure the competency of our workforce.
Understanding the Complexities of Flexible Scheduling
One of the recommendations of the MHA report is more flexible staffing models offering a variety of shift lengths. This type of flexible scheduling requires careful assessment and planning in order to be successful. A mix of different shift lengths can create an awkward patchwork of unfilled shifts and continuity of care issues due to increased patient handoffs if not managed effectively.
Multiple shift lengths can work, but you must have enough resources to cover adequate time off and education. In the current environment, most hospitals don’t have enough resources to provide the time off and education time needed to make this sort of scheduling successful.
With a mix of shift lengths, it is essential to have robust flexible scheduling resources available such as float pool, part-time, and per diem staff in order to mitigate the awkward holes in the schedule created by vacancies and unscheduled time off.
It is also critical that units and facilities understand the impact their vacancy rates have on staffing and scheduling capacity. At a vacancy rate of 7.5%, most hospitals will lose approximately half of their replacement/non-productive resources needed to cover for time off and education. I take a more detailed look at the impact of vacancy rates on staffing capacity in my blog post Nurse Understaffing and the Fallacy of Nursing Budgets.
At today’s average 17% RN vacancy rateNursing Solutions, Inc. (2022). 2022 NSI National Health Care Retention & RN Staffing … Continue reading, many hospitals can’t staff for their baseline budgeted level of patient care which means they have no resources to cover time off and education. Each non-patient care shift scheduled will create another patient care shift that will go unfilled or require unbudgeted resources to staff.
Maryland’s 25% vacancy rate creates a much larger resource deficit than the average hospital. This deficit will be a significant barrier to implementing more flexible staffing models.
Managing Staffing Challenges of Small Numbers of Positions
The MHA report recommends utilizing skill mix models to “…optimize a combination of nursing skills, as well as other occupational and training characteristics of care team (e.g., CNAs, MAs, advance practice providers) and levels to meet patient needs and address complex work depending on skill level.” Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. … Continue reading
A 2021 New England Journal of Medicine study noted significant increases in catheter-associated urinary tract infections, falls, and pressure ulcers during the pandemic.Fleisher, L. A., Schreiber, M., Cardo, D., & Srinivasan, A. (2022). Health care safety during the pandemic and beyond – building a system that ensures resilience. The New England … Continue reading These are metrics that can be positively impacted by the work of CNAs. Answering call lights, bathing, skincare, ambulation, turning, and positioning are all interventions that can be used to improve these metrics. Understaffing and burnout were two of the significant factors cited by the study as contributing to the degradation of these patient safety metrics.
Adding LPNs, Medication Assistants, and more CNAs is a great way to get more hands and eyes on patients. Each interaction with a patient provides an opportunity to assess the patient while providing the caring and compassionate human interaction that so many patients have been missing during this staffing crisis.
One concern is that the budget for LPNs, MAs, and CNAs will likely include fewer FTEs than RNs. Due to this smaller number of FTEs, the effect of vacancies will be more pronounced and make it more difficult to maintain a stable supply of these skills. I discuss this in more detail in my blog post Challenges With Maintaining A Stable Supply of CNAs. While the focus of this article is on CNAs, the issues, concepts, and formulas outlined can apply to any skill where there is a small number of FTEs. Small nursing units employing RNs and LPNs will encounter the same staffing challenges.
Flexible staffing resources such as float pool, part-time, and per diem staff can help to ensure that there are an adequate number of LPNs, MAs, and CNAs available for patient care. An analysis of vacancy rates, unfilled shifts, and the turnover rate can provide insights into the number of flexible staffing FTEs needed.
Nursing Informatics and the Optimal Allocation of Nursing Resources
The staffing crisis presents significant opportunities for nursing informatics professionals in the budgeting, staffing, and scheduling space in nursing.
As I mentioned previously, many of the strategies and initiatives in the MHA report will take months to years to meaningfully impact care at the bedside. We need data-driven, care-centric tools and strategies that we can begin using now to address issues with nurse staffing.
The main component I see missing from the MHA report is there’s no mention of providing nursing and healthcare finance leaders with the tools, data, and education to more effectively manage the resources they have available.
In 2020, the American Nurses Association (ANA), the American Organization for Nursing Leadership (AONL), and the Healthcare Financial Management Association (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 resourcesBegley, R., Cipriano, P. F., & Nelson, T. (2020). Common ground: AONL, ANA, and HFMA Outcomes-Based Staffing Report Provides Guidance, Insights. Nurse Leader, 18(3), … 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 on the 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.
A nursing productivity committee would be an excellent way to address the goals of the report while improving staffing levels, patient and staff satisfaction and, hopefully, costs.McKenna, E., Clement, K., Thompson, E., Haas, K., Weber, W., Wallace, M., Stauffer, C., Frailey, J., Anderson, A., Deascenti, M., Hershiser, L., & Roda, P. I. (2011). Using a nursing productivity … Continue reading
At a minimum, the committee should be comprised of a representative from unit leadership, a finance liaison, and an informatics nurse well-versed in nursing operations and the math of nursing budgets, staffing, scheduling, and productivity.
Given the right tools and data, informatics nurses well versed in staffing and scheduling operations and finance can proactively identify units at risk for staffing problems and provide guidance to nursing and finance leadership on the root causes of the identified issues. Given the many quality, safety, and financial metrics negatively affected by understaffing, even minor improvements in staffing could reap significant rewards for patientsShin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), … Continue reading, patient care staff, and facilities.
Nursing Productivity Committee Ideas
Some ways that the nursing productivity committee could impact staffing and scheduling through increased communication and collaboration:
- The committee could calculate how many hours/shifts the nurse manager can schedule each scheduling period for time off and education before it impacts patient care. By using care-centric modeling concepts, the committee would know that each non-patient care shift scheduled above the Available Replacement (Non-Productive) Hours will remove another shift from patient care. Understaffing would become a more conscious decision as managers would better understand how allocating their resources on a schedule would impact patient care and non-patient care activities.
- The committee could evaluate available replacement/non-productive resources against actual replacement/non-productive utilization. Overutilization of replacement/non-productive time will also remove shifts from patient care.
- The committee can calculate the impact on staffing capacity of 3 0.9 RNs expected to be out on maternity leave in 4 months and begin exploring options for supplementing staff.
- 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.
- The committee can use the care-centric modeling data to provide a transparent assessment of scheduling capacity for the unit’s 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
- Aggregating and evaluating care-centric modeling data for all units can assist nursing directors, CNOs, and other healthcare executives in better understanding staffing and scheduling capacity so that they can establish benchmarks and thresholds for acceptable vs. unacceptable capacity levels for patient care, time off, and education.
The analysis of care-centric modeling data can provide the nurse manager, administration, and finance with simple, measurable metrics to proactively identify staffing and scheduling issues and help inform communication, collaboration, and decisions on resource allocation, hiring, recruitment, and retention activities for units with resource shortages.
Solving the Nurse Staffing Crisis
The nursing shortage and resulting nurse staffing crisis is a complex, multi-faceted problem that has been decades in the making. The Task Force On Maryland’s Future Health Workforce has done an impressive job of identifying issues and crafting strategies to address their workforce problems. The Task Force should ensure that they have no errors in their nursing FTE budget process and that they have an accurate accounting of the resources needed for their workforce. The Task Force should also explore a more holistic understanding of the nursing FTE budget, how vacancy rates impact staffing capacity, and the importance of replacement/non-productive time and how it supports nursing care delivery, the mental health of caregivers, and the education needed to ensure the competency of the workforce.
Care-centric modeling can provide valuable information to all stakeholders in the budgeting, scheduling, and staffing processes. Data from care-centric modeling can allow leaders to evaluate better the level of resources needed to deliver a safe level of patient care while providing adequate replacement to support care delivery via time off and education.
Understanding the mathematical links between the budget, scheduling, and staffing information structures could open the door for more evidence-based managementJones, C., Finkler, S. A., Kovner, C. T., & Mose, J. (2018). Financial Management for Nurse Managers and Executives (5th ed.). Saunders. in nursing. By understanding how management decisions and resource variances impact care delivery, we should be able to link management decisions regarding resource levels that ultimately impact staffing to patient care outcomes and a variety of quality, safety, and financial metrics sensitive to staffing levels.
We cannot solve our problems with the same thinking we used to create them, and we cannot effectively assess the staffing crisis without accurate data on our resource needs. With accurate data, we can take a more data-driven, care-centric approach to evaluate staffing capacity at the unit, facility, and regional levels. While waiting for the longer-term initiatives to begin producing results, we can leverage data to more effectively manage our available resources. With a deeper understanding of how budgets transform into nursing care, the collection, analysis, and reporting of nursing finance and workforce data can help to drive knowledge and wisdom in financial and nursing care delivery decisions that can enormously impact patient care and nursing practice.
|↑1||Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. https://www.mhaonline.org/docs/default-source/default-document-library/2022-state-of-maryland-s-health-care-workforce-report.pdf?sfvrsn=805f7b38_16|
|↑2||Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. https://www.mhaonline.org/docs/default-source/default-document-library/2022-state-of-maryland-s-health-care-workforce-report.pdf?sfvrsn=805f7b38_16|
|↑3||Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. https://www.mhaonline.org/docs/default-source/default-document-library/2022-state-of-maryland-s-health-care-workforce-report.pdf?sfvrsn=805f7b38_16|
|↑4||Jones, C., Finkler, S. A., Kovner, C. T., & Mose, J. (2018). Financial Management for Nurse Managers and Executives (5th ed.). Saunders.|
|↑5||Ward, W. J., Jr. (2015). Health care budgeting and financial management, 2nd edition (2nd ed.). Praeger.|
|↑6||Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. https://www.mhaonline.org/docs/default-source/default-document-library/2022-state-of-maryland-s-health-care-workforce-report.pdf?sfvrsn=805f7b38_16|
|↑7||Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. https://www.mhaonline.org/docs/default-source/default-document-library/2022-state-of-maryland-s-health-care-workforce-report.pdf?sfvrsn=805f7b38_16|
|↑8||Wikipedia contributors. (2022, October 2). Garbage in, garbage out. Wikipedia, The Free Encyclopedia. https://en.wikipedia.org/w/index.php?title=Garbage_in,_garbage_out&oldid=1113657649|
|↑9||Ward, W. J., Jr. (2015). Health care budgeting and financial management, 2nd edition (2nd ed.). Praeger.|
|↑10||Nursing Solutions, Inc. (2022). 2022 NSI National Health Care Retention & RN Staffing Report. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf|
|↑11||Johnston Thayer, Joe Zillmer, Neil Sandberg, Anna R. Miller, Paul Nagel, Alissa MacGibbon. (2022). ‘The New Nurse’ Is the New Normal. https://epicresearch.org/articles/the-new-nurse-is-the-new-normal|
|↑12||Buerhaus, P. I. (2021). Current Nursing Shortages Could Have Long-Lasting Consequences: Time to Change Our Present Course. Nursing Economic$, 39(5), 247–250. https://scholar.google.com/scholar?oi=bibs&cluster=10666219159379248031&btnI=1&hl=en|
|↑13||Nursing Solutions, Inc. (2022). 2022 NSI National Health Care Retention & RN Staffing Report. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf|
|↑14||Maryland Hospital Association. (2022). 2022 State of Maryland’s Health Care Workforce Report. https://www.mhaonline.org/docs/default-source/default-document-library/2022-state-of-maryland-s-health-care-workforce-report.pdf?sfvrsn=805f7b38_16|
|↑15||Fleisher, L. A., Schreiber, M., Cardo, D., & Srinivasan, A. (2022). Health care safety during the pandemic and beyond – building a system that ensures resilience. The New England Journal of Medicine, 386(7), 609–611. https://doi.org/10.1056/NEJMp2118285|
|↑16||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|
|↑17||McKenna, E., Clement, K., Thompson, E., Haas, K., Weber, W., Wallace, M., Stauffer, C., Frailey, J., Anderson, A., Deascenti, M., Hershiser, L., & Roda, P. I. (2011). Using a nursing productivity committee to achieve cost savings and improve staffing levels and staff satisfaction. Critical Care Nurse, 31(6), 55–65. https://doi.org/10.4037/ccn2011826|
|↑18||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|
|↑19||Jones, C., Finkler, S. A., Kovner, C. T., & Mose, J. (2018). Financial Management for Nurse Managers and Executives (5th ed.). Saunders.|
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