Factors to Consider in Decisions About Staffing in Rehabilitation Nursing Settings

Rationale

Staffing decisions involve a process of determining patient care needs and providing the staff skill mix that offers an effective number of nursing hours per patient day to deliver care. Rehabilitation nursing settings differ in patient population, the number of staff available, the talent, experience and skill set of staff, administrative/budgetary issues, admission criteria, levels of care, and workload. Variables to be considered when planning and assigning staff include:

  • Patient Acuity
  • Availability of specialized rehabilitation nursing professionals
  • Accessibility of support systems
  • Availability of substitute/float staff that are appropriately oriented and cross-trained
  • Admissions
  • Discharges
  • Transfers
  • Patients’ diagnoses
  • Cultural diversity of patients
  • Cultural diversity of staff
  • Available technology
  • Availability of resources for evidence based practice
  • Architecture and geography of the environment

Review and accrediting agencies generally expect staffing to be within an assessed level which is based on patients’ diagnoses and patient census. Rehabilitation nurse managers must be creative in meeting the needs of the nursing service areas by scheduling the available staff so that the days of the week and shifts correspond to the needs of the organization and the patient (e.g. bathing, managing bowel programs, and providing patient education activities). Maximum flexibility is desirable in terms of assignment of specialized rehabilitation nursing professionals to meet patient care needs effectively and in a fiscally sound manner.

Value-based care has added new challenges. The Quadruple Aim, (Bodenheimer & Sinsky, 2014) requires staffing levels so that nurses feel successful in meeting patient care needs. This requires strategic planning with the patient, resources and the care giver in mind.

Research demonstrates that good outcomes result from the quality of staff more than quantity (Buhlmun, 2016). Rehabilitation must use big data that includes Functional Independence Measures that are rehab specific, quality measures such as those collected by the National Database of Nursing Quality Indicators (NDNQI®) tool and patient satisfaction data gleaned from resources such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) and Press Ganey scores. Other tools such as The Logical Observation Identifiers Names and Codes (LOINC) developed from the normalizing of data including the Nursing Management Minimum Data Set (NMMDS) is a profession-specific data set adjusted for care setting and can be utilized by rehabilitation organization and organizations providing rehabilitation services to determine how staffing influences both patient experience and outcomes. Most rehabilitation programs already collect the data elements used in the NMMDS.

Recommendations

Since there is not a standard system for determining nurse staffing ratios specific to rehabilitation nursing based on available research, rehabilitation nurse managers should:

  1. Use data to develop an organization-specific, outcomes-driven staffing model based on its nursing value that balances workload, outcomes and staffing satisfaction.
  2. Support nursing in its ongoing quality improvement endeavors that support staffing as it relates to positive patient outcomes, functional improvement, patient satisfaction, nurse satisfaction, and prevention of patient readmissions.
  3. Provide for opportunities to develop staff talent, pay for advanced degrees and establish a clinical ladder that recognizes nurses who prepare to meet the ongoing challenges in caring for patients across the continuum.
  4. Provide input into the selection of a written nurse staffing plan and validation of its applicability to their individual setting.

References

American Nurses Association. (2012). Principles for nurse staffing (2nd ed.). Silver Spring, MD: Author.

Association of Rehabilitation Nurses. (2003). Role Description: Rehabilitation nurse manager. [Brochure]. Retrieved from www.rehabnurse.org.

Benjamin, J. M., & Warner, B. H. (1996). Principles of leadership and management for rehabilitation nurses. In S. P. Hoeman (Ed.), Rehabilitation nursing: Process and application (2nd ed., pp. 70–86). St. Louis: Mosby.

Bodenheimer, T. & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576.

Buhlman, N. (2016). Nurse staffing and patient-experience outcomes: A close connection, combining NDNQI® and patient experience data yields insight into how key variables relate. American Nurse Today, 11(1), 49–52.      

Commission on Accreditation of Rehabilitation Facilities. (2008). Standards manual and interpretive guidelines for medical rehabilitation. Tucson: CARF.

Nelson, A., Powell-Cope, G., Palacios, P., Luther, S.L., Black, T., Hillman, T., et al. (2007). Nurse staffing and patient outcomes in inpatient rehabilitation settings. Rehabilitation Nursing, 32(5), 179–202.

Pruinelli, L., Garcia, A., Delaney, C., Caspers, B., & Westra, B. (2016). Nursing management minimum data set: Cost-effective tool to demonstrate the value of nurse staffing in the big data science era. Nursing Economic$, 34(2), 66–89.

Approved by the ARN Board of Directors August 1995, revised July 1999, revised June 2006, revised October 2014, revised 2017.

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