Staffing metrics for healthcare departments – Why doesn't the number of patients per nurse work?

The healthcare system in Sweden currently faces challenges with bed shortages, resulting in a deteriorating work environment and increased risk of patient harm. The Health and Social Care Inspectorate (IVO) has identified significant patient safety risks in many hospitals, and the National Board of Health and Welfare (Socialstyrelsen), commissioned by the government, has analyzed the situation and concluded that short-term targets indicate a need for 15% or 2,300 more available beds.

There is no shortage of physical beds, but the real challenge lies in retaining and recruiting nurses, particularly those willing to work in inpatient care. This means that a fundamental requirement to address the problem is to provide an attractive work environment in healthcare departments.

Simultaneously, the pressure to keep as many beds open as possible forces facilities to increase the workload on existing staff. This may involve increased overtime and extra weekend shifts to fill the schedule, which does not contribute to a positive work situation for healthcare personnel.

One way to cover short-term gaps is to hire nurses from staffing agencies, but this is costly and not a sustainable solution. Additionally, relying too heavily on agency staff risks further deteriorating conditions for developing the facility and the ability to create an attractive workplace in the department.

Furthermore, most healthcare providers operate with financial deficits, and staffing in inpatient care accounts for a significant portion of the healthcare budget. This makes it a priority to reduce costs and increase productivity as much as possible.

However, excessive productivity can be linked to increased mortality for inpatients ^1,2. It can also be associated with burnout and dissatisfaction with their work situation among nurses ². Similar correlations can also be identified for patients seeking care in emergency departments where capacity constraints are linked to increased mortality ³.

Overall, healthcare managers face a complex and challenging reality. Optimizing productivity in healthcare departments to balance cost, quality, and work environment is a difficult but crucial task. To succeed, relevant indicators to work with are needed.

Patients per nurse (PPN)

In Sweden, the measure of patients per nurse (PPN) is primarily used. It is simple and easy to relate to but unfortunately has significant limitations. The definition varies, but it often only relates to registered nurse staffing during weekday daytime hours. This means it does not account for staffing during evenings, nights, and weekends. An alternative measure could be the average number of patients per nurse per week, but even that measure is problematic. It still does not account for shared resources such as a nurse manager, care coordinator, and similar roles. Of course, these roles can be included in the patients per nurse measure, but it is no longer as simple and intuitive. Another weakness is that other resources such as nursing assistants, kitchen staff, staffing assistants, assistant unit managers, and similar roles are not included in such a measure. Additional measures such as patients per nursing assistant and patients per caregiver can be supplemented, but if central guidelines are to be set for such goals, there is a risk of micromanaging the operation and not giving unit managers sufficient freedom to determine which roles and competencies are required to best meet the care mission within broader frameworks.

Care hours per patient day (CHPPD)

Internationally, more progress has been made in working with staffing indicators. In many countries, "Care-hours-per-patient-day (CHPPD)" has been established as a standard for productivity and workload. CHPPD can be translated into care hours per patient day (CHPPD). It is defined as the total number of work hours for various competencies during a certain period divided by the number of patient days during the same period. Because of how the indicator is designed, it is possible to aggregate the contribution from different competencies into one measure. For example, a healthcare department may have a CHPPD of 10, consisting of 4 hours of nursing, 4 hours of nursing assistance, 1 hour of support, and 1 hour of managerial functions, which can be easily visualized. Thus, the measure captures the contribution from different competencies and support resources in a straightforward manner and also takes into account the overall picture across day, evening, night, and weekend shifts. CHPPD also provides the opportunity to set guidelines for what reasonable productivity is for a certain type of care without controlling and limiting the care unit manager in determining which competencies contribute to the total care time.

Consider the level of care to set realistic goals.

Regardless of whether you choose PPN or CHPPD to establish guidelines and goals for productivity, it is necessary to consider the level of care the department should be able to handle. An intensive care unit, of course, has completely different productivity goals than a regular care department. A fundamental activity is to define different categories of care departments with as clear and objective criteria as possible to then be able to set realistic productivity goals that balance quality, cost, and work environment