1. Partv
Managing l{urnan
Resources

2. 18
Mobilizing Existing
The purpose of this chapter is to discuss an approach to mobilizing
existing nursing resources according to levels of expertise, consid-
ering work and education experience. Assignment patterns are dis-
cussed in terms of organizational variables, nursing resources, and
patient care needs. On completion of this chapter, the reader will
be able to:
1. Discuss nursing resources as a concept.
2. Differentiate between recruitment and retention activities.
3. Explain factors related to the nursing shortage.
4. Relate competency and relicensure issues to availability of
professional nursing resources.
5. Describe a data-based methodology for selecting a nursing as-
signment pattern that meets patient care and organizational
needs.
5. Propose several solutions to recruitment and retention prob-
lems.
Trying to understand recruitment and retention problems in nursing
today is like looking for a straw in the wind and trying to describe its
path. The wind keeps shifting, and a tornadic gust threatens to blow
the whole issue out of our sphere of influence, if not out of nursing's
area of responsibility. Many hospitals have moved in the direction of
nonnursing control of nursing recruitment and retention through the
establishment of human resource departments that control hiring and
firing of all health personnel.
Nursing is the focal point for the the delivery of patient care in all
health care delivery settings. Failure to change or implement new as-
signment patterns, such as primary nursing, may be the result of a lack
249

3. 250 MANAGING HUMAN RESOURCES
of understanding of nursing resources and of the appropriate use of
nurses according to experience and expertise.
NURSING RESOURCES
Nursing resources have been defined by Munson, Beckman, Clinton,
Kever, and Simms (1) in terms of selected variables all of which have
relevance for care assignment and quality care. Table 18.1 identifies
and explains the various nursing resource components, ranging from
staff mix and preparation to commitment, stability, availability, and
special training. This conceptualization provides a broad perspective
on the components of a nursing resource configuration. These compo-
nents are covered in greater detail later in this chapter in the discussion
of assignment patterns. i
RECRUITMENT, RETENTION, AND TURNOVER
Historically, nursing has experienced high turnover and cyclical short- 6
!
q
ages. In 1982, discussions of the nursing shortage were especially ramp- (
o
ant. By 1984, the economy and the advent of prospective payment had 0
c
changed the entire picture of recruitment and retention. Because of the :
large number of nurses in the work force, recruitment became an ir- a-
k
rrl
U
F.
relevant issue, and retention of high-quality, satisfied nurses seemed to
be a possibility for the first time in many years.
Recruitment refers to all those activities carried out by a nursing or
personnel department to attract nurses to a particular work setting for
purposes of interviewing and hiring. Retention activities designed to
keep nurses in the work setting have received less than appropriate at-
tention. Dramatic attempts have sometimes been undertaken to recruit o
a)
regardless of qualifications. The problems that have lead to nursing d
shortages and the difficulties of retaining nurses have not been addressed Ir
on a large scale by nursing and the health care industry.
a
According to Wolf (2), administrative philosophy and policies con-
lr
tribute more than any other factors to a high turnover rate, which is c
the direct result of inadequate attention to retention and staff satisfac- .^.o
cd
!
tion. Wolf further describes salary and job conditions as the leading .. bo
causes of high turnover. Salaries by and large are simply not at the *A
'is
.o,
same level as those of other workers with comparable education in our
society. In addition, there is little difference in nursing pay scales ac- ;.7 rs a
cording to level of preparation and experience. Aiken, Blendon, and
Rogers (3) also cite the limited growth in nurse's salaries as a prime
factor in retention and turnover difficulties. They further suggest that

4. iate use of
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a prime
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251

5. 252 MANAGING HUMAN RESOURCES
in relation to those of other workers, more nurses
as nurses' incomes rise
Johns<
become available for hospital employment, and vacancy rates decline.
leakage
Why do nurses quit their jobs? The following reasons have been ob-
I
evidence
served by the authors over time and have been documented in the lit-
Over the
erature by many others:
of nurses
enty-five
' Low salaries and little reward for experience in the 19r
' Low prestige ing child
. Much responsibility and little recognition visualize<
' Inflexible hours and schedules Variout
and VauS
' Excessive overtime mand for
' Anger expressed by physicians toward nurses faster th:
' Gap between education and practice higher ac
' Lack of autonomy delivery <
' Too much work Rose (7
. Quantity of assignments interferes with quality tional tur
The supp
' Frequent reassignment to unfamiliar units the emph
' Assignment to units not compatible with skills simply d<
' Poor physician-nurse relationships sired. Mo
' Incompetent and unsupportive supervisors lection o
. Lack of opportunity for advancement professior
are no lor
There may be other contributing factors, but these issues appear over Aiken (.
and over again in the literature. Equal pay for equal work is no doubt nurses'p:
incomes a
a major influencing variable, as the gap between nurses' and physicians'
response
incomes has widened dramatically over the last several years (3).
in relativr
control ov
ceived sh<
THE PERCEIVED NURSING SHORTAGE sonnel is s
could be <
In recent years, much attention has been focused on the critical shortage Beyers (
of nurses, particularly in hospitals. For the following reasons, it is dif- and caree
ficult to understand why a shortage is perceived to exist (if, indeed, one as oppose
does any more): agency. Te
not be cot
One fin:
1. There has been an overall decline in the growth of hospitals over the
the vast nr
past three decades. Since 1950, the ratio of hospital beds to population
are opport
has dropped by one-third (a).
settings th
2. Since 1950, the general hospital occupancy rate has declined signif- ing admin
icantly (4). ploring su
3. Since 1950, the nation's output of nurses has doubled (5). model cou

6. MOBILIZING EXISTING RESOURCES 253
ore nurses
Johnson and Vaughn (6) find no statistical evidence of significant
:s decline.
leakage from the profession. On the contrary, they observe that most
: been ob-
evidence provided to support a shortage is based on anecdotal material.
in the lit- Over the last 10 to l5 years, there has been steady growth in the supply
ofnurses. There has also been an increase ofnewly licensed nurses. Sev-
enty-five percent of all nurses are employed, an increase from 55 percent
in the 1960s. Even though nurses may vacate positions temporarily dur-
ing childbirth, they do return. The current supply of nurses should be
visualized as a dynamic, constantly changing, constantly growing entity.
Various reasons are cited for the perceived shortage of nurses. Johnson
and Vaughn (6) call attention to the high probability that employee de-
mand for nurses has been increasing and continues to increase at a rate
faster than the supply of nurses is increasing. This may be due to the
higher acuity rate in all settings and the technological revolution in the
delivery of care.
Rose (7) describes the problem as one of intensity of annual institu-
tional turnover, which ranges from 35 percent to 60 percent nationwide.
The supply of nurses is also influenced by payment mechanisms. With
the emphasis on cost containment, government ceilings on care costs
simply do not allow for the number of nursing positions needed or de-
sired. Moreover, the women's movement continues to influence the se-
lection of nursing as a career, as women may increasingly choose
professions in medicine, law, dentistry, the sciences, or the ministry and
are no longer bound to those in teaching or nursing.
ppear over Aiken (3) equates the perceived shortage to the dramatic increase in
s no doubt
nurses'participation in temporary service agencies to maximize their
physicians' incomes and control their working hours. Agencies have proliferated in
rs (3). response to the increased need for temporary services and the decline
in relative income for nurses. In addition, nurses wish to have more
control over their working hours. One often forgotten reason for the per-
ceived shortage is that the differential cost of a nurse over other per-
sonnel is so small that hospitals may be substituting nurses in jobs that
could be done by nonnurses.
:al shortage Beyers (8) believes that not enough attention is paid to job promotion
rs, ir is dif- and career advancement, which provide functional turnover patterns,
.ndeed, one as opposed to the dysfunctional turnover when employees leave the
agency. Temporary vacancies exist with functional tumover that should
not be counted or depicted as a nursing shortage.
lls over the One final rcason for the pcrceived shortage is thc incomplete usc of
the vast nursing expertise in schools of nursing around the country. Thcre
population
are opportunrties for facultir practice in acutc, long-term, and home carc
se ttings that could be attraitive to schools of nursing, but, to date, nurs-
ined signif- ing administrators and educators have not taken the initiative in ex-
ploring such options. A contract for scrvices or a shared consultation
). model could be developed in most settings.

7. 262 MANAGING HUMAN eE9QrrRqES _
9. Sta
3. Interest in flexible hours with more leisure time and social oppor- Nur
tunities (21). 10. Mic
4. Need for role transition guidance (22). Reli
soci
Perhaps most important is the element of support services. Nurses 1l. Cla'
are more satisfied and more likely to stay in organizations where support ed.
services are adequate and they do not have to carry out extensive non- 12. Joh
tion
nursing tasks.
13. Horr
U.rp
Publ
SUMMARY 14. Shu.
Jour
The nurse administrator should support the competency of nurses by 15. Betz
building on the educational preparation appropriate for their assigned Marr
roles and by using assignment patterns selected through data-based de- 16. Eliol
cisions. Such an approach to using nursing resources differs from that high
t 3(1(
found in traditional nursing texts. The availability of nursing personnel,
17. Cark
coupled with organizalional and patient characteristics, should dictate prim
nursing assignment patterns. Selection of any model without considering June
these variables usually is a contributing factor in dissatisfaction and 18. Shuk
high nurse turnover. Servi
19. Friss
pensi
REFERENCES Decer
20. Duxb
Joum
L Munson, F.C., Beckman, J.S., Clinton, J., Kever, C., and Simms, L.M. Nursing
21. Vik, ]
Assignment Patterns. Ann Arbor, Mi.: Health Administration Press, 1980.
The J,
2. Wolf, G.A. Nursing turnover: some causes and solutions. Nursing Outlook,
April 1981, 29(4), 233-236. 22. Dear,
hospi
3. Aiken, L.H., Blendon, R.J., and Rogers, D.E. The shortage of hospital nurses: 1982,
a new perspe ctle. American J ournal of N ursing, September 1981, 8 1 (9), 1612-
1618.
4. American Hospital Association. Hospital Statistics: Data from the American
Hospital Associtttion 1979 Annual Suwey. Chicago: American Hospital As-
sociation,1980. BIBLIO
5. U.S. Department of Health and Human Services, Division of Health Profes-
sions Analysis. Supply of Manpower in Selected Health Occupations, 1950- Hofmann,
1990. DHHS publication no. (HRA) 80-35. Washington, D.C.: Government reducti<
Printing Office, 1980. tI (11-r
6. Johnson, W.L. and Vaughn, J.C. Supply and demand relations and the Munson, I
shortage of nurses. Nursing and Heabh Care, November 1982, 3(9),497-507 . search, .
7. Rose, M.A. Factors affecting nurse supply and demand: an exploration. The Weisman,
Iournal of Nursing Administration, February 1982, 12(2), 3l-34. Journal
8. Beyers, M., Mullner, R., Byre, C.S., and Whitehead, S.F. Results of the nursing
personnel survey, part 2: RN vacancies and turnover. Journal of Nursing
Administration, May 1983, 13(5), 26-31.

8. MOBILIZINC EXISTING RESOURCES 261
in the same hospital. Shukla (14) found that on matched units, where
nurses had similar educational backgrounds and experience, differences
in quality of care between primary and team nursing disappeared. This
en by the raised the question as to what makes the real difference in quality and
satisfaction: the competency of the nurse or the nursing assignment pat-
Ig the care tcrn.
Betz (15) also found that nurses were not always more satisfied with
volved in
primary nursing. Betz compared three team nursing units with three
ers for a primary nursing units over a year and discovered that primary nurses
were less satisfied than team nurses, depending on educational level.
nners for a Primary nurses had difficulty delegating responsibility, utilizing per-
sonnel, and setting priorities. B.S.N.'s showed the greatest drop in sat-
nsible for a isfaction when moved to team nursing.
stay on a In the long-term care setting, Eliopoulos (16) explores the use of the
registered nurse in a professional manner. She believes it is an unrealistic
)ommon goal in long-term care to increase the ratio of registered nurses, in light
rf nursing
of the number of tasks that can be delegated to nurse assistants. Her
it common
preferred approach is the team assignment pattern.
)lvement In a large research hospital survey, Carlsen and Malley (17) determined
volvement that neither team nor primary nursing afforded sufficient opportunities
)atient's for self-fulfillment, decision making, or independent judgment. Neither
ns (CCC) system provides sufficient opportunities to meet self-actualization needs.
;C)
The need for primary nurses to be superwised was an unexpected finding.
dof In dealing with high turnover, the nurse administrator must not as-
rift
sume that primary nursing is the answer. Jumping on the primary nurse
Nursing As-
bandwagon may be possible only if qualified baccalaureate-prepared
s, 1980, p.5. nurses are available for the primary nurse role. Shukla (18) suggested
acting other that when nurse competency is controlled, the primary nursing structure
ve or simplv does not provide more direct care than does the team or the modular
structure. On the contrary, the primary nursing structure provides the
least amount of direct care, suggesting that the competency of the nurs-
ing staff may have a greater impact than the structure. An additional
finding in Shukla's work was that the modular structure is most pro-
ve way to ductive. Registered nurses did not perform as many nonprofessional or
uate high indirect care tasks. Modular nursing has been defined as a miniteam,
t for con- as it provides the features of both team and primary nursing assignment
'oss units. patterns. The R.N. works in a subunit, or module, with an L.P.N. or aide
and R.N./ but does not follow the same patients if they are transferred to another
subunit.
Other important issues in dealing with turnover problems are pur-
ported to be:
e, but its
1. The propensity to leave the organization (19).
;ing units
2. Inadequate information about leavers and stayers (20).

9. 260 MANAGING HUMAN RESOURCES
TABLE I8.3
Elements of the Nursing Assignment Pattern
in the
nurses
Variable Name Basis for t ariable Definition in qual
Nursing care integration (NCI) The proportion of total care given by the raised
person providing the most care satisfar
Care management integration The number of persons managing the care tern.
(cMr) process at a given time
Betz
Plan-do integration (PDI) The proportion of care givers involved in
primar
the planning of care
primar
Nursing care continuity (NCC) The average number of care givers for a
patient over a seven-day period rvere le
Care management continuily The average number of care planners for a Primar
(CMC) patient over a seven-day period sonnel,
Care management continuity Whether a care planner is responsible for a isfactio
across settings (CMCI) patient before or after patient's stay on a In th
unit register
Nursing coordination (NC) An index that records the most common goal in
pattern of on-unit coordination of nursing of the r
care activities for a patient
preferrt
Care-cure coordination (CCC) Two indexes that record the most common
Patient services coordination pattern of the. nurse's direct involvement Inal,
(PSC) and the proactiveness" of that involvement that nei
in coordinating other inputs to patient's for self-
care requirements from physicians (CCC) system
and from other professionals (PSC) The nee
Intershift coordination (ISC) An index that records the method of In der
communication by which intershift
coordination is achieved sume th
bandwa
SOURCE: F. Munson, J. Beckman, J. Clinton, C. Kever, and L.M. Simms, Nursing As'
sigwnent Pattens LIsers Manual. Ann Arbor, Mi.: Health Administration Press, 1980, p. 5.
nurses i
"Proactiye: taking the initiative in coordination activities, for example, contacting other
that wh
personnel, making referrals, problem solving. Reactire.'not initiating: a passive or simply does no
cooperative response to coordination initiatives from others. structur
least an
ing staft
Implications finding
ductive.
This study has several implications. By providing an effective way to indirect
acquire a data base, the nursing administrator can better evaluate high as it pro
cost assignment patterns, can select a particular component for con- patterns
centrated study, or can more logically make comparisons across units.
but does
This study further suggests the need to view staff satisfaction and R.N./ subunit.
L.P.N. ratios as important aspects of nursing resources.
Other
ported t
Implication for Turutover Problems
Primary nursing may be a better system for organizing care, but its 1. The p
effectiveness is not uniform for all types of nurses, even on nursing units
2. Inade

10. MOBILIZING EXISTING BEIQUBQES 259
TABLE I8.2
Hospital
outcomes Central Elements of the "y"9 |1.'g.l-:4}tt"11
!!t"_c!!!9" Contirtuitv Coordination
Nursing care Nursing care Nursing coordination
integration (NCI) conrinuity (NCc) (NC)
Care management Care management Care-care coordination
integration (CMI) continuity (cMC) (ccc)
Plan-do integration Care management Patient services
Patient (PDI) continuity across coordination (PSC)
care
qua lity settings (CMCI)
outcomes
Additional integration, continuity, and coordination variables were
conceptualizedro complete the profile. Note on Table 18.3 the elements
Person nel
+ satisfaction of integration, care management, continuity across settings, and the co-
outcomes ordination elements of care-cure, patienl services, and intershift coor-
dination.
- Cost of care By collecting specific data, a nursing unit can determine the type of
- outcomes assignment pattern actually in use. It is also possible to look at patient
(Reprinted characteristics and consider which elements of the nursing assignment
,on, Joanne pattern are most closely related to the needs of the patients. For example,
M. Simms, a patient with high psychosocial support needs may benefit tremen-
)80.)
dously from a high level of nursing care integration, that is, care provided
by a single person. By contrast, the patient with multiple and complex
which the care requirements may benefit from the care of several specialists.
ere devel-
Based on nursing resources, it is also possible for a unit to consider
(13) were
whether it is appropriate to move toward greatcr care management in-
/eness, ac-
tegration, a different level of care management continuity, or a different
developed
type of intershift coordination. In summary, the elements of a nursing
s, nursing
assignment pattern can be prioritized in order of importance according
to the availability and competence of the nursing resources.
ized: care A great advantage in using this approach is the opportunity to look
t includes for the weak and strong points in organizational support. For example,
ulation of it is difficult to have high levels of care management continuity when
rventions, nurse staffing or scheduling systems provide a constant rotation of the
of nursing
nursing staff within a hospital. Scheduling and staffing policy are in-
a nursing
tricately related to nursing assignment pattern decisions.
The findings in the Michigan study suggest a betler way to look at
nagement assignment patterns. The identification of the key elements of the nursing
ssignment assignment patlern lead to the development of data collection instru-
llans. In a ments specific to three variables: patient characteristics, nursing rc-
rf the hall sources, and organizational support. The study further demonstrated
r. Nursing that this kind of infcrrmation can bc quantified and displayed in a format
, patterns, lhat can be used to defend an existing pattern or a change to a new
lumber of pattern.

11. 258 MANAGING HUMAN RESOURCES
I nfluencing Professtonal Nursing Quality standards Hospital TABLE
factors: judgments and unit for nursing
empirical structu re process:
outcomes: Central
research that
esta bilsh
and
policy:
rtt"s!!
re lations: Nursinp
integrat
T-----*---t Care mz
Patient I I Comprehensiveness I
integrat
characteristics
l- Connective Nursing
I Accountability I
PIan-do
ttursinc resources propostlons Assignment -+l Patient
| |
pattern I Continuity i ! care
(PDD
I i L-.>j quality
Organizational I
i Coordination I I
support L__________.1 outcomes
J i
f--------- r Addit
| Schedulinc I concept
i ^sturiinc i
i Personnel
p_- of integr
t---r----- +----- --------.1
satisfaction
outcomes ordinati
I Dailv allocations I
rl
I
dinatior
t---l
L-_:_-______-l | - Cost of care By co
outcomes
assignm
FIGURE 18.1 Nursing assignment pattern conceptual framework. (Reprinted
from Nursing Assignment Pattenls (Jser's Manual, by Fred C. Munson, Joanne characte
Schultz Beckman, Jacqueline Clinton, Carolyn Kever, and Lillian M. Simms, pattern i
by permission of Health Administration Press, Ann Arb<tr, Mi., O 19S0.) a patien
dously fr
the organization. Figure 18.1 shows the framework within which the by a sinl
definition of the elements of a nursing assignment pattern were devel- care reql
oped. Four quality attributes identified by Horn and parker (13) were Based
used as the basis for the conceptual framework: comprehensiveness, ac- whether
countability, continuity, and coordination. Instruments were developed tegratior
to measure the influencing factors of patient characteristics, nursing type of ir
resources, and organizational support. assignm(
within [he nursing process, two basic activities are recognized: care to the av
giving and care planning, or management. Care management includes A grea
assessment of patient requirements for nursing care, formulation of for the w
nursing diagnosis, stating outcomes of care and nursing interventions, it is diffi
and evaluation. care giving refers only to the implementation of nursing nurse sta
interventions. Table 18.2 highlights the four central elements of a nursing nursing s
assignment pattern. tricately
These elements vary across assignment patterns. Care management The fin
integration (cMI) would be relatively high in a functional assignment assignmei
pattern and in a primary nursing pattern where one person plans. In a assignme
team assignment pattern in which the team changes sides of the hall ments sp
every week, care management continuity (CMC) would be lower. Nursing sources, i
care integration (NCI) would be high in most primary nursing patterns, that this I
lower in team, and lowest in functional, with the greatest number of that can
care givers. pattern.

12. MoBILIZINc EXISTING RESoURCES 257
I settings.
d division could functionally assign tasks within the team itself, with less concern
:n evolved for the number of personnel rendering direct care to an individual pa-
,d a redis- tient. In functional nursing, the picture of variation is less clear, for few
:luded the nursing departments now identify with this structure. Yet one can rec-
nsed prac- ognize this structure in hospitals, where there is a separate specialist
on getting for activities such as discharge planning, patient education, medications
time and administration, and so on.
asks-cat-
ortance to
;kill levels. A NEW APPROACH TO NURSING ASSIGNMENT
ients' care PATTERNS
[ed within
The purpose of a recent two-year study at the University of Michigan
re basis of was to develop useful tools for nurses in management and clinical prac-
personnel tice who are faced with nursing assignment pattern decisions. The pro-
m nursing ject included (1) development of instruments to measure nursing as-
iary work- signment patterns, patient characteristics, nursing resources, and
he diverse organizational support; and (2) the publication of a nursing assignment
'ed nurses. user's manual (1)
; decisions This demonstration project collected data in four hospitals. Prelim-
:am leader inary work was essential to the quality of the project and included:
:mbers.
[or nursing l. Development of a conceptual framework within which the definition
rg requires of the elements of a nursing pattern could be developed.
lager-per- 2. Literature review of about 270 items selected for their potential con-
s' aide ac- tribution to an understanding of the linkage between patient char-
atient and acteristics, nursing resources, and organizational support and ap-
I practical propriate nursing assignment patterns.
:ontinuum
3. Development of connective propositions from the literature review
nurse. De-
that could translate the data into appropriatc recommendations for
: giver and
a unit's nursing assignment pattern.
ather than
ing assign- 4. Development of the instruments.
.nd no one In developing the essential instmments, the study group found it useful
1e pattern,
to go beyond the traditional nursing assignment patterns (functional,
he primary team, or primary) and to think of three major dimensions in any nurse
plans and utilization pattern: patient characteristics, nursing resources, and or-
scharge or ganizational support.
rsing unit.
lnagement
Conceptual Framework
rder might
lch patient The pattern of nursing assignmcnt on any patient unit may be seen as
:am leader a link between problems, as presented by different patient populations,
and purpose, as expressed bv professional standards and purposes of

13. 256 MANAGING HUMAN RESoURcES
of the use of nursing personnel in providing care in hospital settings.
One type of assignment pattern focuses on specialization and division could fr
of labor, or functional nursing. This type of assignment pattern evolved lor the
in response to political and economic factors that demanded a redis- tient. Ir
tribution of registered nurses during World War II and included the nursing
creation of new nursing personnel categories such as the licensed prac- ognize 1
tical nurse and the nurses' aide. Functional nursing focuses on getting for actir.
the greatest amount of task work done at the least cost in time and adminis
training. This pattern is accomplished by assigning specific tasks-cat-
egorized or ordered according to degree of difficulty and importance to
patient well-being-to nursing personnel with corresponding skill levels. A NEW
The use of multiple personnel to provide elements of a patients' care PATTE
requires a level of coordination and decision making best handled within
a formal unit structure with a well-defined hierarchy. The purl
Following the focus on specific technical excellence as the basis of rvas to dt
assignment patterns was an emphasis on integrating nursing personnel tice who
of varying skill levels into a democratic, close-knit team. Team nursing ject inclr
represents another way of adjusting care to the influx of auxiliary work- signmen
ers and was created to improve patient care by utilizing the diverse organizat
skills of team members under the close guidance of registered nurses. user's me
This pattern shifted much of the authority for making nursing decisions This de
to a lower level in the nursing hierarchy: the registered nurse team leader inary wor
who assumes responsibility for care given by other team members.
The most recent pattern to develop places the responsibility for nursing 1. Develc
care management within the direct care giver. Primary nursing requires of the ,
that the registered nurses' activities change from care manager-per- 2. Literat
sonnel organizer to care manager-care implementer. Nurses' aide ac-
tributi
tivities are refocused away from direct contact with the patient and acteris
toward equipment and supplies. The services of the licensed practical propri:
nurse are not used in this pattern or fall somewhere on a continuum
from direct patient care to direct assistance to the registered nurse. De- 3. Develo
cisions in the care process are usually made by a single care giver and that co
are facilitated through horizontal consultation with peers, rather than a unit's
with line authority. Primary nursing has been the basic nursing assign- -1. Develol
ment pattern used in community health nursing.
Each assignment pattern has had its day of popularity, and no one In devek
best way has emerged for all settings.Indeed, within the same pattern, to go beyc
there is no clear description of nursing responsibility. Within the primary ieam, or p
nursing pattern, the time duration in which a primary nurse plans and utilization
gives care to a patient might span hospital admission to discharge or sanization
be limited to a patients' length of stay on a particular nursing unit.
Within a given day, primary nurse responsibility for care management
Conceptui
may vary from 8 to 24 hours. In team nursing, the team leader might
carefully match patient needs to team member skills so that each patient The patten
must cope with only a limited number of personnel; or the team leader alink betw
and purpor

14. MoBrLrzrQl>(EuNE BqgouRCES 255
competent in their assigned roles. However, these assigned roles cannot
be determined in educational settings away from the work environment.
The technological revolution has created a situation in which education
le past 10
is far behind practice. Nurse administrators are the professionals in the
decreased
best position to see the needs of the patients and the organization.
lant under
Johnson (12) describes competency by the standards of the state of
ill become
New Jersey as "being functionally able to perform duties of an assigned
: questions
role. The functions are performed having drawn conclusion for this ac-
f nursing?
tion from a sound knowledge of related sciences. The judgments made
ork? What
are based on a logical assessment of a given situation. Both deductive
;e workers
and inductive reasoning are imperative to competent practice."
'sing prac- The licensed practical nursing role is a dependent role. For minimal-
level competency in today's dynamic health care system, the practical
onal nurs-
nurse should be prepared at the associate degree level. Registered nurses
nursing is
should be prepared at the baccalaureate level and have studied super-
red knowl-
vision and management. As nurse administrators conduct job and nurs-
Lvioral sci-
ing staff analyses, they need to have competent nurses and nurse as-
ndividuals
sistants in order to develop assignment patterns designed for quality,
es or who
cost-effective care delivery.
vention or
:red nurse
It is no longer acceptable to deny the legal accountability of the
professional nurse by creating such titles as primary or team leader or
practical
modular nurse. Prospective payment legislation demands a quantifi-
oerformed
cation of nursing services. The first unknown to be defined in the equa-
cr dentist.
o minimal
tion is nurse. The nurse administrator has the best key to solving the
profession,
following:
ference in n * assignment pattern : quality care
)s, contro-
N.'s. Inev-
education The assignment pattern is easy to identify once a clear decision has been
frequently made about n (nurse).
ent would Institutional licensure is greatly feared as the antithesis of independent
'ement for professional licensure. If nurses do not assume responsibility for practice
as defined in most state practice acts, it may be only a matter of time
a trained before institutional licensure takes over as a method of competency
;sion with maintenance for relicensure. Nurse administrators must create practice
tability to environments that address the best use of nurses, associate degree
stitutions through doctorate. Nursing assignment patterns based on the creation
lities, and of new titles without attention to the competence of the participants
ls for who lack credibility.
r the basic
rrs, before
nt pattern TRADITIONAL ASSIGNMENT PATTERNS
rncerning During the last three decades, an extensive literature has developed on
nurses be the subject of nursing assignment patterns, reflecting the importance

15. 254 IVIANAC!G Iu I44N &E!9 U 3e El
compel
COMPETENCY AND RELICENSURE
be dete
The tec
The pool of employed nurses has steadily increased over the past 10
years, and the proportion of inactive nurses has substantially decreased is far br
(a).If a clear identification of nursing services is really important under best po
prospective payment, perhaps an analysis of nursing jobs will become Johns
New Jei
as mandatory as continuing education is in many states. Some questions
to be answered in such analysis include: What is the work of nursing? role. Th
What should it be? Who should be doing which parts of the work? What tion fro.
are basr
will be the competencies of the workers? How will the nurse workers
and indr
maintain competency according to their level of expertise?
Most states have health occupation legislation covering nursing prac- The li
tice and licensure provisions that specifically address professional nurs-
level cor
nurse sh,
ing. In the state of Michigan, for example, the practice of nursing is
should b
defined as "the systematic application of substantial specialized knowl-
vision ar
edge and skill derived from the biological, physical, and behavioral sci-
ences, to the care, treatment, counsel, and health teaching of individuals
ing staff
sistants i
who are experiencing changes in the normal health processes or who
cost-effec
require assistance in the maintenance of health and the prevention or
management of illness, injury, or disability" (9). The registered nurse
It is nr
professio
engages in the practice of nursing; the practice of licensed practical
nursing is considered a subfield of the practice of nursing performed modular
cation of
only under the supervision of a registered nurse, physician, or dentist.
Incompetence means a departure from or failure to conform to minimal
tion is ne
following
standards of acceptable and prevailing practice for the health profession,
whether or not actual injury to an individual occurs.
Although the laws in most states clearly describe the difference in
levels of competency between registered and practical nurses, contro-
versy continues to iage about substitution of L.P.N.'s for R.N.'s. Inev-
itably, nursing must come to grips with the idea of a standard education The assigr
for a professional activity. Although "B.S.N. or equivalent" is frequently made abo
used to state a position requirement, no personnel department would Instituti
professionr
ever argue for an M.D. or equivalent as the minimum requirement for
a physician's appointment. as defined
Over the years, nursing has evolved from the services of a trained before ins
nurse who learned skills at the bedside to those of a profession with maintenar
standards of education and practice and recognized accountability to environm,
the public. Credentialing at graduation from accredited institutions through dr
suggests that minimal criteria with respect to faculty, facilities, and of new tit.
program have been met. Nurse administrators set the standards for who lack credil
will do what in nursing in their settings. They need to consider the basic
educational competency of the participants, among other factors, before
deciding on a particular organizational structure or assignment pattern TRADITI
(10).
Fragmented, irreler,'ant discussions prevail nationwide concerning During the
competencies for registered nurses (11). It is important that nurses be
the subjecl

16. !!QB4rzre EXIIIING 3Eq9!4cEq _ _z03
9. State of Michigan Public Health Code, Article 15, Occupations Part 172,
oppor- Nursing. 1978.
10. Michigan Nurses' Association Task Force. Position Paper on Competency for
Relicensure of Michigan Nurses. East Lansing, Mi.: Michigan Nurses' As-
sociation, 1978.
Nurses 11. Clayton, G.M. Identification of professional competencies, in N.L. Chaska,
ed. The Nursing Profession. New York: McGraw-Hill, 1983.
;upport
12. Johnson, H. Maintaining competency: a call for collaboration. lssrzes, Na-
ue non-
tional Council of State Boards of Nursing, Summer 1983,4(2),3.
13. Horn, B.J. and Parker, J.C. Reorganization of Nursing Resources in Hospitals.
Unpublished manuscript. Ann Arbor, Mi.: University of Michigan School of
Public Health, 1975.
14. Shukla, R.K. Primary nursing? Two conditions determine the choice. The
Journal of Nursing Administration, November 1982, f 2Q1),12-15.
rses by 15, Betz, M. Some hidden costs of primary nursing. Nursing and Heakh Care,
;signed March 1981, 11(3), 150-154.
sed de- 16. Eliopoulos, C. Nurse staffing in long-term care facilties: the case against a
rm that high ratio of RNs. The Journal of Nursing Administration, October 1983,
/3(r0), 29-31.
sonnel, 17. Carlsen, R.H. and Malley, J.D. Job satisfaction of staff registered nurses in
dictate primary and team nursing delivery systems. Research in Nursing and Health,
;idering June 1981, 4(2), 251-260.
on and 18. Shukla, R.K. Nursing care structures and productivity. Hospiteil and Health
S ent ic es Admini s trat iorz, November/Deccmber 19 82, 27 (6), 45-5 8.
19. Friss, L. Why RNs quit: the need for management reappraisal of the "pro-
pensity to leave." Hospital and Health Services Administration, November/
December 1982, 27(6), 28-44.
20. Duxbury, M. and Armstrong, G.D. Calculating nurse turnover indices.The
Journal of Nursing Administration, March 1982, 12(3), 18-24.
Nursing
1980.
21. Vik, A.G. and Mackay, R.C. How does the l2-hour shift affect patient care?
The Joutnal of Nursing Administration, January 1982, 12(l), 11-14.
)utlook,
22. Dear, M.R., Celentano, D.D., Weisman, C.S., and Keen, M.F. Evaluating a
hospital nursing internship. The Joumal of Nursing Administration, November
nurses: 1982 , 1 201,), 16-20 .
t, 1612-
nerican
ital As-
BIBLIOGRAPHY
Profes-
1950- Hofmann, P.B. Accurate measurement of nursing turnover: the first step in its
'nment reduction. The J ournal of N ursing Administration, November/December 1 98 l,
1 t (t t-12) , 37
-39 .
nd the Munson, F. and Clinton, J. Defining nursing assignment patterns. Nursing Re-
7-507. search, July/August 1979, 27(4), 243-249.
>n. The Weisman, C.S. Recruit from within: hospital nurse retention in the l980s.The
Journal of Nursing Administration, May t982, 12(5),24-31.
rursing
tursing

17. 19 istrato
staffinl
Nurs
pretati,
Stafnng and Schefuling compol
cation.
personl
entails
Yvonne M. Abdoo on pati
signme
A gre
staffing
The purpose of this chapter is to discuss requirements and consid- describ
erations in nurse staffing and scheduling. The evolution of nurse (l) asse
staffing is briefly explained, and current state-of-the-art systems
are described. Various scheduling methodologies and trends in Nurse st
sound ra
workday length are explored. On completion of this chapter, the required
reader will be able to: patients
number
l. Describe the trends in the development of patient classification
and kin<
systems in nursing. week. . .
2. State four work measurement methods that have been utilized public tl
to measure nursing activity times. and the
3. Identify at least five factors related to physical surroundings
and professional nursing practice that could affect nursing The p
activity times. tifiable,
4. Describe the advantages and disadvantages of: must in
a. Cyclical scheduling. needs (p
to meet
b. Block scheduling.
gorithm
c. Float, or supplemental, nurse staffing. sonal flr
d. A 10-hour workday and a 4-day workweek. variable
e. A l2-hour workday and a 3-day workweek. Devia
f. Centralized versus decentralized scheduling. proach ,
5. Discuss the physiological effects of shift rotation and cisions 1
the implications for nurse staffing. its coml
One of the most critical issues confronting nursing service administrators
today is nurse staffing. Staffing policies and needs affect the nursing THE E'
department budget, staff productivity, quality of care provided to clients,
nursing staff morale, and even turnover. At the same time, nurse staffing Nurse st
requirements are affected by overall hospital policies and by nearly every publishe
other department in the organization, including admitting, lab, x-ray, on the u
dietary, and the like. Thus, it is essential that nursing service admin- the deve
264
a hospitr

18. s'l'Al l,lN{;ANl}:i( lnrt)lrilN(, .l/
272 MANA(;tN(;tttlMAN l{lis()tllt(t,s
Itct'cttct'lo rt grtl':t'rrl ;,l,rrr,,r Pt,rtcclrttc wirs n()l s.'t'rr lry rrrrlsinl'. pr.r:,orrnr.l
of nursing carc rcquircrncnts. l'lris schcnra rcsults in 3u, ol ti I , pt-rssiblc as citlrt'r'c'sst'ttli;rl ot rlt':.itlrlrlt'.'l'[rc wotlt scclttt'rrcr'lrrrtl l)ir('('w('11.ri(.1
basic classification configurations, cach with its own mean nursing timc by othcr kirrrls ol plior itit's" ( I ).
and variance to reflect the nursing work load of medical patients and Improvcntcttl irtttl t'r'lirrr,'rttcttts in dctcrmirri-rtiorr ol nrrrsirrg irc'tivily
another 81 means and variances for surgical patients.Intravenous ther- times can ottl.y occur il thc rrurse has a basic unclcr-starnclirrg ol wollt
apy, catheter care, dressing care, and isolation are included in a special measuremcnt principlcs so that effective collabroratiorr witlt irrclr-rstlitrI
procedures section, since these activities have been found to reflect a engineers will occur. Four basic work mcasurcntcnt tcclrniclucs lrirvt'
high amount o[ nursing time. been utilized in nursing studies to determine thc timc involvccl irr rrtrrsirrli
activities (22):
WORK MEASUREMENT IN NURSING 1. Time study and task frequency
2. Work sampling of nurse activity
The determination of the amount of nursing time required by each pa- 3. Continuous observation of nurses performing activitics
tient for every shift is an essential but by no means simple component 4. Self-reporting of nurse activity.
of a staffing methodology. Nursing has relied primarily upon industrial
engineers and engineering work measurement techniques to quantify Difficulties encountered by nursing in using industrial-basccl w,r'l<
nursing actions, but there are often problems with the values obtained' measurement methods to measure nursing practice are as follows:
For example, many of the allocated time values for patient care deal
only with technical tasks. Difficulties in quantifying nursing times can 1. Many of the allotted time values deal with technical tasks, sirr.t,rlrt,
be attributed to several causes: industrial engineer or observer does not recognize thc assr.ssrrrt,rrr,
evaluation, and psychosocial aspects of the nurse-paticnl t'orr llrt t .
1. The industrial engineer or nonnurse observer does not recognize the Thus, a patient who requires technical tasks could very likcl.y bc r.irlr.rl
assessment, evaluation, and psychosocial aspects of the nurse-patient in a higher category than one who requires psychosocial or- tcirt.lrinli
contact, and the nurse often does not convey these components of activities.
professional nursing practice to the industrial engineer, due to the 2. In developing a patient classification system, some nursing clcltirr.t-
nurse's unfamiliarity with work measurement techniques. ments borrow the nursing times from the classification systcrrrs ol
2. It is often difficult to differentiate between the start and completion others. It is important to realize that the times for one agcncy nt:rv
of a nursing activity. For example, while giving a patient a bath, the not be accurate for another, since the nursing policies and proccclrrr.t,s,
nurse interacts with the patient. How much of the time spent with unit architecture, experience of the nurse, and methocls o[ irrrplt'
the patient should be allocated to the technical task of bath giving menting the work can vary from agency to agency.
and how much to assessment and interaction? 3. Many systems employ the mean time for a task without any corrsitl
3. Although often referred to as time-study or efficiency experts, in- eration of the variance. Abdoo and colleagues (23) havc fburrcl tlr.t
dustrial engineers cannot easily measure the time spent in assessment nursing tasks often vary widely with who performs thc activity irnrl
and interaction. Measurement of repetitious, technical tasks can the method utilized. For example, report time on oruc stucliccl trrrit
readily be done, but determination of times involving professional ranged from 15 to 90 minutes, with a mean of 30 minr-rtcs.
' judgment and skills is much more difficult. 4. The educational and experience background ol thc obscrvcc is rltt''
not considered, nor is a differcntiation made among thc lcvcls ol l{.N.,
Hudson's dissertation, summarized in Aydelottc (1), presents "criteria L.P.N., and nurse assistant or aide.
that support the classification of nursing work as nonrepctitive. He also
5. Mosl stuclics ckr rrol corrsiclcr:
examines questions relating to variations in task prediction time, t<-r
procedure development, and 1o thc inccntivc problcm. Hudson found it er. Thc it1-r;-rl-oltriirlr'ttt'ss ttl lht' rtursing irrtclvt'rrliorr or't ulling lrl tlrt.
difficult to encourage inclivicluals to contplctc task zrssignmcnts withir-r Iirttr' ol ittlt't vctrl iorr.
the time predictcd lirr tlrcir- acconrplislrnrcnt. l-Ic concluclccl thart a tzrsh's b.'l'lrc stal'l irrg, silrrrtlior;rl llrc littrt'ol tlrt'slrrtll,(ovt.1 , r1(l('1 , ()r
time variation was cluc rrot orrly to tlrc irrclivirlrrirlit.y ol tlrc p:tticnt itrttl slr Iislac'toliIy slr Ilt't I)
his c1;nclition ltrrt trlso lo llrt'irrrlivitltrlrlily ol tltc ttttt'sc, ltt't tottccltt ol' t'. Wlrt'llrt'r'printiu,, lrrrrt liorr;rl, or lt.:rrrr rrtrlr,inli ,;r., rrr r.llr.r l.
nursirrg 1-rllrt lit't', irrrrl llrt'plt'tontr'ivr'tl ttoliotr ol lrorv l<t lrt'tlot ttt it. Acl-

19. s't Atrtil N(; AND SqIIEDUIING_ 273
272 MANAGING HUMAN RESOURCES
herence to a present pran or proccdun-'
w:rs .'r sccn by nursing personnel
of nursing care requirements. This schema results in 3o, or 81, possible as either essential or dcsirzibrc. Thc w'r.k
basic classification configurations, each with its own mean nursing time scclu.,',."'urrJfuce were set
by other kinds of prioritics,, (l).
and variance to reflect the nursing work load of medical patients and Improvement and refincmcnts in dctcrn-ri'ertion
another 81 means and variances for surgical patients.Intravenous ther- times can only occur if rhe nurse has a of nursing activity
basic
apy, catheter care, dressing care, and isolation are included in a special measurement principles so that eflectivc "na".rturriing of work
collaborati", *iir, industriar
procedures section, since these activities have been found to reflect a engineers will occur. Four basic work
high amount of nursing time. mcasurcment techniques havc
been utilized in nursing studies to deterrnine
the time irrrir"a in nursing
activities (22):
WORK MEASUREMENT IN NURSING 1. Time study and task frequency
2. Work sampling o[ nurse activitv
The determination of the amount of nursing time required by each pa- 3. Continuous observation of .rt-r.r", perfbrming
tient for every shift is an essential but by no means simple component activities
4. Self-reporting of nurse activity.
of a staffing methodology. Nursing has relied primarily upon industrial
engineers and engineering work measurement techniques to quantify Difficulties encountered by nursing in
nursing actions, but there are often problems with the values obtained. using industrial-based w<_rrk
measurement methods to measure nursing
For example, many of the allocated time values for patient care deal p.J.ti." u." ., follo*s:
only with technical tasks. Difficulties in quantifying nursing times can 1' Many of the allotted time values deal with
be attributed to several causes: industrial engineer or observer d""r ,rot technical tasks, since thc
recognize the asscssmcnt,
evaluarion, and psychosocial urp".r,
l. The industrial engineer or nonnurse observer does not recognize the of the conracr.
assessment, evaluation, and psychosocial aspects of the nurse-patient
Thus, a patient whorequire. t".'ii..t ";;_p;;r
tasks could very likcr.y bc r.tccr
category thin one who requir", pry.hosoiial
contact, and the nurse often does not convey these components of
professional nursing practice to the industrial engineer, due to the
ff*:Ll* ,,,. r"u.hiug
nurse's unfamiliarity with work measurement techniques.
2' In developing a patient classification system, somc nur.sirrg rlt.'rrr.r_
ments borrow the nursing times from
2. It is often difficult to differentiate between the start and completion others' It is imporrant to realize that
the crassifi.u,'i.r,','ror,t.rrrs .r
of a nursing activity. For example, while giving a patient a bath, the the ,i;;"r".:;,,.i',,*,,,,,.u ,,,,,u
not be accurate for another, since the
nurse interacts with the patient. How much of the time spent with nursing
unit architecture, experience of the nurse, policics ^rrtr
the patient should be allocated to the technical task of bath giving and
and how much to assessment and interaction?
menting the work can vary from agency
to agcncy. 'rctrr,rrs,r irrr'r,.
'rrx.t.rrrrr.s,
3' Many systems employ the mean time for u
3. Although often referred to as time-study or efficiency experts, in- eration of the variance. Abdoo and colrcagucs *irr,,,,,, ;rrr't,rr:.itl
,,,1t
dustrial engineers cannot easily measure the time spent in assessment (z.r) irrru,.'r,,,,,,,r rr,,,t
nursing tasks oftenvary widely with who
and interaction. Measurement of repetitious, technical tasks can pcr-lirr.rrs rlrr.;rr rr'rr. ;rrrtl
the method utilized' nor
readily be done, but determination of times involving professional
judgment and skills is much more difficult.
ranged from l5 to 90 minutes, with "*u-pl", a"p,rrr tirrrt'rrr t)rt,:.rr rrrr,,rr ,rrir
o'rr"r,,,,l 3O
4' The educational and experience backglrurrrl .l rrrrrrrtr.r,
rlrt.,lr,,r,r r{,(. r,)lr(.,
Hudson's dissertation, summarized in Aydelotte (l), prcscnts "criteria
not considered, nor is a differentiationir,,,r,'irr(),,,,
L.P.N., antl nurst, assislanl or aidc. rr,,. l,.r,rr., ,r ri.N.,
that support the classification of nursing work as nonrepctitivc. Hc also
examines questions rclating to variations in task prcdiction tinrc, to 5. M<tsl slutlit's rlo rrol corrsiclcr:
procedure dcvelopmcnt, ancl to thc inccntivc prt.rblcnr. llrrclsorr lbtrncl it it.'l'lrt. :rp;lr.olrr.irrlt,nt.ss ol lltt. nut'siltg ttllr.t.r,t,trlt()n
1r{ r til Iilt,, ;rl lltt,
difficult to cnc<-rt.rlagc: irrrlivitlurrls to corrrplr:lt: lask rrssigrrrrrcrrls within Iirttt. ol inl(.1 r.(.nIiorI
thctin-rcprccliclt'tl lirlllrt'illrt'r'otttplislttrrr'rrt.llt't'orrtlrrtlt'rl llrll irllrsk's ll.'l'lrt' sl;rllrrr1, .,rlr:rtr.r ;rt llrt'lilrrt'ol lltt,s,lrrrlt ('.r
tintc varilrliorr r,virs tlrrt'rrol orrly lo tlrt'intlivitlrrlrlilv ol llrt'pirlit'lrl lrrrrl slrlisl;rr lot rlr ,.l,rll, rl) I ln{lr.t , ot
lri. , r"r,lili,,rr lrrrl ,rlq'r l,' llr,. i,r,li*,i,ltr,,litr, ,'l llt,' rrrrr..,. lr,.r', rrrr,',.rrl rrl