By ChrysMarie Suby RN, MS

Are nurse and finance leaders speaking the same language when they analyze RN-to-patient ratios? Follow this example for how to analyze these ratios.

Exhibit: Two Ways of Calculating RN-to-Patient Ratios

 As nursing and finance work cooperatively to ensure that staffing resources support quality patient care, it is critical that we work from a common language with mutually accepted formulas. Confusion and miscommunication occur when finance and nursing leaders are not using the same glossary of terms and the same formulas. Consider the following real-life tale.

The Source of Frustration

The nurses at a large community hospital believed that the ratio of caregivers to patients-particularly the RN-to-patient ratio-was running higher than promised. Staff were frustrated that there never seemed to be enough nurses at the bedside.

Executive leaders had agreed to a 1:5 RN-to-patient ratio for the medical-surgical units. However, from the nurses' perspective, the actual worked ratio was 1 RN to 6 or 7 patients. When nursing leadership spoke with finance representatives, they were told that the RN-to-patient ratios were on target for 1:5 and needed no adjustments.

We selected a representative medical-surgical unit from the hospital's units. The average daily census was 25.9 patients. To analyze the best data, we selected a two-week pay period that did not include a holiday. We measured the ratios based on 12-hour shifts, as that was the most frequently worked shift by RNs. We planned on the ratios being the same between day and night shifts to balance shifts more evenly and minimize four-hour "holes."

The Finance View

For their calculations, finance obtained a list of total RN worked hours for the pay period from the payroll system. Finance's calculations (see the exhibit) showed an RN-to-patient ratio of 1:5.2.

Exhibit 1

The Nursing View

Nursing obtained a list of RN worked hours from the daily, direct care staffing sheets, which were based on the variable staffing plan. This list excluded the nurse manager, charge nurses, and the unit-based educator who did not take patient assignments. Nursing's calculations (see the exhibit on page 14) showed an RN-to-patient ratio of 1:6.47.

Why Was the Outcome Different?

As we reviewed the calculations from each group, it was clear that there was a discrepancy in the definition of terms. Finance asked payroll for "total RN hours," and the calculations made by finance included all the hours worked by all the RNs in the unit, which included the manager, charge nurses, and the unit-based educator.

As we examined the calculations used in other units in this same hospital, we found a lot of variation in how charge nurses were treated.

• Some units included the charge nurses in the indirect hours on all shifts and excluded them in the RN-to-patient ratios calculations.
• Some units included charge nurses as indirect caregivers on the day shift but made them direct caregivers on the evening and night shifts.
• Some units included charge nurses as direct caregivers on all shifts but gave them a lesser ratio of patients then the other nurses.

There was a lack of standardization between departments and units within the same service line about who was a direct and indirect caregiver. No one was speaking the same language, which contributed to everyone's misunderstanding and frustration.

The Solution

As part of the solution, it was agreed that everyone would use the same glossary of terms for direct, indirect, and total worked caregivers. This hospital agreed to use the "Productivity Terms" that appeared in the Fall 2009 The Business of Caring, which is available at www.hfma.org/boc.

It was further agreed that all units would count the shift charge nurses as indirect caregivers, which would exclude them from the RN-to-patient ratios. This would standardize practice and reporting of hours for a clearer interpretation of the ratios. It would also free the charge nurses to be resource nurses to the other staff on the team, and better help ensure direct care resources for the patients.

Finance and nursing also agreed to provide charge nurses with more training in basic budget formulas so that these nurse leaders could answer staff questions about ratios and formulas when unit managers were not working, such as on off-shifts and weekends. 

ChrysMarie Suby, RN, MS, is an international healthcare consultant; President/CEO of the Labor Management Institute, which publishes the PSS™ Annual Survey of Hours Report©; and editor of the newsletter (PSS™) Perspectives of Staffing and Scheduling© (c.suby@lminstitute.com).

Publication Date: Wednesday, January 06, 2010