Nurse staffing levels in American hospitals: A 2001 report

Abstract

Every January for the past 12 years, Lawrenz Consulting has surveyed hospitals regarding demographic and operating trends in nurse staffing. These data results have become a national benchmark for nursing departments across the United States. In January 2001, 186 hospitals in 38 states participated in the data collection. About half of the facilities were community hospitals, a third were teaching facilities, and a little less than 20% were located in a rural setting.Volume is increasingOne of the most noticeable trends this year is increasing hospital occupancy, to a current 74.1% of available beds, which is an increase of 2.3% compared with last year. Five years ago bed occupancy was about 60%, and it was not unusual to see hospitals with only a 50% occupancy rate. This trend contributes to the delays in getting admitted patients from the emergency department to an inpatient bed. Available staffed beds equal 81% of total licensed beds, the highest seen in recent years.Length of stayTable 1Length of patient stays by hospital sizeHospital sizeAverage 2000Average 2001All respondents4.74.2Teaching hospitals5.25.0Community hospitals4.54.2Rural hospitals4.23.5 Open table in a new tab Budgeted full-time equivalent positionsNursing represents 28% of total hospital full-time equivalent positions (FTEs). Of these, registered nurses (RNs) represent 60% of nursing department employees. In rural facilities, RNs as a percentage of total nursing employees is about 50%. At this stage, it is unclear whether we are learning to effectively use unlicensed assistive personnel or whether we are just “short” of RNs. Hospitals report that they are budgeting 13.7% of their nursing budget for unlicensed caregivers. Very few hospitals are budgeting for sitters, although they represent 0.8% of budgeted nursing positions.Reported RN turnover is 20%. This figure was lower in teaching and rural hospitals (10% to 11%) and higher in community hospitals (27%). RN turnover has been steady at this level for the past several years. In this sample, the average age of RNs is 42.4 years, which is slightly less than the national average of 46 years.Deficit demandsHospitals continue to struggle with deficit demands. Deficit demands are circumstances that result in a nurse not being available for work, such as leaves of absence, vacancies, and sick time. Nationally, RN leaves of absence are 4.3% of total RN hours (teaching hospitals, 5.1%; community hospitals, 3.2%; and rural hospitals, 4.8%). In this study, 11.4% of budgeted nursing positions are vacant, an increase of 1.4% compared with last year. Sick time continues to run at 5.0% in hospitals. The National Labor Bureau reports sick time at 3% to 5% in most female-intensive organizations. In total, deficits resulting from leaves of absence, vacancies, and sick time averaged 20.7%. Assessing and planning for the replacement of these deficit demands is an important consideration.The average amount of time hospitals budget for deficit demand is 10.8% of worked hours for nonproductive deficit time, including sick, holiday, and vacation time, an increase in the past few years. In units with long-tenured staff, nonproductive time can be as high as 16%. Education time is budgeted at 2.5%, which also is an increase compared with the past few years. Education time is budgeted at 5% in other industries.Response to deficit demandsHospitals budget an average of 4.4% of worked hours for overtime. However, actual overtime use is currently 5.4% of worked hours, an increase of 0.4% compared with last year. In some teaching and rural hospitals, overtime is as high as 30%, which dramatically increases burnout and turnover. Community hospitals have a high of 18% in overtime. Questions about mandatory overtime were not asked because the definition of mandatory overtime varies. In some hospitals, all overtime is perceived as and categorized as mandatory. It would be helpful for hospitals to clearly define the term.In the past year, agency use decreased from 3.7% to 1.9%, and traveling nurse use decreased from 3.6% to 1.4%. Average agency use was budgeted at 1.2% and traveling nurse use was budgeted at 1.3%—both lower than the amount actually used. Overall, premium labor use (overtime, agency, and traveler) decreased on average by 3.6% to 8.7%. When compared with the deficits of 20.7% of worked hours, these figures indicate that either hospitals are choosing not to replace deficits or that there is a shortage of agency or traveling nursing employees. In addition, a higher number of rural facilities are reporting, and often rural facilities do not have access to agency or traveling nursing employees. Regardless of the reason for the decrease in use of premium labor, it still exceeds the budgeted amount.Intensity of workIn the past 2 decades, work intensity has dramatically increased, with the shortening length of stay and placing of outpatients on inpatient units. As mentioned, increased throughput of patients results in more ADTs, the most workload-intense periods in a patient's length of stay. Many hospitals report that admitting a patient takes between 1 to 1½ hours of nursing time. Workloads also have increased recently with the hiring of new graduate nurses into units that traditionally hired only experienced nurses. Nurses are increasingly fearful of working short staffed because of a multitude of factors including (1) not enough nurses in the workforce, (2) vacancies, and (3) lack of resources to replace deficit demands.Scheduling and acuity systemsEighty percent of schedules are prepared at the unit level. Some hospitals find that 12 to 16 hours are needed to prepare a 4-week schedule. Currently, 64% of hospitals report using a master schedule, as more hospitals move in this direction. A master schedule can offer employees predictability in their work schedule, as long as some flexibility remains.Position control systems are in place in 83% of responding hospitals. Position control that is based in each clinical area and that lists the number of full-time and part-time employees by skill mix in each department is of great value to a hospital.Only 37% of respondents use an acuity system, and 23% use a “home-grown” system. Only 28% of hospitals report satisfaction with their existing system. Existing patient acuity systems may not adequately assess the continuum of patient needs from intensive care to skilled care as provided in most hospitals. Clearly, nurses believe patient acuity has increased during the past decade. A valid acuity system indicates the number of nurses needed to effectively meet patients’ needs, but in today's environment, not only is assessing patient acuity difficult, but finding the necessary nursing resources to meet patient needs may be overwhelming.Nurse staffingMost hospitals track staffing by assessing total worked hours per patient day. Total worked hours includes orientation time, vacation time, and other nonpatient care time. A more valuable system is tracking direct caregiver hours per patient day and the percentage of time it is delivered by RNs. Lately, a great deal of attention has been given to nurse-patient ratios. Proposed legislation in California addresses nurse-patient ratios using licensed nurses. In surveying RN-to-patient ratios, on average in medical-surgical units, one RN is caring for 5.7 patients on the day shift and 7.4 patients on the night shift. This number is slightly less in teaching hospitals and slightly higher in rural facilities. The range of RN-to-patient ratios ranged from 1:4 to 1:11 on the day shift and 1:4 to 1:13 on the night shift. In many facilities, patients are not sleeping on the night shift, making the upper end of this range a large load for nurses. In critical care, RN-to-patient ratios average 1:2 on both the day and night shift but can be as high as 1:7 in some units.Another important reported perimeter is worked hours, that is, hours including all direct and indirect time on the unit but excluding nonproductive time. Indirect time averages 17% on the units. It is higher on telemetry units because of the use of monitor technicians. Medical-surgical unit data were divided into the following categories: medicine, medical-surgical, surgical, orthopedic, and telemetry. In the past, data for diabetic, respiratory, renal, and oncology units were assessed, but with changing patient populations, only 20% of patients on units with these names actually had diagnoses that fit into these categories. It is important for hospitals to re-evaluate existing patient populations to ensure that unit names accurately reflect patient types. The number of medical patients is increasing in most facilities. During the past year, hours per patient day (HPPD) on medical-surgical units has remained relatively consistent, with a mid range of HPPD of 6.8 to 11.8. The mid range of telemetry units is from 7.8 to 11.7 HPPD; hospitals at the higher end of the range tend to be teaching facilities.Mid range worked hours in critical care departments ranges from 14.6 to 25.5 HPPD. Compared with last year, the upper level of this range increased because of shorter lengths of stay, increased recovery of patients in these units, and the corresponding increase in admissions and transfers. Labor and Delivery department hours range from 17.9 to 24.0 HPPD, which is less than last year's range of 23.6 to 29.9. Postpartum and newborn nursery ranges are in the same vicinity but are more narrow than last year. Postpartum hours are currently 7.0 to 9.7 HPPD, and nursery hours are 6.5 to 8.7 HPPD. These numbers indicate a “tightening” of staffing standards in maternal-child departments. Pediatric units reports a mid range of 7.6 to 16.8 HPPD, similar to last year, although slightly broader. Neonatal ICUs reported a mid range of 11.0 to 15.7 HPPD.Mental health departments also have a mid range similar to that of last year—6.3 to 12.7. The mid range in emergency departments is 1.9 to 3.1 HPPD, which is a more narrow range than last year's 1.8 to 3.3 HPPD. On average, emergency departments have a 2.2 HPPD. The challenge in emergency departments is to accurately account for patients awaiting admission. In facilities with a large number of patients waiting for a bed for long periods, allocating additional hours of care in the emergency department, which is equivalent to inpatient HPPD, is important. Formulas have been developed to accurately allocate this time to the emergency department.Float groups/resource teamsHospitals that use centralized float or resource teams decreased from 87% to 71% this year, with many reporting that they are unable to find enough nurses to fill their in-house resource team positions. In the hospitals with a resource team, about half (46%) reported the team is “working well.” When the team is not working effectively, the reported cause is an inadequate number of qualified staff in the float pool. Many nurses report that it is now easier to manage their schedule to meet lifestyle needs by working as part of a unit staff rather than being in a float pool.Management informationFrequently managers do not obtain sufficient data to numerically tell their story about staffing. Similar to using vital signs and laboratory data to determine what is wrong with patients, data on staffing can help discern the source of staffing problems. Daily data are more frequently available in rural hospitals than in community or teaching facilities because the rural facilities more frequently use paper-based tracking completed by house supervisors. Biweekly or more frequent data are available in 61% of the facilities. Obtaining timely data at the end of each pay period is important for managers to effectively manage and respond to staffing trends.RecruitmentHospitals are reporting even longer spans to hire nurses. It currently takes 13.3 weeks to hire a medical/surgical nurse, compared with 10.5 weeks in 2000. Similarly, hiring specialty nurses took 16.6 weeks in 2001, compared with 14 weeks in 2000. Sign-on bonuses increased dramatically, from 48% to 84%. New graduate nurse programs and student scholarship programs also are frequently used strategies for attracting nurses. Referral bonuses, retention bonuses, relocation assistance, and overhiring are infrequently used. Hospitals are returning to use of weekend-only positions, increasing evening and night differentials, and offering bonus pay for extra shifts to entice nurses to work more hours, particularly on the off shifts.Hospitals continue to struggle with recruitment and retention. However, many hospitals report that focusing on competency and scheduling flexibility are major initiatives. Hospitals also report renewed efforts to develop or enhance central resource pools to create some scheduling flexibility. Another frequently used strategy is staffing for fluctuating census. Hospitals are becoming more sophisticated about tracking when patient workload peaks and ebbs and are matching staff schedules to these typical patient patterns. In addition, hospitals are managing unit size to ensure that units run at 85% capacity as often as possible.Data from this survey help define the nursing world in which we live and practice. Today's challenge is creating a new health care world to care for increasing numbers of patients with diminishing staffing resources. Learning and sharing experiences, successes, and failures can help us meet this challenge. Every January for the past 12 years, Lawrenz Consulting has surveyed hospitals regarding demographic and operating trends in nurse staffing. These data results have become a national benchmark for nursing departments across the United States. In January 2001, 186 hospitals in 38 states participated in the data collection. About half of the facilities were community hospitals, a third were teaching facilities, and a little less than 20% were located in a rural setting. Volume is increasingOne of the most noticeable trends this year is increasing hospital occupancy, to a current 74.1% of available beds, which is an increase of 2.3% compared with last year. Five years ago bed occupancy was about 60%, and it was not unusual to see hospitals with only a 50% occupancy rate. This trend contributes to the delays in getting admitted patients from the emergency department to an inpatient bed. Available staffed beds equal 81% of total licensed beds, the highest seen in recent years. One of the most noticeable trends this year is increasing hospital occupancy, to a current 74.1% of available beds, which is an increase of 2.3% compared with last year. Five years ago bed occupancy was about 60%, and it was not unusual to see hospitals with only a 50% occupancy rate. This trend contributes to the delays in getting admitted patients from the emergency department to an inpatient bed. Available staffed beds equal 81% of total licensed beds, the highest seen in recent years. Length of stayTable 1Length of patient stays by hospital sizeHospital sizeAverage 2000Average 2001All respondents4.74.2Teaching hospitals5.25.0Community hospitals4.54.2Rural hospitals4.23.5 Open table in a new tab Budgeted full-time equivalent positionsNursing represents 28% of total hospital full-time equivalent positions (FTEs). Of these, registered nurses (RNs) represent 60% of nursing department employees. In rural facilities, RNs as a percentage of total nursing employees is about 50%. At this stage, it is unclear whether we are learning to effectively use unlicensed assistive personnel or whether we are just “short” of RNs. Hospitals report that they are budgeting 13.7% of their nursing budget for unlicensed caregivers. Very few hospitals are budgeting for sitters, although they represent 0.8% of budgeted nursing positions.Reported RN turnover is 20%. This figure was lower in teaching and rural hospitals (10% to 11%) and higher in community hospitals (27%). RN turnover has been steady at this level for the past several years. In this sample, the average age of RNs is 42.4 years, which is slightly less than the national average of 46 years. Nursing represents 28% of total hospital full-time equivalent positions (FTEs). Of these, registered nurses (RNs) represent 60% of nursing department employees. In rural facilities, RNs as a percentage of total nursing employees is about 50%. At this stage, it is unclear whether we are learning to effectively use unlicensed assistive personnel or whether we are just “short” of RNs. Hospitals report that they are budgeting 13.7% of their nursing budget for unlicensed caregivers. Very few hospitals are budgeting for sitters, although they represent 0.8% of budgeted nursing positions. Reported RN turnover is 20%. This figure was lower in teaching and rural hospitals (10% to 11%) and higher in community hospitals (27%). RN turnover has been steady at this level for the past several years. In this sample, the average age of RNs is 42.4 years, which is slightly less than the national average of 46 years. Deficit demandsHospitals continue to struggle with deficit demands. Deficit demands are circumstances that result in a nurse not being available for work, such as leaves of absence, vacancies, and sick time. Nationally, RN leaves of absence are 4.3% of total RN hours (teaching hospitals, 5.1%; community hospitals, 3.2%; and rural hospitals, 4.8%). In this study, 11.4% of budgeted nursing positions are vacant, an increase of 1.4% compared with last year. Sick time continues to run at 5.0% in hospitals. The National Labor Bureau reports sick time at 3% to 5% in most female-intensive organizations. In total, deficits resulting from leaves of absence, vacancies, and sick time averaged 20.7%. Assessing and planning for the replacement of these deficit demands is an important consideration.The average amount of time hospitals budget for deficit demand is 10.8% of worked hours for nonproductive deficit time, including sick, holiday, and vacation time, an increase in the past few years. In units with long-tenured staff, nonproductive time can be as high as 16%. Education time is budgeted at 2.5%, which also is an increase compared with the past few years. Education time is budgeted at 5% in other industries. Hospitals continue to struggle with deficit demands. Deficit demands are circumstances that result in a nurse not being available for work, such as leaves of absence, vacancies, and sick time. Nationally, RN leaves of absence are 4.3% of total RN hours (teaching hospitals, 5.1%; community hospitals, 3.2%; and rural hospitals, 4.8%). In this study, 11.4% of budgeted nursing positions are vacant, an increase of 1.4% compared with last year. Sick time continues to run at 5.0% in hospitals. The National Labor Bureau reports sick time at 3% to 5% in most female-intensive organizations. In total, deficits resulting from leaves of absence, vacancies, and sick time averaged 20.7%. Assessing and planning for the replacement of these deficit demands is an important consideration. The average amount of time hospitals budget for deficit demand is 10.8% of worked hours for nonproductive deficit time, including sick, holiday, and vacation time, an increase in the past few years. In units with long-tenured staff, nonproductive time can be as high as 16%. Education time is budgeted at 2.5%, which also is an increase compared with the past few years. Education time is budgeted at 5% in other industries. Response to deficit demandsHospitals budget an average of 4.4% of worked hours for overtime. However, actual overtime use is currently 5.4% of worked hours, an increase of 0.4% compared with last year. In some teaching and rural hospitals, overtime is as high as 30%, which dramatically increases burnout and turnover. Community hospitals have a high of 18% in overtime. Questions about mandatory overtime were not asked because the definition of mandatory overtime varies. In some hospitals, all overtime is perceived as and categorized as mandatory. It would be helpful for hospitals to clearly define the term.In the past year, agency use decreased from 3.7% to 1.9%, and traveling nurse use decreased from 3.6% to 1.4%. Average agency use was budgeted at 1.2% and traveling nurse use was budgeted at 1.3%—both lower than the amount actually used. Overall, premium labor use (overtime, agency, and traveler) decreased on average by 3.6% to 8.7%. When compared with the deficits of 20.7% of worked hours, these figures indicate that either hospitals are choosing not to replace deficits or that there is a shortage of agency or traveling nursing employees. In addition, a higher number of rural facilities are reporting, and often rural facilities do not have access to agency or traveling nursing employees. Regardless of the reason for the decrease in use of premium labor, it still exceeds the budgeted amount. Hospitals budget an average of 4.4% of worked hours for overtime. However, actual overtime use is currently 5.4% of worked hours, an increase of 0.4% compared with last year. In some teaching and rural hospitals, overtime is as high as 30%, which dramatically increases burnout and turnover. Community hospitals have a high of 18% in overtime. Questions about mandatory overtime were not asked because the definition of mandatory overtime varies. In some hospitals, all overtime is perceived as and categorized as mandatory. It would be helpful for hospitals to clearly define the term. In the past year, agency use decreased from 3.7% to 1.9%, and traveling nurse use decreased from 3.6% to 1.4%. Average agency use was budgeted at 1.2% and traveling nurse use was budgeted at 1.3%—both lower than the amount actually used. Overall, premium labor use (overtime, agency, and traveler) decreased on average by 3.6% to 8.7%. When compared with the deficits of 20.7% of worked hours, these figures indicate that either hospitals are choosing not to replace deficits or that there is a shortage of agency or traveling nursing employees. In addition, a higher number of rural facilities are reporting, and often rural facilities do not have access to agency or traveling nursing employees. Regardless of the reason for the decrease in use of premium labor, it still exceeds the budgeted amount. Intensity of workIn the past 2 decades, work intensity has dramatically increased, with the shortening length of stay and placing of outpatients on inpatient units. As mentioned, increased throughput of patients results in more ADTs, the most workload-intense periods in a patient's length of stay. Many hospitals report that admitting a patient takes between 1 to 1½ hours of nursing time. Workloads also have increased recently with the hiring of new graduate nurses into units that traditionally hired only experienced nurses. Nurses are increasingly fearful of working short staffed because of a multitude of factors including (1) not enough nurses in the workforce, (2) vacancies, and (3) lack of resources to replace deficit demands. In the past 2 decades, work intensity has dramatically increased, with the shortening length of stay and placing of outpatients on inpatient units. As mentioned, increased throughput of patients results in more ADTs, the most workload-intense periods in a patient's length of stay. Many hospitals report that admitting a patient takes between 1 to 1½ hours of nursing time. Workloads also have increased recently with the hiring of new graduate nurses into units that traditionally hired only experienced nurses. Nurses are increasingly fearful of working short staffed because of a multitude of factors including (1) not enough nurses in the workforce, (2) vacancies, and (3) lack of resources to replace deficit demands. Scheduling and acuity systemsEighty percent of schedules are prepared at the unit level. Some hospitals find that 12 to 16 hours are needed to prepare a 4-week schedule. Currently, 64% of hospitals report using a master schedule, as more hospitals move in this direction. A master schedule can offer employees predictability in their work schedule, as long as some flexibility remains.Position control systems are in place in 83% of responding hospitals. Position control that is based in each clinical area and that lists the number of full-time and part-time employees by skill mix in each department is of great value to a hospital.Only 37% of respondents use an acuity system, and 23% use a “home-grown” system. Only 28% of hospitals report satisfaction with their existing system. Existing patient acuity systems may not adequately assess the continuum of patient needs from intensive care to skilled care as provided in most hospitals. Clearly, nurses believe patient acuity has increased during the past decade. A valid acuity system indicates the number of nurses needed to effectively meet patients’ needs, but in today's environment, not only is assessing patient acuity difficult, but finding the necessary nursing resources to meet patient needs may be overwhelming. Eighty percent of schedules are prepared at the unit level. Some hospitals find that 12 to 16 hours are needed to prepare a 4-week schedule. Currently, 64% of hospitals report using a master schedule, as more hospitals move in this direction. A master schedule can offer employees predictability in their work schedule, as long as some flexibility remains. Position control systems are in place in 83% of responding hospitals. Position control that is based in each clinical area and that lists the number of full-time and part-time employees by skill mix in each department is of great value to a hospital. Only 37% of respondents use an acuity system, and 23% use a “home-grown” system. Only 28% of hospitals report satisfaction with their existing system. Existing patient acuity systems may not adequately assess the continuum of patient needs from intensive care to skilled care as provided in most hospitals. Clearly, nurses believe patient acuity has increased during the past decade. A valid acuity system indicates the number of nurses needed to effectively meet patients’ needs, but in today's environment, not only is assessing patient acuity difficult, but finding the necessary nursing resources to meet patient needs may be overwhelming. Nurse staffingMost hospitals track staffing by assessing total worked hours per patient day. Total worked hours includes orientation time, vacation time, and other nonpatient care time. A more valuable system is tracking direct caregiver hours per patient day and the percentage of time it is delivered by RNs. Lately, a great deal of attention has been given to nurse-patient ratios. Proposed legislation in California addresses nurse-patient ratios using licensed nurses. In surveying RN-to-patient ratios, on average in medical-surgical units, one RN is caring for 5.7 patients on the day shift and 7.4 patients on the night shift. This number is slightly less in teaching hospitals and slightly higher in rural facilities. The range of RN-to-patient ratios ranged from 1:4 to 1:11 on the day shift and 1:4 to 1:13 on the night shift. In many facilities, patients are not sleeping on the night shift, making the upper end of this range a large load for nurses. In critical care, RN-to-patient ratios average 1:2 on both the day and night shift but can be as high as 1:7 in some units.Another important reported perimeter is worked hours, that is, hours including all direct and indirect time on the unit but excluding nonproductive time. Indirect time averages 17% on the units. It is higher on telemetry units because of the use of monitor technicians. Medical-surgical unit data were divided into the following categories: medicine, medical-surgical, surgical, orthopedic, and telemetry. In the past, data for diabetic, respiratory, renal, and oncology units were assessed, but with changing patient populations, only 20% of patients on units with these names actually had diagnoses that fit into these categories. It is important for hospitals to re-evaluate existing patient populations to ensure that unit names accurately reflect patient types. The number of medical patients is increasing in most facilities. During the past year, hours per patient day (HPPD) on medical-surgical units has remained relatively consistent, with a mid range of HPPD of 6.8 to 11.8. The mid range of telemetry units is from 7.8 to 11.7 HPPD; hospitals at the higher end of the range tend to be teaching facilities.Mid range worked hours in critical care departments ranges from 14.6 to 25.5 HPPD. Compared with last year, the upper level of this range increased because of shorter lengths of stay, increased recovery of patients in these units, and the corresponding increase in admissions and transfers. Labor and Delivery department hours range from 17.9 to 24.0 HPPD, which is less than last year's range of 23.6 to 29.9. Postpartum and newborn nursery ranges are in the same vicinity but are more narrow than last year. Postpartum hours are currently 7.0 to 9.7 HPPD, and nursery hours are 6.5 to 8.7 HPPD. These numbers indicate a “tightening” of staffing standards in maternal-child departments. Pediatric units reports a mid range of 7.6 to 16.8 HPPD, similar to last year, although slightly broader. Neonatal ICUs reported a mid range of 11.0 to 15.7 HPPD.Mental health departments also have a mid range similar to that of last year—6.3 to 12.7. The mid range in emergency departments is 1.9 to 3.1 HPPD, which is a more narrow range than last year's 1.8 to 3.3 HPPD. On average, emergency departments have a 2.2 HPPD. The challenge in emergency departments is to accurately account for patients awaiting admission. In facilities with a large number of patients waiting for a bed for long periods, allocating additional hours of care in the emergency department, which is equivalent to inpatient HPPD, is important. Formulas have been developed to accurately allocate this time to the emergency department. Most hospitals track staffing by assessing total worked hours per patient day. Total worked hours includes orientation time, vacation time, and other nonpatient care time. A more valuable system is tracking direct caregiver hours per patient day and the percentage of time it is delivered by RNs. Lately, a great deal of attention has been given to nurse-patient ratios. Proposed legislation in California addresses nurse-patient ratios using licensed nurses. In surveying RN-to-patient ratios, on average in medical-surgical units, one RN is caring for 5.7 patients on the day shift and 7.4 patients on the night shift. This number is slightly less in teaching hospitals and slightly higher in rural facilities. The range of RN-to-patient ratios ranged from 1:4 to 1:11 on the day shift and 1:4 to 1:13 on the night shift. In many facilities, patients are not sleeping on the night shift, making the upper end of this range a large load for nurses. In critical care, RN-to-patient ratios average 1:2 on both the day and night shift but can be as high as 1:7 in some units. Another important reported perimeter is worked hours, that is, hours including all direct and indirect time on the unit but excluding nonproductive time. Indirect time averages 17% on the units. It is higher on telemetry units because of the use of monitor technicians. Medical-surgical unit data were divided into the following categories: medicine, medical-surgical, surgical, orthopedic, and telemetry. In the past, data for diabetic, respiratory, renal, and oncology units were assessed, but with changing patient populations, only 20% of patients on units with these names actually had diagnoses that fit into these categories. It is important for hospitals to re-evaluate existing patient populations to ensure that unit names accurately reflect patient types. The number of medical patients is increasing in most facilities. During the past year, hours per patient day (HPPD) on medical-surgical units has remained relatively consistent, with a mid range of HPPD of 6.8 to 11.8. The mid range of telemetry units is from 7.8 to 11.7 HPPD; hospitals at the higher end of the range tend to be teaching facilities. Mid range worked hours in critical care departments ranges from 14.6 to 25.5 HPPD. Compared with last year, the upper level of this range increased because of shorter lengths of stay, increased recovery of patients in these units, and the corresponding increase in admissions and transfers. Labor and Delivery department hours range from 17.9 to 24.0 HPPD, which is less than last year's range of 23.6 to 29.9. Postpartum and newborn nursery ranges are in the same vicinity but are more narrow than last year. Postpartum hours are currently 7.0 to 9.7 HPPD, and nursery hours are 6.5 to 8.7 HPPD. These numbers indicate a “tightening” of staffing standards in maternal-child departments. Pediatric units reports a mid range of 7.6 to 16.8 HPPD, similar to last year, although slightly broader. Neonatal ICUs reported a mid range of 11.0 to 15.7 HPPD. Mental health departments also have a mid range similar to that of last year—6.3 to 12.7. The mid range in emergency departments is 1.9 to 3.1 HPPD, which is a more narrow range than last year's 1.8 to 3.3 HPPD. On average, emergency departments have a 2.2 HPPD. The challenge in emergency departments is to accurately account for patients awaiting admission. In facilities with a large number of patients waiting for a bed for long periods, allocating additional hours of care in the emergency department, which is equivalent to inpatient HPPD, is important. Formulas have been developed to accurately allocate this time to the emergency department. Float groups/resource teamsHospitals that use centralized float or resource teams decreased from 87% to 71% this year, with many reporting that they are unable to find enough nurses to fill their in-house resource team positions. In the hospitals with a resource team, about half (46%) reported the team is “working well.” When the team is not working effectively, the reported cause is an inadequate number of qualified staff in the float pool. Many nurses report that it is now easier to manage their schedule to meet lifestyle needs by working as part of a unit staff rather than being in a float pool. Hospitals that use centralized float or resource teams decreased from 87% to 71% this year, with many reporting that they are unable to find enough nurses to fill their in-house resource team positions. In the hospitals with a resource team, about half (46%) reported the team is “working well.” When the team is not working effectively, the reported cause is an inadequate number of qualified staff in the float pool. Many nurses report that it is now easier to manage their schedule to meet lifestyle needs by working as part of a unit staff rather than being in a float pool. Management informationFrequently managers do not obtain sufficient data to numerically tell their story about staffing. Similar to using vital signs and laboratory data to determine what is wrong with patients, data on staffing can help discern the source of staffing problems. Daily data are more frequently available in rural hospitals than in community or teaching facilities because the rural facilities more frequently use paper-based tracking completed by house supervisors. Biweekly or more frequent data are available in 61% of the facilities. Obtaining timely data at the end of each pay period is important for managers to effectively manage and respond to staffing trends. Frequently managers do not obtain sufficient data to numerically tell their story about staffing. Similar to using vital signs and laboratory data to determine what is wrong with patients, data on staffing can help discern the source of staffing problems. Daily data are more frequently available in rural hospitals than in community or teaching facilities because the rural facilities more frequently use paper-based tracking completed by house supervisors. Biweekly or more frequent data are available in 61% of the facilities. Obtaining timely data at the end of each pay period is important for managers to effectively manage and respond to staffing trends. RecruitmentHospitals are reporting even longer spans to hire nurses. It currently takes 13.3 weeks to hire a medical/surgical nurse, compared with 10.5 weeks in 2000. Similarly, hiring specialty nurses took 16.6 weeks in 2001, compared with 14 weeks in 2000. Sign-on bonuses increased dramatically, from 48% to 84%. New graduate nurse programs and student scholarship programs also are frequently used strategies for attracting nurses. Referral bonuses, retention bonuses, relocation assistance, and overhiring are infrequently used. Hospitals are returning to use of weekend-only positions, increasing evening and night differentials, and offering bonus pay for extra shifts to entice nurses to work more hours, particularly on the off shifts.Hospitals continue to struggle with recruitment and retention. However, many hospitals report that focusing on competency and scheduling flexibility are major initiatives. Hospitals also report renewed efforts to develop or enhance central resource pools to create some scheduling flexibility. Another frequently used strategy is staffing for fluctuating census. Hospitals are becoming more sophisticated about tracking when patient workload peaks and ebbs and are matching staff schedules to these typical patient patterns. In addition, hospitals are managing unit size to ensure that units run at 85% capacity as often as possible.Data from this survey help define the nursing world in which we live and practice. Today's challenge is creating a new health care world to care for increasing numbers of patients with diminishing staffing resources. Learning and sharing experiences, successes, and failures can help us meet this challenge. Hospitals are reporting even longer spans to hire nurses. It currently takes 13.3 weeks to hire a medical/surgical nurse, compared with 10.5 weeks in 2000. Similarly, hiring specialty nurses took 16.6 weeks in 2001, compared with 14 weeks in 2000. Sign-on bonuses increased dramatically, from 48% to 84%. New graduate nurse programs and student scholarship programs also are frequently used strategies for attracting nurses. Referral bonuses, retention bonuses, relocation assistance, and overhiring are infrequently used. Hospitals are returning to use of weekend-only positions, increasing evening and night differentials, and offering bonus pay for extra shifts to entice nurses to work more hours, particularly on the off shifts. Hospitals continue to struggle with recruitment and retention. However, many hospitals report that focusing on competency and scheduling flexibility are major initiatives. Hospitals also report renewed efforts to develop or enhance central resource pools to create some scheduling flexibility. Another frequently used strategy is staffing for fluctuating census. Hospitals are becoming more sophisticated about tracking when patient workload peaks and ebbs and are matching staff schedules to these typical patient patterns. In addition, hospitals are managing unit size to ensure that units run at 85% capacity as often as possible. Data from this survey help define the nursing world in which we live and practice. Today's challenge is creating a new health care world to care for increasing numbers of patients with diminishing staffing resources. Learning and sharing experiences, successes, and failures can help us meet this challenge.