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Staffing Is More Than a Number

Using Workflow to Determine an Appropriate Nurse Staffing Ratio in a Tertiary Care Neurocritical Care Unit

Hill, Michelle; DeWitt, Jessica

Journal of Neuroscience Nursing: October 2018 - Volume 50 - Issue 5 - p 268–272
doi: 10.1097/JNN.0000000000000387
Clinical Nursing Focus

ABSTRACT Objective: To enhance nursing staff retention and ensure a consistently high standard of care, a study was conducted to determine an appropriate nurse staffing model for a neurocritical care unit. In addition to being critically ill, these patients often require extensive diagnostic testing to determine treatment. Nurses traveling with patients leave higher nurse-patient ratios remaining on the unit. Methods: Prospective observation was used to assess relationships between neurologic assessment, documentation, and the amount of time spent traveling with patients. Patient acuity and nursing experience were also measured. Results: Over the 30-day study period, more than 226 hours were spent traveling, equivalent to approximately 38% of a single nurse’s shift. There was no correlation between the experience of nurses and the time necessary to perform a neurologic assessment. When controlling for acuity, a relationship was found between nursing experience and the time needed to chart an assessment. Conclusions: Significant time was spent every day off the floor, in addition to the documentation and performance of frequent assessments. These results advocate for a staffing position without a dedicated patient assignment but to assist with traveling and high-acuity patients so that safe and attentive care can be consistently given.

Questions or comments about this article may be directed to Michelle Hill, MS RN AGCNS-BC CNRN CCRN SCRN, at She is Stroke Program Coordinator, Riverside Methodist Hospital, Columbus, OH.

Jessica DeWitt, BSN RN, is Neuroscience Outcomes Manager, Riverside Methodist Hospital, Columbus, OH.

The authors declare no conflicts of interests.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

There is no standard process across the country to determine appropriate staffing levels; however, research has shown us that the number of nurses will impact patient outcomes regardless of acuity level.1–3 In relation to critically ill patients, a study by Neuraz et al4 found a significant increase in the risk of intensive care unit (ICU) mortality when the patient-to-nurse ratio was greater than 1:2.5. Frith et al1 published a study in 2010 reporting higher nurse staffing results in a decrease in adverse events and length of stay. The Institute of Medicine’s Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes also identified the importance of nursing care and staffing levels related to patient outcomes.2

Our neurocritical care unit was experiencing high turnover after the introduction of new management, a new electronic health record, and opening of a new unit all within a 3-month span of time. With so many changes happening in such a short period, the leadership team brainstormed ways to improve retention. A previous study conducted by Nadolski et al5 demonstrated decreased turnover after determining ideal staffing on a neuroscience unit, but the focus was not on neurocritical care. We could not undo any of the changes; however, we could look at workflow and adapt. This started us asking the question, “Are neurocritical care nurses performing 14 hours of work in a 12-hour shift?”

Neurocritical care units are unique from other critical care areas. Although all care for the highest acuity patients, neurocritical care patients are known for requiring frequent neurologic assessments, as well as frequent traveling for diagnostic testing. These imaging and diagnostic examinations are often time sensitive and may happen at any time.

Although diagnostic testing may not equal a higher-acuity patient, the nurse is required to leave his/her other patients for extended periods, thus adding patients to another nurse’s assignment. In response to California staffing mandates, Aiken et al3 studied surgery patients and reported a 7% increase in the likelihood of patient death when an additional patient was added to a nursing assignment. Furthermore, a study by Lee et al6 indicated that any exposure to high staffing ratios, even as little as 1 day, greatly increased the risk of mortality for a critical care patient. Often, the nurse who remains on the unit has the time and resources to give only the minimum standard of care for 3 critically ill patients.

The neurocritical care unit studied is located in a 32-bed Joint Commission-certified comprehensive stroke community hospital in the midwestern United States. Common patient diagnoses consist of ischemic and hemorrhagic strokes with varying severities, as well as brain tumors, seizures, traumatic brain injuries, complicated spine surgeries, and other neurological conditions.

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Using our question, “Are neurocritical care nurses performing 14 hours of work in a 12-hour shift?” the leadership team performed an informal survey of the nursing staff to determine what they perceived to take the most time during their shift. Based on feedback from staff, we performed a prospective observation of the following tasks: (1) the amount and frequency of traveling for diagnostic tests, (2) the amount of time spent performing a neurologic assessment, and (3) the amount of time spent documenting a neurologic assessment. Institutional review board approval was not needed as this was measuring care already being provided and the documentation collected every shift and stored in a locked office to protect patient confidentiality. The documentation was disposed of in a secure manner.

Patients were included if they were a patient on the neurocritical care unit and not awaiting transfer to a step-down unit. Patients were excluded if the nurse was not willing to participate in the time study, which has the potential to cause a bias.

Observations were correlated with both the acuity of patients on the unit and the experience of the nurses caring for them. Acuity was measured using the Therapeutic Intervention Scoring System-28 (TISS-28). This tool was validated by Miranda et al7 in a multicenter study consisting of medical and surgical ICUs. Padilha et al8 included a variety of ICUs, and the average TISS-28 score was found to be the same in a neurology ICU as that of a surgical ICU, with a similar number of patients enrolled for each unit. This system was developed to quantify the time needed to provide nursing care activities in any ICU, as well as assess severity of illness in individual patients.7–9

Activities included on the TISS-28 are grouped into 7 categories organized by body system, such as cardiovascular, respiratory, and metabolic. Different point values are provided given the severity of the intervention, such as multiple vasoactive medications or dressing changes. The scale ranges from 0 to greater than 60, with a higher score indicating higher patient acuity. Miranda et al7 determined that 1 point on the TISS-28 was equivalent to 10.6 minutes of nursing care activities, and an average nurse was capable of delivering 46.35 TISS-28 points of care for an 8-hour shift. Using this information and the unit’s current staffing model of 12-hour shifts and a 1:2 patient ratio, it was determined that a nurse could care for 69 TISS-28 points in a shift and any patient with a TISS-28 score of 34 would receive 1:1 nursing care.

Wording was altered slightly, based on feedback from the staff, to resemble current language on the unit. This included adding some examples and definitions to the scoring tool, as well as specifying travel needs under interventions and procedures (Supplemental Digital Content 1, available at Therapeutic Intervention Scoring System-28 scores were collected on each patient every shift. The goal with using the TISS-28 was to quantify the amount of time needed to perform nursing care.

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Data Collection

The first measurement collected was the frequency and time spent traveling to diagnostic tests. To determine this measurement, we wanted to look at the areas to which patients traveled most often. We chose magnetic resonance imaging, neurointerventional radiology, computed tomography, fluoroscopy, x-ray, modified barium swallow, operating room, transthoracic esophageal echocardiogram, radiation oncology, and ultrasound. The charge nurse received a tracking log and was notified of the time and location for all off-unit diagnostic transports and return times. This was done for 1 month, and the top areas traveled were then calculated.

The second measurement collected was the time spent performing a neurologic assessment. To assess whether patient acuity and nurse experience impacted the time required to complete a neurologic assessment, the TISS-28 was completed each shift and subsequent neurologic assessments were timed. The timing started when the nurses “foamed in” to the room and ended when the nurse “foamed out” or stated that the assessment was complete. If other tasks were being completed while the nurse was in the room performing the assessment, the nurse would let the observer know they were done with the assessment and timing was stopped. The primary nurse caring for the patient monitored all assessments to ensure neurologic changes were not missed. The level of experience of the nurse performing the assessment was then collected and converted into months.

Time-in-motion studies were also completed for time spent documenting a neurologic assessment. These studies were meant to determine whether patient acuity and nurse experience impacted the time required to document a neurologic assessment. The timing started when the nurse logged on to the computer and ended when the nurse logged off or declared they were done. The person documenting was required to document a full neurologic assessment, and the use of within defined limits or “unchanged” on any assessment parameters was not permitted. The nurses were informed to only chart the neurologic assessment; any additional charting would be completed after the assessment was entered and would not be included in the total time. The time was calculated using minutes and seconds and then averaged per patient (Table 1).



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All data points were measured for statistical significance using central tendency and regression analysis performed using SAS v9.4.

Of the numerous diagnostic tests used with the neurocritical care population, we determined that the most time spent off the unit was at computed tomography (n = 188; average, 18 minutes or 2.5% of a 12-hour shift), magnetic resonance imaging (n = 70; average, 80 minutes or 11% of a 12-hour shift), and NIR (n = 41; average, 82.5 minutes or 11% of a 12-hour shift). Over the study period of 1 month, 226 hours were spent off unit traveling.

To determine the daily impact, we looked at how many times diagnostic tests were performed. Computed tomography was completed an average of 7 times a day, each trip lasting an average of 18 minutes, for a total of 126 minutes per day. Magnetic resonance imaging was completed an average of 3 times a day, each trip lasting an average of 80 minutes, for a total of 240 minutes. Neurointerventional radiology was completed an average of 2 times a day, each trip lasting an average of 83 minutes, for a total of 166 minutes a day. This traveling was the equivalent of 532 minutes, or 9 hours, per day. When we broke that 9 hours into 12-hour shifts, approximately 4.5 hours of a 12-hour shift were spent off the unit traveling to these tests, indicating that at least 1 nurse was off the unit for 38% of the shift.

The experience of nurses on the unit was shown to have no significant impact on the amount of time to perform a neurologic assessment, even when controlling for acuity (Table 2). Experience levels of nurses on the unit ranged from 3 to 82 months, with an average of 24.5 months. The acuity of the patient was shown to have a significant impact on the amount of time needed to perform a neurologic assessment (Table 2).



As mentioned previously, the experience of nurses on the unit was shown to have no significant impact on the amount of time to chart the neurologic assessment. However, when controlling for acuity, significance was seen between nursing experience and length of neurologic assessment charting time (Table 2). Higher-acuity patients required more charting time for less experienced nurses compared to time spent charting by veteran nurses. This may be explained by the propensity of higher-acuity patients being assigned to more experienced nurses. The higher acuity of patients was reflected through not only increased documentation times but also increased assessment times. Understandably, increased assessment times were also linked with a significantly longer time needed to chart (Table 2).

During a calendar year, 1168 patients were transferred to neurointerventional radiology or operating rooms, which is an average of 5 patients per day that require a 1:1 assignment for recovery per unit policy. Assuming a recovery period of 2 hours, an average of 10.5 hours per day is spent in a 1:1 assignment. On the basis of the amount of recovery time and TISS-28 acuity score, 2.5 patients per day qualified for a 1:1 assignment.

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To our knowledge, this is the only quantifiable description of neurocritical care nursing workflow, which includes significant amounts of time off the floor traveling with patients. The higher-acuity patients in turn required a significantly longer time to assess, in addition to traveling. The experience of nurses also demonstrated that increased time may be needed for newer nurses to document on higher-acuity patients. These factors create an opportunity to support the time needed to provide optimal patient care. By quantifying the workload of neurocritical care nurses, additional staffing may be justified with a potential benefit of increased retention and improved patient outcomes. With the results of our time trial, a “circulator” position was advocated for in addition to three 1:1 patient assignments; these positions are in addition to a charge nurse who does not have a patient assignment.

The circulator position consists of a nurse who does not have a patient assignment but rather travels and assists with patients regardless of acuity. The addition of the circulator nurse frees the primary nurse to stay on the unit with their patient.

The additional 1:1 staffing positions allow high-acuity patients or patients with multiple diagnostic tests scheduled to be placed in a 1:1 assignment. This also frees the nurse caring for high-acuity patients to focus on 1 patient, and nurses who will be spending the day away from the unit at diagnostic testing will not have to monopolize the circulator or frequently leave another patient on the floor.

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The single institution, 1 unit, and small sample size are limitations in this study. Some variability may have occurred during timing of neurologic assessment and assessment charting. Travel times were estimates and variable on the nurse calling the charge nurse when leaving and upon return, as well as the charge nurse documenting these call times. Adverse events and length of stay were not collected during this trial; therefore, we are unable to prove or disprove the effect of patient outcomes. The neurocritical workload related to diagnostic testing and neurologic assessments is thought to be different from mixed units. Similar data from a nonneurocritical care unit would help strengthen this study and further support the implication of the burden neurocritical care nurses feel with their workload.

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Patients in a neurologic critical care unit require more staffing to account for the frequent neurologic assessments, charting, and traveling. Implementing additional staffing will counteract this unique characteristic of neurologic critical care patients and provide a possible tool to enhance retention. Previous research reports the ability to positively impact patient outcomes; further research is needed to determine whether the circulator position and additional staffing improve patient outcomes or staff retention.

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The authors would like to acknowledge the neurocritical care unit staff at Riverside Methodist Hospital for their willingness to help with this project.

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1. Frith KH, Anderson EF, Caspers B, et al. Effects of nurse staffing on hospital-acquired conditions and length of stay in community hospitals. Qual Manag Health Care. 2010;19(2):147–155. doi:10.1097/QMH.0b013e3181dafe3f
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cost effectiveness; neurocritical care; nursing; safe staffing; staffing; staffing models; staffing ratio

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© 2018 American Association of Neuroscience Nurses