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Nursing Practice Keywords: Care hours per patient day/

Safe staffing/Staffing metrics
Discussion
●This article has been double-blind
Nurse management peer reviewed

The Carter review into efficiency in the NHS recommended a new staffing metric be
adopted to measure nursing resources, but workforce experts are not convinced

How should nursing

productivity be measured?
In this article... 5 key
 arter recommendations on measuring nursing resources
C
points
How care hours per patient day are calculated 1 Lord Carter’s
(2016) review of
NHS productivity
Limitations of this approach
recommended that
care hours per
Author Jennifer Hunt is visiting professor Analysis of registered nurse (RN) and patient day
at Anglia Ruskin University healthcare support worker (HCSW) (CHPPD) should be
Abstract Hunt J (2016) How should staffing data in the hospitals participating used to measure
nursing productivity be measured? in the Carter review shows variation, which nurse and
Nursing Times; 112, 39/40: 18-20. is not surprising. All studies on nursing healthcare
The Carter review of efficiency in the NHS workforce in hospitals show differences in assistant resource
published this year recommended that a
new staffing metrics of care hours per
patient day be adopted to measure and
total numbers, skill and grade mix of staff.
This can be due to a number of reasons,
such as the presence or absence of an inten-
2 This method
replaces other
commonly used
compare how hospitals are using their sive care unit or coronary care unit in hos- measures such as
nursing resources. Some workforce pitals which have 1:1 RN staffing. However, whole time
experts have warned that this process fails Carter goes further by stating explicitly equivalents or
to recognise the complexity of care and that this variation is ‘unwarranted’. nurse-patient ratios
could lead to unsafe staffing levels. This
article aims to clarify what is meant by
care hours per patient day and factors that
He suggests that to ensure optimum use
of staff resources, such as nursing, bench-
marks and indicators should be standard-
3 CHPPD are
calculated by
adding the hours of
need to be considered before they are ised so the same metrics are produced RNs and HCSWs
used to determine staff numbers. across all hospitals. For nursing, Carter providing care

N
urses make up the largest
single group of healthcare
workers in acute hospitals and
absorb a high proportion of the
total budget. As a result, it is no surprise
that the Carter review (2016) of NHS
productivity and efficiency in non-spe-
cialist acute hospitals looked at the use of
nursing resources.
Lord Carter’s (2016) review recom-
mends that care hours per patient day
(CHPPD) should become the principal
measure of how hospitals use nurses and
healthcare assistants from April this year.
However, many nurses have found this
new metric confusing, with terms such as
CHPPD used in the review not being fully
understood. It is important that nurses
understand these terms and their implica-
tions so that they can use their expert
knowledge and skills to influence deci-
sions on how nurse numbers and grades
are determined.
proposes using CHPPD as the preferred during 24 hours
option to replace other commonly used and dividing by the
measures, such as wholetime equivalents total number of
(WTEs) or nurse-patient ratios (NPRs). He patients at
suggests its use would enable more accu- midnight
rate comparisons, ensure productivity and
efficiency are evaluated more easily and
show how many staff are required and how
4 Using the
midnight
census does not
many are available. In this article, CHPPD consider the ‘churn’
are explained and key issues involved in of patients during
using the metric are outlined. the day
What are CHPPD?
Counting staff hours
5 The approach
does not
consider the
CHPPD are calculated by adding the hours complexity of
of RNs and HCSWs providing care during care or experience
24 hours and dividing the total by the total of staff
number of patients at the midnight
census. Examples are outlined in Box 1.
To ensure consistency, clarification
is needed as to what constitutes ‘worked
hours’, in particular whether they mean:
» Official shift hours excluding
meal breaks;

www.nursingtimes.net / Vol 112 No 39/40 / Nursing Times 12.10.16 18


Nursing Practice
Discussion
Table 1 Calculation of care hours
per patient day
Care hours per patient day = Hours of RNs + Hours of HCSWs
Total number of patients
Count:
● Paid hours only
● Staff providing direct care only
Example ward: 30 bedded-unit with 12-hour shifts (11 + 1 hour unpaid meal breaks)
Counting paid hours only
(11 hours) of all staff
Grade Number of staff Worked
of staff hours
RN Hours AM 7 + Night 4 = 11
HCSW Hours AM 3 + Night 2 = 5
TOTAL 16
Care hours = 121 + 55 = 176
per patient
30 30
day
» Actual worked hours, including
additional unpaid hours if staff are not
able to take their meal breaks and do
not leave on time;
» Only direct care hours.
There is also the question of whether
‘worked hours’ include all, none or a
specified percentage of RN hours of staff
such as ward managers, clinical special-
ists, student mentors and new graduates.
Counting patient hours
For patient hours, Carter proposes that a
single time point be used to count the
number of occupied beds, namely the mid-
night census. This is the most common
approach used to record patient numbers
and occupancy because it is easy to record
and has high reliability. However, it may
underestimate patient numbers and care
hour requirements because it does not
capture ‘churn’ – admissions, transfers,
discharges, deaths and patients occupying
a bed for less than 24 hours (Fieldston et al,
2012; Simon et al, 2011; Beswick et al 2010).
In the example in Box 2, the
Wednesday/Thursday midnight census
shows there were six patients in a six-bed
room, but only five patients 24 hours later
when the midnight census was recorded
for Thursday/Friday. Yet on Thursday,
nine different patients actually occupied
beds, all of whom received care.
In addition, the midnight census does
not take into account differences in the
amount of care (acuity and dependency)
each patient needs, nor the fact that a
shorter length of stay increases the total
care hours required per patient episode as
shown in Figure 1 (Lawless, 2014).
Nursing
Times.net
Counting staff providing direct
care only (excluding ward sisters)
Number of Worked hours
staff
121.0 10 110.0
55.0 5 55.0
176.0 15 165.0
= 5.8 = 110 + 55 = 165 = 5.5
30 30
Key issues
Metrics such as hours per patient day
(HPPD) and nursing hours per patient day
(NHPPD), referred to by Carter as CHPPD,
have been used for decades in the US to
examine nursing productivity both within
and between hospitals. They are also used
to determine staffing levels based on
national or regional benchmarks and
establish budgets for nursing depart-
ments. NHPPD usually refer to qualified
nurses in the US, so may include only RNs
with degrees or both RNs and those with
older diplomas and/or licensed practical
nurses. HPPD might or might not include
all care staff. NHPPD are also used in sev-
eral states in Australia and are usually
used to describe qualified nurses only.
This is why it is important to understand
which staff are included before accepting
staffing data.
Interpreting CHPPD data and deciding
how best the metric can be used is compli-
cated. In the US, Kirby (2015) has argued
that there are important reasons why hos-
pitals should not be using HPPD as their
key metric either to compare hospitals or to
evaluate nurse staffing, including:
» The results are not adjusted to account
for factors that might require more
nursing care hours, such as age of
patients, severity of patient illness or
differences in the amount of nursing
care required for patients with the
same diagnosis (Jenkins and Welton,
2014);
» The measure does not account for
differences in frequency of admissions
and discharges, or other factors that
might affect nurse staffing needs;
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Box 1. Impact of
‘churn’ on midnight
census
Six-bed room
Night of Wednesday/Thursday:
midnight census six patients
Night of Thursday/Friday: midnight
census five patients
Thursday events
Bed 1
● 10.00 patient discharged
● 10.20 new patient booked for
admission arrived, at 14.00 went to
theatre and at 17.00 arrived back from
theatre
Bed 2
● 11.30 patient discharged
● 11.45 new patient admitted from ED
● 16.30 new patient deteriorated and
was transferred to ICU
● 16.45 new patient transferred from
ICU.
Bed 3
● 22.00 Patient died
● Bed empty
Beds 4-6
● Same patients remained all day
Number of patients on Thursday: nine
● Two patients discharged
● One patient transferred out
● One patient transferred in
● One patient admitted for theatre
● One patient died
● Three patients remained all day
» V arying physical layouts and the extent
of other support services make
different demands on nurses’ time;
» V ariations in nurses’ experience, skill
sets and competency vary widely
between hospitals and influence the
time spent in delivering care and how
nurses respond to patient care needs.
Lord Willis has echoed these concerns
stating that the Carter review “fails to rec-
ognise the complexity of care provided by
nurses and could lead to unsafe staffing
levels” (Lintern, 2016). At the very least,
one needs to know both the budgeted
CHPPD and the actual hours available, be
that at hospital or ward level, and how the
numbers and grades are determined.
Meaningful comparisons can be made only
between units matched on key criteria,
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Nursing Practice
Discussion

such as staff grade and experience, patient

diagnosis, treatment needs, acuity and
FIG 1. Impact of shorter length of stay on
dependency, support staff – just as would
CHPPD (Lawless, 2014)
be done in any clinical trial.
A focus on CHPPD needs to link to 8
quality outcomes (patient, nurse and hos- 7
7
pital). Without these, just counting and
comparing CHPPD provides the price but 6
not necessarily the true cost. We should be Day 1
5 4.5
wary of focusing on productivity and effi- 4 Day 2
4
ciency without also factoring in effective- 3 3 Day 3
ness. We now have considerable evidence 3 Day 4
to show that RN numbers and RN/unquali- 2 Day 5
fied skill mix ratios are related to patient 1 1
outcomes (Needleman, 2011; Kane et al, 1 Day 6
2007; Rafferty et al, 2007) and, as the 0 Day 7
number of patients looked after by each LOS = 7 days:
nurse increases, so does the number of Total 23.5 hours per episode
adverse outcomes such as mortality and
morbidity (Aiken et al 2014; Ball et al, 2013;
Rafferty et al, 2007). Similarly, there is evi- 8 8 8
dence to show that better patient out- 8
comes are achieved with graduate RNs 7
(Aiken et al, 2014).
6 5.5 5.5
Day 1
Conclusion 5 4.5 4.5
CHPPD can be useful but can also be mis- Day 2
4
understood and misused. Unless there are Day 3
very precise definitions for all the key 3 Day 4
terms, we will be comparing oranges and 2 Day 5
apples. As nurses, we need to be sure that
1 Day 6
we know how the metric is defined and
how it is used. We must ensure that the 0 Day 7
variations, which we know exist in the LOS 3 days: 18 hours per episode:
amount of nursing care required even for Total over 7 days 44 hours
patients with the same diagnosis, are
measured. We need to reflect on the
research that has already been done and from a children’s hospital. Hospital Pediatrics;
take the opportunity presented by devel- 2: 1, 10-18. Are you making the most of
opments in the capture of real-time infor- Jenkins P and Welton J (2014) Measuring direct
nursing cost per patient in the acute care setting. the Nursing Times archive?
mation to ensure that the contribution of Journal of Nursing Administration; 44: 5, 257-262.
nurses is fully recorded and understood. Kane RL et al (2007) The association of registered Subscribers to Nursing Times have
Of course, we need to take into account nurse staffing levels and patient outcomes:
unlimited access to our clinical
systematic review and meta-analysis. Medical Care;
productivity and efficiency, but it is effec- 45: 12, 1195-1204. archive, giving you:
tiveness that matters most to patients and Kirby K (2015) Hours per patient day: not the
their families and that should be our main problem, nor the solution. Nursing Economics; 33:  ver 5,000 double-blind peer
O
1, 64-66. reviewed articles, published since
focus in determining nurse staffing num-
Lawless J (2014) Nursing works: patients matter 2000
bers and skill mix. NT and nurses make the difference. Presentation to
Content relevant to nurses in all
Safe Staffing Alliance. (unpublished).
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