Reexamining the Nurse Scheduling Problem: Staffing Ratios and Nursing Shortages*

Legislators at the state and national levels are addressing renewed concerns over the adequacy of hospital nurse staffing to provide quality care and ensure patient safety. At the same time, the well‐known nursing shortage remains an ongoing problem. To address these issues, we reexamine the nurse scheduling problem and consider how recent health care legislation impacts nursing workforce management decisions. Specifically, we develop a scheduling model and perform computational experiments to evaluate how mandatory nurse‐to‐patient ratios and other policies impact schedule cost and schedule desirability (from the nurses' perspective). Our primary findings include the following: (i) nurse wage costs can be highly nonlinear with respect to changes in mandatory nurse‐to‐patient ratios of the type being considered by legislators; (ii) the number of undesirable shifts can be substantially reduced without incurring additional wage cost; (iii) more desirable scheduling policies, such as assigning fewer weekends to each nurse, have only a small impact on wage cost; and (iv) complex policy statements involving both single‐period and multiperiod service levels can sometimes be relaxed while still obtaining good schedules that satisfy the nurse‐to‐patient ratio requirements. The findings in this article suggest that new directions for future nurse scheduling models, as it is likely that nurse‐to‐patient ratios and nursing shortages will remain a challenge for health care organizations for some time.     

The ascendancy of primary care: permanent or temporary?

The conventional wisdom strongly suggests a health care provider food chain for the future: Primary care physicians (PCPs), principally family practitioners, on the top playing the lead role, distantly followed by specialists, with hospitals and other ancillary services even further down the line. Is this a reasonable expectation? Will PCPs dominate the new systems? Or will they be but one of many equally necessary components of these developing integrated health care delivery organizations? Looking at the various models now developing, it would seem that future integrated delivery systems will utilize both PCPs and specialists, but with strong augmentation from a diverse assortment of other health care professionals, including nonphysician providers, educators, and administrators. To separate the illusion of primary care dominance of the coming health care system from the likely reality, we should first determine what is driving the apparent present demand for primary care physicians. Next, we will examine the possible and probable reactions to that demand from an economic standpoint and from the points of view of both health care professionals and the public. Finally, we must try to picture how health care provider organizations of the future are likely to look and how they will integrate their health care professionals.     

Landscape of human resource development research in Korea: results from author co-citation network analysis

The present study examined major trends and issues of Human Resource Development (HRD) research in Korean context applying the author co-citation analysis (ACA) to three primary HRD-related journals in South Korea. Following the analyses of author co-citation frequency, correlation matrix, dendrogram, and the multi-dimensional scaling (MDS) map, the results were found as follows: (1) co-citation network identified seven topical clusters (i.e., human competency improvement for young men and e-learning designers, system approach for training effectiveness, competency for executives and HRD-ers, HRD evaluations, HRD solutions, mentoring in career development, leadership, and the role of professionals), (2) competency appeared as a keyword in multiple clusters, (3) unlike HRD in North America or Europe, learning (informal, organizational, self-directed, and lifelong learning) with a variety of HRD solutions comprised the dominant research stream, and (4) research activities for critical issues, such as diversity, development of workforce minority, and international HRD were largely missing.     

Legal implications of managed care arrangements

Prior to the 1980s, managed care was virtually nonexistent as a force in health care. Presently, 64 percent of employees in America are covered by managed care plans, including health maintenance organizations (20 percent) and preferred provider organizations (44 percent). In contrast, only 29 percent of employees were enrolled in managed care plans in 1988 and only 47 percent in 1991. To date, the primary reason for this incredible growth in managed care has been economic-market pressure to reduce health care costs. For the foreseeable future, political pressures are likely to fuel this growth, as managed care is at the center of President Clinton's national health care plan. Although there are numerous legal issues surrounding managed care, this article focuses primarily on antitrust implications when forming managed care entities. In addition, the corporate practice of medicine doctrine, certain tax issues, and the fraud and abuse laws are discussed.     

The health care system has an eating disorder

The health care system crisis has been proclaimed and analyzed so much by economists, policy analysts, politicians, business executives, and journalists that the key statistics and phrases are becoming as familiar as the lyrics of a popular song-14 percent of the GNP goes to health care, 37 million Americans lack health insurance, too many specialists and not enough primary care physicians, etc. What I have not found is a comprehensive assessment of how the health care system got so sick. The different social science specialists focus on their respective symptoms or organs, but do not propose therapies to treat the entire organism. Ilya Prigogine's Theory of Dissipative Structures (now old hat since he won the Nobel Prize in 1977) demonstrated that self-organizing systems, be they health care systems or individual patients, respond in similar ways to the demands of illness and growth. Therefore, a clinical correlation for the health care system may have more than poetic appeal. I would like to offer the following clinical analogy for what ails our health care system.     

ABMT (autologous bone marrow transplantation): a microcosm of the U.S. health care system

The continuing controversy over appropriate utilization of high-dose chemotherapy (HCDT)-autologous bone marrow transplantation (ABMT) in the treatment of cancer epitomizes the debate in this country over increasing expenditures for the application of health care technology. The debate includes all imaginable constituencies--patients, physicians, hospitals, payers, employers, lawyers, economists, and the media. The issue is fascinating, as it continually presents new twists and turns. Additionally, the way in which the HCDT-ABMT controversy is resolved (or not resolved) will presage the manner in which similar issues are addressed in the 1990s.     

What happened, what next?

Many physicians and other health care professionals breathed a collective sigh of relief when the 103rd Congress adjourned without passing the Clinton Health Security Act or any other health care reform legilsation. The ambition of this brief paper is to describe why health care reform did not pass in 1994, the issues that need to be resolved if we are to pass legislation, the political forces that will need to be addressed before legislation is passed, and the type of struggles we can expect to see in the coming session of Congress.     

Mergers: enhancing human resources management

The health care industry is experiencing merger mania, but the majority of its current leadership underestimates the importance that significant differences in corporate culture and employee morale play among physicians and others in implementing such organizational objectives as enhancing access, reducing cost, and improving quality of care. The key human resources management issues are discussed that are too often overlooked and frequently sidetracked in the formation of powerful health networks now so prevalent in almost every metropolitan region. The authors conclude that in America's intensely competitive managed care environment, there are a number of critical human resources management ingredients that deal makers need to achieve from these mergers in order to ensure their perceived objectives: (1) paying far greater attention to variations in corporate culture and employee morale; (2) reducing total salary and fringe benefit costs; and, (3) concurrently recruiting and maintaining a qualified and stable workforce that focuses more decisively on clinical-fiscal concerns so as to improve quality of patient care at a lower cost.     

Development of hospice and palliative care in the United States

More than 30 years have passed since palliative care was introduced in the United States, and what began as a small rebellion has evolved into a fairly large health care industry. Although the palliative care movement has considerably improved the care given to those at the end of life, many challenges remain for palliative care providers in the United States. This article discusses the history of hospice and palliative care in the United States, the Medicare Hospice Benefit, the growth of hospice and palliative care, and challenges such as the need for regulatory change, workforce issues, improving access to care, and improving the quality of palliative care.     

Flexible home care scheduling

Home care services are in high demand given how they are steadily becoming the primary source of care for the elderly. Powerful decision support tools are indispensable for effectively managing available staff in the context of ever-increasing demand for care and limited caregiver availability. This paper advances home care literature by introducing flexible task durations, thereby enabling tasks to be completed faster and ultimately more care to be scheduled. This new concept, which originates from practice, introduces an additional decision to be made when creating a schedule, thereby greatly increasing the scheduling complexity. Consequently, this paper introduces a new optimization-based decision support model which allows for scheduling with flexible task duration, as well as other types of flexibility. A computational study quantifies the impact of: (i) scheduling with a finer task granularity thereby enabling accurate prioritization of high and low priority care, (ii) flexibility in task duration enabling tasks to be completed faster and more care to be scheduled, and (iii) increasing the number of different locations visited by a caregiver thereby enabling a trade-off between the number of serviced clients and caregiver workload. A new publicly available real-world data set is used, obtained directly from home care organizations operating in Flanders. Analysis of the computational results demonstrates that significant improvements in operational efficiency may be realized with minimal effort required by organizations. Furthermore, the proposed algorithm’s performance is confirmed by comparison against the bounds obtained by solving an integer programming formulation of the problem. Finally, a management policy scheme is proposed which, when gradually implemented in a home care organization, results in a more efficient and therefore cost-effective deployment of its workforce.     

Spirituality and the care of patients at the end-of-life: an essential component of care

Spirituality is an essential component of the care of patients with serious illness and those that are dying. Dame Cicely Saunders developed the hospice movement based on the biopsychosocialspiritual model of care, in which all four dimensions are important in the care of patients. Of all the models of care, hospice and palliative care recognize the importance of spiritual issues in the care of patients and their families. The National Consensus Project Guidelines for Quality Palliative Care, in the United States, provides specific recommendations about all domains of care including the spiritual domain, which is recognized as a critical component of care (The National Consensus Project for Quality Palliative Care www.nationalconsensusproject.org). Studies indicate that the majority of patients would like their spiritual issues addressed, yet find that their spiritual needs are not being met by the current system of care. Interestingly, spirituality is the one dimension that seems to get slightly less emphasis than the biopsychosocial dimensions of care. Some reasons may include the difficulty with definitions of spirituality for clinical and research purposes, the time constraints and financial burdens in the current healthcare system in the United States, and the lack of uniform training for all healthcare professionals. Yet, there are theoretical and ethical frameworks that support spiritual care as well as some educational models in spirituality and health that have been successful in medical education in the United States. Spirituality can be seen as the essential part of the humanity of all people. It is at its root, relational and thus forms the basis of the altruistic care healthcare professionals are committed to. Spirituality has to do with respecting the inherent value and dignity of all persons, regardless of their health status. It is the part of humans that seeks healing, particularly in the midst of suffering. Spiritual care models are based on an intrinsic aspect that calls for compassionate presence to patients as well as an extrinsic component where healthcare professionals address spiritual issues with patients and their loved ones. Currently in the healthcare system, evidence-base models are the criteria for practice recommendations. Yet, spirituality may not be amenable entirely to strict evidence-base criteria. As hospice and palliative care continues to develop as a field, healthcare professionals are challenged to think of ways to advocate for and include the spiritual dimension of care.     

Providing children with health care

Introducing a new column on health policy issues of relevance to physician executives. What are the legislative options to provide children with health care coverage? Federal health initiatives for children have become the next frontier in health care reform. This column defines the problem in the U.S., describes voters' support for a federal initiative, and provides discussion of the options available to federal legislators.     

Sustainability as the lynch pin of public policy and industry initiatives

Does managed care have a sustainable future? So far, managed care has not lived up to its promises and potential. Admittedly, the health care system prior to managed care was a non-system. But its features included committed health care professionals, caring local institutions, freedom of choice, and laws reflecting public confidence. And it was based on the assumption that needed health care services are a customary, moral, and implied legal right of U.S. citizens. In contrast, today's version of managed care is characterized by financial and legal manipulation, "choice" constricted by provider selection of physician panels, and laws reflecting lack of public trust. Managed care can survive its initial foolish years, if it heeds the voices of those urging that two priorities be reflected in public policy, legislative efforts, and business practices. One of these priorities is accountability for today's actions. The other is preserving this country's health care resources. This article explored the concept of sustainability--the need to strike a balance between seeking immediate profit and preserving available resources.     

The Economic Impact of Health Policy Interventions

The rapid aging of the U.S. population, increases in the absolute prevalence of chronic diseases, and the associated rise in the proportion of the GNP expended on medical care all indicate the need for methods to accurately forecast future health care expenditures for specific chronic diseases. Additionally, if these methods are biomedically realistic, they can be used to evaluate the economic implications of specific prevention strategies designed to reduce chronic disease incidence, prevalence, and mortality. Projection strategies that are not biomedically realistic, such as models that assume that risks for demographic subgroups do not change over time (e.g., "static component" models), though possibly accurate over the short run, are not suitable for assessing the long term effects of specific proposed health policy interventions which are designed to alter risks.
In this paper we present a strategy for forecasting health care costs which is based on a model that represents the natural history of a chronic disease in terms of a preclinical state, a clinical state, case fatality rates, cures, and the implications of exogenous medical factors. Using this model we project that the treatment costs associated with respiratory cancer in the white male population of the U.S. may undergo a two-thirds increase in real dollars over the period 1977 to 2000. About one-half of this increase is due to a demographic shift to an older population structure, with the remainder due to higher respiratory cancer incidence rates in younger cohorts. Alteration of certain parameters of the model to simulate various interventions suggests that about three-quarters of the cost of this disease could be eliminated, though realization of any significant part of this savings would require a lengthy phase-in period.     

Cost-effectiveness and coverage policy.

Cost-effectiveness analyses have become a pervasive element of health care. But they have not had a major impact on medical coverage policy. The challenge of implementing cost-effectiveness as a medical coverage criterion is related to the following issues: (1) Contract language does not include cost-effectiveness as a coverage criterion; (2) cost-effectiveness analyses often take the societal, population-based perspective, while health care is delivered on an individual basis; (3) there is no standard methodology for cost-effective analysis; (4) there is no explicit cut-off between cost-effective and cost-ineffective; and (5) cost-effectiveness analyses are not time sensitive.     

Physician-centered management guidelines.

The "Fortune 500 Most Admired" companies fully understand the irreverent premise "the customer comes second" and that there is a direct correlation between a satisfied work force and productivity, service quality, and, ultimately, organizational success. If health care organizations hope to recruit and retain the quality workforce upon which their core competency depends, they must develop a vision strategic plan, organizational structure, and managerial style that acknowledges the vital and central role of physicians in the delivery of care. This article outlines a conceptual framework for effective physician management, a "critical pathway," that will enable health care organizations to add their name to the list of "most admired." The nine principles described in this article are based on a more respectful and solicitous treatment of physicians and their more central directing role in organizational change. They would permit the transformation of health care into a system that both preserves the virtues of the physician-patient relationship and meets the demand for quality and cost-effectiveness.     

A new perspective on quality

The U.S. health care sector consumes nearly 13 percent of our nation's gross national product, $800 billion annually. Our nation allocates the highest amount per capita to health care in the world. Yet many measures of health care outcomes from these expenditures are inferior to other developed nations. The American health care system costs too much, excludes too many, fails too often, contains much excessive and inappropriate care, and knows too little about the effectiveness of the things it does. The purpose of this article is to discuss current payers' perspectives on the potential for quality improvement in the U.S. health care system.     

Implementing workforce development in health care: A conceptual framework to guide and evaluate health service reform

Abstract

The term ‘workforce development’ is increasingly popular in the health-care field. It appears to encompass a range of human and organizational development activity. However, there has been limited explication of the concept of workforce development in Australian health care at area health service levels. It is timely to develop a framework for workforce development and processes to guide any evaluation of the implementation of workforce development strategies. This paper presents a framework that has been developed through consultative processes in an area health service and an associated review of literature.