1. Morgan, Sandy RN, CNRN
  2. Tobin, Patricia PHR, LCSW

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Recent data indicate that, although the nursing shortage eased slightly in 2003, hospitals continue to experience difficulty filling nursing positions. 1 Projections for a long-term nursing supply aren't optimistic. 2 School enrollments in nursing programs won't replace the projected number of nurses planning to retire. 3 The general population's aging, coupled with the aging of nurses, makes finding solutions to the nursing shortage a priority. In addition to the more chronic concerns related to the nursing shortage, hospitals must also address shorter term staffing dilemmas. The seasonal fluctuations of hospital census, patient acuity, and staffing challenges all impact nurse leaders' ability to maintain a safe staffing balance. As a result, we continue to struggle with nurse staffing challenges.


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires hospitals to create a staffing plan that defines staffing effectiveness as the skill mix, competence, and effectiveness related to the services needed. The Florida Hospital Association's (FHA) most recent survey of its hospitals found that the following options were most commonly used in filling vacancies and/or changing service needs:


[white diamond suit]overtime


[white diamond suit]contract/travel nurses


[white diamond suit]on-call staff


[white diamond suit]in-house staffing pools


[white diamond suit]temporary staffing agencies. 4



To everything, there's a season

The aforementioned survey found that 99% of hospital respondents used overtime as a primary approach to replace absent nurses or to handle unusual workloads. An in-house nursing pool, at 97%, was the second most common approach to filling vacant needs, followed closely by temporary staffing agencies or travel nurses, which occurred 94% and 92% of the time. The FHA survey estimated the average hourly rate of in-house pool members at $27.63, overtime at $29.07, travel nurses at $47.10, and contracted nurses at $51.00. 5 Although travel nurse use appears costly, its immediate availability to fill openings is an asset.


Patient care needs and patient census vary from shift to shift, requiring you to frequently reevaluate staffing patterns throughout the day. Seasonal fluctuations in some parts of the country necessitate long-term staff planning to cover projected needs. You may also make long-term staffing projections based on planned family medical leaves, nurse retirements, and other types of turnover, in addition to predicted service line additions. These variables require you to develop strategic and creative initiatives to manage both short- and long-term staffing concerns.


Southwest Florida experiences significant seasonal fluctuations during the winter months, as patient census can surge by as much as 100% during the region's busy tourist season. This upswing is composed of a mainly older adult population, which also elevates the acuity factor. Fawcett Memorial Hospital uses a number of strategies to maintain stable nursing coverage across wide variances in census and acuity. Planning begins 5 to 6 months prior to the season's beginning. The seasonal strategies include:


[white diamond suit]Seasonal core contracts: Hospital core staff members can participate in this voluntary plan, in which they sign a contract and agree to work one additional shift per week from January through April. During this time, they receive additional pay for each hour worked within the extra shift, in addition to the ability to receive overtime pay when they exceed 40 hours. At the end of the contract, they receive a lump sum bonus.


[white diamond suit]Seasonal pay plans: Staff members can work an additional shift for additional seasonal pay without contractual obligation. They, too, can receive overtime pay after exceeding 40 hours.


[white diamond suit]Internal pool seasonal contracts: Before the start of the season, internal pool staff members can contract to work full-time hours at an enhanced pay rate. When the seasonal contract is fulfilled, they receive a completion bonus.


[white diamond suit]Overtime pay: Nurses who exceed 40 hours per week receive overtime pay.


[white diamond suit]Per diem: When internal staff members can't cover the census or acuity surge, per diem staff provide additional support. A staff of nurses is available on short notice at competitive rates.


[white diamond suit]Travel nurses: Nurse leaders query the internal core staff to identify vacancies. Travel nurses are then initiated for the season. Travel nurses are an invaluable resource when core staff can't work enough hours to cover the shifts. Contracting a clinically strong traveler who develops some consistency on a unit can be a great support.


Nurse satisfaction on the rise

After implementing seasonal strategies, along with other efforts to enhance the culture of the workplace, the Fawcett nursing staff documented significant cost savings and increases in staff satisfaction, as nurses were able to obtain higher pay rates during the season. On a scale of 1 to 5, staff satisfaction increased from 3.68 in 2002 to 4.15 in 2004.

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Hospitals continue to struggle with nurse staffing challenges. Nurse leaders must seek creative solutions to develop safe and effective staffing programs. Solutions to the nursing shortage must continue to be a priority. Efforts to enhance nursing satisfaction and retain nurses at the bedside require a team effort of nursing and human resource leadership nationwide.




1. Florida Hospital Association: "Hospital Nurse Vacancy Rates on the Decline." Available online: [Context Link]


2. Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis: "Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020." Available online: [Context Link]


3. Florida Hospital Association: loc cit. [Context Link]


4. Ibid. [Context Link]


5. Ibid. [Context Link]