Three Ways to Spend Less on Nights: Weighing Agency Nurses, Unit Closure Nights and a Shared Staffing Pool Against What Each Would Do to Patients
[Student Name]
University of Phoenix
HSN/476: Healthcare Policy and Financial Management
Week 3 Assignment
[Instructor Name]
[Date]
The hospital, the unit and all figures are a composite written for a model paper.
Last year, my unit spent $214,000 on agency nurses, most of it for night shifts when a staff nurse called in sick or a position was vacant. The hospital's finance committee asked every manager to propose savings, and three ideas came to my unit. This paper estimates what each would save, examines what each would do to patients and recommends one. The central problem of cost control in nursing is that the largest cost, staff, is also the main protection against harm.
Why Nights and Nursing
Night staffing is where savings are sought first because nursing is where the money is. Registered nurse labor accounts for about a quarter of hospital expenditures nationally (Welton, 2011), and on a small unit it is a larger share still. Nights are also where gaps are hardest to fill: staff nurses prefer day shifts, sick calls at 1800 leave few options, and agency contracts fill the difference at a premium. A proposal that touches night staffing therefore touches the unit's largest cost and its thinnest coverage at the same time, which is why the effect on patients must be examined as carefully as the savings.
The Evidence on Staffing and Harm
Any proposal that changes staffing has to be judged against the evidence on outcomes. Needleman et al. (2011) studied 197,961 admissions and 176,696 nursing shifts on 43 units in one academic hospital. Registered nurse staffing was within eight hours of the target on 84% of shifts. Each shift during which registered nurse staffing fell eight hours or more below the target was associated with a 2% increase in the risk of death for the patients exposed to it, and each shift with unusually high patient turnover was associated with a 4% increase. The effect of one shift is small, but patients in the hospital for several days are exposed to many shifts, and the risk accumulates. The study's lesson for a cost-cutting manager is that the danger lies not in average staffing but in the particular shifts that fall short.
Option 1: Stop Using Agency Nurses on Nights
The simplest proposal was to stop booking agency nurses and cover gaps with the charge nurse, the house supervisor or overtime. Agency nurses on my unit cost about $95 an hour, against about $54 for a staff nurse including benefits, and about $81 for a staff nurse working overtime. If all agency hours were covered by overtime instead, the unit would save about $92,000 a year. If some gaps were simply left open, savings would be larger.
The risk is in the gaps. On a unit that must have two registered nurses at all times, leaving a night shift with one nurse, or with a house supervisor who is also covering the emergency department, creates exactly the kind of shift that Needleman et al. (2011) associated with higher mortality. Heavy reliance on overtime also has costs. Nurses working long and extra shifts are more likely to make errors (Rogers et al., 2004), and overtime drives the burnout that produces more vacancies. This option saves money quickly and shifts risk onto patients and staff.
Option 2: Close the Unit to Admissions on Low-Census Nights
A second proposal was to stop admitting new acute patients at night when census falls below five, transferring them to a regional hospital 60 miles away, and to staff the unit with one registered nurse and one assistant on those nights. The finance committee estimated savings of about $70,000 a year.
This option lowers cost by lowering service. It violates the unit's two-nurse minimum, sends rural patients on long transfers at night, which carries its own risk and cost to families, and loses revenue from admissions that would have been paid at cost. It also undermines the reason a critical access hospital exists, which is local access to inpatient care. I judged it unacceptable.
Option 3: A Shared Night Staffing Pool
The third proposal was mine. The inpatient unit and the emergency department both run two registered nurses at night, and their busy periods rarely coincide. Cross-training four nurses to work competently in both areas would create a shared pool from which gaps on either unit could be filled without agency staff. Training would cost about $18,000 in paid education hours and a pay differential of $2 an hour for cross-trained nurses, about $16,000 a year. If the pool covered two-thirds of current agency hours, the net savings would be about $104,000 a year after training and differential costs.
The pool keeps both units at their minimum staffing, so it does not create short shifts. Its risks are different: a nurse floated from the emergency department to inpatients during a quiet night may be recalled if an ambulance arrives, and nurses working outside their home unit need clear competencies. The pool would need a rule that a floated nurse cannot be recalled unless replaced, and a competency checklist completed before any nurse joins it.
Comparing the Options
Option 1 saves about $92,000 but relies on overtime and allows short shifts. Option 2 saves about $70,000 but reduces local access, breaks the minimum staffing rule and loses revenue. Option 3 saves about $104,000 after its costs and keeps every shift at minimum staffing, at the price of a training period and new rules. Only Option 3 lowers cost without increasing the number of understaffed shifts.
Recommendation and Monitoring
I recommend Option 3. Its effect on quality would be monitored monthly through the number of night shifts below the two-nurse minimum on either unit, with a target of zero; falls with injury and medication errors on nights; overtime hours; and turnover among the pool nurses. If understaffed shifts appear or pool nurses leave, the plan would be revised before savings are counted.
Conclusion
Cost control in nursing means choosing which costs to cut in a way that protects the shifts where harm happens. Of three proposals to reduce night staffing costs, a shared cross-trained pool saves the most while keeping every shift staffed. Week 4 will look at how health policy and regulation shape the choices hospitals like mine can make.
References
Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037-1045. https://doi.org/10.1056/NEJMsa1001025
Rogers, A. E., Hwang, W.-T., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212. https://doi.org/10.1377/hlthaff.23.4.202
Welton, J. M. (2011). Hospital nursing workforce costs, wages, occupational mix, and resource utilization. Journal of Nursing Administration, 41(7/8), 309-314. https://doi.org/10.1097/NNA.0b013e3182250a2b
How this HSN 476 Week 3 example is structured
The HSN/476 description names cost controls and fiscal responsibility, and many sections ask students to weigh a cost-control strategy against its effect on quality. This paper compares three real options with numbers, applies research evidence on staffing and outcomes to each, and makes a recommendation that states its trade-offs and how its effect on quality would be monitored. Students search this week as HSN 476 Week 3, HSN476 Wk 3 or HSN/476 Wk 3; all three are the same assignment.
HSN/476 Week 3 questions, answered
What does HSN/476 Week 3 usually ask for?
The course description lists cost controls and fiscal responsibility. Many sections ask students to analyze strategies for controlling costs and their effects on quality, safety and staff.
Does cutting nurse staffing save money?
In the short term, fewer paid hours lower labor costs. Evidence also links understaffed shifts with higher patient mortality, and harms such as falls and infections add costs, so the net effect depends on how the cut is made.
What is a staffing pool?
A group of nurses trained to work on more than one unit, assigned each shift to where they are needed. It lets a hospital match staff to demand without paying premium rates for outside agency nurses.
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