Rebuilding a 40-Bed Ward Roster - and a Cost-Saving Proposal to Cut Night RNs
Ms. R is the nursing superintendent of a 40-bed general medical ward in a district hospital. Last quarter's average bed occupancy was 80%, and the ward establishment is being rebuilt from scratch for the coming year. The hospital's staffing norms are 1 nurse to 4 patients on the morning shift, 1 to 6 on the evening shift and 1 to 8 on the night shift, with one ward sister (senior RN) added on every shift regardless of census. All staff work 8-hour shifts with one weekly off, and the director has approved an additional 15% reserve for annual leave, sickness and training. The administrator proposes replacing one night RN with two unlicensed nursing attendants, arguing that patients are asleep and that this saves money. Six patients on the ward currently need hourly monitoring and there are no high-dependency beds.
1. Calculate the number of RN posts required, showing every step and stating your assumptions.
Read the worked answer
Step 1 - patients in beds: 80% of 40 beds = 32 patients.
Step 2 - staff required per shift, rounded up to whole people:
- Morning: 32 ÷ 4 = 8 nurses
- Evening: 32 ÷ 6 = 5.33 → 6 nurses
- Night: 32 ÷ 8 = 4 nurses
- Ward sister: 1 per shift × 3 = 3
Step 3 - shifts to be covered per day: 8 + 6 + 4 + 3 = 21 shifts.
Step 4 - convert shifts to posts allowing for weekly off: each nurse works 6 of 7 days, so 21 × 7/6 = 24.5 posts.
Step 5 - add the 15% reserve: 24.5 × 1.15 = 28.2 → 29 RN posts.
Assumptions to state explicitly:
- Rounding is always upwards, because a fraction of a nurse cannot cover a shift.
- The 7/6 factor covers only the weekly off; the 15% covers annual leave, sick leave and training. If the hospital's leave entitlement is higher, the reserve should be recalculated rather than assumed.
- Occupancy is held at the last quarter's average; peaks will exceed this.
- The ward sister posts are assumed to be additional to the shift nurses, as the norm states.
- No allowance has been made for a head nurse, clinical nurse educator, or maternity leave beyond the 15%.
The honest caveat: 29 is a census-based establishment figure, not a safe-staffing guarantee. A ratio calculated from average occupancy is a floor, and the ward should have a mechanism to escalate when acuity or census rises.
2. Evaluate the administrator's proposal to replace one night RN with two nursing attendants.
Read the worked answer
The proposal reduces cost but removes a capability, and it should be resisted with a structured argument rather than a general objection.
What attendants legally and competently cannot do:
- Assess a deteriorating patient. Recognising that a drowsy patient has become hypotensive, or that new confusion is hypoglycaemia rather than 'being difficult', is an RN judgement built on assessment.
- Administer intravenous drugs, titrate oxygen, manage a syringe driver, or give a controlled drug with a second checker.
- Interpret and act on an early warning score, or make the decision to escalate to a doctor at 03:00.
- Perform the initial response to a seizure, a fall with head injury, or a cardiac arrest.
Why night is the worst shift to weaken:
- Medical cover is thinnest at night, so the nurse's autonomous judgement matters most, not least.
- Six patients need hourly monitoring. That is 6 patient contacts every hour before any other patient is seen, and it must be done by someone who can act on the finding.
- Delirium, hypoglycaemia, sepsis and bleeding all declare themselves at night.
What the administrator is really buying: two people who can observe and report, but who must still wake an RN. With only one RN for 40 patients, the report may arrive after the window for intervention.
Counter-proposal with numbers: retain 3 RNs and add 1 attendant, or create a 2-RN plus 1-float-RN model, or convert the six monitored patients to a four-bed high-dependency area with a dedicated 1:2 nurse. Present the comparison in whole-time equivalents and incident risk, not as an emotional appeal. Document the concern in writing if overruled.
3. At 100% occupancy the calculation changes. Recompute the requirement and judge whether 29 posts remains a defensible establishment.
Read the worked answer
Recomputation at 100% occupancy (40 patients):
- Morning: 40 ÷ 4 = 10
- Evening: 40 ÷ 6 = 6.67 → 7
- Night: 40 ÷ 8 = 5
- Ward sisters: 3
- Shifts per day: 10 + 7 + 5 + 3 = 25
- Weekly-off factor: 25 × 7/6 = 29.2
- With 15% reserve: 29.2 × 1.15 = 33.5 → 34 RN posts
Judgement: 29 posts was defensible only for the average occupancy of 80% with an acuity mix that matches the ratio norms. At 100% occupancy the ward is short by about 5 posts, so 29 ceases to be defensible - the roster would be filled by overtime, or shifts would go uncovered, and both are unsafe.
But the census is not the real driver - acuity is. Six patients needing hourly monitoring are not captured by a 1:8 night ratio at all. If those six require roughly 1:2, that alone is 3 nurses rather than the 0.75 of a nurse implied by 1:8, so the night shift needs at least 5–6 RNs regardless of whether the ward is 80% or 100% full.
Practical recommendation: set the establishment from the higher of census-based and acuity-based calculations, add a separate float/relief pool rather than inflating every ward's reserve, and build in an escalation ladder (pull a nurse from a low-acuity area, convert beds, or close beds) so that the ratio is a trigger for action rather than a number that is quietly breached night after night.