APNA Members' Corner Articles - July 2009

Continuing the Staffing Discussion
By (Rev.) Benjamin M. Evans, DD, DNP, RN, APN, PMHCNS-BC

Our editor, Michele Valentino, has offered insights about staffing in psychiatric/mental health nursing (PMH). I would like to share a few thoughts based on my role as clinical director of psychiatric services for a large urban medical center.

As I began to ponder my ideas, the refrain from an old song kept creeping in: “the elusive butterfly of life.”  Yes, I know this really dates me! Nurse managers and nurse administrators face daily challenges around staffing that are much like that elusive butterfly.  

Staff nurses rarely if ever face the conundrum of having too much staff. Questions such as the right skill mix, the acuity ratio of a given set of patients, productivity parameters and the dictates of state regulations combine to make the game of spinning plates on thin rods seem like a piece of cake compared to arriving at safe, effective staffing levels. Add to that the organizational rules around staffing, union contractual issues and paid time off, sick calls and self-cancellations and it’s no wonder that staffing in PMH presents a challenge. Of course, we have to ice this little cake with the frosting–PMH nursing often is not the choice of specialty for nursing graduates, who like “action and drama” in the workplace.  (If only they knew!)

In today’s market-driven, business-modeled health care, nurse staffing is optimal when the nursing’s effect on patient outcomes equals the cost of nursing care.  A difficult, inadequately addressed issue is what patient outcomes the specialty is addressing. Nationally, there are 12 core measures altogether in four categories: acute myocardial infarction, community-acquired pneumonia, congestive heart failure, and surgical care improvement project.  None of these addresses PMH issues. Current measures in PMH tend to focus on issues such restraint reduction, elopements, suicide prevention and reduction in toxic medication adverse events. These tend to be more process oriented than outcome oriented and do not lend themselves to assisting in staffing decisions.

Instead, two methods are commonly used—fixed ratios and alternative/acuity measure ratios—individually or in combination.  Thirteen states mandate written staffing plans and one other state has such a law but has not yet instituted it. Problems cited with fixed ratios are the tendency to “foster rigidity,” 1 layoffs of non-licensed personnel and money shifted from technology to RN salary, which can hurt an organization’s profitability.

The American Nurses Association (ANA) believes that nurse staffing ratios need to be required by legislationbut the number itself must be set at the unit level with RN input.This does not always mesh with corporate productivity targets and must be supported by evidence. Although several studies have shown that the addition of registered nurses in patient-care areas trends toward improved outcomes, these studies have been done in general- and critical-care nursing settings, not PMH.

Just as difficult as setting staffing ratios for the nurse manager or administrator in PMH is the determination of acuity mix for patient groups.  In acute PMH settings, a moderate level of acuity often can skyrocket within the same shift by patients’ escalating behavior or the admission of very acutely ill patients. Short-term-stay units may experience multiple admissions on a shift in combination with multiple discharges. Although this increases exponentially the staff nurses’ work, it often is not captured in acuity measures.

As nurse managers and administrators in PMH work to set staffing standards, acuity measures are complex and often hard to quantify. Many acuity programs exist to develop staffing ratios in the general- and critical-care areas based on weighted procedures. PMH nursing relies heavily on psycho-emotional and supportive interventions, which are more difficult to measure and quantify. One PMH acuity system directly targeted for PMH was developed at Acadia Hospital in Bangor, Maine3. Fairly comprehensive, it could serve as a tool for multi-site pilot testing across PMH settings. This type of work could help PMH nursing advance its role in identifying nursing staffing models.

It is clear that the process for determining staffing needs is evolving and there is no clear-cut optimal staffing level. One size does not fit all. In keeping with the ANA consensus, however, staffing needs to be developed with input from the unit nurses and should be based on evidence, not conjecture. Fixed ratios can be detrimental in a PMH setting with variable or rapidly changing acuity. It becomes incumbent on those of us working in the PMH settings to contribute our knowledge and expertise to this effort.


1 Manojlovich, M. Seeking staffing solutions. The American Nurse Today. HealthCom Media. 25-27. March 2009.
2 wwwsafestaffingsaveslives.com accessed March 19, 2009.
3 Patient Classification System/Staffing Plan. Acadia Hospital Corporation. Interdepartmental Directives. October 11, 2007.

Shirley Smoyak Awarded Honorary Doctorate

Press release from Kingston University and St George’s, University of London, June 3, 2009

An American professor who is a legendary figure in the world of psychiatric nursing has been awarded an honorary doctorate by Kingston University and St George’s, University of London.

Shirley Smoyak, a professor in the Division of Continuous Education and Outreach at Rutgers University, New Jersey, has been named an Honorary Doctor of Science. The award was made by the Faculty of Health and Social Care Sciences, run jointly by Kingston and St George’s.

Professor Smoyak, who is also Professor of Public Health in the University of Medicine and Dentistry of New Jersey, said she was delighted to accept her first honorary degree. “It’s a very, very wonderful experience. The highest academic accolade that anyone could have is an honorary degree. It signifies that you have passed some kind of ultimate test of your personal and academic credentials beyond your local institution, and in my case, beyond my country of origin,” she said.

The Faculty’s Professor of Mental Health Nursing Mary Chambers nominated Professor Smoyak for an honorary degree because she was an inspirational figure and a role model for students. “She has boundless energy and enthusiasm for her area of expertise and can explain complex concepts in a way that people can relate to,” she explained. “Shirley’s a star, one of the figureheads of our profession.”

Professor Smoyak’s key achievement, Professor Chambers said, was to bring a theoretical background to psychiatric nursing by developing the work of her mentor, the late Dr Hildegard Peplau. “Together they have brought a critical mindset to the profession,” Professor Chambers explained. “Through their teaching style they have given nurses a lot of confidence in their clinical abilities and their research skills. Both emphasise the ‘give and take’ of a nurse’s role, rather than a patient passively receiving care or a nurse passively carrying out a doctor’s instructions.”

Professor Smoyak has taught courses in mental health and illness, psychiatric and mental health nursing, family dynamics, health care administration, culture and health and qualitative research methods for almost 50 years at Rutgers, the eighth oldest college in the United States. Her current research projects include criminal and clinical perspectives on stalking and an analysis of state psychiatric hospitals.

She is Editor of the Journal of Psychosocial Nursing and Mental Health Services, the only monthly journal serving psychiatric nurses in clinical practice, and is the founder of the American Psychiatric Nurses' Association. In 2004, the Academy of Nursing awarded her the status of a Living Legend.

Professor Smoyak’s parents were from Austria-Hungary and she grew up in a multi-cultural neighbourhood in Perth Amboy, New Jersey. Her family’s neighbours were from various European countries, and she was expected to know their languages well enough to run errands for them.

As an adult, this helped to inspire her focus on cultural sensitivity, which has included work with American Indian tribes in the south west of the United States. She has also worked in El Paso, a border town in Texas, where she taught first generation Mexicans, black students with families in the military, and older white women returning to study.

Professor Smoyak joins a long list of honorary doctors from Kingston University, including film director Lord Attenborough, architect David Chipperfield, former Harrier chief test pilot John Farley, human rights lawyer Geoffrey Bindman and Fairtrade pioneers Josephine Fairley and Craig Sams. 

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The American Psychiatric Nurses Association is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.