Nurse Staffing Visibility: Seeing Who Comes Back and Why It Matters
My colleague Kelley Strandberg recently wrote about the relationship between nurse staffing continuity and fill rate, highlighting how nurse leaders can see which shifts were filled but not which nurses returned. This gap in nurse staffing visibility leaves leaders without a clear picture of staffing continuity. I experienced this problem firsthand as a new graduate, long before I understood why nobody could see it.
My first job, like many nurses, was as a night nurse. I worked on a hospice unit in downtown Detroit – the first of its kind in Michigan – and we spent weeks preparing for the opening. Right before we opened, a staffing problem hit without warning. The weekend staff we’d hired left the organization, and those of us who remained had to cover the shifts until we could find consistent replacements.
As a new grad, my learning curve was already steep, and my preceptor – a genius, compassionate person I’ll never forget – did all she could to make sure I would succeed. On nights that she wasn’t there, I worked with a nurse from a staffing agency.
Every nurse they sent was fully competent and a master of their craft, but they didn’t have full access to the documentation system, which left every med pass, every assessment, and every order to be documented by me. Report at the beginning and end of our shifts took twice as long because both the agency nurse and I needed to give and receive report on every patient on the unit. Each time a new nurse filled a shift, I became the preceptor to orient my new teammate to where supplies and meds were kept, our processes and procedures, and how the agency nurse could best help me collect the necessary information to ensure our medical record was accurate.
This double-duty led to hours of overtime on my part for each shift I worked. I was coached by my manager to “spend less time at the bedside, so you can chart and leave on time.” Caring for people is why I became a nurse, and I naturally bristled at the suggestion.
Enter Donna.
Donna is a compassionate veteran nurse with IV insertion superpowers. I once saw her start a line just above a patient’s pinky toe after I was unable to find a vein. Incredible.
I still remember her name because she kept coming back. Her schedule allowed her to work every open shift. I finally had a shift partner on every shift. We developed a system of rounding assessments and med administration that led to better patient outcomes and on-time clock-outs nearly every shift.
Finding Ways to Measure Continuity of Care
Donna made a difference because she returned. But our staffing systems could tell us a shift was filled, not whether the nurse had worked the unit before, understood its routines, or would come back again. That’s the gap Kelley Strandberg keeps hearing about from nurse leaders.
I was frustrated with my manager, who was likely just as frustrated with all she needed to do, and all of this stemmed from a decision made out of necessity.
No one appeared to have planned for Donna. I knew she kept coming back and that the continuity meant better outcomes, but I’m not certain that any report, dashboard, or leader would have been able to discern the reason for the turnaround.
No One Is to Blame
Every person in the chain that led to my situation was doing everything they could to ensure the people entrusted to our care had the very best. Our systems need to better support the complex flow that happens every day to get the right nurse to the right shift across the country.
Recruiting and HR were reviewing candidates and their credentials, so the best worker filled every shift in a compliant way.
Our schedulers and the nurse manager were making sure that every coverage hole on the calendar had a nurse so that those of us who were employees didn’t burn out.
The agency nurses arrived on time and worked hard to care for patients and give me the information I needed, even though the documentation system had no place for them.
I worked until all the work was done so that care was provided and documented.
Our payroll and billing teams made sure that we were all paid for our efforts and that the patient’s insurance received timely remits that were supported by our documentation.
Each system does what it was designed to do, but the connections between them get lost, and so does the nurse. On the schedule, the nurse is a name; in the vendor portal, an agency ID; on the timesheet, a badge number; and on the invoice, a line item.
True nurse staffing visibility connects records so leaders can see who worked each shift, where they worked, whether their credentials were valid, and whether they returned. Without it, staffing teams can track coverage but not continuity.
This is why the leaders Kelley talks to can’t see return rate.
Ask a manager a simple question like, “Has this nurse worked my unit before?” and the answer means pulling from four or five systems, matching names by hand, and hoping you got it right. Nobody has time to do that for a whole hospital every week, so nobody does.
I think of this as a plan versus a record. The plan is who was supposed to work, where, with which credentials. The record is what happened. Every system holds a piece of the plan, but none of them can compile a complete record.
Continuity and Compliance Beyond the Shift Start
Most staffing systems follow a shift from requisition through the nurse’s arrival, and some even carry it through invoice and payment. But the need for a record doesn’t end when the invoice is paid, and our record problem compounds with every month that passes after a shift.
Nurse staffing visibility supports audit readiness by connecting shift assignments, credential status, actual hours worked, and billing records in one verifiable record.
My QAPI peers will tell you that this visibility becomes mission-critical when The Joint Commission or other accrediting agencies come for their audits and reviews.
Suppose an auditor asks about one shift from six months ago. Who worked it? Was her license active that day? Which unit was she on after the float? Do the hours you paid match the hours she worked?
In nearly every case, the hospital will have done everything right. The nurse was qualified and the hours were worked and properly billed and documented, but proving it means pulling the schedule, asking the agency for records, checking a credential file dated at onboarding, asking a house supervisor what they remember about a float, and lining up timekeeping against the invoice.
I’ve seen this take hours or days, which creates unnecessary exposure. Ask any nurse to finish this sentence: “If it isn’t documented…”
The answer: “…it wasn’t done.” And, while we will all answer with a groan or a roll of our eyes, in nearly every case, the documentation is there if you can just find it. The real exposure is not a hospital that failed to comply, but one that can’t prove it did.
What I Know Now
The handoffs I knew about happened between shifts. At the time, I couldn’t see the full cost of my overtime, finding a nurse for every shift, credential reviews, orientation to hospice and our organization by nursing leadership for each new nurse. Together, those costs left no room to hire a full-time nurse who would have given us the consistency we were missing.
That also means my manager’s advice to spend less time at the bedside wasn’t indifference. I was frustrated with her then. Now I’d defend her. She was likely just as frustrated as I was, making the best call she could with the resources and information she had.
I assumed there was one system for it all. There wasn’t. There were several, and none of them was built to answer the question I would have asked.
Now that I build products, I understand that products are built for personas – key users with a specific job. The vendor portal serves the agency. Timekeeping serves payroll. The scheduler serves the nurse manager. Each solution that was delivered made the individual lives of users better, but there needs to be solutions that provide a complete record, provide continuity, and use those insights to predict and prevent needs both in the moment and before they ever arise.
Do Your Systems Pass the Test?
Now, I’d like to ask you to try this test to see if your systems can identify continuity gaps that your staff can identify on the floor, but your data can’t.
Improving nurse staffing visibility starts with a simple question: Can your systems connect every shift to the nurse who worked it, their credentials, assignment, and staffing history?
Pick a shift worked by a contingent staff member last quarter and, using only your systems, write down:
The name of the nurse who worked it.
Their credential status that day.
The unit they were assigned to, including any floats.
Whether the hours worked matched what you paid and what was billed.
How long does it take? Is it accurate? How many people, systems, and spreadsheets did you have to consult to find the answer?
Oh, and one more question: was that the only shift that nurse worked?
About the Author
Matt Abbott, RN, is Director of Product Management at ShiftMed. He spent eight years in hospice nursing, beginning as an inpatient case manager and later serving as a nurse educator, director of education, and director of clinical services. He was one of six registered nurses who opened the first in-hospital general inpatient hospice unit in Michigan, and he lectured on hospice and palliative care to nursing students at Valparaiso University for four years. He has built software for clinicians since 2018, with a focus on documentation and workforce tools.