OPTIMIZINGNURSE ASSIGNMENT

Jay M. Rosenberger
1
Deborah Buckley Green
2
Bette Keeling
2
Patricia G. Turpin
2
Jianzhong Michael Zhang
1
1
Department of Industrial and Manufacturing Systems Engineering
P.O. Box 19017
University of Texas at Arlington
Arlington, TX 76019-0017
2
School of Nursing
P.O. Box 19407
University of Texas at Arlington
Arlington, TX 76019-0407
Abstract
We review the stages of nurse planning. Our research
focuses on the nal stage, which assigns nurses to pa-
tients. We present a stochastic model for generating
patient scenarios. We use an integer program to assign
nurses to patients in several scenarios, and the objective
is to minimize excess workload on nurses. We provide
computational results that compare the integer pro-
gram to a heuristic and random assignments. Finally,
we discuss areas for future research.
Introduction
One of the greatest problems in health care today is
a shortage of nurses. The shortage will become more
severe because the elderly population is growing in num-
bers, and they need substantially more health services
(Victor and Higginson 1994). Although the demand for
nurses is growing, fewer younger nurses are available for
care. From 1983 to 1998, the number of nurses under
30 years of age decreased by 41% (Lynn 2001). Patients
with insucient nursing care risk relapse, permanent
injury, and even death. Given that nurses as a resource
are scarce, intelligent planning methods are needed to
reduce the burden of the shortage.
One remedy for the shortage is balancing workload
for nurses on duty. Each nurse is typically assigned
a set of patients for a shift. However, some patients
require more attention than others. Consequently, tend-
ing to the needs of a few patients may consume most
of a nurses time, while other patients are neglected.
Neglecting patients is unsafe, and the State Board of
Nursing disciplines nurses for negligence. During the
same shift another nurse may have signicantly less
workload because her patients may require less atten-
tion. The second nurse should assist the rst by taking
on some of the rst nurses patients. Reducing workload
imbalance would improve patient care.
We review the stages of nurse planningnurse bud-
geting, nurse scheduling, nurse rescheduling, and patient
assignment. We describe a stochastic model for the set
of patients in a unit, and we generate several scenar-
ios. We describe a heuristic and a integer programming
model for patient assignment that minimizes overworked
nurses. We compare the solutions fromthe heuristic and
the integer program to a random assignment. Finally,
we discuss conclusions and topics of future research.
Overview of Nurse Planning
Nurses work in a variety of environments including
hospitals, private doctors oces, nursing homes, and
individual homes. Although our research is on nurses
at one hospital, it may be applied to other hospitals
and environments with multiple nurses and patients.
Hospitals in the United States employ two types of
nursesregistered nurses (RNs) and licensed vocational
nurses (LVNs). We describe the four stages of nurse
planning in the following sections.
Nurse Budgeting
In the rst stage, nurse budgeting, nancial planners
forecast the number of nurses needed during a year,
create a budget, and determine how many nurses
they will hire and how many they will out-source
to a nurse agency. Kao and Tung(1980) describe an
autoregressive integrated moving average forecasting
method to predict patient demands over a year,
and Kao and Queyranne (1985) implement a stochas-
tic programming model to optimize a budget for nurses.
Nurse Scheduling
In the second stage, nurse scheduling, a nurse
manager forecasts the number of patients that will
enter a hospital unit over a 4 to 6 week time horizon.
Based upon the forecasted number of patients, she uses
a census matrix to determine the number and level
of nurses needed. When she knows how many nurses
of each type she needs, she creates a schedule that
partitions the time horizon into 8 to 12-hour shifts.
The schedule details which nurses will work during each
shift. Typically, a nurse manager posts a schedule two
weeks before the beginning of the time horizon. Most
academic literature on nurse planning is on scheduling.
Nurse scheduling problems were popular in the 1970s
and early 1980s, including Warner and Prawda (1972),
Miller et al. (1976), Warner (1976). However, very little
has been researched in the United States since then. In
the United Kingdom, most research on nurse scheduling
uses genetic algorithms, such as Burke et al. (2001a
and 2001b), Aickelin and White (2002), and Aickelin
and Dowsland (2003). Other recent research on nurse
scheduling includes Bailey et al. (1997), Jaumard
et al.(1998), Kirkby (1997), Chun et al. (2000), and
Osogami and Imai (2000). Abernathy et al.(1973)
integrate nurse budgeting and scheduling. Because
these algorithms only consider the nurse budgeting
and scheduling stage, they ignore changes in sta
and assume the schedule will be followed as planned.
At some hospitals, such as Baylor Medical Center in
Grapevine, Texas, each nurse has a designated shift
and must request vacation prior to the posting of a
schedule. Because the shifts are often inexible, nurse
scheduling is usually trivial.
Nurse Rescheduling
Because a nurse manager schedules a shift 2 to
8 weeks in advance, the set of nurses scheduled for
the shift may not accurately reect the needs of the
patients. The third stage of nurse planning, nurse
rescheduling, involves revising the set of nurses sched-
uled for a shift. Approximately 90 minutes before each
shift, the nurse supervisor reevaluates the scheduled
nurses based upon the activities of the previous shift,
the patients in the emergency room, and the census
matrix. If she needs more nurses than are scheduled for
the upcoming shift, she attempts to recruit additional
nurses who work as neededPRN nurses, nurses who
work part timepart-time nurses, and nurses who are
not scheduled for the upcoming shifto-duty nurses.
If the supervisor does not recruit a sucient set of
nurses to work the shift, she requests permission to
call a nurse agency from the nurse manager. Upon
approval from the nurse manager, the supervisor hires
temporary agency nurses to satisfy the remaining
shortage. If more nurses are scheduled for the shift
than needed, then the supervisor instructs surplus
PRN nurses and part-time nurses to take the day o
without pay.
Although research literature considers nurse
budgeting and scheduling, we are unaware of any
literature on nurse rescheduling. To improve nurse
rescheduling, a supervisor could consider the cost of
revising the nursing sta and how much attention from
nurses each of the current and incoming patients will
require.
Patient Assignment
In the fourth stage, patient assignment, the charge
nurse assigns patients to each nurse at the beginning of
a shift. Because patients enter and leave the hospital
unit throughout a shift, the charge nurse dynamically
updates patient assignments. However, revised patient
assignments often only include assigning a nurse to a
new admission. Rarely is a patient reassigned a new
nurse during the middle of a shift.
One consideration in patient assignment is workload
balance. Similar to nurse rescheduling, we are unaware
of a any research literature on patient assignment.
A Stochastic Model of Patients in a
Hospital Unit
In this section, we describe a stochastic model of patients
in a unit, and we used this model to generate a random
patient scenario.
Many hospitals use patient classication systems
to estimate the amount of care a patient will require.
Direct care is the amount of time nurses spend with
patients, while indirect care is time spent on other tasks
for the patient, such as documentation of a patients
condition. Table 1 displays an example of direct versus
indirect care given to a patient in four patient classes
in a hospital unit over a month. The column labelled
class is the classication of the patient, pats is
the number of patient days during the month, los
is the average length of stay per patient, pat/day is
Class Pats LOS Pat/Day Direct Indirect
1 1 4.1 0.0 1.3 1.6
2 5 4.1 0.2 2.2 1.6
3 39 4.1 1.3 3.9 1.6
4 441 4.1 14.5 5.1 1.6
Total 486 4.1 16.0 5.0 1.6
Table 1: Direct versus indirect care for each classica-
tion.
Class Day Evening Night
1 1.2 0.7 0.9
2 1.6 1.0 1.2
3 2.4 1.4 1.8
4 2.9 1.7 2.1
Total 2.8 1.6 2.1
Table 2: Care for each classication during each shift.
the number of patients days per day, direct is the
average number of direct care hours, and indirect is
the average indirect care hours. Table 2 demonstrates
the amount of care given per shift. The column day is
the hours of care given during the day shift, evening
is care for the evening shift, and night is that of the
night shift. Although our research uses data from a real
hospital, the data in Tables 1 and 2 have been altered
for condentiality.
We assume that the admit (discharge) process is
poisson. For each classication i, we model the number
of patients of each classication

P
i
in a shift as a poisson
random variable in which the mean E[

P
i
] is the average
number of patient days per day in the unit. For example,

P
3
fromTable 1 is modelled as a poisson randomvariable
with mean E[

P
3
] = 1.3. Given

P
i
, let P
i
equal a set of
patients of classication i of size

P
i
, and let P be the
set of all patients, P =
4
i=1
P
i
.
Each patient must be cared for by a RN over any
24-hour time period. One way to ensure that a patient
receives care from a RN is to assign a RN to each patient
who received care from a LVN on the previous shift. For
each patient p P, we let the probability that patient
p needs to be assigned to a RN as

p
=
number of RNs
number of RNs + number of LVNs
.
Consequently, the number of patients that need to be
assigned to a RN is a binomial random variable with
probability mass function
f(x) =

P
x

x
(1 )

Px
x = 0, . . . ,

P.
Needs Work-
Patient Class RN load
1 3 No 211
2 4 No 346
3 4 No 310
4 4 No 291
5 4 No 312
6 4 Yes 355
7 4 No 313
8 4 No 304
9 4 Yes 350
10 4 No 305
11 4 No 294
12 4 No 329
13 4 No 345
14 4 No 346
Table 3: Scenario 1
A shift is divided into a set of time epochs T. For
each, t T, let d
t
be the length of time from time
epoch t until the next time epoch. In creating random
scenarios, we divided an eight-hour shift into 8 time
epochs, so d
t
was 60 minutes for all t T.
For each patient p P, let random variable a
tp
be
the amount of care, or workload, given to patient p at
time epoch t T. Because patient p may be admitted
or discharged during a shift, the workload of a patient
may vary dramatically throughout the shift. For each
patient p P
i
and each time epoch t T, we model the
patient workload a
tp
as a gamma random variable with
parameters
tp
and , in which E[ a
tp
] =
tp
is the
average care of a class i patient during the shift weighted
by
d
t

tT
d
t
. Consequently, for each p P, the random
variable

tT
a
tp
is a gamma random variable with
parameters

tT

tp
and . In our random scenarios,
we let = 4.
Tables 3, 4, and 5 display the properties of the
patients in Scenarios 1, 2, and 3. Although the
scenarios included the patient workload for each hour,
the tables only show the total patient workload in the
column labelled workload. All three scenarios were
generated from data based upon a medical unit from a
real hospital. Scenario 1 is a day shift with 9 RNs and
1 LVN, Scenario 2 is an evening shift with 4 RNs, and
Scenario 3 is a night shift with 9 RNs and 1 LVN.
An Integer Program for Patient
Assignment
Although patient assignments dynamically change
throughout a shift, most revisions are minor. Conse-
quently, the initial patient assignment often determines
the balance of the workload. We present an integer
Needs Work-
Patient Class RN load
1 3 0 110
2 3 0 97
3 3 0 111
4 4 0 91
5 4 0 117
6 4 0 135
7 4 0 114
8 4 0 104
9 4 0 112
10 4 0 110
11 4 0 90
12 4 0 138
13 4 0 106
14 4 0 130
Table 4: Scenario 2
Needs Work-
Patient Class RN load
1 3 No 108
2 3 No 177
3 4 No 165
4 4 No 220
5 4 No 192
6 4 No 171
7 4 No 205
8 4 No 179
9 4 No 196
10 4 No 209
11 4 No 208
12 4 No 172
13 4 Yes 245
14 4 No 220
15 4 No 185
16 4 No 181
17 4 No 185
18 4 No 195
19 4 No 230
20 4 Yes 246
21 4 No 196
22 4 No 157
23 4 No 206
Table 5: Scenario 3
program for the initial assignment of nurses to patients
for a nursing shift in a hospital unit. We assume that
the charge nurse knows how many patients enter the
unit, when patients enter and leave the unit, and the
workloads of the patients; that is, for each patient p P,
and each time epoch t T, the workload a
tp
, is a known
realization of the random variable a
tp
.
Let N be the set of nurses for the shift. Although
patients can usually be nursed by either an RN or an
LVN, some states, such as Texas, require that every
patient be assessed by an RN within any 24-hour time
period. Consequently, nurse managers will assign RNs
to patients who were assigned LVNs in the previous shift.
We assume that a charge nurse determines which nurses
can be assigned to which patients before optimizing
patient assignment. For each patient p P, let N(p)
be the set of nurses which can be assigned to patient p.
For each nurse n N, let P(n) be the set of patients
that can be assigned to nurse n; that is, S(n) = {p
P|N(p) n}. For each patient p P, and nurse
n N(p), let assignment variable
X
pn
=

1 if patient p P is assigned
to nurse n N(p),
0 otherwise.
For each time epoch t T and each nurse n N,
let excess workload variable O
tn
be the total patient
workload in excess of d
t
assigned to nurse n at time
t. As the excess workload of a nurse increases, her
patients receive less attention, which is unsafe. The
patient assignment model (PA) is
min

tT

nN
O
tn
(1)

nN(p)
X
pn
= 1 p P (2)

pP(n)
a
ts
X
pn
d
t
+O
tn
t T, n N (3)
X
pn
{0, 1} p P, n N(p) (4)
0 O
tn
t T, n N (5)
Objective (1) minimizes the excess workload. The rst
constraint setthe patient assignment constraints (2)
ensure that every patient is assigned a nurse. For each
time epoch t T, a workload constraint in set (3)
limits the workload of nurse n N to the duration
of the epoch plus the excess workload. Constraint set
(4) requires that the assignment variables be binary,
and constraints (5) ensure that the excess workload
variables are nonnegative.
Total Excess
Patient Workload
Case Algorithm Minutes Minutes %
1 Rand 4411 656 14.9%
1 Heur 4411 545 12.4%
1 PA 4411 542 12.3%
2 Rand 1565 72 4.6%
2 Heur 1565 38 2.4%
2 PA 1565 7 0.4%
3 Rand 4448 391 8.8%
3 Heur 4448 363 8.2%
3 PA 4448 347 7.8%
Table 6: The computational results comparing solutions
from PA, heuristic solutions, and random assignments
for Scenarios 1,2, and 3
Heuristic Approach
In addition to the integer program, we created a
heuristic that assigns nurses to patients. The heuristic
only considers the total care time of the patients and
ignores the care time for the time epochs. When the
number of nurses divides the number of patients evenly,
the heuristic assigns the patients with the greatest and
least required care time to the same nurse. Otherwise,
the heuristic assigns the patients with greatest required
care to the nurses who are assigned to fewer patients.
Computational Results
For each scenario, we assigned the nurses to patients
using PA, the heuristic, and a random assignment. We
compared the excess workload, and Table 6 displays
the results. In all three cases, PA outperformed the
heuristic and the random assignment. Solutions to PA
reduce the excess workload between 44 and 114 minutes
over a random assignment and 3 and 31 minutes over
the heuristic, which reduces the burden of the current
nursing shortage.
Future Research
Although nurse scheduling is prevalent in the litera-
ture, we are unaware of any research on rescheduling
sta and assigning nurses to patients. Considering that
temporary agency nurses are expensive and used fre-
quently, hospitals could reduce costs by making better
decisions with their regularly scheduled nurses. Reduc-
ing imbalances in workloads assigned to nurses could
help alleviate pressure placed on many nurses.
We presented a stochastic model to generate pa-
tients scenarios in a hospital unit. We implemented
an integer program that assigns nurses to patients and
minimizes excess workload. We provided computational
results demonstrating the eectiveness of the model.
In the patient assignment model (PA), we assume
that the charge nurse knows how many patients will
enter the hospital unit, when patients will enter and
leave the hospital unit, and the patient workload. In
practice, these variables are unknown, and we intend to
develop a stochastic programming model that considers
several random scenarios for the patient workload. To
solve the stochastic patient assignment problem, we can
use a Benders decomposition formulation in which the
master problem assigns the nurses to patients, and the
continuous workload variables are determined in the
second stage (Birge and Louveaux 1997).
The total number of possible scenarios is extremely
large. However, we can reduce the total by considering a
reasonable number of likely scenarios. Furthermore, we
can generate typical workloads by examining historical
data and using autoregressive techniques to generate
workload forecasts. These forecasts may depend on the
diagnoses of the patients currently on the oor and in
the emergency room.
The objective function of the integer program pe-
nalizes excessive workload. However, if a nurse is as-
signed patients whose hospital rooms are far apart, the
nurse may spend valuable time walking among rooms.
Consequently, the objective function could penalize an
assignment in which a nurse cares for patients in distant
rooms.
Whena nurse supervisor reschedules nurses, she may
call upon additional nurses if needed or send home excess
PRN or part-time nurses. By including these nurses and
their salaries into the model, a nurse supervisor could
optimize the set of nurses for the shift. For instance,
she could evaluate the tradeo between decreasing the
excess workload of the nurses versus increasing the cost
of employing a temporary agency nurse.
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Author Biographies
JAYM. ROSENBERGERis an Assistant Professor
in the Department of Industrial and Manufacturing
Systems Engineering at the University of Texas at
Arlington. He received a bachelors degree in mathe-
matics from Harvey Mudd College, a masters degree
in industrial engineering and operations research the
University of California at Berkeley, and a Ph.D. in
Industrial Engineering at the Georgia Institute
of Technology. He won the First Place Pritsker
Doctoral Dissertation Award from the Institute of
Industrial Engineers. His email and web addresses
are <jrosenbe@uta.edu> and <http://ie.uta.edu/
index.cfm?fuseaction=professordescription&
userid=2842>.
DEBORAH BUCKLEY GREEN is a Clini-
cal Instructor at the University of Texas at Arlington.
She teaches critical care in the generic BSN program.
She received her bachelors degree from Southwest
Missouri State University and Masters of Science
at the University of Oklahoma, and is currently
a student in the Ph.D. Nursing program at Texas
Womans University. She is a Registered Nurse at
Baylor Medical Center in Grapevine, Texas. Her
primary work experience has been with open-heart
and cardiothoracic surgical patients. Her email
and web addresses are <dgreen@uta.edu> and
<http://www.uta.edu/nursing/p-green.htm>.
BETTE KEELING is an Assistant Clinical In-
structor in the School of Nursing at the University
of Texas at Arlington. She received her bachelors
from the University of Louisiana at Monroe, her
masters from the University of Texas at Arlington,
and a Ph.D. from Texas Womans University. She
is a Registered Nurse, and her clinical positions
are in medical-surgical nursing, operating room,
newborn nursery, shared care (mother-baby unit),
and neonatal intensive care. Her research interests
include nursing administration and leadership. Her
email and web addresses are <bkeeling@uta.edu> and
<http://www.uta.edu/nursing/p-keeling>.
PATRICIA MARIE GRAY TURPIN is an
Assistant Clinical Professor in the School of Nursing
at the University of Texas at Arlington and a Nurse
Researcher at Harris Methodist Hospital in Fort
Worth, Texas. She is a Registered Nurse. Her clinical
experiences include critical care and long term care.
She has consulted for nurse stang and scheduling
programs. She received a bachelors degree from
The University of Texas Medical Branch; Masters
and Ph.D. degrees from The University of Texas
at Austin. She is the Director of the Center for
Leadership in Nursing and Health Care. Her email
and web addresses are <pturpin@uta.edu> and
<http://www.uta.edu/nursing/p-pturpin.htm>.