Optimizing Patient Distribution Through the Adaptation of the RAFAELA System by Strengthening the Role of Nurse Unit Managers to Achieve Equitable Nursing Workload Distribution
DOI:
https://doi.org/10.37287/ijghr.v8i5.2434Keywords:
competency level, nurse staffing, nursing workload, nurse unit manager, RAFAELA systemAbstract
Increasing patient complexity and Bed Occupancy Rate (BOR) have contributed to higher nursing workload at X hospital. These conditions potentially lead to imbalanced workload distribution, nurse fatigue, and decreased quality of care and patient safety. This study aimed to optimize competency-based nurse staffing through the role of Nurse Unit Managers (NUMs) in managing nursing workload at X hospital. This study used a project improvement approach conducted during nursing management residency activities in inpatient units on the 5th, 10th, 11th, 12th, and 13th floors of X hospital from April to May 2026. Data were collected through observations, semi-structured interviews, and document reviews. Problem analysis was conducted using the POSAC approach and fishbone analysis. The intervention was implemented through competency-based staffing using the RAFAELA System as a nursing intensity measurement tool. Most patients had partial to total dependency levels with high clinical complexity. The nurse-to-patient ratio increased to 1:9–11 during full BOR conditions. Patient assignment was previously based on room location rather than patient complexity and nurses’ competency levels, resulting in workload imbalance. The implementation of competency-based staffing assisted NUMs in distributing patients more objectively according to patient complexity and nurses’ competencies. Competency-based nurse staffing optimization through strengthening the role of NUMs and utilization of the RAFAELA System has the potential to improve nursing service effectiveness, support patient safety, and create more proportional workload distribution.
References
Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kozka, M., Lesaffre, E., McHugh, M. D., Moreno-Casbas, M. T., Rafferty, A. M., Schwendimann, R., Scott, A., Tishelman, C., van Achterberg, T., & Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824–1830. https://doi.org/10.1016/S0140-6736(13)62631-8
Aiken, L. H., et al. (2018). Nurse staffing and patient outcomes in acute care hospitals. Journal of Nursing Administration.
Allen, D., et al. (2023). Professional judgement and nurse staffing decision-making in hospital settings. International Journal of Nursing Studies.
Allen, D., Jacob, N., Strange, H., Jones, A., Burton, C., & Rafferty, A. M. (2023). “It’s not just about the numbers”: Inside the black box of nurses’ professional judgement in nurse staffing systems in England and Wales: Insights from a qualitative cross-case comparative study. International Journal of Nursing Studies, 147, 104586. https://doi.org/10.1016/j.ijnurstu.2023.104586
American Nurses Association. (2021). Principles for nurse staffing. https://www.nursingworld.org/practice-policy/nurse-staffing/
Benjamin, E., Romain, S., Vital, C., Blake, C., Peterson, C., & Chung, J. (2025). “They don’t know what it’s really like:” qualitative insights into inpatient cardiac nurses’ perceived workload. BMC Nursing, 24(1), 1083. https://doi.org/10.1186/s12912-025-03723-4
Brady, N., O’Connell, S., Gilligan, D., Madden, C., Gannon, L., Howson, V., Ball, J. E., Murphy, A., Griffiths, P., Duffield, C., Scott, P. A., Carthy, V. J. C. M., & Drennan, J. (2025). Planned changes to nurse leadership, staffing and Skill‐Mix: impact on the working environment, job satisfaction and intention to leave. Journal of Advanced Nursing, 81(9), 5973–5983. https://doi.org/10.1111/jan.16752
Bvumbwe, T., & Mtshali, N. G. (2018). Transforming nursing education to strengthen health system in Malawi: an exploratory study. The Open Nursing Journal, 12(1), 93–105. https://doi.org/10.2174/1874434601812010093
Carayon, P., & Gürses, A. P. (2008). Nursing workload and patient safety—A human factors engineering perspective. Dalam R. G. Hughes (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK2657/
Dall’Ora, C., et al. (2022). Nurse staffing and patient safety outcomes: Recent evidence and implications. International Journal of Nursing Studies.
Dall’Ora, C., Saville, C., Rubbo, B., Turner, L., Jones, J., & Griffiths, P. (2022b). Nurse staffing levels and patient outcomes: A systematic review of longitudinal studies. International Journal of Nursing Studies, 134, 104311. https://doi.org/10.1016/j.ijnurstu.2022.104311
Dillner, P., Göransson, K. E., Norman, M., Unbeck, M., & Förberg, U. (2025). Nurse staffing skill mix and acuity-adjusted provision ratios in Swedish neonatal care: A cohort benchmark study. International Journal of Nursing Studies Advances, 10, 100471. https://doi.org/10.1016/j.ijnsa.2025.100471
Duffield, C., et al. (2010). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244–255. https://doi.org/10.1016/j.apnr.2009.12.004
Drennan, J., Murphy, A., McCarthy, V. J., Ball, J., Duffield, C., Crouch, R., Kelly, G., Loughnane, C., Murphy, A., Hegarty, J., Brady, N., Scott, A., & Griffiths, P. (2024). The association between nurse staffing and quality of care in emergency departments: A systematic review. International Journal of Nursing Studies, 153, 104706. https://doi.org/10.1016/j.ijnurstu.2024.104706
Fagerström, L., et al. (2000). Professional assessment of optimal nursing care intensity level (PAONCIL) as a part of the RAFAELA system.
Fagerström, L., & Vainikainen, P. (2014). Nursing intensity and workload measurement using the RAFAELA system.
Fagerström, L., et al. (2014). RAFAELA patient classification system as a tool for nurse staffing and workload measurement.
Fagerström, L., et al. (2018). Nursing workload, patient safety incidents, and mortality using the RAFAELA system.
Fagerström, L., Kinnunen, M., & Saarela, J. (2018). Nursing workload, patient safety incidents and mortality: an observational study from Finland. BMJ Open, 8(4), e016367. https://doi.org/10.1136/bmjopen-2017-016367
Griffiths, P., et al. (2018). Nurse staffing, nursing workload, and patient outcomes: A review of evidence. International Journal of Nursing Studies. https://doi.org/10.1016/j.ijnurstu.2018.04.016
Griffiths, P., et al. (2019). Nurse staffing levels and patient mortality in acute hospital settings. BMJ Quality & Safety. https://doi.org/10.1136/bmjqs-2018-008043
Griffiths, P., Saville, C., Ball, J., Jones, J., Pattison, N., & Monks, T. (2019). Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion. International Journal of Nursing Studies, 103, 103487. https://doi.org/10.1016/j.ijnurstu.2019.103487
Griffiths, P., et al. (2020). Patient acuity, skill mix, and nurse staffing approaches in modern healthcare systems.
Griffiths, P., Maruotti, A., Saucedo, A. R., Redfern, O. C., Ball, J. E., Briggs, J., Dall’Ora, C., Schmidt, P. E., & Smith, G. B. (2018). Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Quality & Safety, 28(8), 609–617. https://doi.org/10.1136/bmjqs-2018-008043
Haryati, T. S. (2018). Manajemen Keperawatan: Pendekatan Praktis. Jakarta: Penerbit Buku Kedokteran EGC.
Huber, D. (2018). Leadership and Nursing Care Management (6th ed.). Elsevier.
International Council of Nurses. (2021). The global nursing shortage and nurse retention. https://www.icn.ch
Kalisch, B. J., et al. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509–1517. https://doi.org/10.1111/j.1365-2648.2009.05027.x
Ladd, M., et al. (2020). SWOT analysis in healthcare strategic planning.
Lewin, K. (1951). Field Theory in Social Science: Selected Theoretical Papers. Harper & Row.
Lillehol, B. M., et al. (2018). Experiences of using the RAFAELA system in nurse staffing and workload management.
Marquis, B. L., & Huston, C. J. (2012). Leadership Roles and Management Functions in Nursing: Theory and Application. Lippincott Williams & Wilkins.
Marquis, B. L., & Huston, C. J. (2017). Leadership Roles and Management Functions in Nursing: Theory and Application (9th ed.). Wolters Kluwer.
Malatji, M., Ally, H., & Makhene, A. (2017). Nurses experiences regarding staffing patterns in the surgical wards of a private hospital in Gauteng South Africa. Health SA Gesondheid, 22, 325–332. https://doi.org/10.1016/j.hsag.2017.04.002
Musy, S. N., et al. (2021). Registered nurse staffing and inpatient mortality: A systematic review and meta-analysis. https://doi.org/10.1111/jonm.13316
Musy, S. N., Endrich, O., Leichtle, A. B., Griffiths, P., Nakas, C. T., & Simon, M. (2021). The association between nurse staffing and inpatient mortality: A shift-level retrospective longitudinal study. International Journal of Nursing Studies, 120, 103950. https://doi.org/10.1016/j.ijnurstu.2021.103950
Peraturan Menteri Kesehatan Republik Indonesia Nomor 40 Tahun 2017 tentang Pengembangan Jenjang Karir Profesional Perawat Klinis. https://peraturan.bpk.go.id
Rauhala, A., & Fagerström, L. (2004). Determining optimal nursing intensity: The RAFAELA method.
Robbins, S. P., & Judge, T. A. (2017). Organizational Behavior. Pearson.
Shin, S., Park, J. D., & Shin, J. H. (2020). Improvement plan of nurse staffing standards in Korea. Asian Nursing Research, 14(2), 57–65. https://doi.org/10.1016/j.anr.2020.03.004
Stanley, D. (2016). Clinical Leadership in Nursing and Healthcare: Values into Action. Wiley Blackwell.
Whiting, L. S. (2008). Semi-structured interviews: guidance for novice researchers. Nursing Standard, 22(23), 35–40. https://doi.org/10.7748/ns2008.02.22.23.35.c6420
Ware, A., Blumke, T., Hoover, P., & Arreola, D. (2024). Calculating Optimal patient to nursing Capacity: Comparative analysis of traditional and new methods. JMIR Nursing, 7, e59619. https://doi.org/10.2196/59619
West, E., Barron, D. N., Harrison, D., Rafferty, A. M., Rowan, K., & Sanderson, C. (2014). Nurse staffing, medical staffing and mortality in Intensive Care: An observational study. International Journal of Nursing Studies, 51(5), 781–794. https://doi.org/10.1016/j.ijnurstu.2014.02.007
World Health Organization. (2020). State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership. https://www.who.int/publications/i/item/9789240003279
Yeşilyurt, T., Baykal, Ü., & Göktepe, N. (2021). Nurse managers’ views on why nurses leave their jobs: A qualitative study. Collegian Journal of the Royal College of Nursing Australia, 28(6), 720–728. https://doi.org/10.1016/j.colegn.2021.08.002
Zainal, N. H., Rasudin, N. S., & Musa, K. I. (2026). Factors influencing clinical decision-making skills among nurses in Malaysia: A three-level general linear mixed-effects analysis. International Journal of Nursing Studies Advances, 10, 100493. https://doi.org/10.1016/j.ijnsa.2026.100493
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Indonesian Journal of Global Health Research
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
