The Math Error Hiding Inside the Nursing Shortage

Editor’s note: The Commission for Nurse Reimbursement recently completed the inaugural cohort of its Fellowship in Nursing Economics (FINE), a program designed to help nurses understand the financial, operational, and economic forces shaping healthcare. Each Fellow completed a capstone project exploring a challenge facing nursing today, and this series highlights the three projects selected by their peers as the strongest in the cohort. Second in the series: Robert Wingo, whose research documents a decades-old math error hiding inside the formula most commonly taught in nursing finance. Read the first, from Niki Pham, on which types of nurse-founded healthcare companies scale and why.

I have been a nurse since 1992. For most of that time I believed the shortage was a supply problem: not enough nurses, too many jobs. Then I found something underneath it. The problem is less about how many nurses exist than about how we count the ones we need.

A medical-surgical floor needs 100 FTEs to run. An FTE is one full-time schedule’s worth of hours. Eighty of those 100 deliver care at the bedside. The other 20 cover the hours those 80 are necessarily away from it, for orientation, education, and time off. The most common formula in nursing finance education starts at 80, adds 20 percent of 80, and budgets 96. The unit needed 20 support FTEs and was funded for 16.

Support is a share of the whole staff, not a percentage added to the bedside count. Those four FTEs are not an add-on to the care. They are part of delivering it. The unit opens its fiscal year four FTEs short, and no amount of scheduling afterward puts them back.

Nursing labor is the largest line in most hospital budgets, and the workforce size is set in that formula long before anyone builds a schedule. I recognized the error years before this fellowship. The corrected math has been in the literature since 1984, when the operating budget chapter of the primary graduate nursing finance textbook called the common method “not theoretically correct” and printed the right one. It was ignored, while the flawed version quietly understaffed units wherever it was used.

Want to see more Nurse.org articles in your Google results? Add us as a preferred source.

Once I found the error, convincing anyone it mattered proved to be the harder problem.

I first tried the direct route, bringing it to organizations and leaders positioned to act. The proof takes less than a minute to follow. The response was still a version of “We’ve always done it this way.”

So I changed strategy. My fellowship project became a grassroots advocacy effort in two parts: research, then public education. Rather than keep pressing institutions and leaders to act, I set out to document how widespread the error is and put it directly in front of the nurses who live with its consequences.

First came the research, which meant documenting how far the error had spread. Tracing the most common budgeting formula taught in nursing finance, I found the same structural error in more than 40 published sources across the United States, the United Kingdom, Australia, and Saudi Arabia, reaching back to a document from 1960.

The error appears in nursing finance textbooks, in peer-reviewed journal articles, in accredited continuing education that nurse leaders take for certification renewal, and in government workforce planning frameworks that set staffing for entire health systems. That range is the reason it is hard to see from inside a hospital. A nurse manager almost never meets this as a formula to evaluate. They meet it as the method, already built into the budget worksheet they were handed, taught by the course their employer paid for, with the authority of the people who trained them behind it.

Two features of hospital finance keep it out of view. Budget variance analysis measures actual spending against the budgeted FTE count, and never asks whether that count was derived correctly. And no verification step is built into the method.

One exists, and it takes a single line. Take the total FTEs a budget proposes and multiply by the share of staff meant to be at the bedside. The result should equal the bedside FTEs the unit needs. On the unit above, where bedside care is 80 percent of the staff, a correct budget of 100 passes the check: 80 percent of 100 is 80. The budget of 96 produced by the common method fails the check: 80 percent of 96 is 76.80, not 80. A budget that claims to fund 80 bedside positions actually supports 76.80 of them. The budget does not fund the care hours it claims to fund. There are several sound ways to size a nursing workforce, and they agree with one another. This one does not, and it produces a lower number every time. 

In the sources I documented, the allowance for time away from the bedside runs from about 6 percent in 1960 to roughly 24 percent in current frameworks. At 20 percent, a hospital that should budget 500 FTEs is short 20 of them before anyone schedules a shift. 

A shortfall this small, one unit and one budget cycle at a time, rarely sets off alarms. It is also why a mathematical error has lasted this long. Sociologists call the result the normalization of deviance, the slow drift by which a flawed routine becomes accepted because it has not yet caused visible harm. “We’ve always done it this way” is not a defense of the math. It is a description of how deviance becomes routine. I traced the full chain, decade by decade and source by source, in What the Challenger Disaster and Nurse Staffing Have in Common.

I developed a framework earlier in my career: Nurse Staffing Information Structures, or NSIS. It maps the staffing lifecycle in layers, from budget through care delivery to patient outcomes, and a counting mistake at the budget layer distorts every layer built on top of it. During the fellowship I added the layer it was missing: reimbursement, the question of how nursing care gets paid for, at the foundation beneath the budget. 

So I treat this as a reimbursement problem, not only a staffing problem. Reimbursement reform depends on measuring what nursing care actually costs. If the staffing baseline is structurally low, every negotiation built on it is negotiating for the wrong number. We cannot accurately price what we cannot accurately count.

The education took the form of a publishing campaign: ten articles and a steady run of posts and comments aimed at nurses and healthcare leaders. More than 100,000 people saw it. In April 2026, Becker’s Hospital Review gave the error its first national coverage. The coverage was new. The finding was not. William Ward, a health finance scholar at Johns Hopkins, had put it in print in 2016, writing that the common method “is clearly incorrect and will always result in a budget that lacks sufficient staff.” That work now feeds a formal correction effort aimed at the publishers and agencies that carry the error.

>>Listen to The Latest Nurse News Podcast

I spent years believing that the right argument, delivered to the right office, would be enough. It was not. The work gained traction only when I stopped asking permission and started building the evidence and the audience in public.

That has changed how I approach every problem since. I no longer start by asking who has the authority to fix something. I start by asking what can be documented, and who is living with the consequences without having been told why. Authority responds to a record and an audience far more reliably than it responds to being right.

For other nurses, the useful part is smaller than it sounds. You do not need a title or a committee seat to document something. Most of what I found was sitting in published sources that anyone can read. What was missing was somebody willing to count it and say so out loud. The verification check above is one line of arithmetic. If you can get your unit’s budgeted FTE count and the share of staff meant to be at the bedside, you can run it yourself this week.

Disclosure: Robert Wingo is co-founder of a pre-launch nurse workforce planning and management software company and has a commercial interest in the budgeting methods described here.

Sources With the Error and Corrections

Sources That Contain the Error

A representative selection, spanning textbooks, professional education, and government workforce frameworks in four countries.

Gunn, M. L. (1960). A method for developing a master staffing plan for the nursing service department. Catholic Hospital Association.

McKenna, E., Clement, K., Thompson, E., Haas, K., Weber, W., Wallace, M., Stauffer, C., Frailey, J., Anderson, A., Deascenti, M., Hershiser, L., & Roda, P. I. (2011, December). Using a nursing productivity committee to achieve cost savings and improve staffing levels and staff satisfaction. Critical Care Nurse, 31(6), 55-65.

National Quality Board. (2013, November). How to ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity and capability. NHS England.

American Organization for Nursing Leadership. (2019). Finance and business skills for nurse managers: Session 2, understanding FTEs & budgeting (Course presentation slides). American Organization for Nursing Leadership (AONL); Healthcare Financial Management Association (HFMA).

Aseeri, H. (2019). Method of estimating the staffing plan (Presentation slides). King Saud Medical City.

State of Queensland (Queensland Health). (2021, August 10). Business planning framework: The methodology for nursing and midwifery workload management (6th ed.). Queensland Health.

Thomas, P. L., & Harris, J. L. (2023). Procuring and sustaining resources: The budgeting process. In L. A. Roussel, J. L. Harris, & P. L. Thomas (Eds.), Management and leadership for nurse administrators (9th ed.). Jones & Bartlett Learning.

Department of Health, Western Australia. (2026, February 16). Nursing and midwifery workforce planning framework (Version 2.0). Office of the Chief Nursing and Midwifery Officer, Department of Health, Western Australia.

The Correction on Record

Other published sources use the correct method. These three are the ones that identify the common method as incorrect. The earliest is from 1984.

Graf, C. M. (1984). The operating budget. In S. A. Finkler (Ed.), Budgeting concepts for nurse managers (1st ed., pp. 62-103). W.B. Saunders. Footnote, p. 73.

Graf, C. M. (1992). The operating budget. In S. A. Finkler (Ed.), Budgeting concepts for nurse managers (2nd ed., Ch. 8). W.B. Saunders. P. 182.

Ward, W. J., Jr. (2016). Health care budgeting and financial management (2nd ed., pp. 129-130). Praeger.

🤔 Does your unit’s budgeted FTE count pass the one-line check? Tell us your experience with this calculation in the comments.

Nursing Industry Research