EP9 Nurses are involved in staffing and scheduling based on established guidelines, such as ANA’s Principles for Nursing Staffing, to ensure that RN assignments meet the needs of the patient population.
Provide two examples, with supporting evidence, from different practice settings when input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate for a change in patient acuity, patient population, resources, or redesign of care.
Example 1
NAME OF INITIATIVE
Staffing for High Acuity Critical Care (Therapeutic Hypothermia) Patients
BACKGROUND & PURPOSE
There is a body of evidence that demonstrates the link of nurse staffing to patient outcomes. Therefore, adequate and appropriate staffing is an ongoing priority in healthcare in order to provide safe and effective care. Appropriate nurse staffing is a match of registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation (ANA’s Principles of Nurse Staffing, 2012). In essence, adequate staffing is a complex issue as it takes into consideration several factors such as nurse education, training and competency; patient load, intensity and acuity; availability of support staff, situational demands and organizational culture. Homestead Hospital’s Intensive Care Unit (ICU) staff strives to provide safe, competent patient care while faced with a constantly changing demand and environment. Its staffing guidelines are based on the AACN’s Staffing and Workforce Development initiative and grounded by the ANA’s Principles for Nursing Staffing. (EP9 01 ICU/ PCU Staffing Guidelines & Unit Overview)
The new National Quality Measure put forth by Centers for Medicare & Medicaid Services (CMS) regarding patient throughput helps to ensure that patients are where they belong in a timely manner. It is also a Joint Commission standard to be able to provide the same level of care to patients regardless of their physical location, which for critical care patients is even more of a challenge. As a result of these regulatory requirements, clinical nurses have become more aware of the need to quickly accommodate patient admissions into their units.
Modifying RN Staffing Assignments for a Change in Patient Acuity
By nature, patients in the ICU require treatment modalities that are more labor intensive. One such therapy, therapeutic hypothermia (TH), also requires special training of the nurses to ensure competency. Therapeutic hypothermia involves bringing the core temperature of patients who have a return of spontaneous circulation post cardiac arrest to 33º Celsius for a 24-hour period then re-warming to normothermia. This therapy is used to protect fragile brain tissue susceptible to injury related to hypoxemia and decreased perfusion that occurs as a result of the cardiac arrest. Due to the amount of monitoring needed on these patients, a 1:1 nurse-patient ratio is maintained during the cooling and re-warming phases of these patients. Staffing for this unpredictable circumstance demands flexibility and teamwork.
Nurses’ Involvement in Staffing and Scheduling
These patients are typically initially identified as TH candidates in the Emergency Department (ED). Barring the need to transfer these patients to another facility, they are admitted to the ICU. Once identified as a TH candidate, the ED staff communicates with Nurse House Supervisor who in turn communicates this with the ICU Patient Care Supervisor (PCS). At this point, the ICU PCS facilitates the patient’s transfer from the ED and arranges for staffing. Ideally, an additional RN is utilized. A collaborative effort is made between the staffing office and ICU in calling additional nurses to come in. However, if a TH patient is admitted in the middle of a shift and no extra RN is available, adjustments are made to the current assignments by the PCS based on staff on hand and input from the clinical nurses in order to accommodate the 1:1 nurse-patient ratio while providing safe and competent care to the rest of the patients. (EP9 02 Email from Andrea Tilleman RN)
METHODS & APPROACH
Established Staffing Guidelines
Staffing guidelines are reviewed annually and more frequently, as needed, by Patient Care Manager Leslie Everett, RN. These are communicated to the staffing office and reviewed at staff meetings annually and more often, as needed, to obtain feedback from the staff. (EP9 03 November 2013 Staff Meeting Minutes) Additionally, she utilized published documents such as ANA’s Principles for Nurse Staffing in evaluating appropriate staffing needs for the department as described below:
Core Components of Nurse Staffing |
How Met |
Appropriate nurse staffing is critical to the delivery of quality, cost-effective health care. |
Appropriate nurse staffing remains a priority for the Nursing Services department. It is a fluid process with nurses across all levels participating in staffing decisions using objective information in making decisions and benchmarked data in evaluating quality and cost-effectiveness of care. |
All settings should have well-developed staffing guidelines with measurable nurse sensitive outcomes specific to that setting and healthcare consumer population that are used as evidence to guide daily staffing. |
ICU/PCU has established staffing guidelines and Care Delivery System for that serve as guides in making staffing decisions. |
Registered nurses are full partners working with other healthcare professionals in collaborative, interdisciplinary partnerships. |
This is accomplished by daily interdisciplinary rounding; rounding with physicians; face-to-face communication with the interprofessional team; and electronic communication through the interprofessional plan-of-care (IPOC). |
Registered nurses, including direct care nurses, must have a substantive and active role in staffing decisions to assure the necessary time with patients to meet care needs and overall nursing responsibilities. |
Clinical nurses’ participate in staffing decisions through variety of methods: staff meetings, Unit Practice Council (UPC) meetings, nurse leader rounding with staff, self scheduling, NDNQI RN satisfaction survey and action planning, employee engagement survey and action planning, daily assignments, shift huddles. |
Staffing needs must be determined based on an analysis of healthcare consumer status (e.g., degree of stability, intensity, and acuity), and the environment in which the care is provided. Other considerations to be included are: professional characteristics, skill set, and mix of the staff, and previous staffing patterns that have been shown to improve outcomes. |
PCS performs shift review of acuity based on nurse input; information from the recently implemented Cerner-Clairvia acuity system; and interdisciplinary rounds with intensivist/e-ICU. Nurse leaders review performance improvement, e-ICU and risk data monthly. Clinical nurse educators conduct learning needs assessment to obtain nurses’ input on topics for annual competencies and continuing education. |
Appropriate nurse staffing should be based on allocating the appropriate number of competent practitioners to a care situation; pursuing quality of care indices; meeting consumer-centered and organizational outcomes; meeting federal and state laws and regulations; and attending to a safe, quality work environment. |
PCS in collaboration with clinical nurses and house supervisors review staffing needs every shift prior to assignments. They make assignments based on acuity, skill mix and nurse competency. The Cerner-Clairvia acuity system serves as an additional tool in developing the shift assignment and trending staffing patterns and needs. |
Cost effectiveness is an important consideration in delivery of safe, quality care. |
Patient Care Managers review financial data monthly (Departmental Responsibility Report) and use it together with benchmarking data (Action OI) to establish and adjust budgetary needs. |
Reimbursement structure should not influence nurse staffing patterns or the level of care provided. |
Staffing patterns and guidelines are established based on patient care needs combined with nurse skill and competency; reimbursement structure is not a consideration. |
Input from Clinical Nurses
Training a nurse to take care of a patient receiving TH requires many hours and commitment. In 2008, when the therapeutic hypothermia program started at Homestead Hospital, only 24% of ICU nurses were trained. As awareness grew on the potential benefits of this therapy, ICU staff has seen an increased use of TH and thus an increased demand for trained nurses. Since only a few nurses were initially trained, this core group became overworked and overstressed due to the lack of flexibility in staffing for this therapy. Thus, the ICU clinical nurses identified a need for improvement with regards to staffing for TH. Clinical Nurse Andrea Tilleman, RN, one of the nurses who attended the first round of training, spoke with Everett about the overuse of the few nurses trained in TH. She suggested that additional nurses be trained. Coincidentally, Clinical Nurse Specialist Rosemary Lee, ARNP sent out surveys to the clinical nurses with regards to annual unit-based competencies in August 2012. Through the surveys, TH was indeed identified as a topic of interest among the staff. Acting on Tilleman’s suggestion, Everett met with her nursing leadership team and discussed TH training (EP9 04 September ICU/ PCU Nursing Leadership Minutes 9/26/12). Lee then contacted Clinical Educator Karen Baez, RN about arranging for more TH classes. Baez offered the classes in September and October of 2012 and again in August 2013. She invited nurses from ICU and ED to attend. Clinical Nurse Joyce Nealey, RN, also felt the impact of being one of the few nurses trained in TH. Seeing the need for more trained staff, Nealey volunteered to act as the unit expert and attended a”train the trainer” course together with Clinical Nurse Claudelle Stafford, RN. Nealey and Stafford were added to the staffing office list as staff to be called, when needed, to take care of TH patients. This helped in initially alleviating the TH staffing issues.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Joyce Nealey, RN |
Clinical Nurse |
ICU |
Unit Expert on TH |
Andrea Tilleman, RN |
Clinical Nurse |
ICU |
TH trained RN who provided the input |
Claudelle Stafford, RN |
Clinical Nurse |
ICU |
Unit Expert on TH |
Rosemary Lee DNP, ARNP, CCNS, CCRN, ACNP-BC |
Clinical Nurse Specialist |
ICU |
Facilitated TH training |
Karen Baez, BSN, RN, CEN |
Clinical Nurse Educator |
Clinical Learning |
Conducted TH training |
Leslie Everett BSN, RN, CCRN |
Patient Care Manager |
ICU |
Provided training support and resources |
OUTCOMES
As a result of the collaboration between ICU leadership and staff, ICU had seen an increase in the number of nurses trained to take care of TH patients. In 2014, the number of trained ICU nurses has increased from 24% to 86% (34 nurses). (EP9 05 TH Course Completion Report) This increase has allowed for more flexibility in staffing; decreased stress among those initially trained; and more competent nurses to assist in caring for these patients.
Summary of Attachments/Hyperlinks/Evidences:
EP9 01 ICU/ PCU Staffing Guidelines & Unit Overview
EP9 02 Email from Andrea Tilleman RN
EP9 03 November 2013 Staff Meeting Minutes
EP9 04 September ICU/ PCU Nursing Leadership Minutes 9/26/12
EP9 05 TH Course Completion Report
Example 2
NAME OF INITIATIVE
Advocating for Full-time Equivalent (FTE) in MedSurg 3 (MS3)
BACKGROUND & PURPOSE
MS3 is a 13-room medical/surgical/telemetry inpatient throughput/transitional unit for adult patients (ages 18 and above). The unit consists of 13 private rooms. It was initially established to improve the emergency department (ED) throughput by having an area for patients to be cared for during periods of increased census that exceeded inpatient bed capacity. More than 90% of inpatient admissions present through the ED. Activation of the surge capacity plan triggers the opening of MS3. During periods of high patient volume in which the National Emergency Department Overcrowding Study (NEDOCS) score is >61, the surge capacity plan is activated and staffing adjustments are made to open MS3 as an overflow unit to decompress the crowding in ED. NEDOCS is a tool used to quantitatively describe /measure hospital crowding. To open MS3, the Staffing office would place calls to other nurses and request them to come in. Nevertheless, 2 nurses, 1 unit clerk and 1 clinical partner (CP) were typically pulled from the other medical/surgical/telemetry units and assignments were adjusted to staff the additional 13 beds on MS3 as there were no dedicated FTEs for that unit. The frequency of this happening increased as ED volumes continued to climb. From February 2012 to February 2013, MS3 was opened for a total of 77 days.
Nurses’ Involvement in Staffing and Scheduling
Nurses are actively involved in the determination of their work schedule through electronic self-scheduling (Web Scheduler) software. This program is a component of Ansos One Staff, a scheduling system that enables them to enter their preferred work schedule and days off. The system is accessible to them 24/7 at work (intranet access) or from the privacy of their home (internet access). After the nurse completes his/her schedule, the department leader reviews it for approval. The leader approves schedule requests based on anticipated staffing needs.
Established Staffing Guidelines
The staffing of the medical/surgical/telemetry departments is based on the department staffing guidelines. (EP9 06 Medical/Surgical/Telemetry Staffing Guidelines) The staffing guidelines are established through the collaboration of the nursing staff and leaders. The guidelines are reviewed annually and any changes in the staffing guidelines, if needed, are brought to the attention of the staff to obtain their input. In addition, patient care managers use foundational documents such as ANA’s Principles for Nurse Staffing in evaluating appropriate staffing needs for the department as described below:
Core Components of Nurse Staffing |
How Met |
Appropriate nurse staffing is critical to the delivery of quality, cost-effective health care. |
Appropriate nurse staffing remains a priority for the Nursing Services department. It is a fluid process with nurses across all levels participating in staffing decisions using objective information in making decisions and benchmarked data in evaluating quality and cost-effectiveness of care. |
All settings should have well-developed staffing guidelines with measurable nurse sensitive outcomes specific to that setting and healthcare consumer population that are used as evidence to guide daily staffing. |
There are established staffing guidelines and Care Delivery System for 3 South, MS4, MS5 that serve as guide in making staffing decisions. |
Registered nurses are full partners working with other healthcare professionals in collaborative, interdisciplinary partnerships. |
This is accomplished by nurses rounding with physicians; face-to-face communication with the interprofessional team; and electronic communication through the interprofessional plan-of-care (IPOC). |
Registered nurses, including direct care nurses, must have a substantive and active role in staffing decisions to assure the necessary time with patients to meet care needs and overall nursing responsibilities. |
Clinical nurses’ participate in staffing decisions through variety of methods: staff meetings (EP9 07 MS3 Staff Meeting Minutes 6/26/14), Unit Practice Council (UPC) meetings, nurse leader rounding with staff, self scheduling, NDNQI RN satisfaction survey and action planning, employee engagement survey and action planning, daily assignments, shift huddles. |
Staffing needs must be determined based on an analysis of healthcare consumer status (e.g., degree of stability, intensity, and acuity), and the environment in which the care is provided. Other considerations to be included are: professional characteristics, skill set, and mix of the staff, and previous staffing patterns that have been shown to improve outcomes. |
PCS performs shift review of acuity based on nurse input and information from the recently implemented Cerner-Clairvia acuity system. Nurse leaders review performance improvement and risk data monthly. Clinical nurse educators conduct learning needs assessment to obtain nurses’ input on topics for annual competencies and continuing education. |
Appropriate nurse staffing should be based on allocating the appropriate number of competent practitioners to a care situation; pursuing quality of care indices; meeting consumer-centered and organizational outcomes; meeting federal and state laws and regulations; and attending to a safe, quality work environment. |
PCS in collaboration with clinical nurses and house supervisors review staffing needs every shift prior to assignments. They make assignments based on acuity, skill mix and nurse competency. The Cerner-Clairvia acuity system serves as an additional tool in developing the shift assignment and trending staffing patterns and needs. |
Cost effectiveness is an important consideration in delivery of safe, quality care. |
Patient Care Managers review financial data monthly (Departmental Responsibility Report) and use it together with benchmarking data (Action OI) to establish and adjust budgetary needs. |
Reimbursement structure should not influence nurse staffing patterns or the level of care provided. |
Staffing patterns and guidelines are established based on patient care needs combined with nurse skill and competency; reimbursement structure is not a consideration. |
Input from Clinical Nurses
The opening of MS3 as a reaction to census was an inefficient way to staff and resulted in dissatisfaction among the medical/surgical/telemetry nurses. Clinical Nurses Glenice Stanton, RN and Susie Collins, RN articulated this concern to Patient Care Supervisor Maria Carillo, RN while Carillo was rounding. Stanton suggested being more proactive with opening MS3 by having a more permanent staffing plan. This would minimize pulling of nurses from the medical/surgical/telemetry floors. (EP9 08 Rounding Log). Carillo brought Stanton and Collins’ input to the January 2013 Special Nursing Leadership Council meeting led by Chief Nursing Officer and VP Gail Gordon, RN. Nursing leaders, including directors, patient care managers, and patient care supervisors (PCS) attended the meeting. Based on the result of the recent employee engagement survey, Gordon specifically asked her nurse leaders to harvest nurses input on the following areas prior to the meeting.
- What was working well?
- How do you want to be rewarded and recognized?
- What “do my opinion counts” mean to you?
- Provide examples of “co-worker not committed to quality work”.
- What are our areas of opportunities (systems or processes that need improvement)?
She then facilitated table top and group exercises to determine recurring themes. The challenge with staffing MS3 emerged as one of the dominant topics that clinical nurses were concerned of.
METHODS & APPROACH
Modifying RN Staffing Assignments for Increased Patient Volume
Based on Stanton and Collin’s input and the need to facilitate ED patient throughput, Gordon called a meeting with Chief Executive Office Bill Duquette, Chief Financial Officer Erik Long, Magnet Project Director Julie David, ARNP, Critical Care Services Assistant Vice President Ana Cabrera ARNP, Assistant Vice President of Nursing Ann Marie Allen, RN, Medical-Surgical Nursing Administration-Clerical Manager Raul Botana, and Medical-Surgical/Telemetry Patient Care Managers, Linda Simpson, RN, Maureen Allen, RN and Hector Aleman, RN. During this meeting Gordon presented data and justification to support her request of having dedicated staff to for MS3 that would enable it to open 3 days a week. Duquette and Long approved Gordon’s proposal during this meeting and an action plan was formulated. The group wanted to implement visible change quickly and decided to initially fill MS3’s staffing through the Centralized Staffing Center (CSC), an internal BHSF staffing pool used to supplement nurse staffing needs, while Botana worked out the FTE approval process with the finance department. (EP9 09 Medical-Surgical RN Satisfaction Meeting E-mail 3/27/13) Thereafter, Botana met with Finance Manager Liliana Fong and obtained approval for new FTEs allotted to MS3. Botana hired 2 nurses, 1 care partner (CP) and unit clerk in September 2013. MS3 started operating 3 days a week as an overflow unit in October 2013. ED patient throughput continued to be a challenge. Early in January 2014 during the Department Strategic Planning meeting, Botana together with Patient Care/House Supervisor Laurie Cogar, RN presented the concept of expanding MS3 into an admission/discharge/overflow unit to alleviate ED congestion. This meeting was participated in by various leaders such as the CNO, CEO, ED Medical Director, ED Nurse Director, and Nursing Administration/Staffing Director. The leaders endorsed Botana’s proposal. He obtained additional approval for 20.1 FTEs which equated to 15 nurses and 8 CPs as a pilot program to open MS3 24/7. Botana moved fast and by the end of January 2014, he was able to staff MS3 during the day shifts. In May 2014, he filled all open FTEs and staffed both day and night shifts. Since these additional FTEs were approved in the second quarter of the fiscal year and were not budgeted, the increased man hours were reflected as a negative variance in his monthly Departmental Responsibility Report (DRR). (EP9 10 FY14 MS3 Staffing Budget and DRR)
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Glenice Stanton, RN |
Clinical Nurse |
MS5 |
Provided input and suggestion for MS3 staffing |
Susie Collins, RN |
Clinical Nurse |
MS5 |
Provided input on MS3 staffing |
Maria Carrillo, BSN, RN, CMSRN |
Patient Care Supervisor |
MS5 |
Brought clinical nurses input on MS3 staffing to the attention of other nursing leaders |
Raul Botana, MSN, RN |
Patient Care Manager |
Nursing Administration-Clerical |
Manager for MS3 and obtained approval for dedicated FTEs |
Liliana Fong |
Assistant Controller |
Finance |
Adjusted FTE budget to allowed dedicated staff for MS3 |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Nursing Administration |
Advocated for dedicated MS3 FTEs and executive sponsor |
Julie David, MSN, ARNP, ANP-BC |
Director |
Magnet Designation |
Facilitated initial MS3 staffing meeting |
OUTCOMES
MS3 is now able to support ED patient throughput without having to pull nurses from the other Medical/Surgical/Telemetry unit staffing. This allowed each unit to staff based on their established staffing guidelines. The changes made based on clinical nurses input were received favorably by the nurses as evidenced by 2014 NDNQI RN Practice Environment Score (PES) score of 3.15 (NDNQI benchmark = 2.84 for 100-199 bed size) exceeding national benchmark on the “Staffing and Resource Adequacy” domain.
Summary of Attachments/Hyperlinks/Evidences
EP9 06 Medical/Surgical/Telemetry Staffing Guidelines
EP9 07 MS3 Staff Meeting Minutes 6/26/14
EP9 08 Rounding Log
EP9 09 Medical-Surgical RN Satisfaction Meeting E-mail 3/27/13
EP9 10 FY14 MS3 Staffing Budget and DRR