- Email: [email protected]
Leveraging Staff Nurse Engagement to Design Effective Patient Care Assignments
Leveraging Staff Nurse Engagement to Design Effective Patient Care Assignments Sally Szumlas, RN, MS, CPHQ, NEA-BC
N
o nurse ever wants to come to work and
nurse-patient assignments in a workable staffing plan.
face an impossible assignment. Providing
This article synthesizes recent literature and presents
an evidence-driven infrastructure is critical to address-
strategies for nurse leaders to consider when tailoring
ing the continuous challenge of managing effective
a framework for staffing excellence.
T
he relationship between nurse staffing and patient safety/quality of care has been well-documented. As Clarke1 noted, in nearly every study, researchers have found distinct differences between outcomes in facilities with the highest versus the lowest levels of registered nurses (RNs), where
46
Nurse Leader
better-staffed hospitals had significantly lower rates of adverse events. However, the conversation for nurse leaders should no longer be focused on the numbers of nurses and patients, but rather, emphasize the effectiveness of nursing care and hours spent providing care. Irrespective of budget compliance,
April 2013
Table 1. Key Strategies for Staffing Excellence
Strategies for Staffing Excellence
Action Steps for Managers
Improve staff engagement and teamwork
Use shared governance forums with front line nurses to: • Create a culture of partnership and accountability through consistency, dialogue, and idea and data sharing • Develop and vet staffing plans, openly using nursing hours per patient day, patient outcomes data, and industry benchmarks • Adopt staffing, value-added nursing, and outcomes indicators to nurse-sensitive quality plans • Share frequent, visible data updates on staffing and patient outcomes with teams • Recognize and celebrate individual and team successes!
Create role clarity around critical nursing functions
•
•
•
Establish infrastructure to support nursing assignment guidelines
•
•
Evaluate unit workload: • Understand the factors affecting nursing work time • Define critical-to-quality nursing functions relevant to your patients and aligned with best practice • Identify non value added (NVA) work consuming staff time • Measure the frequency/cost of NVA activitie Establish action plans to minimize or eradicate basic system issues and NVA time • Empower staff to escalate and/or delegate issues in real time to accountable interdisciplinary support teams Vet and adopt critical to quality (CTQ) nursing functions as part of standard nursing role on your unit Standardize CTQ staff nurse functions in unit charge nurse report and integrate to regular staff and team dialogues (i.e., prioritize daily goal of care, care plan elements, critical shift responsibilities for nurses and staff, etc.) Prioritize time allotment for performing CTQs in nursing care assignment and handoff communication tools
staffing excellence cannot be achieved unless the care delivered in the hospital setting is aligned with clinical evidence to improve patient and family outcomes. Additionally, leadership support is key to guide staffing decisions and assignment equity. Kerfoot2 observes that nurse leaders who create engagement do so by matching staff member strengths with needed work. This further supports the strategy for nurse managers to implement staffing processes that align staff skills and competencies with prioritized patient needs. Moreover, nurse leaders can impact both nursing workload and patient outcomes by distinguishing those interventions that nurses are critically prepared and accountable to perform, and redirecting or eliminating those that do not add value to unit operations or care outcomes, and should not interfere with the delivery of high-quality nursing care. In his 2011 interview in Nursing Economics, Peter Buerhaus, RN, PhD, FAAN emphasized that the most important agenda for nursing leadership is to focus the profession on innovations and elevation of practice in support of staff nurses to achieve effective outcomes of care.3 www.nurseleader.com
Rather than applying arbitrary ratios to nurse staffing, Buerhaus advocates strongly for finding better ways to allow nurses to excel in practice and bring forward the human aspects and art of nursing.3 Furthermore, true engagement of the staff nurse with work unit processes is vital to achieving effective patient care assignments and high-quality handoff dialogue, both of which are essential to continuity, quality, and safety. Staff nurse engagement is dependent on role clarity, teamwork, and the accepted model of care delivery. Role clarity refers specifically to defining those nursing functions that are critical to quality (CTQ), and supporting effective delegation or escalation of non-nursing tasks/problems. Published studies do not generally prescribe “correct” nurse staffing for particular situations, specific patient types, or ranges of acuity,1 nor does more necessarily equal better nurse staffing. However, note that implicit in the outcomes data is the assumption that comprehensive nursing care has been delivered according to prevailing practice standards. Thus, the need for careful consideration in staffing and assignment decisions is reinforced; most
Nurse Leader
47
importantly to ensure sufficient time and accountability to provide the unmeasured, yet vital, aspects of professional nursing care such as monitoring, assessing, critical thinking, interdisciplinary collaboration/continuum planning, and managing patient education. A key function of nursing leadership is the evaluation of staffing data and feedback about workload distribution from nurses and patients.1 Effective nurse leaders know that nursing judgment remains at the core of staffing decisions to ensure that skill mix, experience, patient complexity, and continuity of care needs are balanced and supported on a shift-to-shift basis.4 Yet, several recent studies consistently document omissions from essential nursing care in the acute setting.5–7 B.J. Kalish5 showed nine themes of patient care that were regularly overlooked by nurses, most frequently ambulation, turning, feedings, patient/family education, discharge planning, emotional support, hygiene, measuring/documenting intake and output, and surveillance. Study participants cited short staffing, high acuity/intensity related to patient turnover (ADT), inadequate orientation, assignment inequity, lack of supplies/equipment, and poor handoffs and teamwork as the primary reasons for missed care. Hendrich et al.6 measured sources of nursing inefficiency in the medical-surgical setting, and revealed that the majority of nursing practice time was accounted for by documentation (35%) medication administration (17%), and care coordination (21%), with only 19% of nursing hours, on average, being consumed by actual patient care. In a three-hospital study in 2009, Storfjell et al.7 found that the primary driver of nursing non-value added (NVA) time was rework and delay from poorly functioning hospital systems and work processes. NVA activities accounted for an average of 28% of all RN wages, or between $660,000 and $757,000 per unit annually. This study found similar process areas to be the most frequent drivers of NVA time (assignment/staffing; shift report; access to supplies, equipment, or medications; work fluctuations with admission-dischargetransfer process; transport delays; documentation system problems; and poor communication patterns), and underscored the cost of actual wasted nursing hours that could otherwise have been allocated to optimizing care. Several important themes for nurse leaders arise from these studies, as outlined in Table 1: 1) engage frontline staff to evaluate components of nursing workload, 2) identify and eradicate basic system issues plaguing your staff with NVA work, and 3) clarify the nursing role and patient assignment guidelines on your unit by clearly incorporating value-added, population-specific nursing functions to workload and assignment tools/worksheets. This infrastructure will better align actual nursing practice with desired, value added nursing standards to improve continuity, peer-to-peer accountability, and interdisciplinary teamwork. What tools can support the nurse leader to efficiently implement and reinforce such changes? Crist-Grundman and Mulrooney8 discuss the importance of creating a culture of teamwork, collaboration, and accountability to achieve staffing excellence. What’s more, by integrating basic princi-
48
Nurse Leader
ples for staffing excellence, nurse leaders can assemble an evidence-based assignment model that elevates attention to patient priorities for nursing interventions, and supports staff members to sustain these practices over time. Consider a paradigm shift: O’Rourke and White9 describe six “rights” as critical components of staffing excellence, including a match of the “right” person and “right” resources with the “right” patient, at the “right” time for the “right” reason in the “right” place. To delineate this, the authors suggest integrating two questions to a needs assessment of each patient prior to assignment-making, “What is known about the patient, their care plan, and needs?” And, ”How do the professional role competencies and skill of the incoming caregivers match up to these needs?”9 This information is key to delivering patient-centered care and can be gleaned from a standardized charge nurse report or wellstructured patient classification system. Along with the overall projection of nursing hours, this information can be used to create a meaningful balance in nurse–patient assignments, even in complex settings. The paradigm enhances role clarity by helping nurses look beyond hourly tasks to visualize those professional nursing functions essential to each patient’s care, and strengthens accountability for thoughtful care planning, teamwork, and interdisciplinary communication to improve the effectiveness of overall nursing care. In the 2012 Research to Action Project: Applied Workplace Solutions for Nurses,10 Fram and Morgan cited that staff nurses want to provide more input to assessing patient acuity, changes in patient needs, and staffing requirements. The authors provide specific definitions of nursing functions that should be considered in assignment-making, including: • Inputs: • Patient characteristics, associated acuity classifications, time requirements • Nursing competencies, special skills/interests/abilities • Throughputs: • Defined nursing care processes (nursing “deliverables” or CTQ outcomes relevant to the shift, including tasks and human support interventions) • Outputs: • Performance metrics that display impact on nursing workload (hours per patient day), budget, operational process measures (i.e., hospital system performance including equipment/medication turnaround times, ADT throughput measures) and nurse-sensitive quality of care indicators (process and outcome, including care plan/handoff compliance measures, adverse events, and patient care outcome measures) Ultimately, by incorporating better planning for nursing inputs and throughputs to shift assignment guidelines, nursing arts can be better integrated to the essential tasks of front line caregivers, which facilitates more accurate measurement of the true impact of professional nursing care. Additional teamwork strategies for nurse managers may include options such as standardizing shift times (i.e., all 8- or 12-hour periods) or clustering nursing teams into smaller groups to enhance communication and work-pattern consis-
April 2013
tency (i.e., by day of week, shift, geographic area). Ensuring clarity of common goals across teams is critical, as well as regularly infusing recognition to celebrate individual and team success to unit activities.2,8,11 The literature validates the time-consuming and high-cost impact that navigating hospital systems has on typical nursing workflow. Rather than absorbing NVA nursing time in the nurse staffing budget and assignment roster, studies suggest that nurse leaders can heighten professional practice and reduce task-oriented waste by clearly defining nursing interventions and redirecting accountability for system problems. Including clearly defined nursing interventions, staff competencies, and shift-to-shift accountability as part of assignment design can serve to deliver consistently more efficient and high-quality nursing care. This model also serves important content for future systems research to test the clarified professional role of nursing against operational process and clinical outcome measures. NL References 1. Clarke S. Balancing staffing and safety. Nurs Manage. 2003;34(6):44-48. 2. Kerfoot K. Staff engagement: it starts with the leader. Nurs Econ. 2007; 25:47-48. 3. Douglas K, Kerfoot K. A provocative conversation with Peter I. Buerhaus, PhD, RN, FAAN. Nurs Econ. 2011;29:169-182. 4. Hanson D. IONL position statement: role of nurse leader. Illinois Organization of Nurse Leaders. 2012. http://www.ionl.org/?page⫽PositionStatements. 5. Kalish BJ. Missed nursing care: a qualitative study. J Nurs Care Qual. 2006; 21:303-313. 6. Hendrich A, Chow M, Skierczynski B, Lu Z. A 36-hospital time and motion study: how do medical surgical nurses spend their time? Permanente J. 2008;12(3):25-34. 7. Storfjell J, Ohlson S, Fitzpatrick T, Wetasim K. Non-value add time: the million-dollar nursing opportunity. J Nurs Admin. 2009;39:38-45. 8. Crist-Grundman D, Mulrooney G. Effective workforce management starts with leveraging technology, while staffing optimization requires true collaboration. Nurs Economics. 2011;29(4):195-200. 9. O’Rourke M, White A. Professional role clarity and competency in health care staffing—the missing pieces. Nurs Econ. 2011; 9:183-188. 10. Fram N, Morgan B. Ontario: Linking nursing outcomes, workload and staffing decisions in the workplace: the Dashboard Project. In: Canadian Journal of Nursing Leadership. Applied Workplace Solutions for Nursing: Research to Action Project. Toronto, ON, Canada: Longwoods; 2012:114-125. 11. Kalish BJ, Begeny SM. Improving unit teamwork. J Nurs Adm. 2005;35(12):550-56.
Sally Szumlas, RN, MS, CPHQ, NEA-BC, is director of quality at Family Health Network in Chicago, Illinois, and can be reached at [email protected]. Acknowledgment The author gratefully acknowledges Kathy Malloch, PhD, MBA, RN, FAAN, for her guidance and wisdom in the development of this article. 1541-4612/2013/ $ See front matter Copyright 2013 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2012.12.001
www.nurseleader.com
Nurse Leader
49
N
o nurse ever wants to come to work and
nurse-patient assignments in a workable staffing plan.
face an impossible assignment. Providing
This article synthesizes recent literature and presents
an evidence-driven infrastructure is critical to address-
strategies for nurse leaders to consider when tailoring
ing the continuous challenge of managing effective
a framework for staffing excellence.
T
he relationship between nurse staffing and patient safety/quality of care has been well-documented. As Clarke1 noted, in nearly every study, researchers have found distinct differences between outcomes in facilities with the highest versus the lowest levels of registered nurses (RNs), where
46
Nurse Leader
better-staffed hospitals had significantly lower rates of adverse events. However, the conversation for nurse leaders should no longer be focused on the numbers of nurses and patients, but rather, emphasize the effectiveness of nursing care and hours spent providing care. Irrespective of budget compliance,
April 2013
Table 1. Key Strategies for Staffing Excellence
Strategies for Staffing Excellence
Action Steps for Managers
Improve staff engagement and teamwork
Use shared governance forums with front line nurses to: • Create a culture of partnership and accountability through consistency, dialogue, and idea and data sharing • Develop and vet staffing plans, openly using nursing hours per patient day, patient outcomes data, and industry benchmarks • Adopt staffing, value-added nursing, and outcomes indicators to nurse-sensitive quality plans • Share frequent, visible data updates on staffing and patient outcomes with teams • Recognize and celebrate individual and team successes!
Create role clarity around critical nursing functions
•
•
•
Establish infrastructure to support nursing assignment guidelines
•
•
Evaluate unit workload: • Understand the factors affecting nursing work time • Define critical-to-quality nursing functions relevant to your patients and aligned with best practice • Identify non value added (NVA) work consuming staff time • Measure the frequency/cost of NVA activitie Establish action plans to minimize or eradicate basic system issues and NVA time • Empower staff to escalate and/or delegate issues in real time to accountable interdisciplinary support teams Vet and adopt critical to quality (CTQ) nursing functions as part of standard nursing role on your unit Standardize CTQ staff nurse functions in unit charge nurse report and integrate to regular staff and team dialogues (i.e., prioritize daily goal of care, care plan elements, critical shift responsibilities for nurses and staff, etc.) Prioritize time allotment for performing CTQs in nursing care assignment and handoff communication tools
staffing excellence cannot be achieved unless the care delivered in the hospital setting is aligned with clinical evidence to improve patient and family outcomes. Additionally, leadership support is key to guide staffing decisions and assignment equity. Kerfoot2 observes that nurse leaders who create engagement do so by matching staff member strengths with needed work. This further supports the strategy for nurse managers to implement staffing processes that align staff skills and competencies with prioritized patient needs. Moreover, nurse leaders can impact both nursing workload and patient outcomes by distinguishing those interventions that nurses are critically prepared and accountable to perform, and redirecting or eliminating those that do not add value to unit operations or care outcomes, and should not interfere with the delivery of high-quality nursing care. In his 2011 interview in Nursing Economics, Peter Buerhaus, RN, PhD, FAAN emphasized that the most important agenda for nursing leadership is to focus the profession on innovations and elevation of practice in support of staff nurses to achieve effective outcomes of care.3 www.nurseleader.com
Rather than applying arbitrary ratios to nurse staffing, Buerhaus advocates strongly for finding better ways to allow nurses to excel in practice and bring forward the human aspects and art of nursing.3 Furthermore, true engagement of the staff nurse with work unit processes is vital to achieving effective patient care assignments and high-quality handoff dialogue, both of which are essential to continuity, quality, and safety. Staff nurse engagement is dependent on role clarity, teamwork, and the accepted model of care delivery. Role clarity refers specifically to defining those nursing functions that are critical to quality (CTQ), and supporting effective delegation or escalation of non-nursing tasks/problems. Published studies do not generally prescribe “correct” nurse staffing for particular situations, specific patient types, or ranges of acuity,1 nor does more necessarily equal better nurse staffing. However, note that implicit in the outcomes data is the assumption that comprehensive nursing care has been delivered according to prevailing practice standards. Thus, the need for careful consideration in staffing and assignment decisions is reinforced; most
Nurse Leader
47
importantly to ensure sufficient time and accountability to provide the unmeasured, yet vital, aspects of professional nursing care such as monitoring, assessing, critical thinking, interdisciplinary collaboration/continuum planning, and managing patient education. A key function of nursing leadership is the evaluation of staffing data and feedback about workload distribution from nurses and patients.1 Effective nurse leaders know that nursing judgment remains at the core of staffing decisions to ensure that skill mix, experience, patient complexity, and continuity of care needs are balanced and supported on a shift-to-shift basis.4 Yet, several recent studies consistently document omissions from essential nursing care in the acute setting.5–7 B.J. Kalish5 showed nine themes of patient care that were regularly overlooked by nurses, most frequently ambulation, turning, feedings, patient/family education, discharge planning, emotional support, hygiene, measuring/documenting intake and output, and surveillance. Study participants cited short staffing, high acuity/intensity related to patient turnover (ADT), inadequate orientation, assignment inequity, lack of supplies/equipment, and poor handoffs and teamwork as the primary reasons for missed care. Hendrich et al.6 measured sources of nursing inefficiency in the medical-surgical setting, and revealed that the majority of nursing practice time was accounted for by documentation (35%) medication administration (17%), and care coordination (21%), with only 19% of nursing hours, on average, being consumed by actual patient care. In a three-hospital study in 2009, Storfjell et al.7 found that the primary driver of nursing non-value added (NVA) time was rework and delay from poorly functioning hospital systems and work processes. NVA activities accounted for an average of 28% of all RN wages, or between $660,000 and $757,000 per unit annually. This study found similar process areas to be the most frequent drivers of NVA time (assignment/staffing; shift report; access to supplies, equipment, or medications; work fluctuations with admission-dischargetransfer process; transport delays; documentation system problems; and poor communication patterns), and underscored the cost of actual wasted nursing hours that could otherwise have been allocated to optimizing care. Several important themes for nurse leaders arise from these studies, as outlined in Table 1: 1) engage frontline staff to evaluate components of nursing workload, 2) identify and eradicate basic system issues plaguing your staff with NVA work, and 3) clarify the nursing role and patient assignment guidelines on your unit by clearly incorporating value-added, population-specific nursing functions to workload and assignment tools/worksheets. This infrastructure will better align actual nursing practice with desired, value added nursing standards to improve continuity, peer-to-peer accountability, and interdisciplinary teamwork. What tools can support the nurse leader to efficiently implement and reinforce such changes? Crist-Grundman and Mulrooney8 discuss the importance of creating a culture of teamwork, collaboration, and accountability to achieve staffing excellence. What’s more, by integrating basic princi-
48
Nurse Leader
ples for staffing excellence, nurse leaders can assemble an evidence-based assignment model that elevates attention to patient priorities for nursing interventions, and supports staff members to sustain these practices over time. Consider a paradigm shift: O’Rourke and White9 describe six “rights” as critical components of staffing excellence, including a match of the “right” person and “right” resources with the “right” patient, at the “right” time for the “right” reason in the “right” place. To delineate this, the authors suggest integrating two questions to a needs assessment of each patient prior to assignment-making, “What is known about the patient, their care plan, and needs?” And, ”How do the professional role competencies and skill of the incoming caregivers match up to these needs?”9 This information is key to delivering patient-centered care and can be gleaned from a standardized charge nurse report or wellstructured patient classification system. Along with the overall projection of nursing hours, this information can be used to create a meaningful balance in nurse–patient assignments, even in complex settings. The paradigm enhances role clarity by helping nurses look beyond hourly tasks to visualize those professional nursing functions essential to each patient’s care, and strengthens accountability for thoughtful care planning, teamwork, and interdisciplinary communication to improve the effectiveness of overall nursing care. In the 2012 Research to Action Project: Applied Workplace Solutions for Nurses,10 Fram and Morgan cited that staff nurses want to provide more input to assessing patient acuity, changes in patient needs, and staffing requirements. The authors provide specific definitions of nursing functions that should be considered in assignment-making, including: • Inputs: • Patient characteristics, associated acuity classifications, time requirements • Nursing competencies, special skills/interests/abilities • Throughputs: • Defined nursing care processes (nursing “deliverables” or CTQ outcomes relevant to the shift, including tasks and human support interventions) • Outputs: • Performance metrics that display impact on nursing workload (hours per patient day), budget, operational process measures (i.e., hospital system performance including equipment/medication turnaround times, ADT throughput measures) and nurse-sensitive quality of care indicators (process and outcome, including care plan/handoff compliance measures, adverse events, and patient care outcome measures) Ultimately, by incorporating better planning for nursing inputs and throughputs to shift assignment guidelines, nursing arts can be better integrated to the essential tasks of front line caregivers, which facilitates more accurate measurement of the true impact of professional nursing care. Additional teamwork strategies for nurse managers may include options such as standardizing shift times (i.e., all 8- or 12-hour periods) or clustering nursing teams into smaller groups to enhance communication and work-pattern consis-
April 2013
tency (i.e., by day of week, shift, geographic area). Ensuring clarity of common goals across teams is critical, as well as regularly infusing recognition to celebrate individual and team success to unit activities.2,8,11 The literature validates the time-consuming and high-cost impact that navigating hospital systems has on typical nursing workflow. Rather than absorbing NVA nursing time in the nurse staffing budget and assignment roster, studies suggest that nurse leaders can heighten professional practice and reduce task-oriented waste by clearly defining nursing interventions and redirecting accountability for system problems. Including clearly defined nursing interventions, staff competencies, and shift-to-shift accountability as part of assignment design can serve to deliver consistently more efficient and high-quality nursing care. This model also serves important content for future systems research to test the clarified professional role of nursing against operational process and clinical outcome measures. NL References 1. Clarke S. Balancing staffing and safety. Nurs Manage. 2003;34(6):44-48. 2. Kerfoot K. Staff engagement: it starts with the leader. Nurs Econ. 2007; 25:47-48. 3. Douglas K, Kerfoot K. A provocative conversation with Peter I. Buerhaus, PhD, RN, FAAN. Nurs Econ. 2011;29:169-182. 4. Hanson D. IONL position statement: role of nurse leader. Illinois Organization of Nurse Leaders. 2012. http://www.ionl.org/?page⫽PositionStatements. 5. Kalish BJ. Missed nursing care: a qualitative study. J Nurs Care Qual. 2006; 21:303-313. 6. Hendrich A, Chow M, Skierczynski B, Lu Z. A 36-hospital time and motion study: how do medical surgical nurses spend their time? Permanente J. 2008;12(3):25-34. 7. Storfjell J, Ohlson S, Fitzpatrick T, Wetasim K. Non-value add time: the million-dollar nursing opportunity. J Nurs Admin. 2009;39:38-45. 8. Crist-Grundman D, Mulrooney G. Effective workforce management starts with leveraging technology, while staffing optimization requires true collaboration. Nurs Economics. 2011;29(4):195-200. 9. O’Rourke M, White A. Professional role clarity and competency in health care staffing—the missing pieces. Nurs Econ. 2011; 9:183-188. 10. Fram N, Morgan B. Ontario: Linking nursing outcomes, workload and staffing decisions in the workplace: the Dashboard Project. In: Canadian Journal of Nursing Leadership. Applied Workplace Solutions for Nursing: Research to Action Project. Toronto, ON, Canada: Longwoods; 2012:114-125. 11. Kalish BJ, Begeny SM. Improving unit teamwork. J Nurs Adm. 2005;35(12):550-56.
Sally Szumlas, RN, MS, CPHQ, NEA-BC, is director of quality at Family Health Network in Chicago, Illinois, and can be reached at [email protected]. Acknowledgment The author gratefully acknowledges Kathy Malloch, PhD, MBA, RN, FAAN, for her guidance and wisdom in the development of this article. 1541-4612/2013/ $ See front matter Copyright 2013 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2012.12.001
www.nurseleader.com
Nurse Leader
49