Improving Nursing Staffing Methodology and Nursing Sensitive Outcomes with the Addition of a Patient Centered Acuity Measure

Background: Assigning the correct nursing resources to hospitalized patients positively impacts patient outcomes. The current process for matching nurses to patients is highly variable and involves a combination of simple ratios, historical workload data, and expert opinion but lacks objective measurement of the patient’s condition. Objectives: This project evaluated change in selected quality indicators and the daily unit-level management of nursing resources after implementing the Troubled Outcome Risk (TOR) into existing nursing staffing methodology in a Department of Veterans Affairs hospital. Methods: TOR provides objective measurement of individual patient allostatic load. Daily calculation of TOR scores for each patient on the study unit and nursing staffing methodology were used by charge nurses to determine assignments. Nursing sensitive indicators including length of stay, transfers to intensive care unit, hospital acquired pressure ulcer (HAPU), 30-day readmissions, and nursing surveillance indicators including rapid response team activation and cardiac arrests were compared before and after implementing TOR. Results: There was a reduction of HAPU rates that exceeded the stated goal after implementation of TOR. Other indicators did not meet project goals. Prior to implementation of TOR, nurse assignments clustered in specific locations; after implementation 16.7% were without regard to location. None of the results were statistically significant; yet we observed a small-medium effect size between intervention and assignment change. Conclusions: The implementation of TOR did not result in significant differences in nursing sensitive outcomes, however charge nurses appear to have changed staff nurse assignments using TOR as an addition to existing methodology. Future study with a larger sample over a longer period of time may yield different results

Integrated patient-to-room and nurse-to-patient assignment in hospital wards

Assigning patients to rooms and nurses to patients are critical tasks within hospitals that directly affect patient and staff satisfaction, quality of care, and hospital efficiency. Both patient-to-room assignments and nurse-to-patient assignments are typically agreed upon at the ward level, and they interact in several ways such as jointly determining the walking distances nurses must cover between different patient rooms. This motivates to consider both problems jointly in an integrated fashion. This paper presents the first optimization models and algorithms for the integrated patient-to-room and nurse-to-patient assignment problem. We provide a mixed integer programming formulation of the integrated problem that considers the typical objectives from the single problems as well as additional objectives that can only be properly evaluated when integrating both problems. Moreover, motivated by the inherent complexity that results from integrating these two NP-hard and already computationally challenging problems, we devise an efficient heuristic for the integrated patient-to-room and nurse-to-patient assignment problem. To evaluate the running time and quality of the solution obtained with the heuristic, we conduct extensive computational experiments on both artificial and real-world instances. The artificial instances are generated by a parameterized instance generator for the integrated problem that is made freely available

Implementation of a Patient Acuity Tool and the Impact on Nurse Satisfaction

Increased workloads contribute to nurse stress, affect nurse-patient relationships, and can ultimately lead to nurse turnover (O’Connell, Nettleton, Bunting, & Eichar, 2020). Nurse satisfaction can also be influenced by nurse-patient assignments (Allen, 2019). Implementation of a patient acuity tool (PAT) to balance workload and evenly distribute patient acuity in nurse-patient assignments can improve nurse job satisfaction, quality of care, and nurse retention (Firestone-Howard, Gonzalez, Dudjak, & Rader, 2017; Al-Dweik & Ahmad, 2019). Discussions were held on a 20-bed medical-surgical unit in an acute care hospital with stakeholders that included the nurse manager, charge nurses and bedside nurses at staff meetings and shift huddles regarding the implementation plan of the patient acuity tool (PAT) change project. The PAT was well received and a pilot phase for implementing a PAT was initiated. Pre-PAT survey data was obtained showing the need for a change in the way assignments were given. The PAT was successfully initiated and utilized for 4 weeks in which weekly discussions continued and feedback was obtained from the nurse staff. The implementation phase was abruptly shortened due to the unexpected closure of the unit due to impact of the Coronavirus pandemic. The post-PAT survey data and verbal feedback obtained from stakeholders was enough to identify a marked improvement in nurse satisfaction with nurse-patient assignments post-implementation of the PAT as well as the high frequency of usage of the tool. The results received support the notion that using a PAT for making nurse-patient assignments can positively influence nurse satisfaction. The data surprisingly identified additional unanticipated benefits to the unit including patient safety and quality of care

Acuity, nurse staffing and workforce, missed care and patient outcomes. A cluster-unit-level descriptive comparison

Aim: To compare patient acuity, nurse staffing and workforce, missed nursing care and patient outcomes among hospital unit-clusters. Background: Relationships among acuity, nurse staffing and workforce, missed nursing care and patient outcomes, are not completely understood. Method: Descriptive design with data from four unit-clusters: medical, surgical, combined and stepdown units. Descriptive statistics were used to compare acuity, nurse staffing coverage, education and expertise, missed nursing care, and selected nurse-sensitive outcomes. Results: Patient acuity in general (medical, surgical and combined) floors is similar to step-down units, with an average of 5.6 required RN hours per patient day. In general wards, available RN hours per patient day reach only 50% of required RN hours to meet patient needs. Workforce measures are comparable among unit-clusters, and average missed nursing care is 21%. Patient outcomes vary among unit-clusters. Conclusion:Patient acuity is similar among unit-clusters, whilst nurse staffing coverage is halved in general wards. While RN education, expertise and missed care are comparable among unitclusters, mortality, skin injuries and risk of family compassion fatigue rates are higher in general wards. Implications for nursing management: Nurse managers play a pivotal role in hustling policy-makers to address structural understaffing in general wards, to maximize patient safety outcomes

A Systematic Review of Acuity-Based Staffing in Acute Healthcare Environments

Nursing leadership is responsible for considering the equity of patient care assignments when providing nursing care. Nursing leadership is responsible for assuring the delivery of patient care assignments with the intent to offer nurses an unbiased, evenly distributed patient load. Effective distribution of patient care assignments ensures patients receive the safest, most efficient, and highest quality of care. The purpose of this project was to provide nursing leadership with an executive summary of a systematic review of evidence-based research on the structure and process of making patient care assignments, and it provided evidence on how those patient care assignments affect the quality of care provided to patients. The researcher conducted a systematic review of the literature to inform stakeholders about best practices used for acuity- based staffing. The systematic review of the literature involved using the PRISMA model as a structured assessment to screen and eliminate articles during the article search. All data from the systematic review were synthesized to collectively determine each acuity-based tool’s effects on patient care assignments within the acute care settings. The review of articles found that the implementation of acuity-based staffing tools in an acute care setting is associated with outcomes that included self-efficacy or retention, patient and nurse satisfaction, quality of care, and other additional findings. This systematic review of literature provided information to healthcare professionals about literature and the influence of implementing acuity-based staffing tools for patient care assignments in acute care settings. The project also included an implication of analysis for leaders and recommendations for change and future research

A Grounded Theory of Patient Flow Management within the Emergency Department

Background: Emergency department (ED) crowding is an urgent threat to patient safety and negatively impacts healthcare staff and institutions. Patient flow researchers have employed a range of methods to address this crisis, including an increase in the use of operations research and operations management strategies. However, identified patient flow solutions are inadequate. Research describing the complexities of patient flow processes and investigating the work and contributions of ED nurses is needed. Purposes: The purposes of this study were to explore how ED nurses perform patient flow management and to develop a constructivist grounded theory of patient flow management within the ED. Methods: A conceptual foundation for patient flow management was first established using evolutionary concept analysis and expanded concept analysis approaches. This study then employed constructivist grounded theory and situational analysis methodologies to examine the work of ED nurses. Data was collected through 29 focus groups and interviews with 27 participants and 64 hours of participant observations across four EDs. Data analysis relied on coding, constant comparative analysis, and memo-writing to identify emergent themes and develop a substantive theory. Findings: Concept analyses defined patient flow management as the application of ED experience, holistic perspectives, dynamic data, and complex considerations of multiple priorities by ED nurses to promote patient safety within their scope of responsibility. The study offers three main contributions: a theoretical model of the work of ED patient flow management, a theoretical framework to describe holistic considerations of factors that impact departmental capacity and nurse engagement in patient flow management, and a grounded theory of patient flow management capacity and engagement that describes how ED nurses adapt patient flow management strategies according to patient burden. Conclusion: This study offers a new conceptual and theoretical foundation to understand the work of patient flow management. This novel perspective centralizes the work of ED nurses as active agents in patient flow processes and describes their strategies and contributions to meet patient care needs. Several practical considerations are offered to engage and support nurses in their roles as patient flow managers, improve patient flow processes, and further investigate ED nurse patient flow management

An Exploration Of Charge Nurse Decision-Making Related To The Nurse-Patient Assignment On Adult Medical-Surgical Inpatient Units

ABSTRACT AN EXPLORATION OF CHARGE NURSE DECISION-MAKING RELATED TO THE NURSE-PATIENT ASSIGNMENT ON ADULT MEDICAL-SURGICAL INPATIENT UNITS Colin Plover Julie Sochalski, PhD, RN, FAAN Statement of the Problem: In adult inpatient medical-surgical settings, the nurse-patient assignment serves as a strategy to organize the delivery of nurse-patient care. How nurse-patient care is organized through the nurse-patient assignment affects both nurse and patient outcomes, yet no best practice method of developing the nurse-patient assignment exists. Current literature demonstrates limited investigations of charge nurse reflections on their decision-making related to the nurse-patient assignment. Charge nurse perspectives are important because charge nurses drive the decision-making through which patient care is allocated. Despite their integral role, little is known about charge nurse perspectives on the process of the development of the nurse-patient assignment, what factors charge nurses consider and how they consider them when allocating patient care. Procedure and Methods: A qualitative descriptive approach was chosen and a semi-structured interview guide was used to conduct interviews with 18 charge nurses across four medical-surgical units. Attention was paid to the process of patient care allocation through the nurse-patient assignment, the factors which charge nurses found to be the most and least important, and how they prioritize these factors in their decision-making process. Results: The interviews revealed both common and divergent practices with respect to charge nurses’ process of developing the nurse-patient assignment, the factors that they considered, and how they considered these factors when making patient care allocation decisions. These common and divergent practices were identified by themes and sub-themes respectively. Themes identified how all charge nurses described processes of gathering information involving the application of frameworks with shared aims through which they synthesized specific factors in common ways to develop an assignment that aligned with a common constellation of goals. Sub-themes identified variation with respect to where charge nurses sourced their information, the factors they considered, their strategies for considering factors, how they considered factors, factor terminology and their specific goals. Conclusions: The insight this investigation provides into charge nurse development of the nurse-patient assignment has implications for practice environments that include ways to inform research which may serve to improve patient safety, nurse outcomes and the efficiency and cost effectiveness with which patient care is organized and delivered

Charge Nurse Expertise: Implications for Decision Support of the Nurse-Patient Assignment Process

University of Minnesota Ph.D. dissertation. 2019. Major: Health Informatics. Advisor: David Pieczkiewicz. 1 computer file (PDF); 201 pages.Each day, across thousands of medical-surgical inpatient nursing units, charge nurses make decisions about which nurse will care for each patient. Recent attempts have been made to introduce health information technology (HIT) solutions to automate the nurse-patient assignment process. This research investigated charge nurse decision making during the nurse-patient assignment process as an exemplar of the larger question: How can we leverage information technology to improve decision making in healthcare, while respecting individual clinician expertise and the unique context of individualized patient care? Four primary questions were used to guide research of the process, decision factors, goals and context of nurse-patient assignments. A mixed-methods approach of qualitative interviews (N = 11) and quantitative surveys (N = 135) was used. Findings related to the charge nurse decision making process indicate that measurable, nurse-sensitive indicators of patient outcomes have not yet been standardized for nurse-patient assignments. HIT solutions and quality improvement efforts should define, collect and analyze measurable outcome criteria prior to attempting to improve or augment existing nurse-patient assignment practices to prevent unintended consequences. When clear outcome measurements have been identified, informatics researchers and professionals should investigate the ability of machine learning to recognize goal priorities and factor weighting from patient, nurse and environmental factors within existing HIT solutions. Until that time, HIT solutions augmenting the nurse-patient assignment process should be designed with flexible configurations, to enable goals, decision factors and factor weights can be varied by hospital, unit, charge nurse and shift, in order to best meet the needs of charge nurses

Longitudinal Study of the Variation in Patient Turnover and Patient-to-Nurse Ratio: Descriptive Analysis of a Swiss University Hospital

Variations in patient demand increase the challenge of balancing high-quality nursing skill mixes against budgetary constraints. Developing staffing guidelines that allow high-quality care at minimal cost requires first exploring the dynamic changes in nursing workload over the course of a day.; Accordingly, this longitudinal study analyzed nursing care supply and demand in 30-minute increments over a period of 3 years. We assessed 5 care factors: patient count (care demand), nurse count (care supply), the patient-to-nurse ratio for each nurse group, extreme supply-demand mismatches, and patient turnover (ie, number of admissions, discharges, and transfers).; Our retrospective analysis of data from the Inselspital University Hospital Bern, Switzerland included all inpatients and nurses working in their units from January 1, 2015 to December 31, 2017. Two data sources were used. The nurse staffing system (tacs) provided information about nurses and all the care they provided to patients, their working time, and admission, discharge, and transfer dates and times. The medical discharge data included patient demographics, further admission and discharge details, and diagnoses. Based on several identifiers, these two data sources were linked.; Our final dataset included more than 58 million data points for 128,484 patients and 4633 nurses across 70 units. Compared with patient turnover, fluctuations in the number of nurses were less pronounced. The differences mainly coincided with shifts (night, morning, evening). While the percentage of shifts with extreme staffing fluctuations ranged from fewer than 3% (mornings) to 30% (evenings and nights), the percentage within "normal" ranges ranged from fewer than 50% to more than 80%. Patient turnover occurred throughout the measurement period but was lowest at night.; Based on measurements of patient-to-nurse ratio and patient turnover at 30-minute intervals, our findings indicate that the patient count, which varies considerably throughout the day, is the key driver of changes in the patient-to-nurse ratio. This demand-side variability challenges the supply-side mandate to provide safe and reliable care. Detecting and describing patterns in variability such as these are key to appropriate staffing planning. This descriptive analysis was a first step towards identifying time-related variables to be considered for a predictive nurse staffing model