Nurse staffing is a complex issue. Matchingthe right nurse to the right patient at theright time requires an understanding of theindividual patient’s need for care, nurse characteristics,workflows, and the context of care, includingorganizational culture and access to resources.
Many experts believe patient acuity is an importantcomponent of nurse staffing becauseacuity-informed staffing approaches have beenshown to improve patient outcomes and enhancenurse satisfaction. Patient acuity systemshave been around for many years, but earliersystems required extra work by nurses and producedsubjective results. Nurse leaders hesitatedto adjust staffing when every patient was describedas having “high needs.” Current technologyused to generate acuity scores in today’s systemsenables objective, valid, and reliable measuresthat can inform staffing decisions.
Massachusetts recently passed legislation requiring,among other things, acuity-adjustedstaffing in intensive care units (ICUs). Therefore,nurses in Massachusetts are now discussingstrategies for using acuity to optimize patientcare.
A panel of nurse leaders explored this issue ata roundtable, “Using Acuity: Optimizing PatientCare and Nursing Workload,” held in December2015. The panel presented research and real-lifeexamples to illustrate how astute determinationof patient acuity can optimize patient outcomesand help balance nurse workloads. (See Who,what, when, where, and why.)
The panel discussion was hosted by CeCeLynch, MS, RN, NEA-BC, FACHE, vice presidentof patient care services and chief nurse executiveat Lowell General Hospital (LGH) in Lowell, Massachusetts.The moderator was Lillee Smith Gelinas,MSN, RN, FAAN, Editor-in-Chief of AmericanNurse Today and system chief nursing officer forCHRISTUS Health.
Using acuity to optimize patient care and nursing workload
The goal of the roundtable, Lillee Gelinas, MSN, RN, FAAN, began, was to present information and tools for nursing leaders to implement in their organizations. “We want to stimulate a national conversation on this important topic,” she said. “How do we use acuity to optimize outcomes through nurse staffing?” Gelinas discussed the impact of the Affordable Care Act and the challenge to adopt the Triple Aim: better access, better quality care at lower cost. She also pointed out that healthcare organizations are looking through the lens of state legislation focused on safe nurse-patient ratios. (See Nurse staffing legislation.) Whatever the motivation, Gelinas said, “At the end of the day, we’re trying to achieve better care at lower cost so we can have a viable healthcare system.”
Gelinas noted that this era is a challengingone for nursing, with competing pressures forboth nursing and healthcare dollars. Becausenursing salaries are the largest operational expensein acute care, many organizations considercutting nursing positions when they have toreduce costs.
At the same time, though, it’s an exciting timefor nursing. One example is the electronic healthrecord (EHR), which makes rich clinical dataavailable; computer analysis of this data offersbetter decisional support for nurses.
Panel leaders were asked to share their expertiseon patient acuity-adjusted staffing, exploringthe question: How do we ensure patients get thecare they need while creating a safe, effectivework environment for nurses?
Before introducing the first speaker, Gelinasdiscussed the problem of variations in definingand implementing acuity-adjusted staffing in themore than 5,600 hospitals across the country. Forthe purpose of this panel discussion, she definedacuity as the individual patient’s need for care.
Shared governance: The key toimplementing change
Andrea Erickson, MSN, RN, CNML,director of inpatient critical care servicesat LGH, spoke of the large taskher organization faced as it worked tocomply with the Massachusettsstaffing bill passed in November 2014. Using theshared governance model to guide its journey, LGHbegan to develop and implement an acuity tool tomeet the state’s January 2017 deadline.
The shared governance model, Erickson explained,proved vital to LGH as it worked towardimplementing those changes. (See Shared governancemodel.) “Shared governance gives nursespower in their practice,” she said. “It gives them avoice, which promotes innovation and allowsthem control over their practice. It lets nurses extendtheir influence beyond their unit walls andpermits staff in the leadership team to share in thedecision making process.”
The shared governance model at LGH keepsthe patient and family as the central focus, withunit-based councils and evidence-based practiceson the second tier, followed by other councils andcommittees that funnel up through the coordinatingcouncil. The acuity-tool advisory committeebegan the process for developing an acuity toolby identifying key stakeholders, including management, educators, informatics experts, and staffRNs across both campuses. (See Key stakeholders.)The aim, Erickson said, was to include individualswith varied levels of experience who worked variedshifts.
Erickson explained, “We used the Johari windowconcept to identify stakeholders based on two parameters— interest and power. We focused onthose who fell into the high-interest, high-powersection of the grid.”
The committee then conducted a survey to determinewhich indicators determined high acuityand which warranted 1:1 or 1:2 nursing care. Afterthe survey was completed, the committee developeda task force of nursing administrators,informatics experts, educators, and 6 to 10 staffRNs who met and communicated regularly. Ericksonremarked, “We relied heavily on email andone-to-one meetings in both ICUs to identify bestpractices related to patient acuity, whether theywere practices occurring in Massachusetts or otherstates with mandated safe staffing ratios.” Theorganization maintained quality reporting, includingcentral line–associated bloodstream infectionrates, catheter–associated urinary tract infectionrates, and pressure ulcer and patient fallsincidence.
Erickson stressed the importance of seeking tounderstand how these changes affect work areas,resources, and staff educational needs. “Changetakes hard work and requires engraining the culture,”she pointed out. “This kind of project has tobe nurtured and grown from beginning to end.”She emphasized the necessity of preserving nursing’svoice in the process. “At the end of the day,we want an acuity-tool system that fulfills requirementsof the law, but we don’t want to lose nursingjudgment along way,” she said. “We muststrike a balance between science and judgment,marked by open dialogue, trust, and teamwork.”
Acuity-adjusted staffing linkedto better outcomes
Eileen T. Lake, PhD, RN, FAAN, JessieM. Scott Term Chair in Nursing andHealth Policy at the University ofPennsylvania School of Nursing, presentedresearch on acuity-adjustednurse staffing as it relates to preterm infant outcomes.Among the 912 neonatal ICUs (NICUs) in theUnited States, sizable variations in mortality existthat can’t be attributed to infant factors, Lake said.
The goal of measuring acuity-adjusted staffingwas threefold, Lake explained, “First, to look at howinfant acuity relates to the assignment a nurse receives.Second, to see how accounting for acuity andstaffing relates to infant outcomes. And third, tolook at how nurse workload relates to infant acuity.”
Research shows staffing is significantly associatedwith infection among very low-birth-weight infants;15% of these infants develop an infection,which in turn doubles their risk of mortality. Literaturefindings also reveal staffing influences the rateof breast milk at discharge. Across hospitals, aracial disparity in breast milk at discharge exists,linked to poorer staffing in hospitals with predominantlyAfrican-American patients. Of particularnote, hospitals with a largely minority populationhad higher rates of infection and discharge withoutbreast milk. They also had a higher degree of nurseunderstaffing and poorer practice environments.
Lake said that across the acuity spectrum, all ofthe infants had similar parent needs, includingteaching, emotional support, and developmentalsupport. “We observed that when nurses care formultiple low-acuity infants, if you add events andparent needs together, their workloads are actuallyhigher than those of nurses who care for one ortwo high-acuity infants,” she noted. “This shows usthat acuity has a significant relationship withstaffing and outcomes but doesn’t account completelyfor workload.”
Lake went on to discuss the need for adequatedecisional support in the NICU setting, includingacuity assessment systems that apply to that setting,as well as the need to ensure that these systemsare evidence based.
Acuity calculation driven bynursing documentation
Miriam Halimi, DNP, MBA, RN-BC,vice president and chief nursing informaticsofficer at Trinity Health inLivonia, Michigan, discussed the importanceof using an electronic healthsystem that’s integrated with nursing documentation.According to Halimi, this helps ensure thatacuity-level calculation doesn’t come at the cost ofdirect nursing time. “We hypothesized that an acuity system that’s electronic and integrated withnursing documentation will create better and timelierinformation, leading to better decisions thatoptimize both the process and practice of nursingcare,” she said. “We’re looking to leverage an acuitysolution that will allow for flexibility and providethe information needed in real time to supportnursing down to the unit level.”
Trinity Health, new to using an integrated acuitysolution, successfully implemented a solution withina 6-month period at one of its hospitals in fall2015; a second hospital is scheduled to go live withits solution this spring. While nursing leadershipdebated whether all nurses should have access tothe tools, ultimately they decided that was the bestway to go. Halimi said this approach providesgreater transparency.
The Trinity Health planning team focused onkeeping staff nurses engaged throughout theprocess by:
• using scheduling and acuity solutions togetherto provide powerful tools that empower nurses
• giving staff nurses access to acuity tools, as wellas education on how to use them
• leveraging the role of a patient-outcomes expert toensure partnership in the use of acuity tools daily.
Halimi showed a screenshot of a medical-surgicalcritical-care evaluation depicting how an acuityscore is generated based on the nursing interventionsclassification and nursing outcomes classification(NOC). “For instance, in the respiratory domain,a patient on room air would be considereduncompromised and receive a score of 5. But a patienton a ventilator would be considered severelycompromised, with a score of 1,” she explained.“The lower the score, the more severely deviatedthe patient is and the more nursing care he or sheneeds. Therefore, the level of acuity is higher.” Thesystem calculates acuity scores every 4 hours, withscores generated 2 hours before shift change, to ensurethe most updated scores. This helps identifyappropriate staffing for the next shift. (See Nursingdocumentation and acuity levels.)
How does an integrated acuity system work? Byentering and saving clinical documentation inthe EHR, which is sent automatically to the acuitysolution. The acuity solution maps the observationsand values using the NOC and indicatorvalues. Mapping of the clinical documentation isassigned to a domain (each domain has multipledata elements), which identifies the patient’s acuityassessment within that domain.
As Trinity leaders evaluate implementation ofthe acuity tool, Halimi said, they’re looking atmeasuring such outcomes as staffing expenses,staff and patient satisfaction, and productivity.“Acuity matters with or without the [nursestaffing]law,” Halimi concluded, pointing outthat acuity-adjusted nurse staffing holds importancewhether or not it’s mandated by legislation.“An integrated acuity solution creates accuracyand precision in staffing, ultimately moving towardpositive patient outcomes.”
Balanced staffing: Wherefinance and operationsconverge
William Dan Roberts, PhD, ACNP,data and analytics scientist at StonyBrook Medicine in Long Island, NewYork, moved the discussion in anotherdirection. He addressed how patient acuity affectsnurse staffing from both a financial and an operationalperspective. He stressed the dynamic natureof patient acuity, stating, “It changes by the minute,by the hour, by the shift, so you want to make sureyou’re able to be flexible with your staffing.”
Staffing is more than just allocating full-timeequivalents (FTEs) during a budgeting process,Roberts said. Considering the FTE allocation thathas been allotted is important. This includesachieving a balanced schedule based on how nursesand unlicensed assistant personnel are scheduled.From this, the allocated skill mix for the dayis available for assigning to patient needs.
Roberts posed a pertinent question: How can apatient’s needs be best matched with the nurse’sskills to allow for the best nursing care, while stillmeeting the expected care processes and outcomesnecessary for efficient and cost-effectivehealthcare delivery? To view his formula forachieving this, see Staffing: Financial to operational.
The forms above show the usual financial allocationof staff during the budgeting process. Theyincorporate Roberts’ staffing formula, which includesassignment, RN competency, and patientacuity. The staffing formula relies on operationaland financial flexibility.
Roberts showed a screenshot of a nurse-staffingdocument depicting a breakdown of the nursingworkload on a general medicine unit during theday shift, illustrating the effect of patient acuity onnursing care hours. “Predictably, we can ask, whatis the nursing work going to be for that patient?Does the nurse have a balanced workload? Howdo we achieve that? We would reallocate resourcesso that nurse is able to carry the load,” he said.
Roberts went on to explore differences in demandbetween the medical ICU (MICU) and themedical intermediate care (MICR) unit, with a slide illustrating a higher workload demand in theMICR unit. Data aggregated from acuity calculatingtools created visibility that allowed more staffcoverage for the MICR unit by adding anothernurse to each shift. It also enabled leaders to advocatefor additional unlicensed assistant personnelas well as support staff, such as physical therapyand respiratory therapy, for the MICR unit.
Roberts closed with an encouraging message:Nursing and finance departments can work togetherto use the data effectively. He stressed the needfor objective measures and standard terminologyto ensure congruency among organizations.
Patient acuity: Realizing theclinical potential
Amy L. Garcia, MSN, RN, directorand chief nursing officer for workforceand capacity management withCerner Corporation, spoke about theexciting potential for patient acuitydata to promote efficient, cost-effective care withbetter patient outcomes. She discussed the use ofacuity to inform the assignment of nurses to patients,as well as levels of care. She highlighted thiswith an example of a patient who was beingtreated for a myocardial infarction. Garcia explainedthat a patient who follows the typical recoverytrajectory might be ready for transfer fromthe ICU to a step-down unit after about 50 hours,then discharged home after about 30 hours of careon a telemetry or step-down unit.
Taking patient variance into account, Garciapointed out, a patient who recovers more quicklythan expected may be a low-acuity outlier on anICU. Likewise, a patient who recovers more slowlythan expected may be transferred to a lower levelof care, resulting in the nurse having a largerworkload than he or she can manage in a settingmeant for lower-acuity patients.Garcia discussed the positive effect of aligningacuity with adjusted nursing hours per patient day,which promotes budget neutrality and optimizesnurse-to-patient assignments. Garcia noted thatnurse-to-patient assignments are often made by dividingthe available nursing hours by the numberof patients and assigning the nurse to a number ofbeds or a geographic area. However, this practiceignores fundamental questions: How many hoursof care does an individual patient need to progresstoward optimal outcomes? Can that care be deliveredon this unit? And which nurse is best suited toprovide that care? Garcia showed an illustration ofa system that provides visibility to the nursingworkload, adjusted for acuity, census, and activityon the unit (See Balancing workloads).
One East Coast hospital she works with implementedacuity considerations to help balance nurses’caseloads. “The rate of staff who called out of theirshifts on med surg units dropped 42%,” Garcia said.“Nurses were able to see that their caseloads werebalanced and that when they came to work, theyhad a good opportunity to actually make a difference.That’s what we ask for in nursing—to be ableto impact patient care in a positive way. Balancedworkloads are important.” She concluded that whenthe right nurse is aligned with the right patient atthe right time, both nurses and patients benefit. “Inan ideal world, organizations can view nursing asan investment rather than a cost center,” she said.
Garcia noted that the work of nursing is complex,beyond just a simple list of nursing tasks orvital signs. She shared how Cerner approachesacuity—based on the nursing work needed tochange patient outcomes. Patients have a widerange of needs, including activities of daily living,physical, psychosocial, learning, perceived health(such as pain scales), and family support. Each aspectof care is important. For example, a patientwho has suffered a stroke may have few medicationsand little technology; instead, the nurse mayneed to focus on swallowing, teaching self-care, orusing strategies to cope with depression. Familymembers have much to learn to ensure a successfuldischarge—and that takes nursing time. Thework of nursing is holistic, and acuity systemsshould represent the needs of the whole patient.
Nurses weigh in
In a question-and-answer period after the paneldiscussion, three major themes emerged.
Psychosocial needs and the nurse’sworkload
Several panelists agreed on the need to improve documentationof, and consideration for, the psychosocialwell-being of the patient and family. Patientand family support needs vary and hinge on manyfactors. We must continue to look at what organizationsare doing, concretely and quantifiably, to takepatient and family needs into consideration whenit comes to staffing. As Garcia pointed out, “Withacuity, it’s very easy to focus narrowly on a list oftasks or interventions. That’s one of the reasonsCerner uses a nursing taxonomy to help us definemore broadly the holistic needs of the patient andfamily within the context of their personal lives.”
The churn: Workload associated withpatient admissions, transfers, anddischarges
Nurses spend considerable time performing anddocumenting admission and discharge assessments.The work can vary in intensity, dependingon individual patient characteristics. For instance,admission of a patient who is unable to communicateor has complex care needs (such as a bonemarrow-transplant patient) can be quite intense.
The time required to transfer patients also variesfrom one unit to another, relative to workflowsand the facility’s physical setting. Discharge timevaries, too. With a newborn infant, for example,discharge is faster if the parents have receivedsome education before discharge day, rather thanreceiving all of it at the time of discharge.
Measuring nursing work intensity
Roberts stated that when considering acuity andstaffing, we need to incorporate tools that accountfor two characteristics—the patient’s physiologicparameters, which are used to create the plan ofcare); and nursing work intensity, which describesthe measure of work required to care for the patient.We should continue to emphasize how tomeasure nursing work, as well as the parametersassociated with the patient’s physiologic state.
Acuity-adjusted staffing: A promisingfuture
Although response to legislative staffing guidelineshas provided a more urgent incentive for developingacuity-adjusted staffing tools, each panelist expressedoptimism about acuity-adjusted staffingand the promise it holds for improving both patientoutcomes and nursing workload. Nonetheless,Gelinas reiterated that an acuity score is merely anumber until it’s harmonized with each patient’sunique needs. “After working with acuity systemsfor a while now, I believe acuity is just a numberuntil you align it with a process or an outcome.Acuity alone is not a magic bullet,” she noted,adding that acuity must be considered within thecontext of the care required for a specific patient.
For a robust discussion of variables that affectstaffing, including acuity, read the 2015 white paper“Optimal Nurse Staffing to Improve Quality of Careand Patient Outcomes.”Commissioned by the American Nurses Associationand developed by Avalere Health, LLC, in collaborationwith nurses and policy experts, this documentcan be used as a resource to advocate for and implementsound, evidence-based staffing plans.
Meaghan O’Keeffe is a freelance writer and clinical editor based in Framingham,Massachusetts.
