Nurses have an obligation to be stewards of the resources of our patients and organization as well as advocates to ensure that highest quality of care is provided. The American Academy of Ambulatory Care Nursing (AAACN) has identified that “an adequate number of ambulatory care nurses are available to meet the patient care needs for the practice setting and maintain a safe and caring work environment” (Swan, 2005). The challenge is in defining what adequate means. Moreover, the larger task is in describing what it means to have effective nurse staffing and the factors that influence it.
Nurse staffing in ambulatory settings is often the result of an organic process involving physician preference, available resources, and administrative priorities. “The lack of nursing staffing guidelines in ambulatory settings can result in RNs, LPNs, and UAP practicing either below or above their training and licensure scope of practice” (Deeken et al, 2017). The vast majority of literature regarding nurse staffing is focused on the hospital inpatient setting. There is a need to define and quantify nursing workload for settings beyond inpatient care. Defining and quantifying the work of nursing are steps towards further understanding the economic value of nursing care.
The purpose of this project was to identify a framework for determining the number and skill of nursing staff needed in an ambulatory multi-specialty practice setting. With constantly changing staffing level, it is always a challenge for Specialty Clinic nursing leadership to predict appropriate staffing levels based on scientific model and facts. Nursing leadership envisioned a scalable analytical model that will help improve the efficiency and productivity of the Specialty Clinic departments.
Methods:
The first phase of this work focused on the identification and quantification of all discrete nursing activities performed across the 15 specialties of the Specialty Clinic. The goal of this project was to create a compendium of nursing work/tasks that would describe activities which were identical across practices and include work that was specific to discrete specialty practices. This all-inclusive compendium would then be used as a framework to quantify the nursing time spent on each discrete activity over a period of two weeks. Each team member, RN, LPN, and UAP were asked to complete a daily time-study during the two week period to capture potential daily variation in volume and workload. Every one of the 15 specialty practices did the time-study during the same two weeks to ensure full and focused participation. Patient visits were the volume metric collected and used to understand the relationship between the volume of patients visiting the clinic each day and the nursing time required to care for those visiting patients.
Following the two week data collection period, the project team reviewed the results for each specialty one at a time with nursing leaders to evaluate the percentage of time spent by each team member on the individual activities. This work defined the current state of nursing time spent in each specialty practice. The nurse leaders were then able to identify what percentage of time each team member should spend on the individual nursing activities for that practice and define an ideal state. Because this work was calculated in time increments, it was able to then be translated into hours of care and needed FTE.
Result:
The work of creating the compendium of nursing activities was an iterative process. After a series of five PDSA (plan, do, study, and act) cycles the list was comprehensive and clear enough for staff to easily understand and accurately classify the work being performed. The list was also divided into three major groupings, visit care, non-visit care and administrative work. These groupings were important to the nurse leaders in understanding and addressing the volume of nursing work that occurs on behalf of a specific patient even when patients aren’t physically present in the clinic. This also provided a proportion of work that could be allocated out per patient visit. Each patient visit was assigned the respective portion of visit work, non-visit work and administrative tasks.
The culmination of this first phase of work resulted in the nurse leaders for each specialty receiving an Excel workbook that included a worksheet allowing for the calculation of nursing role-specific FTE needed based on patient visit volumes. Other worksheets in the workbook included the all-inclusive compendium of nursing work, the quantified list of specific nursing work for that practice, and space to add future work/activities into the list for the purpose of predictive modeling based on anticipated changes in patient volume.
The next phase of this work will be testing to see if the ideal staffing model identified for each practice can work in the real world. Each specialty will evaluate if their identified model will not only support daily patient care, but what, if any difference is made in nursing sensitive outcomes for the patients.