WORKFORCE MANAGEMENT A new patient-acuity tool …

1 Have you ever struggled toclassify a patient s acuitylevel? If so, you re notalone. Have you everlooked at your patient as-signments and wondered, Why arethe assignments so unfair? How willI care for all my patients effective-ly? Again, you re not alone. Most nurses expect patient as-signments to be equitable, witheach nurse bearing a fair share ofthe workload so all patients can re-ceive excellent care. Nurses job satisfaction dependspartly on their workload and theirper ceived ability to deliver high-quality care. Nurse-sensitive indica-tors (including pressure ulcers, falls,medication errors, nosocomial infec-tions, pain MANAGEMENT , and pa-tient satisfaction) depend largely onnursing care and are affected bynurses ability to recognize and in-tervene when a patient s conditionchanges.

2 Nursing workloads directlyinfluence a nurse s ability to assessthoroughly and promote excellentpatient outcomes. When patient as-signments aren t equitable, nursesmay feel inadequate and frustrated. Problems also can arise when allnurses are assigned the same num-ber of patients without regard foracuity levels. Yet determining pa-tients acuity to promote more equi-table assignments can be challeng-ing. Some hospitals or nursing unitsuse an established acuity tool. Oth-ers rely on charge nurses judgmentsof patient acuity. Our nurses were getting restlessAt Indiana University Health BallMemorial Hospital in Muncie, wemoved our progressive care unit(PCU) to a newly constructed areaof our regional medical center.

3 Ashort time later, we noticed increas-es in patient volumes, comorbidi-ties, device support, and overallacuity. The patients nursing-carerequirements varied widely, so as-signing the same number of pa-tients to all nurses would mean unequal assignments. Although were using an acuityassessment tool, our increasinglydissatisfied nurses deemed it inef-fective. It called for nurses to rankeach patient as a 1, 2, or 3 basedon their individual perception ofthe patient s status or difficulty ofcare required. But the tool wasn tproviding useful information be-cause nurses perceptions varied;also the cultural norm tends tomake nurses rate most patients a2. In addition, when more staffnurses were needed, we lacked anobjective measure to make a casefor obtaining additional our hospital tested a newnurse-satisfaction survey, nurses discontent with their workload be-came apparent.

4 Then a PCU direct-care nurse ap-proached the unit-based council(UBC) and asked for an evaluationof our acuity tool. The nurse man-ager and UBC agreed that equitablepatient assignments and adequateunit staffing could be addressed byimproving the tool. Following theIowa model of evidence-basedpractice (EBP), the UBC formed ateam of staff nurses, charge nurses,unit manager, clinical nurse special-ist, and nurse researcher to explorethe inquiry. 2014 American Nurse Today1 Leading the WayWORKFORCEMANAGEMENTA new patient-acuity toolpromotes equitable nurse-patient assignments By Michelle Kidd, MS, RN, ACNS-BC, CCRN; Kimberly Grove, BSN, RN, PCU; Melissa Kaiser, BSN, RN, PCU; Brandi Swoboda, RN, PCU; and Ann Taylor, BS, RN, PCUWhen a 2 acuity ratingisn t truly a 2 2 American Nurse TodayVolume 9, Number the evidence told usThe team s literature review found alimited amount of research pertain-ing to acuity tools for PCUs, eventhough hospital expenses decreaseand high-quality nursing care in-creases when leaders are empow-ered with better, more detailedknowledge of patient acuity andnursing workloads.

5 A recurrenttheme in the literature: nurses voic-es add value to processes and nurs-es should be involved in assessingtheir own workloads and makingdecisions about resources. Evidencealso suggested that involving staff indeveloping an acuity assessmenttool would yield a valued, more effi-cient instrument that could improvenurse satisfaction and job retention. Formulating a planDuring our literature review, wefound a tool to adapt for our adultPCU. On a flip chart in the nurses lounge, we displayed our existingtool alongside the new tool we d re-vised from the literature search. Staffviewed both tools and provided in-put into what made a patient s caredifficult, time-consuming, or com-plex. This gave us a better picture ofPCU patients and helped us ensureall tasks were represented, from theleast to the most meetings clarified keyelements of acuity that guided con-tinued evolution of the new tool.

6 Tool-development strategiesIn our new tool, criteria categoriesincluded complicated procedures,education, psychosocial/therapeuticinterventions, number of oral med-ications, and complicated drugsand other medications. Rating options on the tool run from 1through 4, with 1 indicating lowacuity and 4 indicating high are based on nursing timeneeded to complete a task, emo-tional and physical energy expendi-ture required, expertise required,frequency of tasks and interven-tions, and follow-up assessmentsrelated to a specific task. Ratingsfor all five criteria categories aresummed up to obtain a total acuityscore for each patient, ranging from1 to 60. Then the total scores areclustered into acuity categoryscores, which range from 1 to 4,with 1 being the lowest acuity and4 being the highest.

7 (See Acuitycriteria categories.) Now we were ready to test thenew tool. Initially, charge nursesfrom each shift tested it with thesame patients on different we found that scores be-tween shifts weren t congruent, wetested the tool again, with chargenurses on the same shift assessingthe same patients separately. Thistrial yielded an inter-rater reliabilityof 85% an acceptable congruencylevel across nurse trial provided insight intoacuity differences between shiftsand helped determine how to usethe tool. With our previous acuitytool, tasks and procedures of therater s shift determined acuity, withno consideration of upcoming tasksor procedures for the next shift. Sofor the new tool, the team and staffagreed nurses would proactivelyscore acuity for the oncoming shiftby calculating current and projectedneeds and medications.

8 Measuring outcomesWe identified three outcome meas-ures as indicators of the effective-ness of the new acuity approach. First, the team developed aneight-item survey to measurenurse satisfaction with the newacuity assessment process, whichnurses completed 1 month be-fore the new process began andthen 1 month, 6 months, and 12months later. Next, the team identified itemsThis chart shows the five acuity categories in the new acuity tool developed for theprogressive care unit at Indiana University Health Ball memorial Hospital. In eachcategory, nurses rate each patient from 1 (lowest acuity) to 4 (highest acuity).Acuity categoryExamples of care required Complicated procedures1: Pulse oximetry, telemetry2: Trach care, nasogastric tube, fall risk3: Continuous biphasic positive airway pressure, tracheotomy care, ostomy care, chest tube, peritoneal dialysis4: Total care; restraints; confused, restless, combativeEducation1: Standard2: New medications3: Discharge today, pre- or postprocedure status4: New diagnosis, multiple comorbiditiesPsychosocial or therapeutic 1: Three or fewer per shiftinterventions2: Three to five per shift3: Six to 10 per shift; delirium.

9 End of life4: More than 10 per shiftOral medications1: One to five2: Six to ten3: 11 to 154: 16 or moreComplicated drugs and 1: Glucometer with coverageother medications2: Two to five medications3: Heparin protocol, more than five medications, total parenteral nutrition4: Blood products, tube feeding, cardiac drug or insulin dripAcuity criteria categories 2014 American Nurse Today3on the standardized annual em-ployee engagement and satisfac-tion survey, specifically targetingworkload and perception ofquality of care delivered. Finally, we tracked nurse-sensitive indicators affected byworkload, including falls andhospital-acquired pressure ulcers. Translating scores into patientassignmentsTo translate acuity scores into equi-table patient assignments, chargenurses collected the acuity tools thatdirect-care nurses completed foreach patient, and calculated totalacuity scores and acuity categoryscores near the end of their the charge nurses designednurse-patient assignments by con-sidering both the category scorefrom 1 to 4 and the total acuityscore of 0 to 60 for each patient,aiming to keep category scores bal-anced across nurses.

10 Charge nursesalso considered the geographic lo-cation of rooms on the unit, needfor continuity of care, and congru-ency between nurses expertise andpatient needs. (See Current acuitytoolon last page.) Unit-wide rolloutBefore we rolled out the new tool,direct-care nurses on our team pro-vided education to all PCU strategies included show-ing video clips of patient scenarios,presenting case studies so nursescould practice using the tool, andplaying a game-show exercise tostimulate discussion of the benefitsof acuity scoring. Nurses voiced fa-vorable responses to the new tool,specifically the benefits of empower-ment, assurance of quality care, pa-tient safety and satisfaction, nurseretention, and equitable team encouraged staff to pro-vide feedback on the new processand expect revisions to ensure its ef-fectiveness and sustainability.