AACN Advanced Critical Care Volume 25, Number 2, pp. 94–100 © 2014, AACN
Creating a Healthy
Workplace
Nancy Blake, RN, PhD, CCRN, NEA-BC Department Editor
Three Structures for a Healthy Work Environment Robert L. Dent, RN, DNP, MBA, NEA-BC, CENP Cori Armstead, RN, MSN, CEN Brenda Evans, RN, MSN, CCRN, CNML
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idland Memorial Hospital (MMH) is a 464-bed facility located in rural west Texas with a 48-bed critical care unit. Like many other organizations, sustaining a healthy work environment for our nursing staff is important, as we provide excellent care and services in a patient- and family-centered care delivery model. This column focuses on 3 primary structures that must exist to establish a healthy work environment, including leadership, design, and staffing. Each of the structures for a healthy work environment has been developed following a review of research and evidence-based practices showing improvement in outcomes. Leadership Structure Leadership is extremely important. Not only is leadership important to manage day-to-day operations, but it also is important to continually inspire people and constantly adjust to the changing environment. At MMH, we have incorporated a leadership structure that includes a divisional director, clinical managers, a dedicated educator, and a shared governance structure to address a healthy work environment. Clinical Management
A clinical manager is on duty 24 hours per day most days of the week, and approximately 4 are available per unit. Each manager works 12-hour shifts. Up to 80% of a clinical manager’s time is spent in the clinical environment rounding on employees, patients, and medical staff, assisting where needed. They spend up to 25% of their time completing administrative responsibilities. As part of the administrative responsibilities of the clinical manager, each of them supervises about 20 employees. The clinical manager completes a performance check-in with their employees at least quarterly. Other responsibilities are divided among the managers and include high-level pillars such as financial, quality, patient satisfaction, and employee indicators. Each clinical manager is the content expert in the area assigned to them.
Robert L. Dent is Vice President, Patient Care Services; Chief Nursing Officer, Midland Memorial Hospital; and Dean, Health Sciences Division, Midland College, 400 Rosalind Redfern Grover Pkwy, Midland, TX 79701 ([email protected]). Cori Armstead is Assistant Chief Nursing Officer, Midland Memorial Hospital, Midland, Texas. Brenda Evans is Director, Critical Care Services, Midland Memorial Hospital, Midland, Texas. The authors declare no conflicts of interest. DOI: 10.1097/NCI.0000000000000024
94 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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This structure fosters a healthy work environment through visibility, staff development, mentoring, adaptability, and shared decision making. The highly visible clinical manager supports relationship management and accountability through observation and skillful communication. The clinical managers develop a relationship of trust. Clinical performance and knowledge expertise demonstrated within clinical interactions are measured and documented. With employees, the clinical manager assists in creating a professional development plan individualized to the nurses’ learning needs. A unique awareness of a team’s ability to use or integrate technology into clinical processes that promote safe patient care is attained within the clinical manager structure. As some have said, “all within a 12-hour shift,” the clinical manager negotiates staffing, evaluates skill, and documents team performance within the patient care environment. This information is exchanged between shared management structures. The staff development and relationships processed during clinical manager interactions within the environment help them better respond to the patient care needs and cannot be found easily in other management structures. A feeling that “we can call the clinical manager to demonstrate any skill we are uncomfortable performing without supervision” is repeatedly verbalized. This type of clinical learning environment fosters mentoring and staff development. Overall, the clinical manager structure promotes patient safety and employee satisfaction.
Each unit has its own unit-based council, which is chaired by a frontline nurse and cochaired by a clinical manager. In the unit-based council, the relationships of the clinical managers and frontline staff actively affect the environment of the department. Here, everyone knows what is happening within the department with outcomes (eg, finance, quality, patient experience, and people). This team creates action plans for improvement and plans for recognitions and celebrations. The unit-based council selects its representatives to the organizationwide shared governance councils. The organization-wide shared governance council, Exemplary Professional Practice Council, chose the AACN Synergy Model for Patient Care1 in 2009 as the care delivery model. The core concept of this care delivery model is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. Synergy results when the needs and characteristics of a patient are matched with a nurse’s competencies.1 The clinical manager strategically matches the needs of the patient with the right nurse using electronic tools. Electronic Tools
Midland Memorial Hospital implemented a comprehensive electronic medical record with computerized physician order entry and barcode medication administration in early 2007. Over time, we integrated a learning management system, an electronic staffing scheduling system, and a patient classification system. Nurses’ documentation was mapped to the patient classification system using Nursing Outcomes Classification2 for acuity-based assignments. A challenge to overcome is having the documentation done in real time or within the same timeframe care is provided to optimally staff in real time. Addressing staffing resources is discussed later in this column. The learning management system captures the competencies of the staff as well as continuing nursing education, certifications, and other information describing the nurses’ passions related to nursing and nursing care. Synergy happens as the clinical manager understands the frontline staff, understands the nurses’ fervor for nursing care, and makes assignments based on matching the patients’ and families’ needs with the right nurse. Day to day, the clinical manager is acutely aware of a nurse’s performance at the bedside, allowing for true identification of educational
Shared Governance Structure
In 2008, a shared governance structure was created for organization-wide frontline clinical staff engagement in the environment in which nurses practice. Shared governance has the capacity to improve the work environment, practice, and the patient’s experience. Council members serve 2-year terms and are eligible to chair the council their second year. Each of the organization-wide shared governance councils is chaired by a frontline nurse and cochaired by a clinical manager. Each council has a director liaison and is made up of at least 50% frontline staff, except the Nurse Staffing Advisory Council (NSAC), which is composed of 60% frontline registered nurses. More on the NSAC is shared later in this column. However, the strongest part of the shared governance structure is the unit-based council (Figure 1). 95
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Figure 1: Midland Memorial Hospital shared governance structure. This figure is available in color in the article on the journal website, www.aacnadvancedcriticalcare.com, and the iPad.
needs as well as clinical ability and readiness for the next level in learning and skill development. The clinical manager acts as a mentor and guides the clinical experiences that could otherwise jeopardize the safety of the patient. The clinical manager and the frontline nurse work with the educator for ongoing staff development. The leadership structure, including shared governance and technology tools, supports a healthy working environment that enhances patient safety, nursing quality, and service outcomes.
included in the design of the building and their units. The process of design began years earlier and included many site visits to understand what we really wanted in the units to provide the best possible care for our patients and their families. Mock rooms were created; staff studied them and made recommendations for change, as needed. Healthy work environments have many integral components, including architectural design, technological resources, and patient care equipment to minimize physical stress on care providers. The design at MMH placed significant emphasis on increasing staff efficiency. Each unit’s design minimizes distances
Design Structure Midland Memorial Hospital opened a new patient tower in December 2012. Staff was 96
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between essential care function locations, thereby increasing provider efficiency and reducing provider fatigue and walking distances. Each patient room incorporates healing aspects of natural sunlight through large plate-glass windows and soothing color schemes.
Patient Care Equipment
Ceiling-mounted patient care lifts are installed in every patient room to reduce the risk of workplace injuries from patient transfers or repositioning. Nurses and other staff are trained to use the lifts for bedside transfers, elevating extremities to provide wound care or to simply reposition the patient in the bed. In the bariatric rooms, the patient lifts extend into the bathrooms and shower area. Since the implementation of Safe Patient Handling Initiatives in December 2012, the number of work-related back injuries has decreased significantly. As we opened our new tower, we were excited, yet still met some challenges. Although we spent considerable time with all departments on workflow, after moving into the tower, many processes had to be improved. Approximately 3 to 6 months were required to work out the nuances of the new work environment. Some things could not be anticipated until we were in the new building and experienced the new work flows and equipment. The interdisciplinary teams worked hard to get back to a state of normalcy during a time of year we generally experience our highest volumes.
Architectural Design
Patient rooms are located on the outside perimeter of each floor, with utility rooms in the center core, providing accessibility from all patient room hallways. Each floor is constructed with a medication room, clean utility stockroom, soiled utility containment room, and nourishment room for every 12 to 17 beds. The design promotes increased nursing time with patients and families by minimizing the distance to access patient care supplies. In addition to the proximity of supplies, alcoves outside every patient room were included in the design to further promote staff efficiency. Technology Resources
Each alcove includes windows with enclosed blinds to provide a direct view into each patient room. The alcoves have a computer, desk phone, and medicine cabinet to secure patients’ daily medications directly outside their rooms. This design enables nurses to document without returning to a central nurses’ station and provides for additional patient monitoring without disturbing the patient. The alcove pharmacy cabinets are secured with radio frequency identification (RFID) readers limiting access only to providers with approved privileges. At the beginning of the shift, nurses pull the scheduled patient medications from centrally located medication rooms and secure them in the alcove cabinets. Computer documentation stations also are located in each patient room to facilitate real-time documentation and opportunities to share diagnostic results with patients and their family members. At each bedside is a vital sign machine interfaced with the electronic medical record. The nurses no longer have to write the vital signs down and then place them into the patient’s record. It is now done real time. A barcode scanner has been installed for medication administration at every bedside. Essentially, as we designed the building, we conscientiously made an effort to reduce the amount of time staff were hunting and gathering supplies and equipment to provide care. We placed those items as close to the patient as possible.
Staffing Structure Much has been done during the past several years to improve staffing resources available to nursing units. In this section, we give a historical perspective of staffing resources, what has been done to improve them, and how we came to the decisions we made. Prior to 2010, the MMH budgeted to benchmarks in the National Database of Nursing Quality Indicators (NDNQI), which is a program of the American Nurses Association and is administered on behalf of the American Nurses Association by The University of Kansas School of Nursing.3 From 2010 to 2013, we increased our budgeted nursing hours per patient day from the 25th percentile to the 50th percentile of NDNQI participating hospitals. In fiscal year 2014, beginning in October 2013, we again increased the budgeted nursing hours per patient day to the NDNQI 75th percentile, with a minimum staffing guideline at the NDNQI 25th percentile. Next, we discuss the resources and incentives available to the critical care unit to achieve at least the 25th percentile and, optimally, the now budgeted 75th percentile. Midland Memorial Hospital historically spent more than $4 million per year in agency staffing. In 2007, we created an internal Resource Team and “Grab Bag Incentives” for staff. The 97
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Resource Team consists of nursing staff required to work 1 weekday shift and 1 weekend shift per month and 1 minor holiday and 1 major holiday per year. These nurses work in areas of their competency as needed. The Grab Gag Incentive is a criterion-met (eg, vacancies, volume) and time-limited (usually 13 weeks) monetary incentive for nursing staff to pick up additional shifts or to change shifts to meet a particular need. In 2008, after studying best practices, we executed a campaign to recruit 80 nurses in 80 days. We surpassed our goal and ended the use of external agency staffing on a regular basis. For years, we have limited the use of travel nurses to only cover for peak census and anticipated Family Medical Leave time. The use of travel nurses is planned and truly short term.
for nurse staffing and the desired outcomes. A budget was established and supported by members of NSAC and the executive staff. Dent then defended the staffing budget through presentations to the Finance Committee of the Board, Board of Trustees, and Board of Directors. The budget was approved to be effective October 1, 2013, for the new fiscal year. Dent held an MMH Nurse Staffing Conference with members of the NSAC and nursing leadership group comprising nursing directors, clinical managers, and educators. The conference’s objectives included a review and discussion of the literature related to nurse staffing, a review of the fiscal year 2014 staffing guidelines, an illustration of the predictive and proactive staffing with self-scheduling, an illustration on making assignments on the basis of acuity, and establishment of a link between the working environments and staffing guidelines to expected outcomes. Many nurse staffing publications were discussed, but clearly the one that had the greatest impact on the MMH’s decision to staff to the NDNQI 75th percentile was the study published by Needleman and colleagues.4 In their landmark 2002 study of 799 hospitals, Needleman and colleagues4 found that improving the registered nurse skill mix to the NDNQI 75th percentile resulted in reductions in length of stay and adverse outcomes. Once the budget was approved and before beginning the new fiscal year, Dent met with Cori Armstead, assistant chief nursing officer, the human resources director, and each nursing director individually to review and balance position control. In addition to improving the position control to reflect the NDNQI 75th percentile, we planned for a 12% turnover rate. Therefore, in addition to creating positions to reflect the 75th percentile, additional “on-boarding positions” were created and established by division. For example, a 12% turnover rate was established for the critical care unit combined with the forecasted turnover of the emergency department. Those hired into the on-boarding positions will loop through each area and will be placed in the next available open position, which reduces the amount of time to fill a vacancy.
Improving Staffing Numbers
In 2010, in an effort to continually improve our nurse-sensitive outcomes, we budgeted our staffing at the NDNQI 50th percentile. Quarterly reports are made to the NSAC. These reports consist of the nursing hours per patient day, nurse-sensitive quality outcomes as reported from NDNQI, and other pertinent items. This council creates a charter each year to improve something that is meaningful for the council related to nurse staffing. After a review of the current internal and external landscape of health care, the team brainstorms all ideas to improve the environment related to nurse staffing and nurse outcomes. After the brainstorming session, each member of the council chooses his or her top 3 choices to work on within the next year. The council takes the top choice to create a charter. Once a charter is completed, the council moves to the next top choice for improvement focus. During 2013, members of the NSAC began reviewing evidence-based staffing articles and research publications. It was evident from our review of these publications that MMH should budget to the NDNQI 75th percentile to achieve optimal outcomes with patient satisfaction and nurse-sensitive quality indicators. The now minimum staffing guideline was established at the NDNQI 25th percentile, our absolute minimum for patient care. As part of MMH’s executive staff, Robert Dent, vice president, Patient Care Services, and chief nursing officer, reviewed the evidence with the nursing directors and with the NSAC. Once a shared vision for staffing was established, Dent met with members of the executive staff, in particular the chief executive officer and chief financial officer, to review the vision
Additional Staff Resources
Midland Memorial Hospital nursing leaders are strong supporters of The Future of Nursing report published in 2010 by the Institute of Medicine.5 As such, MMH supports nursing 98
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staff through tuition assistance and other processes for nurses to obtain their bachelor of science degrees in nursing (BSNs). From 2007 to 2013, the number of BSNs or higher has increased from less than 10% to approximately 40%. In addition, MMH supports a nurse residency program to improve the gap between nursing school and the practice environment. The nurse residency program has improved our recruitment and retention of new graduate nurses. Midland Memorial Hospital nursing leaders were early adopters of fatigue management guidelines. Dent served on the Practice Committee of the Texas Nurses Association, where he was introduced to the literature on fatigue and patient safety implications. A charter was created to address fatigue management, and a subcommittee was formed to review the literature and to propose a Fatigue Management Guideline for direct patient caregivers (Appendix).6 The staffing structure is multifaceted. Using the many evidence-based best practices, and staffing studies that have been published, we believe that we have created a staffing structure that works. The staffing structure includes the following: • Self-scheduling within an electronic staffing and scheduling system • Acuity-based assignments using a patient classification system mapped from our electronic medical record with Nursing Outcomes Classification • Position control based on an NDNQI 75th percentile
• Forecasting turnover at a predetermined rate and prehiring into on-boarding positions • An established internal Resource Team • Incentives for staff to pick up additional shifts • A fatigue management guideline. Summary We have identified 3 structures to create and sustain a healthy work environment. Each health care environment is complex. Not all patients are the same, not all nurses are the same, and not all cultures and environments are the same. Midland Memorial Hospital nursing leaders will continue to review and understand the literature, to improve nursing practice. Our leaders have a strong desire to create and sustain a healthy work environment for our nursing staff, thereby providing a great patient care experience with optimal nurse-sensitive outcomes. REFERENCES 1. American Association of Critical-Care Nurses. The AACN Synergy Model for Patient Care. http://www.aacn.org/wd/ certifications/content/synmodel.pcms. Published 2013. Accessed December 17, 2013. 2. Mosby Inc. Nursing Outcomes Classification (NOC), Fourth Edition. St Louis, MO: Elsevier Inc; 2008. 3. NDNQI. About NDNQI. http://www.nursingquality.org/ About-NDNQI#get-started. Published 2013. Accessed December 17, 2013. 4. Needleman J, Buerhaus PI, Stewart M, et al. Nurse staffing in hospitals: is there a business case for quality? Health Affairs. 2006;25(1):204–211. 5. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. 6. Eck Birmingham S, Dent RL, Ellerbe S. Reducing the impact of RN fatigue on patient and nurse safety. Nurse Leader. 2013;11(6):31–34.
Appendix: Midland Memorial Hospital’s Fatigue Management Guideline GUIDELINE TITLE: FATIGUE MANAGEMENT—Direct Patient Caregivers PURPOSE: To provide a strategy that recognizes and manages the potential negative consequences of sleep deprivation and sustained work hours on patient outcomes and staff well-being. GUIDELINE: The direct patient caregiver is responsible and accountable for individual practice and understanding the consequences of fatigue in preserving integrity and safety. Guidelines for length of hours worked and number of hours worked in a patient care assignment during a period of seven days will be followed. DEFINITIONS: On-call: A designated period of time, outside of the designated hours assigned, or of the designated hours of operation, when direct patient caregivers are available to respond to patient care needs for unplanned circumstances or urgent or emergent conditions. 99 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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Call hours worked: Actual time the on-call personnel are called into the hospital to work. Extended work period/sustained work hours: Work periods of more than 12.5 hours with limited opportunities to rest or sleep. Extended hours worked per week: Any hours in excess of 60 hours per week. Fatigue: A response to predefined conditions that has physiological and performance consequences. It is identified as deterioration in human performance arising as a consequence of changes in the physiological condition. Contributing factors include, but are not limited to: time on task, time and duty period duration, and time since awake when beginning the duty period, acute or chronic sleep debt, circadian disruption, multiple time zones, and shift work. Circadian rhythm: 24-hour cycle of behavior and physiology generated by an internal biological clock located in the hypothalamus. It regulates the daily cyclical patterns of sleep and wakefulness. It compels the body to fall asleep and wake up and regulates hour to hour waking behavior reflected in fatigue, alertness, and cognitive ability. Off Duty: A period of uninterrupted time during which an individual is free from work-related duties. GUIDELINES: 1. Except in emergency situations, direct patient caregivers should not work in direct patient care assignments more than 12.5 consecutive hours in a 24-hour period, not more than 60 hours in a 7-day period, and not scheduled more than three consecutive 12-hour shifts. Working outside of these parameters requires Manager and/or Director approval. 2. Off-duty periods should be inclusive of an uninterrupted sleep cycle, a break from continuous professional responsibilities, and a period of time of not less than 8 hours to perform activities of daily living. 3. Arrangements will be made in relation to the hours worked, to provide additional time off for direct patient caregivers working a longer shift, an extra shift, or hours worked on-call to accommodate an adequate off-duty recuperation period. 4. The number of shifts, or on-call shifts, assigned during a 7-day period should reflect the above guidelines as to number of sustained work hours and adequate recuperation periods. 5. An individual’s ability to meet an increased work demand should be taken into account. 6. All direct patient caregivers should uphold their ethical responsibility to patients and to themselves to arrive at work adequately rested and prepared for duty. 7. In extreme conditions (ie, surge management or a disaster), staff may be asked to work additional hours, following the above guidelines for fatigue management. 8. Leaders have a responsibility to monitor staff fatigue, provide breaks, and release staff as soon as possible. RESOURCES: Bosek, M. S. (2001). Mandatory overtime: Professional duty, harms, and justice. JONAS Healthcare Law Ethics Regulations, 3(4), 99-102. Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. American Operating Room Nurse, 87(6), 1191-1204. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment for nurses. Washington, DC: The National Academies Press. Rogers, A. E., Hwang, W. T., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs (Millwood), 23(4), 202-212. Trinkoff, A. M., Le, R., Geiger-Brown, J., & Lipscomb, J. (2007). Work schedule, needle use, and needlestick injuries among registered nurses. Infection Control and Hospital Epidemiology, 28(2), 156-164.
100 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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Nancy Blake, RN, PhD, CCRN, NEA-BC Department Editor
Three Structures for a Healthy Work Environment Robert L. Dent, RN, DNP, MBA, NEA-BC, CENP Cori Armstead, RN, MSN, CEN Brenda Evans, RN, MSN, CCRN, CNML
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idland Memorial Hospital (MMH) is a 464-bed facility located in rural west Texas with a 48-bed critical care unit. Like many other organizations, sustaining a healthy work environment for our nursing staff is important, as we provide excellent care and services in a patient- and family-centered care delivery model. This column focuses on 3 primary structures that must exist to establish a healthy work environment, including leadership, design, and staffing. Each of the structures for a healthy work environment has been developed following a review of research and evidence-based practices showing improvement in outcomes. Leadership Structure Leadership is extremely important. Not only is leadership important to manage day-to-day operations, but it also is important to continually inspire people and constantly adjust to the changing environment. At MMH, we have incorporated a leadership structure that includes a divisional director, clinical managers, a dedicated educator, and a shared governance structure to address a healthy work environment. Clinical Management
A clinical manager is on duty 24 hours per day most days of the week, and approximately 4 are available per unit. Each manager works 12-hour shifts. Up to 80% of a clinical manager’s time is spent in the clinical environment rounding on employees, patients, and medical staff, assisting where needed. They spend up to 25% of their time completing administrative responsibilities. As part of the administrative responsibilities of the clinical manager, each of them supervises about 20 employees. The clinical manager completes a performance check-in with their employees at least quarterly. Other responsibilities are divided among the managers and include high-level pillars such as financial, quality, patient satisfaction, and employee indicators. Each clinical manager is the content expert in the area assigned to them.
Robert L. Dent is Vice President, Patient Care Services; Chief Nursing Officer, Midland Memorial Hospital; and Dean, Health Sciences Division, Midland College, 400 Rosalind Redfern Grover Pkwy, Midland, TX 79701 ([email protected]). Cori Armstead is Assistant Chief Nursing Officer, Midland Memorial Hospital, Midland, Texas. Brenda Evans is Director, Critical Care Services, Midland Memorial Hospital, Midland, Texas. The authors declare no conflicts of interest. DOI: 10.1097/NCI.0000000000000024
94 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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This structure fosters a healthy work environment through visibility, staff development, mentoring, adaptability, and shared decision making. The highly visible clinical manager supports relationship management and accountability through observation and skillful communication. The clinical managers develop a relationship of trust. Clinical performance and knowledge expertise demonstrated within clinical interactions are measured and documented. With employees, the clinical manager assists in creating a professional development plan individualized to the nurses’ learning needs. A unique awareness of a team’s ability to use or integrate technology into clinical processes that promote safe patient care is attained within the clinical manager structure. As some have said, “all within a 12-hour shift,” the clinical manager negotiates staffing, evaluates skill, and documents team performance within the patient care environment. This information is exchanged between shared management structures. The staff development and relationships processed during clinical manager interactions within the environment help them better respond to the patient care needs and cannot be found easily in other management structures. A feeling that “we can call the clinical manager to demonstrate any skill we are uncomfortable performing without supervision” is repeatedly verbalized. This type of clinical learning environment fosters mentoring and staff development. Overall, the clinical manager structure promotes patient safety and employee satisfaction.
Each unit has its own unit-based council, which is chaired by a frontline nurse and cochaired by a clinical manager. In the unit-based council, the relationships of the clinical managers and frontline staff actively affect the environment of the department. Here, everyone knows what is happening within the department with outcomes (eg, finance, quality, patient experience, and people). This team creates action plans for improvement and plans for recognitions and celebrations. The unit-based council selects its representatives to the organizationwide shared governance councils. The organization-wide shared governance council, Exemplary Professional Practice Council, chose the AACN Synergy Model for Patient Care1 in 2009 as the care delivery model. The core concept of this care delivery model is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. Synergy results when the needs and characteristics of a patient are matched with a nurse’s competencies.1 The clinical manager strategically matches the needs of the patient with the right nurse using electronic tools. Electronic Tools
Midland Memorial Hospital implemented a comprehensive electronic medical record with computerized physician order entry and barcode medication administration in early 2007. Over time, we integrated a learning management system, an electronic staffing scheduling system, and a patient classification system. Nurses’ documentation was mapped to the patient classification system using Nursing Outcomes Classification2 for acuity-based assignments. A challenge to overcome is having the documentation done in real time or within the same timeframe care is provided to optimally staff in real time. Addressing staffing resources is discussed later in this column. The learning management system captures the competencies of the staff as well as continuing nursing education, certifications, and other information describing the nurses’ passions related to nursing and nursing care. Synergy happens as the clinical manager understands the frontline staff, understands the nurses’ fervor for nursing care, and makes assignments based on matching the patients’ and families’ needs with the right nurse. Day to day, the clinical manager is acutely aware of a nurse’s performance at the bedside, allowing for true identification of educational
Shared Governance Structure
In 2008, a shared governance structure was created for organization-wide frontline clinical staff engagement in the environment in which nurses practice. Shared governance has the capacity to improve the work environment, practice, and the patient’s experience. Council members serve 2-year terms and are eligible to chair the council their second year. Each of the organization-wide shared governance councils is chaired by a frontline nurse and cochaired by a clinical manager. Each council has a director liaison and is made up of at least 50% frontline staff, except the Nurse Staffing Advisory Council (NSAC), which is composed of 60% frontline registered nurses. More on the NSAC is shared later in this column. However, the strongest part of the shared governance structure is the unit-based council (Figure 1). 95
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Figure 1: Midland Memorial Hospital shared governance structure. This figure is available in color in the article on the journal website, www.aacnadvancedcriticalcare.com, and the iPad.
needs as well as clinical ability and readiness for the next level in learning and skill development. The clinical manager acts as a mentor and guides the clinical experiences that could otherwise jeopardize the safety of the patient. The clinical manager and the frontline nurse work with the educator for ongoing staff development. The leadership structure, including shared governance and technology tools, supports a healthy working environment that enhances patient safety, nursing quality, and service outcomes.
included in the design of the building and their units. The process of design began years earlier and included many site visits to understand what we really wanted in the units to provide the best possible care for our patients and their families. Mock rooms were created; staff studied them and made recommendations for change, as needed. Healthy work environments have many integral components, including architectural design, technological resources, and patient care equipment to minimize physical stress on care providers. The design at MMH placed significant emphasis on increasing staff efficiency. Each unit’s design minimizes distances
Design Structure Midland Memorial Hospital opened a new patient tower in December 2012. Staff was 96
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between essential care function locations, thereby increasing provider efficiency and reducing provider fatigue and walking distances. Each patient room incorporates healing aspects of natural sunlight through large plate-glass windows and soothing color schemes.
Patient Care Equipment
Ceiling-mounted patient care lifts are installed in every patient room to reduce the risk of workplace injuries from patient transfers or repositioning. Nurses and other staff are trained to use the lifts for bedside transfers, elevating extremities to provide wound care or to simply reposition the patient in the bed. In the bariatric rooms, the patient lifts extend into the bathrooms and shower area. Since the implementation of Safe Patient Handling Initiatives in December 2012, the number of work-related back injuries has decreased significantly. As we opened our new tower, we were excited, yet still met some challenges. Although we spent considerable time with all departments on workflow, after moving into the tower, many processes had to be improved. Approximately 3 to 6 months were required to work out the nuances of the new work environment. Some things could not be anticipated until we were in the new building and experienced the new work flows and equipment. The interdisciplinary teams worked hard to get back to a state of normalcy during a time of year we generally experience our highest volumes.
Architectural Design
Patient rooms are located on the outside perimeter of each floor, with utility rooms in the center core, providing accessibility from all patient room hallways. Each floor is constructed with a medication room, clean utility stockroom, soiled utility containment room, and nourishment room for every 12 to 17 beds. The design promotes increased nursing time with patients and families by minimizing the distance to access patient care supplies. In addition to the proximity of supplies, alcoves outside every patient room were included in the design to further promote staff efficiency. Technology Resources
Each alcove includes windows with enclosed blinds to provide a direct view into each patient room. The alcoves have a computer, desk phone, and medicine cabinet to secure patients’ daily medications directly outside their rooms. This design enables nurses to document without returning to a central nurses’ station and provides for additional patient monitoring without disturbing the patient. The alcove pharmacy cabinets are secured with radio frequency identification (RFID) readers limiting access only to providers with approved privileges. At the beginning of the shift, nurses pull the scheduled patient medications from centrally located medication rooms and secure them in the alcove cabinets. Computer documentation stations also are located in each patient room to facilitate real-time documentation and opportunities to share diagnostic results with patients and their family members. At each bedside is a vital sign machine interfaced with the electronic medical record. The nurses no longer have to write the vital signs down and then place them into the patient’s record. It is now done real time. A barcode scanner has been installed for medication administration at every bedside. Essentially, as we designed the building, we conscientiously made an effort to reduce the amount of time staff were hunting and gathering supplies and equipment to provide care. We placed those items as close to the patient as possible.
Staffing Structure Much has been done during the past several years to improve staffing resources available to nursing units. In this section, we give a historical perspective of staffing resources, what has been done to improve them, and how we came to the decisions we made. Prior to 2010, the MMH budgeted to benchmarks in the National Database of Nursing Quality Indicators (NDNQI), which is a program of the American Nurses Association and is administered on behalf of the American Nurses Association by The University of Kansas School of Nursing.3 From 2010 to 2013, we increased our budgeted nursing hours per patient day from the 25th percentile to the 50th percentile of NDNQI participating hospitals. In fiscal year 2014, beginning in October 2013, we again increased the budgeted nursing hours per patient day to the NDNQI 75th percentile, with a minimum staffing guideline at the NDNQI 25th percentile. Next, we discuss the resources and incentives available to the critical care unit to achieve at least the 25th percentile and, optimally, the now budgeted 75th percentile. Midland Memorial Hospital historically spent more than $4 million per year in agency staffing. In 2007, we created an internal Resource Team and “Grab Bag Incentives” for staff. The 97
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Resource Team consists of nursing staff required to work 1 weekday shift and 1 weekend shift per month and 1 minor holiday and 1 major holiday per year. These nurses work in areas of their competency as needed. The Grab Gag Incentive is a criterion-met (eg, vacancies, volume) and time-limited (usually 13 weeks) monetary incentive for nursing staff to pick up additional shifts or to change shifts to meet a particular need. In 2008, after studying best practices, we executed a campaign to recruit 80 nurses in 80 days. We surpassed our goal and ended the use of external agency staffing on a regular basis. For years, we have limited the use of travel nurses to only cover for peak census and anticipated Family Medical Leave time. The use of travel nurses is planned and truly short term.
for nurse staffing and the desired outcomes. A budget was established and supported by members of NSAC and the executive staff. Dent then defended the staffing budget through presentations to the Finance Committee of the Board, Board of Trustees, and Board of Directors. The budget was approved to be effective October 1, 2013, for the new fiscal year. Dent held an MMH Nurse Staffing Conference with members of the NSAC and nursing leadership group comprising nursing directors, clinical managers, and educators. The conference’s objectives included a review and discussion of the literature related to nurse staffing, a review of the fiscal year 2014 staffing guidelines, an illustration of the predictive and proactive staffing with self-scheduling, an illustration on making assignments on the basis of acuity, and establishment of a link between the working environments and staffing guidelines to expected outcomes. Many nurse staffing publications were discussed, but clearly the one that had the greatest impact on the MMH’s decision to staff to the NDNQI 75th percentile was the study published by Needleman and colleagues.4 In their landmark 2002 study of 799 hospitals, Needleman and colleagues4 found that improving the registered nurse skill mix to the NDNQI 75th percentile resulted in reductions in length of stay and adverse outcomes. Once the budget was approved and before beginning the new fiscal year, Dent met with Cori Armstead, assistant chief nursing officer, the human resources director, and each nursing director individually to review and balance position control. In addition to improving the position control to reflect the NDNQI 75th percentile, we planned for a 12% turnover rate. Therefore, in addition to creating positions to reflect the 75th percentile, additional “on-boarding positions” were created and established by division. For example, a 12% turnover rate was established for the critical care unit combined with the forecasted turnover of the emergency department. Those hired into the on-boarding positions will loop through each area and will be placed in the next available open position, which reduces the amount of time to fill a vacancy.
Improving Staffing Numbers
In 2010, in an effort to continually improve our nurse-sensitive outcomes, we budgeted our staffing at the NDNQI 50th percentile. Quarterly reports are made to the NSAC. These reports consist of the nursing hours per patient day, nurse-sensitive quality outcomes as reported from NDNQI, and other pertinent items. This council creates a charter each year to improve something that is meaningful for the council related to nurse staffing. After a review of the current internal and external landscape of health care, the team brainstorms all ideas to improve the environment related to nurse staffing and nurse outcomes. After the brainstorming session, each member of the council chooses his or her top 3 choices to work on within the next year. The council takes the top choice to create a charter. Once a charter is completed, the council moves to the next top choice for improvement focus. During 2013, members of the NSAC began reviewing evidence-based staffing articles and research publications. It was evident from our review of these publications that MMH should budget to the NDNQI 75th percentile to achieve optimal outcomes with patient satisfaction and nurse-sensitive quality indicators. The now minimum staffing guideline was established at the NDNQI 25th percentile, our absolute minimum for patient care. As part of MMH’s executive staff, Robert Dent, vice president, Patient Care Services, and chief nursing officer, reviewed the evidence with the nursing directors and with the NSAC. Once a shared vision for staffing was established, Dent met with members of the executive staff, in particular the chief executive officer and chief financial officer, to review the vision
Additional Staff Resources
Midland Memorial Hospital nursing leaders are strong supporters of The Future of Nursing report published in 2010 by the Institute of Medicine.5 As such, MMH supports nursing 98
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staff through tuition assistance and other processes for nurses to obtain their bachelor of science degrees in nursing (BSNs). From 2007 to 2013, the number of BSNs or higher has increased from less than 10% to approximately 40%. In addition, MMH supports a nurse residency program to improve the gap between nursing school and the practice environment. The nurse residency program has improved our recruitment and retention of new graduate nurses. Midland Memorial Hospital nursing leaders were early adopters of fatigue management guidelines. Dent served on the Practice Committee of the Texas Nurses Association, where he was introduced to the literature on fatigue and patient safety implications. A charter was created to address fatigue management, and a subcommittee was formed to review the literature and to propose a Fatigue Management Guideline for direct patient caregivers (Appendix).6 The staffing structure is multifaceted. Using the many evidence-based best practices, and staffing studies that have been published, we believe that we have created a staffing structure that works. The staffing structure includes the following: • Self-scheduling within an electronic staffing and scheduling system • Acuity-based assignments using a patient classification system mapped from our electronic medical record with Nursing Outcomes Classification • Position control based on an NDNQI 75th percentile
• Forecasting turnover at a predetermined rate and prehiring into on-boarding positions • An established internal Resource Team • Incentives for staff to pick up additional shifts • A fatigue management guideline. Summary We have identified 3 structures to create and sustain a healthy work environment. Each health care environment is complex. Not all patients are the same, not all nurses are the same, and not all cultures and environments are the same. Midland Memorial Hospital nursing leaders will continue to review and understand the literature, to improve nursing practice. Our leaders have a strong desire to create and sustain a healthy work environment for our nursing staff, thereby providing a great patient care experience with optimal nurse-sensitive outcomes. REFERENCES 1. American Association of Critical-Care Nurses. The AACN Synergy Model for Patient Care. http://www.aacn.org/wd/ certifications/content/synmodel.pcms. Published 2013. Accessed December 17, 2013. 2. Mosby Inc. Nursing Outcomes Classification (NOC), Fourth Edition. St Louis, MO: Elsevier Inc; 2008. 3. NDNQI. About NDNQI. http://www.nursingquality.org/ About-NDNQI#get-started. Published 2013. Accessed December 17, 2013. 4. Needleman J, Buerhaus PI, Stewart M, et al. Nurse staffing in hospitals: is there a business case for quality? Health Affairs. 2006;25(1):204–211. 5. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. 6. Eck Birmingham S, Dent RL, Ellerbe S. Reducing the impact of RN fatigue on patient and nurse safety. Nurse Leader. 2013;11(6):31–34.
Appendix: Midland Memorial Hospital’s Fatigue Management Guideline GUIDELINE TITLE: FATIGUE MANAGEMENT—Direct Patient Caregivers PURPOSE: To provide a strategy that recognizes and manages the potential negative consequences of sleep deprivation and sustained work hours on patient outcomes and staff well-being. GUIDELINE: The direct patient caregiver is responsible and accountable for individual practice and understanding the consequences of fatigue in preserving integrity and safety. Guidelines for length of hours worked and number of hours worked in a patient care assignment during a period of seven days will be followed. DEFINITIONS: On-call: A designated period of time, outside of the designated hours assigned, or of the designated hours of operation, when direct patient caregivers are available to respond to patient care needs for unplanned circumstances or urgent or emergent conditions. 99 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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Call hours worked: Actual time the on-call personnel are called into the hospital to work. Extended work period/sustained work hours: Work periods of more than 12.5 hours with limited opportunities to rest or sleep. Extended hours worked per week: Any hours in excess of 60 hours per week. Fatigue: A response to predefined conditions that has physiological and performance consequences. It is identified as deterioration in human performance arising as a consequence of changes in the physiological condition. Contributing factors include, but are not limited to: time on task, time and duty period duration, and time since awake when beginning the duty period, acute or chronic sleep debt, circadian disruption, multiple time zones, and shift work. Circadian rhythm: 24-hour cycle of behavior and physiology generated by an internal biological clock located in the hypothalamus. It regulates the daily cyclical patterns of sleep and wakefulness. It compels the body to fall asleep and wake up and regulates hour to hour waking behavior reflected in fatigue, alertness, and cognitive ability. Off Duty: A period of uninterrupted time during which an individual is free from work-related duties. GUIDELINES: 1. Except in emergency situations, direct patient caregivers should not work in direct patient care assignments more than 12.5 consecutive hours in a 24-hour period, not more than 60 hours in a 7-day period, and not scheduled more than three consecutive 12-hour shifts. Working outside of these parameters requires Manager and/or Director approval. 2. Off-duty periods should be inclusive of an uninterrupted sleep cycle, a break from continuous professional responsibilities, and a period of time of not less than 8 hours to perform activities of daily living. 3. Arrangements will be made in relation to the hours worked, to provide additional time off for direct patient caregivers working a longer shift, an extra shift, or hours worked on-call to accommodate an adequate off-duty recuperation period. 4. The number of shifts, or on-call shifts, assigned during a 7-day period should reflect the above guidelines as to number of sustained work hours and adequate recuperation periods. 5. An individual’s ability to meet an increased work demand should be taken into account. 6. All direct patient caregivers should uphold their ethical responsibility to patients and to themselves to arrive at work adequately rested and prepared for duty. 7. In extreme conditions (ie, surge management or a disaster), staff may be asked to work additional hours, following the above guidelines for fatigue management. 8. Leaders have a responsibility to monitor staff fatigue, provide breaks, and release staff as soon as possible. RESOURCES: Bosek, M. S. (2001). Mandatory overtime: Professional duty, harms, and justice. JONAS Healthcare Law Ethics Regulations, 3(4), 99-102. Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. American Operating Room Nurse, 87(6), 1191-1204. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment for nurses. Washington, DC: The National Academies Press. Rogers, A. E., Hwang, W. T., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs (Millwood), 23(4), 202-212. Trinkoff, A. M., Le, R., Geiger-Brown, J., & Lipscomb, J. (2007). Work schedule, needle use, and needlestick injuries among registered nurses. Infection Control and Hospital Epidemiology, 28(2), 156-164.
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