The charge nurse is responsible for creating daily nurse/patient assignments, which are based on the patient’s location within a unit and the clinical judgment of the charge nurse.
THE PROBLEM
Assignments generally do not include an objective assessment of the patient’s workload or acuity. As a result, nurses may be responsible for multiple high-acuity patients simultaneously.
Nurses at Sentara Leigh Hospital were interested in a more objective approach to making nurse/patient assignments. They began evaluating nursing workload tools used in real time to guide these decisions.
“The existing literature has provided numerous examples of workload measurement tools in nursing,” says Kelsey Jones, RN, project coordinator of Sentara Health Patient Acuity Nursing Tool (PANT). “Each of these tools had its own strengths, such as using the electronic health record, identifying key elements of patient care and defining both direct and indirect elements of care.
“However, a number of limitations prevented the implementation of these tools at Sentara Leigh Hospital,” she noted. “These limitations include redundant manual data entry, assessments based only on retrospective data, and infrequent updates to workload assessments.”
Because patient census and workload requirements are constantly changing, nurse assignment models must be flexible and updated with near real-time patient information to form a daily decision support tool. As a result, nurses did not find an appropriate evidence-based system to identify patient workload and acuity based on objective data.
PROPOSAL
Historically, nurses have lacked a reliable method to measure and manage the complexity of care. Charge nurses created nursing assignments based on their judgment, daily patient count, and headcount at the start of each shift. This inconsistently took into account nursing workload and patient care needs.
“In 2016, two medical-surgical clinical nurses approached the hospital’s nursing research forum with a proposal to create a tool that would quantify patient workload and ensure fair distribution of patient care needs among nursing staff,” Jones recalls. “Approval for the project was obtained from the system’s chief nursing officer and the Nurse Executive Council.
“The CNO served as the executive sponsor of the project and integrated a nursing workload algorithm into the nursing strategic plan, allocating time and resources for development, testing, and integration within the healthcare system.”
An interprofessional team created an automated, rules-based algorithm (the Patient Acuity Nursing Tool, or PANT) to capture the time needed to provide safe, high-quality patient care in near real-time. The PANT development team included clinical nurses, a nurse project manager, EHR systems analysts, healthcare researchers, a biostatistician, and nurse scientist.
MEETING THE CHALLENGE
PANT is an internally developed algorithm unique to Sentara Health.
“The PANT team followed quality improvement methodology to design the PANT algorithm, involving clinical staff at every stage of development,” explains Jones. “First, the team identified nursing workloads based on nursing care standards and internal competency tools.
“The team worked with nursing staff and IT team members to determine the amount of time and EHR documentation associated with each workload item,” she continued. “The IT team members built the PANT algorithm and ran tests to confirm that the algorithm worked as expected. PANT team members worked with clinical nurse staff to validate that the patient-specific PANT score reflected the nursing workload that was carried out.”
Data analyst team members performed a series of descriptive analyzes (basic descriptive statistics describing workload data distribution, normality, missing data, and outliers) to validate the algorithm’s functionality.
“PANT has now been implemented in more than 100 inpatient units across all twelve hospitals within the Sentara system,” Jones reported. “The development of PANT educational materials – for example, tip sheets and computer-based learning modules – and the integration of PANT during orientation for nurse, supervisor and manager roles have improved awareness, knowledge and use of the algorithm.
“The PANT score is used by the charge nurse team to more equitably distribute daily patient assignments,” she continued. “Staff continue to use their clinical judgment and thorough knowledge of the needs of both patients and staff in conjunction with the objective PANT score.”
Nursing leadership uses the PANT score to better articulate nursing workload at the patient and department level. PANT data is included in multiple dashboards, allowing operations leaders to view real-time and historical or trend data.
RESULTS
An unbalanced or unevenly distributed workload and the feeling that there is insufficient time to complete nursing tasks can increase the risk of burnout and staff turnover. As the national nurse shortage continues, PANT is a data-driven tool that maximizes outcomes for patients and nurses, Jones said.
“The PANT tool has been extensively validated and found to accurately reflect nursing workload for patient populations in medical surgical, oncology, intermediate and critical care,” said Jones. “This workload score is used by clinical staff and leaders to inform decisions at an operational level.
“PANT workload scores were translated into nursing hours per patient day (NHPPD) and compared to the predetermined NHPPD defined in staff schedules,” she continued. “The comparison of PANT with the NHPPD staffing roster has informed the overall functionality of PANT. This is a unique feature of the tool and provides clarity on the differences between nursing units within the same nurse census and staffing matrix.”
ADVICE FOR OTHERS
“Interdisciplinary collaboration is key,” exclaimed Jones. “Creating a team that spans all areas – IT, data analytics and clinical – brings different perspectives. Involving frontline team members in tool design and development is essential to creating buy-in on user level and ultimately for project success.
“It is also important to connect the project to the organization’s strategic plan,” she added. “This ensures that the project receives support and organizational resources, which promotes success.”
Nursing workload tools help articulate the intensity of work performed by direct care staff, she said.
“The ability to articulate this helps promote understanding across non-clinical teams, informing conversations around patient needs, clinical workloads and traditionally designed census-based staffing systems,” she concluded.
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