Exemplary Professional Practice Source of Evidence - EP9

Nurses are involved in staffing and scheduling based on established guidelines, such as ANA's Principles for Nurse Staffing, to ensure that RN assignments meet the needs of the patient population.

EP9: Provide two examples, with supporting evidence, from different practice settings when input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate for a change in patient acuity, patient population, resources, or redesign of care.

According to the American Nurses Association Principles for Nurse Staffing (2012): 1. Appropriate nurse staffing is critical to the delivery of quality, cost-effective health

care.2. All settings should have well-developed staffing guidelines with measurable

nurse sensitive outcomes specific to that setting and healthcare consumerpopulation that are used as evidence to guide daily staffing.

Example a: Modifying RN staffing assignments in the Oncology Unit

The Oncology Nursing Society (ONS) does not make specific recommendations for Oncology staffing ratios, suggesting instead that staffing be based on patient acuity, the skill and experience of the RN, and available ancillary staff and technology (ONS [Lamkin], 2005).

The Medical Oncology Unit, 5M, is a 36-bed inpatient unit at our Hopewell campus that cares for patients with a variety of medical and oncology related conditions. The staffing ratio on this unit, usually, is one to six. This ratio is often adjusted to ensure qualitypatient care and safe administration of chemotherapy, and can range from one to five toone to one for acute patients with multiple additional medications.

Communication is a key factor in adjusting staffing ratios. Licensed Independent Practitioners (LIPs) provide 24-hour notification of chemotherapy orders, whenever possible. The LIP alerts the charge nurse of any additional medications or procedures to occur. The charge nurse uses this information to determine the acuity level of the patient and reviews staffing to determine if additional resources are needed. The charge nurse communicates this information to the Assistant Nurse Manager (ANM) and Nurse Manager (NM) when alternate staff must be called in to maintain safe patient care. In Attachment 1, RN staffing was adjusted from six to seven to schedule a chemotherapycertified nurse to accommodate the patient receiving chemotherapy (Attachment 1). Nurses on 5M are asked to achieve chemotherapy certification within one year of hire.

Only certified chemotherapy nurses are able to administer these potent, high-risk medications. If there are no available certified nurses on the unit, when chemotherapy is ordered, this is communicated to the NM so that supplementary staff can be called in. At times, chemotherapy is ordered to be administered during the same day. When this occurs, the charge nurse reviews patient assignments and adjusts as needed. An

additional nurse is called in if safe ratios cannot be maintained, based on current personnel, or an additional chemotherapy certified nurse is needed. In the example shown, the assignments with chemotherapy patients are adjusted to a one to five ratio(Attachment 2).

Staff huddles occur twice a day, at the beginning of the day and night shifts (Attachment 3). The huddle provides an opportunity for staff nurses to report any patient concerns or changes in status. The charge nurse uses this information to further modify patient assignments as necessary.

Reference Lamkin, L. (2005). Reasons for not establishing oncology nursing staffing standards.

Oncology Issues, 20(5), 37.

Example b: Nurses adapting their patient assignments to meet the needs of a patient’s changing acuity in the Neuro ICU

The condition of critically ill patients fluctuates throughout their hospital stay. It is important that nurse staffing decisions consider more than a fixed nurse to patient ratio. The AACN (American Association of Critical Care Nurses) issues Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. Standard four addresses appropriate staffing. The AACN states that matching nurse’s skill level with the acuity and needs of the patient is essential. Utilizing a fixed nurse to patient ratio ignores variability in patient’s needs and patient acuity. Kathleen Morris, MSN, RN, CCRN, Director of the Neuro ICU has always fostered autonomy among her nurses. She encourages them to make staffing decisions based on best practice and the needs of the patients. The following is an example of nurses adapting RN assignments based on a patient’s changing acuity.

A 21 year old male (we’ll call him RS), who was involved in a motorcycle accident, was admitted in August, 2015 into the Neuro ICU. As a result of the accident, the patient was paraplegic. The patient was very ill and developed Acute Respiratory Distress Syndrome (ARDS). RS was hemodynamically unstable, he was tracheally intubated, placed on a ventilator, and was placed on multiple drips including intravenous sedation. As a result of his ARDS, it was deemed, by the medical team, that he was a good candidate for a RotoProne bed. This specialty bed facilitates prone ventilation which increases oxygenation in most patients with ARDS. This patient was extremely unstable and, coupled with the complexities of managing the specialty bed, RS required a maximum amount of care. The Neuro ICU nurses were concerned about the hours of care this patient needed and wanted to ensure that the best care would be delivered to this patient. Kristina Pejic, BSN, RN staff nurse, Kim Watson, RN Assistant Nurse Manager, and Sudha Ramamoorthi, RN, staff nurse huddled regarding the care needs of RS. They determined that it was essential that RS receive one to one care.(Attachment 1)

On that particular shift, all the nurses were assigned, so they devised a plan that would free a nurse for one-to-one care. First, they assessed whether their charge nurse had

an assignment. Very often, as circumstances necessitate, the nurse in charge will take a light assignment. Secondly, they then assessed whether one of the other nurses had a light assignment and could possibly accommodate another patient in order to free a nurse. Finally, if no other options remain, they will consult with Kathleen Morris MSN, RN, CCRN, Director of the Neuro ICU, to provide additional staffing for this and the following shifts. The staff frequently uses problem solving strategies to ensure that their patients receive the best care that can be provided. As a result of their caring tactics and dedication to excellent care, RS survived his trauma, was sent home, and is doing quite well. Reference The AACN (American Association of Critical Care Nurses). (20). Standards for

establishing and sustaining healthy work environments: A journey to excellence, 2nd Ed.

Exemplary Professional

Practice Exhibits for SOE - EP9

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EP9b: Attachment 1

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EP 9 Final DocSOE Cover PageEP9a Attachment 1 Staffing SheetEP9a Attachment 2 Assignment Sheet w ChemoEP9a Attachment 3 Huddle SheetEP9b Attachment 1 Staffing Sheet