The charge nurse is responsible for creating daily nurse/patient assignments, which are informed by the location of the patient within a unit and the clinical judgment of the charge nurse.

THE PROBLEM

Assignments typically do not incorporate objective assessment of workload or patient acuity. As a result, nurses could be responsible for several high-acuity patients at the same time.

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 yielded numerous examples of nursing workload measurement tools," said Sentara Health Patient Acuity Nursing Tool (PANT) Project Coordinator Kelsey Jones, RN. "Each of these tools had its own strength, 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 precluded implementation of these tools at Sentara Leigh Hospital," she noted. "These limitations included redundant manual data entry, assessments based on retrospective data only, and infrequent updates to workload assessments."

Because patient census and requisite workload change constantly, nurse assignment models must be flexible and updated with near real-time patient information to inform a daily decision support tool. As a result, the nurses did not find an appropriate evidence-based system to identify workload and patient acuity that was driven by objective data.

PROPOSAL

Historically, nurses lacked a reliable method to measure and manage care complexity. Charge nurses created nurse assignments based on judgment, patient daily census and the number of staff at the beginning of each shift. This inconsistently accounted for 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 quantified patient workload and ensured an equitable distribution of patient care needs among nursing staff," Jones recalled. "Project approval was obtained from the system's chief nursing officer and Nurse Executive Council.

"The CNO served as the project's executive sponsor and incorporated a nursing workload algorithm into the nursing strategic plan, with time and resources allocated for development, testing and integration within the health system."

An interprofessional team created an automated, rule-based algorithm (the Patient Acuity Nursing Tool, or PANT) to capture the time required to provide safe, quality patient care in near real time. The PANT development team consisted of clinical nurses, a nurse project manager, EHR system analysts, health services researchers, 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 in each stage of the development," Jones explained. "First, the team identified the nursing workload items based on nursing standards of care and internal competency tools.

"The team collaborated 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 performed testing to confirm the algorithm operated as expected. PANT team members collaborated with clinical nurse staff to validate the patient-specific PANT score was reflective of the nursing workload being performed."

Data analyst team members performed a series of descriptive analyses (basic descriptive statistics describing the distribution of the workload data, normality, missingness and outliers) to validate the functionality of the algorithm.

"PANT has now been implemented in more than 100 inpatient units across all 12 hospitals within the Sentara system," Jones reported. "Development of PANT educational materials – for example, tipsheets and computer-based learning modules – and incorporation of PANT during orientation for nurse preceptor, charge 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 intimate understanding of both patient and staff needs in combination with the objective PANT score."

Nursing leadership use the PANT score to better articulate nursing workload at the patient level and unit level. PANT data has been incorporated into multiple dashboards, enabling operational leaders to view real-time and historical or trended data.

RESULTS

Unbalanced or unevenly distributed workloads and a perception of insufficient time to complete nursing tasks can increase the risk of burnout and turnover. As the nationwide nursing shortage continues, PANT is a data-driven tool that maximizes patient and nursing outcomes, Jones said.

"The PANT tool has been extensively validated and determined to be an accurate reflection of nursing workload for medical surgical, oncology, intermediate and critical-care patient populations," Jones reported. "This workload score is used by clinical staff and leaders to inform decisions at the operational level.

"PANT workload scores were translated into nursing hours per patient day (NHPPD) and compared to the pre-determined NHPPD defined in staffing grids," she continued. "The comparison of PANT to staffing grid NHPPD informed the overall functionality of PANT. This is a unique attribute of the tool and provides clarity around nursing unit differences within the same nursing census-staffing matrix."

ADVICE FOR OTHERS

"Interdisciplinary collaboration is key," Jones exclaimed. "Establishing a team that includes all areas – IT, data analysis and clinical – brings varying perspectives to the table. Involving front-line team members in tool design and development is essential to establishing user-level buy-in, and ultimately, project success.

"Also, connecting the project to the organization's strategic plan is important," she added. "This ensures the project receives support and organizational resources, fostering success."

Nursing workload tools help articulate the intensity of work being performed by direct-care staff, she said.

"The ability to articulate this helps foster understanding with non-clinical teams, informing conversations related to patient needs, clinical workload and traditionally designed census-based staffing systems," she concluded.

Follow Bill's HIT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.