Rudisill, Pamela T. DNP, RN, NEA-BC, FAAN; Callis, Carlene BS, MHA; Hardin, Sonya R. PhD, RN, CCRN, NP-C; Dienemann, Jacqueline PhD, RN, NEA-BC, FAAN; Samuelson, Melissa DNP, RN, NEA, BC
Healthcare systems in the United States must bridge the transition from volume to value-based models. Components required to succeed include clinical integration, implementation of technology, and clinical performance improvement with operational efficiencies to manage financial constraints.1 Nursing services encompass the majority of the workforce in today’s acute care hospitals.2 Historically, models of care have been based on a mix of registered nurses (RNs) and unlicensed assistive personnel (UAP) with occasional reference to licensed practical nurses (LPNs) and the assignment of workload. Evidence supports that patient needs are best met by planned skill mix and recognition that nurses are knowledge workers and need to be utilized in that manner.3,4 Models-of-care redesign that embeds improving efficiency and increasing accountability to patients’ clinical outcomes requires a cultural transformation.1 All major changes in care design should be evaluated for their evidence-based and desired changes. The purpose of this study was to evaluate a pilot implementation of a shared accountability delivery model for medical-surgical patients that allowed licensed nurses and UAP to practice at their full authority through delegation and collaboration in RN-led teams.
The healthcare system in the United States is in a state of rapid and unprecedented change with pressures to improve clinical quality and patient health and increase patient satisfaction, while curtailing costs. The Institute of Medicine report5 cites 10 recommendations to ensure better health, higher-quality care, and lower costs. One recommendation was to optimize operations by continually improving healthcare operations to reduce waste, streamline care delivery, and focus on activities that improve patient health. The primary challenge of delivering care in acute settings is managing increasingly complex patients with shorter lengths of stay (LOSs) while ensuring integration of care upon discharge and beyond.
Recent studies demonstrate that lowering costs is dependent on increasing patient safety rather than changing nursing salary or staffing expenses.6 Nursing factors influencing patient outcomes include number of hours per patient-day (number of staff), quality of work environment, educational level of nurses, and mix of skills among nursing staff. These factors interact among each other with varying effects on patient outcomes.7-11 Increasingly, nurse satisfaction is related to recognition that RNs are knowledge workers whose time should be utilized in decision making regarding patient care and safety.4
Nursing Care Delivery Models
Delivery of nursing care has traditionally been delivered in 1 of 4 ways.12-14 Shirey14 discusses the advantages and disadvantages of various models. The earliest model is patient allocation or total patient care with groups of patients assigned to 1 nurse with no UAPs. Because of shortages during and after World War II, task or functional nursing was emphasized, allocating more complex care to RNs and routine care to UAPs. Team nursing evolved with RNs as leaders of UAPs for a group of patients. Primary nursing identified 1 nurse to assume 24-hour responsibility for a patient with communication to RNs, LPNs, and UAPs who participated in care throughout the patient stay. This model of care has been coined relationship-based care.12 One new, novel approach is to expand primary care to coordinating care after discharge, with the RN assuming care as the primary nurse for readmissions.14,15 This model of care fits in the new modes of accountable care transition coordination.
The recent Institute of Medicine report on the future of nursing16 advocates for RNs to perform to their fullest potential and to become effective leaders and partners in the organization. This parallels the American Organization of Nurse Executives guiding principles for the role of the nurse in future patient care delivery.17 These position statements call for new innovative models of nursing care delivery. In 2005, Partners Healthcare in Boston, Massachusetts, conducted a search of innovative nursing care delivery models for adult, acute care patients that integrated technology, support systems, and new roles to improve quality, efficiency, and cost. They identified over 40 models that shared common elements of an elevated RN role, sharpened focus on the patient, smoothed patient transitions and handoffs, leveraged technology, driven by results that were measured systematically, and used for feedback to improve the innovations.18 A few new models emerged requiring shared accountability.19 In reviewing these models, our team realized several approaches underutilized RN delegation, did not utilize LPNs at all, and did not require RNs, UAPs, or LPNs to practice to their full scope.
We did identify 1 computer simulation model utilizing the RN, LPN, and UAP, which incorporated principles of the lean to enhance the role of the RN, LPN, and UAP in the care delivery of patients.20 Lean is a concept adapted from manufacturing to streamline processes, reduce cost, and improve care delivery. Each process must add value or be eliminated as waste (or muda in Japanese) so that ultimately every step adds value to the process.21 The simulation demonstrated that teams of RN, LPN, and UAP assigned in a mix to fit patient acuity of a group of patients wasted less time than patient allocation assignments.
Development of Novel Nursing Care Redesign
We decided to develop a shared accountability model utilizing RN-led teams with LPNs and UAPs, functioning to their fullest potential, matching the skill-mix potential to meet the patient’s needs. We piloted the model on medical-surgical units in 3 community hospitals in 3 states.
The goals were to improve clinical quality of care and nurse job satisfaction through use of accountable teams and balanced caregiver workload while controlling or reducing costs.
The pilot was implemented on 1 medical-surgical unit at each of 3 hospital sites in Alabama, Tennessee, and Mississippi. Each hospital differed in overall bed size and urban/rural market location. The leadership in administration (chief executive officer, chief nursing officer) was supportive and knowledgeable of lean principles, the purpose of the nursing care redesign, and the importance of evaluation.
Our 1st step was to review the scope of practice for RNs, LPNs, and UAPs in each state where we planned to pilot the program (Alabama, Tennessee, and Mississippi). We then reviewed the job descriptions at the hospitals and found that all legal functions were not included. Policies, competencies, and job descriptions were revised for the LPN and UAP to ensure highest level of practice. To ensure patient safety, education was developed and provided to UAPs and LPNs to achieve competencies in all functions. Examples of the enhanced competencies for the UAPs included simple dressing change, oxygen setup, performing blood sugars, discontinuing Foley catheters, and discontinuing peripheral intravenous lines. The LPN-enhanced competencies varied the most among the selected states. Some included administering intravenous medications and starting intravenous lines.
In order to assess level of patient needs, an acuity tool was needed that was valid, efficient, portable between units, reliable, and maintainable.22 Duke University Hospital System had designed and evaluated a tool beginning in 2003 that assesses patient’s acuity based on the complexity of care or instability of a patient’s health status. Nurses used it with a personal digital device. In time, it had been modified to reduce input while maintaining validity for multiple settings. Patients are assessed on 6 patient factors and 4 nursing care demand factors, resulting in 1 of 4 levels of complexity of care. The results are to ensure balance of workload with competency level of staff and patient acuity. The tool was used with permission (e-mail communication, August 2012, November 2012, August 2013). The Morse falls risk assessment23 and Braden skin care assessment24 were added to the tool. No formal evaluation of the modified tool has been made. New processes adopted were bedside shift report for all caregivers of the team and formal bed huddles for teams to be done at a minimum of every 4 hours with new acuity assessment, daily patient goals, and expected LOS review, as well as any identified patient safety issues (Figure 1).
The clinical outcome data chosen for evaluation were based on existing methodologies and collection practices reported to the Centers for Medicare & Medicaid Services and other national organizations. These included falls per 1,000 patient-days, falls with injury severity of greater than 1, rate of hospital-acquired pressure ulcers, medication errors per 10,000 doses, number of sentinel events, and number of near misses. Unit LOS; rate of readmissions for congestive heart failure (CHF), myocardial infarction (MI), and pneumonia within 30 days; and core measure scores were also collected. Cost was based on average LOS and cost per patient-day. Patient satisfaction used the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data across the 8 domains.25 New survey questionnaires on nurse and physician satisfaction were developed for the specific medical-surgical units that reflected key elements on the model design and based on the hospital-wide surveys performed by Press Ganey.25
Institutional review board approval was received from the University of North Carolina at Charlotte, Charlotte, NC. Materials were prepared, and site coordinators were trained in data collection of patient outcomes and confidentiality processes to distribute and collect questionnaires. Upon collection, data and questionnaires were forwarded to the office of the corporate chief nurse executive for data entry. Original forms were stored in a locked cabinet.
To establish a baseline for all key metrics prior to implementation, the following were collected: (1) nurse/staff and physician satisfaction, (2) patient outcomes and patient safety indicators, (3) financial information, and (4) patient satisfaction. For the clinical outcome and financial metrics, data for the same 6 months of the planned pilot in the previous year were used.
Each pilot hospital assumed responsibility for implementing the education in new skills and verifying that all UAPs and LPNs had mastered the identified competencies prior to initiating the model. Job descriptions were updated. RNs’ job expectations shifted to focus on decision making for delegation and assurance of quality, patient teaching, patient care coordination, and collaboration with other health professionals. Each team had an RN leader and either 2 UAPs or 1 LPN and 1 UAP. Patient assignments were for that shift. Each job description was reviewed to ensure clarity of role function.
An 8-hour course for all the nursing staff on the pilot medical-surgical units at the 3 hospitals was designed and led by the research team. The course began with an overview of the new delivery model and job descriptions for RNs, LPNs, and UAPs. The new acuity tool was reviewed, and its purpose to share workload fairly discussed. The plan to assess patient care needs and review in huddles every 4 hours to maintain equity was reviewed. Delegation and collaboration were then discussed with case examples. Emphasis was placed on each person working to their enhanced scope of practice and to share accountability for patient outcomes. This was followed by a simulation exercise where staff was assigned teams with case scenarios. Nurses left expressing enthusiasm for their new roles.
Implementation and Evaluation
The new model was introduced, and all staff was provided support to comply. When turnover occurred during the 6 months of the study, categories of new hires were chosen to support the model implementation. At the end of the 6-month period, all metrics were collected and measured against the established baseline.
Nurse satisfaction showed the most statistically significant improvement in comparison to all other measures included in the study. Forty-four nurses (86%) completed the presurvey, and 36 (69%) completed the postsurvey. A paired-samples test was performed to identify any significant change from the implementation of the new care model. While all responses demonstrated a positive trend, 6 items showed statistically significant improvement: teamwork among coworkers, appropriate delegation, sense of accomplishment in their work, enjoyment coming to work, satisfaction with workload, and satisfaction with job (Table 1). Patient satisfaction showed slight improvement according to the HCAHPS scores in 3 of the 8 domains. Within the 8 domains, physician communication resulted in a statistically significant improvement at P = 0.013 when an analysis of variance was performed.
Most clinical quality indicators showed signs of improvement, including core measures, hospital-acquired pressure ulcers, medication errors, near misses, and CHF, MI, and pneumonia readmissions. Independent t tests of samples were performed to examine the difference between the mean of incidence of indicator before and after the intervention. Although improved, none were statistically significant (Table 2). A composite core measure score for the hospitals, excluding elements of care provided in the emergency department, revealed improvements in the pilot hospitals.
Financially, the pilot resulted in reductions in costs. Cost reduction was realized through the use of proper discharge of lower-acuity patients, proper work allocation, and staffing-mix allocations resulting from workload rebalancing. Based on analysis on each unit, using year-over-year comparison, case mix–adjusted LOS decreased by 0.39 days on average for all 3 units. In addition, the ALOS average for the 3 units was below the mean LOS by 0.38. In addition, all 3 units resulted in reductions in salary per patient-day of approximately 2% to 3%. One of the 3 units proved to be the best comparative model, as it had the most stability in its workforce and adhered closely to the staffing workload balance guidelines. This unit reported an equivalent decrease in RN hours to the increase in LPN and UAP hours (a rebalance of approximately 5.0 full-time equivalents).
Improving the Environment of the Workplace
Although the study did not set out to improve the workplace environment, the achievements in this area deserve special recognition. It was noted by all 3 pilot sites that the engagement in innovation, education, and new tools and methodologies brought about an excitement to the workplace, which resulted in improved job satisfaction and caregivers reporting a feeling of significance and value.
The care redesign resulted in an almost immediate and significant improvement in patient, physician, and staff satisfaction. The improvement in teamwork has been remarkable. The unit went from the most challenging unit for nurses to work, and therefore, a unit to avoid, to the unit where most med/surg nurses want to work. (Hospital chief executive officer)
Participating in the care redesign pilot gave a focus and spotlight to the unit for the physicians and staff. We worked diligently on turning around the culture and motivating the staff toward embracing change and the new processes. (Hospital chief nursing executive)
The teamwork that occurs with the UAP having a higher skill allows the licensed nurse to spend more time with patients. (Hospital staff nurse)
Several limitations were associated with doing research in a natural setting. For example, 1 site lacked optimal staffing, and turnover in nursing leadership occurred at another. There was an omission to include physicians in the education about the model that resulted in some confusion. This may have impacted physician response rate before and after implementation. A limitation was that 13 physicians (76%) completed the preimplementation survey, and only 6 (35%) completed the postimplementation survey. This was too small of a sample to statistically evaluate the perspective of physicians on the units where the intervention was implemented. Future studies are needed with a larger sample of medical-surgical units for a longer period to rule out the Hawthorne effect for increased satisfaction and possibly allow for changes in clinical outcomes to reach significance over time.
This novel, shared accountability model for medical-surgical units that emphasized utilization of RN, LPN, and UAP full scope of practice had promising initial findings. Results suggest that positive clinical outcomes, along with nurse job satisfaction, can be obtained while providing cost savings. The findings are similar to other results reported by Hall et al10 and Fairbrother et al,26 who reported on new care delivery models with advanced nurse responsibility and team shared accountability. However, Tran et al19 found that job satisfaction declined because of the delegation required. They also differ from Aiken et al7 regarding improvement in clinical outcomes; that study found the key variable to be increase in the RN-to-patient ratio. These preliminary findings in our study support further investigation on the use of these innovations.
Nursing has a crucial role in shaping the future of healthcare delivery. It is imperative that innovation to engage nurses in leadership for better health, better care, and less costs be ongoing. This model is 1 example to further evidence-based delivery models of care maximizing the skills of the existing workforce.
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