Leadership and Staff Working Collaboratively to Develop Appropriate Staffing Guidelines

The journey for a new policy and appropriate staffing began at Harbor UCLA (University of California Los Angeles) Medical Center critical care units. This hospital is operated by the Los Angeles County Department of Health Services (DHS), which serves a diverse ethnic and socioeconomic patient population. This facility has 5 different critical care units, all serving a variety of care needs that include but are not limited to adult cardiothoracic, trauma/surgical, coronary care, medical, and neurosurgical services. Patients in these units are extremely critically ill and require multiple resource-intensive approaches of care throughout their hospital stay. Changes in patient acuity can occur rapidly in these patients, affecting the nurse-to-patient ratios at any time.

Although the hospitals for the Los Angeles DHS system in California required minimum staffing ratios that were 1 nurse to 2 patients and had requirements to staff by acuity as well, there were times when patients needed 1:1 staffing for extended periods of time. There were no guidelines on what constituted the need for 1:1 staffing, providing an opportunity to develop criteria for those patients in order to avoid nurses having to provide care for 2 very critically ill patients simultaneously. Examples of the care provided to these patients include, but are not limited to, administering multiple blood transfusions, actively titrating multiple medication and/or vasoactive infusions, drawing frequent blood samples, replacing electrolytes, and performing continuous renal replacement therapy and frequent assessments. Those tasks frequently required more than 1 nurse at a time to complete. One-to-one nurse-to-patient ratios were determined on the basis of subjective assessments by the charge nurse and the bedside nurse together.

The critical care nurses shared their concerns with the chief nursing officer (CNO) about appropriate staffing. The idea for this project began when one of the critical care nurses approached the CNO with a small list of criteria that the staff had developed. The organization had recently implemented shared governance and shared decision-making between leadership and frontline staff, which is important for a healthy work environment. The CNO was very supportive of staff-driven decisions. The budgets that were developed in previous years were set with a nurse-patient ratio of 1 nurse to 2 patients. Over time, the acuity of the patients increased for a small subset of patients in this busy trauma center, but the staffing budget and process had not changed.

The CNO asked the staff to develop objective criteria to identify the subset of intensive care unit (ICU) patients who required this time-intensive level of care. Until that time, nurses were struggling with providing safe patient care and did not feel supported by leadership. After that discussion, the CNO spoke to the director of critical care services and asked for a small work group of staff and leaders to work on these criteria. With the milieu ripe for change, a task force composed of frontline ICU nurses representing each 1 of the 5 adult ICUs, a nurse manager, 2 clinical nurse specialists (CNSs), and the director of critical care services was formed. With nursing leadership in full support of this project, this task force was empowered to meet routinely for several weeks to develop a draft of the 1:1 criteria that would ensure patient safety, safe nursing practice, and efficient use of resources. This CNS-led team of committed ICU nurses was driven to challenge the status quo and make an impactful change in patients’ lives and their working environment. They carefully examined the criteria, engaged in meaningful discussions to understand the different perspectives of their fellow nurses in the various specialty-specific ICUs, and worked as a team to come to consensus in this process. One challenge the task force encountered was the lack of references or data in the literature on 1:1 or 24-hours-of-care staffing in the ICU. None of the other facilities in their health care system had a 1:1 staffing policy either, so once the first draft was developed, it was important to include nurses from the other DHS hospitals before the list was finalized for the system and ready for review by leadership. The task force also incorporated other facility-specific criteria. The process that was followed to formulate the work is outlined in the Table.

Once the guidelines were developed and approved (see the Figure for the guidelines), the criteria were included in the new Cerner staffing system (Acuity Scheduling and Time Employee Resource [ASTER]), by the Los Angeles General Medical Center, a DHS hospital that was the first to go live on the new system. ASTER allows informed decisions about assignment of ICU patients by offering transparent analysis of staff workloads. The acuity system also considers admissions, discharge, and transfers when it generates the number of nurses needed. The system generally identifies the appropriate acuity for the patient, but in instances where it does not, the charge nurse can trigger the 1:1 criterion by putting a note in the system.

The guidelines standardized the 1:1 and 1:2 patient assignments across DHS hospitals and decreased subjective assessments. Furthermore, the transparency of equitable assignments increased staff morale by decreasing questions regarding high-acuity assignments. Satisfaction with staffing has improved throughout the system with implementation of the new guidelines.

Nurse staffing is influenced by various critical factors, such as patient acuity, admissions and transfer rates, discharges, and the physical layout of the nursing unit. In general, the 1:1 guidelines are a great objective document to determine those patients who cannot be in a paired patient assignment due to the level of care that is needed. One of the criteria indicating a 1:1 assignment is a patient who is on continuous renal replacement therapy (CRRT), typically because these patients have additional critical care issues and are not stable. However, stable patients on CRRT alone can be in a paired assignment with another patient. This is one of the criteria that is flexible depending on other issues that are happening with the patient.

The staff came forward and established the 1:1 criteria to provide a standardized guideline and workflow for staff to follow. Prior to implementing these criteria, staff satisfaction with appropriate staffing was low; after implementation, staff satisfaction has improved. The process of leadership and staff working together to develop appropriate staffing supports a healthy work environment. This work reflected several of AACN’s Healthy Work Environment Standards³  including true collaboration, effective decision-making, appropriate staffing, and authentic leadership demonstrated by the leaders who supported this staff-driven work.