Measuring nurse productivity and patient acuity and intensity can improve care and increase staff satisfaction. Implementing different staffing tools and models can be a difficult but rewarding feat.

Erin Noel, BSN, RN, OCN®, oncology team lead of the outpatient infusion center at Baylor Scott and White McClinton Cancer Center, Georgina (Gigi) Rodgers, RN, BSN, OCN®, NE-BC, director of clinical cancer services at the Taussig Cancer Institute at the Cleveland Clinic, Beth (Joy) Prabhakar, RN, BSN, OCN®, permanent charge nurse of the bone marrow transplant unit at the University of Colorado Health Center, and Theresa Melville, MS, RN, OCN®, nurse educator of the outpatient infusion center at Virginia Commonwealth University Massey Cancer Center, participated in a panel discussion on this topic during a session at the 42nd Annual Congress in Denver, CO. Each provided answers to questions about their own practices and different staffing models that were implemented in a question-and-answer format.

How did each of you and your team recognize a need for revised staffing protocols?

Rodgers: Our health system—which includes 15 sites in Ohio—was working on cost and operational efficiencies. We started by going out to the different sites and noticed a disparity in the number of nurses and a mix of staff members at each site based on patient volumes. This disconnect led us to work on how to create a model that was fair and equitable.

Prabhakar: Our facility doubled in the number of beds and onboarded more than 30 new graduates. We had a diversity of nurse experience, and we found that more experienced nurses had larger workloads. We also found inappropriate staffing assignments. We needed standardization to balance out assignments and have nurses at the bedside more and feeling less stressed.

Noel: The facility was fast-growing, with no secretary to organize charts. We operated on a first-come, first-served basis, with nurses just grabbing charts when they were free. This led to uneven workloads, as nurses work at different paces, and this led to nurse overtime and decreased satisfaction. We also experienced some friction when some nurses were doing more than others. We replicated an acuity tool to fix this.

Melville: We had issues with patient satisfaction at our clinic. We also had an extremely large vacancy rate, with only four full-time employees (FTEs) in the department, as well as many different models of care going on.

Once you recognized a staffing issue, how did you convince others and get people to engage?

Melville: Through staff meetings, and we carved out focus groups with the nursing director. They heard about the dissatisfaction and wanted nurses to see patients more and triage instead of doing administrative work. We presented a vision for a nursing model to the chief nursing officer and vice president of ambulatory.

Rodgers: We have an “affinity” group with 95 participants who meet every other month, where we discussed potential changes. We also went to each site in Ohio and spent a significant amount of time looking at the number of nurses and volume data, asking questions such as, “Did they have proper ancillary personnel?” We met with the frontline nurse manager and administrator of each site to present our findings: “This is what your site looks like. These are some things we think we can do to help.”

Prabhakar: We had to meet with our medical division to make sure they were on board. It was difficult at first to get the ball rolling. We wanted to make nursing assignments that would create nurse satisfaction, so these needed to be made by the nurses. We met one-on-one and conducted preimplementation surveys to get nurse buy-in. Change is hard, and we needed nurses to believe in the changes.

Noel: Nurses were concerned about not being able to take care of their favorite patients. With the increasing volume and patient load, they cannot have all of their favorite patients at once. We noted that you can still talk to and say hello to your favorites, you just cannot take care of them all at once.

When you talk to team members about change, and it impacts the staffing model and their nurse life, there can be wide variance in expectations for outcomes of these changes. It is important that these expectations are managed. How was this accomplished at your facility?

Noel: The team identified several goals that we wanted to gain from this process. One was safe and efficient patient care. Another was an increase in nurse satisfaction and to make sure assignments were equally distributed.

Prabhakar: Nursing satisfaction was most important. We created a preimplementation survey to find out current barriers and then use that information to overcome them. We created complete workflows around how frontline administrators were making assignments, so this was a frontline nurse-driven tool. By the end, people felt they had a hand in it.

Rodgers: During our assessments, we found that some nurses were taking care of six to seven patients per day, but also on the phone with drug companies registering people, doing prior authorizations, scheduling calls, etc. And some of these calls could have gone to a nonclinical person. We tried to disperse nonclinical work so nurses were focused on direct patient care, education, and follow-up.

Melville: The largest goal was to decrease variation in nursing practice. We wanted to make nursing look the same in different departments. We also wanted one nursing point of contact for people who were calling in. Other goals included enhancing patient education and implementing follow-up calls to manage symptoms and see how they are doing. We had a lot of goals!

Nothing happens in isolation. These changes were probably not the only thing going on in your unit at the time. How were you able to maintain that focus on what you were trying to accomplish?

Melville: After all these meetings and planning, we decided to pilot what we were talking about, choosing the leukemia/lymphoma unit first. We found that nurses were happy to give away administrative things and focus their time on patients. It was very successful, and people were happy.

Prabhakar: We implemented the tool full-time. We showed staff data to demonstrated what they were doing, and this was helpful for them.

Noel: We used surveys to keep momentum going during the first year. We got to see anonymous comments and grow from that.

Rodgers: We went slowly but surely, site by site. Many sites did not need much change, so we focused on the sites that needed the most assistance and rolled it out over the course of a year to each of the 15 sites.

New things can come along, such as treatment regimens, and can throw plans off balance. How do you incorporate new things into these updated tools and models without going back to square one?

Prabhakar: We call this a fluid acuity document.

Noel: Adding new treatments and coming together as a team to figure out what level of care it requires is how we handled it.

Melville: Since we changed to a more disease-specific model, we re-evaluate teams when new providers come and go.

Rodgers: We are constantly trying to take a look at overall volumes. We looked at treatments and types of patients coming in to each site to make sure we are not overestimating or underestimating FTEs.

What words of wisdom do you have for others tackling this kind of project?

Melville: Over-communication. Unfortunately, we do not communicate as well as we think we do.

Prabhakar: Communication is key. Another thing for me is that you can get lost in being a charge nurse and creating this tool but not talking to and taking into account the people who it is affecting. Keep that in the forefront.

Noel: Transparency and open communication is what helped guide each team member’s involvement in this process. Make sure you are all working as a team to make this successful. 

Rodgers: We had group and individual meetings and offered telephone and Skype meetings to make sure we had a line of communication, so it is not just “us” and “them.” Allow the staff to come in and ask questions. Let the frontline team understand what you are trying to accomplish, and listen when they have suggestions.

Noel, E., Rodgers, G., Prabhakar, B., & Melville, M.T. (2017). Staffing for safety: It’s about the patient, not the numbers. Session presented at the ONS 42nd Annual Congress, Denver, CO, May 5, 2017. Retrieved from