What Is ONS’s Perspective on the Ambulatory Staffing Dilemma?

August 23, 2017 by Laurl Matey MSN, RN, CHPN

Appropriate nurse staffing is only one of the critical factors that contribute to optimal patient outcomes and is as important as the systems, technology, and quality standards in any care setting. The relationship between poor staffing, daily variation in quality, and increased workload to increased care errors, missed care, and patient and nurse dissatisfaction is well described. (See Figure 1 for additional reading.)

Despite that knowledge, much of staffing in the outpatient setting is not grounded in evidence, and an astounding number of variables contribute to the problem. In the 2016 ONS member survey, 64% of respondents identified staffing as the top concern in response to, “What are the most pressing challenges you face today in your practice?” Staffing in the outpatient setting has had less attention in than in the inpatient setting that, for many years, has used acuity tools to determine staffing.

Setting-Based Variables

Standardization of staffing in the outpatient care setting is a challenge because many variables need to be considered in a staffing model.

Personnel-Based Variables

Personnel variables contribute to whether staffing is appropriate, including:

State of the Knowledge

Most traditional staffing models use a case-mix index (a proxy for acuity) that is calculated from an average of all hospitalized patients, and therefore is not as accurate for higher acuity areas, such as oncology. More innovative approaches use a combination of forecasting of patient populations and mathematical calculations (e.g., x chairs multiplied by y patients) but assume an adequate number of nurses in the calculation. Some U.S. states have mandated ratios that focus on nurse-patient ratios but do not include ratio of patients to assistive personnel, which is a known contributor to effective staffing models. (See Figure 3 for additional reading.) To complicate the issue further, the concept of adequate staffing can be a subjective experience. It may be poorly associated not only with case mix index but also with nursing variables. Finally, the availability of educational and practical support (e.g., advanced practice nurses and manager support) contributes to a perception of staffing adequacy.

Despite the overwhelming variables, we do have data to begin benchmarking best practices, including:

How You Can Contribute to the Evidence

In response to these challenges, ONS is collaborating with expert members to more fully understand the unique nature of outpatient oncology nursing staffing, and this is where you can help. A new online community, the ONS Ambulatory Staffing Initiative, is now available, with targeted questions designed to gather member-driven data and fully analyze and develop strategies to address outpatient staffing needs.

Excellence in staffing combines what we already know, such as historical member survey data, with innovative use of technologies to gather current evidence to guide decision-making. If you are responsible for staffing or scheduling, visit the community and share your best practices for staffing outpatient centers.


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