Partners in Care

FigureThe COVID-19 pandemic exacerbated the nursing shortage, causing critically low staffing levels, higher-than-normal nurse-to-patient ratios, higher nursing turnover, and reduced supportive resources. Many direct care nurses and unlicensed assistive personnel (UAP) frequently expressed their distress and frustration at being unable to meet their patients' needs. A study by Aiken and colleagues in 2021 found that nurse burnout was common and associated with higher turnover. More than 50% of nurses indicated that there weren't enough staff and that they considered interventions focused on improving care delivery as more important to their mental health and well-being than interventions focused on improving their mental health. Improving nurse staffing was ranked highest among intervention options.1 Health Affairs published a study in April 2022 indicating that the healthcare workforce lost at least 100,000 RNs in 2021.2 Additionally, the American Hospital Association reported federal data showing a potential loss of nearly 500,000 RNs in 2022, bringing the overall RN shortage to 1.1 million.3 More specifically, inpatient nurses report higher intent to leave their position than nurses working in other settings. A McKinsey & Company report indicated that inpatient RN intent to leave increased from 35% in the fall of 2022 to 45% in March 2023.4 The lack of RNs impacts team culture, nurse well-being, patient outcomes, and the country's overall health.5 The number of people who need care is increasing, and the number of RNs needed to care for an aging population is already insufficient. Healthcare systems must invest in RNs working top-of-scope and aim to improve job satisfaction and retention by creating environments and structures that enable RNs to spend more time with patients, participate in professional growth activities, coach and mentor other nurses, and have a voice in decisions that impact their work.6 Patient-care model redesign is a key systematic and structural intervention that will contribute to the improvement and future sustainability of healthcare delivery and the nursing workforce. BACKGROUND Patient-care delivery models have emerged and evolved over time, based on social, economic, and technologic changes. Traditional models include total patient care, functional care, team nursing, and primary care nursing. The models differ in clinical decision-making, work allocation by role, communication, and management.7-9 Many roles contribute to and facilitate the delivery of patient care. Therefore, new care models must leverage teamwork, delegation, and technology to improve RN workloads and manage more complex patients effectively.6 Nurses want to spend more time with their patients; thus, it's essential to align nurses' work to have the most impact on care delivery. Utilizing technology and delegating to UAP roles or support staff could reduce net nursing time by 5% to 10% during a 12-hour shift.6 However, resources and processes differ on distinct nursing units, at various levels of care, and within specialties, so it's unreasonable to believe that one care delivery model applies to all settings. An overarching approach includes individual nursing unit customization of processes and tactics to meet the unique needs of the unit and patient population. Patient-care delivery models should be tailored to include nurse leaders and guided by frontline staff who are directly involved in the day-to-day care-delivery workflow. This approach supports the principles of professional governance that are foundational to creating positive practice environments and are associated with many positive staff and patient outcomes.10-12 Recruitment and retention of nursing staff remains a leading healthcare challenge in a post-COVID-19 era. The 2024 NSI National Health Care Retention & RN Staffing Report indicates RN turnover at 18.4%, and nurses working in telemetry, step-down, emergency, behavioral health, and medical-surgical areas experienced the highest turnover.13 Due to recruitment and retention challenges, reliance on contract labor continues, which is financially and culturally unsustainable. Many organizations are considering new and innovative ways to deliver patient care that's more efficient and less expensive. Because few health systems have fully implemented or scaled new models of patient care that include virtual and/or team nursing, there's a paucity of contemporary evidence highlighting these new models and demonstrating measurable outcomes. Model description Historically, within the UCHealth system, the medical-surgical units practiced a primary patient-care model, whereby during the day shift, there was approximately 1 RN for every 4 to 5 patients and 1 UAP (such as a nursing assistant or patient sitter) for every 10 to 12 patients, with a skill mix of approximately 75% nurses and 25% UAP. With nursing turnover rates above 25%, long time-to-fill rates for open RN positions due to limited RN candidates, and unsustainable reliance on travel nurses, the healthcare system's medical-surgical units often ran higher than budgeted nurse-to-patient ratios without an increase in UAP. Additionally, the limited UAP were frequently reallocated to provide one-to-one patient sitter coverage. Rather than implement a top-down, one-size-fits-all model, each participating nursing unit leveraged its unit-based professional governance council to design its ideal patient-care model. The challenge was changing the unit's skill mix while staying within the salary budget. Finance supported the use of increased total care hours to offset the decrease in RN hours and increase in UAP hours. Purpose Traditional primary care nursing models are unsustainable and will be even more so in the future. Therefore, a new patient-care delivery model was designed to recognize the current and future impact of the nursing shortage, challenges with nurse retention, and impact on patient outcomes and organizational efficiency. The primary goal of this quality improvement (QI) project was to build a new patient-care model, named Partners in Care (PIC), that surrounds nurses with clinical support, removes barriers to efficient care delivery, and empowers top-of-scope practice. The goals of a successful PIC implementation would be to improve nurse retention/reduce turnover, decrease the reliance on nursing full-time-equivalents (FTEs), and remain budget neutral (direct care worked dollars per patient day). METHODS Sample and setting The PIC QI project was implemented across a large, multisite healthcare system in Colorado. The first phase of the patient-care model redesign implementation consisted of two units, and the second phase included three units. See Table 1 for a description of the units that were part of Phase I and Phase II. TABLE 1: - Description of Phase I and Phase II PIC units Unit # of beds Hospital Brief description Phase I: Unit 1 Medical-Surgical 36 Community Acute care medical-surgical unit specializing in general medical, and postsurgical orthopedic and spine care. Phase I: Unit 2 Orthopedics 36 Academic Acute care unit treating injuries and conditions involving bones, joints, and muscles, including arthroscopic surgery, joint preservation, repair, and replacement to relieve chronic hip and knee pain, orthopedic trauma surgeries, spine surgeries, osseointegration, and limb restoration. Phase II: Unit 3 Neurosciences 25 Community Acute care medical-surgical unit specializing in stroke and neurologic disorders. Certified comprehensive stroke unit. Phase II: Unit 4 Medical-Surgical 36 Community Acute care unit caring for acute and chronic conditions such as asthma, chronic obstructive pulmonary disease, renal disease, diabetic ketoacidosis, deep vein thrombosis, flu, hypertension, pulmonary embolism, pneumonia, sepsis, urinary tract infections, and COVID-19. Phase II: Unit 5 Medical 46 Academic Acute care unit caring for complex medical patients experiencing acute infectious processes or acute or chronic episodes related to long-standing disease. Commonly seen diagnoses include: sickle cell crisis, chronic obstructive pulmonary disease exacerbation, blood glucose imbalances/management, drug and alcohol withdrawal and support, respiratory infections (COVID-19, respiratory syncytial virus, tuberculosis), sepsis, complicated wound care, and encephalopathy treatment and source management. Intervention Each unit was empowered to design the ideal skill mix tailored to meet its patients' needs, guided by principles of team-based care and financial stewardship. For example, an orthopedics unit may deploy UAP with specialized mobility training, whereas a neuroscience unit may aim for one-to-one RN-to-UAP ratios for higher-acuity patients. The only limitation was staying within the unit's budgeted direct care worked dollars per patient day. Units conducted multiple “design-the-day” sessions to determine the optimal skill mix for the new care models. Each session included frontline nurses, UAP, the nurse manager, the director, and the clinical educator. The team first identified and mapped the care processes that the nurses and UAP completed each day and night shift. Then, the tasks were categorized into those that a nurse must do and those that could be done by UAP, noting tasks that could be delegated to UAP (see Table 2). The team used a visual map that included the list of care processes, assigned by role and time of day, to determine the best skill mix for the unit. This map ensured nurses worked at their full scope and the correct UAP were present with the necessary skills at the appropriate times. The skill mix was then evaluated using a financial model to confirm that the new care model was within budget. TABLE 2: - Examples of care processes that can be delegated to UAP Activities of daily living: bathing, showering, toileting, oral care Input and output tracking, meal assistance (ordering, setup, clear-away) Diagnostics: vital signs, blood glucose, bladder scanning, postvoid residuals Lab draws, dressing changes, I.V. placement Time-sensitive tasks, such as Turn Teams and bathroom break rounding Telemetry placement, lead maintenance, battery changes Chlorhexidine gluconate (CHG) bathing/wipes for indwelling urinary catheters and central lines Financial assessment The healthcare system bases the inpatient unit's financial budget on paid hours per patient day. To determine the total number of paid hours each day, the paid hours standard was multiplied by the average daily census. For example, if a unit's paid hours standard is 11.4 and the average daily census is 33, the unit could utilize 376 total paid hours per day and stay within budget. Paid hours include bedside care, orientation, education, and nonproductive time (for example, paid time off or leave of absence). Because the care model redesign doesn't include orientation, patient sitters, or nonproductive time, the team developed a model to measure the impact of PIC on bedside care hours and the associated salary expense. Bedside care hours include regular and overtime hours for direct care nurses and UAP. These hours are referred to as direct care worked hours/salaries. The budgeted direct care worked salary expense became the maximum threshold for the new care model. To simplify an example, one RN FTE has a salary expense similar to that of two UAP. Before the patient-care model redesign, a unit utilized 18 RNs and 7 UAP during a 24-hour period when at full capacity. The new care model utilizes 14 RNs and 14 UAP (see Table 3). TABLE 3: - Basic principle of the financial impact of PIC # RNs/day RN cost factora Cost RN # UAP/day UAP cost factora Cost UAP Staff total cost equivalent Skill mix (%) Traditional model 18 2 36 7 1 7 43 72 RN 28 UAP Partners in Care 14 2 28 14 1 14 42 50 RN 50 UAP aCost factor of 2 to 1 for simplicity Outcomes measured The main outcomes for this project included: turnover, budget/financial impact, and skill mix/RN FTE. Implementation Phase I units implemented PIC in August 2021, and implementation for Phase II units was from March to June 2023. These units were selected due to staffing vacancies and urgency. Each nurse manager determined key stakeholders and developed their guiding coalition, including such roles as charge RNs and lead UAP.14 This coalition participated in retreats and weekly planning meetings, where there was a safe space to discuss concerns, vent, reflect, and be vulnerable. This coalition was integral in gathering feedback from staff, building trust, and leading a successful implementation. Through the unit “design-the-day” sessions, RNs and UAP evaluated the current model and identified what was and wasn't working. This evaluation helped to inform the new patient-care delivery model with updated roles, responsibilities, and workflows. Each unit worked collaboratively with strategy and finance leaders to finalize the design, calculate the skill mix, and confirm the budget. A team of professional development experts created a corresponding standardized curriculum when the new patient-care delivery model was structured with updated roles and responsibilities. The curriculum focused on change management principles, collaboration, and communication within work partnerships. Specific topics included effective communication, delegation, appropriate supervision and evaluation, leadership skills, and role clarity for individuals and teams. Tactics and examples of overcoming fear of change, promoting partnership, and empowering delegation were included. The curriculum also highlighted the benefits of team nursing and creating specialized, standardized work that's meaningful and measurable. All team were to a was to practice the of delegation, provide feedback on changes, and general and scope of practice from the practice sessions to a comprehensive that was a to all Phase I and Phase II units. Staff was to all new team the the to practice as part of their and was developed as needed to enable all roles to at the of their and the patient-care delivery model change also the unit's The team with and and many council meetings, during which they created concerns, and support and Each nurse manager developed a communication that included with individual team and involving in a PIC and planning was and were The nurse were and to build Through and they to improving the and were appropriate for the of turnover, and skill mix were conducted and were to the of model unique and organizational that outcomes. This project was evaluated using resources. The project was determined to be quality improvement and meet the of per the of Health and wasn't The goal of the PIC care model was to reduce nurse turnover, decrease reliance on nursing and remain budget neutral in direct care worked dollars per patient day. The turnover for and nurses is the number of and in the period by the average of the for and nurses in the The turnover is an A turnover is a positive of a higher retention of the PIC units a decrease in the turnover at with the improvement from to unit's turnover the two units that are 12 the unit has seen a improvement of a decrease in turnover, and the medical unit has seen a improvement (see Table Additionally, a of each that only one nurse the health system due to the PIC model. The most common for was of TABLE - RN turnover and (%) Skill mix (%) Unit 1 12 PIC Phase I: Unit 1 RN 25 UAP RN UAP Phase I: Unit 2 RN UAP RN UAP Phase II: Unit 3 72 RN 28 UAP RN UAP Phase II: Unit 4 RN UAP RN 42 UAP Phase II: Unit 5 UAP 43 UAP turnover at includes of turnover and of turnover at 12 includes only data due to time Skill mix is the of nurses and UAP working within a unit. The nursing skill mix is the nursing FTE by the total nursing and UAP FTE. All PIC units their nursing skill mix with their budgeted FTE. the UCHealth system, developed and implemented a new team-based patient-care model that reliance on RNs by increased overall patient-care and within budget for direct care worked salary expense. on RNs by skill mix to meet patient-care needs may to that nurse staffing or hours patient and patient outcomes weren't reported as a part of this project improving these outcomes wasn't a However, the team was necessary to outcomes (such as injuries and and patient were and there were during or the implementation of Many units in quality and of patient these wasn't a one-size-fits-all to patient-care delivery. Each care and patient population in this project was unique and each unit needed to a model that its needs for safe staffing and increased overall patient-care hours. team-based and leadership the development of the model, which for is in teamwork, skills, and a to challenges and quality patient to patient outcomes and future model with the healthcare system's virtual health are with quality units that implemented PIC turnover at and only one RN the health system due to The decrease in turnover could be to RNs the time to meet all patient needs, which to higher job part of the a was developed to the team on of being on patient-care tasks and over time, with the data demonstrating that the number of indicating that frequently with patient-care tasks and and for Phase I and II units. Additionally, the of the care delivery model based on the needs of each unit professional and that when provide RNs with the to in they have job outcomes than those at that include nurses in it's that the improvement in turnover is in with the RN turnover of improvement of turnover, job and of the care model will be necessary for potential and and should be considered to determine patient-care model and with nurse and patient outcomes. are when and new patient-care delivery models. and communication is The nurse leaders of the PIC units time and planning communication and with the individual and team meetings, leadership and was used to provide and and to and leaders and best related to communication and ensured and processes for team communication Additionally, leaders time and space for team to and their the change in patient-care delivery. The development of and education, with the roles and principles of the designed model, an role in the of and with professional development experts during the is for successful care models. the of focused on team principles, communication, delegation, and for new and roles so that was at the of their Staffing and are important to when planning and a new patient-care model. Staffing ratios day and night and many units developed their for staffing to are patient 4 hours or new patients, and including or behavioral Additionally, staff to of and and UAP only supported one or two and were among care and the of was considered to the care RNs helped unit staffing needs. Before staff were of the change in the care model. staff were to a unit with the new patient-care model, they a that and could be or lead RN would a for all staff of a unit with a new care model wasn't as they would to the primary nursing care these nurses often to the unit of the new care model. The of change that the nurse must manage as a part of a new model of care be a new patient-care delivery model is a that time, and potential challenges and include a of for the nurse With new and roles, and with all team more unit leadership and is important to manage and lead the With a complex and changing healthcare PIC wasn't the only change the nurse was so a leadership team to with other and provide was believe the team-based approach is more and specialized experts patients with care. However, new patient-care roles could lead to patient important to a and standardized of the model for patients and that all team are and their role on the care rounding supports the of this practice. The new patient-care model can contribute to in team and communication thus, and other structured communication processes are the at the and the shift, there can be a of role, and the overall care for the day. The new model is and which can be when there are staff or necessary to and with the staffing the support of nursing leadership is The system's nursing and the were to the successful design and implementation of A of this patient-care model project is that with organizations and professional the model leveraged frontline and the people to the work a voice in the care this units developed an effective patient-care delivery model with frontline team support at the and the nursing team was to its the current and of the nursing for new patient-care delivery models is leaders need to be and current workforce challenges, and and implement new ways of working to care delivery. will and with a on the future to patient care is This is the of there's more to and are a few to this project that are important to Because this is a QI it's to contribute to However, as many organizations are considering new models of patient care, it's important to effective and and provide The are only and and is The healthcare is and many and other were implemented during these time which could have the nurse leaders must position their organizations to the new of the nursing which is by organizational and a for to use care models that on RNs and contract labor is unsustainable and a the future new clinical roles and patient-care delivery models is to meet this to frontline to a unique model that the needs of the patient population is Nurses must for models of care that the necessary to deliver optimal patient care in a and which will to and nurses to design care models that support patient in the to Partners in care delivery for the future the The for this nursing professional development is to be at need to an and in to will of all for only one correct for each A for this is correct can of hours and the have the of the at For is will hours for this nursing professional development is as a of nursing professional development by the American Nurses on This is also by the of for hours. is also an of nursing by the of and is in all The for this is