Christi Welter (Host): Welcome to Nurses Connect, a podcast from Children's Health dedicated to exploring critical issues and dynamic topics that shape the nursing profession today. I'm Kristy Welter, program Manager of Nursing Communications,

Brennan Lewis (Host): and I'm b Brendan Lewis, senior Vice President of Nursing Excellence, innovation, and Patient Experience. We are your co-host for Nurses Connect, and we are so happy you have joined us today. On this episode, we are discussing workload acuity based staffing and how this innovative approach to tailoring nurse staffing to meet patient needs can lead to enhanced patient outcomes and nurse satisfaction.

Christi Welter (Host): We have two guests today, vice President of Nursing Marshall Stevenson and Vice President of Nursing, Natalie Denson. Welcome to Nurses Connect, Marshall and Natalie. Thanks for having us. We excited to be here.

Brennan Lewis (Host): All right. To get us started, Nellie, why don't you tell me a little bit about what is workload acuity based staffing?

Natalie Denson: Yeah, so we actually started this journey about. 10 years ago here at Children's. So, historically we have done nurse to patient ratios when we think of how we staff, to provide care. So we have been looking at, for years now, what it takes to actually take care of a patient.

So when you think of a patient, they have different scores that are created based on modalities or procedures or. how often you're having to assess the patient and through that came the workload acuity. So how we tie staffing to it is we determine based on each individual patient's workload acuity, what that average nurse to patient acuity should look like, for each individual unit.

Brennan Lewis (Host): That's great, Sue. Why did we decide to implement a workload acuity based staffing, uh, here at Children's Health?

Marshall Stevenson: So we, chose to do a workload acuity score. it started around for me around 2022, when I was the director, senior director of the. picu, we were getting a lot of staff that were coming to us saying that, the hours per patient day that we were using, or the way we were making our assignments were just a little bit crazy that The nurses didn't have the time to provide care, they didn't have the time to, do their charting or talk to their families or educate.

So we started thinking about, workload acuity and Jeffrey pounds. And, his team were working on the workload acuity committee. And so we reached out to Jeffrey and just asked the simple question, Jeffrey, what is an acuity score that we should be using in the critical care space? And Jeffrey's great response was, I don't know.

You need to help me answer that question. So that's what started the journey around 2022. So we put together a PI team with Tiago and the PI team, and we started just working through the process with the critical care space. started, going through and doing time studies with the nurses, looking at.

What they're actually doing on an hourly basis, on a daily basis, on a shift basis. And so then we started working back into that. And so with that and with the help of Jeffrey Pounds and the workload acuity committee, we were able to start putting together what an ideal score was.

And so through that whole process, that's how we've kind of gotten to this point today.

Christi Welter (Host): And I know you mentioned we've been doing this for about 10 years. has this been implemented hospital-wide?

Natalie Denson: So, no. the scoring for patients and the acuity portion of that with Jeffrey's team started about 10 years ago. Hmm. However, the implementation of Acuity based. Staffing really is 2022 is when Marshall started in the picu. And then 2024 is when it started in the acute care space. and by the end of 2024 is when we had expanded to all care spaces really into the first quarter of 2025.

And now we're just in the monitor and sustained phase of if we need to make changes based on. Patient changes within the units or if there's like an acuity change that we need to look at the scoring. for those we still work with Jeffrey and team on that.

Christi Welter (Host): What did the process

Natalie Denson: look like for rolling that out? So, same as with Tiago in the PICU space. he did the same thing within all of our care spaces. So time studies, talking with the nurses, really understanding what does a patient care tech do, what does a nurse do, do we have any other resources?

How does that all fit in? And then helping to come up with, just that average workload, acuity per nurse. what we found to be interesting is in the critical care spaces that average workload acuity per nurse pretty much was consistent across all of those. And the same for acute care, which is what we were hoping for, that we would find like you would have an average workload per nurse you needed.

what changed was the amount of resources and what that might look like for those care spaces. So you may actually need an additional patient care technician because we should be delegating more. Or you need an extra resource because that unit just admits and discharges a lot of patients.

Brennan Lewis (Host): I love, hearing this, you know, how this project unfold is starting with the critical care area and really leveraging the talent of Jeffrey, who's a clinical informatics, leader within our organization and Tiago who leads our performance improvements. So it's just a great example of pulling together expertise to, move something forward.

so Describe what a charge nurse workflow looks like when they're using this workload acuity tool to make assignments.

Marshall Stevenson: So with the charge nurse there's not a ton different in their day-to-day function. They still manage the unit the way they did prior to when we were doing hours per patient day. The difference is, is that we do have a charge nurse, wizard within Epic that kind of helps guide the charge nurse so they don't have to, Write down all of the numbers from shift to shift and hour to hour, they can go Epic.

And Epic kind of helps them say, within your unit, you have two patients that would look good together on a numbers. Now granted that is just a purely visual opportunity for the charge nurse to look at. It still gives the nurse the ability to say. I see that this is saying these two patients should be together, but I don't like how these actually look together because, this patient has a very demanding diagnosis or something like that, that I know is going to really, put a lot of strain on the nurse so they're able to still kind of manipulate how the assignments are done.

but in the big Picture, epic kind of helps guide them along the way so that if they are in a situation where they. could make one decision or another Epic can help them kind of solidify what is potentially the right decision to go. Yeah.

Brennan Lewis (Host): When you were building or evaluating your workload acuity for critical care, talk about how you integrated clinical nurses into that work. Yeah,

Marshall Stevenson: So we were able to actually get a couple of bedside nurses to join the workload acuity, committee with Jeffrey Pounds and his team. And they actually did bring. good insight to the scoring. So a task is, given to the patient. So is it, central line dressing changes or is it a ventilator check or is it a medication?

And so each of those tasks are then allotted, an amount of time, five minutes to that procedure, 15 minutes due to do that procedure. And so. the clinical nurses were actually able to sit with the committee and really say, I know you've given this task 25 minutes, but it's really not a 25 minute task and you've given this task five minutes.

This task actually does take about 20 minutes. And so they were able to kind of manipulate and change the scoring to really, Impact how the nurses were actually caring for the patients at the bedside as opposed to just, I haven't taken care of patients in X amount of time and I think this is what the score should be.

we really did get the frontline staff involved in those conversations and still to this day, they're still part of that. They still meet monthly. They try not to make too many changes to the roles in a year. I think. the change is like two or three changes per year is what they'll work on.

but they won't make massive changes to the whole scoring system at the same time.

Brennan Lewis (Host): I love, how you integrated clinical nurse's voice into the work. Otherwise, oftentimes when we miss that step, we miss the mark and so it's so important. and you highlighted that they meet monthly and, now that workload acuity, team meets with the Clinical Informatics Council. So integrating them formally into our professional governance structure, so.

Natalie Denson: Yeah, I think a key point in doing this entire project was like the time studies and going and actually shadowing the nurses to actually see what they're doing, to help make the difference as well. Because, we can think we know, however, if you're not actually in their shoes and walking and seeing in every one of the care spaces that we have, you don't truly understand.

Christi Welter (Host): Yeah, that sounds like a really important initiative. can you talk a little bit about the outcomes, both from a patient perspective and a nurse satisfaction perspective?

Marshall Stevenson: Yeah. So from the, nurse satisfaction side, there's been a lot of improvements, on the nurse satisfaction side. So when we implemented this in the critical care space in 2022 and in 2023, we saw a really large spike in, nurse satisfaction. They were really satisfied with the workload. They felt that their voice was heard, that they were able to actually articulate.

What their acuity was, what was actually happening at the bedside. And then being able to express that to the leadership team, to provide the nursing resources that they needed.

Brennan Lewis (Host): to add on, you know, year over year since you guys have implemented the workload acuity based, we've seen an increase, particularly around the magnet question focused on staffing of units, and we continue to see that year over year increase. and, it's really in the top quartile, when we compare ourselves to our benchmark.

So it, really has proven that we are making a difference. You guys are making a difference with this workload acuity tool.

Natalie Denson: I believe we also saw an improvement in the, Culture of patient safety survey as well. Mm-hmm. Around staffing. Yeah. So, which is fantastic to hear. one thing that we did do with the acuity based staffing project is when it was finalized, we used that working with finance to create an updated hours per patient day.

Mm-hmm. So we are still utilizing hours per patient day. however, we're doing it from a different lens by using the acuity based staffing to help drive some of them.

Brennan Lewis (Host): Okay. Once you had this workload acuity tool, studied, validated, especially based on the different patient care environments, how did you work to get your staffing plans updated?

Natalie Denson: Yes, so, through the staffing committee, our staffing office really helped drive some of that. So as we were going live towards the end of the year, most of, the care areas had gone live with their updated, Model based on the acuity based staffing, and we just rolled it in to their staffing plans, getting ready for 2025, within the staffing committee just to make sure that we were ensuring that all nurses understood and had a voice in what we were doing as well.

Brennan Lewis (Host): What's one thing you say would be the most challenging aspect of trying to implement the workload acuity into our workflows.

Natalie Denson: the time study portion of it, getting the amount of time needed to really understand what's going on in each of the care spaces. you're still doing it in a snapshot of time and, and as much as you want to be able to get everything you possibly can. I found that to be a little challenging.

Marshall Stevenson: I think one aspect that's been challenging is. Getting the nurses to, stay on the workload acuity. So once you've done the time studies, you've implemented workload acuity, maintaining that kind of. Evaluation of what it looks like and what it's supposed to be from shift to shift. I think, while it's okay to kind of pivot from shift to shift, sometimes, sometimes what we do is we start to drift and then we stay drifted and then we drift a little bit further and trying to get back corrected.

So just maintaining the workload acuity, what everybody agreed on and how we're gonna move forward as opposed to, well now this kid is sicker, so I need more nurses because the acuity is. Something that it's, kind of expanded on that.

Brennan Lewis (Host): So kind of drifting back to how assignments were previously made Yeah. Versus really using the new tool to kind of stay aligned. Correct. With that.

Natalie Denson: That makes sense. Which I'm glad you said that. this is where Carrie Hurst and the staffing office really come in. So she has created a tool that our administrative supervisors are using and so. it's color coded So as they're talking in the charge nurse meetings, they look at their overall workload acuity of the unit, and then how many nurses they have, and it color codes it for them and helps drive those conversations.

So again, as Marshall was saying, so we're not drifting, but we're keeping it at the forefront, in every conversation we have as it relates to staffing.

Christi Welter (Host): What does the future look like for this? are you all still, working to refine it or, just really looking at, rolling it out across the hospital

Natalie Denson: so we have it everywhere that it can currently go now. I would love, if we could figure out a way to do something like this in our emergency department, and other care spaces that we currently aren't able to, um. Right now we are just still monitoring. So, with the help of our administrative supervisors in our staffing office, really, it's a.

Three time a day monitoring. So they're using it to help drive staffing decisions within all the care spaces. so we're just monitoring it for now. working with the workload acuity committee. and then just, checking in with the different areas on if they're noticing any challenges and if there's anything that we need to,

Christi Welter (Host): What are some of the limitations? I know you mentioned that we're not able to implement it in the emergency department. what are some of those limitations?

Natalie Denson: Some of it is just the workload acuity scoring within those care space that it hasn't been developed there. that you can't. Obviously create an average score per nurse if you don't have the same type scoring system within those care spaces. The other thing to take into account is, although it works really, really well for us.

Marshall mentioned earlier about when I'm looking as a charge nurse at making my assignment, sometimes I may believe that although this says this is a great pair, it may not be, there could be other, Parts of a patient care assignment such as social, concerns or other things that really we haven't been able to get into with the workload acuity score that we have to use our judgment.

Brennan Lewis (Host): Okay. That makes sense. So the importance of charge nurses still holding the clinical judgment, critical thinking aspect of their role, that this is really a tool that helps inform Absolutely.

Marshall Stevenson: this is also a tool that hasn't. Been widely, seen across the country, either there's certain aspects of workload acuity that are in the adult world, but this is really the first time it's been really implemented in the pediatric world. So, while we think we have done a really great job at getting, to this point, of time right now, there's still a lot that we need to learn and still continue to adjust along the way.

So there's still a lot of work to be done, in this process.

Brennan Lewis (Host): One of the things you mentioned, Natalie, so for either of you to answer is really what advice would you give other nurse leaders, other nurse executives of how do you partner with your finance leadership team? Because they are still very focused on hours per patient day, or HPPD. What advice or what approach did you take to really partner with finance to be able to make some adjustments in your HPPD based on the findings of workload acuity?

Natalie Denson: I think just open dialogue. Yeah. Honestly, we are very lucky with our finance partners and they are open to hearing, what does it take to staff and what do you need to provide the care for these patients? And I really do believe this approach has allowed for us to continue.

we historically would say, oh, the patient's, the acuity's just so high. Well, what does that actually mean? And so we actually have data to show what it means to care for patients, because a patient. in an acute care unit, in a patient in our C-V-I-C-U or the PICU are much different.

And so this allows for us to really drive that conversation. It is just a data point, but it, opens up that conversation, and I think has gotten us a lot further than historically when we would just say that, oh man, it's just so busy.

Brennan Lewis (Host): Natalie, I love that you highlighted how, in the past, you know, nurses inherently can say this patient just very complex, very challenging, but it's. Been difficult to really articulate that and translate that over into the finance world. And so, it sounds like this tool has really helped, bring language forward so that you can com communicate more of like, we actually have.

A number that we've been able to validate internally that gives a voice to what nurses are perceiving complex patient assignments.

Natalie Denson: Any one patient is not the same as another patient within your care space. And so this really helps say like, it doesn't mean we just need three nurses for 12 patient. It may mean that we need many more just based on what's happening within that unit.

Marshall Stevenson: Yeah. 'cause with the hours per patient day, that's all it's counting is the number of patients that are in a bed and the number of people it takes to care for them. It does not take into any of the other things that we've talked about. Acuity in the sense of psychosocial, the acuity of, death and dying, right?

If you have a child that potentially had a severe trauma and now we're working through the dying process. That really does take a lot of time from the bedside nurse that isn't sometimes picked up in hours per patient day. So really being able to articulate that in the acuity side of that, has really benefited the bedside staff.

Christi Welter (Host): If another organization was interested in implementing workload acuity based staffing, what recommendations would you have for them in terms of how they, how they can get started? what might be the first steps?

Natalie Denson: I believe that having a good, informatics partner and team to help, work with nursing on what it means. as Marshall was mentioning earlier on the, like the scoring of, uh, different procedures, what it might take, the minutes that it might take, and then just. Working with the PI team to really determine in each of those care spaces, like, the time studies and just working together.

I think it's important, that we're listening and having our nurses involved for sure. So.

Marshall Stevenson: On my side, I would say having a good connection with your senior executive team because they are the ones that help support this, right? So even if you may fall slightly flat as you start the process, you need a team that's really willing to hear you out and get you through the process as opposed to, well, this didn't work for a month, so let's go ahead and scratch that and go back to the other one.

So, we have been very fortunate to have, a senior executive team that, believes in this and has really supported us along the way. then our finance team, as Natalie has mentioned, they've been great partners and they've been, very open and receptive to our comments and our, recommendations. They give their recommendations and it's been a, great partnership.

So I think those are two other aspects that are really very important as well.

Brennan Lewis (Host): what's something we haven't covered that you would want the audience that's listening to know about workload acuity.

Marshall Stevenson: I would say workload acuity isn't. The fix all. It is another tool that we have been able to use that really does give the bedside nurse a voice. you just have to work with your team and try to figure out what is the best, way to manage your staffing and your day to day.

Like, I think, those are the. Important sides of it. It may be workload acuity, it may be hours per patient day. It could be something that we haven't even thought about before. But, don't just go down one pathway and go, this is gonna be our fix. Like, that's not gonna solve anything.

So just being open and, receptive to ideas and thoughts through the process.

Natalie Denson: Yeah, I would say just if, you are finding that your workload acuity or what is happening within your care space has changed, or if you wanna look at something, please, escalate those. Use our workload acuity committee, with Jeffrey Ho and others to help us guide and make those decisions and changes as needed.

Christi Welter (Host): All right, well, it's time to wrap up this episode of Nurses Connect. Thank you both for joining us today.

Marshall Stevenson: Thanks for having us.

Brennan Lewis (Host): If you wanna know more about Nursing at Children's Health, we encourage you to visit children's dot com slash nursing annual report. Here you'll find information that summarizes a variety of our nursing initiatives. Thank you to our listeners for joining us today. We'll talk to you next time on Nurses Connect.