Improving Work Environment and Retention in a Progressive Care Unit (Part 1

Improving work environment and retention in a progressive care unit (Part 1 of 2)

Suzanne Beels, MSN, RN, AGCNS-BC, CCRN; Susan Blankenship, MS, BSN, RN, PCCN - CVI Surgery & Educational and Organizational Development

Methods and procedures

In June 2020, concerns were brought to Cardiovascular Institute (CVI) leaders regarding high turnover rates amongst 7SPCU nurses, a Cardiovascular Progressive Care Unit (PCU). The 7MPCU and 9SPCU employees were combined in December 2019 to form a new CVI surgery PCU. Nurses were challenged with learning skills to care for cardiac, vascular, and thoracic surgery patients: creating a lengthy competency validation list of high-level skills.

Purpose and aims

The purpose of this quality improvement project was to appropriate a weekday floating charge nurse (FCN) to support RN staffing levels on the CVI Surgery PCU. Project aims were to increase RN retention rate and increase the overall ‘Appropriate Staffing’ Standard Score.

Current state of knowledge

The American Association of Critical Care Nurses (AACN) led the way in defining and measuring the impact of work environment on patient and nurse outcomes in acute and critical care units. The Healthy Work Environment (HWE) survey collected data and focused on six standards for creating an HWE: True collaboration, skilled communication, effective decision-making, meaningful recognition, appropriate staffing, and authentic leadership. Ulrich et al. identified five themes in their review of nurse work environment studies completed from 2005-2017, one of which was the positive correlation of HWEs with psychological health, job satisfaction, and retention (2019, p. 68). They also noted HWEs were negatively correlated with emotional strain and burnout (Lampo, 2019).

Description of population and benefit

7SPCU is a 20-bed PCU. The benefits of establishing a weekday FCN were to develop and maintain frontline clinical expertise and improve the work environment.

Methods and procedures

The FCN role was developed to address employee feedback while meeting the project goals. The FCN did not carry a standard patient assignment but was available on the unit to fill any gaps in care. By utilizing the most experienced nurses in the FCN role, they were the most knowledgeable and versatile RNs to handle the responsibilities.

Specifics of the role:

• Daily tracking of time allocation: Out of the 370-day pilot, the FCN was utilized 140 days • FCN hours were scheduled as 8-12-hour shifts during high churn as staffing permitted • Exclusions included nightshift, weekends, and holidays • The FCN was pulled back into staffing as a bedside RN with a patient assignment when 7SPCU or another PCU required support

FCN time was allocated into primary categories as identified on the graph below. Most of the shift was spent in direct patient care raather then managing throughput.

A planning team met weekly to identify if adjustments were needed. Employees gave ongoing feedback to the Unit Director. Quarterly updates were provided to surgeons and other CVI Unit Directors during interdisciplinary quality meetings and daily huddles.

Assessment and outcome measures and data collection

Power-Bi was used to evaluate RN turnover rates.

Quarterly HWE surveys were administered to track ongoing engagement and feelings of support. Results were discussed during staff meetings and informally as situations arose. The project measures included “Appropriate Staffing” and “Skilled Communications.”

Findings

Turnover

The RN turnover rate from fiscal year 2020 was 23.6%. In 2021, it decreased to 14.55%. Reasons for leaving the unit changed from concerns with workload and acuity to promotions, retirements, and relocation.

OVERALL STANDARD: Staffing must ensure the effective match between patient needs and nurse competencies. The overall pre-project score was 58.97% of RNs disagree the standard is being met. The post-project score was 15.56%.

Three individual questions elicit the overall response to the overall standard. They included:

•Q3. The pre-project score was 62.82% disagree. The post-project score was 13.33%. •Q8. The pre-project score was 53.85% disagree. The post-project score was 13.33%. •Q12. The pre-project score was 53.84% disagree. The post-project score was 20%.

*See diagram next page.

Impact

The goal of maintaining current nurses was the impetus of the project, but the overall unit impact was significant. HWE surveys showed less dissatisfaction with appropriate staffing. There was a positive progression in morale and job satisfaction. The FCN role was performed less than half of the time, yet positive outcomes were still recognized. Anecdotal conversations with nurses reflected a more positive work experience. Multiple nurses who had either left the unit or submitted resignations had returned or remained. Additional incidental outcomes occurring simultaneously included:

• decrease in CVI PACU hold times which improved throughput and decreased OR downtime • low HAI rates • increased number of quality rounds • improved patient satisfaction

*See part 2 in the next Within Reach to learn about project recommendations.

References

• Lampo, D. (2019). American Association of Critical Care Nurses [AACN]: Staffing in acute and critical care. Retrieved from AACN https://www.aacn.org/clinical-resources/staffing# • McGaffigan, P. (2019). American Association of Critical Care Nurses [AACN]: Keys to appropriate staffing. Retrieved from AACN https://www.aacn.org/nursing-excellence/nurse-stories/keys-to-appropriate-staffing • Samoya, A. (2019, September). Creating healthy work environments: An evidence-based toolkit for nurses. Retrieved from AACN website https://www.aacn.org/~/media/aacn-website/nursing-excellence/healthy-workenvironment/hwetoolkit.pdf?la=en • Ulrich, B., Barden, C., Cassidy, L., & Var-Davis, N. (2019). Critical care nurse work environments 2018: Findings and implications. Critical Care Nurse, 39(2), 67-84. Retrieved from http://aacnjournals.org’ccnonline/articlepdf/39/2/67/116850/67