You're Pulling Me Where?

MedSurg Nursing, Dec, 1998 by Barbara L. Arvanitopulos, Margaret K. Camino

Elizabeth, an 8-year-veteran pediatric nurse is pulled to a busy adult medical-surgical unit. She reviews the care plans for her seven-patient assignment. Worries set in over her ability to care for adult patients during a hectic 3 pm to 11 pm shift. She tells the charge nurse, "I don't think I can take care of these patients because I'm unfamiliar with many of these orders." The charge nurse replies, "Don't worry, I'll help you if I can. There really isn't anyone else."

The Beginning

Elizabeth's story is commonplace in hospitals throughout the country and is an issue for staff nurses and leadership. Many nurses voice concerns to leadership about their ability to provide safe patient care when pulled outside their specialty.

At the authors' institution, leadership listened to us and recommended a continuous improvement (CI) team be formed to represent all nursing areas. Twenty-five staff nurses plus a nursing unit leader, assistant unit leader, nursing educator, and nursing supervisor committed time and effort to this project. The CI team was led by a nursing business analyst and assisted by a facilitator.

To say the least, the atmosphere in the room during the first meeting was tense. Many were skeptical. Nurses voiced frustration and anger about the current pull process. Most did not understand the CI concept or how it could make a difference with this volatile situation.

Senior leadership from nursing administration attended the first meeting to welcome the team. They shared their vision and clarified why nurses were pulled, yet openly acknowledged the nurses' concerns. They explained how critical it was to have staff nurses redesign the pull process.

They gave direction, yet staff knew they were empowered to "blow up" the process and do whatever necessary to make it work.

Some Facts

At the first working meeting, the opportunity to improve the current system of pulling nurses throughout the hospital was addressed. The need to match staffing with acuity and census was essential. Staff nurses had concerns about competency and safety of patient care. The nursing business office prepared a report showing that staff nurses worked 9.4% of their time on other units. Additionally, there was a 28% increase from the previous year in the number of times nurses worked outside their specialty area. Since more of their time was being spent on other floors, the nurses' goal was to ensure an environment that enabled them to continue to deliver safe, quality care.

Teamwork

For 3 months, the CI team met on a weekly basis. The ground rules stated that a meeting could only be held if 80% of the members were present. No meetings were canceled. Participants brainstormed, shared pull stories, and identified ways to improve the process. Looking at the data, common themes emerged for both problems and solutions. The team organized these themes into three categories of (a) patient care safety, (b) nurse responsibility, and (c) leadership support. At this point, the group began believing they could move forward as a team to redesign a process that would work for all of our nurses. This was their turning point.

Patient Care Safety

The system to address patient care safety issues includes a patient assignment based upon the pulled nurses' level of experience and assigning a resource nurse. Several communications tools were developed in the new pulling process.

* Pull staff communication matrix

* Welcome packet

* Evaluation of pull experience form

During a brainstorming session the CI leader summarized the group's thoughts. "Your skill level must drive the type of assignment and need for a resource nurse in order to safely care for patients."

This concept is the basis of the communication matrix. By unit, it lists the self-assessed skill level of each nurse for every nursing unit. The skill levels are designated as NE (no experience), LE (limited experience) or EXP (experienced). For example, on one unit the operational definition of an EXP (experienced) nurse requires a working knowledge of post-operative care, ostomy and wound teaching, trauma care, central line management, tube feeding, and chest tube management (see Table 1).

Table 1.
Pull Staff Communication Matrix

Associate Name   Rehab   Post Partum   Adult MH   Orthopedics   ICU

Florence         LE      LE            N E        LE            EXP
 Nightingale
Clara Barton     EXP     LE            EXP        NE            NE
Nancy Nurse      EXP     NE            LE         EXP           NE

Associate Name   Pulmonary

Florence         EXP
Nightingale
Clara Barton     LE
Nancy Nurse      LE

NE = No Experience

LE = Limited Experience

EXP = Experienced

Secondly, to ensure patient care safety, each unit provides a pulled nurse with a resource nurse. Three levels of resource nurses are available: co-assigned, resource-plus, and resource. A coassigned nurse shares a patient assignment with the NE nurse. They work together to determine what the NE nurse can and cannot safely do in their joint assignment. A resource-plus nurse is assigned to a pulled nurse listed as LE. The resource-plus nurse is actively involved with the patient care assignment including the review of care plans to identify the type of assistance the pulled nurse requires for the shift. A pulled nurse listed as EXP is assigned a resource nurse to give support and answer questions as needed.