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VA Nursing: Effectiveness and Entry

The VA Office of Nursing Services (ONS), along with QUERI, has established a Partnered Evaluation Initiative (PEI) – VA Nursing: Effectiveness and Entry – with a team of researchers from HSR&D's Center for Clinical Management Research (CCMR) in Ann Arbor, MI. The primary goals of this PEI are to:

• Evaluate the impact of strategic initiatives in order to inform decisions about maintaining, modifying, and expanding programs; and
• Assess the implementation of strategic initiatives, and variations in implementation success across sites, in order to inform the QUERI program about successful implementation.

One ongoing evaluation is of the Staffing Methodology (SM) initiative.

Through the provisions of VHA Directive 2010-034, Staffing Methodology for VHA Nursing Personnel (July 19, 2010), all VA healthcare facilities were mandated to use a standardized method of determining appropriate direct-care staffing by nursing personnel by September 30, 2011. The Directive outlined a multi-step, data-driven process that was designed to assist nurse leaders in projecting full-time employees required for safe and effective care across all inpatient units. These projections were intended to inform budget development in each facility. The process includes the establishment of unit-and facility-level expert panels. For example, unit-level panels are comprised of nursing staff that represent all nursing roles, such as Registered Nurses, Licensed Practical Nurses, nursing assistants, and healthcare technicians. Fundamental to the staffing methodology process is the engagement of frontline nursing staff and nurse managers, who collect unit-specific data, including nursing hours spent on various activities and nurse-sensitive outcome indicators. This information is used to calculate expected staffing needs and is presented to facility leadership for budgetary planning.

As part of the evaluation, the PEI research team conducted telephone interviews and electronic surveys of nurse executives and their staff involved with the coordination of the staffing methodology directive. Interviewees reported that the inclusion of frontline nursing staff in the process, and having staffing recommendations approved and funded was good for morale. One interviewee stated that "the ability to go back to the staff and say, 'You were part of a process, this is what you say you needed and look, it was funded,' does make a huge difference." An interviewee at a facility with a high level of implementation of the staffing directive indicated there was a high level of ownership of the process, knowledge, and accountability at all levels of the organization. For example, clinic and facility leadership met daily to look at the variance of actual staffing from predicted staffing needs. "Everybody knows about it because in the morning meetings with all of the service chiefs, clinical, and director of the Pentad [Core structure, including Facility Director, Associate Director, Chief of Staff, Associate Director of Patient Care Services, and Assistant Director] we have an electronic spreadsheet that's uploaded on a big screen, so they see our census by unit. They see our target; they see our actual and calculated variance... Every single person knows [staffing methodology] in terms of the executive leadership team, non-nursing positions, you name it."

Although implementation of the directive was often constrained by financial barriers of the facilities, survey respondents agreed that unit nurses had become engaged with the staffing methodology process. One respondent noted that "unit-based leadership and some of the unit staff have embraced the theory and practice of [staffing methodology]." Another respondent echoed, "Most nursing leaders and some frontline staff embraced the concept of staffing methodology." And another commented that "Our process is strong and we've seen a lot more frontline engagement from panel members."

This PEI research team will continue to evaluate this initiative and its impact on the nursing needs of Veterans.

Anne Sales, PhD, RN
Principal Investigator: VA Nursing: Effectiveness and Entry