Optimizing enactment of nursing roles: redesigning care processes and structures

Figures & data

Figure 1 Adapted from the Nursing Effectiveness Model.¹¹

Table 1 Demographics of study sample of nursing providers

	Redesign unit		Control unit
	Pre-redesign	Post-redesign	Pre-redesign	Post-redesign
	n=21	n=30	n=34	n=26
Professional designation
RN	15 (75.0)	20 (68.2)	23 (68.4)	17 (66.7)
HCA	5 (25.0)	9 (31.8)	11 (31.6)	9 (33.3)
Age, M (sD)	47.4 (12.6)	39.2 (14.6)	47.4 (11.6)	43.7 (10.8)
20 to 34 years	4 (18.8)	6 (21.7)	8 (23.8)	13 (51.7)
35 to 44 years	1 (5.0)	6 (21.7)	6 (19.1)	3 (10.3)
45 to 54 years	9 (40.6)	13 (43.5)	6 (19.1)	4 (13.8)
>54 years	3 (15.6)	4 (13.0)	13 (38.1)	6 (24.1)
sex
Male	2 (9.5)	5 (17.2)	1 (3.0)	3 (11.5)
Female	19 (90.5)	24 (82.8)	32 (97.0)	23 (88.5)
Education
LPN certificate	1 (6.1)	2 (7.7)	5 (14.3)	5 (20.7)
RN diploma	10 (48.5)	9 (30.8)	13 (38.1)	8 (31.0)
Bachelor’s degree in nursing	6 (27.3)	8 (26.9)	8 (23.8)	7 (27.6)
Other bachelor’s degree	0 (0.0)	2 (7.7)	2 (9.5)	0 (0.0)
Other	4 (18.2)	8 (26.9)	5 (14.3)	5 (20.7)
Number of years in practice
0 to 2	3 (15.6)	4 (12.0)	3 (9.5)	8 (31.0)
3 to 5	2 (9.4)	5 (16.0)	8 (23.8)	4 (17.2)
6 to 10	4 (18.8)	8 (28.0)	0 (0.0)	4 (17.2)
11 to 15	5 (21.9)	4 (12.0)	2 (4.8)	1 (3.5)
>15	7 (34.4)	9 (32.0)	21 (61.9)	8 (31.0)
Observations
RN unique providers, N	15	15	13	12
RN shifts, N	20	19	15	17
HCA unique providers, N	5	7	6	6
HCA shifts, N	8	8	9	8

Note: Data are presented as N (%), except where indicated otherwise.

Abbreviations: RN, registered nurse; HCA, health care aide; M, mean; SD, standard deviation; LPN, licenced practical nurse.

Table 2 Minutes per shift on activities related to clinical role accountabilities and other work pre- and post-redesign

Activity categories	Redesign unit			Control unit
	Pre-redesign	Post-redesign	Change	Pre-redesign	Post-redesign	Change
Registered nurse
coordination of care	45.8 (12.6)	61.1 (15.7)	15.3 (3.1)	61.3 (18.7)	61.3 (16.8)	0.0 (−1.9)
Patient and family assessment and support	16.8 (4.6)	16.1 (4.2)	−0.7 (−0.4)	17.1 (5.0)	8.2 (2.3)	−8.9 (−2.7)
Biomedical assessment	28.6 (8.0)	22.2 (5.8)	−6.4 (−2.2)	25.5 (7.1)	25.5 (6.8)	0.0 (−0.3)
Medications and treatments	48.0 (13.2)	51.4 (13.3)	3.4 (0.1)	39.8 (11.2)	45.2 (12.3)	5.4 (1.1)
Activities of daily living and personal care	47.2 (13.0)	38.7 (10.1)	−8.4 (−2.9)	48.7 (13.3)	35.0 (9.6)	−13.7 (−3.7)
Mobilization	5.2 (1.5)	3.1 (0.8)	−2.1 (−0.7)	2.2 (0.6)	3.2 (0.9)	1.0 (0.3)
Engagement	10.0 (2.7)	9.8 (2.5)	−0.2 (−0.2)	5.4 (1.7)	13.4 (3.8)	8.0 (2.1)
spatial organization	22.1 (6.1)	19.2 (4.9)	−2.9 (−1.2)	18.0 (4.7)	25.5 (6.9)	7.5 (2.2)
Documentation and information review	76.3 (20.9)	86.6 (22.5)	10.3 (1.6)	75.8 (21.4)	90.8 (24.4)	15.0 (3.0)
administration	11.4 (3.2)	16.4 (4.1)	4.9 (0.9)	12.7 (3.1)	16.3 (4.4)	3.6 (1.3)
Washing hands	12.9 (3.5)	5.7 (1.5)	−7.2 (−2.0)	4.1 (1.2)	3.5 (1.0)	−0.5 (−0.2)
Travel	48.6 (12.8)	70.1 (17.0)	21.5 (4.2)	48.7 (12.6)	54.3 (13.5)	5.6 (0.9)
Health care aide
coordination of care	68.8 (20.2)	22.7 (7.4)	−46.1 (−12.8)	47.3 (14.3)	30.4 (10.0)	−16.8 (−4.3)
Patient and family assessment and support	42.9 (15.1)	35.5 (11.9)	−7.4 (−3.2)	50.9 (14.9)	34.7 (12.4)	−16.1 (−2.5)
activities of daily living and personal care	120.7 (33.5)	111.8 (39.1)	−8.9 (5.6)	111.4 (33.3)	108.5 (37.6)	−2.9 (4.3)
Mobilization	0.1 (0.0)	2.2 (0.7)	2.1 (0.7)	0.1 (0.1)	2.9 (0.9)	2.7 (0.8)
cleaning and organizing	42.1 (12.3)	32.6 (9.8)	−9.5 (−2.5)	55.6 (16.5)	27.8 (9.5)	−27.8 (−7.0)
Documentation and information review	6.2 (1.7)	12.3 (4.5)	6.1 (2.8)	2.9 (1.0)	0.5 (0.2)	−2.4 (−0.8)
administration	5.6 (2.6)	17.3 (5.0)	11.7 (2.4)	4.5 (1.3)	6.1 (1.8)	1.6 (0.5)
Washing hands	6.7 (1.9)	8.6 (3.1)	2.0 (1.2)	11.4 (3.3)	4.0 (1.5)	−7.4 (−1.8)
Travel	56.7 (16.4)	58.0 (16.1)	1.3 (−0.3)	62.6 (17.7)	78.3 (23.1)	15.7 (5.4)

Note: Data are presented as mean (%) minutes per shift.

Table 3 Unit-based strategic plan

Priorities for change	Strategies
Structure: unit
• Match the right staff mix to patient population needs	• created and sent a business case to the unit’s director in support of hiring licensed practical
• support role accountability and clarity among unit providers through team development	nurses and increasing the availability of a clinical nurse educator and pharmacists to the unit
	• changed health care aide start times to match start times of registered nurses
• cultivate collaborative approach to service delivery	• Implemented “buddy teams” (two to three registered nurses: one health care aide)
• Promote patient safety through improved communications (ie, better handoffs)	• Developed shift-to-shift report parameters to inform “getting to know the patient” and patient assignments
Process: nursing role accountabilities
• Expand nurse knowledge and skill base to better understand geriatric population from a monitoring and risk surveillance perspective (physical and psychosocial)	• Presented information about risk assessment and population needs to change team and staff
	• Provided a synthesis of the literature on discharge planning, chronic illness, and risk assessment
	• Developed “did you know...” information posters and posted on unit
• complete a more comprehensive nursing assessment of patients	• Initiated inservices for health care aides on competencies in skin care and charting of intake and output of fluids
• Increase time spent on patient and family assessment and support, discharge planning, and care coordination	• Laminated pocket-sized cards outlining assessment priorities for registered nurses and suggested topics for round discussions
	• I nsulin pens ordered to present opportunities for teachable moments
Process: unit workflow
• Increase responsiveness and time for value-added activities by reducing unit travel time and interruptions	• Relocated equipment, linen, and paper supplies
	• created cheat sheet for computerized patient care information system
	• created phone log
	• Established point of care family contact
	• Placed insulin pens at bedside

Table 4 Bivariate regression results: registered nurse observation data

Activity categories	Unit effect	Time effect	Redesign effect	Constant
	B (SE)^a~[CI]^b	B (SE)^a~[CI]^b	B (SE)^a~[CI]^b	B (SE)^a~[CI]^b
Coordination of care	−15.51 (8.26)	−0.03 (9.41)	15.31 (12.03)	61.29 (7.34)
R^Citation2=0.08, F(3,67)=2.79, P=0.047	[−32.00 to 0.98]	[−18.82 to 18.75]	[−8.72 to 39.33]	[46.63 to 75.94]
Patient and family assessment and support	−0.34 (−3.38)	−8.94^** (−2.75)	8.20 (−4.29)	17.13 (−2.36)
R^Citation2=0.14, F(3,67)=6.27, P<0.001	[−7.08 to 6.39]	[−14.43 to −3.46]	[−0.36 to 16.75]	[12.43 to 21.84]
Biomedical assessment	3.09 (−4.38)	0.02 (−3.75)	−6.45 (−6.10)	25.49 (−2.13)
R^Citation2=0.03, F(3,67)=0.63, P=0.60	[−5.65 to 11.83]	[−7.46 to 7.50]	[−18.62 to 5.73]	[21.25 to 29.73]
Medications and treatments	8.14 (−5.42)	5.37 (−5.10)	−1.95 (−7.70)	39.81 (—4.11)
R^Citation2=0.06, F(3,67)=1.34, P=0.27	[−2.68 to 18.95]	[−4.80 to 15.55]	[−17.32 to 13.42]	[31.61 to 48.02]
Activities of daily living and personal care	−1.52 (−5.40)	−13.70^* (−6.32)	5.26 (−7.99)	48.67 (−4.49)
R^Citation2=0.11, F(3,67)=2.66, P=0.06	[− 12.30 to 9.26]	[−26.32 to −1.08]	[− 10.68 to 21.20]	[39.71 to 57.63]
Mobilization	3.00^* (− 1.24)	1.04 (−1.22)	−3.09 (−1.71)	2.19 (−0.83)
R^Citation2=0.09, F(3,67)=2.02, P=0.12	[0.53 to 5.47]	[−1.39 to 3.47]	[−6.51 to 0.32]	[0.53 to 3.85]
Engagement	4.57 (−2.47)	7.97 (−4.60)	−8.20 (−5.44)	5.41 (−1.20)
R^Citation2=0.05, F(3,67)=2.46, P=0.07	[−0.37 to 9.51]	[−1.21 to 17.14]	[−19.07 to 2.66]	[3.01 to 7.82]
spatial organization	4.09 (−2.98)	7.48^* (−3.50)	−10.39 (−5.27)	18.04 (−2.35)
R^Citation2=0.06, F(3,67)=1.71, P=0.17	[−1.87 to 10.05]	[0.50 to 14.46]	[−20.90 to 0.13]	[13.34 to 22.74]
Documentation and information review	0.54 (−6.59)	15.02 (−9.45)	−4.74 (−12.53)	75.78 (—4.13)
R^Citation2=0.06, F(3,67)=1.39, P=0.25	[−12.60 to 13.69]	[−3.84 to 33.88]	[−29.76 to 20.27]	67.53 to 84.03]
Administration	−1.28 (−4.27)	3.59 (3.29)	1.34 (−5.33)	12.72 (−2.6)
R^Citation2=0.04, F(3,67)=0.86, P=0.46	[−9.80 to 7.24]	[−2.96 to 10.15]	[−9.30 to 11.99]	[7.53 to 17.90]
Washing hands	8.87^* (−3.6)	−0.51 (−0.75)	−6.69 (−3.88)	4.05 (−0.42)
R^Citation2=0.16, F(3,67)=2.80, P<0.001	[1.69 to 16.04]	[−2.01 to 0.99]	[−14.44 to 1.06]	[3.20 to 4.89]
Travel	−0.07 (−5.19)	5.59 (−5.53)	15.87^* (−7.17)	48.7 (−4.48)
R^Citation2=0.28, F(3,67)=7.99, P<0.001	[−10.43 to 10.29]	[−5.44 to 16.61]	[1.55 to 30.18]	[39.76 to 57.64]

Notes:

a Unstandardized coefficient (standard error [SE]);

b 95% confidence interval (CI).

* P<0.05;

** P<0.01.

Table 5 Bivariate regression results: health care aide observation data

Activity categories	Unit effect	Time effect	Redesign effect	Constant
	B (SE)^a~[CI]^b	B (SE)^a~[CI]^b	B (SE)^a~[CI]^b	B (SE)^a~[CI]^b
coordination of care	21.54 (12.46)	−16.84 (10.88)	−29.29^* (13.73)	47.28 (9.42)
R^Citation2=0.46, F(3,29)= 12.04, P<0.001	[−3.94 to 47.03]	[−39.09 to 5.40]	[−57.38 to −1.21]	[28.00 to 66.55]
Patient and family assessment and support	−7.96 (−13.38)	−16.11^* (−6.96)	8.67 (−15.34)	50.85 (−5.21)
R^Citation2=0.10, F(3,29)=2.09, P=0.12	[−35.32 to 19.40]	[−30.35 to −1.88]	[−22.70 to 40.03]	[40.19 to 61.51]
activities of daily living and personal care	9.28 (−17.39)	−2.89 (−8.70)	−6.05 (−21.30)	111.43 (−7.36)
R^Citation2=0.03, F(3,29)=0.21, P=0.89	[−26.29 to 44.86]	[−20.70 to 14.92]	[−49.61 to 37.50]	[96.38 to 126.48]
Mobilization	−0.04 (−0.16)	2.74^** (−0.77)	−0.66 (−1.27)	0.13 (−0.13)
R^Citation2=0.35, F(3,29)=5.77, P=0.003	[−0.37 to 0.28]	[1.16 to 4.32]	[−3.26 to 1.93]	[−0.14 to 0.40]
cleaning and organizing	−13.48 (−7.49)	−27.80^** (−6.96)	18.34 (−10.29)	55.55 (−5.83)
R^Citation2=0.37, F(3,29)=5.91, P=0.003	[−28.79 to 1.83]	[−42.04 to −13.56]	[−2.70 to 39.38]	[43.63 to 67.47]
Documentation and information review	3.25 (−1.99)	−2.37 (−1.37)	8.49^* (−3.34)	2.91 (−1.33)
R^Citation2=0.49, F(3,29)= 11.31, P<0.001	[−0.82 to 7.33]	[−5.18 to 0.44]	[1.65 to 15.33]	[0.19 to 5.63]
administration	1.1 (−4.56)	1.62 (−2.69)	10.1 (−6.72)	4.48 (−1.23)
R^Citation2=0.26, F(3,29)=2.75, P=0.06	[−8.23 to 10.43]	[−3.89 to 7.12]	[−3.64 to 23.84]	[1.97 to 6.99]
Washing hands	−4.67^* (−2.02)	−7.38^** (−1.99)	9.34^** (−2.68)	11.35 (−1.87)
R^Citation2=0.35, F(3,29)=6.82, P=0.001	[−8.80 to −0.55]	[−11.45 to −3.32]	[3.86 to 14.83]	[7.53 to 15.17]
Travel	−5.93 (−8.24)	15.71 (−9.50)	−14.43 (−11.56)	62.62 (−6.65)
R^Citation2=0.23, F(3,29)=2.60, P=0.07	[−22.78 to 10.91]	[−3.72 to 35.13]	[−38.07 to 9.21]	[49.02 to 76.23]

Notes:

a Unstandardized coefficient (standard error [SE]);

b 95% confidence interval (CI).

* P<0.05;

** P<0.01.

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