Welcome to the latest in a series of interviews conducted by the AMSN Digital Content Committee (DCC) with session presenters from the 2024 AMSN Convention. Shara Rhodes, DNP, RN, NEA-BC, MEDSURG-BC, NPDA-BC®, vice chair of the DCC, talks with Hannah Ruehlman, DNP, RN, ONC, about her convention session, “Acuity-Based Assignments: Improving Nurses’ Satisfaction While Decreasing Nurse Turnover Rates.”

Rhodes: To start, I'd like to delve deeper into the underlying issues leading to nurse dissatisfaction and turnover as a cornerstone for your project. What are some of the drivers that led you to focus on acuity-based assignments as an indicator for nursing dissatisfaction and ultimately leading to turnover in the medical-surgical nursing space?

Ruehlman: I have worked in the medical-surgical nursing space for about seven years now, 10 years in total in the setting as I started as an aide during my nursing school journey. I have lived in this realm for a while and consistently noticed that staff and nurses in general would consistently voice dissatisfaction regarding the number of patients they had and the “acuity” of those patients. It is consistently voicing: “My group is very heavy. My patients do not belong together. This one requires too much work. The amount of attention each patient needs does not meet what I am able to provide them at this time.”

During my years on the unit as I grew as a leader, I had staff come to me and say, “Hannah, I can't keep doing this” or “I don't know if I'm meant to be a nurse” because of how their assignments were made. Why does this nurse have it this way versus that nurse having it that way? There was an overall concern about how assignments were made from a staff perspective because I started in that role. Then moving to a leadership role, I saw the disconnect from the charge nurse role and how the assignment was made to how it was translated to the frontline. Just observation and living in the climate were what really led to my research.

Rhodes: I can certainly see how that lived experience connects with how assignment-making can address these root causes. There's a lot of chatter in medical-surgical nursing right now about what's contributing to the turnover. In your presentation, you also talked about how traditional nursing theorists like Patricia Benner are still impacting the nursing discipline. Even in today's nursing world, it's so different in the last four to five years. Can you talk about how Benner’s theory overlays the nursing profession today?

Ruehlman: Given the last four to five years, reflecting on the dreaded “C” word of COVID, nurses coming out of school today do not have the same level of clinical experience in some instances. This was true at the time of implementation of my project in 2023. The nurses who are graduating are the nurses who started their programs during the height of the pandemic, where all their clinicals were virtual. They were not taught how to walk into a patient's room and introduce themselves — those basic foundations that you learn through your clinical experience was limited or delayed for these nurses.

So, when you reflect on Benner's theory of novice to expert, it really identifies what we talked about in our presentation: the complexity gap, the experience gap that we have among nurses. During the pandemic, a tremendous number of nurses left the bedside for various reasons, and it left us with this gap between experienced nurses and nurses coming out of nursing school without the same level of experience of nurses graduating five years prior to that. How do we help experienced nurses understand the knowledge that these nurses coming out of nursing school now have?

And that is when I turned to the novice to expert theory. For example, Shara, you have been here for 10 years. You can walk in here with your eyes closed and take care of that patient. You are an expert. But we also have nurses who truly are novices. Some will argue that Benner would even call a new graduate nurse an advanced beginner because of their clinical experience, but I think at the time of my project’s implementation, some of them were really coming out as novices because of that lack of experience during their nursing school time due to the environment in which they went to school.

Taking the steps in Benner’s theory enabled my charge nurses to see where each nurse falls. Then attaching that to our acuity tool helped my staff make assignments that reflected a true assignment because we had staff at every level. We had novice, advanced beginner, competent, proficient, and expert nurses. But I needed to connect the dots for them in a way that wasn’t just saying they didn't have the experience, and Benner's theory helped outline what not having experience meant or how their experience lined up with where they were on this pendulum or timeline, if you will, of their career.

Rhodes: I love that you talk about how your charge nurse is influential in that space. What are some of the specific strategies or tools you use to effectively assess patient acuity and match it with those nursing skill sets you just described? And how did you decide what "right" looked like?

Ruehlman: For the basis of our implementation at the time, when we first rolled it out, we used the electronic tool built into our electronic medical record (EMR). Our EMR had the ability to run a report based on orders in the patient’s chart — nursing documentation — which translated into a score. It was more objective data; it took a lot of the subjectivity out of it. Everybody is going to have a different picture of what the acuity of a patient looks like, so we wanted to implement a tool that put every patient on the same neutral playing field.

The EMR tool provides a number from zero to roughly 200, and some of the pre-work I did for this project involved looking at this tool over time prior to implementation to determine the mean acuity score for our unit and then translate that into the novice to expert timeline. The mean was 70 to 72 for a novice nurse, 72 to 74 for an advanced beginner, 76 to 78 for a competent nurse, and up for proficient and expert nurses. It did not mean that every patient a nurse had needed a score in that range; the mean of the nurse’s assignment had to be in that range.

We were on a 30-bed unit, and this allowed my charge nurses to say, “Here are our 30 patients, and to get Hannah’s five patients, we’re going to pick patients one, two, seven, and 10 and compile them.” One of the patients could have a higher acuity score but pairing them with patients with lower acuity scores could get them to that mean while allowing those nurses to gain clinical experience as novices and advanced beginners to escalate their care and advance in their careers.

This was a foreign concept to the charge nurses, so I had to explain it exactly like I am doing here — this is why we are doing it; this is what it looks like. I also provided some hands-on education with exercises for my charge nurses prior to implementation. I printed out a unit census and created a picture of every patient and their acuity score. Then I took the set of nurses who were scheduled, and as a group during these education sessions, we worked through what an assignment looks like.

How can we create an assignment that matches each nurse’s level of experience with an acuity score that is within the suggested range, giving novice nurses higher acuity patients to allow them to grow without overloading expert nurses with several high-acuity patients?

There was no exact “right.” There were several ways we could have flexed the assignment to meet the need. It was more like, let us look at one situation because in healthcare, nothing is black and white; we live in a world of gray. How can we work through it to decide what “right” looks like at that time? It was a lot of trial and error; this was the tool, this was our information, and how do we compile them to get where we needed to go?

Rhodes: One of the statements you made is, “There's no standard for what ‘right’ is. It's what ‘right’ looks like at that time.” Taking important factors into consideration is a part of the art of nursing we have to rediscover. I believe it's important to equip medical-surgical nurses with knowledge about the implementation and the evaluation processes. As you created the tool, you talked about how you drilled into what's “right” at the time in different scenarios. How did you then measure the impact of acuity-based assignments on nurse satisfaction and turnover rates?

Ruehlman: Pre-implementation, even pre-education, I rolled out what is called a healthcare vitality instrument. It is a tool that is used to assess a feeling, the overall concept of satisfaction. I asked very simple questions like: Do you enjoy your job? On a Likert scale of strongly disagree to strongly agree, how often is acuity considered when your assignment is made? How likely are you to leave your job within the next four months? That was the implementation timeline.

After using those kinds of questions to assess and gather baseline data, I took the same survey and sent it out 10 weeks after we implemented the tool. I compared the two surveys and was able to assess that satisfaction increased when using acuity to influence an assignment. Turnover was a little harder to assess due to the project’s short timeline. The turnover rate did decrease, but it decreased by about half a percentage. But with one specific question we asked (How likely are you to leave your job within the next four months?), we saw a higher number of individuals who were less likely to do so. We could then imply that utilizing this tool is going to impact our turnover rates in the long run, even though we did not see it at that current moment.

Rhodes: Your data and your presentation were certainly indicative of remarkable changes that are in the forefront. As we close here, I want you to think about that medical-surgical nurse who's looking around them and seeing what's happening in terms of satisfaction and retention. Can you provide some thoughts in terms of any barriers you would expect that nurse to have in trying to implement this tool as a practice in their unit, and any words of encouragement that you feel are important to mention to that nurse?

Ruehlman: My biggest barrier was getting nurses on board. Right away, I was hit in the face with, “This is not going to work. How do you think this is going to influence us? This is just going to create more work for me because now I have to create these tools, and I have to meet the mean.”

I got a lot of these rebuttals of why it would not work, but every day, I encouraged the staff to give it a try. Keep going, keep pushing forward. Keep saying, “This is what we're going to do,” and start teaching them every day to try.

We did find flaws in the original tool, and it was helpful having that consistent, open communication with my charge nurses, who are using the tool, to say, “Tell me about the flaws. Tell me what you are seeing that is not working. Help me understand this.” As we eventually spread this work to another unit, I was able to take those barriers identified from unit one and translate them into how we use the tool on unit two to make it more user-friendly.

If you have an idea, something that you want to do, try it, and be OK if it fails because failure is the first attempt at learning. For high-reliability organizations, we have to be obsessed with failure. If we do not look at failure as a positive thing and learn and keep trying, we are never going to advance our practice. We cannot live in the world of “that's how we've always done it” because that is what we are trying to get away from. Yes, that is how we have always done it. But why have we always done it that way? Why can't we change it and just to continue to push? Because the more you push, the more you are going to get people on your campaign to make a change in medical-surgical nursing.

We do so much as medical surgical nurses. Every day we have the ability to impact, and it just takes one person to ask that one question, and that is my favorite question: Why? All the time people are like, “Well, we can't do it this way.” Ask, “Why?” Really challenge your co-workers, everyone you work with on your unit, outside your unit, even ancillary staff. There are so many things we individually impact through our medical-surgical nursing role, and if you can continue to ask “why,” you can go far and continue to challenge what we are doing. So, keep at it. That is my biggest piece of advice: Do not give up.

Rhodes: Lastly, could you talk a little about the feedback you received at the convention on your presentation?

Ruehlman: Post-presentation and post-convention, my presentation co-host, Sarah [Varney, MSN, RN], and I had so many individuals saying how much they appreciated it and how much they looked forward to taking this style of work back to their home base and starting to look at how they can implement it, especially using the EMR.

A lot of them did not realize it was a tool that they could use to help. Having that objective tool and looking at how we adjusted the tool throughout implementation on unit two to really meet the needs received overwhelmingly positive feedback. This was my first time doing any form of presentation. The comments like “This is awesome. You did a great job” were just so encouraging to keep going.

Rhodes: Thank you so much, Hannah. I appreciate your time and your amazing insights. I think you're definitely someone we all should be watching in nursing today, and I am so excited for the future of healthcare because of your acuity-based staffing tool. Do you have any final thoughts to share?

Ruehlman: Just own your practice. Be proud to be a medical-surgical nurse. We touch a lot as medical-surgical nurses, and we need to be proud of that.