A new staffing grid focused on improving patient, nurse and staff satisfaction contributed to reducing patient falls by 50% and staff injuries by 81% over approximately one year at Sharp Memorial Hospital in San Diego.

The initiative also increased staff’s perception of adequate staffing 43%, and the combined outcomes resulted in an estimated annual fiscal impact of $1,086,147.

The project was spearheaded by Boni Bogart, BSN, RN, PCCN, and Julie Tarbell, BSN, RN, both charge nurses and clinical leads on one of four specialty progressive care units (PCUs) at the hospital, this one specializing in medical cardiopulmonary patients. The 32-bed unit has 17 progressive care certified nurses (PCCNs).

Bogart says night nurses on the unit often expressed concern about staffing, particularly their perception that there was not enough ancillary support. They typically had only two aides, and sometimes only one, to share among up to 12 nurses on the night shift, she says.

“As a progressive care unit, we have high acuity patients and we must do a lot of critical thinking, so without the ancillary support, our nurses were being torn between doing primary care and going through all the critical thinking that was necessary for the patient to receive the best care,” she says. “So, we sat down and talked with the frontline staff to ask what they thought would make them feel comfortable taking care of their patients, and the consistent answer was that they thought they didn’t have enough ancillary support. They felt like they were constantly toileting and running to call lights, which took them away from critical tasks like medication and doing discharge education.”

Bogart and Tarbell looked at moving the PCU to more of a team approach to nursing and redesigning the nursing grid, seeking ratio of one aide to two or three nurses. In formalizing the project, they established specific goals: increase patient perception of staff responsiveness to needs by a 10th percentile on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), decrease patient falls 5%, increase staff satisfaction, increase perception of adequate staffing by 10% on a staff survey, and decrease employee injuries by 5%.

Nurses Given a Voice

There was initial resistance and skepticism, Bogart says, but that was overcome by giving the nurses a voice in what happened.

“Bringing it from the frontline staff, showing them that this something that came from the frontline and wasn’t handed down by management, was key,” Bogart says. “We tried to keep that up at every step along the way, getting their input at different points and keeping this as a project driven by the nurses and not something that administration was telling us to do.”

The project started in January 2016. The key challenges they faced include the inclusion of float and travel staff, getting buy-in from the naysayers, training and retraining novice healthcare assistants (HCAs), peer-to-peer accountability of expected roles, delegation, and aligning the new staffing grid with productivity targets. They also faced unit flooring construction that had half of the unit shut down for approximately a month, along with excessive floating of unit staff and unexpected prolonged union negotiations.

The different staffing ratios between day shift and night shift contributed to staff dissatisfaction, Tarbell says. The new staffing grid they designed changed the ratios to provide more ancillary staff.

“Our staffing ratio on the day shift was three patients to one nurse, and night shift had always been four-to-one. We were asking the staff on day shift to go to four-to-one, so we would have fewer RNs on the floor but could accommodate more ancillary staff,” Tarbell says.

The night shift was happy with that because they got more ancillary staff and were already at four-to-one. The day shift had to be convinced that going to four-to-one was going to be beneficial to everyone.

“They already felt like they were barely keeping their heads above water with the three-to-one ratio, and now we were asking them to take on another patient. On the surface, it didn’t look like we were doing them any favors, but we had to show them that with the additional ancillary staff they could benefit from the new grid,” Tarbell says. “It took some time to convince them that by working as a team with another nurse and an aide, they were going to have more time to take care of their patients safely and effectively because they have the help.”

Culture Change Took Finesse

Bogart notes that even though the hospital was responding to their concerns about staffing, some nurses found it difficult to accept the new arrangement.

“We created the new grid, but then we had to talk about what this was going to look like on the floor, because this was going to be a huge culture change for us. Our nurses are used to being primary care and sometimes not using the ancillary staff on the unit during their shifts because the aides were tied up with the other 11 nurses,” Bogart says. “They had wanted more help, but at the same time they had to learn to delegate because they were so used to doing everything themselves when they didn’t have the help.”

Tarbell says she and Bogart had assumed that the nurses knew how to delegate, but that proved not to be the case and they had to help the nurses learn delegation skills. The use of float and travel nurses also proved problematic, necessitating a training session at the beginning of the shift to show them how the unit operated and used the HCAs.

“Once this was all set we had a two-hour mandatory meeting for staff to show them how this worked, but the float and travel staff didn’t get that training, so we had to do it each time a new person arrived for a shift,” Tarbell says.

Workflow Analysis Helped

In devising the new staffing grid and ratios, Bogart and Tarbell conducted a workflow analysis for each staffing role in the PCU, asking nurses to describe what they typically did on their shifts from moment to moment. That helped them show the nurses how they could better allocate their time if they had ancillary staff who could take on some those time-consuming tasks, but it had limitations.

“We were breaking down their days to show them the different things that took them away from the patient care they really needed to be doing, but we also learned that that was something subject to constant change. We couldn’t say we were going to provide the perfect day, because everything changes from one day to the next,” Bogart says. “We were trying to say you’re going to have more good days than bad days under this system, and that’s realistic. It was hard at some points because we were trying to find a perfect solution and we kind of took it personally when we realized we couldn’t, but then we focused on the idea of making things so much better than they were before.”

New healthcare aides were hired for the new staffing grids, with the assumption that they were trained and ready to go, but the PCU nurses soon found out that they were not. That set the effort back a while as the new HCAs were trained, or retrained, for their duties.

HCAs now do more than they did before this initiative, such as taking vital signs. Individual aides always stick to a smaller area on the unit, with the two or three nurses on their teams, rather than moving up and down the unit’s hallways, which happen to be particularly long. That means each HCA can achieve more during a shift because he or she is travelling less, Bogart says.

Improved HCAHPS, Fewer Infections

They used a workflow model survey with both registered nurses and HCAs, administered pre-implementation of the project and during the last month of data collection. The four-question survey assessed staff’s perception of staffing and allocation of resources.

Improving staff satisfaction and perception were only part of the project, Bogart and Tarbell say, because they knew that happier employees work better. That translates directly into better-quality care and outcomes, they say.

In addition to the positive effects on falls, injuries, and staff perceptions, Bogart and Tarbell say the project generated positive feedback from float staff, with some asking to work on the unit, and HCAs feel more empowered. There have been zero catheter-associated urinary tract infections (CAUTIs) since the project rollout, and a significant reduction in hospital-acquired Clostridium difficile infections.

The overall results for HCAHPS (top box) increased six percentile points, and nurse communication increased 14 percentile points.

Listen to Staff Feedback

The project succeeded in part because Bogart and Tarbell listened to feedback from the staff and took their opinions into consideration when devising changes and tweaking plans as they unfolded, Tarbell says.

“If you want to implement something like this, you must be visible on the floor and listen to what people say,” Tarbell says. “That was instrumental in making that culture change for us.”

Bogart agrees and advises not expecting unanimous approval for every step along the way, even when trying to respect the opinions of staff members.

“In the beginning, we were afraid of not making everyone happy all at once. We had all these great ideas that were coming from the frontline staff, but obviously not 100% of everyone is going to be in favor of every change,” Bogart says. “But we finally found a workflow that adjusted everything in a positive direction, even if it’s not perfect. It’s taken a long time, but even the naysayers seem happy now and we don’t disregardthe death look as nurses came on shift because they thought they might have to take on a fourth patient. You just have to know that you won’t make everyone happy all the time, but you can still move forward.”

Support Creative Staffing Solutions

Bogart and Tarbell created the quality improvement project as part of the American Association of Critical-Care Nurses (AACN) Clinical Scene Investigator Academy. AACN practice excellence director Devin Bowers, MSN, RN, NE-BC, in Aliso Viejo, CA, says it illustrates common findings in many quality initiatives.

“It’s important to get staffing right. Inappropriate staffing can have devastating consequences to our patients’ safety and nurses’ well-being. Solving nurse staffing challenges requires creativity and commitment at all levels,” she says. “There is no simple one-size-fits-all solution or fixed ratio that can address the complexities involved with appropriate staffing, especially in acute and critical care.”

Staffing is a complex process with the goal of matching the needs of patients and their families with the competencies of nurses and other members of the interprofessional team, she says.

The CSI participants at Sharp Memorial took on the challenge and developed a staffing solution that worked for their unit’s patients, nurses and care team, with measurable clinical and fiscal improvements, he says. Supporting this type of nurse-led innovative thinking is one approach hospitals might consider in addressing staffing issues, she says.

“By empowering staff nurses — those at the frontline of patient care — to initiate change and improve everyday processes, hospitals can find creative solutions to diverse healthcare challenges,” Bowers says.


  • Boni Bogart, BSN, RN, PCCN, Clinical Lead, Sharp Memorial Hospital, San Diego. Email: boni.bogart@sharp.com.
  • Devin Bowers, MSN, RN, NE-BC, Practice Excellence Director, American Association of Critical-Care Nurses, Aliso Viejo, CA. Telephone: (800) 809- 2273.
  • Julie Tarbell, BSN, RN, Clinical Lead, Sharp Memorial Hospital, San Diego. Email: julie.tarbell@sharp.com.