1. Schaeffer, Robin MSN, RN, CNE
  2. Wicker, Teri PhD, RN, NE-BC
  3. Stevens, Carol PhD, RN
  4. Flanagan-Hyde, Sharon MA

Article Content

Appropriate hospital nurse staffing continues to frustrate both nurses and nurse leaders. Managers lack reliable data to predict an appropriate nurse workload that can support safe and effective patient care, and staffing assignments are often based on how many nurses are available rather than the acuity of care needed for safe and effective patient care. Inconsistencies in appropriate staffing can impact both patient and nurse outcomes.1

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Today, many Arizona hospitals are associated with larger healthcare systems and staffing is driven by organizational policy. Organizations are challenged to not only be fiscally responsible, but also professionally responsible. This balancing act forces nurse leaders to be creative in identifying mechanisms for attaining and sustaining leverage within their facilities when making staffing decisions. Nurses and managers quickly learn the important skill of advocacy to promote safe work environments. Nurses are natural patient advocates but frequently aren't able to advocate for themselves and their profession, often turning to their state nurses association for guidance.


Many state-based nurses associations have been in place for over 100 years and have earned the status of the "voice of nursing" in their state. This status has been achieved through advocacy initiatives motivated by ethical and moral principles. Experience and political savvy have allowed state nurses associations to influence state-level policies that impact high-stakes issues such as scope of practice and patient safety. Arizona Nurses Association (AzNA) is the constituent state nurses association of the American Nurses Association. For these reasons, the AzNA board of directors chose to advance the dialogue statewide on the persistent problem of staffing.


A priority project

Over the last few years, the AzNA has received increasing numbers of phone calls and e-mails from clinical nurses working in both urban and rural areas on the topic of safe nurse staffing. The concerns range from patient safety issues (for example, excessive patient load leading to fear of making medication errors or an inability to deliver optimal care) to their own well-being, including personal health issues, fatigue, and moral distress.


With the AzNA mission "to advance the nursing profession for a healthy Arizona" in mind, the AzNA board of directors voted to make hospital nurse staffing their priority initiative for 2015. This decision resulted from increasing nurse complaints about staffing, a direct correlation with the AzNA mission, and a legislative bill focused on nurse staffing introduced into the 2015 legislative session by an Arizona senator.2 AzNA board members realized the complexity and persistent problem of nurse staffing, as well as the importance of their advocacy role and potential to impact this issue.


The process

The AzNA priority staffing initiative was based on a previously successful mandatory overtime initiative that was a result of community collaboration. It was created with three assumptions:


* Hospital nurse staffing is a complex issue that requires a multistakeholder focus similar to the "it takes a village" model.


* If the AzNA acted as the convener, it could expand the conversation to a diverse community of stakeholders.


* Bringing a diverse, multistakeholder group to the table would generate hypotheses for action and also identify opportunities to test these hypotheses (for example, the Arizona Commerce Authority awards workforce-related grants).



In April 2014, the AzNA hired a professional facilitator and convened an exploratory roundtable to begin the initiative. The use of a professional facilitator was important due to the potential impact of the dialogue, the emotional nature of staffing issues, and the overall complexity of the problem. Included in the conversation were four members of the AzNA board of directors, the AzNA executive director, two national nurse staffing experts, and five CNOs representing three major health systems and two hospitals. The intent of the meeting was to build the strategic foundation for the staffing initiative.


Of great importance for success was identification of a framework to conduct the work. The group agreed on the 4QP Emergent Learning Platform approach facilitated by a 4QP Emergent Learning certified master practitioner.3 Emergent Learning helps groups work together to address complex issues and achieve systems-level change. Three foundational questions were posed to the group and their responses documented (see Table 1).

Table 1: Foundationa... - Click to enlarge in new windowTable 1: Foundational questions and answers

Using the first step of Emergent Learning, the Before Action Review (BAR) was convened in August 2014. The BAR would identify the best way to design and implement a multistakeholder conversation on safe nurse staffing in Arizona that included consideration of data, shared insights based on the data, hypotheses for action, and opportunities to test the hypotheses and make course corrections as needed. The group worked through five questions:


1. What are the intended results of the multistakeholder conversation?


2. What will success look like?


3. What challenges might you encounter?


4. What have you learned from similar situations?


5. What will make you successful this time?



The BAR then identified the framing question to be used to invite stakeholders to a 4-hour conversation called the Day of Dialogue. The framing question decided on was: How do we change hospital nurse staffing in Arizona to be more healing for patients and more satisfying for nurses? This question served to focus the group and guide all discussions.


Day of Dialogue

A date in April 2015 was chosen for the Day of Dialogue. The reason for the 7-month gap was the need to spend time recruiting representatives from the identified stakeholder groups to include clinical nurses, C-suite executives (especially chief financial officers [CFOs]), charge nurses, nursing and nonnursing leaders, patients, and representatives from the state board of nursing, hospital association, local organization of nurse executives, commerce authority, and workforce investment boards. Recruitment was easy with clinical nurses and community members, but all other stakeholder groups proved challenging. Some middle managers stated that they felt uncomfortable in a conversation with clinical nurses, and CFOs never answered inquiries. Overall, 31 people were present for the Day of Dialogue (a state-level legislator accepted but had to cancel the day of the event). See Table 2 for the distribution of attendees.

Table 2: Day of Dial... - Click to enlarge in new windowTable 2: Day of Dialogue attendees

Preparation for the Day of Dialogue was focused and purposeful. Each attendee was given access to a file that included 24 different staffing articles collected by the literature review team. Attendees were instructed to read at least three of the articles in preparation for the Day of Dialogue. Five tables of six to eight participants with representation from at least one clinical nurse, nurse manager/CNO, local or national thought leader, community member, and AzNA board of directors member were arranged to facilitate learning conversations. The facilitator prompted the group through various instructions in the Emergent Learning Table structure (see Table 3).

Table 3: Emergent Le... - Click to enlarge in new windowTable 3: Emergent Learning table structure

The first step was to identify and categorize "truths on the ground"-data and stories that participants shared and insights based on those "ground truths." Nine categories related to the staffing issue were identified:


* nurse well-being


* costs and budgets


* acuity


* management issues and work climate


* patient education


* patient safety


* metrics


* inclusion of clinical nurses in dialogues


* nursing education.



A sample of content from six of the categories appears in Table 4.

Table 4: Ground trut... - Click to enlarge in new windowTable 4: Ground truths and insights related to staffing

The day ended with each table generating one or more hypotheses of what they thought should occur next and the anticipated result. Although the intent of the day was to leave the room agreeing on specific hypotheses to test, the group was unable to clearly link actions to opportunities, primarily due to time constraints. Table 5 identifies 4 of 12 identified hypotheses.

Table 5: Identified ... - Click to enlarge in new windowTable 5: Identified hypotheses

Evaluations from the Day of Dialogue were positive. Participants valued the transparency of the conversations, thought having a variety of stakeholders at each table was valuable, recognized that it was the beginning of an important initiative, and were hopeful that the conversations would continue.


Results and recommendations

The After Action Review (AAR) was conducted with the leadership team 10 days after the event. Discussion centered around intended versus actual results and recommendations moving forward. The consensus of the leadership team was to convene another Day of Dialogue with the goal of transforming the hypotheses into actionable plans. It's unlikely that all 12 hypotheses will move to the action stage. It will be important to have a wider group of participants to include more nurse managers. The leadership team feels this is achievable because word of the AzNA initiative has been gaining traction and notoriety within various hospital systems throughout Arizona.


The challenge for nurse leaders will be how to prepare nurse managers to understand what makes effective staffing. Nursing leadership is at a crossroads as they continue to find workarounds and learn new methods for advocating for the resources needed to promote safe staffing. Moving forward, resources need to include stakeholders who can influence sustainable staffing models that can impact care delivery.



Just before submission of this article, the AzNA received mixed feedback about this initiative. Apparently, administrative stakeholders have some apprehension discussing this issue out of their respective institutions, citing financial and management pressure from above and staff pressure from below. Community stakeholder groups have embraced the issue from a patient safety focus, notifying the AzNA of financial grant opportunities to test various hypotheses.


Clinical nurses continue to contact the AzNA with their staffing concerns, and recent social media polling yields the same priority concern of hospital nurse staffing. It's obvious that the elephant is again awake in Arizona!




1. Baggett M, Batcheller J, Blouis AS, et al. Excellence and evidence in staffing: a data-driven model for excellence in staffing (2nd edition). Nurs Econ. 2014;32(3 suppl):1-36. [Context Link]


2. Hospital nurse staffing requirements, SB 1412, 52nd Leg, 1st Sess (Ariz. 2015). [Context Link]


3. Fourth Quadrant Partners, LLC. The world doesn't stand still. [Context Link]