An Aligned Care Model to Improve Nurse Engagement

By Stephen Miller

This blog post is adapted from the article “An Aligned Care Model to Improve Nurse Engagement and Quality Outcomes” published in Radiation Oncology News for Administrators, Vol 33, No. 5.

When I joined Cedars-Sinai in 2020, we had great people and advanced technology, but our staffing levels were not where they needed to be, and there was overlap in roles and

responsibilities among different job codes and different team members. Nurses (RNs) were doing tasks that medical assistants (MAs) were supposed to do, and nurse practitioners (NPs) weren’t practicing at top of license because they didn’t have RNs assisting them.

A Nurse Leader

Research suggests a nurse leader drives nurse engagement, improves retention and can drive visionary or transformational changes within the department.^1–3 A nurse leader is behavior-based and embodies softer skills like emotional awareness, sensitivity and collaboration, whereas a nurse manager has more technical skills and is more process-, problem- or task-based.

We got approval to expand an existing nurse manager role, which was creative because we didn’t have to worry about getting a new position approved. Our current nurse leader embodies all these qualities. Our RNs and MAs report up through the nurse leader. Filling the nurse leader position enabled us to execute needed changes to improve our quality of care, our patient experience and our nurse engagement.

Using Data

Once we had the nurse leader in place, we focused on data. The American College of Radiology (ACR) had some broad guidelines of one full-time nurse for every 200 to 300 patients seen each year. A 2019 survey by the American Society of Clinical Oncology (ASCO) showed an average of 0.9 RNs and 0.3 MAs per full-time physician. The American Society for Radiation Oncology (ASTRO) and APEx don’t have specific nursing criteria. We used the guidelines to demonstrate to senior leadership that we had a huge gap and we showed we needed one new RN and one new MA. We also showed pretty significant volume growth across the past few years, which helped our case. I recommend using whatever data that you have—even if it’s not perfect—because our data also helped us get buy-in with the clinical and physician teams.

A Primary Nursing Model

We implemented a primary nursing model in which each nurse becomes much more of an expert because they are aligned to certain physicians and certain diseases. There’s continuity of care when one nurse has ownership over a panel of patients and is working with the same physician. Patients benefit when they see a familiar face every day or most days when they’re in clinic. A physician with an aligned team and one point person is more inclined to invest in their staff and in their training.  

RNs assigned to physicians have 1–2 days each week with either no scheduled clinic volume or a very low number of patients. On these low-volume days, the primary nurse spends time navigating their patients, doing education, teaching prep via phone, or supporting more general tasks such as helping on CT sim, assisting with IV contrast items, etc. This model builds in a support system, where a nurse can cover for whomever might be absent. We also implemented regularly scheduled care team meetings that occur with the physician, aligned RN and MA, and aligned scheduler. These meetings have become a key forum to coordinate care, educate the team and increase engagement.

Our base care model is consistent and standardized for all patients, all diseases, all doctors and all nursing teams. We have disease-specific nuances—for example, the questionnaire a prostate patient receives differs from the one given to a lung patient. We were intentional about making the questionnaire specific to the disease level and limiting any doctor-specific requests. In addition, our standardized base model makes coverage easier during staff absences because processes do not vary tremendously. A covering RN has clear guidelines because our RNs and physicians document the disease-specific nuances so there is clear documentation and handoff.

Outcomes

Our physicians have reported a higher overall level of quality in nursing care. Our engagement scores show an uptick in employee engagement for our nurse population. Staff are meeting more outside of clinic to discuss clinic workflows and patient care logistics. Overall, all staff feel like they’re better able to anticipate their patients’ needs, because the care team meetings help to ensure preparation for clinic, improve communication and proactively identify any gaps in care. The care team isn’t finding out about issues at the last minute.

Prior to implementing the care model, MAs were rooming the patients 40 percent of the time; that metric has improved to 90 percent of the time, indicating top-of-license practice. Nurses now focus more on nursing-specific intake, assessments, education and symptom management. We’ve improved RN education for side effects prior to radiation start date significantly; the primary RN has provided side effect education over 75 percent of the time, which demonstrates the success of our methodology for alignment. Nurses feel like they have much higher disease site-specific expertise and knowledge and a better understanding of specific clinic workflow preferences. They also report they’re practicing top of license much more and they feel the physicians are available and willing to answer their questions.

Key Takeaways for Administrators

Having a triad leadership team—with operations, nurses and physicians—is critical for success. I recommend engaging and empowering the frontline staff by soliciting their input regarding what works and what doesn’t. Everyone’s voice needs to be heard and all parties need to be equally involved in the process; otherwise, efforts will not cascade down to frontline workers. By letting staff know their voices matter and supporting their ideas from a leadership standpoint, you can facilitate change. If you can’t follow through on a recommendation or idea, it’s important to explain why to staff so that they understand.

It might be harder to achieve nurse alignment in a smaller clinic where you’re only seeing a handful of patient types and you only have two or three clinical staff. But that doesn’t mean you can’t still have care team meetings or refine your processes, roles and responsibilities. Engaging your team in the process and having champions within each functional group is critical.

Cultural change isn’t easy nor is changing the relationships with different role types within the clinic. But we have achieved that: our staff members submit more ideas and raise issues more often; our RNs and MAs feel supported by their nurse leader; and our RNs have grown and developed as clinical professionals. The culture we established through this project keeps manifesting as other items or issues pop up where staff are more vocal, and they’re driving the change within the clinic, which is really special to see. Also, seeing much tighter relationships develop between the doctors, RNs, MAs and the schedulers is wonderful, where previously they were functioning in silos.

References:

1. Upenieks V. What constitutes effective leadership? Perceptions of magnet and non-magnet nurse leaders. Journal of Nursing Administration. 2003;33(9):456–67.
2. Kotter, J. P. Management is (still) not leadership. Harvard Business Review, January 9.
3. Cowden, T., Cummings, G., and Profetto-McGrath, J. Leadership practices and staff nurses’ intent to stay: A systematic review. Journal of Nursing Management. 2011;19(4):461–77.

Stephen Miller is director, Breast Center & Radiation Oncology at Cedars-Sinai Medical Center.

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