ORIGINAL ARTICLE

Collaborative practice: Matching staff skills to patientneeds and checking baseline staffing levelsAnne Harvey, BA, Hons; Cindy Priddy, BS, MA

Abstract—Vancouver Coastal Health uses a collaborative practice process to enable nursing units to be proactive and adaptquickly to changing patient population needs using a standardized and integrated approach. The process involves clinical directors,frontline managers, staff, and union representatives from the outset and is based on a registered nurse/licensed practicalnurse/patient care aide collaborative model of practice. Results show a total return on investment in 2.4 years.

Collaborative practice at Vancouver Coastal Health(VCH) was born of past experiences of benchmark-ing projects that failed. The Vancouver Health Ser-

vice Delivery Area, which provides acute and residentialcare to residents of Vancouver and whose largest facility isthe Vancouver General Hospital, had been in a deficitposition for 2 years, and a major international businessconsultancy had been engaged to help bring costs undercontrol.The consultants observed that the Registered Nurse

(RN)/Licensed Practical Nurse (LPN)/Patient Care Aide (PCA)staffing ratios were high compared with other hospitals.They recommended a benchmarking exercise comparingRN staffing levels on similar units at like-sized hospitalsacross Canada and the United States.The hospital had been through two similar exercises in

the recent past. The previous exercise had generated me-dia criticism from the British Columbia Nurses Union andwidespread discontent among clinical managers and direc-tors concerned about deterioration in patient care. Con-cerns manifested in discussions about the applicability ofthe benchmarks to specialty, medical, and surgical unitswhose patient populations were more or less similar tobenchmark hospitals. There is always an argument to makethat an intensive care unit, a bone marrow transplant unit,or a spine unit does not have the same patient populationfrom hospital to hospital; the procedures and patient acu-ity differ; and, therefore, the staffing should be different.These concerns limited the amount of change that hadbeen achieved previously.Re-drawing or challenging the boundaries between

professional groups and established job roles is a major

From Vancouver Coastal Health, Vancouver, British Columbia, Canada.Corresponding author: Cindy Priddy, BS, MA, Vancouver Coastal Health

601 West Broadway, Vancouver, British Columbia V5Z 4C2, Canada.(e-mail: Cindy.priddy@vch.ca).

Healthcare Management Forum 2011 24:184–1870840-4704/$ - see front matter© 2011 Canadian College of Health Leaders. Published by Elsevier Inc. Allrights reserved.

doi:10.1016/j.hcmf.2011.08.003

organizational challenge.1 A “positive” human resourcemanagement culture may facilitate changes in workroles that bring both personal and organizational ben-efits.2 Researchers recommend the development of anin-house change methodology shaped by employee par-ticipation.3

At VCH, the Chief Operating Officer of the VancouverHealth Service Delivery Area and the Vice President ofHuman Resources proposed a new process of engagingfrontline staff and managers in reviewing patient needs ontheir unit and matching the staffing mix to those needs.The model was based on an RN/LPN/PCA collaborativemodel of practice and involved union representatives aswell as clinical directors.

DEVELOPING THE COLLABORATIVE PRACTICEPROCESS AND TOOLS

Professional practice was engaged to develop the practiceexpectations, essentially defining the role RNs and LPNs areregulated to play in the patient care team as well as the roleunlicensed PCAs play. Establishing clear practice expectationswas foundational to the process because within British Co-lumbia (BC) there had been long-term role confusion be-tween RNs and LPNs. The development of both RN and LPNspecialty roles added further confusion as to where generalistand specialist professional roles fit on the scope spectrum.Fundamental to the introduction of LPNs in units where

they had previously not worked was clarification of thequestion of the RNs’ responsibility for patients cared for byLPNs. Table 1 was developed following discussions withboth the College of Registered Nurses of BC, the College ofLicensed Practical Nurses of BC, the BC Nurses Union, andthe Hospital Employees’ Union, which represents LPNs.Figure 1 shows the placement of an individual RN with aunique practice profile in the health professions scopes.Figure 1 and Table 1 were provided to staff at unit meet-ings as part of the orientation beginning each collaborativepractice project to create a common understandingof scopes and roles. Once the practice expectations were

established, the collaborative practice process was

COLLABORATIVE PRACTICE: MATCHING STAFF SKILLS TO PATIENT NEEDS AND CHECKING BASELINE STAFFING LEVELS

designed and standardized. The major phases of the pro-cess are shown in Figure 2.The process has nine major steps: (1) define the patient

population; (2) determine the acuity of patients on the unit;(3) determine the routine care needs of patients on the unit;(4) identify the current staffing profile on the unit; (5) involvethe unit staff, manager, and union representatives in devel-oping a new staffing model based on the patient care needs;(6) present the newmodel to provincial union representativesand develop labour adjustment plans for the changes instaffing; (7) determine how many positions are needed in-cluding vacation relief positions, hire any needed new staff,and develop new rotations; (8) educate unit staff on collab-orative practice model before implementation of new staffingmodel and hold unit meeting 2 months post-implementationto clarify any role confusions; and (9) put responsive staffingalgorithm in place for in-charge nurses and patient care co-ordinators. In addition, the following tools were developed toassist with data collection and implementation: unit/popula-tion profile, acuity and dependency scale, nursing skills inven-tory, staffing algorithm, standard education modules, andfloating guidelines.After implementation of collaborative practice, weekly

“safety huddles” were held on each unit in which questionsregarding clarity or roles and issues with model were

Table 1. Practice expectations for nursing roles

RNs

Regulated YesClient AllCollaborative practice context IndependentAssignment of client care Assigns and reassigns

Client assessment Makes decisions to plan careCare planning Leads and coordinates

Nursing intervention Coordinates and oversees

Evaluation of interventions Monitors, interprets, revises care plan

Figure 1. Nursing scopes of practice.

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discussed. If there was a question related to the scope ofpractice, it was forwarded to the professional practiceleader who would investigate and respond back with aclarification document, and if any changes in scope wereimplemented they were updated on the nursing skills in-ventory. This enabled leadership to address issues imme-diately as they arose on the units.

EVALUATING COLLABORATIVE PRACTICEOUTCOMES IN ACUTE CARE

Considerable progress was made in phase 1 projects at Van-couver General Hospital. Units with high levels of RN overtimeand vacancies were prioritized to reduce the financial costs ofovertime and the resultant stress on the nursing workforce.Almost 29 Full-time Equivalents (FTEs) of PCAs and 9.4 FTEs ofLPNs were added in these units, and almost 37 FTEs of RNswere taken out of those units and placed in vacancies onother units, saving a little over $1 million annually (Table 2).Overtime was significantly decreased on six of the sevenunits, and there was a significant decrease in vacancies on allthe participating units.

APPLYING THE COLLABORATIVE PRACTICEPROCESS IN RESIDENTIAL CARE

Although the focus for collaborative practice was acutecare in phase 1, in phase 2 the process was successfullyadapted for residential care. The same nine steps outlinedpreviously were used; however, the tools were revised tobetter capture residential patient needs. For example, theunit survey was revised to reflect long-term care needs,and the resident assessment instrument was used in lieu ofthe acuity and dependency scale used in acute care.Two residential care facilities implemented the collabora-

tive practice model in 2010: Evergreen House and BanfieldPavilion. Evergreen House cares for 235 residents and is lo-cated on the same site as Lions Gate Hospital. Banfield Pavil-

LPNs PCAs

s Noble with predictable outcomes Assigned tasks, not the care of clienterdependent (team) Dependentcepts assignments Accepts tasksntifies status and actual orpotential problems Communicates observationsllaborates and contributes Contributeslects and implementsinterventions Performs assigned tasksnitors, recognizes, participatesin care plan revisions Communicates observations

YeStaIntAcIde

CoSe

Mo

ion cares for 192 residents and is located on the Vancouver

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Harvey and Priddy

General Hospital footprint. Both facilities began the processfor collaborative practice in early November 2009 with imple-mentation occurring in the summer and fall of 2010. Thisproject involved approximately 100 stakeholders across VCHand included representatives from British Columbia NursesUnion and Hospital Employees Union, resident care coordi-nators, RNs, LPNs, Residential Care Aides (RCAs), unit clerks,operations leaders, educators, professional practice leaders,and Human Resource leaders.As with previous units, the collaborative practice proj-

ects at Banfield Pavilion and Evergreen House showedelements of a “fair process” such as engagement, explana-tion for decisions, and clarity of expectations.4 For exam-ple, nurses participated in collecting resident data, and allstaff were invited to share feedback and ideas throughdata display events, communication boards, and sugges-tion boxes. Union representatives, RNs, LPNs, RCAs, andunit clerk representatives participated in working groupsessions and on implementation teams.

Figure 2. Collaborative practice process map.

Table 2. Collaborative practice staffing model changes in acute

Phase 1: acute an

Unit Change PCA FTEs Change in LP

Acute spine �3.2 0.0Acute care of elderly �10.0 �3.0Center for surgical innovations �2.1 0.0Burns/plastics/trauma �2.0 0.0Tuberculosis 0.0 �7.0Sub-acute medicine �10.0 �3.0Ortho reconstruction �1.5 �2.4Total �28.8 �9.4

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STAFFING MODEL CHANGES IN RESIDENTIAL CARE

Before implementing collaborative practice, the care teamsat Evergreen House and Banfield Pavilion included RNs andRCAs. LPNs were not used in either facility. However, thepatient population, as reflected in the resident assessmentinstrument and unit profile, indicated that a better matchof staffing resources to patient needs would include LPNs.Table 3 below summarizes the changes in staffing.

REDEPLOYMENT AND TRANSITION SUPPORT

VCH seeks to actively show respect for all staff as valuablemembers of the organization. Therefore, early in the de-velopment of the collaborative practice process, VCH com-mitted to retaining employees whose positions are af-fected by changes in staffing models. For Evergreen Houseand Banfield, this commitment resulted in the redeploy-ment of 47 RNs. Of those, 28 were redeployed to sub-acute

-acute care units

s Change in RN FTEs Net FTE changes

Annual savings(including overtime

reduction)$000s (CDN)

�3.7 �0.5 $ 200�13.0 0 $ 350�2.2 0.0 $ 60�2.0 0 $ 50�5.0 �2.0 $ 50�7.0 0.0 $ 200�4.0 �0.1 $ 100

�36.9 �1.3 $1010

d sub

N FTE

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COLLABORATIVE PRACTICE: MATCHING STAFF SKILLS TO PATIENT NEEDS AND CHECKING BASELINE STAFFING LEVELS

and acute units. To enable a successful transition, compre-hensive educational support was provided.The learning and development team at VCH developed

and completed learning assessments for RNs to developlearning plans to enable them to successfully transitioninto new roles in sub-acute and acute care. A 14-weekeducator-supported transition plan was developed and in-cluded 6 weeks of clinical, classroom, and simulation train-ing based on identified learning needs and 8 weeks ofsupported precepting in the new area of practice.The investment in RN education needs assessments and

transition support programs totaled over $1 million. How-ever, as shown in Table 4, savings from the staffing modelchanges enabled a total return on investment in just over2 years, and both sites are projected to see a combinedannual savings of over $800K.

IMPLEMENTATION SUPPORT TO WORKCOLLABORATIVELY

In addition to providing support to staff redeployed toother areas, support was also provided to those who weretransitioning to a new model of care. First, at each site, atransition coordinator and an LPN mentor were hired tochampion the changes at the frontline level. These roleswere vital to helping staff make the transition to the newmodel. Second, education was provided to all staff on thescope of practice, role clarity, how to adapt assignments toresident needs, and team communication. This education

Table 3. Collaborative practice staffing model changes in reside

Phase 2: resi

Facility Change in RCA FTEs Change in LPN FTEs

Evergreen House �1.59 �27.30Banfield Pavilion 0.0 �25.86Total �1.59 �53.16

Table 4. Return on investment from collaborative practice inresidential care

Costs (amounts expressed in thousands)

Total costs of transition to new models $1,246SavingsSavings year 1 $ 225Savings year 2 $1,070Savings year 3 $1,070Net savings year 3 $ 669Return on investment 2.4 yrs

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provided the foundational concepts for working collabora-tively together that was then reinforced daily by the tran-sition coordinator and LPN mentor and other operationalleaders. Critical to the success of the new models has beenestablishing daily huddles in which RNs, LPNs, and RCAsroutinely come together to talk about resident priorities.

CONCLUSIONS

At the start of this project, there was no objective approachto determine baseline staffing. Historically, once baselinestaffing numbers on a unit were established, there wererarely changes regardless of changes in the patient popu-lation or practice or care protocols. The use of externalconsultants and benchmarking with other hospitals acrossdiverse patient care units has often been the means forevaluating staffing mix. Although differences in skill-mixbalance for hospitals and nursing homes have been clear,differences between units such as medical/surgical andcritical care are less clear. Nurses and nurse managers needto work together to find the best balance for the staff andpatients.5

The collaborative practice program has provided an in-novative and proactive approach to match staff resourcesto patient/resident needs. The program enables nursingunits to be proactive and adapt quickly using a standard-ized and integrated approach with input from key stake-holders. At VCH, the project has proven suitable for acuteand residential care settings and is currently being adaptedto other healthcare disciplines as well.

REFERENCES

1. Doyal L, Cameron A. Reshaping the NHA workforce. BMJ. 2000;320:1023–1024.

2. Adams A, Lugsden E, Chase J, et al. Skill-mix changes and workintensifications in nursing. Work Employ Soc. 2000;14:541–555.

3. Sibbald B, Shen J, McBride A. Changing the skill-mix of the healthcare workforce. J Health Serv Res Policy. 2004;9(suppl 1):28–38.

4. Kim WC, Mauborgne R. Fair process: Managing in the knowl-edge economy. Harv Bus Rev. 2003;75:65–75.

5. Johnson SH. Improving nurse satisfaction with skill-mix changes.

care

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hange in RN FTEs Net FTE changes Annual savings $000s

�24.81 0.90 $ 397�25.25 0.71 $ 673�50.06 �1.61 $1,070

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Recruit Retent Restruct Rep. 1998;6:5–7.

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