ONS Staffing Position Statement: Ambulatory Treatment Centers

Appropriate nurse staffing levels contribute to the delivery of safe quality care and optimal patient outcomes. However, developing nurse staffing models, particularly in the ambulatory setting, is an ongoing challenge. Within this position statement, the term ambulatory setting includes infusion centers that provide treatment to patients with cancer, including non-chemotherapy treatment centers (e.g., blood products) and radiation therapy treatment centers. These settings share commonalities, including rapid turnover of patients and the administration of some type of treatment or intervention. Nurse staffing refers to the clinical nurses in the setting and does not include advanced practice nurses or nurses in other roles.

Oncology treatments continue to transition to the ambulatory setting, and the care needed for patients is multifaceted. Many inpatient staffing models exist, with federal and state regulations often driving the requirements for nurse staffing levels. No standard staffing model or nurse-to-patient ratio currently exists for ambulatory infusion/chemotherapy treatment centers or radiation therapy treatment centers.

In previous surveys of Oncology Nursing Society (ONS) members, staffing is frequently cited as a top concern. Determining appropriate staffing can be complex, with several variables affecting decisions, including patient-, personnel-, and institution-based. Some centers have developed home-grown tools or implemented a commercial product to address scheduling and staffing. Many of these tools are based on the acuity rating of the patient and may incorporate other factors, such as a nurse’s skill set and experience. However, acuity is not just measured by time spent in the infusion center. The care needs of the patient and his or her support system are complex and can fluctuate throughout the care spectrum.

In addition to surveys of membership, ONS has engaged with members on the topic of ambulatory staffing via the online ONS Communities, focus groups, and email inquiries sent to ONS. Based on member feedback, survey data, and a review of the existing literature, ONS has developed this position statement to provide recommendations and guidance for ambulatory centers as they develop their specific staffing plan. Definitions of terminology are provided (American Nurses Association, 2017, 2019):

Appropriate nurse staffing: A match of RN expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation

Scheduling: A set number and type of staff to be allocated for an anticipated workload and defined future period, typically 4–12 weeks; translate budget and forecast into a tactical plan for meeting expected patient volumes, service, and care requirements

Staffing: Day-to-day operations that assess and determine the shift allocation of nursing resources to ensure adequate staffing for each shift and on each unit or department; typically planned within 4–48 hours of the work shift

Patient classification/acuity: The methods and processes of determining, validating, and monitoring individual patient and family care requirements over time to assist in such determinations as unit staffing, patient assignments, case mix analysis, budget planning and defense, per patient cost of nursing services, variable billing, and the maintenance of quality assurance standards

It is the position of ONS that

•  RNs are critical to safety and quality in the ambulatory oncology setting.

•  Staffing must be locally determined due to the complexity of factors in the ambulatory setting.

•  The time a patient spends in the treatment center does not equal acuity.

•  Ambulatory settings should consider key variables to assist in the creation of location-specific staffing. Some variables to consider include the following:

–  Patient-based: population mix, care needs, need for translator, education needs

–  Treatment-based: treatment regimen, premedications, observation period

–  Personnel-based: education, licensure, certification, level of experience, presence of assistive staff, role delineation, scope of practice, other resources (e.g., volunteers, pharmacists, financial advisors)

–  Institution-based: number of chairs, beds, radiation treatment units, physical location (e.g., freestanding center, attached to a hospital, located in a rural setting), operating hours, services provided, accreditation requirements

•  Nurses in the ambulatory setting, particularly nurse managers, should be educated in the use of data in the determination of and advocacy for staffing that supports quality care in their setting.

•  Professional nursing associations, academic institutions, healthcare organizations, and government regulatory agencies should collaborate on initiatives related to staffing in the ambulatory setting.

•  Ongoing analysis of appropriate staffing models is needed to best plan for quality care delivery in these complex environments.

Approved by the ONS Board of Directors, October 2019.