nurse staffing assignment sheet

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For assignments to be successful, you need to determine the needs of both nurses and patients. Nursing assignments, usually help to determine the daily activities of the nurses, the patient meets and assessments, coordinate different shifts and maintain a specific length of working hours. To meet this challenge of preparing nursing assignment sheets , you can take the assistance of sheet templates and learn the process eventually.

Step 1: Gather Information

Step 2: determine the process, step 3: set shift priorities, step 4: evaluating success, step 5: keep updating.

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• South Dakota Nurse November 2018 issue is now available.

8 Steps for Making Effective Nurse-Patient Assignments

This article appears on page 14 of

South Dakota Nurse November 2018

Reprinted from American Nurse Today

Successful assignments require attention to the needs of both nurses and patients.

YOUR MANAGER wants you to learn how to make nurse­ patient assignments. What? Already? When did you be­came a senior nurse on your floor? But you’re up to the challenge and ready to learn the process.

Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments.

1. Find a mentor

Most nurses learn to make nurse-patient assignments from a colleague. Consider asking if you can observe your charge nurse make assignments. Ask questions to learn what factors are taken into consideration for each assignment. Nurses who make assignments are aware of their importance and are serious in their efforts to consider every piece of information when making them. By asking questions, you’ll better understand how priorities are set and the thought that’s given to each assignment. Making nurse-patient assignments is challenging, but with your mentor’s help, you’ll move from novice to competent in no time.

2. Gather your supplies (knowledge)

Before completing any nursing task, you need to gather your supplies. In this case, that means knowledge. You’ll need information about the unit, the nurses, and the patients. (See What you need to know.) Some of this information you already know, and some you’ll need to gather. But make sure you have everything you need before you begin making assignments. Missing and unknown information is dangerous and may jeopardize patient and staff safety. The unit and its environment will set the foundation for your assignments. The environment (unit physical layout, average patient length of stay [LOS]) defines your process and assignment configuration (nurse-to-patient ratios). You’re probably familiar with your unit’s layout and patient flow, but do you know the average LOS or nurse-to-patient ratios? Do you know what time of day most admissions and discharges occur or the timing of certain daily activities? And do other nursing duties need to be covered (rapid response, on call to another unit)? Review your unit’s policy and procedures manual for unit staffing and assignment guidelines. The American Nurses Association’s ANA ‘s Principles for Nurse Staffing 2nd edition also is an excellent resource.

Review the assignment sheet or whiteboard used on your unit. It has clues to the information you need. It provides the framework for the assignment-making process, including staff constraints, additional duties that must be covered, and patient factors most important on your unit. Use the electronic health record (EHR) to generate various useful pieces of patient information. You also can use the census sheet, patient acuity list, or other documents of nursing activity, such as a generic hospital patient summary or a unit-specific patient report that includes important patient factors.

Depending on your unit, the shift, and the patient population, you’ll need to consider different factors when making assignments. Ask yourself these ques­tions: What patient information is important for my unit? Does my unit generate a patient acuity or work­load factor? What are the time-consuming tasks on my unit (medications, dressing changes, psychosocial support, total care, isolation)? Which patients require higher surveillance or monitoring? Finally, always talk to the clinical nurses caring for the patients. Patient conditions change faster than they can be documented in the EHR, so rely on the clinical nurses to confirm each patient’s acuity and individual nurses’ workloads. Nurses want to be asked for input about their patients’ condition, and they’re your best resource.

Now ask yourself: How well do I know the other nurses on my unit? This knowledge is the last piece of information you need before you can make assignments. The names of the nurses assigned to the shift can be found on the unit schedule or a staffing list from a centralized staffing office. If you know the nurses and have worked with them, you’ll be able to determine who has the most and least experience, who’s been on the floor the longest, and who has specialty certifications. You’ll also want to keep in mind who the newest nurses are and who’s still on orientation.

3. Decide on the process

Now that you’ve gathered the information you need, you’re ready to develop your plan for assigning nurses. This step usually combines the unit layout with your patient flow. Nurses typically use one of three processes–area, direct, or group–to make assignments. (See Choose your process.)

4. Set priorities for the shift

The purpose of nurse-patient assignments is to provide the best and safest care to patients, but other goals will compete for consideration and priority. This is where making assignments gets difficult. You’ll need to consider continuity of care, new nurse orientation, patient requests and satisfaction, staff well-being, fairness, equal distribution of the workload, nurse development, and workload completion.

5. Make the assignments

Grab your writing instrument and pencil in that first nurse’s name. This first match should satisfy your highest priority. For example, if nurse and any other returning nurses are reassigned to the patients they had on their previous shift. If, however, you have a complex patient with a higher-than-average acuity, you just assigned your best nurse to this patient. After you’ve satisfied your highest priority, move to your next highest priority and match nurses with unassigned patients and areas.

Sounds easy, right? Frequently, though, you’ll be faced with competing priorities that aren’t easy to rate, and completing the assignments may take a few tries. You want to satisfy as many of your priorities as you can while also delivering safe, quality nursing care to patients. You’ll shuffle, move, and change assignments many times before you’re satisfied that you’ve maximized your priorities and the potential for positive outcomes. Congratulate yourself–the nurse-patient assignments are finally made.

6. Adjust the assignments

You just made the assignments, so why do you need to adjust them? The nurse-patient assignment list is a living, breathing document. It involves people who are constantly changing–their conditions improve and deteriorate, they’re admitted and discharged, and their nursing needs can change in an instant. The assignment process requires constant evaluation and reevaluation of information and priorities. And that’s why the assignments are usually written in pencil on paper or in marker on a dry-erase board. As the charge nurse, you must communicate with patients and staff throughout the shift and react to changing needs by updating assignments. Your goal is to ensure patients receive the best care possible; how that’s ac­complished can change from minute to minute.

7. Evaluate success

What’s the best way to eval­uate the success of your nurse-patient assignments? Think back to your priorities and goals. Did all the patients receive safe, quality care? Did you maintain continuity of care? Did the new nurse get the best orientation experience? Were the assignments fair? Measure success based on patient and nurse outcomes.

Check in with the nurses and patients to get their feedback. Ask how the assignment went. Did everyone get his or her work done? Were all the patients’ needs met? What could have been done better? Get specifics. Transparency is key here. Explain your rationale for each assignment (including your focus on patient safety) and keep in mind that you have more information than the nurses. You’re directing activity across the entire unit, so you see the big picture. Your colleagues will be much more understanding when you share your perspective. When you speak with patients, ask about their experiences and if all their needs were met.

8. Keep practicing

Nurse-patient assignments never lose their complexity, but you’ll get better at recognizing potential pitfalls and maximizing patient and nurse outcomes. Keep practicing and remember that good assignments contribute to nurses’ overall job satisfaction.

What you need to know

Before you make decisions about nurse-patient assignments, you need as much information as possible about your unit, nurses, and patients.

Common patient decision factors Demographics •    Age •    Cultural background •    Gender •    Language

Acuity •    Chief complaint •    Code status •    Cognitive status •    Comorbidities •    Condition •    Diagnosis •    History •    Lab work •    Procedures •    Type of surgery •    Vital signs •    Weight

Workload •    Nursing interventions •    Admissions, discharges, transfers •    Blood products •    Chemotherapy •    Drains •    Dressing changes •    End-of-life care •    I.V. therapy •    Lines •    Medications •    Phototherapy •    Treatments •    Activities of daily living •    Bowel incontinence •    Feedings •    Total care

Safety measures •    Airway •    Contact precautions •    Dermatologic precautions •    Fall precautions •    Restraints •    Surveillance

Psychosocial support •    Emotional needs •    Familial support •    Intellectual needs

Care coordination •    Consultations •    Diagnostic tests •    Orders •    Physician visit

Common nurse decision factors Demographics •    Culture/race •    Gender •    Generation/age •    Personality

Preference •    Request to be assigned/not assigned to a patient

Competence •    Certification •    Education •    Efficiency •    Experience •    Knowledge/knowledge deficit •    Licensure •    Orienting •    Skills •    Speed •    Status (float, travel)

Choose your process

Your nurse-patient assignment process may be dictated by unit layout, patient census, or nurse-to-patient ratio. Most nurses use one of three assignment processes.

Area assignment This process involves assigning nurses and patients to areas. If you work in the emergency department (ED) or postanesthesia care unit (PACU), you likely make nurse-patient assignments this way. A nurse is assigned to an area, such as triage in the ED or Beds 1 and 2 in the PACU, and then patients are assigned to each area throughout the shift.

Direct assignment The second option is to assign each nurse directly to a patient. This process works best on units with a lower patient census and nurse-to-patient ratio. For example, on a higher-acuity unit, such as an intensive care unit, the nurse is matched with one or two patients, so a direct assignment is made.

Group assignment With the third option, you assign patients to groups and then assign the nurse to a group. Bigger units have higher censuses and nurse-to-patient ratios (1:5 or 1:6). They also can have unique physical features or layouts that direct how assign­ments are made. A unit might be separated by hallways, divided into pods, or just too large for one nurse to safely provide care to patients in rooms at opposite ends of the unit. So, grouping patients together based on unit geography and other acuity/workload factors may be the safest and most effective way to make assignments.

You also can combine processes. For example, in a labor and delivery unit, you can assign one nurse to the triage area (area process) while another nurse is as­signed to one or two specific patients (direct process). Unit characteristics direct your process for making assignments. Your process will remain the same unless your unit’s geography or patient characteristics (length of stay, nurse-patient ra­tio) change.

Stephanie B. Allen is an assistant professor at Pace University in Pleasantville, New York.

Selected references Allen SB. The nurse-patient assignment process: What clinical nurses and patients think. MEDSURG Nurs. 2018;27(2):77-82. Allen SB. The nurse-patient assignment: Purposes and decision factors. J Nurs Adm. 2015;45(12):628-35. Allen SB. Assignments matter: Results of a nurse-patient assignment survey. MEDSURG Nurs [in press]. American Nurses Association (ANA). ANA‘s Principles for Nurse Staffing. 2nd ed. Silver Spring, MD: ANA; 2012.

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Evidence-Based Research on Staffing by Acuity

ANA’s Principles for Nurse Staffing, Third Edition (2020)

Acuity-Based Staffing: Balance Cost, Satisfaction, Quality, and Outcomes

Matching Nursing Assignment to Patients’ Acuity Level: The Road to Nurses’ Satisfaction

A Comparison of a Standardized Method of Identifying Nursing Staff Needs with Measures of Nursing Staff Needs by Patient Acuity

A New Patient-Acuity Tool Promotes Equitable Nurse-Patient Assignments

Addressing Patient Acuity and Nurse Staffing Issues in the Acute Care Setting: A Review of the Literature

Nurses’ Satisfaction Related to Implementing Patient Acuity Tool-Based Assignment

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Printable Daily Staffing Sheets & Schedule Export

• Platform: Manager
• From Your: Desktop

Table of Contents

Daily staffing sheets can be generated from the Schedule Month, Week, or Day page for the timeframe of your choosing. The staffing sheet will export to a printer-friendly .pdf file.

To access the daily staffing sheet, go to Schedule and click the Print icon in the upper right corner under “Draft Schedule”. Select the “Print Staffing Sheet” option from the dropdown.

In the “Print Staffing Sheet” modal, confirm the date(s) that you’d like to generate the staffing sheet for:

Select the event types (both working and non-working events) you would like to display on the printed schedule. The “Include Open Shifts” toggle will allow you to include open shift opportunities in the sheet.

Select “Print” to generate and download the .pdf file. This will display your daily staffing information and allow for additional notes on census, assignments, etc.

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Development of a Nursing Assignment Tool Using Workload Acuity Scores

To determine a just and consistent practice for creating nursing assignments.

BACKGROUND:

Traditional methods of assigning patients to nurses may lead to unbalanced nursing workload. This article describes the ongoing, hospital-wide effort to evaluate and implement a nursing assignment tool based on electronic health record (EHR) functionality and auto-calculated nursing workload scores.

EHR records of individual patient workload scores from all hospital units were collected from August 2017 to June 2018. A nurse-specific total workload score was summed for each staff. Then, each hospital unit’s mean nurse workload score and standard deviation, along with the unit’s nurse-to-patient ratio, were used to calculate levels of high, medium, and low nursing workload measurement (NWM).

Mean patient-specific workload scores varied greatly across hospital units. Unit-specific nurse-to-patient ratios were factored into NWM scores to create ranges for assignments that were relatively consistent across the institution.

CONCLUSION:

The use of objective, electronically generated nursing workload scores, combined with traditional nurse-to-patient ratios, provides accurate real-time nurse staffing needs that can inform best practice in staffing. The confirmation of individual patient workload scores and an appreciation for the complexity of EHR vendor rules are necessary for successful implementation. Automation ensures patient safety, staff satisfaction, and optimal resource allocation.

The focus in healthcare has been to increase quality while maintaining costs. Donabedian’s model for improving quality is based on the triad of structure, process, and outcomes and is often used in current patient outcomes and value-based payment models. 1 Newer methodologies include the Quality Health Outcome Model, which uses pathways for associating nursing care and quality. Others focus on the National Database of Nursing Quality Indicators (NDNQI) to review nurse staffing and outcomes. 2 Research has shown that when administrators decrease staff in an effort to lower costs, quality decreases and adverse events increase. 3 , 4 Given that nurse staffing comprises 40% of hospital budgets, it is imperative that optimal nurse assignments continue to meet standards of quality care and improve patient outcomes. 3 , 4 The process of how nursing assignments are distributed in healthcare settings has evolved from uninformed to scientific. 5 Multiple factors, from budgeting and operations to staff satisfaction and patient safety, have driven this evolution. Nursing assignments are often based on room proximity, mandated nurse-to-patient ratio, patient’s medical diagnosis, and continuity of care from shift to shift. In reality, nursing activity will vary throughout a patient’s length of stay based on a combination of prescribed tasks including education, nursing interventions, and psychosocial needs, in addition to medical diagnosis. The NDNQI method for staff assignments uses the hours per patient day (HPPD) as a standard when evaluating staffing. 4 – 6 Managers take into account the average number of staff they have on a given unit and compute the assignment from that information. However, using the traditional methods of creating assignments without objective data may lead to unbalanced nurse workload; in other words, intensity of nursing care varies based on patient-specific needs and abilities. Ideally, assignments should take into account changes in any patient-related tasks, inclusive of psychosocial status, medical status, care transitions, and nursing plans of care. NDNQI has proven to be more accurate than HPPD in determining patient needs as it includes admission, discharge, transfer, and other activities that take up a nurse’s time. 7 Through appropriate documentation of patient-specific activity and utilization of a standard and reliable workload measurement system, nursing assignments become more equitable. 2 To create a process that takes the complexity of nursing care into consideration when making shift assignments, it is 1st necessary to assess the amount of nursing activity required by a single patient and translate into a workload score. 8 – 10

The 2nd step, and focus of the current article, is to sum the patient workload score attributed to each nurse on duty to plan nursing assignments and distribute the total work of the unit safely and equitably. Workload-based staffing technology satisfies an essential function that meets diverse patient needs when determining nursing assignments.

Calculating a workload score takes into account dynamic patient care demands that often change from shift to shift or even hour to hour. Historically, resource allocation and staff assignment did not take the ever-changing patient care requirements into consideration. 5 According to the American Nurses Association (ANA), “Greater benefit can be derived from staffing models that consider the number of nurses and/or the nurse-to-patient ratios and can be adjusted to account for unit and shift level factors.” 11 Using a workload score in combination with an electronic health record (EHR)–based assignment tool offers an opportunity for real-time patient-centered resource allocation. By leveraging existing documentation, the nursing workload measurement (NWM) allows for agility and accuracy in nurse staffing assignments.

It has been well documented that HPPD-based or diagnostic related group–based assignments do not accurately equate to perceived nursing workload. 7 The term workload is interpreted differently among healthcare professionals. Given that, according to Merriam-Webster, 12 the medical definition of workload is keenness of sense perception , it is vital to clarify this in relation to patient care. For this project, the operational definition of workload included the amount of nursing care needed, patient reliance on nursing, staff allocation, and workload measurement. 5 , 13 The term workload-based reflects an aggregate of medical- and nursing-related tasks, as well as other aspects, such as risk factors, admission, transfer, and discharge activities. 14 The intention of a patient-specific workload score generated by EHR documentation is to estimate the intensity of nursing work the patient will require in the upcoming shift. Unless a standard is applied to account for the intensity of nursing activity required for a patient during a shift, the process of distributing nursing assignments becomes biased.

Significance

Aiken et al 15 have led the battle regarding patient safety and the level of staffing needed to maintain this goal. There are currently no federal regulations to establish appropriate guidelines for safe patient care related to nurse staffing. The Safe Staffing for Nurse and Patient Safety Act of 2018 (S. 2446, H.R. 5052) proposes clear directives related to nurse staffing levels for hospitals that receive reimbursement from Medicare. 15 One such requirement is that minimum ratios are identified and adaptable based on “the level and variability of intensity of care required by patient under existing conditions.” 16 In this Act, Congress acknowledged the abundance of evidence supporting the correlation between safe nurse staffing and improved patient outcomes. The fact that this federal legislation has not passed should not negate its importance when addressing safe staffing. States are also actively addressing safe staffing legislation. Regulations are beginning to affect payments based on staffing models, and union contracts are demanding that healthcare organizations adopt workload-driven systems. 11 The proposed federal legislation acknowledged that Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington have enacted this as recommended. 11 As stated in the Lippincott Blog: “14 states currently addressed nurse staffing in hospitals in law/regulations: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA.” 17 California is the only state with unit-specific mandated minimum nurse ratios, whereas other states have developed committees and public disclosure of ratios. Massachusetts has written into law specific nurse-to-patient ratios for the ICU of 1:1 or 1:2. Man-dating a minimum nurse-to-patient ratio by no means restricts the ability of organizations to increase ratios according to need. 16

In this study, we are motivated by the current national discussion to provide insight on how to harness emerging EHR technologies to provide hospital-wide nurse staffing assignments based on real-time patient need. Our aim is to incorporate the ANA position on staffing, namely, that staffing should focus not only on ratio, and there is variation between nurse experience, hospitals, units, and shifts. 11 The current study integrates regularly captured patient workload scores with traditional nurse-to-patient ratios into an automated data nursing assignment tool (NAT).

Materials and Methods

In the fall of 2017, our organization, an approximately 400-bed tertiary care, rural academic medical center, located in New England, implemented an EHR-based workload tool that measures patient-specific nursing workload. The institutional review board granted exempt status to conduct this quality improvement work.

Prior to implementation, decisions were made by the organization to adapt EHR rules to a point value associated with each nursing task. There are 9 components that make up an individual patient score: assessments, medications, lines/drains/airways, risks, wounds, orders, activities of daily living, admission and transfer/discharge. The tool automates an individual patient workload score based on 300 available rules that look retrospectively and prospectively for certain elements within existing documentation as well as orders. The proprietary nature of the tool does not allow the authors to disclose the details of the rules that drive the workload score. The score is updated at the following times: 3:00 AM, 9:00 AM, 3:00 PM, and 9:00 PM. The times are set to allow for “filed status” of scores. It is important to note that the times were not set to allow for late documentation, but for the batch job to run. The next phase, and the focus of this article, was to use this individual patient-level EHR data as the driver to implement a patient-centered objective and automated NAT.

To create an impartial assignment, the average workload scores on each unit were addressed. The authors felt this was important to compare unit scores so we would know if it was appropriate to use a universal assignment score, or whether this should be department specific. Having implemented the nursing workload tool, data were collected from August 2017 to June 2018. EHR-generated data were obtained using a web-based report of all patients and their workload numbers. We compiled the summary score of all patients assigned to one nurse, which is equivalent to the total workload score for that nurse. We examined the mean, SD, and median values to understand the distribution of the data. Nurse workload scores were aggregated at the department level and transformed into 3 categories indicating low, medium, and high workload, based on 1 SD from the mean department score. To set the ranges for these categories, the department level mean ± 1 SD was multiplied by each department-specific nurse-to-patient ratio. In some instances, fractional numbers were used to accommodate for units that have different nurse-to-patient ratios on the night shift. For example, a nurse-to-patient ratio of 3.5:1 was used for a unit with a 3:1 nurse-to-patient ratio on days and 4:1 nurse-to-patient ratio on nights. The result was department-specific NWM categories for nurse assignments that were represented with a color to indicate when the combined patient assignments for each nurse fell within a low, medium, or high range. The upper limit of the high range was determined by adding 200 to the lower limit of the high category. This value is only needed to program the ranges in the EHR, so it is somewhat arbitrary. However, after examining maximum values since August 2017, it is unlikely that this number will be exceeded.

The mean patient workload score varied greatly across departments, ranging from a mean score in pediatrics of 64 to a mean in ICU medical of 196 ( Table 1 ). Aggregated patient scores at the nurse level were summed across all units and compared. This aggregated number represents the NWM for a single nurse assignment having taken into account the unit’s nurse-to-patient ratio. The NWM score falls within the predefined ranges of low, medium, or high. For medium, the optimal NWM range in pediatrics with a nurse-to-patient ratio multiplier of 4 is 144 to 432, whereas in ICU medical, a nurse-to-patient ratio multiplier of 2 defines an optimal range of 272 to 512. As a visual indicator of the ranges, the NAT will be implemented with stoplight colors, with green representing the medium-level, or ideal, range. Yellow will indicate that the assignment is in the low range, indicating that a nurse still has capacity to care for additional patients, and red is in the high range relative to nursing workload. These categories will provide decision support to charge nurses and managers to determine nurse-to-patient ratios and assignments in real time, according to patient-centered needs.

Patient-Level and Nurse Assignment–Level Work Acuity Scores Across Departments in an Academic Hospital

All scores from Web Intelligence over 11.5 months (7/17 to 6/18 four times per day).

Nurse-to-patient ratio multiplier is an average in cases when a unit has different ratio standards for day and night shifts.

Strengths and Limitations

Because of the proprietary limitations of the EHR vendor, the direct application of ranges reported in our study cannot be generalized to other institutions. Nonetheless, the process of evaluating department-specific measures to derive appropriate ranges and staffing assignments can be universally adopted. Data were collected from a single academic center, which reduces the generalizability of our study. However, the sample size included 26,985 records and covered a 12-month period across all departments.

The major finding of this article demonstrates that patient workload scores, combined with minimum department-specific nurse-to-patient ratios, provide accurate patient needs to generate fair, hospital-wide staff assignments. As expected, patient workload scores varied by department. What was not expected were the higher scores observed in departments that were traditionally viewed as having lower patient care needs; that is, in the hospice unit, when we looked closer, scores were comparable to the ICU.

Our work demonstrates that a NAT allows the person responsible for making nursing assignments, usually the charge nurse, to quickly assess and adjust a nurse’s workload. The cumulative NWM score is translated into a visual indicator using color and a slide bar. The colors change based on a range of scores customized to each unit. When developing our approach, research into other organizations’ strategy to develop the ranges for the NAT yielded sparse results. It was determined that a descriptive statistical approach would be utilized to define and maintain each unit’s optimal range. Nurse managers were presented with the proposed ranges and educated on the logic behind the process and development of the tool. Work is ongoing to fully implement this assignment tool into everyday practice at the institution to ensure staff assignments are fair and unbiased. Most managers responded positively and are eager to use this tool when available. However, there was some reluctance to using patient workload scores as a basis for a staff assignment tool. The inpatient psychiatric unit staff initially did not feel this tool would be applicable to their care model. The range of scores for this unit was 30 to 90, with an outlier of 205. Data revealed that outliers in the psychiatric unit were dramatically visible and could be directly attributed to increased patient care needs, which we believe reinforced the reliability of the workload scores.

The next phase of developing an improved practice of assigning staff will require that staff schedules are batch uploaded to the EHR and into the NAT. The availability of the daily nurse schedule is a vital component for successful implementation; however, it was outside the scope of the current project. Once implemented, the staff responsible for assigning patients will drag and drop a patient’s name to the assigned nurse. A bar under the staff nurse’s name will fill with the color to indicate the current status of his/her assigned workload. The patient’s workload score will be automatically updated 4 times per day to adjust to real-time documentation and upcoming orders. As the score is dependent on nursing documentation, complete and real-time documentation of patient care will produce the most reliable score ( Figure 1 ).

Nursing assignment tool workflow.

There will be ongoing monitoring of this tool to ensure usability following implementation. Some nurse managers expressed concern with the stoplight color scheme and have suggested that a gradation of a single color may be more useful. The middle range is the optimal assignment. An assignment classified as red may be construed as precarious or undesirable. Color scheme changes will be considered pending feedback after implementation. Continued review of the ranges will also be necessary as documentation standards change or updates to the EHR are made that may lead to breakage of rules used to calculate scores.

Patient safety issues are rightly at the center of concern regarding ineffective staffing models. Studies have drawn a direct line between nursing workload and staffing ratios and avoidable deaths. 6 , 10 , 16 Patient safety is only one of the concerns that can be addressed by utilizing a NAT for staffing decisions. Other areas of concern that may be addressed include staff retention, burnout, and work satisfaction. 8 Identifying and remediating workload disparities will allow managers to allocate staffing resources appropriately, including using flexible staff when needed. 13 “Fixed staffing numbers or ratios only identify minimum staffing levels and do not adjust for the ever-changing nature of patient care needs.” 3

The national conversation continues to reflect positively on agile nursing assignment processes that flex with patient needs. 9 , 18 , 19 However, there are logistic and cultural barriers to implementation. Another challenge to the adoption of this technology may be the geography related to specific patient locations in the hospital unit. Adjusting nursing assignments based strictly on nursing workload may fail to take location of patients into consideration. Some departments currently base assignment on room location, as there are physical barriers in the unit design. Changing the status quo of the process to assign patients to nurses may be challenging in some units. One unit manager reported that they assign nurses up to 24 hours in advance, making the every 6-hour update to the nurse workload score less valuable and less sensitive to acuity and condition changes, as well as nurse competence. Clearly, each institution will require adjustments that can be easily managed from the back end of this flexible product. Engagement with operational leaders is a vital component of implementation. Such systems that leverage EHR technology have the potential to impact excellence in nursing practice.

Future versions of this tool will allow a charge nurse to quickly match patients to nurses based on continuity of care, expertise, and location. Coordinating care at this level of granularity will help ensure the patient is paired with the right nurse for the current phase of care to achieve patient safety, staff satisfaction, and optimal resource allocation. The use of objective, data-driven, electronically generated NWM scores based on actual patient workload, combined with nurse-to-patient ratios, provides accurate real-time nurse staffing needs that can lead to best practice in staffing. The validation of workload scores and an appreciation for the complexity of vendor rules are necessary for successful implementation.

Acknowledgments

The authors acknowledge Geoffrey Tarbox, MBA, RN, for his work on the Excel spreadsheets; and Petrice DiDominic, MSN, RNC-OB, for her help with the Workload Acuity Tool.

R.T.E. was supported by award number UL1TR001086 from the National Center for Advancing Translational Sciences of the National Institutes of Health.

The authors declare no conflicts of interest.

Nurse Staffing

Our health care system faces immense challenges. Cost-cutting decisions, an aging population, increased patient complexity and need, and an aging workforce all contribute to the current nurse staffing crisis that is negatively affecting nurses’ mental health and well-being.

Evidence shows appropriate  nurse staffing   contributes to improved patient outcomes and greater satisfaction for both patients and nurses. Addressing nurse staffing challenges supports our nurses, our patients, and our nation’s health and well-being.

Minimum nurse-to-patient ratios is one of many alternatives and solutions to achieve appropriate nurse staffing. The American Nurses Association (ANA) supports enforceable ratios as an essential approach to achieving appropriate nurse staffing .

Long-standing nurse staffing challenges will require multiple strategies. When considered together, they will improve the work environment and the ability of nurses to consistently provide safe patient care.

Appropriate nurse staffing is achievable , and the ANA supports all nurses in advocating for the staffing solutions they find most suitable in their practice settings. Read on to find out more about how ANA is working to improve nurse staffing and how you can get involved.

Nurse Staffing Crisis

Questions to ask in making the decision to accept a staffing assignment for nurses, workforce management, pcas, and the rfp process, nurse burnout, nurse retention strategies, nurse schedules, why nurses quit, in this section.

Position Statements & Principles

Research & Data

Nurse Staffing Task Force

Legislation & Regulation

In the news

ANA Position Statements & Principles

Nursing Staffing Requirements to Meet the Demands of Today’s Long Term Care Consumer

Recommendations from the Coalition of Geriatric Nursing Organizations (CGNO)

CGNO Position Statement Endorsed by ANA: November 12, 2014

Principles for Nurse Staffing, 3rd Edition

The 2019 ANA Principles for Nurse Staffing identify the major elements needed to achieve optimal staffing, which enhances the delivery of safe, quality care. These principles and the supporting material in this publication will guide nurses and other decision-makers in identifying and developing the processes and policies needed to improve nurse staffing at every practice level and in any practice setting.

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Research & Data

• Staffing White Paper - Learn ANA's 7 Core Components of Nurse Staffing

Patient Safety: A Shared Responsibility

Read OJIN article

Why Causal Inference Matters to Nurses: The Case of Nurse Staffing and Patient Outcomes

Centralized vs decentralized staffing: two case studies.

Read American Nurse Today article

Staffing committees: A safe staffing solution that includes engagement

Identifying and maintaining the appropriate nurse staff numbers and mix is critical to the delivery of quality patient care. Numerous studies reveal an association between higher levels of experienced RN staffing and lower rates of adverse patient outcomes.

When health care employers fail to recognize the association between RN staffing and patient outcomes, laws and regulations become necessary.

• State Legislative & Regulatory Issues
• Federal Legislation
• Nurse Staffing Measures

In the News

American nurses association underscores urgency for safe staffing solutions, including minimum nurse-to-patient ratios.

ANA underscores the urgency for Congressional leaders and the Centers for Medicare Medicaid Services to advance efforts to implement safe staffing standards, including minimum nurse-to-patient ratios.

Hundreds of Nurses Urge the US Congress to Address the Nurse Staffing Crisis and Longstanding Work Environment Issues

Insufficient nurse staffing and longstanding work environment issues jeopardize patient safety and negatively impact nurses across the country.

New ANA President Dr. Jennifer Mensik Kennedy to Tackle Pressing Nursing Workforce Issues

Today the American Nurses Association (ANA), the premier association representing the interests of the nation’s more than 4.4 million nurses, welcomes its newest president, Jennifer Mensik Kennedy, PhD, MBA, RN, NEA-BC, FAAN.

United Health Foundation Launches $3.1 Million Partnership with American Nurses Foundation to Fight Nurse Burnout and Attrition

Today the United Health Foundation, the philanthropic foundation of UnitedHealth Group (NYSE: UNH), announced a three-year, $3.1 million grant partnership with the American Nurses Foundation to fight nurse burnout.

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What works: Equitable nurse-patient assignments using a workload tool

One unit’s experience developing and implementing a process change.

• Implementation of a workload tool can promote equitable workloads and improve perceived nurse satisfaction.
• Continuous collaboration within the multi-levels of leadership and bedside nurses is essential to improve compliance.
• Sufficient time is needed to allow the workload tool to be incorporated into standard practice.

Nurses on a 36-bed medical/surgical telemetry unit in a metropolitan hospital expressed frustration with their nursing workload. Many of them felt that the time needed to safely care for their patients wasn’t always considered when nurse-patient shift assignments were made. The nurses also voiced concerns about unfair assignments.

To address this problem, two bedside nurses (O’Connell and Nettleton), launched a project to understand the problem of unsafe and unfair patient assignments and the benefits of using a workload tool to equalize them. During our literature review, we discovered a simple one-page tool (Kidd and colleagues, 2014, myamericannurse.com/wp-content/uploads/2014/03/ant3-Workforce-Management-Acuity-304.pdf , see the second page of the article) that classifies nursing workload into a rating system that the charge nurse uses before change of shift to make assignments based on individual patient scores. Here is how we successfully adapted and implemented the tool to improve staff satisfaction.

Uncovering the evidence

Over the past 15 years, advances in technology and documentation have added to nursing responsibilities. Research shows that extensive workloads can cause nurses to feel a loss of control, overwhelmed, and stressed. Improved workload management may reduce stress and its negative impact on nurses, leading them to work with a higher level of integrity and loyalty to their organization.

Research indicates that using a workload tool can help promote equitable nurse-patient assignments, which may improve nurse job satisfaction. During our literature search, we discovered several studies found that nurses believed their assignments were more fair after implementing a workload tool. For example, a study by Firestone-Howard and colleagues suggests that nurse input on their assignments improved verbal communication and increased job satisfaction. When management engages nurses to participate in patient assignments, they feel their value is being acknowledged and that they’re part of a team, which can enhance unit camaraderie.

What we did

We introduced the 2014 paper acuity tool to the unit nurses, giving them ample time to review it. We then deployed an email survey via SurveyMonkey.com to evaluate nurses’ perceived workload distribution and job satisfaction. Included in the survey were open-ended questions asking about their current nursing assignments and suggestions for revising the sample tool to make it unit specific.

After reviewing the presurvey results, we revised the initial workload tool to meet the staff’s suggestions by deleting and adding tasks pertinent to the unit. After revisions were made, we led brief educational sessions on the unit at various times to accommodate all shifts. In these sessions, we taught nurses how to use the revised workload tool and used a case scenario to demonstrate its proper use. In our check-ins during the initial training, we found that bedside nurses were excited and willing to be actively involved in the entire change process, which at times led us to make additional unit-specific revisions to the tool.

Throughout the 12-week project, nursing staff shared suggestions for improving the tool and identified the need for an additional revision to it, including the addition of another level to the scoring system. At the end of the 12 weeks, we deployed another survey to re-evaluate nurses’ perceived workload distribution and job satisfaction.

Before implementing the workload tool, 28% of nurses felt their assignments were fair and equal compared to 57% postimplementation. The tool was being used nearly 52% of the time; when it was used, 70% of nurses felt that it helped equally distribute nurse-patient assignments. Postimplementation data analysis demonstrated a 34% increase in satisfaction with the distribution of patient workload in nurses’ daily assignments.

Initial successes and challenges

The high level of staff nurse and leader engagement in this project was remarkable, which suggests two things. First, the problem of unfair and unsafe patient assignments is a shared and prevalent problem. Bedside nurses who feel the stress of burdensome workloads were invested in trying to fix the problem. Second, management wanted to hear from them.

Bedside nurses are crucial to patient safety, so they must be included in any change process. Their input and engagement can make all the difference in the success of a project. Involving them helps improve nurse satisfaction, communication, and collaboration, all of which has an impact on patient safety.

Although the workload tool improved nurse satisfaction, some nurses felt that because it was on paper it added to their already busy schedules. We know this can lead to nonadherence, so the next step will be to see if the tool can be incorporated into the electronic health record.

We also may have initially underestimated the fear that change can produce. Implementing any new project can make staff feel uneasy. Anticipating this uneasiness, we used engagement strategies—such as acknowledging the staff’s involvement in the change process, remaining transparent throughout, and providing support when needed—to get ready for the change ahead, but we realize that more effort in this area would have been helpful.

What we learned

Collaboration between bedside nurses and all levels of leadership was essential to successfully implement the workload tool. We don’t know yet whether it will be fully adopted on our unit, but we gained some unexpected knowledge about change and its effects on staff.

We were reminded to be patient and understanding. Sufficient time is key for change to be incorporated into standard practice. When relationships are built based on trust and respect, participants will reciprocate with honest feedback. Including bedside nurses in decisions about future change will promote an eagerness to participate in creating a stronger community on the unit.

Nurses’ time is valuable, so education and training should accommodate their schedules. Using email, SurveyMonkey, and the TigerText app made communication easy and allowed us to reach nurses who couldn’t attend trainings or check-ins on their off days.

With collaboration, patience, trust, respect, and open communication, the change process can result in improved care quality and nurse work satisfaction.

Amanda L. O’Connell is a float pool nurse at Trinity Health Of New England Saint Francis Hospital and Medical Center in Hartford, Connecticut. Rita M. Nettleton is a medical/surgical staff nurse at Charlotte Hungerford Hospital in Torrington, Connecticut. Dawn R. Bunting is an adjunct professor at the University of Hartford in West Hartford, Connecticut, and nursing division director at Capital Community College in Hartford, Connecticut. Susan Eichar is an associate professor at the University of Hartford in West Hartford,  Connecticut.

Chiulli KA, Thompson J, Reguin-Hartman KL. Development and implementation of a patient acuity tool for a medical-surgical unit. MedSurg Matters . 2014;23(2):1,9-12. amsn.org/sites/default/files/private/medsurg-matters-newsletter-archives/marapr14.pdf

Ericksen K. Nursing burnout: Why it happens and how to avoid it. Rasmussen College. February 27, 2018. rasmussen.edu/degrees/nursing/blog/nursing-burnout-why-it-happens-and-what-to-do-about-it

Firestone-Howard B, Zedreck Gonzales JF, Dudjak LA, Ren D, Rader S. The effects of implementing a patient acuity tool on nurse satisfaction in a pulmonary medicine unit. Nurs Adm Q. 2017;41(4):E5-14.

Hairr DC, Salisbury H, Johannsson M, Redfern-Vance N. Nurse staffing and the relationship to job satisfaction and retention. Nurs Econ . 2014 ; 32(3):142-7.

Harper K, McCully C. Acuity systems dialogue and patient classification system essentials. Nurs Adm Q . 2007;31(4):284-99.

Kidd M, Grove K, Kaiser M, Swoboda B, Taylor A. A new patient-acuity tool promotes equitable nurse-patient assignments. Am Nurse Today . 2014;9(3):1-4.

Lowe M, Santamaria N, Tacey M, Rowe L. Nursing absenteeism following the introduction of the Northwick Park Dependency Scale Hospital version (NPDS-H) in the rehabilitation setting. Australas Rehabn Nurses Assoc J . 2015;18(1):11-7.

MacPhee M, Dahinten VS, Havaei F. The impact of heavy perceived nurse workloads on patient and nurse outcomes. Adm Sci . 2017;7(1):7.

Thomasos E, Brathwaite EE, Cohn T, Nerey J, Lindgren CL, Williams S. Clinical partners’ perceptions of patient assignments according to acuity. MedSurg Nurs . 2015;24(1):39-45.

Vortherms J, Spoden B, Wilcken J. From evidence to practice: Developing an outpatient acuity-based staffing model. Clin J Oncol Nurs. 2015;19(3):332-7.

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2.3 Tools for Prioritizing

Prioritization of care for multiple clients while also performing daily nursing tasks can feel overwhelming in today’s fast-paced health care system. Because of the rapid and ever-changing conditions of clients and the structure of one’s workday, nurses must use organizational frameworks to prioritize actions and interventions. These frameworks can help ease anxiety, enhance personal organization and confidence, and ensure client safety.

Acuity and intensity are foundational concepts for prioritizing nursing care and interventions. Acuity refers to the level of client care that is required based on the severity of a client’s illness or condition. For example, acuity may include characteristics such as unstable vital signs, oxygenation therapy, high-risk IV medications, multiple drainage devices, or uncontrolled pain. A “high-acuity” client requires several nursing interventions and frequent nursing assessments.

Intensity addresses the time needed to complete nursing care and interventions such as providing assistance with activities of daily living (ADLs), performing wound care, or administering several medication passes. For example, a “high-intensity” client generally requires frequent or long periods of psychosocial, educational, or hygiene care from nursing staff members. High-intensity clients may also have increased needs for safety monitoring, familial support, or other needs. [1]

Many health care organizations structure their staffing assignments based on acuity and intensity ratings to help provide equity in staff assignments. Acuity helps to ensure that nursing care is strategically divided among nursing staff. An equitable assignment of clients benefits both the nurse and client by helping to ensure that client care needs do not overwhelm individual staff and safe care is provided.

Organizations use a variety of systems when determining client acuity with rating scales based on nursing care delivery, client stability, and care needs. See an example of a client acuity tool published in the American Nurse in Table 2.3. [2] In this example, ratings range from 1 to 4, with a rating of 1 indicating a relatively stable client requiring minimal individualized nursing care and intervention. A rating of 2 reflects a client with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex client who requires frequent intervention and assessment. This client might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk client. For example, this individual may be experiencing frequent changes in vital signs, may require complex interventions such as the administration of blood transfusions, or may be experiencing significant uncontrolled pain. An individual with a rating of 4 requires more direct nursing care and intervention than a client with a rating of 1 or 2. [3]  

Table 2.3. Example of a Client Acuity Tool [4]

Read more about using a client acuity tool on a medical-surgical unit.

Rating scales may vary among institutions, but the principles of the rating system remain the same. Organizations include various client care elements when constructing their staffing plans for each unit. Read more information about staffing models and acuity in the following box.

Staffing Models and Acuity

Organizations that base staffing on acuity systems attempt to evenly staff client assignments according to their acuity ratings. This means that when comparing client assignments across nurses on a unit, similar acuity team scores should be seen with the goal of achieving equitable and safe division of workload across the nursing team. For example, one nurse should not have a total acuity score of 6 for their client assignments while another nurse has a score of 15. If this situation occurred, the variation in scoring reflects a discrepancy in workload balance and would likely be perceived by nursing peers as unfair. Using acuity-rating staffing models is helpful to reflect the individualized nursing care required by different clients.

Alternatively, nurse staffing models may be determined by staffing ratio. Ratio-based staffing models are more straightforward in nature, where each nurse is assigned care for a set number of clients during their shift. Ratio-based staffing models may be useful for administrators creating budget requests based on the number of staff required for client care, but can lead to an inequitable division of work across the nursing team when client acuity is not considered. Increasingly complex clients require more time and interventions than others, so a blend of both ratio and acuity-based staffing is helpful when determining staffing assignments. [5]

As a practicing nurse, you will be oriented to the elements of acuity ratings within your health care organization, but it is also important to understand how you can use these acuity ratings for your own prioritization and task delineation. Let’s consider the Scenario B in the following box to better understand how acuity ratings can be useful for prioritizing nursing care.

You report to work at 6 a.m. for your nursing shift on a busy medical-surgical unit. Prior to receiving the handoff report from your night shift nursing colleagues, you review the unit staffing grid and see that you have been assigned to four clients to start your day. The clients have the following acuity ratings:

Client A: 45-year-old client with paraplegia admitted for an infected sacral wound, with an acuity rating of 4.

Client B: 87-year-old client with pneumonia with a low-grade fever of 99.7 F and receiving oxygen at 2 L/minute via nasal cannula, with an acuity rating of 2.

Client C: 63-year-old client who is postoperative Day 1 from a right total hip replacement and is receiving pain management via a PCA pump, with an acuity rating of 2.

Client D: 83-year-old client admitted with a UTI who is finishing an IV antibiotic cycle and will be discharged home today, with an acuity rating of 1.

Based on the acuity rating system, your client assignment load receives an overall acuity score of 9. Consider how you might use their acuity ratings to help you prioritize your care. Based on what is known about the clients related to their acuity rating, whom might you identify as your care priority? Although this can feel like a challenging question to answer because of the many unknown elements in the situation using acuity numbers alone, Client A with an acuity rating of 4 would be identified as the care priority requiring assessment early in your shift.

Although acuity can a useful tool for determining care priorities, it is important to recognize the limitations of this tool and consider how other client needs impact prioritization.

Maslow’s Hierarchy of Needs

When thinking back to your first nursing or psychology course, you may recall a historical theory of human motivation based on various levels of human needs called Maslow’s Hierarchy of Needs. Maslow’s Hierarchy of Needs reflects foundational human needs with progressive steps moving towards higher levels of achievement. This hierarchy of needs is traditionally represented as a pyramid with the base of the pyramid serving as essential needs that must be addressed before one can progress to another area of need. [6] See Figure 2.1 [7] for an illustration of Maslow’s Hierarchy of Needs.

Maslow’s Hierarchy of Needs places physiological needs as the foundational base of the pyramid. [8] Physiological needs include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second level of Maslow’s hierarchy reflects safety needs. Safety needs include elements that keep individuals safe from harm. Examples of safety needs in health care include fall precautions. The third level of Maslow’s hierarchy reflects emotional needs such as love and a sense of belonging. These needs are often reflected in an individual’s relationships with family members and friends. The top two levels of Maslow’s hierarchy include esteem and self-actualization. An example of addressing these needs in a health care setting is helping an individual build self-confidence in performing blood glucose checks that leads to improved self-management of their diabetes.

So how does Maslow’s theory impact prioritization? To better understand the application of Maslow’s theory to prioritization, consider Scenario C in the following box.

You are an emergency response nurse working at a local shelter in a community that has suffered a devastating hurricane. Many individuals have relocated to the shelter for safety in the aftermath of the hurricane. Much of the community is still without electricity and clean water, and many homes have been destroyed. You approach a young woman who has a laceration on her scalp that is bleeding through her gauze dressing. The woman is weeping as she describes the loss of her home stating, “I have lost everything! I just don’t know what I am going to do now. It has been a day since I have had water or anything to drink. I don’t know where my sister is, and I can’t reach any of my family to find out if they are okay!”

Despite this relatively brief interaction, this woman has shared with you a variety of needs. She has demonstrated a need for food, water, shelter, homeostasis, and family. As the nurse caring for her, it might be challenging to think about where to begin her care. These thoughts could be racing through your mind:

Should I begin to make phone calls to try and find her family? Maybe then she would be able to calm down.

Should I get her on the list for the homeless shelter so she wouldn’t have to worry about where she will sleep tonight?

She hasn’t eaten in a while; I should probably find her something to eat.

All these needs are important and should be addressed at some point, but Maslow’s hierarchy provides guidance on what needs must be addressed first. Use the foundational level of Maslow’s pyramid of physiological needs as the top priority for care. The woman is bleeding heavily from a head wound and has had limited fluid intake. As the nurse caring for this client, it is important to immediately intervene to stop the bleeding and restore fluid volume. Stabilizing the client by addressing her physiological needs is required before undertaking additional measures such as contacting her family. Imagine if instead you made phone calls to find the client’s family and didn’t address the bleeding or dehydration – you might return to a severely hypovolemic client who has deteriorated and may be near death. In this example, prioritizing emotional needs above physiological needs can lead to significant harm to the client.

Although this is a relatively straightforward example, the principles behind the application of Maslow’s hierarchy are essential. Addressing physiological needs before progressing toward additional need categories concentrates efforts on the most vital elements to enhance client well-being. Maslow’s hierarchy provides the nurse with a helpful framework for identifying and prioritizing critical client care needs.

Airway, breathing, and circulation, otherwise known by the mnemonic “ABCs,” are another foundational element to assist the nurse in prioritization. Like Maslow’s hierarchy, using the ABCs to guide decision-making concentrates on the most critical needs for preserving human life. If a client does not have a patent airway, is unable to breathe, or has inadequate circulation, very little of what else we do matters. The client’s ABCs are reflected in Maslow’s foundational level of physiological needs and direct critical nursing actions and timely interventions. Let’s consider Scenario D in the following box regarding prioritization using the ABCs and the physiological base of Maslow’s hierarchy.

You are a nurse on a busy cardiac floor charting your morning assessments on a computer at the nurses’ station. Down the hall from where you are charting, two of your assigned clients are resting comfortably in Room 504 and Room 506. Suddenly, both call lights ring from the rooms, and you answer them via the intercom at the nurses’ station.

Room 504 has an 87-year-old male who has been admitted with heart failure, weakness, and confusion. He has a bed alarm for safety and has been ringing his call bell for assistance appropriately throughout the shift. He requires assistance to get out of bed to use the bathroom. He received his morning medications, which included a diuretic about 30 minutes previously, and now reports significant urge to void and needs assistance to the bathroom.

Room 506 has a 47-year-old woman who was hospitalized with new onset atrial fibrillation with rapid ventricular response. The client underwent a cardioversion procedure yesterday that resulted in successful conversion of her heart back into normal sinus rhythm. She is reporting via the intercom that her “heart feels like it is doing that fluttering thing again” and she is having chest pain with breathlessness.

Based upon these two client scenarios, it might be difficult to determine whom you should see first. Both clients are demonstrating needs in the foundational physiological level of Maslow’s hierarchy and require assistance. To prioritize between these clients’ physiological needs, the nurse can apply the principles of the ABCs to determine intervention. The client in Room 506 reports both breathing and circulation issues, warning indicators that action is needed immediately. Although the client in Room 504 also has an urgent physiological elimination need, it does not overtake the critical one experienced by the client in Room 506. The nurse should immediately assess the client in Room 506 while also calling for assistance from a team member to assist the client in Room 504.

Prioritizing what should be done and when it can be done can be a challenging task when several clients all have physiological needs. Recently, there has been professional acknowledgement of the cognitive challenge for novice nurses in differentiating physiological needs. To expand on the principles of prioritizing using the ABCs, the CURE hierarchy has been introduced to help novice nurses better understand how to manage competing client needs. The CURE hierarchy uses the acronym “CURE” to guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras. [9]

“Critical” client needs require immediate action. Examples of critical needs align with the ABCs and Maslow’s physiological needs, such as symptoms of respiratory distress, chest pain, and airway compromise. No matter the complexity of their shift, nurses can be assured that addressing clients’ critical needs is the correct prioritization of their time and energies.

After critical client care needs have been addressed, nurses can then address “urgent” needs. Urgent needs are characterized as needs that cause client discomfort or place the client at a significant safety risk. [10]

The third part of the CURE hierarchy reflects “routine” client needs. Routine client needs can also be characterized as “typical daily nursing care” because the majority of a standard nursing shift is spent addressing routine client needs. Examples of routine daily nursing care include actions such as administering medication and performing physical assessments. [11] Although a nurse’s typical shift in a hospital setting includes these routine client needs, they do not supersede critical or urgent client needs.

The final component of the CURE hierarchy is known as “extras.” Extras refer to activities performed in the care setting to facilitate client comfort but are not essential. [12] Examples of extra activities include providing a massage for comfort or washing a client’s hair. If a nurse has sufficient time to perform extra activities, they contribute to a client’s feeling of satisfaction regarding their care, but these activities are not essential to achieve client outcomes.

Let’s apply the CURE mnemonic to client care in the following box.

If we return to Scenario D regarding clients in Room 504 and 506, we can see the client in Room 504 is having urgent needs. He is experiencing a physiological need to urgently use the restroom and may also have safety concerns if he does not receive assistance and attempts to get up on his own because of weakness. He is on a bed alarm, which reflects safety considerations related to his potential to get out of bed without assistance. Despite these urgent indicators, the client in Room 506 is experiencing a critical need and takes priority. Recall that critical needs require immediate nursing action to prevent client deterioration. The clientin Room 506 with a rapid, fluttering heartbeat and shortness of breath has a critical need because without prompt assessment and intervention, their condition could rapidly decline and become fatal.

In addition to using the identified frameworks and tools to assist with priority setting, nurses must also look at their clients’ data cues to help them identify care priorities. Data cues are pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition. For example, have the client’s vital signs worsened over the last few hours? Is there a new laboratory result that is concerning? Data cues are used in conjunction with prioritization frameworks to help the nurse holistically understand the client’s current status and where nursing interventions should be directed. Common categories of data clues include acute versus chronic conditions, actual versus potential problems, unexpected versus expected conditions, information obtained from the review of a client’s chart, and diagnostic information.

Acute Versus Chronic Conditions

A common data cue that nurses use to prioritize care is considering if a condition or symptom is acute or chronic. Acute conditions have a sudden and severe onset. These conditions occur due to a sudden illness or injury, and the body often has a significant response as it attempts to adapt. Chronic conditions have a slow onset and may gradually worsen over time. The difference between an acute versus a chronic condition relates to the body’s adaptation response. Individuals with chronic conditions often experience less symptom exacerbation because their body has had time to adjust to the illness or injury. Let’s consider an example of two clients admitted to the medical-surgical unit complaining of pain in Scenario E in the following box.

As part of your client assignment on a medical-surgical unit, you are caring for two clients who both ring the call light and report pain at the start of the shift. Client A was recently admitted with acute appendicitis, and Client B was admitted for observation due to weakness. Not knowing any additional details about the clients’ conditions or current symptoms, which client would receive priority in your assessment? Based on using the data cue of acute versus chronic conditions, Client A with a diagnosis of acute appendicitis would receive top priority for assessment over a client with chronic pain due to osteoarthritis. Clients experiencing acute pain require immediate nursing assessment and intervention because it can indicate a change in condition. Acute pain also elicits physiological effects related to the stress response, such as elevated heart rate, blood pressure, and respiratory rate, and should be addressed quickly.

Actual Versus Potential Problems

Nursing diagnoses and the nursing care plan have significant roles in directing prioritization when interpreting assessment data cues. Actual problems refer to a clinical problem that is actively occurring with the client. A risk problem indicates the client may potentially experience a problem but they do not have current signs or symptoms of the problem actively occurring.

Consider an example of prioritizing actual and potential problems in Scenario F in the following box.

A 74-year-old woman with a previous history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital for pneumonia. She has generalized weakness, a weak cough, and crackles in the bases of her lungs. She is receiving IV antibiotics, fluids, and oxygen therapy. The client can sit at the side of the bed and ambulate with the assistance of staff, although she requires significant encouragement to ambulate.

Nursing diagnoses are established for this client as part of the care planning process. One nursing diagnosis for this client is Ineffective Airway Clearance . This nursing diagnosis is an actual problem because the client is currently exhibiting signs of poor airway clearance with an ineffective cough and crackles in the lungs. Nursing interventions related to this diagnosis include coughing and deep breathing, administering nebulizer treatment, and evaluating the effectiveness of oxygen therapy. The client also has the nursing diagnosis Risk for Skin Breakdown based on her weakness and lack of motivation to ambulate. Nursing interventions related to this diagnosis include repositioning every two hours and assisting with ambulation twice daily.

The established nursing diagnoses provide cues for prioritizing care. For example, if the nurse enters the client’s room and discovers the client is experiencing increased shortness of breath, nursing interventions to improve the client’s respiratory status receive top priority before attempting to get the client to ambulate.

Although there may be times when risk problems may supersede actual problems, looking to the “actual” nursing problems can provide clues to assist with prioritization.

Unexpected Versus Expected Conditions

In a similar manner to using acute versus chronic conditions as a cue for prioritization, it is also important to consider if a client’s signs and symptoms are “expected” or “unexpected” based on their overall condition. Unexpected conditions are findings that are not likely to occur in the normal progression of an illness, disease, or injury. Expected conditions are findings that are likely to occur or are anticipated in the course of an illness, disease, or injury. Unexpected findings often require immediate action by the nurse.

Let’s apply this tool to the two clients previously discussed in Scenario E.  As you recall, both Client A (with acute appendicitis) and Client B (with weakness and diagnosed with osteoarthritis) are reporting pain. Acute pain typically receives priority over chronic pain. But what if both clients are also reporting nausea and have an elevated temperature? Although these symptoms must be addressed in both clients, they are “expected” symptoms with acute appendicitis (and typically addressed in the treatment plan) but are “unexpected” for the client with osteoarthritis. Critical thinking alerts you to the unexpected nature of these symptoms in Client B, so they receive priority for assessment and nursing interventions.

Handoff Report/Chart Review

Additional data cues that are helpful in guiding prioritization come from information obtained during a handoff nursing report and review of the client chart. These data cues can be used to establish a client’s baseline status and prioritize new clinical concerns based on abnormal assessment findings. Let’s consider Scenario G in the following box based on cues from a handoff report and how it might be used to help prioritize nursing care.

Imagine you are receiving the following handoff report from the night shift nurse for a client admitted to the medical-surgical unit with pneumonia:

At the beginning of my shift, the client was on room air with an oxygen saturation of 93%. She had slight crackles in both bases of her posterior lungs. At 0530, the client rang the call light to go to the bathroom. As I escorted her to the bathroom, she appeared slightly short of breath. Upon returning the client to bed, I rechecked her vital signs and found her oxygen saturation at 88% on room air and respiratory rate of 20. I listened to her lung sounds and noticed more persistent crackles and coarseness than at bedtime. I placed the client on 2 L/minute of oxygen via nasal cannula. Within five minutes, her oxygen saturation increased to 92%, and she reported increased ease in respiration.

Based on the handoff report, the night shift nurse provided substantial clinical evidence that the client may be experiencing a change in condition. Although these changes could be attributed to lack of lung expansion that occurred while the client was sleeping, there is enough information to indicate to the oncoming nurse that follow-up assessment and interventions should be prioritized for this client because of potentially worsening respiratory status. In this manner, identifying data cues from a handoff report can assist with prioritization.

Now imagine the night shift nurse had not reported this information during the handoff report. Is there another method for identifying potential changes in client condition? Many nurses develop a habit of reviewing their clients’ charts at the start of every shift to identify trends and “baselines” in client condition. For example, a chart review reveals a client’s heart rate on admission was 105 beats per minute. If the client continues to have a heart rate in the low 100s, the nurse is not likely to be concerned if today’s vital signs reveal a heart rate in the low 100s. Conversely, if a client’s heart rate on admission was in the 60s and has remained in the 60s throughout their hospitalization, but it is now in the 100s, this finding is an important cue requiring prioritized assessment and intervention.

Diagnostic Information

Diagnostic results are also important when prioritizing care. In fact, the National Patient Safety Goals from The Joint Commission include prompt reporting of important test results. New abnormal laboratory results are typically flagged in a client’s chart or are reported directly by phone to the nurse by the laboratory as they become available. Newly reported abnormal results, such as elevated blood levels or changes on a chest X-ray, may indicate a client’s change in condition and require additional interventions.  For example, consider Scenario H in which you are the nurse providing care for five medical-surgical clients.

You completed morning assessments on your assigned five clients. Client A previously underwent a total right knee replacement and will be discharged home today. You are about to enter Client A’s room to begin discharge teaching when you receive a phone call from the laboratory department, reporting a critical hemoglobin of 6.9 gm/dL on Client B. Rather than enter Client A’s room to perform discharge teaching, you immediately reprioritize your care. You call the primary provider to report Client B’s critical hemoglobin level and determine if additional intervention, such as a blood transfusion, is required.

Prioritization Principles & Staffing Considerations [13]   

With the complexity of different staffing variables in health care settings, it can be challenging to identify a method and solution that will offer a resolution to every challenge. The American Nurses Association has identified five critical principles that should be considered for nurse staffing. These principles are as follows:

• Health Care Consumer: Nurse staffing decisions are influenced by the specific number and needs of the health care consumer. The health care consumer includes not only the client, but also families, groups, and populations served. Staffing guidelines must always consider the client safety indicators, clinical, and operational outcomes that are specific to a practice setting. What is appropriate for the consumer in one setting, may be quite different in another. Additionally, it is important to ensure that there is resource allocation for care coordination and health education in each setting.
• Interprofessional Teams: As organizations identify what constitutes appropriate staffing in various settings, they must also consider the appropriate credentials and qualifications of the nursing staff within a specific setting. This involves utilizing an interprofessional care team that allows each individual to practice to the full extent of their educational, training, scope of practice as defined by their state Nurse Practice Act, and licensure. Staffing plans must include an appropriate skill mix and acknowledge the impact of more experienced nurses to help serve in mentoring and precepting roles.
• Workplace culture: Staffing considerations must also account for the importance of balance between costs associated with best practice and the optimization of care outcomes. Health care leaders and organizations must strive to ensure a balance between quality, safety, and health care cost. Organizations are responsible for creating work environments, which develop policies allowing for nurses to practice to the full extent of their licensure in accordance with their documented competence. Leaders must foster a culture of trust, collaboration, and respect among all members of the health care team, which will create environments that engage and retain health care staff.
• Practice environment: Staffing structures must be founded in a culture of safety where appropriate staffing is integral to achieve client safety and quality goals. An optimal practice environment encourages nurses to report unsafe conditions or poor staffing that may impact safe care. Organizations should ensure that nurses have autonomy in reporting and concerns and may do so without threat of retaliation. The ANA has also taken the position to state that mandatory overtime is an unacceptable solution to achieve appropriate staffing.  Organizations must ensure that they have clear policies delineating length of shifts, meal breaks, and rest period to help ensure safety in client care.
• Evaluation: Staffing plans should be consistently evaluated and changed based upon evidence and client outcomes. Environmental factors and issues such as work-related illness, injury, and turnover are important elements of determining the success of need for modification within a staffing plan. [14]   
• Oregon Health Authority. (2021, April 29). Hospital nurse staffing interpretive guidance on staffing for acuity & intensity . Public Health Division, Center for Health Protection. https://www.oregon.gov/oha/ph/providerpartnerresources/healthcareprovidersfacilities/healthcarehealthcareregulationqualityimprovement/pages/nursestaffing.aspx ↵
• Ingram, A., & Powell, J. (2018). Patient acuity tool on a medical surgical unit. American Nurse . https://www.myamericannurse.com/patient-acuity-medical-surgical-unit/ ↵
• Kidd, M., Grove, K., Kaiser, M., Swoboda, B., & Taylor, A. (2014). A new patient-acuity tool promotes equitable nurse-patient assignments. American Nurse Today, 9 (3), 1-4. https://www.myamericannurse.com/a-new-patient-acuity-tool-promotes-equitable-nurse-patient-assignments / ↵
• Welton, J. M. (2017). Measuring patient acuity. JONA: The Journal of Nursing Administration, 47 (10), 471. https://doi.org/10.1097/nna.0000000000000516 ↵
• Maslow, A. H. (1943). A theory of human motivation. Psychological Review , 50 (4), 370–396. https://doi.org/10.1037/h0054346 ↵
• “ Maslow's_hierarchy_of_needs.svg ” by J. Finkelstein is licensed under CC BY-SA 3.0 ↵
• Stoyanov, S. (2017). An analysis of Abraham Maslow's A Theory of Human Motivation (1st ed.). Routledge. https://doi.org/10.4324/9781912282517 ↵
• Kohtz, C., Gowda, C., & Guede, P. (2017). Cognitive stacking: Strategies for the busy RN. Nursing2021, 47 (1), 18-20. https://doi.org/10.1097/01.nurse.0000510758.31326.92 ↵
• ANA. (2024). Principles for nurse staffing. Retrieved from https://www.nursingworld.org/practice-policy/nurse-staffing/staffing-principles/ ↵

The level of patient care that is required based on the severity of a patient’s illness or condition.

A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.

A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.

Prioritization strategies often reflect the foundational elements of physiological needs and safety and progress toward higher levels.

Airway, breathing, and circulation.

Pieces of clinical information that direct the nurse toward a potential “actual problem” or a change in condition.

Conditions having a sudden and severe onset.

Have a slow onset and may gradually worsen over time.

Nursing problems currently occurring with the patient.

A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.

Conditions that are not likely to occur in the normal progression of an illness, disease or injury.

Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Staffing patterns show the occupational makeup of an industry in percentages. For example, a (simplified) staffing pattern for the industry “Hospitals” might show that 10% of jobs in the hospitals industry are occupied by surgeons, 15% by general practitioners, 20% by nurses, 5% by information technology support staff, 5% by janitors, 1% by chief executives, and so on. ​ An inverse staffing pattern applies the same theory as regular staffing pattern to regional industries. Inverse staffing patterns identify the industries currently employing a specific occupation, including those which are likely to be hiring due to growth or displacing workers due to contraction. It is a table of percentages that shows an average of how regional occupations are divided up among regional industries. For example, a (simplified) inverse staffing pattern for registered nurses may show that 70% of RNs are employed by hospitals, 10% by local government (i.e., public schools), 10% by nursing homes, and 10% by offices of physicians. ​ The short video below explains how to use the Staffing Pattern and Inverse Staffing Pattern reports.