An Exploration Of Charge Nurse Decision-Making Related To The Nurse-Patient Assignment On Adult Medical-Surgical Inpatient Units

ABSTRACT AN EXPLORATION OF CHARGE NURSE DECISION-MAKING RELATED TO THE NURSE-PATIENT ASSIGNMENT ON ADULT MEDICAL-SURGICAL INPATIENT UNITS Colin Plover Julie Sochalski, PhD, RN, FAAN Statement of the Problem: In adult inpatient medical-surgical settings, the nurse-patient assignment serves as a strategy to organize the delivery of nurse-patient care. How nurse-patient care is organized through the nurse-patient assignment affects both nurse and patient outcomes, yet no best practice method of developing the nurse-patient assignment exists. Current literature demonstrates limited investigations of charge nurse reflections on their decision-making related to the nurse-patient assignment. Charge nurse perspectives are important because charge nurses drive the decision-making through which patient care is allocated. Despite their integral role, little is known about charge nurse perspectives on the process of the development of the nurse-patient assignment, what factors charge nurses consider and how they consider them when allocating patient care. Procedure and Methods: A qualitative descriptive approach was chosen and a semi-structured interview guide was used to conduct interviews with 18 charge nurses across four medical-surgical units. Attention was paid to the process of patient care allocation through the nurse-patient assignment, the factors which charge nurses found to be the most and least important, and how they prioritize these factors in their decision-making process. Results: The interviews revealed both common and divergent practices with respect to charge nurses’ process of developing the nurse-patient assignment, the factors that they considered, and how they considered these factors when making patient care allocation decisions. These common and divergent practices were identified by themes and sub-themes respectively. Themes identified how all charge nurses described processes of gathering information involving the application of frameworks with shared aims through which they synthesized specific factors in common ways to develop an assignment that aligned with a common constellation of goals. Sub-themes identified variation with respect to where charge nurses sourced their information, the factors they considered, their strategies for considering factors, how they considered factors, factor terminology and their specific goals. Conclusions: The insight this investigation provides into charge nurse development of the nurse-patient assignment has implications for practice environments that include ways to inform research which may serve to improve patient safety, nurse outcomes and the efficiency and cost effectiveness with which patient care is organized and delivered

Charge Nurse Expertise: Implications for Decision Support of the Nurse-Patient Assignment Process

University of Minnesota Ph.D. dissertation. 2019. Major: Health Informatics. Advisor: David Pieczkiewicz. 1 computer file (PDF); 201 pages.Each day, across thousands of medical-surgical inpatient nursing units, charge nurses make decisions about which nurse will care for each patient. Recent attempts have been made to introduce health information technology (HIT) solutions to automate the nurse-patient assignment process. This research investigated charge nurse decision making during the nurse-patient assignment process as an exemplar of the larger question: How can we leverage information technology to improve decision making in healthcare, while respecting individual clinician expertise and the unique context of individualized patient care? Four primary questions were used to guide research of the process, decision factors, goals and context of nurse-patient assignments. A mixed-methods approach of qualitative interviews (N = 11) and quantitative surveys (N = 135) was used. Findings related to the charge nurse decision making process indicate that measurable, nurse-sensitive indicators of patient outcomes have not yet been standardized for nurse-patient assignments. HIT solutions and quality improvement efforts should define, collect and analyze measurable outcome criteria prior to attempting to improve or augment existing nurse-patient assignment practices to prevent unintended consequences. When clear outcome measurements have been identified, informatics researchers and professionals should investigate the ability of machine learning to recognize goal priorities and factor weighting from patient, nurse and environmental factors within existing HIT solutions. Until that time, HIT solutions augmenting the nurse-patient assignment process should be designed with flexible configurations, to enable goals, decision factors and factor weights can be varied by hospital, unit, charge nurse and shift, in order to best meet the needs of charge nurses

Multiple Criteria Decision Models for Nurse-Patient Assignment: Balancing Workload and Continuity of Care

Continuity of care is critical for delivering high-quality care, yet has seldom been considered in models supporting nurse-patient assignment decisions within inpatient units. Research in the nursing literature suggests that assigning nurses to patients they have cared for previously can help reduce care-related error rates and increase patient satisfaction. However, it is also essential to ensure that patient workloads are allocated to nursing staff in a balanced manner to avoid overwork and burnout. This study investigates the tradeoffs associated with the assignment of patients to nurses in inpatient settings under the dual objective of maximizing continuity of care and minimizing workload imbalance. We develop a hybrid method that balances the need for fair workload distribution and continuity of care, and demonstrate the extent of the tradeoff between the level of continuity achieved and the associated cost in workload balance. To reduce the impact of this tradeoff, we relax the goal of maximizing continuity by introducing an acuity threshold. Here, patients with acuity values above the threshold vi are targeted for continuity-based assignment, and remaining patients are assigned to minimize workload imbalance. We evaluate the utility of introducing the threshold under a variety of hospital environmental conditions using a simulation model of the inpatient environment. Our findings show that it is possible to provide a substantial continuity assignment with a marginal impact on workload imbalance under the hybrid policy using the acuity threshold. In virtually all cases studied, the results show that it is possible to use the acuity threshold and gain the benefits of continuity of care, even under conditions of a strong preference for minimizing acuity imbalance

Identifying relationship between patient acuity indicators and nurse workload

July 2013.A Thesis presented to the Faculty of the Graduate School at the University of Missouri In Partial Fulfillment of the Requirements for the Degree Master of Science, Industrial Engineering.Thesis supervisor: Dr. Mustafa Sir.Patient classification systems are commonly used in nursing units to assess how many nursing care hours are needed to care for patients. In current practice, these systems utilize several patient acuity indicators to produce a single number for given patient, which is called the acuity score. These systems then provide staffing recommendations for a given patient census based on these acuity scores. Our new approach offers a mathematical model which uses patient acuity indicators data from a commercial patient classification system called AcuityPlus and a nurse workload survey from two nursing units at the University of Missouri Hospital. The model distributes workload calculated as a function of patient acuity indicators and nurses' perceived workload among nurses in a balanced way. More specifically, we consider nurses' preferences by conducting a survey in order to determine how much the workload of a nurse increases for each indicator. The purpose of this study is to conduct a comprehensive analysis of patient acuity indicators as a mean of balancing workload of nurses, and suggest nurse staffing and assignment models to aid decision-making. Our numerical results suggest that the proposed nurse-patient assignment models achieve a more balanced assignment of workload among nurses compared to assignment based on acuity scores from the commercial patient classification system.Includes bibliographical references (pages 66-68)

Exploring the workload balance effects of including continuity-based factors in nurse-patient assignments

Workload balance in nurse-patient assignments is important for ensuring quality in patient care. Unbalanced workloads can lead to high levels of nursing stress, medical errors, lower-quality outcomes, and higher costs. Studies have pro-posed assignment strategies based on patient acuity, location, and characteristics of specialized units. These methods do not address the part of workload associated with continuity in care coordination, and the potential benefits associated with continuity-based assignments. We present the results of a pilot simulation study comparing an acuity-oriented method to a continuity-based approach, using acuity as a measure of workload. Our results suggest that a purely continuity-based approach can result in skewed workloads when measured by patient acuity. In future work, we plan to consider hybrid methods, which may be able to provide the benefits of both continuity and acuity based methods

Perspectives on Pay for Performance in Nursing: Key Considerations in Shaping Payment Systems to Drive Better Patient Care Outcomes

Explores the advantages, obstacles, and risks of pay-for-performance systems in nursing and starting points for effective measurement. Makes recommendations including supporting research and reflecting nursing's complexity and centrality in system design

Implementing Patient Acuity Scale on a Medical-Surgical Unit

Problem: Nurses commonly report dissatisfaction with their workload levels due to inequity of shift assignments. Imbalanced workload distribution has been shown to lead to missing or delayed care. Increased nursing workload has been linked to increased fall rates, healthcare associated infections, and avoidable deaths. Research has shown that patient classification is more accurate when an instrument is used. The purpose of this quality improvement project was to implement a patient acuity tool to aid nurse-patient shift assignments on a medical-surgical unit. The project aimed to provide a standardized and objective method of measuring patient acuity. Methods: The project took place on a 30-bed medical-surgical unit of a Midwest suburban hospital employing 26 registered nurses. Nurses were asked to complete a pre-intervention survey regarding nurse perception on workload distribution. During the eight week intervention period, nurses on the unit were asked to complete an acuity tool for each patient assigned to their care. According to the tool, each patient was assigned an acuity level 1-4. Charge nurses utilized patient acuity levels to balance workload in nurse-patient assignments for the oncoming shift. After the intervention period, nurses were asked to complete a survey assessing perception of workload distribution as well as satisfaction with acuity tool implementation. Results: Acuity tools were completed for every patient on the unit on 43% of shifts while no tools were completed on 42% of shifts. The average patient acuity on shifts with complete acuity information was 2.08. The average difference in nursing workload score range was 2.17. Significant increases were found in nursing perception of fair and even workload distribution (p=0.023) as well as the RN’s assessment of patient acuity being reflected in patient assignments (p=0.001). Nurses on the study unit found the acuity tool easy to use and effective at evenly distributing patient acuity. Implications for Practice: This project along with existing research indicates that the use of an objective acuity tool assists in distributing workload evenly with regards to nurse-patient assignments. Steps need to be made to increase compliance in order to experience the full benefits of acuity tool use. Increased education, surveillance, and leadership involvement could be beneficial to increase compliance

Implementation of a Patient Acuity Tool and the Impact on Nurse Satisfaction

Increased workloads contribute to nurse stress, affect nurse-patient relationships, and can ultimately lead to nurse turnover (O’Connell, Nettleton, Bunting, & Eichar, 2020). Nurse satisfaction can also be influenced by nurse-patient assignments (Allen, 2019). Implementation of a patient acuity tool (PAT) to balance workload and evenly distribute patient acuity in nurse-patient assignments can improve nurse job satisfaction, quality of care, and nurse retention (Firestone-Howard, Gonzalez, Dudjak, & Rader, 2017; Al-Dweik & Ahmad, 2019). Discussions were held on a 20-bed medical-surgical unit in an acute care hospital with stakeholders that included the nurse manager, charge nurses and bedside nurses at staff meetings and shift huddles regarding the implementation plan of the patient acuity tool (PAT) change project. The PAT was well received and a pilot phase for implementing a PAT was initiated. Pre-PAT survey data was obtained showing the need for a change in the way assignments were given. The PAT was successfully initiated and utilized for 4 weeks in which weekly discussions continued and feedback was obtained from the nurse staff. The implementation phase was abruptly shortened due to the unexpected closure of the unit due to impact of the Coronavirus pandemic. The post-PAT survey data and verbal feedback obtained from stakeholders was enough to identify a marked improvement in nurse satisfaction with nurse-patient assignments post-implementation of the PAT as well as the high frequency of usage of the tool. The results received support the notion that using a PAT for making nurse-patient assignments can positively influence nurse satisfaction. The data surprisingly identified additional unanticipated benefits to the unit including patient safety and quality of care

Nursing News & Views - Feburary 2019

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A Systematic Review of Acuity-Based Staffing in Acute Healthcare Environments

Nursing leadership is responsible for considering the equity of patient care assignments when providing nursing care. Nursing leadership is responsible for assuring the delivery of patient care assignments with the intent to offer nurses an unbiased, evenly distributed patient load. Effective distribution of patient care assignments ensures patients receive the safest, most efficient, and highest quality of care. The purpose of this project was to provide nursing leadership with an executive summary of a systematic review of evidence-based research on the structure and process of making patient care assignments, and it provided evidence on how those patient care assignments affect the quality of care provided to patients. The researcher conducted a systematic review of the literature to inform stakeholders about best practices used for acuity- based staffing. The systematic review of the literature involved using the PRISMA model as a structured assessment to screen and eliminate articles during the article search. All data from the systematic review were synthesized to collectively determine each acuity-based tool’s effects on patient care assignments within the acute care settings. The review of articles found that the implementation of acuity-based staffing tools in an acute care setting is associated with outcomes that included self-efficacy or retention, patient and nurse satisfaction, quality of care, and other additional findings. This systematic review of literature provided information to healthcare professionals about literature and the influence of implementing acuity-based staffing tools for patient care assignments in acute care settings. The project also included an implication of analysis for leaders and recommendations for change and future research