2.3 Tools for Prioritizing

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

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]

Scenario B

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.

Scenario C

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.

Scenario D

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.

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.

Scenario E

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.

Scenario F

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.

Scenario G

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.

Scenario H

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:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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]