NUR2832 Section 17 Leadership and Professional Identity (11 Weeks) – Online Plus – 2022 Winter Quarter
Module 05 Assignment – Scheduling and Staffing
Top of Form
Bottom of Form
Module 05 Content
1.
Top of Form
Scheduling and Staffing
Competency
Collaborate in healthcare delivery systems settings for improved patient outcomes.
Scenario
You are making a staffing assignment knowing that you are short-staffed. You have five registered nurses (RNs), two licensed practical nurses (LPNs), and two nursing assistants. Those nine employees need to provide a 12-hour shift of services to 30 clients with a high acuity required to a ratio of nurse to client at 1:3.
Client acuity level
·
Six acuity level 1
· Eight acuity level 2
· Nine acuity level 3
· Seven acuity level 4
You will use the acuity-based staffing model to develop the staffing assignment based on the needs of the clients. You will use the created template.
Instructions
As you create this assignment, include the following in an email to your manager to justify your short-staffing plan:
· Complete the staffing assignment based on the acuity level.
· Defend how you would direct the staff to their assigned roles for this shift and provide a rationale for the staffing assignment.
· Describe how you would communicate with each level of care provider to assure the best outcomes possible.
· Address how you would ensure client equity in the delivery of services.
· Provide stated ideas with professional language and attribution for credible sources with correct APA citation, spelling, and grammar.
·
· Resources
For assistance completing this assignment, review the article titled
Patient Acuity Model
.
Leadership and Professional Identity
Staff
ing Assignment Template
Staffing Available
· 5 RN
2
LPN 2
NA
·
30 patients
Acuity
Level 1 – 6 Patients
1. Room 2301 Susan is a 93-year-old who fell at home and is waiting for nursing home placement who uses a walker and requires assistance to the bathroom and ADLs
2. Room 2312 Fredrick is a 57-year-old who is recovering from a knee replacement who needs educational reinforcement and is going home today.
3. Room 2319 Joshua is a 63-year-old who was in for cardioversion and is going home today.
4. Room 2329 Brian is a 49-year-old who has been diagnosed with hypertension and Alzheimer’s Disease who wanders off the unit and needs assistance with ADLs.
5. Room 2304 James is a 95-year-old who has osteoarthritis and needs help getting out of bed, bathing, and dressing.
6. Room 2307 Francis is a 39-year-old who will be discharged today. She received discharge teaching yesterday about her ruptured appendix wound and wants to review the care instructions before she leaves.
Acuity Level 2 – 8 Patients
1. Room 2302 Brooke is a 33-year-old who was admitted with new-onset DM with uncontrolled blood sugars. She has started on new medications, including insulin, and needs additional patient and family education.
2. Room 2311 Mark is an 83-year-old who is on isolation for MRSA and is on IV antibiotics and ten other medications.
3. Room 2320 Jeffrey is a 63-year-old who is non-compliant with his medications and came in with hypertension and crackles in his lungs. He has daily labs and has a wound on his left foot.
4. Room 2330 Leslie is a 46-year-old who had unstable angina and had a cardiac catheterization yesterday late afternoon and stayed over for observation.
5. Room 2305 Traci is a 72-year-old who has a history of heart disease, a history of myocardial infarction, and mild dementia.
6. Room 2308 Alecia is a 33-year-old who was experiencing chest pain and is scheduled for a stress test later today.
7. Room 2303 Theodore is a 22-year-old who has had DM since he was a 10-years-old who requires medication adjustments.
8. Room 2318 Bruce is a 45-year-old who was placed on isolation for C-Diff and is on several IV mediations.
Acuity Level 3 – 9 Patients
1. Room 2306 Amelia is an 83-year-old after a stroke and requires total care.
2. Room 2313 Audrey is a 78-year-old with newly diagnosed COPD.
3. Room 2317 Abigail is a 90-year-old who is a diabetic with a chronic leg infection.
4. Room 2328 Roxanne is an 82-year-old with newly diagnosed lung cancer.
5. Room 2322 Nancy is a 56-year-old with chronic kidney disease and on peritoneal dialysis.
6. Room 2323 Dennis is a 35-year-old who was admitted with right upper quadrant pain that radiates to the right shoulder.
7. Room 2314 Roger is a 46-year-old who is wasted and malnourished. She has severe diarrhea.
8. Room 2309 Terry is a 59-year-old who has bladder cancer with painless hematuria.
9. Room 2310 Barry is a 54-year-old who has a history of mitral valve regurgitation.
Acuity Level 4 – 7 Patients
1. Room 2315 Karen is a 45-year-old who had an acute myocardial infarction with percutaneous coronary intervention.
2. Room 2321 Fredrick is a 43-year-old who was admitted after an overdose and required close monitoring.
3. Room 2327, Samantha is a 57-year-old with severe abdominal pain with no bowel sounds.
4. Room 2324 Robbie is a 62-year-old who has been vomiting and pain in the abdomen.
5. Room 2325 Jenny is a 58-year-old MVA who has a tracheostomy.
6. Room 2326 Annette is a 68-year-old who had a bowel resection and colostomy.
7. Room 2316, David is a 54-year-old with weakness and a decreased level of consciousness.
|
RN 1 |
RN 2 |
RN 3 |
RN 4 |
RN 5 |
|||||||||||||
|
Room # |
Acuity | ||||||||||||||||
|
LPN 1 |
LPN 2 |
CNA 1 |
CNA 2 |
Staff · 5 RN · 2 LPN · 2 CNA 30 patients · 6 acuity level 1 · 8 acuity level 2 · 9 acuity level 3 · 7 acuity level 4 |
|||||||||||||
06/16/2020
A
OFFICIAL NEWSLETTER
Volume 23 – Number 2
March/April 2014
Patient acuity has increased due to more complex patient populations. This objective,
quantitative tool is used to assign acuity ratings, adjust staffing ratios, assign
appropriate skill mix, and balance workload to maximize safe, effective care.
A 148-bed community hospital, which is part of a large academic health system, has seen
physician specialists admit more complex patient cases to a 36-bed medical-surgical unit
over the past few years. The usual census in the past included patients who had experienced
an appendectomy, hysterectomy, or cholecystectomy. Many of these patients are now dis-
charged from the outpatient surgery service. Today, the population on this unit includes
patients who have undergone a thoracotomy with placement of multiple chest tubes, multi-
level spinal fusion, and laminectomy, patients recovering from cranio-neurosurgical proce-
dures, and patients of prostatectomy and urologic reconstruction surgeries. The “overnight
observation” patients are now bariatric surgery patients with precise regimens to follow or
bilateral mastectomy patients.
The nurses on this medical-surgical unit began to feel the impact of the increase in
patient acuity while their staffing ratios remained the same. They also felt an imbalance in
workload among the team at times when the assignments did not accurately reflect patient
acuity nor balance the skill mix of the staff.
Charge nurses, who made the nurse-patient assignments for each 12-hour shift,
attempted to balance the workload by using a subjective evaluation of patient acuity and the
unit’s nursing skill mix. Assignments were often made under time-pressure and with limited
information. The staff nurses requested a more objective and equitable way of defining acuity
ratings to promote safer patient care. The unit’s Clinical Nurse Specialist and Nurse Manager
were supportive and felt it important to advocate for the nurses and their patients.
continued on page
9
INSIDE THIS ISSUE
Nutrition to Improve Outcomes: Healthy to Undernourished: Post-Hospital Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Nursing Management of Constipation in the Medical-Surgical Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Strategies for Nurse Educators: Restructuring the New Nurse Orientation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Drug Update: NSAIDs: Is Naproxen the Safest Choice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
CNE
9
866-877-2676 Volume 23 – Number 2
… Israel, R.J. (2008). Subcutaneous
methylnaltrexone for treatment of opi-
oid-induced constipation in patients with
advanced illness: A double-blind, random-
ized, parallel group, dose-ranging study.
Journal of Pain and Symptom Management,
35(5), 458-468.
Rao, S. (2009). Constipation: Evaluation and
treatment of colonic and anorectal
motility disorders. Gastrointestinal
Endoscopy Clinics of North America, 19(1)
117-139.
Rao, S.S., & Go, J.T. (2009). Treating pelvic floor
disorders of defecation: Management or
cure? Current Gastroenterology Report,
11(4), 278-287.
Rao, S.S., & Go, J.T. (2010). Update on the man-
agement of constipation in the elderly:
New treatment options. Clinical
Interventions in Aging, 5, 163-171.
Sakharpe, A., Lee, Y., Park G., & Dy, V. (2012).
Stercoral perforation requiring subtotal
colectomy in a patient on methadone
maintenance therapy. Case Reports in
Surgery. doi:10.1155/2012/176143
Tack, J., & Müller-Lissner, S. (2009). Treatment
of chronic constipation: Current phar-
macologic approaches and future direc-
tions. Clinical Gastroenterology and
Hepatology, 7(5), 502-508.
Tack, J., Müller-Lissner, S., Stanghellini, V.,
Boeckxstaens, G., Kamm, M., Simren, M.,
… Fried, M. (2011). Diagnosis and treat-
ment of chronic constipation – A
European perspective. Neurogastro-
enterology & Motility, 23(8), 697-710.
Additional Reading
Higgins, D. (2006). How to administer an
enema. Nursing Times, 102(20), 24.
Literature Review
A literature search completed in
CINAHL® used the search terms
patient classification, clinical assess-
ment, and acuity score for the year
2004 and forward. Articles were exam-
ined for relevance to our setting and
resources. For instance, methods using
proprietary software were reviewed
for concepts but not considered for
implementation.
Twigg and Duffield (2009) agreed
that nurse workload is difficult to
define and measure, yet necessary to
ensure adequate staffing for safe patient
care. They reviewed methods of deter-
mining nursing workload that have
been used historically and agreed that it
remains a complex process.
Brennan and Daly (2009) cited
tools that have been used to determine
patient acuity, yet agreed that there is
inconsistency in how acuity is defined
and measured. They agreed that meas-
urement of patient acuity should incor-
porate patient severity of illness and
nursing workload factors.
Figure 1.
Original 20 Categories and Final 10 Categories
Tamburro, West, Piercy, Towner,
and Fang (2004) found that the nursing
acuity score for pediatric oncology
intensive care patients predicted sur-
vival and affirmed the insight of the
bedside nurse in assessing severity of
illness. Although their patient popula-
tion was different, the acuity system
they developed that used both clinical
severity and nursing workload indica-
tors provided guidance in the develop-
ment of our tool. Friese, Earle, Silber,
and Aiken (2010) related certain clinical
severity scores to patient mortality.
Brewer (2006) combined and refined
over 30 variables into 16 acuity charac-
teristics. Our tool incorporated patient
characteristics used by Brewer, such as
respiratory and cardiac management,
isolation status, activities of daily living,
and wound management. Brewer’s
methodology of consolidating variables
was used to influence the design of our
acuity tool.
Rauhala and Fagerström (2004)
discussed the RAFAELA system, a
mnemonic they created, comparing
patient acuity with nurse resources. The
RAFAELA system assigns points based
Patient Acuity Tool
continued from page 1
Special Issue of
MedSurg Matters! to
Focus on Education
The July/August issue of
MedSurg Matters! will have an
emphasis on nursing education.
Explored topics will include: educa-
tion initiatives based on the Institute
of Medicine’s Future of Nursing
report, collaborative learning and
the professional growth of student
nurses, and emerging roles for
nurses after health care reform.
Keep an eye on your mailbox this
summer for this exciting theme
issue.
Academy of Medical-Surgical Nurses www.amsn.org
10
on care intensity for patient needs and
uses the Professional Assessment of
Optimal Nursing Care Intensity Level
(PAONCIL) tool, which establishes
optimal nursing intensity per caregiver.
The RAFAELA system – used primarily
in Finland for outpatient departments,
psychiatric nursing care, primary health
care, and long-term or home care –
was complicated to use and not appli-
cable to our patient population.
DeLisle (2009) found that using an
acuity tool representative of patient
status and clinical intensity could be
used to assist in equitable distribution
of nursing workload. The acuity tool
rated patients a Level I-V based on
nursing time required to administer
chemotherapy in an outpatient ambula-
tory oncology unit. Although this was
not our patient population, this infor-
mation was helpful in considering clini-
cal severity and nursing workload indi-
cators in determining acuity and making
patient assignments.
The literature was helpful in stimu-
lating discussion about how to define
acuity, but a specific patient acuity
assessment tool appropriate for our
medical-surgical patient population was
not found.
Using input from staff nurses, the
authors set out to develop a compre-
hensive acuity assessment tool that
could be used objectively and consis-
tently by the staff. The intention was to
utilize this tool to make appropriate
patient assignments and balance the
unit workload to maximize safe, effec-
tive patient care.
Method
The authors held roundtable dis-
cussions that were open to all staff on
the unit over a period of several
months. Discussions included “what
defines acuity” and “how to differenti-
ate levels of acuity.” The team talked
about what “counts” – illness of the
patient or how much nursing time is
required to care for them or both.
What about the psychological “work”
of dealing with an anxious, upset, or
confused patient?
At first, the proposed acuity tool
had 20 categories (see Figure 1). The
number of categories and descriptors
were refined over a period of eight
weeks by the researchers with input
from the nurses and manager. Through
discussions and continual assessment of
the patient population, the team was
able to refine descriptors that identified
different levels of acuity. After ten revi-
sions, the final tool consisted of 10 cat-
egories – six related to patient clinical
severity and four related to nurse
workload (see Figure 2).
Figure 2.
Final Acuity Tool
11
866-877-2676 Volume 23 – Number 2
Using the tool, a typical, uncompli-
cated postoperative patient was rated a
2.A complex surgical patient with more
extensive care needs was a 3, and a
patient at high risk for a decline in sta-
tus or requiring frequent nursing care
or assessment would have a 4 rating.
Patients were rated a 2, 3, or 4 in each
of the ten categories. For example, in
the respiratory category, a stable
laparoscopic cholecystectomy patient
might need oxygen per nasal cannula at
2 liters per minute (lpm) for the first 24
hours due to the carbon dioxide gas
used to inflate the abdomen during the
procedure and would be identified as a
2. A patient requiring oxygen support
above 2 lpm per nasal cannula, perhaps
due to cardiac status would be a 3. A
patient with decompensating respira-
tory status requiring a full-face oxygen
mask would have a 4 rating.
Results
Content validity was verified using
the input of the nursing staff and man-
ager during the ten design and revision
meetings. The resulting acuity tool was
Figure 3.
Results – Subjective, Validation, and Implementation
piloted and validated for usability and
feasibility on all shifts at varying times
and days of the week. During this
phase, a total of 40 nurses assessed 183
patients. Patients were scored in each
of the ten categories. Initially, raw
scores were used and converted to an
overall acuity rating of 2, 3, or 4.
Refinement of the tool showed that a
score of 3 for any category gave the
patient a final 3 acuity rating, and a 4
score in any category gave a final 4 rat-
ing. This refinement eliminated the need
to perform mathematical calculations
and greatly reduced the complexity of
use. Acuity ratings using the tool were
then compared to ratings assigned by
charge nurses using their traditional,
subjective method.
During the trial period, the charge
nurses rated 51% of patients as 2 and
49% of patients as 3 (none of the
patients received a 4). When nurses
used the new tool for the same
patients concurrently, 32% of patients
were a 2, 53% were a 3, and 15%
were a 4 rating (see Figure 3). These
ratings reflected the nurses’ percep-
tions of their patients’ acuity. There
was agreement among management
and the researchers that nurses were
not overstating the number of high-
acuity patients.
Implementation
The next phase was to implement
the new acuity tool. Beginning July 18,
2011, each nurse rated his or her
patients’ acuity using the tool. During
this phase, 43 nurses rated 488
patients. Data revealed that 51% of the
patients received an acuity rating of 2,
38% received a 3 rating, and 12%
received a 4 rating (see Figure 3). Data
collected using the objective tool
showed that our previous subjective
method failed to identify high-acuity
patients.
Acuity indicators were analyzed to
determine frequencies of occurrence
(see Figure 4). The most frequently
occurring driver for a patient rating of
4 was activities of daily living and isola-
tion (for example, the care required for
a paraplegic and a quadraplegic postop-
erative patient due to nursing work-
load). The second most common driver
Figure 4.
Drivers of Acuity by Category
Academy of Medical-Surgical Nurses www.amsn.org
12
Figure 5.
Sample Unit Assignment Based on Patient Acuity and Nurse Experience
for a 4 was wound/ostomy (for exam-
ple, a high-output ileostomy patient
requiring frequent monitoring of out-
put volume, site leakage, and fluid/elec-
trolyte imbalance). The top drivers for
an acuity rating of 3 were activities of
daily living, patient’s isolation status, and
admit/discharge/transfer.
The acuity ratings completed by
nurses are now given to charge nurses
to make the assignment for the oncom-
ing shift. The typical nurse-patient ratio
of 5:1 is adjusted to 4:1 if a nurse has a
patient with a rating of 4. Novice nurses
are assigned patients with acuity ratings
of 2 or 3, and assignments are balanced
to distribute the unit workload (see
Figure 5).
Discussion
This tool incorporates clinical
severity and nurse workload indicators
to determine acuity and is used to
make patient assignments in alignment
with appropriate skill mix and staffing
ratios. Nurses supported having an
objective tool to use in assessing
patient acuity to provide safe care,
adjust staffing ratios, and balance unit
workload. Experienced nurses were
assigned higher acuity patients. The
chief nursing officer, operation adminis-
trators, and nurse manager support
using the new acuity tool to adjust
staffing ratios each shift according to
patient needs.
The advantages of the tool are
simplicity, cost, and customization. The
tool does not require complex docu-
mentation (i.e., any 4 is a 4) and
requires about ten seconds per patient
per shift to complete. It does not
require expensive information technol-
ogy support. Finally, the tool is easily
adapted to the unique needs of any
patient population.
Conclusions
Our experience illustrates that the
use of the collaboration process by
management and staff nurses can lead
to the development of an objective,
quantitative acuity tool to assign patient
acuity to medical-surgical patients. This
unit used this tool to effectively deter-
mine nurse-patient ratios and develop a
safer nursing workload. Currently, the
authors are mentoring other units at
our hospital to facilitate the develop-
ment of an acuity tool for their patient
populations.
References
Brennan, C.W., & Daly, B.J. (2009). Patient acu-
ity: A concept analysis. Journal of Advanced
Nursing, 65, 1114-1126.
Brewer, B.B. (2006). Is patient acuity a proxy
for patient characteristics of the AACN
Synergy Model for Patient Care? Nursing
Administration Quarterly, 30(4), 351-357.
DeLisle, J. (2009). Designing an acuity tool for
an ambulatory oncology setting. Clinical
Journal of Oncology Nursing, 13(1), 45-50.
Friese, C.R., Earle, C.C., Silber, J.H., & Aiken,
L.H. (2010). Hospital characteristics, clin-
ical severity, and outcomes for surgical
oncology patients. Surgery, 147(5), 602-
609. doi:10.1016/j.surg.2009.03.014
Rauhala, A., & Fagerström, L. (2004).
Determining optimal nursing intensity:
The RAFAELA method. Journal of
Advanced Nursing, 45(4), 351-359.
Tamburro, R.F., West, N.K., Piercy, J., Towner, G.,
& Fang, H. (2004). Use of the nursing acu-
ity score in children admitted to a pedi-
atric oncology intensive care unit.
Pediatric Critical Care Medicine, 5(1), 35-
39.
Twigg, D., & Duffield, C. (2009). A review of
workload measures: A context for a new
staffing methodology in Western
Australia. International Journal of Nursing
Studies, 46, 132-140.
Kathy Chiulli, MSN, RN, CMSRN,
was a Medical-Surgical Clinical Nurse
Specialist, Inpatient Medical-Surgical
Units, Duke Raleigh Hospital, Raleigh, NC,
at the time this article was written.
Jackie Thompson, MSN, RN,
CMSRN, was a Stroke Coordinator,
Duke Raleigh Hospital, Raleigh, NC, at the
time this article was written.
Kristi L. Reguin-Hartman, BSN,
RN, was an Education Resource
Specialist, WakeMed Hospital, Raleigh,
NC, at the time this article was written.
Copyright of Med-Surg Matters is the property of Jannetti Publications, Inc. and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder’s express written permission. However, users may print, download, or email articles for
individual use.
A
OFFICIAL NEWSLETTER
Volume 23 – Number 2
March/April 2014
Patient acuity has increased due to more complex patient populations. This objective,
quantitative tool is used to assign acuity ratings, adjust staffing ratios, assign
appropriate skill mix, and balance workload to maximize safe, effective care.
A 148-bed community hospital, which is part of a large academic health system, has seen
physician specialists admit more complex patient cases to a 36-bed medical-surgical unit
over the past few years. The usual census in the past included patients who had experienced
an appendectomy, hysterectomy, or cholecystectomy. Many of these patients are now dis-
charged from the outpatient surgery service. Today, the population on this unit includes
patients who have undergone a thoracotomy with placement of multiple chest tubes, multi-
level spinal fusion, and laminectomy, patients recovering from cranio-neurosurgical proce-
dures, and patients of prostatectomy and urologic reconstruction surgeries. The “overnight
observation” patients are now bariatric surgery patients with precise regimens to follow or
bilateral mastectomy patients.
The nurses on this medical-surgical unit began to feel the impact of the increase in
patient acuity while their staffing ratios remained the same. They also felt an imbalance in
workload among the team at times when the assignments did not accurately reflect patient
acuity nor balance the skill mix of the staff.
Charge nurses, who made the nurse-patient assignments for each 12-hour shift,
attempted to balance the workload by using a subjective evaluation of patient acuity and the
unit’s nursing skill mix. Assignments were often made under time-pressure and with limited
information. The staff nurses requested a more objective and equitable way of defining acuity
ratings to promote safer patient care. The unit’s Clinical Nurse Specialist and Nurse Manager
were supportive and felt it important to advocate for the nurses and their patients.
continued on page
9
INSIDE THIS ISSUE
Nutrition to Improve Outcomes: Healthy to Undernourished: Post-Hospital Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Nursing Management of Constipation in the Medical-Surgical Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Strategies for Nurse Educators: Restructuring the New Nurse Orientation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Drug Update: NSAIDs: Is Naproxen the Safest Choice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
CNE
9
866-877-2676 Volume 23 – Number 2
… Israel, R.J. (2008). Subcutaneous
methylnaltrexone for treatment of opi-
oid-induced constipation in patients with
advanced illness: A double-blind, random-
ized, parallel group, dose-ranging study.
Journal of Pain and Symptom Management,
35(5), 458-468.
Rao, S. (2009). Constipation: Evaluation and
treatment of colonic and anorectal
motility disorders. Gastrointestinal
Endoscopy Clinics of North America, 19(1)
117-139.
Rao, S.S., & Go, J.T. (2009). Treating pelvic floor
disorders of defecation: Management or
cure? Current Gastroenterology Report,
11(4), 278-287.
Rao, S.S., & Go, J.T. (2010). Update on the man-
agement of constipation in the elderly:
New treatment options. Clinical
Interventions in Aging, 5, 163-171.
Sakharpe, A., Lee, Y., Park G., & Dy, V. (2012).
Stercoral perforation requiring subtotal
colectomy in a patient on methadone
maintenance therapy. Case Reports in
Surgery. doi:10.1155/2012/176143
Tack, J., & Müller-Lissner, S. (2009). Treatment
of chronic constipation: Current phar-
macologic approaches and future direc-
tions. Clinical Gastroenterology and
Hepatology, 7(5), 502-508.
Tack, J., Müller-Lissner, S., Stanghellini, V.,
Boeckxstaens, G., Kamm, M., Simren, M.,
… Fried, M. (2011). Diagnosis and treat-
ment of chronic constipation – A
European perspective. Neurogastro-
enterology & Motility, 23(8), 697-710.
Additional Reading
Higgins, D. (2006). How to administer an
enema. Nursing Times, 102(20), 24.
Literature Review
A literature search completed in
CINAHL® used the search terms
patient classification, clinical assess-
ment, and acuity score for the year
2004 and forward. Articles were exam-
ined for relevance to our setting and
resources. For instance, methods using
proprietary software were reviewed
for concepts but not considered for
implementation.
Twigg and Duffield (2009) agreed
that nurse workload is difficult to
define and measure, yet necessary to
ensure adequate staffing for safe patient
care. They reviewed methods of deter-
mining nursing workload that have
been used historically and agreed that it
remains a complex process.
Brennan and Daly (2009) cited
tools that have been used to determine
patient acuity, yet agreed that there is
inconsistency in how acuity is defined
and measured. They agreed that meas-
urement of patient acuity should incor-
porate patient severity of illness and
nursing workload factors.
Figure 1.
Original 20 Categories and Final 10 Categories
Tamburro, West, Piercy, Towner,
and Fang (2004) found that the nursing
acuity score for pediatric oncology
intensive care patients predicted sur-
vival and affirmed the insight of the
bedside nurse in assessing severity of
illness. Although their patient popula-
tion was different, the acuity system
they developed that used both clinical
severity and nursing workload indica-
tors provided guidance in the develop-
ment of our tool. Friese, Earle, Silber,
and Aiken (2010) related certain clinical
severity scores to patient mortality.
Brewer (2006) combined and refined
over 30 variables into 16 acuity charac-
teristics. Our tool incorporated patient
characteristics used by Brewer, such as
respiratory and cardiac management,
isolation status, activities of daily living,
and wound management. Brewer’s
methodology of consolidating variables
was used to influence the design of our
acuity tool.
Rauhala and Fagerström (2004)
discussed the RAFAELA system, a
mnemonic they created, comparing
patient acuity with nurse resources. The
RAFAELA system assigns points based
Patient Acuity Tool
continued from page 1
Special Issue of
MedSurg Matters! to
Focus on Education
The July/August issue of
MedSurg Matters! will have an
emphasis on nursing education.
Explored topics will include: educa-
tion initiatives based on the Institute
of Medicine’s Future of Nursing
report, collaborative learning and
the professional growth of student
nurses, and emerging roles for
nurses after health care reform.
Keep an eye on your mailbox this
summer for this exciting theme
issue.
Academy of Medical-Surgical Nurses www.amsn.org
10
on care intensity for patient needs and
uses the Professional Assessment of
Optimal Nursing Care Intensity Level
(PAONCIL) tool, which establishes
optimal nursing intensity per caregiver.
The RAFAELA system – used primarily
in Finland for outpatient departments,
psychiatric nursing care, primary health
care, and long-term or home care –
was complicated to use and not appli-
cable to our patient population.
DeLisle (2009) found that using an
acuity tool representative of patient
status and clinical intensity could be
used to assist in equitable distribution
of nursing workload. The acuity tool
rated patients a Level I-V based on
nursing time required to administer
chemotherapy in an outpatient ambula-
tory oncology unit. Although this was
not our patient population, this infor-
mation was helpful in considering clini-
cal severity and nursing workload indi-
cators in determining acuity and making
patient assignments.
The literature was helpful in stimu-
lating discussion about how to define
acuity, but a specific patient acuity
assessment tool appropriate for our
medical-surgical patient population was
not found.
Using input from staff nurses, the
authors set out to develop a compre-
hensive acuity assessment tool that
could be used objectively and consis-
tently by the staff. The intention was to
utilize this tool to make appropriate
patient assignments and balance the
unit workload to maximize safe, effec-
tive patient care.
Method
The authors held roundtable dis-
cussions that were open to all staff on
the unit over a period of several
months. Discussions included “what
defines acuity” and “how to differenti-
ate levels of acuity.” The team talked
about what “counts” – illness of the
patient or how much nursing time is
required to care for them or both.
What about the psychological “work”
of dealing with an anxious, upset, or
confused patient?
At first, the proposed acuity tool
had 20 categories (see Figure 1). The
number of categories and descriptors
were refined over a period of eight
weeks by the researchers with input
from the nurses and manager. Through
discussions and continual assessment of
the patient population, the team was
able to refine descriptors that identified
different levels of acuity. After ten revi-
sions, the final tool consisted of 10 cat-
egories – six related to patient clinical
severity and four related to nurse
workload (see Figure 2).
Figure 2.
Final Acuity Tool
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Using the tool, a typical, uncompli-
cated postoperative patient was rated a
2.A complex surgical patient with more
extensive care needs was a 3, and a
patient at high risk for a decline in sta-
tus or requiring frequent nursing care
or assessment would have a 4 rating.
Patients were rated a 2, 3, or 4 in each
of the ten categories. For example, in
the respiratory category, a stable
laparoscopic cholecystectomy patient
might need oxygen per nasal cannula at
2 liters per minute (lpm) for the first 24
hours due to the carbon dioxide gas
used to inflate the abdomen during the
procedure and would be identified as a
2. A patient requiring oxygen support
above 2 lpm per nasal cannula, perhaps
due to cardiac status would be a 3. A
patient with decompensating respira-
tory status requiring a full-face oxygen
mask would have a 4 rating.
Results
Content validity was verified using
the input of the nursing staff and man-
ager during the ten design and revision
meetings. The resulting acuity tool was
Figure 3.
Results – Subjective, Validation, and Implementation
piloted and validated for usability and
feasibility on all shifts at varying times
and days of the week. During this
phase, a total of 40 nurses assessed 183
patients. Patients were scored in each
of the ten categories. Initially, raw
scores were used and converted to an
overall acuity rating of 2, 3, or 4.
Refinement of the tool showed that a
score of 3 for any category gave the
patient a final 3 acuity rating, and a 4
score in any category gave a final 4 rat-
ing. This refinement eliminated the need
to perform mathematical calculations
and greatly reduced the complexity of
use. Acuity ratings using the tool were
then compared to ratings assigned by
charge nurses using their traditional,
subjective method.
During the trial period, the charge
nurses rated 51% of patients as 2 and
49% of patients as 3 (none of the
patients received a 4). When nurses
used the new tool for the same
patients concurrently, 32% of patients
were a 2, 53% were a 3, and 15%
were a 4 rating (see Figure 3). These
ratings reflected the nurses’ percep-
tions of their patients’ acuity. There
was agreement among management
and the researchers that nurses were
not overstating the number of high-
acuity patients.
Implementation
The next phase was to implement
the new acuity tool. Beginning July 18,
2011, each nurse rated his or her
patients’ acuity using the tool. During
this phase, 43 nurses rated 488
patients. Data revealed that 51% of the
patients received an acuity rating of 2,
38% received a 3 rating, and 12%
received a 4 rating (see Figure 3). Data
collected using the objective tool
showed that our previous subjective
method failed to identify high-acuity
patients.
Acuity indicators were analyzed to
determine frequencies of occurrence
(see Figure 4). The most frequently
occurring driver for a patient rating of
4 was activities of daily living and isola-
tion (for example, the care required for
a paraplegic and a quadraplegic postop-
erative patient due to nursing work-
load). The second most common driver
Figure 4.
Drivers of Acuity by Category
Academy of Medical-Surgical Nurses www.amsn.org
12
Figure 5.
Sample Unit Assignment Based on Patient Acuity and Nurse Experience
for a 4 was wound/ostomy (for exam-
ple, a high-output ileostomy patient
requiring frequent monitoring of out-
put volume, site leakage, and fluid/elec-
trolyte imbalance). The top drivers for
an acuity rating of 3 were activities of
daily living, patient’s isolation status, and
admit/discharge/transfer.
The acuity ratings completed by
nurses are now given to charge nurses
to make the assignment for the oncom-
ing shift. The typical nurse-patient ratio
of 5:1 is adjusted to 4:1 if a nurse has a
patient with a rating of 4. Novice nurses
are assigned patients with acuity ratings
of 2 or 3, and assignments are balanced
to distribute the unit workload (see
Figure 5).
Discussion
This tool incorporates clinical
severity and nurse workload indicators
to determine acuity and is used to
make patient assignments in alignment
with appropriate skill mix and staffing
ratios. Nurses supported having an
objective tool to use in assessing
patient acuity to provide safe care,
adjust staffing ratios, and balance unit
workload. Experienced nurses were
assigned higher acuity patients. The
chief nursing officer, operation adminis-
trators, and nurse manager support
using the new acuity tool to adjust
staffing ratios each shift according to
patient needs.
The advantages of the tool are
simplicity, cost, and customization. The
tool does not require complex docu-
mentation (i.e., any 4 is a 4) and
requires about ten seconds per patient
per shift to complete. It does not
require expensive information technol-
ogy support. Finally, the tool is easily
adapted to the unique needs of any
patient population.
Conclusions
Our experience illustrates that the
use of the collaboration process by
management and staff nurses can lead
to the development of an objective,
quantitative acuity tool to assign patient
acuity to medical-surgical patients. This
unit used this tool to effectively deter-
mine nurse-patient ratios and develop a
safer nursing workload. Currently, the
authors are mentoring other units at
our hospital to facilitate the develop-
ment of an acuity tool for their patient
populations.
References
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ity: A concept analysis. Journal of Advanced
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Brewer, B.B. (2006). Is patient acuity a proxy
for patient characteristics of the AACN
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Kathy Chiulli, MSN, RN, CMSRN,
was a Medical-Surgical Clinical Nurse
Specialist, Inpatient Medical-Surgical
Units, Duke Raleigh Hospital, Raleigh, NC,
at the time this article was written.
Jackie Thompson, MSN, RN,
CMSRN, was a Stroke Coordinator,
Duke Raleigh Hospital, Raleigh, NC, at the
time this article was written.
Kristi L. Reguin-Hartman, BSN,
RN, was an Education Resource
Specialist, WakeMed Hospital, Raleigh,
NC, at the time this article was written.
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