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A New Patient Acuity Tool to Support Equitable Patient Assignments in a Progressive Care Unit


Making fair and equitable staffing decisions and patient assignments created complexities and undue nursing dissatisfaction on a 20-bed progressive care unit. Common themes shared by the nursing staff included inadequate staffing ratios, increased workload, and unease for patient safety. On the basis of these concerns, a unit-based needs assessment provided insight into what perceived and actual barriers exist preventing nurses from providing excellent care. Information gathered helped determine what could be done to overcome some barriers, and performing a comprehensive unit profile assessment allowed for better insight into how the unit was currently functioning. A comprehensive review of literature was undertaken to examine articles related to patient acuity utilizing the electronic databases CINAHL, PubMed, and MEDLINE. Key words and phrases included the following: acuity, patient acuity, acuity tools, progressive care acuity, nurse-patient assignment, workload, nursing assignments, and equitable staffing. Utilizing the results of the nurse survey, and information gained from articles gathered during the literature review, a patient acuity tool was created. The tool was believed to be an accurate representation of the patients' acuity, and the majority of charge nurses reported that they utilized the patient acuity tool score when making nurse-patient assignments. Overall staff satisfaction and perceptions of nurse-patient assignment equity were improved.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

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8 Steps for Making Effective Nurse-Patient Assignments

Staff Writer

This article appears on page 14 of

South Dakota Nurse November 2018

opens in a new window

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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making fair nursing assignments

Patient acuity tool on a medical-surgical unit

patient acuity tool medical surgical unit ant

Use a tool for consistent, objective, and quantifiable patient assignments.

By Andrea Ingram, BSN, RN-BC, and Jennifer Powell, BSN, RN

When a patient refuses a nurse assignment

8 steps for making effective nurse-patient assignments

Using technology to make evidence-based staffing assignments

patient acuity tool medical surgical unit

In 2016, three RNs on a complex 23-bed medical-surgical unit at Durham VA Health Care System identified a recurring complaint by nursing staff that patient assignments were inconsistent and unequal. An average of five RNs and one charge nurse were assigned five patients per nurse per shift. The nursing assignment system included placing patients in one of two categories: “standard patient” or “involved care” patient. The problem was the subjectivity of these terms; they had no supporting evidence. The result was frustrated nurses, which prompted the unit to develop a process improvement project.

Purpose and goals

We used evidence-based information to create an objective acuity tool to establish patient assignments. The tool uses both clinical patient characteristics and workload indicators to score patients from 1 to 4 based on acuity level. This approach gives nurses the power to score their patient, then report to the charge nurse so that RN assignments for the oncoming shift are quantifiable and equitable. It also gives them the opportunity to assess the level of patient safety risk.

The goals of the tool are to:

The patient acuity tool

Each patient is scored on a 1-to-4 scale (1, stable patient; 2, moderate-risk patient; 3, complex patient; 4, high-risk patient) based on the clinical patient characteristics and the care involved (workload.) Each nurse scores his or her patients, based on acuity, for the upcoming shift and relays this information to the charge nurse, who then assigns patients before the shift change. The handoff report between RNs allows each to validate patients’ current acuity and care needs. (See Patient acuity tool .)

patient acuity tool medical surgical unit sidebar clinical characteristics


Anecdotal reports by the RN staff and our observations prompted the collection of data from staff. Some of the staff comments about the current system included:

We conducted a literature review and eventually combined two existing tools and restructured them to create our acuity tool. Before implementing the process improvement project, we used the newly created tool to assess the current average distribution of total acuity among nurse assignments, and we asked RNs to complete a 10-question survey to measure their satisfaction with patient assignments and perceptions of patient safety. We then taught the RNs how to use the tool and placed color-coded, laminated copies at every nursing computer.

The tool was pilot tested for 28 days. After the first 14 days, we conducted an audit to assess compliance, which revealed that average compliance among all four shifts was 35%. We then collected data on the average distribution of total acuity among nurse assignments. Progress e-mails were sent to staff, and individual follow-ups were held to promote compliance. At the end of the 28 days, we conducted another compliance audit, which revealed an average compliance among all four shifts of 77%, an increase of 220%.

At the end of the pilot study, we reviewed patient assignments before and after implementing the acuity tool to assess their equality, and we surveyed RNs about the two goals we set for the project: improve nurse satisfaction and increase nurse perception of patient safety.

Equality of patient assignments

To determine the equality of nurses’ assignments within a shift, the difference in total acuity between the highest and lowest scoring assignments was obtained. (See RN assignments using acuity tool .)

patient acuity tool medical surgical unit sidebar rn assignments

Before implementing the acuity tool, the average distribution of total acuity between highest and lowest nurse assignments for each shift was 4.83 (using a scale of 1 = lowest acuity and 4 = highest acuity). After implementation, the average distribution of total acuity between highest and lowest nurse assignments was 3.06, a 36.6% improvement in equality and accuracy.

Goal 1: Improve nurse satisfaction

Three of the 10 questions in the nurse survey were aimed at nurse satisfaction, including RN perception of patient assignment equality, having input into making assignments, and frequency of feeling overwhelmed with patient assignments. The most significant change occurred with the question “Please rate how frequently you feel overwhelmed with your patient assignment.” Response options were never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). According to the survey, the weighted average of nurse satisfaction was 3.19 before implementing the acuity tool and 2.84 (11% improvement) after.

Goal 2: Increase nurse perception of patient safety 

When asked to respond to the statement “I feel like patient safety is a concern when I accept my patient assignment,” RN staff chose from the following options: never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). The weighted average was 3.38 pre-implementation and 3.21 post-implementation, a 5% improvement in RNs’ perception of patient safety. After reviewing the annual performance improvement data, we found no direct correlation between using the acuity tool and patient safety measurements (rate of falls, medication errors, and restraint use). However, by distributing high-acuity patients among nurses, this tool, used in conjunction with other current actions, can reduce the need for patient safety measures such as using sitters and frequent rounding.

We attributed many of the challenges faced during the implementation of this project to staff assignment changes during some 24-hour periods. Sometimes patient assignments changed every 4 hours because of differences in nurse shift length, which left the staff with no consistent communication between shifts. The charge nurse would also occasionally take a patient assignment when patient acuity was high and RN census was low, resulting in outliers in data.

Another challenge included RN staff changes during the pilot study, leading to gaps in education about proper use of the tool, decreased feedback, and less data in post-implementation than pre-implementation. As part of our sustainment plan, we’ll incorporate education on the tool in new staff orientation, adapt it to other medical-surgical units in the hospital, and continue quarterly audits to assess compliance.

Given the original concern by staff that assignments were unequal, one of the strengths of this acuity tool is that it allows nurses to become stakeholders in making patient assignments. In addition, it also gives the charge nurse an objective way to justify assignment rationale. The tool costs no money to implement and requires no special technology. In addition, it’s noninvasive to the unit’s workflow, easy to implement, and easily adapted to different units and their specific needs. We’ve also found that the tool enhances the shift-to-shift handoff report and that it can be used to assign patients based on nurse competence (novice nurses, expert nurses, etc.).

Striking a balance

The patient acuity tool addresses the important issue of unbalanced nurse-patient assignments and helps nurses influence decision-making in their organizations. Our research found that an objective patient acuity tool on a medical-surgical floor could increase assignment equality, improve nurse satisfaction, and improve nurse perception of patient safety. The tool is now being piloted on other units at this facility, and we’ve received consults from other facilities in the Veterans Affairs Health Care System.

Andrea Ingram is a medical-surgical certified nurse at the VA Health Care System in Durham, North Carolina. Jennifer Powell is a neonatal intensive care unit nurse at Novant Health Hemby Children’s Hospital in Charlotte, North Carolina.

Selected references

Chiulli KA, Thompson J, Reguin-Hartman KL. Development and implementation of a patient acuity tool for a medical-surgical unit . Academy of Medical-Surgical Nurses. 2014;23(2):1, 9-12.

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

23 Comments . Leave new

would like to know more about this classification tool, is it still in use or has it been revised? can it be used without copywrite restrictions? is it electronically available

Yes, you can use it but must source the tool appropriately.

I am interested to know how to utilize this acuity tool. I have several nurses complain about assignments, this might be something that our unit could utilize to better assignments.

My name is Tijuana L Parker and we want to use your tool on our unit to see if we can balance the assignments better and improve nurse satisfaction.

Hi Mrs. Andrea Ingram, and Jennifer Powell,

I would like to ask if there is any educational material on how di you roll out your acuity tool.

Dear Mrs. Andrea Ingram, and Jennifer Powell

My name is Myriam Valdema, a DNP student. Thank you for such a fantastic study. I am writing my final project on a patient-acuity tool’s effect on job satisfaction in a medical-surgical Unit. We are currently using the block method to make assignments, and it is not working well for the nurses. With your permission, I would like to use the tool to provide better patient assignments while improving patients’ safety.

Sincerely, Myriam Valdema BSN, RN

Thank you for the great article Andrea Ingram and Jennifer Powell. I am writing to seek permission to reuse the tool for our tertiary hospital. Let me know the psychometric properties of the tool or Has it been tested for validity and reliability. Sincerely Dr.Asha Raj Sudha

Dear Mrs. Andrea Ingram, and Jennifer Powell, Thank you for a very intersting study. We are interested in implementing it in our hospital. May we ask : 1) Is it applicable to all types of patient population or restricted to medical surgical as the the title of the article suggests? 2) Has it been tested for validity and reliability and can be safely used to assess the patients acuity. 3) Has it been successfuly in other hospitals? 4) Is there a copyright if want to use?

We started a project on my unit about four years ago using EPIC to created a tool for our surgical trauma progressive care. Working with our EMR nurse team, we were able to customize the tool to fit our patient population. If you would like more information, please let me know.

Patrice, I would love to know how you utilized EPIC to create an acuity tool. I am currently working on finding or creating one for my department. I would love if you could reach out to me. My personal email is wiels1987 at gmail. Thank you.

Interesting article, thank you for acknowledging and taking action to help improve a system. It would be ideal to have a universal acutiy tool that all units can adapt to their speciality. I was wondering how you than use this tool to decide how many staff you require on the ward? If you have so many orange and red level patients, are you able to aquire more staff? Or are you only using this tool to allocate patients equitably between the 5 staff you have?

I was wondering if we would be able to reference the acuity tool in an EVB project we are doing?

This is an interesting article, but I think the use of quantitative measures such as means on ordinal scales is incorrect. First, the score (1, stable patient; 2, moderate-risk patient; 3, complex patient; 4, high-risk patient) is made to be ordinal, therefore, the interpretation “the average distribution of total acuity between highest and lowest nurse assignments for each shift was 4.83” is not appropriate and should not be used. The difference between “stable patient”, “moderate-risk patient” and “complex patient” are not equal. In other words, one cannot assume that the difference between responses is equidistant even though the numbers assigned to those responses are. The same interpretive problem is present for the question “Please rate how frequently you feel overwhelmed with your patient assignment”. The response options were never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). The comment : “the weighted average of nurse satisfaction was 3.19 before implementing the acuity tool and 2.84 (11% improvement) after.”, is also incorrect. I would suggest reporting the percentage of each classes and the median (1). This would be transparent and avoid false interpretations if the answers were clustered at the high and low extremes.

Secondly, I understand the need to have an objective tool and I also chase this goal, but when I read the table “RN assignments using acuity tool”, I come to the conclusion that it is not at all objective and that the nurse’s classification is completely subjective. Either the tool needs to be less interpretation-free and have more quantitative criterias or the nurses need to have the same interpretation of each criteria before using the tool.

I want to thank you for your work as it is a great start and hope you continue to enhance this potentially powerful tool.

Vincent Morissette-Thomas, Statistician and Data Scientist

1. Sullivan, Gail M., and Anthony R. Artino Jr. “Analyzing and interpreting data from Likert-type scales.” Journal of graduate medical education 5.4 (2013): 541-542.

Nice article on acuity. Many years I developed numerous acuity systems from P.I.C.U., to ED and Psychiatric units.

I am interested in using a Patient Acuity tool for my DNP project. Can I use this tool? Thank you. Catherine Bell MSN RNC

Dear Mrs. Andrea Ingram, and Jennifer Powell, I am interested in using a Patient Acuity tool for my project. Can I use this tool? Thank you.

Thank you Great article. I was wanting to contact author about the possibility of using this tool.

I am writting in regards to “patient acuity tool on a medical surgical unit” I am currently connected with a regional hospital (government owned) here in the philippines with a bed capacity of 800 but in reality it is way more than that since we are not allowed to refuse a patient since we are the end refferal hospital in our region.. my hospital have not adapted any tool on patient assignment that most often led to nurse job unsatisfaction and burnt out. And i think your study will be of great help. But before my hospital can adapt this, it has to be grounded with a study and so I will be making a study on this and would like to use also your survey with some revisions that is applicable to us if you could allow me. Thank you in advance.

Thank you all for the responses to the article! I am sorry it has taken me this long to respond, but I would love to provide the survey used. Unfortunately, I’m only able to find 6 of the 10 questions (my account used for the online survey was deleted) but I hope these questions help you.

Re: Liz Doll, I’m so glad you would find this tool helpful. You are more than welcome to adapt our tool to fit your patient population. I hope it works out well for your staff!

1. How long have you been a nurse? 2. How long have you been a nurse on 6A? (the name of our unit) 3. In my opinion, I feel that patient assignments are equal between nursing staff. (Strongly agree, agree, neutral, disagree, strongly disagree.) 4. In my opinion, I feel like I have input into making the nursing assignments. (Strongly agree, agree, neutral, disagree, strongly disagree.) 5. Please rate how frequently you feel overwhelmed with your patient assignment. (Frequently, sometimes, rarely, never.) 6. I feel like patient safety is a concern when I accept my patient assignment. (Every shift, frequently, sometimes, rarely, never.)

Loved this study and was wondering if there’d be a way to get a copy of the survey used? Thank you!

Is there a way to get a copy of the survey questions used? This is a great article!

Thank you for this insightful article. Our hospital is expanding beds and we have been using this tool to ensure our new units are properly staffed. With your permission, our team would like to make slight modifications to this tool to better fit our unique patient population. Please let me know your thoughts!

I am writing in regards to “Patient acuity tool on a medical-surgical unit” (Morrow and Powell, 2018). I believe patient acuity is a critical aspect to take into consideration when looking at staffing and nursing assignments. I agree with method the article used, creating a tool to score patient acuity. It is important to have an objective way to determine the acuity and fairly assign patients to a nurse. Having a balanced assignment benefits not only nurses by decreasing their workload, but also extends to the patients by giving them better outcomes. As a bedside nurse I have experienced overwhelming, unbalanced patient assignments. Being stretched thin forces me to be more task-oriented rather than patient centered, as I would prefer. Several months ago the unit I work for started utilizing a tool similar to the one mentioned in the article. By giving us an objective way to rate the acuity of a patient it lead to more balanced the assignments. It gave us more of a say in the assignments, the charge nurses ask us our opinions on our patient group and if they need to be separated for the next shift. This makes us feel as though we have a voice and give the charge nurse an objective way to fairly make assignments (Morrow, 2018). Overall, RNs who rated their assignments as appropriate were more likely to be satisfied with their jobs, intend to stay on their current units, and deliver quality care to patients than those who rated their assignments as inappropriate. Registered nurses who said that their assignments were appropriate are more likely have higher job satisfaction and deliver higher quality care to patients as opposed to nurses who said their patient assignments were inappropriate and unbalanced (Choi, 2018). I find that in my own practice, a balanced mix of acuity within an assignment group I am able to spend more face-to-face time with each patient as opposed to having a group of patients who are all considered high acuity. Utilizing a patient classification system is a low cost tool that nurse leaders can ensure that nurses are receiving equal assignments.

Sincerely, Carrie Young, RN

References Choi, J (2018). Registered Nurse Perception of Patient Assignment Linking to Working Conditions and Outcomes. Journal of Nursing Scholarship, 50(5). Retrieved from https://doi-org.liblink.uncw . edu/10.1111/jnu.12418

Morrow, A. & Powell, J. (2018). Patient acuity tool on a medical-surgical unit. American Nurse Today, 13(4). Retrieved from https://www.myamericannurse.com/patient-acuity-meidcal-surgical-unit

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Nurse-Patient Assignments: A Fresh Look

As hospitals continue to try to reduce costs, improve operations and still provide quality care, one area that might benefit from an evidence-based practice review could be nurse-patient assignments.

There’s certainly no shortage of complaints and concerns about the process among nursing units.

Whether it’s concerns about favoritism leading to unfair nurse-patient assignments or whether it’s heavy workloads leading to frustration and burnout – nurse workloads and how they are created are gaining attention.

Even the training behind them is under scrutiny.

For example, in one limited study of 58 nurses, researcher Stephanie Allen of Pace University asked a group of nurses how they learned to make nurse-patient assignments. Six percent of the respondents said they learned in their primary undergraduate program, while another 9 percent said they got formal hospital training. But three out of four respondents (76%) said it was a colleague or learned on their own.

In addition, 9 out of 10 of the nurses surveyed said they had at some point made a nurse-patient assignment and the majority of them indicated that they began making assignments within 2 years of graduating from nursing school. 1

Perhaps more alarming, 74% of the nurses surveyed said they knew someone who transferred or left their position because of unhappiness with their nurse-patient assignments and almost all of them said that their daily nurse-patient assignment was extremely or very important to their overall job satisfaction.

Some other interesting findings from this particular study:


What are the implications of this study and others related to workload and nurse-patient assignments?

There’s still much work to be done.

Whether it’s the result of insufficient nurse-patient ratios or cost-cutting measures, the evidence has been building that heavy nursing workloads can adversely affect the delivery of care. In addition, there’s also compelling evidence to suggest that matching the right nurse to the right patient in the “right environment” can lead to positive quality and safety outcomes. In another study where a computerized decision support system (CDSS) was implemented to assist nurses and nursing teams with their daily, recurring nurse-to-patient assignment process, the researchers concluded that creating well-balanced, high-quality assignments is crucial to “ensuring patient safety, quality of care, and job satisfaction for nurses.” 2

And yet, almost all nurse-patient assignments today in most hospitals are done manually and backed with little or no training.

Patient acuity tools haven’t proven to be all that helpful either.

While some EHR systems and patient classification systems have been moving towards trying to attach some kind of coding or numbering system to different acuities, problems surface.

For example, it’s not unusual for a patient acuity classification system coming out of the EHR to be more geared towards physicians and their needs instead of the needs of nurses, which makes it either unusable or cumbersome to try to customize.

Then there’s the problem of patient acuity or classification systems specifically geared towards nurses.

They might be able to code a patient’s condition and allow for a charge nurse to assign a particular nurse based on that coding. But it still doesn’t take into account a host of other factors that need to be considered when trying to match the right nurse to the right patient.

For example, what about geography AND patient acuity? How can those two be balanced?

Furthermore, what if you want to also try to factor in continuity? Now, instead of using just one criteria – patient acuity – you’re suddenly dealing multiple variables at once in a maddening juggling act that challenges even the most savvy and experienced nurse.

Imagine the difficulties of this patient-assignment task on a nurse with one to two years of experience. With little or no training and no viable tools, charge nurses and others are left to come up with balanced, fair and meaningful workloads at a time when budgets continue to be tightened and greater care is not only asked for, but demanded.

It’s an unfair battle.

No wonder frustration, burnout and even turnover is high. Charge nurses and others are being asked to do the impossible

Maybe it’s time to take a fresh look at nurse-patient assignments, especially since it can be argued (and the evidence supports it) that they are one of the pillars of quality inpatient nursing care.

1  Assignments Matter: Results From a Nurse-Patient Assignment Surve y. Stephanie B. Allen, PhD, MSN, MS, BSN, ASN. Lienhard School of Nursing, College of Health Professions, Pace University, Pleasantville, NY. 44TH Biennial Convention, Sigma Global Nursing Excellence

2  developing and testing a computerized decision support system for nurse-to-patient assignment: a multimethod study . van oostveen cj1, braaksma a, vermeulen h.comput inform nurs. 2014 jun;32(6):276-85. doi: 10.1097/cin.0000000000000056., recent posts.

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  1. 8 steps for making effective nurse-patient assignments

    for making nurse-patient assignments. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Consider asking if you can observe your charge nurse make assign-ments. Ask questions to learn what factors are taken into consideration for each assignment. Nurses who make assignments are aware of their importance and

  2. A New Patient Acuity Tool to Support Equitable Patient

    Making fair and equitable staffing decisions and patient assignments created complexities and undue nursing dissatisfaction on a 20-bed progressive care unit. Common themes shared by the nursing staff included inadequate staffing ratios, increased workload, and unease for patient safety.

  3. 8 Steps for Making Effective Nurse-Patient Assignments

    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.

  4. Nurse-Patient Assignments: A Fresh Look

    79% of the respondents said they made assignments for a shift other than their own 41% of nurses knew someone who called out sick because of an assignment 41% said if they could choose only one purpose when making assignments, it would be “best care” IMPLICATIONS OF NURSE-PATIENT ASSIGNMENTS