assignment sheet for nurses

The Ultimate Nursing Report Sheet Guide - Free Downloads!

As a nurse, you know the importance of clear and concise communication, especially when it comes to patient care. Nursing report sheets play a vital role in ensuring seamless handovers between shifts, ultimately contributing to improved patient outcomes. However, navigating these sheets can sometimes feel overwhelming, especially for new nurses.

What are Nursing Report Sheets?

Nursing report sheets are standardized forms used to document a patient's condition, including vital signs, medications, treatments, and any relevant observations. They serve as a communication tool between nurses, ensuring continuity of care throughout the patient's journey.

Benefits of Using Nursing Report Sheets:

• Improved patient care: Clear and accurate documentation facilitates better communication and collaboration among healthcare professionals, leading to improved patient care.
• Enhanced safety: Reporting potential risks and concerns helps identify and address issues promptly, ensuring patient safety.
• Reduced errors: Standardized formats minimize the risk of errors and omissions associated with free-form documentation.
• Increased efficiency: Pre-structured templates save time and improve efficiency during shift changes.

Essential Components of a Nursing Report Sheet:

• Patient demographics: Basic information like name, age, diagnosis, and admitting date.
• Vital signs: Temperature, pulse, blood pressure, respiratory rate, and oxygen saturation.
• Medications: Current medication list, including dosages, frequencies, and routes of administration.
• Treatments: Treatments received and planned, including interventions like dressing changes, oxygen therapy, and suctioning.
• Laboratory and diagnostic reports: Summary of recent tests and results.
• Neurological status: Level of consciousness, orientation, and any neurological deficits.
• Pain assessment and management: Description of pain, pain score, and current pain management strategies.
• Fluid intake and output: Total intake and output for the shift.
• Activity and mobility: Level of independence and assistance required for daily activities.
• Skin integrity: Assessment of skin condition and any pressure injuries.
• Nutritional status: Dietary intake and any nutritional concerns.
• Discharge planning: Current discharge plan and any anticipated needs.

Tips for Using Nursing Report Sheets Effectively:

• Complete the sheet comprehensively and accurately.
• Use clear and concise language.
• Document all relevant observations and concerns.
• Proofread the sheet carefully before handing off to the next nurse.
• Ask questions and clarify any uncertainties.
• Utilize standardized abbreviations and terminology.

By mastering nursing report sheets, you can enhance communication, improve patient care, and ensure a smooth and safe transition between shifts. Remember, accurate and efficient reporting is not just a good practice, it's a vital aspect of providing quality patient care.

10 Free Nursing Report Sheet Downloads

Our report sheets are used extensively throughout health systems across the country.

• Download and print PDFs, or edit in Google Docs/Microsoft Word.
• 1-4 patients per sheet, with portrait and landscape options.
• SBAR and Brain format:  Perfect for Med-Surg, ICU, Tele, Step-Down, and ER units.

1. Full-Size SBAR Nurse Report Sheet

• Perfect for new grads and nursing students
• Fly through report by circling options instead of writing everything
• 1 patient per sheet
• SBAR format
• Great for all units

2. Brain Nursing Report Sheet Template

• Brain format

3. ICU Nurse Report Sheet

• Great for ICU

4. Mini SBAR Nursing Report Sheet

• 3 patients per sheet
• Quick report taking with circling options
• Great for med surg and tele units

5. 4 Patient Nurse Report Sheet

• 4 patients per sheet

6. Brain Nursing Report Sheet

7. 2 Patient Landscape Nurse Report Sheet

• 2 patients per sheet

8. 3 Patient SBAR Nurse Report Sheet

9. Full-size Nurse Report Sheet Template

10. History and Physical Template

• H&P format
• Great for nurse practitioners and NP students

Free Downloads!

How to Create Your Own Patient Prep Worksheet

Keith Rischer – Ph.D., RN, CCRN, CEN

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Student assignments are necessary to know the impact of education on school students, keeping in mind the standard and surroundings of education. A student assignment can determine the potential strength of every individual student. To perceive the progress and result of the method of education followed in your faculty or school you’ll be able to use sheet templates that how your given assignment sheet worked out to the nursing students of your institute.

Step 1: Set a Goal

Step 2: rating scale, step 3: guarantee qualified surroundings, step 4: live student satisfaction, step 5: implement your assignment results.

Nursing Student CV Template

Nursing student smart goals template, nursing student mission statement template, nursing student cover letter, nursing student reference letter, nursing student care plan template.

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The Definitive Guide to Nursing Assignment Sheets

Your guide to nursing assignment rubric, the ultimate guide to choosing nursing assignment topics, introduction.

Nursing assignment sheets are indispensable tools in the healthcare profession. They serve as organized documents that outline a nurse’s responsibilities and tasks during a shift. Understanding and utilizing these sheets effectively is crucial for providing high-quality patient care. This guide aims to equip college students pursuing nursing careers with the knowledge and skills needed to navigate nursing assignment sheets proficiently.

Understanding Nursing Assignment Sheets

Definition and purpose.

A nursing assignment sheet is a structured document that contains essential information about a patient, including their name, room number, diagnosis, and specific care requirements. Its primary purpose is to ensure that nurses have a clear and organized overview of their duties for a particular shift.

Formats and Variations

Assignment sheets may vary in format based on the healthcare facility and individual preferences. Some are paper-based, while others have transitioned into electronic formats. Understanding the variations allows nurses to adapt to different systems seamlessly.

Components of a Nursing Assignment Sheet

Patient information.

This section provides vital details about the patient, including their full name, room number, diagnosis, and any specific conditions or precautions that need to be considered.

Vital Signs Monitoring

Assignment sheets include a section for recording and monitoring vital signs such as heart rate, blood pressure, respiratory rate, and temperature. This information is crucial for assessing a patient’s overall health and detecting any changes or abnormalities.

Medication Administration Schedule

A detailed schedule of medication administration is typically outlined on the assignment sheet. This includes the name of the medication, dosage, route of administration, and specific times for each dose.

Care Tasks and Procedures

This section lists the specific care tasks and procedures that need to be performed for each patient. It may include activities like wound dressing changes, catheter care, or any other specialized procedures.

Special Instructions and Precautions

Any unique requirements or precautions related to a patient’s condition are highlighted in this section. It may include dietary restrictions, mobility limitations, or isolation protocols.

Shift Handoff Notes

As shifts change, nurses must communicate important information to ensure continuity of care. The assignment sheet may have a designated area for shift handoff notes, where outgoing and incoming nurses can exchange critical updates.

Importance of Accurate Documentation

Accurate and detailed documentation on nursing assignment sheets is paramount for several reasons:

• Patient Safety : Precise documentation ensures that each patient receives the appropriate care and medications, reducing the risk of errors.
• Continuity of Care : Clear documentation facilitates smooth transitions between shifts, allowing for seamless care delivery.
• Legal and Ethical Compliance : Proper documentation serves as legal and ethical protection for nurses, providing a record of the care provided.

Tips for Effective Use of Nursing Assignment Sheets

Organizing information.

Prioritize organizing information in a systematic and easily accessible manner. Highlight critical details to ensure they are not overlooked during busy shifts.

Prioritizing Tasks

Evaluate each patient’s needs and prioritize tasks accordingly. Focus on urgent and essential care activities first.

Maintaining Clarity and Legibility

Write legibly and use standardized abbreviations to ensure that the information recorded can be easily understood by other healthcare professionals.

Updating Promptly and Accurately

Regularly update the assignment sheet with any changes in a patient’s condition or care plan. Timely updates are crucial for providing safe and effective care.

Common Mistakes to Avoid

Misinterpretation of information.

Failing to fully understand the information on the assignment sheet can lead to incorrect or incomplete care.

Delayed or Incomplete Documentation

Procrastination in documenting care activities can result in critical information being missed or forgotten.

Failing to Communicate Changes

Neglecting to communicate changes in a patient’s condition or care plan with the rest of the healthcare team can lead to gaps in care.

Utilizing Technology in Nursing Assignment Sheets

In recent years, electronic health records (EHRs) have become increasingly prevalent in healthcare facilities. These digital systems have streamlined the process of managing assignment sheets. While electronic systems offer benefits like easy access to patient information and improved accuracy, they also come with their own set of challenges, such as the need for training and potential technical issues.

Case Studies: Successful Application of Nursing Assignment Sheets

Case study 1: cardiac care unit.

In a busy cardiac care unit, accurate documentation on assignment sheets played a crucial role in monitoring patients’ vital signs and ensuring timely administration of medications. This meticulous approach contributed to improved patient outcomes.

Case Study 2: Surgical Ward

In a surgical ward, effective use of assignment sheets ensured that post-operative care was administered according to specific surgeon orders. Nurses were able to track wound care, pain management, and mobility restrictions, leading to successful recoveries.

Balancing Assignment Sheets with Critical Thinking

While assignment sheets provide essential guidance, it’s important for nurses to also rely on their critical thinking skills. There may be situations where a patient’s condition changes rapidly, requiring immediate action that may not be explicitly outlined on the assignment sheet. In such cases, a nurse’s clinical judgment and critical thinking abilities take precedence.

Mastering the use of nursing assignment sheets is a vital skill for any aspiring nurse. By understanding their purpose, components, and best practices for utilization, students can ensure they provide safe and effective care to their patients. Additionally, embracing technology and maintaining a balance between adherence to assignment sheets and critical thinking will empower nurses to excel in their roles.

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• South Dakota Nurse November 2018 issue is now available.

8 Steps for Making Effective Nurse-Patient Assignments

This article appears on page 14 of

South Dakota Nurse November 2018

Reprinted from American Nurse Today

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

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

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

1. Find a mentor

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

2. Gather your supplies (knowledge)

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

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

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

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

3. Decide on the process

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

4. Set priorities for the shift

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

5. Make the assignments

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

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

6. Adjust the assignments

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

7. Evaluate success

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

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

8. Keep practicing

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

What you need to know

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

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

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

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

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

Psychosocial support •    Emotional needs •    Familial support •    Intellectual needs

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

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

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

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

Choose your process

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

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

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

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

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

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

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

8 steps for making effective nurse-patient assignments

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

Takeaways:  

• Making nurse-patient assignments is challenging but rewarding. 
• Nurse-patient assignments are created based on knowledge and understanding of nursing unit environment, nurse qualities, and patient characteristics. 
• Clinical nurses are vital resources for critical changes in patient status. 
• Nurse-patient assignments should be frequently reassessed and changed as needed to ensure continuous, safe, quality nursing care.

By Stephanie B. Allen, PhD, RN, NE-BC

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Development of a Nursing Assignment Tool Using Workload Acuity Scores

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

BACKGROUND:

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

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

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

CONCLUSION:

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

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

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

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

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

Significance

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

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

Materials and Methods

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

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

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

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

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

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

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

Strengths and Limitations

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

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

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

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

Nursing assignment tool workflow.

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

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

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

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

Acknowledgments

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

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

The authors declare no conflicts of interest.

Charge Nurse Checklist

Review and update patient assignment sheet, communicate and delegate responsibilities to nursing team.

• 1 Administer Medications
• 2 Assist with Patient Transfers
• 3 Provide Emotional Support

Conduct shift change briefings

• 1 Patient Condition
• 2 Medication Updates
• 3 Treatment Plan Updates

Verify the accuracy of patient's medication and treatment plans

• 1 Medication Dosages
• 2 Frequency of Administration
• 3 Treatment Procedures

Oversee direct patient care delivery

• 1 Vital Sign Monitoring
• 2 Medication Administration
• 3 Wound Dressing
• 4 Assistance with Mobility
• 5 Dietary Management

Monitor patients' progress and update medical records

• 1 Vital Signs
• 3 Medication Changes
• 4 Treatment Modifications
• 5 Lab Results

Approval: Clinical rounds

• Review and update patient assignment sheet Will be submitted
• Communicate and delegate responsibilities to nursing team Will be submitted
• Conduct shift change briefings Will be submitted
• Verify the accuracy of patient's medication and treatment plans Will be submitted
• Oversee direct patient care delivery Will be submitted
• Monitor patients' progress and update medical records Will be submitted

Arrange for patient consultations or treatments as needed

• 1 Radiology Appointment
• 2 Physical Therapy Session
• 3 Surgical Procedure
• 4 Specialist Consultation

Monitor and replenish supplies and medications as needed

• 1 Medication Inventory
• 2 Equipment Availability
• 3 Stocking Consumables
• 4 Ordering Supplies
• 5 Checking Expiry Dates

Approval: Medication reconciliation

Handle patients complaints and concerns effectively, give emotional and psychological support to patients and their families, oversee safety and infection control practices.

• 1 Hand Hygiene Compliance
• 2 Isolation Precautions
• 3 Safety Equipment Checks
• 4 Biohazard Waste Management
• 5 Fall Prevention Measures

Review and sign off nursing documentation

Approval: safety and hygiene practices.

• Oversee safety and infection control practices Will be submitted
• Review and sign off nursing documentation Will be submitted

Liaise with physicians and other healthcare professionals

• 1 Physician
• 2 Pharmacist
• 3 Physical Therapist
• 4 Social Worker
• 5 Occupational Therapist

Authorize patient discharges according to hospital protocol

• 1 Completion of Treatment Plan
• 2 Arrangement of Home Care Services
• 3 Patient Education
• 4 Medication Reconciliation
• 5 Follow-up Appointments

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