nursing case study prioritization

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Cover of Nursing Management and Professional Concepts

Nursing Management and Professional Concepts [Internet].

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Chapter 2 - Prioritization

2.1. prioritization introduction, learning objectives.

• Prioritize nursing care based on patient acuity

• Use principles of time management to organize work

• Analyze effectiveness of time management strategies

• Use critical thinking to prioritize nursing care for patients

• Apply a framework for prioritization (e.g., Maslow, ABCs)

“So much to do, so little time.” This is a common mantra of today’s practicing nurse in various health care settings. Whether practicing in acute inpatient care, long-term care, clinics, home care, or other agencies, nurses may feel there is “not enough of them to go around.”

The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work (i.e., floating), implementing mandatory staffing and/or overtime, utilizing travel nurses, or using other practices to meet patient care demands.[ 1 ] Staffing strategies can result in nurses experiencing increased patient assignments and workloads, extended shifts, or temporary suspension of paid time off. Nurses may receive a barrage of calls and text messages offering “extra shifts” and bonus pay, and although the extra pay may be welcomed, they often eventually feel burnt out trying to meet the ever-expanding demands of the patient-care environment.

A novice nurse who is still learning how to navigate the complex health care environment and provide optimal patient care may feel overwhelmed by these conditions. Novice nurses frequently report increased levels of stress and disillusionment as they transition to the reality of the nursing role.[ 2 ] How can we address this professional dilemma and enhance the novice nurse’s successful role transition to practice? The novice nurse must enter the profession with purposeful tools and strategies to help prioritize tasks and manage time so they can confidently address patient care needs, balance role demands, and manage day-to-day nursing activities.

Let’s take a closer look at the foundational concepts related to prioritization and time management in the nursing profession.

2.2. TENETS OF PRIORITIZATION

Prioritization.

As new nurses begin their career, they look forward to caring for others, promoting health, and saving lives. However, when entering the health care environment, they often discover there are numerous and competing demands for their time and attention. Patient care is often interrupted by call lights, rounding physicians, and phone calls from the laboratory department or other interprofessional team members. Even individuals who are strategic and energized in their planning can feel frustrated as their task lists and planned patient-care activities build into a long collection of “to dos.”

Without utilization of appropriate prioritization strategies, nurses can experience time scarcity , a feeling of racing against a clock that is continually working against them. Functioning under the burden of time scarcity can cause feelings of frustration, inadequacy, and eventually burnout. Time scarcity can also impact patient safety, resulting in adverse events and increased mortality.[ 1 ] Additionally, missed or rushed nursing activities can negatively impact patient satisfaction scores that ultimately affect an institution’s reimbursement levels.

It is vital for nurses to plan patient care and implement their task lists while ensuring that critical interventions are safely implemented first. Identifying priority patient problems and implementing priority interventions are skills that require ongoing cultivation as one gains experience in the practice environment.[ 2 ] To develop these skills, students must develop an understanding of organizing frameworks and prioritization processes for delineating care needs. These frameworks provide structure and guidance for meeting the multiple and ever-changing demands in the complex health care environment.

Let’s consider a clinical scenario in the following box to better understand the implications of prioritization and outcomes.

Imagine you are beginning your shift on a busy medical-surgical unit. You receive a handoff report on four medical-surgical patients from the night shift nurse:

• Patient A is a 34-year-old total knee replacement patient, post-op Day 1, who had an uneventful night. It is anticipated that she will be discharged today and needs patient education for self-care at home.

• Patient B is a 67-year-old male admitted with weakness, confusion, and a suspected urinary tract infection. He has been restless and attempting to get out of bed throughout the night. He has a bed alarm in place.

• Patient C is a 49-year-old male, post-op Day 1 for a total hip replacement. He has been frequently using his patient-controlled analgesia (PCA) pump and last rated his pain as a “6.”

• Patient D is a 73-year-old male admitted for pneumonia. He has been hospitalized for three days and receiving intravenous (IV) antibiotics. His next dose is due in an hour. His oxygen requirements have decreased from 4 L/minute of oxygen by nasal cannula to 2 L/minute by nasal cannula.

Based on the handoff report you received, you ask the nursing assistant to check on Patient B while you do an initial assessment on Patient D. As you are assessing Patient D’s oxygenation status, you receive a phone call from the laboratory department relating a critical lab value on Patient C, indicating his hemoglobin is low. The provider calls and orders a STAT blood transfusion for Patient C. Patient A rings the call light and states she and her husband have questions about her discharge and are ready to go home. The nursing assistant finds you and reports that Patient B got out of bed and experienced a fall during the handoff reports.

It is common for nurses to manage multiple and ever-changing tasks and activities like this scenario, illustrating the importance of self-organization and priority setting. This chapter will further discuss the tools nurses can use for prioritization.

2.3. TOOLS FOR PRIORITIZING

Prioritization of care for multiple patients while also performing daily nursing tasks can feel overwhelming in today’s fast-paced health care system. Because of the rapid and ever-changing conditions of patients and the structure of one’s workday, nurses must use organizational frameworks to prioritize actions and interventions. These frameworks can help ease anxiety, enhance personal organization and confidence, and ensure patient safety.

Acuity and intensity are foundational concepts for prioritizing nursing care and interventions. Acuity refers to the level of patient care that is required based on the severity of a patient’s illness or condition. For example, acuity may include characteristics such as unstable vital signs, oxygenation therapy, high-risk IV medications, multiple drainage devices, or uncontrolled pain. A “high-acuity” patient requires several nursing interventions and frequent nursing assessments.

Intensity addresses the time needed to complete nursing care and interventions such as providing assistance with activities of daily living (ADLs), performing wound care, or administering several medication passes. For example, a “high-intensity” patient generally requires frequent or long periods of psychosocial, educational, or hygiene care from nursing staff members. High-intensity patients may also have increased needs for safety monitoring, familial support, or other needs.[ 1 ]

Many health care organizations structure their staffing assignments based on acuity and intensity ratings to help provide equity in staff assignments. Acuity helps to ensure that nursing care is strategically divided among nursing staff. An equitable assignment of patients benefits both the nurse and patient by helping to ensure that patient care needs do not overwhelm individual staff and safe care is provided.

Organizations use a variety of systems when determining patient acuity with rating scales based on nursing care delivery, patient stability, and care needs. See an example of a patient acuity tool published in the American Nurse in Table 2.3 .[ 2 ] In this example, ratings range from 1 to 4, with a rating of 1 indicating a relatively stable patient requiring minimal individualized nursing care and intervention. A rating of 2 reflects a patient with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex patient who requires frequent intervention and assessment. This patient might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk patient. For example, this individual may be experiencing frequent changes in vital signs, may require complex interventions such as the administration of blood transfusions, or may be experiencing significant uncontrolled pain. An individual with a rating of 4 requires more direct nursing care and intervention than a patient with a rating of 1 or 2. [3]

Example of a Patient Acuity Tool [ 4 ]

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Q8h VS A & O X 4	Q4h VS CIWA < 8	Q2h VS Delirium CIWA > 8	Unstable VS
Stable on RA	O2 < 2L NC	O2 > 2L NC	O2 via mask
VS	Temp < 98.7 F Pacemaker/AICD HR > 130	Change in BP Temp > 100.3 F	Unstable rhythm Afib
PO/IVPB	TPN, heparin infusion, blood glucose, PICC for blood draws	CBI 1 unit blood transfusion Fluid bolus	> 1 unit blood transfusion Chemotherapy
< 2 JP, hemovac, neph tube	Chest to water seal NG tube	Chest tube to suction Drain measured Q2 hrs	Drain measured Q1 hr CT > 100 mL/2 hrs
Pain well- managed with PO or IV meds Q4 hrs	PCA, nerve block Nausea/Vomiting	Q2h pain management	Uncontrolled pain with multiple pain devices
Stable transfer, routine discharge	Discharge to outside facility	New admission, discharge to hospice	Complicated post-op
Independent	Assist with ADLs Two-person assist out of bed Isolation	Turns Q2h Bedrest Respiratory isolation	Paraplegic Total care

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

Rating scales may vary among institutions, but the principles of the rating system remain the same. Organizations include various patient care elements when constructing their staffing plans for each unit. Read more information about staffing models and acuity in the following box.

Staffing Models and Acuity

Organizations that base staffing on acuity systems attempt to evenly staff patient assignments according to their acuity ratings. This means that when comparing patient assignments across nurses on a unit, similar acuity team scores should be seen with the goal of achieving equitable and safe division of workload across the nursing team. For example, one nurse should not have a total acuity score of 6 for their patient assignments while another nurse has a score of 15. If this situation occurred, the variation in scoring reflects a discrepancy in workload balance and would likely be perceived by nursing peers as unfair. Using acuity-rating staffing models is helpful to reflect the individualized nursing care required by different patients.

Alternatively, nurse staffing models may be determined by staffing ratio. Ratio-based staffing models are more straightforward in nature, where each nurse is assigned care for a set number of patients during their shift. Ratio-based staffing models may be useful for administrators creating budget requests based on the number of staff required for patient care, but can lead to an inequitable division of work across the nursing team when patient acuity is not considered. Increasingly complex patients require more time and interventions than others, so a blend of both ratio and acuity-based staffing is helpful when determining staffing assignments.[ 5 ]

As a practicing nurse, you will be oriented to the elements of acuity ratings within your health care organization, but it is also important to understand how you can use these acuity ratings for your own prioritization and task delineation. Let’s consider the Scenario B in the following box to better understand how acuity ratings can be useful for prioritizing nursing care.

You report to work at 6 a.m. for your nursing shift on a busy medical-surgical unit. Prior to receiving the handoff report from your night shift nursing colleagues, you review the unit staffing grid and see that you have been assigned to four patients to start your day. The patients have the following acuity ratings:

Patient A: 45-year-old patient with paraplegia admitted for an infected sacral wound, with an acuity rating of 4.

Patient B: 87-year-old patient with pneumonia with a low grade fever of 99.7 F and receiving oxygen at 2 L/minute via nasal cannula, with an acuity rating of 2.

Patient C: 63-year-old patient who is postoperative Day 1 from a right total hip replacement and is receiving pain management via a PCA pump, with an acuity rating of 2.

Patient D: 83-year-old patient admitted with a UTI who is finishing an IV antibiotic cycle and will be discharged home today, with an acuity rating of 1.

Based on the acuity rating system, your patient assignment load receives an overall acuity score of 9. Consider how you might use their acuity ratings to help you prioritize your care. Based on what is known about the patients related to their acuity rating, whom might you identify as your care priority? Although this can feel like a challenging question to answer because of the many unknown elements in the situation using acuity numbers alone, Patient A with an acuity rating of 4 would be identified as the care priority requiring assessment early in your shift.

Although acuity can a useful tool for determining care priorities, it is important to recognize the limitations of this tool and consider how other patient needs impact prioritization.

Maslow’s Hierarchy of Needs

When thinking back to your first nursing or psychology course, you may recall a historical theory of human motivation based on various levels of human needs called Maslow’s Hierarchy of Needs. Maslow’s Hierarchy of Needs reflects foundational human needs with progressive steps moving towards higher levels of achievement. This hierarchy of needs is traditionally represented as a pyramid with the base of the pyramid serving as essential needs that must be addressed before one can progress to another area of need.[ 6 ] See Figure 2.1 [ 7 ] for an illustration of Maslow’s Hierarchy of Needs.

Maslow’s Hierarchy of Needs places physiological needs as the foundational base of the pyramid.[ 8 ] Physiological needs include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second level of Maslow’s hierarchy reflects safety needs. Safety needs include elements that keep individuals safe from harm. Examples of safety needs in health care include fall precautions. The third level of Maslow’s hierarchy reflects emotional needs such as love and a sense of belonging. These needs are often reflected in an individual’s relationships with family members and friends. The top two levels of Maslow’s hierarchy include esteem and self-actualization. An example of addressing these needs in a health care setting is helping an individual build self-confidence in performing blood glucose checks that leads to improved self-management of their diabetes.

So how does Maslow’s theory impact prioritization? To better understand the application of Maslow’s theory to prioritization, consider Scenario C in the following box.

You are an emergency response nurse working at a local shelter in a community that has suffered a devastating hurricane. Many individuals have relocated to the shelter for safety in the aftermath of the hurricane. Much of the community is still without electricity and clean water, and many homes have been destroyed. You approach a young woman who has a laceration on her scalp that is bleeding through her gauze dressing. The woman is weeping as she describes the loss of her home stating, “I have lost everything! I just don’t know what I am going to do now. It has been a day since I have had water or anything to drink. I don’t know where my sister is, and I can’t reach any of my family to find out if they are okay!”

Despite this relatively brief interaction, this woman has shared with you a variety of needs. She has demonstrated a need for food, water, shelter, homeostasis, and family. As the nurse caring for her, it might be challenging to think about where to begin her care. These thoughts could be racing through your mind:

Should I begin to make phone calls to try and find her family? Maybe then she would be able to calm down.

Should I get her on the list for the homeless shelter so she wouldn’t have to worry about where she will sleep tonight?

She hasn’t eaten in awhile; I should probably find her something to eat.

All of these needs are important and should be addressed at some point, but Maslow’s hierarchy provides guidance on what needs must be addressed first. Use the foundational level of Maslow’s pyramid of physiological needs as the top priority for care. The woman is bleeding heavily from a head wound and has had limited fluid intake. As the nurse caring for this patient, it is important to immediately intervene to stop the bleeding and restore fluid volume. Stabilizing the patient by addressing her physiological needs is required before undertaking additional measures such as contacting her family. Imagine if instead you made phone calls to find the patient’s family and didn’t address the bleeding or dehydration – you might return to a severely hypovolemic patient who has deteriorated and may be near death. In this example, prioritizing emotional needs above physiological needs can lead to significant harm to the patient.

Although this is a relatively straightforward example, the principles behind the application of Maslow’s hierarchy are essential. Addressing physiological needs before progressing toward additional need categories concentrates efforts on the most vital elements to enhance patient well-being. Maslow’s hierarchy provides the nurse with a helpful framework for identifying and prioritizing critical patient care needs.

Airway, breathing, and circulation, otherwise known by the mnemonic “ABCs,” are another foundational element to assist the nurse in prioritization. Like Maslow’s hierarchy, using the ABCs to guide decision-making concentrates on the most critical needs for preserving human life. If a patient does not have a patent airway, is unable to breathe, or has inadequate circulation, very little of what else we do matters. The patient’s ABCs are reflected in Maslow’s foundational level of physiological needs and direct critical nursing actions and timely interventions. Let’s consider Scenario D in the following box regarding prioritization using the ABCs and the physiological base of Maslow’s hierarchy.

You are a nurse on a busy cardiac floor charting your morning assessments on a computer at the nurses’ station. Down the hall from where you are charting, two of your assigned patients are resting comfortably in Room 504 and Room 506. Suddenly, both call lights ring from the rooms, and you answer them via the intercom at the nurses’ station.

Room 504 has an 87-year-old male who has been admitted with heart failure, weakness, and confusion. He has a bed alarm for safety and has been ringing his call bell for assistance appropriately throughout the shift. He requires assistance to get out of bed to use the bathroom. He received his morning medications, which included a diuretic about 30 minutes previously, and now reports significant urge to void and needs assistance to the bathroom.

Room 506 has a 47-year-old woman who was hospitalized with new onset atrial fibrillation with rapid ventricular response. The patient underwent a cardioversion procedure yesterday that resulted in successful conversion of her heart back into normal sinus rhythm. She is reporting via the intercom that her “heart feels like it is doing that fluttering thing again” and she is having chest pain with breathlessness.

Based upon these two patient scenarios, it might be difficult to determine whom you should see first. Both patients are demonstrating needs in the foundational physiological level of Maslow’s hierarchy and require assistance. To prioritize between these patients’ physiological needs, the nurse can apply the principles of the ABCs to determine intervention. The patient in Room 506 reports both breathing and circulation issues, warning indicators that action is needed immediately. Although the patient in Room 504 also has an urgent physiological elimination need, it does not overtake the critical one experienced by the patient in Room 506. The nurse should immediately assess the patient in Room 506 while also calling for assistance from a team member to assist the patient in Room 504.

Prioritizing what should be done and when it can be done can be a challenging task when several patients all have physiological needs. Recently, there has been professional acknowledgement of the cognitive challenge for novice nurses in differentiating physiological needs. To expand on the principles of prioritizing using the ABCs, the CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras.[ 9 ]

“Critical” patient needs require immediate action. Examples of critical needs align with the ABCs and Maslow’s physiological needs, such as symptoms of respiratory distress, chest pain, and airway compromise. No matter the complexity of their shift, nurses can be assured that addressing patients’ critical needs is the correct prioritization of their time and energies.

After critical patient care needs have been addressed, nurses can then address “urgent” needs. Urgent needs are characterized as needs that cause patient discomfort or place the patient at a significant safety risk.[ 10 ]

The third part of the CURE hierarchy reflects “routine” patient needs. Routine patient needs can also be characterized as “typical daily nursing care” because the majority of a standard nursing shift is spent addressing routine patient needs. Examples of routine daily nursing care include actions such as administering medication and performing physical assessments.[ 11 ] Although a nurse’s typical shift in a hospital setting includes these routine patient needs, they do not supersede critical or urgent patient needs.

The final component of the CURE hierarchy is known as “extras.” Extras refer to activities performed in the care setting to facilitate patient comfort but are not essential.[ 12 ] Examples of extra activities include providing a massage for comfort or washing a patient’s hair. If a nurse has sufficient time to perform extra activities, they contribute to a patient’s feeling of satisfaction regarding their care, but these activities are not essential to achieve patient outcomes.

Let’s apply the CURE mnemonic to patient care in the following box.

If we return to Scenario D regarding patients in Room 504 and 506, we can see the patient in Room 504 is having urgent needs. He is experiencing a physiological need to urgently use the restroom and may also have safety concerns if he does not receive assistance and attempts to get up on his own because of weakness. He is on a bed alarm, which reflects safety considerations related to his potential to get out of bed without assistance. Despite these urgent indicators, the patient in Room 506 is experiencing a critical need and takes priority. Recall that critical needs require immediate nursing action to prevent patient deterioration. The patient in Room 506 with a rapid, fluttering heartbeat and shortness of breath has a critical need because without prompt assessment and intervention, their condition could rapidly decline and become fatal.

In addition to using the identified frameworks and tools to assist with priority setting, nurses must also look at their patients’ data cues to help them identify care priorities. Data cues are pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition. For example, have the patient’s vital signs worsened over the last few hours? Is there a new laboratory result that is concerning? Data cues are used in conjunction with prioritization frameworks to help the nurse holistically understand the patient’s current status and where nursing interventions should be directed. Common categories of data clues include acute versus chronic conditions, actual versus potential problems, unexpected versus expected conditions, information obtained from the review of a patient’s chart, and diagnostic information.

Acute Versus Chronic Conditions

A common data cue that nurses use to prioritize care is considering if a condition or symptom is acute or chronic. Acute conditions have a sudden and severe onset. These conditions occur due to a sudden illness or injury, and the body often has a significant response as it attempts to adapt. Chronic conditions have a slow onset and may gradually worsen over time. The difference between an acute versus a chronic condition relates to the body’s adaptation response. Individuals with chronic conditions often experience less symptom exacerbation because their body has had time to adjust to the illness or injury. Let’s consider an example of two patients admitted to the medical-surgical unit complaining of pain in Scenario E in the following box.

As part of your patient assignment on a medical-surgical unit, you are caring for two patients who both ring the call light and report pain at the start of the shift. Patient A was recently admitted with acute appendicitis, and Patient B was admitted for observation due to weakness. Not knowing any additional details about the patients’ conditions or current symptoms, which patient would receive priority in your assessment? Based on using the data cue of acute versus chronic conditions, Patient A with a diagnosis of acute appendicitis would receive top priority for assessment over a patient with chronic pain due to osteoarthritis. Patients experiencing acute pain require immediate nursing assessment and intervention because it can indicate a change in condition. Acute pain also elicits physiological effects related to the stress response, such as elevated heart rate, blood pressure, and respiratory rate, and should be addressed quickly.

Actual Versus Potential Problems

Nursing diagnoses and the nursing care plan have significant roles in directing prioritization when interpreting assessment data cues. Actual problems refer to a clinical problem that is actively occurring with the patient. A risk problem indicates the patient may potentially experience a problem but they do not have current signs or symptoms of the problem actively occurring.

Consider an example of prioritizing actual and potential problems in Scenario F in the following box.

A 74-year-old woman with a previous history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital for pneumonia. She has generalized weakness, a weak cough, and crackles in the bases of her lungs. She is receiving IV antibiotics, fluids, and oxygen therapy. The patient can sit at the side of the bed and ambulate with the assistance of staff, although she requires significant encouragement to ambulate.

Nursing diagnoses are established for this patient as part of the care planning process. One nursing diagnosis for this patient is Ineffective Airway Clearance . This nursing diagnosis is an actual problem because the patient is currently exhibiting signs of poor airway clearance with an ineffective cough and crackles in the lungs. Nursing interventions related to this diagnosis include coughing and deep breathing, administering nebulizer treatment, and evaluating the effectiveness of oxygen therapy. The patient also has the nursing diagnosis Risk for Skin Breakdown based on her weakness and lack of motivation to ambulate. Nursing interventions related to this diagnosis include repositioning every two hours and assisting with ambulation twice daily.

The established nursing diagnoses provide cues for prioritizing care. For example, if the nurse enters the patient’s room and discovers the patient is experiencing increased shortness of breath, nursing interventions to improve the patient’s respiratory status receive top priority before attempting to get the patient to ambulate.

Although there may be times when risk problems may supersede actual problems, looking to the “actual” nursing problems can provide clues to assist with prioritization.

Unexpected Versus Expected Conditions

In a similar manner to using acute versus chronic conditions as a cue for prioritization, it is also important to consider if a client’s signs and symptoms are “expected” or “unexpected” based on their overall condition. Unexpected conditions are findings that are not likely to occur in the normal progression of an illness, disease, or injury. Expected conditions are findings that are likely to occur or are anticipated in the course of an illness, disease, or injury. Unexpected findings often require immediate action by the nurse.

Let’s apply this tool to the two patients previously discussed in Scenario E. As you recall, both Patient A (with acute appendicitis) and Patient B (with weakness and diagnosed with osteoarthritis) are reporting pain. Acute pain typically receives priority over chronic pain. But what if both patients are also reporting nausea and have an elevated temperature? Although these symptoms must be addressed in both patients, they are “expected” symptoms with acute appendicitis (and typically addressed in the treatment plan) but are “unexpected” for the patient with osteoarthritis. Critical thinking alerts you to the unexpected nature of these symptoms in Patient B, so they receive priority for assessment and nursing interventions.

Handoff Report/Chart Review

Additional data cues that are helpful in guiding prioritization come from information obtained during a handoff nursing report and review of the patient chart. These data cues can be used to establish a patient’s baseline status and prioritize new clinical concerns based on abnormal assessment findings. Let’s consider Scenario G in the following box based on cues from a handoff report and how it might be used to help prioritize nursing care.

Imagine you are receiving the following handoff report from the night shift nurse for a patient admitted to the medical-surgical unit with pneumonia:

At the beginning of my shift, the patient was on room air with an oxygen saturation of 93%. She had slight crackles in both bases of her posterior lungs. At 0530, the patient rang the call light to go to the bathroom. As I escorted her to the bathroom, she appeared slightly short of breath. Upon returning the patient to bed, I rechecked her vital signs and found her oxygen saturation at 88% on room air and respiratory rate of 20. I listened to her lung sounds and noticed more persistent crackles and coarseness than at bedtime. I placed the patient on 2 L/minute of oxygen via nasal cannula. Within 5 minutes, her oxygen saturation increased to 92%, and she reported increased ease in respiration.

Based on the handoff report, the night shift nurse provided substantial clinical evidence that the patient may be experiencing a change in condition. Although these changes could be attributed to lack of lung expansion that occurred while the patient was sleeping, there is enough information to indicate to the oncoming nurse that follow-up assessment and interventions should be prioritized for this patient because of potentially worsening respiratory status. In this manner, identifying data cues from a handoff report can assist with prioritization.

Now imagine the night shift nurse had not reported this information during the handoff report. Is there another method for identifying potential changes in patient condition? Many nurses develop a habit of reviewing their patients’ charts at the start of every shift to identify trends and “baselines” in patient condition. For example, a chart review reveals a patient’s heart rate on admission was 105 beats per minute. If the patient continues to have a heart rate in the low 100s, the nurse is not likely to be concerned if today’s vital signs reveal a heart rate in the low 100s. Conversely, if a patient’s heart rate on admission was in the 60s and has remained in the 60s throughout their hospitalization, but it is now in the 100s, this finding is an important cue requiring prioritized assessment and intervention.

Diagnostic Information

Diagnostic results are also important when prioritizing care. In fact, the National Patient Safety Goals from The Joint Commission include prompt reporting of important test results. New abnormal laboratory results are typically flagged in a patient’s chart or are reported directly by phone to the nurse by the laboratory as they become available. Newly reported abnormal results, such as elevated blood levels or changes on a chest X-ray, may indicate a patient’s change in condition and require additional interventions. For example, consider Scenario H in which you are the nurse providing care for five medical-surgical patients.

You completed morning assessments on your assigned five patients. Patient A previously underwent a total right knee replacement and will be discharged home today. You are about to enter Patient A’s room to begin discharge teaching when you receive a phone call from the laboratory department, reporting a critical hemoglobin of 6.9 gm/dL on Patient B. Rather than enter Patient A’s room to perform discharge teaching, you immediately reprioritize your care. You call the primary provider to report Patient B’s critical hemoglobin level and determine if additional intervention, such as a blood transfusion, is required.

2.4. CRITICAL THINKING AND CLINICAL REASONING

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 1 ] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action. Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [2]

When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet patient-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their patients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their patients may be late if one of the patients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the patient-care team.

Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Patients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of patient-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with patients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today’s health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe patient care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.

2.7. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

Temperature	98.9 °F (37.2°C)
Heart Rate	182 beats/min
Respirations	36 breaths/min
Blood Pressure	152/90 mm Hg
Oxygen Saturation	88% on room air
Capillary Refill Time	>3
Pain	9/10 chest discomfort

Physical Assessment Findings
Glasgow Coma Scale Score	14
Level of Consciousness	Alert
Heart Sounds	Irregularly regular
Lung Sounds	Clear bilaterally anterior/posterior
Pulses-Radial	Rapid/bounding
Pulses-Pedal	Weak
Bowel Sounds	Present and active x 4
Edema	Trace bilateral lower extremities
Skin	Cool, clammy

Nursing Action	Indicated	Contraindicated	Nonessential
Apply oxygen at 2 liters per nasal cannula.
Call imaging for a STAT lung CT.
Perform the National Institutes of Health (NIH) Stroke Scale Neurologic Exam.
Obtain a comprehensive metabolic panel (CMP).
Obtain a STAT EKG.
Raise the head-of-bed to less than 10 degrees.
Establish patent IV access.
Administer potassium 20 mEq IV push STAT.

The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among C ritical needs, U rgent needs, R outine needs, and E xtras.

You are the nurse caring for the patients in the following table. For each patient, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.

	Critical	Urgent	Routine	Extra
Patient exhibits new left-sided facial droop
Patient reports 9/10 acute pain and requests PRN pain medication
Patient with BP 120/80 and regular heart rate of 68 has scheduled dose of oral amlodipine
Patient with insomnia requests a back rub before bedtime
Patient has a scheduled dressing change for a pressure ulcer on their coccyx
Patient is exhibiting new shortness of breath and altered mental status
Patient with fall risk precautions ringing call light for assistance to the restroom for a bowel movement

II. GLOSSARY

Airway, breathing, and circulation.

Nursing problems currently occurring with the patient.

The level of patient care that is required based on the severity of a patient’s illness or condition.

A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.

Conditions having a sudden onset.

Conditions that have a slow onset and may gradually worsen over time.

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[ 1 ]

A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 2 ]

A strategy for prioritization based on identifying “critical” needs, “urgent” needs, “routine” needs, and “extras.”

Pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition.

Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.

Prioritization strategies often reflect the foundational elements of physiological needs and safety and progr ess toward higher levels.

A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.

A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.

A prioritization strategy including the review of planned tasks and allocation of time believed to be required to complete each task.

A feeling of racing against a clock that is continually working against you.

Conditions that are not likely to occur in the normal progression of an illness, disease, or injury.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 - Prioritization.
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PRIORITIZATION INTRODUCTION
TENETS OF PRIORITIZATION
TOOLS FOR PRIORITIZING
CRITICAL THINKING AND CLINICAL REASONING
LEARNING ACTIVITIES

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Prioritization, Delegation, and Assignment in Nursing NCLEX Practice Questions (100 Items)

Prioritization, Delegation, and Assignment Nursing Test Banks for NCLEX RN

In this NCLEX guide , we’ll help you review and prepare for prioritization, delegation, and assignment in your nursing exams. For this nursing test bank , improve your prioritization, delegation , and patient assignment skills by exercising with these practice questions. We will also be teaching you test-taking tips and strategies so you can tackle these questions in the NCLEX with ease. The goal of these practice quizzes and reviewers is to help student nurses establish a foundation of knowledge and skills on prioritization, delegation, and assignment.

Quiz Guidelines

Before you start, here are some examination guidelines and reminders you must read:

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Prioritization, Delegation, and Assignment Practice Quiz

This section contains the practice questions to exercise your knowledge on nursing prioritization, delegation, and assignment. As with other quizzes, be sure to read and understand the question carefully. For prioritization, delegation, and assignment questions, read each choice carefully before deciding on your answer. Good luck and answer these questions at your own pace. You are here to learn.

Quizzes included in this guide are:

Quiz No.	Quiz Title	Questions

1		25
2		25
3		25
4		25

Nursing Prioritization, Delegation and Assignment Reviewer for Nurses

This is your guide to help you answer NCLEX priority, delegation, and assignment style questions.

NCLEX Tips for Nursing Prioritization, Delegation, and Assignment questions:

Here are six tips and strategies to help you ace NCLEX questions about delegation, assignment, and prioritization.

1. Do not make decisions based on resolutions

Do not make decisions concerning the management of care issues based on resolutions you may have witnessed during your clinical experience in the hospital or clinic setting. As a student nurse , you are constantly reminded that NCLEX questions are to be solved and responded to in the context of “Ivory Tower Nursing.” That is, if you only had one patient at a time, loads of assistive personnel, countless supplies, and equipment. This is what people mean when they refer to “ textbook nursing .” But when you’re in the real world without the time and resources, you adjust. Your clinical rotation in management may have been less than ideal but remember that in NCLEX, the answers to the questions are seen in nursing textbooks or journals. Always bear in mind, “Is this textbook nursing care?”

2. Never delegate the functions of assessment, evaluation and nursing judgment.

Throughout your nursing education , you learned that assessments, nursing diagnosis , establishing expected outcomes, evaluating care and any other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge are the responsibilities of the registered professional nurse. You cannot give these responsibilities to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides.

3. Identify tasks for delegation based on the client’s needs.

Delegate activities for stable patients because some of these needs are relatively predictable and more frequently encountered. These are somewhat routinized and without the need for high levels of professional judgment and skill. But if the patient is unstable, the needs are acute and become unpredictable, ever-changing, and rarely encountered based on the patient’s changing status. These needs should not be delegated.

4. Ensure the appropriate education, skills, and experience of personnel performing delegated tasks.

Delegate activities that involve standard, consistent, and unchanged systems and procedures. The care of a patient with chest tubes and chest drainage can be delegated to either another RN or a licensed practical nurse. Therefore, the authorizing RN must ensure that the nurse is qualified, skilled, and competent to perform this intricate task, observe the patient’s response to this treatment, and ensure that the equipment is operating suitably and accurately.

The care of a stable chronically ill patient who is comparatively stable and more anticipated than a seriously ill and unstable acute patient can be assigned to the licensed practical nurse, and assistance with the activities of daily living and basic hygiene and comfort care can be assigned and delegated to an unlicensed assistive staff member like a nursing assistant or a patient care technician. Activities that frequently occur in daily patient care can be delegated. Bathing, feeding , dressing , and transferring patients are examples.

Procedures that are complex or complicated should not be delegated, especially if the patient is highly unstable.

5. Remember priorities!

Recall and understand Maslow’s Hierarchy of Needs , the ABCs (Airway, Breathing, Circulation ), and stable versus unstable. It is necessary to know and understand the priorities when deciding which patient the RN should attend to first. Remember that you can see only one patient or perform one activity when answering questions that require you to establish priorities.

Always keep in mind that improper and inappropriate assignments can lead to inadequate quality of care, unexpected care outcomes, the jeopardization of client safety, and even legal consequences. Right assignment of care to others, including nursing assistants, licensed practical nurses, and other registered nurses, is certainly one of the most significant daily decisions nurses make.

6. Additional Test Taking Tips and Strategies

Questions using keywords such as “ best ,” “ essential ,” “ highest priority ,” “ primary ,” “ immediate ,” “ first ,” or “ initial response ” are asking for your prioritizing skills.
Know the patient’s purpose of care, current clinical condition, and outcome of care in order to determine and plan priorities.
Identify the priority patient based on the following: patient’s age, day of admission/ surgery , or the number of body systems involved.
Unlicensed assistive personnel (UAP) such as nurses’ aides, certified nursing assistants, attendants, health aides are not allowed to delegate. Only a registered nurse can delegate tasks.
In some states, Licensed Practical Nurses ( LPN ) may delegate to a UAP depending on the state nursing practice .
Ensure the appropriate knowledge, skills, and experience of personnel performing the delegated tasks.
Do not delegate teaching, assessment , planning , evaluating, and nursing judgment to an unlicensed nurse.
A client with an unstable and unpredictable condition cannot be delegated to a UAP’s or LPNs.
Delegate tasks that involve standard, simple procedures such as bathing , dressing , feeding , and transferring patients.
Student nurses, float nurses, personal assistants, and other personnel may require levels of guidance and supervision.

Nursing Prioritization

Prioritization is deciding which needs or problems require immediate action and which ones could be delayed until later because they are not urgent. In the NCLEX, you will encounter questions that require you to use the skill of prioritizing nursing actions. These nursing prioritization questions are often presented using the multiple-choice format or via ordered-response format. For a review, in an ordered-response question format , you’ll be asked to use the computer mouse to drag and drop your nursing actions in order or priority. Based on the information presented, determine what you’ll do first, second, third, and so forth. Directions are provided with the question. To help you answer nursing prioritization questions, remember the three principles commonly used:

1. Remember ABC’s (airway, breathing, and circulation).

Patients with obvious respiratory problems or interventions to provide airway management are given priority.

2. Maslow’s Hierarchy of Needs

Use Maslow’s hierarchy of needs as a guide to prioritize by determining the order of priority by addressing the physiological needs first.

There are five different levels of Maslow’s hierarchy of needs:

Physiological Needs. The basic physiological needs have the highest priority and must be met first. Some examples of physiological needs include oxygen, food, fluid, nutrition , shelter, sleep , clothing, and reproduction.
Safety Needs. Safety can be divided into physical and physiological. These include health, property, employment, security of the environment, and resources.
Social Needs. These include love, family, friendship, and intimacy.
Esteem. These include confidence, self-esteem , respect, and achievement.
Self-actualization. These include creativity, morality, and problem-solving.

3. Using the Nursing Process

The nursing process is a systematic approach to assess and give care to patients. Assessment should always be done first before planning or providing interventions.

Delegation in Nursing

Delegation is the transference of responsibility and authority for an activity to other health care members who are competent to do so. The “delegate” assumes responsibility for the actual performance of the task and procedure. The nurse (delegator) maintains accountability for the decision to delegate and for the appropriateness of nursing care rendered to the patient. The role of a registered nurse also includes delegating care, assigning tasks, organizing and managing care, supervising care delivered by other health care providers while effectively managing time! The NCLEX includes questions related to this unique nursing role of delegation.

5 Rights of Delegation in Nursing

The following are the five rights of delegation in nursing:

Right Person. The licensed nurse and the employer and the delegatee are responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity.
Right Tasks. The activity falls within the delegatees’ job description or is included as part of the nursing practice settings established written policies and procedures. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
Each delegation situation should be specific to the patient, the licensed nurse, and the delegatee.
The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee should ask any clarifying questions as part of two-way communication . This communication includes any data that needs to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation.
The delegatee must understand the terms of the delegation and must agree to accept the delegated activity.
The licensed nurse should ensure that the delegatee understands that she or he cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse.
Right Circumstances. The health condition of the patient must be stable. If the patient’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation.
The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating patient outcomes . The delegatee is responsible for communicating patient information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary.
The licensed nurse should ensure appropriate documentation of the activity is completed.

Recommended Resources

Recommended books and resources for your NCLEX success:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

Illustrated Study Guide for the NCLEX-RN® Exam The 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. This study guide gives you a robust, visual, less-intimidating way to remember key facts. 2,500 review questions are now included on the Evolve companion website. 25 additional illustrations and mnemonics make the book more appealing than ever.

NCLEX RN Examination Prep Flashcards (2023 Edition) NCLEX RN Exam Review FlashCards Study Guide with Practice Test Questions [Full-Color Cards] from Test Prep Books. These flashcards are ready for use, allowing you to begin studying immediately. Each flash card is color-coded for easy subject identification.

11 thoughts on “Prioritization, Delegation, and Assignment in Nursing NCLEX Practice Questions (100 Items)”

Very helpful. A LPN graduate who has taken the nclex four times. It gives me a quick overview. Thanks

Love it!!! These made me think. They up there with ReMar and uWorld.

Very helpful thanks

In which order will the nurse perform the following actions as she prepares to leave the room of a client with airborne precautions after performing oral suctioning?

please your order for this question is wrong

I have learned a lot from the NursesLabs. Love it!

Nurse Pietro receives an 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take FIRST? First- Speak with parents as to how injury occurred??? Yes, this is going to take place but this the first thing to do? Perhaps the wording needs to change as I have been “textbook” taught, treat first, then question in cases of suspected abuse.

good questions which test your analyzing and critical thinking skils

Thank you for making this free. It is my additional resources. This has been very helpful. I really appreciate that you are helping all future nurses to be at their best .

I’m really grateful for this excercise which aids in preparing for the NCLEX. Thanks

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2.3 Tools for Prioritizing

Organizations use a variety of systems when determining patient acuity with rating scales based on nursing care delivery, patient stability, and care needs. See an example of a patient acuity tool published in the American Nurse in Table 2.3. [2] In this example, ratings range from 1 to 4, with a rating of 1 indicating a relatively stable patient requiring minimal individualized nursing care and intervention. A rating of 2 reflects a patient with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex patient who requires frequent intervention and assessment. This patient might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk patient. For example, this individual may be experiencing frequent changes in vital signs, may require complex interventions such as the administration of blood transfusions, or may be experiencing significant uncontrolled pain. An individual with a rating of 4 requires more direct nursing care and intervention than a patient with a rating of 1 or 2. [3]

Table 2.3 Example of a Patient Acuity Tool [4]

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

Staffing Models and Acuity

Patient A: 45-year-old patient with paraplegia admitted for an infected sacral wound, with an acuity rating of 4.

Patient B: 87-year-old patient with pneumonia with a low grade fever of 99.7 F and receiving oxygen at 2 L/minute via nasal cannula, with an acuity rating of 2.

Patient C: 63-year-old patient who is postoperative Day 1 from a right total hip replacement and is receiving pain management via a PCA pump, with an acuity rating of 2.

Patient D: 83-year-old patient admitted with a UTI who is finishing an IV antibiotic cycle and will be discharged home today, with an acuity rating of 1.

Although acuity can a useful tool for determining care priorities, it is important to recognize the limitations of this tool and consider how other patient needs impact prioritization.

Maslow’s Hierarchy of Needs

When thinking back to your first nursing or psychology course, you may recall a historical theory of human motivation based on various levels of human needs called Maslow’s Hierarchy of Needs. Maslow’s Hierarchy of Needs reflects foundational human needs with progressive steps moving towards higher levels of achievement. This hierarchy of needs is traditionally represented as a pyramid with the base of the pyramid serving as essential needs that must be addressed before one can progress to another area of need. [6] See Figure 2.1 [7] for an illustration of Maslow’s Hierarchy of Needs.

Maslow’s Hierarchy of Needs places physiological needs as the foundational base of the pyramid. [8] Physiological needs include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second level of Maslow’s hierarchy reflects safety needs. Safety needs include elements that keep individuals safe from harm. Examples of safety needs in health care include fall precautions. The third level of Maslow’s hierarchy reflects emotional needs such as love and a sense of belonging. These needs are often reflected in an individual’s relationships with family members and friends. The top two levels of Maslow’s hierarchy include esteem and self-actualization. An example of addressing these needs in a health care setting is helping an individual build self-confidence in performing blood glucose checks that leads to improved self-management of their diabetes.

So how does Maslow’s theory impact prioritization? To better understand the application of Maslow’s theory to prioritization, consider Scenario C in the following box.

Should I begin to make phone calls to try and find her family? Maybe then she would be able to calm down.

Should I get her on the list for the homeless shelter so she wouldn’t have to worry about where she will sleep tonight?

She hasn’t eaten in awhile; I should probably find her something to eat.

The third part of the CURE hierarchy reflects “routine” patient needs. Routine patient needs can also be characterized as “typical daily nursing care” because the majority of a standard nursing shift is spent addressing routine patient needs. Examples of routine daily nursing care include actions such as administering medication and performing physical assessments. [11] Although a nurse’s typical shift in a hospital setting includes these routine patient needs, they do not supersede critical or urgent patient needs.

The final component of the CURE hierarchy is known as “extras.” Extras refer to activities performed in the care setting to facilitate patient comfort but are not essential. [12] Examples of extra activities include providing a massage for comfort or washing a patient’s hair. If a nurse has sufficient time to perform extra activities, they contribute to a patient’s feeling of satisfaction regarding their care, but these activities are not essential to achieve patient outcomes.

Let’s apply the CURE mnemonic to patient care in the following box.

If we return to Scenario D regarding patients in Room 504 and 506, we can see the patient in Room 504 is having urgent needs. He is experiencing a physiological need to urgently use the restroom and may also have safety concerns if he does not receive assistance and attempts to get up on his own because of weakness. He is on a bed alarm, which reflects safety considerations related to his potential to get out of bed without assistance. Despite these urgent indicators, the patient in Room 506 is experiencing a critical need and takes priority. Recall that critical needs require immediate nursing action to prevent patient deterioration. The patient in Room 506 with a rapid, fluttering heartbeat and shortness of breath has a critical need because without prompt assessment and intervention, their condition could rapidly decline and become fatal.

Acute Versus Chronic Conditions

Actual Versus Potential Problems

Consider an example of prioritizing actual and potential problems in Scenario F in the following box.

Although there may be times when risk problems may supersede actual problems, looking to the “actual” nursing problems can provide clues to assist with prioritization.

Unexpected Versus Expected Conditions

Handoff Report/Chart Review

Imagine you are receiving the following handoff report from the night shift nurse for a patient admitted to the medical-surgical unit with pneumonia:

Diagnostic Information

Prioritization Principles & Staffing Considerations [13]

With the complexity of different staffing variables in healthcare settings, it can be challenging to identify a method and solution that will offer a resolution to every challenge. The American Nurses Association has identified five critical principles that should be considered for nurse staffing. These principles include:

Health Care Consumer: Nurse staffing decisions are influenced by the the specific number and needs of the healthcare consumer. The healthcare consumer includes not only the client, but also families, groups, and populations served. Staffing guidelines must always consider the patient safety indicators, clinical, and operational outcomes that are specific to a practice setting. What is appropriate for the consumer in one setting, may be quite different in another. Additionally, it is important to ensure that there is resource allocation for care coordination and health education in each setting.
Interprofessional Teams: As organizations identify what constitutes appropriate staffing in various settings, they must also consider the appropriate credentials and qualificiations of the nursing staff within a specific setting. This involves utilizing an interprofessional care team that allows each individual to practice to the full extent of their educational, training, scope of practice as defined by their state nurse practice act, and licensure. Staffing plans must include an appropriate skill mix and acknowledge the inmpact of more experienced nurses to help serve in mentoring and precepting roles.
Workplace culture: Staffing considerations must also account for the importance of balance between costs associated with best practice and the optimization of care outcomes. Healthcare leaders and organizations must strive to ensure a balance between quality, safety, and healthcare cost. Organizations are responsible for creating work environments which develop policies allowing for nurses to practice to the full extent of their licensure in accordance with their documented competence. Leaders must foster a culture of trust, collaboration, and respect among all members of the healthcare team which will create environments that engage and retain healthcare staff.
Practice environment: Staffing structures must be founded in a culture of safety where appropriate staffing is integral to achieve patient safety and quality goals. An optimal practice environment encourages nurses to report unsafe conditions or poor staffing that may impact safe care. Organizations should ensure that nurses have autonomy in reporting and concerns and may do so without threat of retaliation. The ANA has also taken the position to state that Mandatory overtime is an unacceptable solution to achieve appropriate staffing. Organizations must ensure that they have clear policies delineating length of shifts, meal breaks, and rest period to help ensure safety in patient care.
Evaluation: Staffing plans should be consistently evaluated and changed based upon evidence and client outcomes. Environmental factors and issues such as work related illness, injury, and turnover are important elements of determining the success of need for modification within a staffing plan. [14]
Oregon Health Authority. (2021, April 29). Hospital nurse staffing interpretive guidance on staffing for acuity & intensity . Public Health Division, Center for Health Protection. https://www.oregon.gov/oha/ph/providerpartnerresources/healthcareprovidersfacilities/healthcarehealthcareregulationqualityimprovement/pages/nursestaffing.aspx ↵
Ingram, A., & Powell, J. (2018). Patient acuity tool on a medical surgical unit. American Nurse . https://www.myamericannurse.com/patient-acuity-medical-surgical-unit/ ↵
Kidd, M., Grove, K., Kaiser, M., Swoboda, B., & Taylor, A. (2014). A new patient-acuity tool promotes equitable nurse-patient assignments. American Nurse Today, 9 (3), 1-4. https://www.myamericannurse.com/a-new-patient-acuity-tool-promotes-equitable-nurse-patient-assignments / ↵
Welton, J. M. (2017). Measuring patient acuity. JONA: The Journal of Nursing Administration, 47 (10), 471. https://doi.org/10.1097/nna.0000000000000516 ↵
Maslow, A. H. (1943). A theory of human motivation. Psychological Review , 50 (4), 370–396. https://doi.org/10.1037/h0054346 ↵
" Maslow's_hierarchy_of_needs.svg " by J. Finkelstein is licensed under CC BY-SA 3.0 ↵
Stoyanov, S. (2017). An analysis of Abraham Maslow's A Theory of Human Motivation (1st ed.). Routledge. https://doi.org/10.4324/9781912282517 ↵
Kohtz, C., Gowda, C., & Guede, P. (2017). Cognitive stacking: Strategies for the busy RN. Nursing2021, 47 (1), 18-20. https://doi.org/10.1097/01.nurse.0000510758.31326.92 ↵
ANA. (2024). Principles for nurse staffing. Retrieved from https://www.nursingworld.org/practice-policy/nurse-staffing/staffing-principles/ ↵

The level of patient care that is required based on the severity of a patient’s illness or condition.

A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.

A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.

Prioritization strategies often reflect the foundational elements of physiological needs and safety and progress toward higher levels.

Airway, breathing, and circulation.

Pieces of clinical information that direct the nurse toward a potential “actual problem” or a change in condition.

Conditions having a sudden and severe onset.

Have a slow onset and may gradually worsen over time.

Nursing problems currently occurring with the patient.

A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.

Conditions that are not likely to occur in the normal progression of an illness, disease or injury.

Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.

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Using Multiple-Client Unfolding Case Studies to Improve Critical Thinking and Prioritization Skills in Nursing Students

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1 By Heather Englund, PhD, RN, Assistant Professor, University of Wisconsin Oshkosh College of Nursing, [email protected].
PMID: 31274664
DOI: 10.1097/NNE.0000000000000715

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The ABCs of Nursing Prioritization

Marymount nursing students learning the principles of nursing prioritization

Prioritization is essential for nurses. The ability to look at a situation and determine what is most important, what is time-sensitive, what is critical to the desired outcome and ultimately what to do first and next is prioritization. The purpose of this blog is to explore strategies and guidelines behind prioritizing nursing care to assist current and future nurses in this critical thinking process.

Prioritizing Patient Care

The ability of nurses to prioritize patient care is paramount because it largely determines success or failure in delivering quality health care. The consequences of poor nursing prioritization can be severe, but experienced nurses know the rewards of making wise determinations of how to order their time, actions and attention throughout any given day.

Patient care delivery requires prioritization in several different ways. Nurses decide which actions to take regarding the health care of each patient. Nurses are also often required to decide which patient of a substantial caseload they attend to first.

In some situations and health care settings, nurses have more time to make decisions thoughtfully. In fast-paced environments where complex health conditions may have rapid status changes, prioritizing patient care can be a moment-by-moment series of quick choices. Therefore, it is beneficial for nurses to be well acquainted with general rules and principles for guiding prioritization.

Often called the ABCs of nursing prioritization, these systematic approaches may become second nature to expert nurses and are lifelines for newer nurses who may be less familiar and less comfortable when complex cases inevitably arise.

ABCs of Nursing Prioritization

Perhaps you are looking to enter your second career as a nurse. You may attempt to envision a typical day if you choose to pursue a nursing degree. Imagine you are assigned to care for your very first simulated patient as a student. The patient in the simulation laboratory is gasping for air and has skin that is beginning to turn pale in color with blue undertones. You understand this is an urgent moment, and a nursing faculty member asks what you will do.

The ABCs of nursing prioritization is the starting point for making these decisions. The ABCs are a mnemonic for making it simpler to remember what is most important when you are in these sometimes stressful situations.

A stands for airway
B stands for breathing
C stands for circulation

Life-threatening circumstances may exist when these ABCs of nursing are involved. If the patient’s airway is not open, they cannot breathe. If the patient’s breathing is shallow, labored or hindered, the lack of oxygen intake may instantly become extremely serious. If the patient is profusely bleeding or circulation is otherwise blocked or impaired, the body tissues may not have the blood flow required to sustain vital organ function.

As a nurse, your first job is to remember that these ABCs are the highest priority to address in alphabetical order. Maslow’s hierarchy of needs and the nursing process are additional tools for guiding the decisions of prioritization. Next, we will explore these organized approaches to prioritizing patient care.

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Maslow’s Hierarchy of Needs

Current nurses have likely learned about Maslow’s hierarchy of needs. Abraham Maslow noted that humans are motivated to meet certain needs before they can achieve a higher level of needs. In other words, some conditions are foundational and must be met before seeking to have additional needs met.

Maslow’s hierarchy of needs is visualized as a pyramid. Needs at the bottom of the pyramid are required as prerequisites to meeting needs higher on the pyramid. The categories of needs in Maslow’s theory are as follows (from the bottom of the pyramid to the top of the pyramid):

Physiological needs
Safety needs
Love and belonging needs
Esteem needs
Self-actualization

Using Maslow’s hierarchy of needs as a framework for prioritizing patient care is one step towards improving patient outcomes . When caring for a patient, the priority is to work toward meeting the patient’s physiological needs. These include stabilizing health conditions and ensuring adequate food, water, rest, shelter and clothing.

Maslow’s hierarchy of needs essentially states that when a person’s physiological needs are met, the person may then become motivated to meet their safety needs. These include areas of life that bring security, such as financial stability, health promotion, disease prevention and environmental safety. Job security and secure housing arrangements are in the category of safety needs.

It’s important to remember that the hierarchy of needs may not translate to a perfectly stepwise process in practice. There may be some overlap from one level to another — for example, a person may desire love and belonging but is still working on their basic safety requirements. But generally speaking, Maslow’s hierarchy shows that once a person’s physiologic and safety needs are met, a person begins to have the motivation to seek love and belonging.

Nurses may reference Maslow’s hierarchy of needs when advocating for patients, especially when a foundational unmet need prevents a patient from reaching higher levels. For example, patients experiencing a physiologic condition may worry about their job performance or safety because of their health status. Maslow’s hierarchy indicates that physiological needs must be met before safety, safety before love and belonging, love and belonging before esteem and esteem before self-actualization.

The Nursing Process

ABCs of nursing prioritization and Maslow’s hierarchy of needs can be considered while nurses also apply the steps of the nursing process. The nursing process is interconnected and cyclical, and includes the following stages:

Assessment: the collection of information about the patient’s condition
Diagnosis: identification of the problem to be addressed
Planning: determination along with the patient on how to manage the diagnosis
Implementation: carrying out the plan of care
Evaluation: assessment of whether implementation has met the goals of the care plan

Nurses using the nursing process begin with assessing a patient, remembering to assess airway, breathing and circulation first. Subjective and objective information is collected through a patient history and physical examination. Then, a nursing diagnosis is made, followed by planning for how to address the diagnosis. Finally, the plan is implemented and evaluated. The care team must then perform regular reassessments to determine patient outcomes, which may necessitate altering the plan.

Family nurse practitioners also use the nursing process. When a family nurse practitioner prescribes pharmacologic therapy for an infection, and the patient returns to the clinic without symptom resolution after treatment, the treatment can be evaluated as ineffective. At this point, the nurse practitioner will reassess the patient, confirm or alter the diagnosis and potentially prescribe an alternative therapeutic regimen.

If the patient does not take the medication as directed, the implementation phase of the nursing process did not happen as planned. This may require an adjustment to the plan of care. In some states, nurse practitioners have the authority to prescribe medications independently. In other states, nurse practitioners are advocating for full practice authority. In all states, nurse practitioners use the nursing process to organize and prioritize patient care.

How to Prioritize Care

When prioritizing patient care, it often helps to ask yourself some questions to ensure you make the best decisions. Some questions nurses can consider include:

If I do not attend to this situation immediately, how will this affect the patient?
Are there smaller tasks I can complete quickly or delegate safely?
Which actions will have a substantial impact on a patient’s health condition?
What can I do alone, and what requires the assistance of another nurse or physician?

It is a high priority to consider what actions will harm a patient if not completed immediately. Patient safety is critical — yours is, too. Consider how to use all available resources to manage time wisely. Nursing is a gratifying career when patients experience quality care, and nursing prioritization is one of the most critical skills for patient satisfaction.

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Fundamentals of Nursing: Client Prioritization Part 1

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Client prioritization is a favorite topic in the majority of nursing exams. Why wouldn’t it be? A huge chunk of the National Boards and NCLEX ® questions fall under client prioritization and delegation. We’ll be delving into client prioritization and discuss delegation in a separate video.

Prioritization Matters

It is vital for nursing students to know how to prioritize clients to identify which client gets care first easily. Considering that nursing has a lot of elements involved and time management is vital, one must be critical in managing a wide array of responsibilities that can be quite overwhelming. Not only is this important in a hospital setting but also prioritizing gets quite tricky in the exams.

Prioritization without the ABCs

They don’t make it like they used to – the nursing exams. Because sometimes, the questions that come out are the ones you least expected. We all know prioritizing is tied to the ABCs – airway, breathing, and circulation; technically, you are figuring out the client who has the higher chance of dying first.

But what if, during your exam, you were given a client prioritization question that is not an ABC? How are you going come up with the correct answer?

Currently, test questions about client prioritization don’t only focus on the ABCs; they also focus on matters like safety, infection and laboratory values among other things. So, how are you going to deal with questions without the ABCs?

After your ABCs, safety comes next in the hierarchy. So, if your client has an altered state of consciousness, it will be directly correlated to his or her safety; making it a huge priority because clients who are at risk for fall may hurt themselves and will endure further injury.

Sepsis and ABGs

Between a client who just came out of a surgical procedure versus someone who is going through sepsis, who should receive immediate attention? It would be the client with infection. Neutropenic precaution for people who have cancers is also included in this hierarchy.

ABG results showing respiratory acidosis which may lead to criteria for acute respiratory distress syndrome (ARDS) is another priority since it will be related to the ABCs. So between someone who has infection versus someone who has respiratory acidosis, the respiratory acidosis client comes first.

Side note: To avoid confusion between septic clients or those going into the Systemic Inflammatory Reactive Syndrome (SIRS) criteria versus those who have problems with their ABGs, you first need to have basic knowledge of the different components. By being familiar with what goes on between your SIRS and your ABGs, it would be easier for you to identify which should be prioritized.

Laboratory Values of the Lungs and Heart

Prioritizing clients with regards to their laboratory values, you have to consider the normal and abnormal values of the cardiac enzymes – CRP, CPK, and troponin. If you were given a question that focuses on laboratory values of the heart or lungs, you mainly have to point out which client is more likely to die. That would be the one who has the profound laboratory values.

When referring to diagnosis, it’s usually the post-operative clients that get immediate care. Therefore, if you get a question that asks you, “Who among the following would you see first?” The post-op client is a priority.

Which of the following clients must be checked first?

The client who has been in the hospital for three days after being diagnosed with COPD exacerbation
The post-MI client who’s been around for a day or two
The client who just came out of the operating room after having an angiocath

In this scenario, you will choose letter C since there are a lot of complications that may happen within the first few hours after the operation. These clients are sedated and are at risk for bleeding; which is also the reason why assessment and care for post-op clients are not delegated. Asthma exacerbation is also high on the diagnosis list.

Pain is low on the prioritization list because people do not die of pain. You have to keep in mind that prioritization is always based on the idea of choosing the client that has an increased chance of dying. Pain is manageable, and the discomfort can be tolerated for a certain period.

What to Remember

Client prioritization depends on the client’s status at a given moment. So you just need to identify who is at risk for danger or who is at risk for death. If you’ve observed, these clients who are post-operative, who have acute asthma attacks, or who have neutropenic precautions can all be qualified under top priority. Therefore, choosing your answer will greatly depend on the changes seen in the client and the severity of the condition.

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Using Multiple-Client Unfolding Case Studies to Improve Critical Thinking and Prioritization Skills in Nursing Students

Englund, Heather PhD, RN

By Heather Englund, PhD, RN, Assistant Professor, University of Wisconsin Oshkosh College of Nursing, [email protected] .

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How to Help Students Set Correct Priorities in the Clinical Setting

Search results and study selection and inclusion process [ 52 ]

Characteristics of included studies

The studies had multiple purposes, aiming to develop practice, implement a new approach, improve quality, or to develop a model. The 31 studies (across 32 hits) were case series studies ( n = 27), mixed methods studies ( n = 3) and a quasi-experimental study ( n = 1). All studies were published between the years 2004 and 2021. The highest number of papers was published in year 2020.

Table 2 describes the characteristics of included studies and Additional file 3 offers a narrative description of the studies.

Methodological quality assessment

Quasi-experimental studies.

We had one quasi-experimental study (ref 31). All questions in the critical appraisal tool were applicable. The total score of the study was 8 (out of a possible 9). Only one response of the tool was ‘no’ because no control group was used in the study (see Additional file 4 for the critical appraisal of included studies).

Case series studies . A case series study is typically defined as a collection of subjects with common characteristics. The studies do not include a comparison group and are often based on prevalent cases and on a sample of convenience [ 53 ]. Munn et al. [ 45 ] further claim that case series are best described as observational studies, lacking experimental and randomized characteristics, being descriptive studies, without a control or comparator group. Out of 27 case series studies included in our review, the critical appraisal scores varied from 1 to 9. Five references were conference abstracts with empirical study results, which were scored from 1 to 3. Full reports of these studies were searched in electronic databases but not found. Critical appraisal scores for the remaining 22 studies ranged from 1 to 9 out of a possible score of 10. One question (Q3) was not applicable to 13 studies: “Were valid methods used for identification of the condition for all participants included in the case series?” Only two studies had clearly reported the demographic of the participants in the study (Q6). Twenty studies met Criteria 8 (“Were the outcomes or follow-up results of cases clearly reported?”) and 18 studies met Criteria 7 (“Q7: Was there clear reporting of clinical information of the participants?”) (see Additional file 4 for the critical appraisal of included studies).

Mixed-methods studies

Mixed-methods studies involve a combination of qualitative and quantitative methods. This is a common design and includes convergent design, sequential explanatory design, and sequential exploratory design [ 46 ]. There were three mixed-methods studies. The critical appraisal scores for the three studies ranged from 60 to 100% out of a possible 100%. Two studies met all the criteria, while one study fulfilled 60% of the scored criteria due to a lack of information to understand the relevance of the sampling strategy well enough to address the research question (Q4.1) or to determine whether the risk of nonresponse bias was low (Q4.4) (see Additional file 4 for the critical appraisal of included studies).

Intervention or program components

The intervention of program components were categorized and described using the TiDier checklist: name and goal, theory or background, material, procedure, provider, models of delivery, location, dose, modification, and adherence and fidelity [ 48 ]. A description of intervention in each study is described in Additional file 5 and a narrative description in Additional file 6 .

Leadership problems

In line with the inclusion criteria, data for the leadership problems were categorized in all 31 included studies (see Additional file 7 for leadership problems). Three types of leadership problems were identified: implementation of knowledge into practice, the quality of clinical care, and resources in nursing care. A narrative summary of the results is reported below.

Implementing knowledge into practice

Eleven studies (35%) aimed to solve leadership problems related to implementation of knowledge into practice. Studies showed how to support nurses in evidence-based implementation (EBP) (ref 3, ref 5), how to engage nurses in using evidence in practice (ref 4), how to convey the importance of EBP (ref 22) or how to change practice (ref 4). Other problems were how to facilitate nurses to use guideline recommendations (ref 7) and how nurses can make evidence-informed decisions (ref 8). General concerns also included the linkage between theory and practice (ref 1) as well as how to implement the EBP model in practice (ref 6). In addition, studies were motivated by the need for revisions or updates of protocols to improve clinical practice (ref 10) as well as the need to standardize nursing activities (ref 11, ref 14).

The quality of the care

Thirteen (42%) focused on solving problems related to the quality of clinical care. In these studies, a high number of catheter infections led a lack of achievement of organizational goals (ref 2, ref 9). A need to reduce patient symptoms in stem cell transplant patients undergoing high-dose chemotherapy (ref 24) was also one of the problems to be solved. In addition, the projects focused on how to prevent pressure ulcers (ref 26, ref 29), how to enhance the quality of cancer treatment (ref 25) and how to reduce the need for invasive constipation treatment (ref 30). Concerns about patient safety (ref 15), high fall rates (ref 16, ref 19), dissatisfaction of patients (ref 16, ref 18) and nurses (ref 16, ref 30) were also problems that had initiated the projects. Studies addressed concerns about how to promote good contingency care in residential aged care homes (ref 20) and about how to increase recognition of human trafficking problems in healthcare (ref 21).

Resources in nursing care

Nurse leaders identified problems in their resources, especially in staffing problems. These problems were identified in seven studies (23%), which involved concerns about how to prevent nurses from leaving the job (ref 31), how to ensure appropriate recruitment, staffing and retaining of nurses (ref 13) and how to decrease nurses’ burden and time spent on nursing activities (ref 12). Leadership turnover was also reported as a source of dissatisfaction (ref 17); studies addressed a lack of structured transition and training programs, which led to turnover (ref 23), as well as how to improve intershift handoff among nurses (ref 28). Optimal design for new hospitals was also examined (ref 27).

Main features of evidence-based leadership

Out of 31 studies, 17 (55%) included all four domains of an evidence-based leadership approach, and four studies (13%) included evidence of critical appraisal of the results (see Additional file 8 for the main features of evidence-based Leadership) (ref 11, ref 14, ref 23, ref 27).

Organizational evidence

Twenty-seven studies (87%) reported how organizational evidence was collected and used to solve leadership problems (ref 2). Retrospective chart reviews (ref 5), a review of the extent of specific incidents (ref 19), and chart auditing (ref 7, ref 25) were conducted. A gap between guideline recommendations and actual care was identified using organizational data (ref 7) while the percentage of nurses’ working time spent on patient care was analyzed using an electronic charting system (ref 12). Internal data (ref 22), institutional data, and programming metrics were also analyzed to understand the development of the nurse workforce (ref 13).

Surveys (ref 3, ref 25), interviews (ref 3, ref 25) and group reviews (ref 18) were used to better understand the leadership problem to be solved. Employee opinion surveys on leadership (ref 17), a nurse satisfaction survey (ref 30) and a variety of reporting templates were used for the data collection (ref 28) reported. Sometimes, leadership problems were identified by evidence facilitators or a PI’s team who worked with staff members (ref 15, ref 17). Problems in clinical practice were also identified by the Nursing Professional Council (ref 14), managers (ref 26) or nurses themselves (ref 24). Current practices were reviewed (ref 29) and a gap analysis was conducted (ref 4, ref 16, ref 23) together with SWOT analysis (ref 16). In addition, hospital mission and vision statements, research culture established and the proportion of nursing alumni with formal EBP training were analyzed (ref 5). On the other hand, it was stated that no systematic hospital-specific sources of data regarding job satisfaction or organizational commitment were used (ref 31). In addition, statements of organizational analysis were used on a general level only (ref 1).

Scientific evidence identified

Twenty-six studies (84%) reported the use of scientific evidence in their evidence-based leadership processes. A literature search was conducted (ref 21) and questions, PICO, and keywords were identified (ref 4) in collaboration with a librarian. Electronic databases, including PubMed (ref 14, ref 31), Cochrane, and EMBASE (ref 31) were searched. Galiano (ref 6) used Wiley Online Library, Elsevier, CINAHL, Health Source: Nursing/Academic Edition, PubMed, and the Cochrane Library while Hoke (ref 11) conducted an electronic search using CINAHL and PubMed to retrieve articles.

Identified journals were reviewed manually (ref 31). The findings were summarized using ‘elevator speech’ (ref 4). In a study by Gifford et al. (ref 9) evidence facilitators worked with participants to access, appraise, and adapt the research evidence to the organizational context. Ostaszkiewicz (ref 20) conducted a scoping review of literature and identified and reviewed frameworks and policy documents about the topic and the quality standards. Further, a team of nursing administrators, directors, staff nurses, and a patient representative reviewed the literature and made recommendations for practice changes.

Clinical practice guidelines were also used to offer scientific evidence (ref 7, ref 19). Evidence was further retrieved from a combination of nursing policies, guidelines, journal articles, and textbooks (ref 12) as well as from published guidelines and literature (ref 13). Internal evidence, professional practice knowledge, relevant theories and models were synthesized (ref 24) while other study (ref 25) reviewed individual studies, synthesized with systematic reviews or clinical practice guidelines. The team reviewed the research evidence (ref 3, ref 15) or conducted a literature review (ref 22, ref 28, ref 29), a literature search (ref 27), a systematic review (ref 23), a review of the literature (ref 30) or ‘the scholarly literature was reviewed’ (ref 18). In addition, ‘an extensive literature review of evidence-based best practices was carried out’ (ref 10). However, detailed description how the review was conducted was lacking.

Views of stakeholders

A total of 24 studies (77%) reported methods for how the views of stakeholders, i.e., professionals or experts, were considered. Support to run this study was received from nursing leadership and multidisciplinary teams (ref 29). Experts and stakeholders joined the study team in some cases (ref 25, ref 30), and in other studies, their opinions were sought to facilitate project success (ref 3). Sometimes a steering committee was formed by a Chief Nursing Officer and Clinical Practice Specialists (ref 2). More specifically, stakeholders’ views were considered using interviews, workshops and follow-up teleconferences (ref 7). The literature review was discussed with colleagues (ref 11), and feedback and support from physicians as well as the consensus of staff were sought (ref 16).

A summary of the project findings and suggestions for the studies were discussed at 90-minute weekly meetings by 11 charge nurses. Nurse executive directors were consulted over a 10-week period (ref 31). An implementation team (nurse, dietician, physiotherapist, occupational therapist) was formed to support the implementation of evidence-based prevention measures (ref 26). Stakeholders volunteered to join in the pilot implementation (ref 28) or a stakeholder team met to determine the best strategy for change management, shortcomings in evidence-based criteria were discussed, and strategies to address those areas were planned (ref 5). Nursing leaders, staff members (ref 22), ‘process owners (ref 18) and program team members (ref 18, ref 19, ref 24) met regularly to discuss the problems. Critical input was sought from clinical educators, physicians, nutritionists, pharmacists, and nurse managers (ref 24). The unit director and senior nursing staff reviewed the contents of the product, and the final version of clinical pathways were reviewed and approved by the Quality Control Commission of the Nursing Department (ref 12). In addition, two co-design workshops with 18 residential aged care stakeholders were organized to explore their perspectives about factors to include in a model prototype (ref 20). Further, an agreement of stakeholders in implementing continuous quality services within an open relationship was conducted (ref 1).

Critical appraisal

In five studies (16%), a critical appraisal targeting the literature search was carried out. The appraisals were conducted by interns and teams who critiqued the evidence (ref 4). In Hoke’s study, four areas that had emerged in the literature were critically reviewed (ref 11). Other methods were to ‘critically appraise the search results’ (ref 14). Journal club team meetings (ref 23) were organized to grade the level and quality of evidence and the team ‘critically appraised relevant evidence’ (ref 27). On the other hand, the studies lacked details of how the appraisals were done in each study.

The perceived effects of evidence-based leadership

Perceived effects of evidence-based leadership on nurses’ performance.

Eleven studies (35%) described perceived effects of evidence-based leadership on nurses’ performance (see Additional file 9 for perceived effects of evidence-based leadership), which were categorized in four groups: awareness and knowledge, competence, ability to understand patients’ needs, and engagement. First, regarding ‘awareness and knowledge’, different projects provided nurses with new learning opportunities (ref 3). Staff’s knowledge (ref 20, ref 28), skills, and education levels improved (ref 20), as did nurses’ knowledge comprehension (ref 21). Second, interventions and approaches focusing on management and leadership positively influenced participants’ competence level to improve the quality of services. Their confidence level (ref 1) and motivation to change practice increased, self-esteem improved, and they were more positive and enthusiastic in their work (ref 22). Third, some nurses were relieved that they had learned to better handle patients’ needs (ref 25). For example, a systematic work approach increased nurses’ awareness of the patients who were at risk of developing health problems (ref 26). And last, nurse leaders were more engaged with staff, encouraging them to adopt the new practices and recognizing their efforts to change (ref 8).

Perceived effects on organizational outcomes

Nine studies (29%) described the perceived effects of evidence-based leadership on organizational outcomes (see Additional file 9 for perceived effects of evidence-based leadership). These were categorized into three groups: use of resources, staff commitment, and team effort. First, more appropriate use of resources was reported (ref 15, ref 20), and working time was more efficiently used (ref 16). In generally, a structured approach made implementing change more manageable (ref 1). On the other hand, in the beginning of the change process, the feedback from nurses was unfavorable, and they experienced discomfort in the new work style (ref 29). New approaches were also perceived as time consuming (ref 3). Second, nurse leaders believed that fewer nursing staff than expected left the organization over the course of the study (ref 31). Third, the project helped staff in their efforts to make changes, and it validated the importance of working as a team (ref 7). Collaboration and support between the nurses increased (ref 26). On the other hand, new work style caused challenges in teamwork (ref 3).

Perceived effects on clinical outcomes

Five studies (16%) reported the perceived effects of evidence-based leadership on clinical outcomes (see Additional file 9 for perceived effects of evidence-based leadership), which were categorized in two groups: general patient outcomes and specific clinical outcomes. First, in general, the project assisted in connecting the guideline recommendations and patient outcomes (ref 7). The project was good for the patients in general, and especially to improve patient safety (ref 16). On the other hand, some nurses thought that the new working style did not work at all for patients (ref 28). Second, the new approach used assisted in optimizing patients’ clinical problems and person-centered care (ref 20). Bowel management, for example, received very good feedback (ref 30).

The measured effects of evidence-based leadership

The measured effects on nurses’ performance.

Data were obtained from 20 studies (65%) (see Additional file 10 for measured effects of evidence-based leadership) and categorized nurse performance outcomes for three groups: awareness and knowledge, engagement, and satisfaction. First, six studies (19%) measured the awareness and knowledge levels of participants. Internship for staff nurses was beneficial to help participants to understand the process for using evidence-based practice and to grow professionally, to stimulate for innovative thinking, to give knowledge needed to use evidence-based practice to answer clinical questions, and to make possible to complete an evidence-based practice project (ref 3). Regarding implementation program of evidence-based practice, those with formal EBP training showed an improvement in knowledge, attitude, confidence, awareness and application after intervention (ref 3, ref 11, ref 20, ref 23, ref 25). On the contrary, in other study, attitude towards EBP remained stable ( p = 0.543). and those who applied EBP decreased although no significant differences over the years ( p = 0.879) (ref 6).

Second, 10 studies (35%) described nurses’ engagement to new practices (ref 5, ref 6, ref 7, ref 10, ref 16, ref 17, ref 18, ref 21, ref 25, ref 27). 9 studies (29%) studies reported that there was an improvement of compliance level of participants (ref 6, ref 7, ref 10, ref 16, ref 17, ref 18, ref 21, ref 25, ref 27). On the contrary, in DeLeskey’s (ref 5) study, although improvement was found in post-operative nausea and vomiting’s (PONV) risk factors documented’ (2.5–63%), and ’risk factors communicated among anaesthesia and surgical staff’ (0–62%), the improvement did not achieve the goal. The reason was a limited improvement was analysed. It was noted that only those patients who had been seen by the pre-admission testing nurse had risk assessments completed. Appropriate treatment/prophylaxis increased from 69 to 77%, and from 30 to 49%; routine assessment for PONV/rescue treatment 97% and 100% was both at 100% following the project. The results were discussed with staff but further reasons for a lack of engagement in nursing care was not reported.

And third, six studies (19%) reported nurses’ satisfaction with project outcomes. The study results showed that using evidence in managerial decisions improved nurses’ satisfaction and attitudes toward their organization ( P < 0.05) (ref 31). Nurses’ overall job satisfaction improved as well (ref 17). Nurses’ satisfaction with usability of the electronic charting system significantly improved after introduction of the intervention (ref 12). In handoff project in seven hospitals, improvement was reported in all satisfaction indicators used in the study although improvement level varied in different units (ref 28). In addition, positive changes were reported in nurses’ ability to autonomously perform their job (“How satisfied are you with the tools and resources available for you treat and prevent patient constipation?” (54%, n = 17 vs. 92%, n = 35, p < 0.001) (ref 30).

The measured effects on organizational outcomes

Thirteen studies (42%) described the effects of a project on organizational outcomes (see Additional file 10 for measured effects of evidence-based leadership), which were categorized in two groups: staff compliance, and changes in practices. First, studies reported improved organizational outcomes due to staff better compliance in care (ref 4, ref 13, ref 17, ref 23, ref 27, ref 31). Second, changes in organization practices were also described (ref 11) like changes in patient documentation (ref 12, ref 21). Van Orne (ref 30) found a statistically significant reduction in the average rate of invasive medication administration between pre-intervention and post-intervention ( p = 0.01). Salvador (ref 24) also reported an improvement in a proactive approach to mucositis prevention with an evidence-based oral care guide. On the contrary, concerns were also raised such as not enough time for new bedside report (ref 16) or a lack of improvement of assessment of diabetic ulcer (ref 8).

The measured effects on clinical outcomes

A variety of improvements in clinical outcomes were reported (see Additional file 10 for measured effects of evidence-based leadership): improvement in patient clinical status and satisfaction level. First, a variety of improvement in patient clinical status was reported. improvement in Incidence of CAUTI decreased 27.8% between 2015 and 2019 (ref 2) while a patient-centered quality improvement project reduced CAUTI rates to 0 (ref 10). A significant decrease in transmission rate of MRSA transmission was also reported (ref 27) and in other study incidences of CLABSIs dropped following of CHG bathing (ref 14). Further, it was possible to decrease patient nausea from 18 to 5% and vomiting to 0% (ref 5) while the percentage of patients who left the hospital without being seen was below 2% after the project (ref 17). In addition, a significant reduction in the prevalence of pressure ulcers was found (ref 26, ref 29) and a significant reduction of mucositis severity/distress was achieved (ref 24). Patient falls rate decreased (ref 15, ref 16, ref 19, ref 27).

Second, patient satisfaction level after project implementation improved (ref 28). The scale assessing healthcare providers by consumers showed improvement, but the changes were not statistically significant. Improvement in an emergency department leadership model and in methods of communication with patients improved patient satisfaction scores by 600% (ref 17). In addition, new evidence-based unit improved patient experiences about the unit although not all items improved significantly (ref 18).

Stakeholder involvement in the mixed-method review

To ensure stakeholders’ involvement in the review, the real-world relevance of our research [ 53 ], achieve a higher level of meaning in our review results, and gain new perspectives on our preliminary findings [ 50 ], a meeting with 11 stakeholders was organized. First, we asked if participants were aware of the concepts of evidence-based practice or evidence-based leadership. Responses revealed that participants were familiar with the concept of evidence-based practice, but the topic of evidence-based leadership was totally new. Examples of nurses and nurse leaders’ responses are as follows: “I have heard a concept of evidence-based practice but never a concept of evidence-based leadership.” Another participant described: “I have heard it [evidence-based leadership] but I do not understand what it means.”

Second, as stakeholder involvement is beneficial to the relevance and impact of health research [ 54 ], we asked how important evidence is to them in supporting decisions in health care services. One participant described as follows: “Using evidence in decisions is crucial to the wards and also to the entire hospital.” Third, we asked how the evidence-based approach is used in hospital settings. Participants expressed that literature is commonly used to solve clinical problems in patient care but not to solve leadership problems. “In [patient] medication and care, clinical guidelines are regularly used. However, I am aware only a few cases where evidence has been sought to solve leadership problems.”

And last, we asked what type of evidence is currently used to support nurse leaders’ decision making (e.g. scientific literature, organizational data, stakeholder views)? The participants were aware that different types of information were collected in their organization on a daily basis (e.g. patient satisfaction surveys). However, the information was seldom used to support decision making because nurse leaders did not know how to access this information. Even so, the participants agreed that the use of evidence from different sources was important in approaching any leadership or managerial problems in the organization. Participants also suggested that all nurse leaders should receive systematic training related to the topic; this could support the daily use of the evidence-based approach.

To our knowledge, this article represents the first mixed-methods systematic review to examine leadership problems, how evidence is used to solve these problems and what the perceived and measured effects of evidence-based leadership are on nurse leaders and their performance, organizational, and clinical outcomes. This review has two key findings. First, the available research data suggests that evidence-based leadership has potential in the healthcare context, not only to improve knowledge and skills among nurses, but also to improve organizational outcomes and the quality of patient care. Second, remarkably little published research was found to explore the effects of evidence-based leadership with an efficient trial design. We validated the preliminary results with nurse stakeholders, and confirmed that nursing staff, especially nurse leaders, were not familiar with the concept of evidence-based leadership, nor were they used to implementing evidence into their leadership decisions. Our data was based on many databases, and we screened a large number of studies. We also checked existing registers and databases and found no registered or ongoing similar reviews being conducted. Therefore, our results may not change in the near future.

We found that after identifying the leadership problems, 26 (84%) studies out of 31 used organizational data, 25 (81%) studies used scientific evidence from the literature, and 21 (68%) studies considered the views of stakeholders in attempting to understand specific leadership problems more deeply. However, only four studies critically appraised any of these findings. Considering previous critical statements of nurse leaders’ use of evidence in their decision making [ 14 , 30 , 31 , 34 , 55 ], our results are still quite promising.

Our results support a previous systematic review by Geert et al. [ 32 ], which concluded that it is possible to improve leaders’ individual-level outcomes, such as knowledge, motivation, skills, and behavior change using evidence-based approaches. Collins and Holton [ 23 ] particularly found that leadership training resulted in significant knowledge and skill improvements, although the effects varied widely across studies. In our study, evidence-based leadership was seen to enable changes in clinical practice, especially in patient care. On the other hand, we understand that not all efforts to changes were successful [ 56 , 57 , 58 ]. An evidence-based approach causes negative attitudes and feelings. Negative emotions in participants have also been reported due to changes, such as discomfort with a new working style [ 59 ]. Another study reported inconvenience in using a new intervention and its potential risks for patient confidentiality. Sometimes making changes is more time consuming than continuing with current practice [ 60 ]. These findings may partially explain why new interventions or program do not always fully achieve their goals. On the other hand, Dubose et al. [ 61 ] state that, if prepared with knowledge of resistance, nurse leaders could minimize the potential negative consequences and capitalize on a powerful impact of change adaptation.

We found that only six studies used a specific model or theory to understand the mechanism of change that could guide leadership practices. Participants’ reactions to new approaches may be an important factor in predicting how a new intervention will be implemented into clinical practice. Therefore, stronger effort should be put to better understanding the use of evidence, how participants’ reactions and emotions or practice changes could be predicted or supported using appropriate models or theories, and how using these models are linked with leadership outcomes. In this task, nurse leaders have an important role. At the same time, more responsibilities in developing health services have been put on the shoulders of nurse leaders who may already be suffering under pressure and increased burden at work. Working in a leadership position may also lead to role conflict. A study by Lalleman et al. [ 62 ] found that nurses were used to helping other people, often in ad hoc situations. The helping attitude of nurses combined with structured managerial role may cause dilemmas, which may lead to stress. Many nurse leaders opt to leave their positions less than 5 years [ 63 ].To better fulfill the requirements of health services in the future, the role of nurse leaders in evidence-based leadership needs to be developed further to avoid ethical and practical dilemmas in their leadership practices.

It is worth noting that the perceived and measured effects did not offer strong support to each other but rather opened a new venue to understand the evidence-based leadership. Specifically, the perceived effects did not support to measured effects (competence, ability to understand patients’ needs, use of resources, team effort, and specific clinical outcomes) while the measured effects could not support to perceived effects (nurse’s performance satisfaction, changes in practices, and clinical outcomes satisfaction). These findings may indicate that different outcomes appear if the effects of evidence-based leadership are looked at using different methodological approach. Future study is encouraged using well-designed study method including mixed-method study to examine the consistency between perceived and measured effects of evidence-based leadership in health care.

There is a potential in nursing to support change by demonstrating conceptual and operational commitment to research-based practices [ 64 ]. Nurse leaders are well positioned to influence and lead professional governance, quality improvement, service transformation, change and shared governance [ 65 ]. In this task, evidence-based leadership could be a key in solving deficiencies in the quality, safety of care [ 14 ] and inefficiencies in healthcare delivery [ 12 , 13 ]. As WHO has revealed, there are about 28 million nurses worldwide, and the demand of nurses will put nurse resources into the specific spotlight [ 1 ]. Indeed, evidence could be used to find solutions for how to solve economic deficits or other problems using leadership skills. This is important as, when nurses are able to show leadership and control in their own work, they are less likely to leave their jobs [ 66 ]. On the other hand, based on our discussions with stakeholders, nurse leaders are not used to using evidence in their own work. Further, evidence-based leadership is not possible if nurse leaders do not have access to a relevant, robust body of evidence, adequate funding, resources, and organizational support, and evidence-informed decision making may only offer short-term solutions [ 55 ]. We still believe that implementing evidence-based strategies into the work of nurse leaders may create opportunities to protect this critical workforce from burnout or leaving the field [ 67 ]. However, the role of the evidence-based approach for nurse leaders in solving these problems is still a key question.

Limitations

This study aimed to use a broad search strategy to ensure a comprehensive review but, nevertheless, limitations exist: we may have missed studies not included in the major international databases. To keep search results manageable, we did not use specific databases to systematically search grey literature although it is a rich source of evidence used in systematic reviews and meta-analysis [ 68 ]. We still included published conference abstract/proceedings, which appeared in our scientific databases. It has been stated that conference abstracts and proceedings with empirical study results make up a great part of studies cited in systematic reviews [ 69 ]. At the same time, a limited space reserved for published conference publications can lead to methodological issues reducing the validity of the review results [ 68 ]. We also found that the great number of studies were carried out in western countries, restricting the generalizability of the results outside of English language countries. The study interventions and outcomes were too different across studies to be meaningfully pooled using statistical methods. Thus, our narrative synthesis could hypothetically be biased. To increase transparency of the data and all decisions made, the data, its categorization and conclusions are based on original studies and presented in separate tables and can be found in Additional files. Regarding a methodological approach [ 34 ], we used a mixed methods systematic review, with the core intention of combining quantitative and qualitative data from primary studies. The aim was to create a breadth and depth of understanding that could confirm to or dispute evidence and ultimately answer the review question posed [ 34 , 70 ]. Although the method is gaining traction due to its usefulness and practicality, guidance in combining quantitative and qualitative data in mixed methods systematic reviews is still limited at the theoretical stage [ 40 ]. As an outcome, it could be argued that other methodologies, for example, an integrative review, could have been used in our review to combine diverse methodologies [ 71 ]. We still believe that the results of this mixed method review may have an added value when compared with previous systematic reviews concerning leadership and an evidence-based approach.

Our mixed methods review fills the gap regarding how nurse leaders themselves use evidence to guide their leadership role and what the measured and perceived impact of evidence-based leadership is in nursing. Although the scarcity of controlled studies on this topic is concerning, the available research data suggest that evidence-based leadership intervention can improve nurse performance, organizational outcomes, and patient outcomes. Leadership problems are also well recognized in healthcare settings. More knowledge and a deeper understanding of the role of nurse leaders, and how they can use evidence in their own managerial leadership decisions, is still needed. Despite the limited number of studies, we assume that this narrative synthesis can provide a good foundation for how to develop evidence-based leadership in the future.

Implications

Based on our review results, several implications can be recommended. First, the future of nursing success depends on knowledgeable, capable, and strong leaders. Therefore, nurse leaders worldwide need to be educated about the best ways to manage challenging situations in healthcare contexts using an evidence-based approach in their decisions. This recommendation was also proposed by nurses and nurse leaders during our discussion meeting with stakeholders.

Second, curriculums in educational organizations and on-the-job training for nurse leaders should be updated to support general understanding how to use evidence in leadership decisions. And third, patients and family members should be more involved in the evidence-based approach. It is therefore important that nurse leaders learn how patients’ and family members’ views as stakeholders are better considered as part of the evidence-based leadership approach.

Future studies should be prioritized as follows: establishment of clear parameters for what constitutes and measures evidence-based leadership; use of theories or models in research to inform mechanisms how to effectively change the practice; conducting robust effectiveness studies using trial designs to evaluate the impact of evidence-based leadership; studying the role of patient and family members in improving the quality of clinical care; and investigating the financial impact of the use of evidence-based leadership approach within respective healthcare systems.

Data availability

The authors obtained all data for this review from published manuscripts.

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Acknowledgements

We want to thank the funding bodies, the Finnish National Agency of Education, Asia Programme, the Department of Nursing Science at the University of Turku, and Xiangya School of Nursing at the Central South University. We also would like to thank the nurses and nurse leaders for their valuable opinions on the topic.

The work was supported by the Finnish National Agency of Education, Asia Programme (grant number 26/270/2020) and the University of Turku (internal fund 26003424). The funders had no role in the study design and will not have any role during its execution, analysis, interpretation of the data, decision to publish, or preparation of the manuscript.

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Study design: MV, XL. Literature search and study selection: MV, KH, TL, WC, XL. Quality assessment: YT, SH, XL. Data extraction: JC, MV, JV, WC, YT, SH, GL. Analysis and interpretation: MV, SH. Manuscript writing: MV. Critical revisions for important intellectual content: MV, XL. All authors read and approved the final manuscript.

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Differences between the original protocol

We modified criteria for the included studies: we included published conference abstracts/proceedings, which form a relatively broad knowledge base in scientific knowledge. We originally planned to conduct a survey with open-ended questions followed by a face-to-face meeting to discuss the preliminary results of the review. However, to avoid extra burden in nurses due to COVID-19, we decided to limit the validation process to the online discussion only.

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Välimäki, M., Hu, S., Lantta, T. et al. The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review. BMC Nurs 23 , 452 (2024). https://doi.org/10.1186/s12912-024-02096-4

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2.3 Tools for Prioritizing

Organizations use a variety of systems when determining patient acuity with rating scales based on nursing care delivery, patient stability, and care needs. See an example of a patient acuity tool published in the American Nurse in Table 2.3. [2] In this example, ratings range from 1 to 4, with a rating of 1 indicating a relatively stable patient requiring minimal individualized nursing care and intervention. A rating of 2 reflects a patient with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex patient who requires frequent intervention and assessment. This patient might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk patient. For example, this individual may be experiencing frequent changes in vital signs, may require complex interventions such as the administration of blood transfusions, or may be experiencing significant uncontrolled pain. An individual with a rating of 4 requires more direct nursing care and intervention than a patient with a rating of 1 or 2. [3]

Table 2.3 Example of a Patient Acuity Tool [4]