Search

This study surveyed 114 registered nurses throughout Ohio to determine if there was a relationship between patient acuity and perceived fatigue. Also examined for a potential relationship to perceived fatigue were nurse-patient ratios (NPRs) and the method by which nurse-patient assignments (NPAs) were created. In addition, participants were asked to rate 15 nursing tasks to identify which imposed the most fatigue. Two validated fatigue scales, the Fatigue Assessment Scale (FAS) and the Occupational Fatigue Exhaustion Recovery (OFER) scale were used to capture participants perception of fatigue at their workplace. Results indicated that the interaction between patient acuity and NPR was significantly related to FAS ratings while NPR had a significant relationship to acute fatigue on the OFER scale. It was concluded that most nurses experience substantial fatigue, with high acuity patients having an overall greater impact, according to FAS ratings. OFER scale ratings suggest nurses only exhibit higher levels of acute fatigue for assignments containing more than five patients. For scheduling practices, it was recommended that NPAs shall contain fewer high acuity patients than lower acuity patients to minimize FAS ratings. Additionally, OFER-AF suggests that assignments should contain no more than five patients to mitigate the absence of lower acute fatigue levels.

As the largest sector of healthcare, nurses are the primary providers of patient care. By 2025, it is estimated that there will be a shortage of over 250,000 registered nurses (RNs) (American Association of Colleges of Nursing, 2011). Factors contributing to the nursing shortage include increased complexity of patients and decreased staffing that leads to decreased job satisfaction (Fox & Abrahamson, 2009). Over half of neonatal intensive care nurses reported missing at least one nursing task per shift when staffing was inadequate or patient acuity was high (TubbsCooley, Pickler, Younger, & Mark, 2015). The purpose of this evidence-based practice (EBP) project was to evaluate the effects of incorporating patient acuity into nursing assignments on nursing satisfaction and workload measures over a 3-month period. Kanter’s (1996) theory of structural empowerment and the Iowa model (2015) were used to guide the project on two medical units at a large pediatric hospital. Assignments for RNs were made by charge nurses who considered total patient acuity and each nurse’s proficiency level when making assignments. Nurses were surveyed using the Nurse Workload Satisfaction Questionnaire (NWSQ) pre- and post-implementation. In addition, two workload measures – pain reassessment within 30 minutes and medication given within 1 hour of scheduled time – were monitored throughout the study. Using paired t-tests, NWSQ scores showed a statistically significant increase in overall RN satisfaction. The mean pre-intervention NWSQ scores (M = 35.14, SD = 8.245) were compared to the mean post intervention NWSQ scores (M = 29.23, SD = 6.195, t = 2.833, p = .014). Other statistically significant improvements were found in the relational portion of the NWSQ, which gauges colleague relationships. There were no changes in the success rate of the two workload measures. Findings from this project support the incorporation of patient acuity into the nursing assignment process.

Challenges in the healthcare industry, including nursing shortages and low nursing retention, have resulted in nurses’ job dissatisfaction. Improving work environment and workload can lead to improved and equitable nursing shift assignments, which may improve nursing job satisfaction. The purpose of this EBP project was to (a) implement a patient acuity tool in the hospital unit, (b) assess its effectiveness in appropriating nursing shift assignments, and (c) evaluate its effect on nursing job satisfaction. The Evidence Based Medicine (EBM) Model was used as a guide to facilitate the transition of the best evidence into practice. As suggested within the evidence, utilization of a patient acuity tool in appropriating nursing shift assignments should increase nursing job satisfaction as compared with assignments based on charge nurse’s judgment alone. Based on an extensive review of the best available evidence from the literature and professional input from staff nurses, a patient acuity tool was created. Upon organizational and academic approval, education of the staff nurses on tool utilization was completed and the project was implemented. To determine the effectiveness of the tool, pre-and post-implementation, the Nursing Workplace Satisfaction Questionnaire (NWSQ) was administered. Paired sample t tests were conducted to analyze mean pre-and post-test scores in all three domains (intrinsic, extrinsic and relational) of the NWSQ. Statistically significant differences (t (19) = -2.67, p .05). All of the project participants stated that the use of the tool was quick and easy, 60% noted marked improvement in equity of shift assignments and 85% would like to continue using the tool after project completion. Also, 55% of participants reported better balanced nursing shift assignments with the tool utilization. Incorporation of the acuity tool in the clinical setting over a longer period of time might improve nursing job satisfaction.

Problem: The increased demand for emergency care in the United States (U.S.) has been well-documented and there is growing utilization of nurse practitioners in U.S. emergency departments. However, little is known about the nurse practitioner (NP) role in the emergency department setting within the past five years.Purpose: The purpose of this project was to describe the demographic characteristics of patients, patient conditions treated, diagnostic tests ordered, and procedures performed by nurse practitioners in a national sample of U.S. emergency departments. Methodology: This secondary analysis used a non-experimental quantitative, descriptive exploratory design to review data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national sample of visits to U.S. emergency departments. Results: From July 1 through December 31, 2010, there were 462 unique patient encounters in NHAMCS with the nurse practitioner as the sole provider of care. Most (91.8%) visits occurred in metropolitan/urban regions and in not-for-profit hospitals (78.1%). More than half of the patients were female (54.5%), 76.4% of participants were aged 44 years or younger, and approximately two-thirds (68.2%) identified as Caucasian. 65.5% of patient visits were for Emergency Severity Index (ESI) Level 4 (semi-urgent) and Level 5 (non-urgent) visits. The most frequent illnesses were ENT-related, while the most common injuries were related to falls. Diagnostic (laboratory, ECG) and imaging testing was ordered in 56.1% and 37.2% of respective patient encounters. Procedures were performed in 36.6% of visits. Medications were prescribed for a large majority of emergency visits (82.9%). NSAIDS (16.9%), narcotic analgesics (7.1%), and non-narcotic analgesics (5.6%) were the most commonly prescribed drug classes. Implications: This project reveals that most nurse practitioners working in emergency settings care for a variety of ESI Level 4 and Level 5 acuity patients in metropolitan and urban regions. As the utilization of nurse practitioners in emergency settings increases, the need for well-educated, academically prepared nurse practitioners in emergency care will become greater. Aligning graduate-level academic preparation, increasing continuing education offerings in emergency care, targeting advanced practice competencies, and supporting secondary certification in the specialty in accordance with the APRN Consensus Model, are essential. Future interdisciplinary research targeting the NP role in the ED is warranted.

Despite rich data on the association between nurse staffing and patient outcomes, evidence regarding the number and combination of nursing resources that optimize patient outcomes is lacking. One method of determining nurse staffing is patient acuity measurements, but inconsistencies exist in how acuity is defined and measured. The purpose of this study was to clarify the concept of acuity, recommend a standardized definition of acuity, and assess the psychometric properties of the Oncology Acuity Tool (OAT), a patient acuity tool currently in use on an inpatient oncology unit.Procedures included assessing inter-rater reliability (IRR), surveying expert oncology nurses for content validity, using a visual analog scale for concurrent validity, and assessing whether acuity scores predicted one of two acute events, patient falls and rapid response team consults, for predictive validity. Results demonstrated high inter-rater reliability (ICC=0.953, CI 0.914, 0.977; p 0.78; S-CVI=0.82; 84% of items had kappa statistics (k*) of good [k*=0.6-0.74] or excellent [k*>0.74]). Acuity scores during the shift of the acute event were significant predictors of rapid response team consults (OR=2.25, CI 1.45, 3.48; pThese data indicate that the OAT is a psychometrically sound instrument that demonstrates high reliability and validity for measuring acuity prospectively in the oncology inpatient population. These findings can be used in future research in oncology populations to test acuity as a structure and process variable in studies that examine the relationship between acuity-based staffing and patient outcomes. The methodology used in this study can be applied to the development of acuity tools in other populations and tests of the relationship between acuity-based staffing decisions and better patient outcomes.

The past decade has seen increased patient acuity and shortened lengths of stays in acute care hospitals (Australian Institute of Health and Welfare (AIHW), 2005), resulting in an intensification of the work undertaken by nursing staff in hospitals. Changes in nursing work have also been compounded by the proliferation of health care roles, a blurring of skill boundaries (AIHW, 2001; Buchan & Dal Poz, 2002; Hayman, Cioffi & Wilkes, 2006; Jones and Cheek, 2003) and an aging nursing workforce that is predominantly working part-time (Creegan, Duffield & Forrester, 2003). Moreover, with increasing demand for acute care beds (ABS, 2005), there is simply not enough licensed nursing staff to fill current vacancies (AIHW, 2005; Duffield & O’Brien-Pallas, 2002). Since 2003, the main response from the Australian government to the declining numbers of nursing workers has been to recruit more people to the nursing profession. However, it is becoming clear that recruitment alone is not enough, with shortages growing even as nursing school enrolments are increasing; therefore, it was timely to undertake a study to understand nurses’ perceptions of scope of practice to improve future efficiency in the nursing workforce by using the information derived to provide baseline data to guide workforce planning. The specific aim of this study was to understand how medical and surgical nurses, from two Queensland hospitals, conceive their scope of practice in response to the available grade mix and skill mix of nurses—licensed and unlicensed—and other health care professionals in the acute care setting. By exploring these meanings, this study aimed to build an understanding of how nursing work patterns were shifting in the face of changing patient acuity, patient profiles and nursing skill mix. To address this aim, a constructivist methodology was used that allowed for exploration of nursing role and scope of practice. While the notion of constructivism best describes the main approach to this study, it was also naturalistic to the extent that participants were reflecting on day-to-day experiences. The method used in this study is situated around the Critical Incident Technique (CIT) (Flanagan, 1954). CIT generates data representing experiences or perceptions of aspects of best and worst practice (Byrne, 2001). The researcher asked 20 registered nurse (RN) and enrolled nurse (EN) participants to discuss up to two particular significant events during which they were undertaking a patient care activity they perceived they should be undertaking, and up to two events during which they believed those activities should have either been delegated or undertaken by a higher level of care provider. Using the CIT in this way, allowed the researcher to gain an understanding of the nursing scope of practice and the interactions between nurses and other clinicians (Byrne, 2001) while also minimising pre-interpretation of the events by participants and focusing on a rich description of the chosen event (Flanagan, 1954). Purposive sampling was used to assist with the discovery of opposing points of view (Guba & Lincoln, 1989) with all RN and EN participants being employed on selected medical and surgical wards within two large hospitals based in South East Queensland. Inductive analysis, a process for searching for themes within the data, rather than imposing theories on the data (Guba & Lincoln, 1989), was used. Analysis revealed that the nursing work environment was changing. This was causing nursing staff to question what it meant to provide patient care given the increased numbers of health care workers (HCWs) in the acute care setting, rising patient acuity, and increased patient turnover. RNs were struggling with the notions that ‘hands-on’ care was sometimes not the best use of their time, and delegation did not equate with laziness. Five themes arose from the data: (1) good nurses work in proximity to patients providing total patient care; (2) safeguarding patients; (3) privileging patients without mental illness or cognitive impairment; (4) developing teamwork strategies; and (5) picking up the slack to ensure patient safety. Findings have shown that negotiation has become a fundamental aspect of nursing practice given the variety of nursing care providers currently employed in acute care settings. Previously, there wasn’t a need for nurses to negotiate care between licensed and unlicensed staff because HCWs were not employed in these settings. Negotiation has allowed nurses to redefine appropriate nurse–patient proximity, promote patient safety and find innovative ways of working in nursing teams. Practice negotiation will become a prominent topic over the coming years as hospital administrators struggle to employ licensed nurses.