what is a nursing assignment

The Ultimate Guide to Nursing Assignments: 7 Tips and Strategies

Nursing assignments are a critical component of every nursing student’s academic journey. They serve as opportunities to test your knowledge, apply theoretical concepts to real-world scenarios, and develop essential skills necessary for your future nursing career. However, tackling nursing assignments can often be overwhelming, particularly when you’re juggling multiple responsibilities. In this comprehensive guide, we provide valuable tips, strategies, and expert assignment help services to help you excel in your nursing assignments. Whether you’re struggling with research, structuring your assignment, or proofreading, we’re here to support you every step of the way.

Understanding the Nursing Assignments

To excel in nursing assignments , it’s crucial to start by thoroughly understanding the requirements. Take the time to carefully read the assignment prompt, paying close attention to the topic, word count, formatting guidelines, and any specific instructions provided by your instructor. Understanding these key components will ensure that you meet all the necessary criteria.

Conducting Thorough Research

Once you have a clear understanding of the assignment, it’s time to conduct thorough research. Solid research forms the foundation of any successful nursing assignment. Begin by gathering relevant and credible sources, such as nursing textbooks, scholarly articles, reputable websites , and academic databases specific to nursing. These resources will provide you with evidence-based information to support your arguments and demonstrate your understanding of the topic.

Creating a Well-Structured Outline

A well-structured outline is essential for organizing your thoughts and ensuring a logical flow in your nursing assignment. An effective outline acts as a roadmap, guiding you through the writing process and ensuring that you cover all the necessary points.

At [Your Service Name], our expert writers can assist you in creating a comprehensive outline tailored to your specific assignment. By collaborating with us, you can receive personalized guidance in organizing your ideas effectively and structuring your assignment in a logical manner. Our writers understand the nuances of nursing assignments and can help you identify the most important concepts and supporting evidence to include.

Using a Professional Tone

Maintaining a professional tone throughout your nursing assignment is crucial. As aspiring healthcare professionals, it’s essential to communicate your ideas with clarity, conciseness, and professionalism. Use clear and concise language, avoiding jargon or slang that may hinder the reader’s understanding. Present your arguments and supporting evidence in a logical and coherent manner, demonstrating your ability to think critically and apply nursing principles.

Our expert writers have extensive experience in academic writing within the field of nursing. They possess a deep understanding of the professional tone required for nursing assignments and can ensure that your assignment is written to the highest standards. By collaborating with us, you can receive guidance in maintaining a professional tone and effectively conveying your ideas.

Incorporating Practical Examples

In addition to a professional tone, incorporating practical examples into your nursing assignment can greatly enhance its quality. Practical examples bring theoretical concepts to life, illustrating their application in real-life scenarios. They demonstrate your understanding of nursing principles and showcase your ability to bridge the gap between theory and practice.

Our team consists of experienced nursing professionals who can assist you in incorporating relevant practical examples into your assignment. Drawing from their extensive knowledge and expertise, they can provide you with real-life scenarios or case studies that strengthen the impact and credibility of your work. By collaborating with us, you can elevate the quality of your assignment by demonstrating your ability to apply nursing concepts in practical settings.

Proofreading and Editing

Proofreading and editing are essential steps in the assignment writing process. They ensure that your nursing assignment is polished, error-free, and effectively communicates your ideas. After completing the initial draft, it’s crucial to take a break and return to your work with fresh eyes. During the proofreading stage, carefully review your assignment for grammar, spelling, punctuation, and sentence structure. Correct any errors and inconsistencies that may affect the clarity and professionalism of your writing.

At nursingresearchhelp.com , we have a dedicated team of proofreaders and editors who specialize in nursing assignments. They meticulously review your work, ensuring that it adheres to formatting guidelines and meets the highest standards of academic writing. Our proofreaders and editors will help you refine your assignment, ensuring that it is polished and error-free. By collaborating with us, you can rest assured that your assignment will be thoroughly reviewed and refined before submission.

Seeking Help When Needed

In addition to proofreading and editing, it’s important to seek help when needed. Nursing assignments can be challenging, and it’s perfectly normal to require assistance. Whether you’re facing difficulties in understanding the assignment prompt, need guidance in specific areas, or simply want a fresh perspective on your work, don’t hesitate to reach out for support.

Our friendly and knowledgeable support team is always available to address any questions or concerns you may have. We understand the unique challenges faced by nursing students and can provide you with the guidance and clarification you need. By seeking help when needed, you can overcome obstacles and ensure the successful completion of your nursing assignments.

Mastering nursing assignments is within your reach with the right tips, strategies, and expert assignment help services. At nursingresearchhelp.com we are committed to supporting nursing students in excelling in their academic pursuits. Our experienced writers, proofreaders, and editors can provide personalized assistance throughout the assignment writing process, ensuring that your assignments meet the highest standards of quality and professionalism.

With our help, you can confidently tackle your nursing assignments and overcome any challenges you may face. Visit our website nursingresearchhelp.com to learn more about our services and how we can support you in achieving academic excellence. Whether you need guidance in understanding the assignment, conducting thorough research, creating a well-structured outline, using a professional tone, incorporating practical examples, or ensuring a polished final product, we are here to assist you. Trust us for reliable and professional assignment help tailored to your needs.

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How To Refuse an Unsafe Patient Assignment as a Nurse

What is a safe nursing assignment, when should you refuse an assignment, how to refuse a patient assignment.

You walk into work, ready to spend the next 12 hours taking care of your patients and providing them with the best nursing care possible.  You look at your patient assignment and see you have one extra patient than usual, as well as only one CNA for your entire nursing unit.  Your charge nurse has a full patient assignment too, making her less available to offer help and support.  You hear machines beeping, bed alarms sounding, and patients yelling, and you stop and think to yourself “is this safe?”

Does this scenario sound familiar to you as a nurse?  

Being given an inappropriate assignment can be very overwhelming and stressful.  Your patients need you to show up and take care of them, and your nursing team needs you, and you want to help.

But where do you draw the line, and say “NO”, to a patient assignment?  What is an unsafe assignment, and can a nurse refuse an assignment?

An appropriate nursing assignment is any patient assignment where the nurse can safely and effectively provide all the necessary care for their patients, and have the necessary tools, training, medications, knowledge, resources, and equipment to perform their nursing duties for those patients.

The definition of a safe and appropriate nursing assignment is variable, has to do with much more than patient ratios alone, and will vary by state and facility.

Per the American Nurses Association (ANA), nurses have not only a right but also an obligation to assess and determine if they can safely and appropriately provide care on any given patient assignment.  They provide this list of questions that every nurse should be asking themselves before accepting any patient assignment.

What does an inappropriate or unsafe patient assignment look like, and what are some reasons you might stop and consider refusing the assignment or asking your leader for changes to the assignment?

Too Many Patients

There are only 2 states in the US that have laws mandating nurse-to-patient ratios , California and Massachusetts.  Some states, but not all of them, have mandatory reporting requirements for staffing.  Others have staffing committees with some nurse members to assist in making staffing decisions, but still no mandated ratios.

You will learn as you gain more nursing experience how many patients are too much for you as one nurse.  This will depend on your unit’s acuity level, patient population, and the individual staffing policies at your facility.

• Inappropriate distribution of patient acuity

5 “walkie-talkie” patients are vastly different from 5 patients on high-level oxygen.  The ability to understand what constitutes high acuity will also come with more nursing experience.  You may not know or understand, what the acuity level is of a COVID patient on continuous BIPAP, until you have cared for that type of patient.

Also take into consideration how many discharges or empty rooms you have, if you have any patients on continuous drips or pain pumps, your patient’s mobility level, and if your patient is scheduled for any procedure that will warrant intense post-procedure monitoring when they return.

A particular patient’s acuity can change with each shift, which means nursing management must be in close communication with the team and get accurate patient acuity updates before making each assignment.

Inadequate knowledge or training

Are you being asked to care for a post-surgical patient on gynecology, when you normally take care of patients recovering from a stroke?  Are you being asked to care for pediatric patients when you have only ever cared for adults?  Maybe you are being asked to do something you think may be out of your scope of practice as a nurse.  This would be a reason to voice concern and ultimately refuse a particular assignment.

No Supplies or Help

Do you have all of the equipment you need to do your job?  Do you know where your code cart is, and can you safely and effectively help your patient in an emergency?  Are your medications stocked, machines in good working order, and can you get extra help if you need it?

If you don’t have all of the above, keeping your patients safe could be a challenge, and this alone would deem your assignment unsafe.

If you find yourself in any of the above situations, or others in which you feel your license and patient safety are in jeopardy,  can you refuse to take the assignment ?

The ANA upholds that “ registered nurses – based on their professional and ethical responsibilities – have the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.”  Read the full ANA position statement here.

It is not only your right as a nurse, but also your duty, to raise concern and ultimately refuse an unsafe, inappropriate assignment.  Here are some tips on how you can bring up these concerns and refuse your assignment as a nurse.

Know your rights, and be prepared to state them

It is solely your responsibility as a nurse to know your rights, as well as your responsibilities, in the state in which you practice as a nurse. Each state has its own Nurse Practice Act, which defines by law what you can, and cannot do, as a nurse.  It also contains your nursing scope of practice.   Visit the NCSBN website to quickly navigate to each state's Nurse Practice Act .

The NCSBN also provides a great decision-making tool to help explain the proper process of determining whether or not a certain activity is within the nurse’s scope.

Be prepared to refer to the Nursing Code of Ethics , and verbalize any statement of your nursing rights when communicating about your patient assignment with your leader.  By knowing your rights as a nurse, and being ready to state them, you can clearly and effectively communicate with your manager why you want to refuse an assignment when placed in an unsafe situation.

Don’t Create a Nurse-Patient Relationship

Before you decide to accept any patient assignment, you need to avoid any activity that could be considered creating a nurse-patient relationship.  There is a fine line between refusing a patient assignment, and nurse abandonment, which also varies state by state.  

For example in Arizona, the board of nursing defines patient abandonment as a nurse severing or ending the nurse-patient relationship, after creating the relationship, without giving handoff or reporting to another capable nurse to take over that patient's care.

Here are some things that may be considered for establishing a nurse-patient relationship:

Viewing the patient’s electronic medical record

Saying hi to the patient, or going into their room at all

Taking orders from a doctor regarding that patient

Administering any type of patient care such as assisting them to the bathroom, taking them a food tray, or administering them any medications.

It is critical to read up on your state’s Nurse Practice Act and get a very clear definition of what patient abandonment is in your state.  Your state’s board of nursing will have the resources needed to give you directions on the correct process of refusing an assignment in your state of licensure.

Do Your Research and Be Prepared

Nurses are always thinking ahead, preparing for what can go wrong with our patients, and ready to act in case of any emergency.  We know exactly what equipment we will need for our patients, and would never allow our patients to be without adequate IV access.

Apply this same principle to the safety of your nursing license, your patients, and your team, by doing your research on the process of refusing a patient assignment correctly.  Study your facilities policies, your nursing rights, and your state’s Nurse Practice Act.

It is your responsibility to know these things, and you don’t want to be scrambling at the very last second trying to do this research when you are being pressured at the moment to take a dangerous assignment.

Keep Everything in Writing

If you do end up voicing any sort of staffing or patient safety concerns, or ultimately refusing an assignment, always make sure you are communicating it to all of the appropriate leaders and follow your chain of command.

Send an email to all members of your leadership team to summarize the situation, and provide thorough documentation of why you are refusing an assignment, with adequate details.

Keep any paper records for yourself, just in case.

Help Find Solutions

Refusing a patient assignment will have an impact on all of the patients in the unit, the entire hospital, as well as the rest of the members of the healthcare team.  It is your right, and duty, to refuse an inappropriate assignment.  But try to be as professional and flexible as possible, keeping the ultimate goal of patient safety in mind.

Can you and your team brainstorm with your nursing leader on other ways to make everyone’s assignments safe and appropriate, such as:

Calling in a resource RN to help with patient care tasks

Re-arranging the patient assignment to re-distribute patient acuity better among all nurses

Obtaining a 1:1 sitter for all confused patients, ensuring their safety and also freeing up your extra time for your other patients?

Better assigning the patients to nurses based on their appropriate certifications, and expertise?

Ultimately you are a team, and you are there for your patients and each other.  The goal is patient safety, and if you don’t speak up and refuse to take an inappropriate assignment, your patient’s well-being and your nursing license are on the line.  

Be prepared to have these conversations, and be well-versed in your rights as a nurse.  By refusing inappropriate assignments, you are advocating for yourself, and your patients, and being a voice for positive change in healthcare.

Amy was surgical PCU/Telemetry unit as a new grad for over 10 years; the last year and a half of that time being Telemetry COVID nursing. She stepped away from the bedside and is currently working PRN as a concierge nurse. Amy has a passion for budgeting. Follow her on Instagram, Facebook, and on her website Real Desert Mama , where she talks about budgeting, saving money, and tips and motivation on how to live a great life and achieve your financial goals through budgeting

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3.3 Assignment

Nursing team members working in inpatient or long-term care settings receive patient assignments at the start of their shift. Assignment refers to routine care, activities, and procedures that are within the legal scope of practice of registered nurses (RN), licensed practical/vocational nurses (LPN/VN), or assistive personnel (AP). [1] Scope of practice for RNs and LPNs is described in each state’s Nurse Practice Act. Care tasks for AP vary by state; regulations are typically listed on sites for the state’s Board of Nursing, Department of Health, Department of Aging, Department of Health Professions, Department of Commerce, or Office of Long-Term Care. [2]

See Table 3.3a for common tasks performed by members of the nursing team based on their scope of practice. These tasks are within the traditional role and training the team member has acquired through a basic educational program. They are also within the expectations of the health care agency during a shift of work. Agency policy can be more restrictive than federal or state regulations, but it cannot be less restrictive.

Patient assignments are typically made by the charge nurse (or nurse supervisor) from the previous shift. A charge nurse is an RN who provides leadership on a patient-care unit within a health care facility during their shift. Charge nurses perform many of the tasks that general nurses do, but also have some supervisory duties such as making assignments, delegating tasks, preparing schedules, monitoring admissions and discharges, and serving as a staff member resource. [3]

Table 3.3a Nursing Team Members’ Scope of Practice and Common Tasks [4]

An example of a patient assignment is when an RN assigns an LPN/VN to care for a client with stable heart failure. The LPN/VN collects assessment data, monitors intake/output throughout the shift, and administers routine oral medication. The LPN/VN documents this information and reports information back to the RN. This is considered the LPN/VN’s “assignment” because the skills are taught within an LPN educational program and are consistent with the state’s Nurse Practice Act for LPN/VN scope of practice. They are also included in the unit’s job description for an LPN/VN. The RN may also assign some care for this client to AP. These tasks may include assistance with personal hygiene, toileting, and ambulation. The AP documents these tasks as they are completed and reports information back to the RN or LPN/VN. These tasks are considered the AP’s assignment because they are taught within a nursing aide’s educational program, are consistent with the AP’s scope of practice for that state, and are included in the job description for the nursing aide’s role in this unit. The RN continues to be accountable for the care provided to this client despite the assignments made to other nursing team members.

Special consideration is required for AP with additional training. With increased staffing needs, skills such as administering medications, inserting Foley catheters, or performing injections are included in specialized training programs for AP. Due to the impact these skills can have on the outcome and safety of the client, the National Council of State Board of Nursing (NCSBN) recommends these activities be considered delegated tasks by the RN or nurse leader. By delegating these advanced skills when appropriate, the nurse validates competency, provides supervision, and maintains accountability for client outcomes. Read more about delegation in the “ Delegation ” section of this chapter.

When making assignments to other nursing team members, it is essential for the RN to keep in mind specific tasks that cannot be delegated to other nursing team members based on federal and/or state regulations. These tasks include, but are not limited to, those tasks described in Table 3.3b.

Table 3.3b Examples of Tasks Outside the Scope of Practice of Nursing Assistive Personnel

As always, refer to each state’s Nurse Practice Act and other state regulations for specific details about nursing team members’ scope of practice when providing care in that state.

Find and review Nurse Practice Acts by state at www.ncsbn.org/npa.

Read more about the Wisconsin’s Nurse Practice Act and the standards and scope of practice for RNs and LPNs Wisconsin’s Legislative Code Chapter N6.

Read more about scope of practice, skills, and practices of nurse aides in Wisconsin at DHS 129.07 Standards for Nurse Aide Training Programs.

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation . https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• McMullen, T. L., Resnick, B., Chin-Hansen, J., Geiger-Brown, J. M., Miller, N., & Rubenstein, R. (2015). Certified nurse aide scope of practice: State-by-state differences in allowable delegated activities. Journal of the American Medical Directors Association, 16 (1), 20–24. https://doi.org/10.1016/j.jamda.2014.07.003 ↵
• RegisteredNursing.org. (2021, April 13). What is a charge nurse? https://www.registerednursing.org/specialty/charge-nurse/ ↵
• RegisteredNursing.org. (2021, January 27). Assignment, delegation and supervision: NCLEX-RN. https://www.registerednursing.org/nclex/assignment-delegation-supervision/ ↵
• State of Wisconsin Department of Health Services. (2018). Medication administration by unlicensed assistive personnel (UAP): Guidelines for registered nurses delegating medication administration to unlicensed assistive personnel. https://www.dhs.wisconsin.gov/publications/p01908.pdf ↵

Routine care, activities, and procedures that are within the authorized scope of practice of the RN, LPN/VN, or routine functions of the assistive personnel.

Making adjustments to medication dosage per an established protocol to obtain a desired therapeutic outcome.

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Home / NCLEX-RN Exam / Assignment, Delegation and Supervision: NCLEX-RN

Assignment, Delegation and Supervision: NCLEX-RN

Identifying tasks for delegation based on client needs, the "right task" and the "right person": identifying tasks for delegation based on client needs, ensuring the appropriate education, skills, and experience of personnel performing delegated tasks, assigning and supervising the care provided by others, communicating tasks to be completed and report client concerns immediately, organizing the workload to manage time effectively, utilizing the five rights of delegation, evaluating delegated tasks to ensure the correct completion of the activity or activities, evaluating the ability of staff members to perform the assigned tasks for the position, evaluating the effectiveness of staff members' time management skills.

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of assignment, delegation, and supervision in order to:

• Identify tasks for delegation based on client needs
• Ensure appropriate education, skills, and experience of personnel performing delegated tasks
• Assign and supervise care provided by others (e.g., LPN/VN, assistive personnel, other RNs)
• Communicate tasks to be completed and report client concerns immediately
• Organize the workload to manage time effectively
• Utilize the five rights of delegation (e.g., right task, right circumstances, right person, right direction or communication, right supervision or feedback)
• Evaluate delegated tasks to ensure correct completion of activity
• Evaluate the ability of staff members to perform assigned tasks for the position (e.g., job description, scope of practice, training, experience)
• Evaluate the effectiveness of staff members' time management skills

The assignment of care to others, including nursing assistants, licensed practical nurses, and other registered nurses, is perhaps one of the most important daily decisions that nurses make.

Proper and appropriate assignments facilitate quality care. Improper and inappropriate assignments can lead to poor quality of care, disappointing outcomes of care, the jeopardization of client safety, and even legal consequences.

For example, when a registered nurse delegates aspects of patient care to a licensed practical nurse that are outside of the scope of practice of the licensed practical nurse, the client is in potential physical and/or psychological jeopardy because this delegated task, which is outside of the scope of practice for this licensed practical nurse, is something that this nurse was not prepared and educated to perform. This practice is also illegal and it is considered practicing outside of one's scope of practice when, and if, this licensed practical nurse accepts this assignment. All levels of nursing staff should refused to accept any assignment that is outside of their scope of practice.

• How is the Scope of Practice Determined for a Nurse?
• Scope of Practice vs Scope of Employment
• RN Scope of Practice

Delegation, simply defined, is the transfer of the nurse's responsibility for the performance of a task to another nursing staff member while retaining accountability for the outcome. Responsibility can be delegated. Accountability cannot be delegated. The delegating registered nurse remains accountable for all client care despite the fact that some of these aspects of care can, and are, delegated to others.

Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs' position description or job descriptions, the employing facility's policies and procedures, and legal aspects of care such as the states' legal scopes of practice for nurses, nursing assistants and other members of the nursing team.

The " Five Rights of Delegation " that must be used when assigning care to others are:

• The "right" person
• The "right" task
• The "right" circumstances
• The "right" directions and communication and
• The "right" supervision and evaluation

In other words, the right person must be assigned to the right tasks and jobs under the right circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or job. The nurse supervises the person and determines whether or not the job was done in the correct, appropriate, safe and competent manner.

The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

Some client needs are relatively predictable; and other patient needs are unpredictable as based on the changing status of the client. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routinized and without the need for high levels of professional judgment and skill. Some client needs are acute, ever changing and/or rarely encountered; and other patient needs are chronic, relatively stable, more predictable, and more frequently encountered.

Based on these characteristics and the total client needs for the group of clients that the registered nurse is responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to.

For example, a new admission who is highly unstable should be assigned to a registered nurse; the care of a stable chronically ill patient who is relatively stable and more predictable than a serious ill and unstable acute client can be delegated 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. Lastly, the care of a client with chest tubes and chest drainage can be delegated to either another registered nurse or a licensed practical nurse, therefore, the registered nurse who is delegating must insure that the nurse is competent to perform this complex task, to monitor the client's response to this treatment, and to insure that the equipment is functioning properly.

The staff members' levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for. Some staff members may possess greater expertise than others. Some, such as new graduates, may not possess the same levels of knowledge, past experiences, skills, abilities, and competencies that more experienced staff members possess. Some may even be more competent in some aspects of client care than other aspects of client care. For example, a licensed practical nurse on the medical surgical floor may have more knowledge, skills, abilities, and competencies than a registered nurse in terms of chest tube maintenance and care because they may have, perhaps, had years of prior experience in an intensive care area of another healthcare facility before coming to your nursing care facility.

Delegation should be done according to the differentiated practice for each of the staff members. A patient care technician, a certified nursing assistant, a licensed practical nurse, an associate degree registered nurse and a bachelor's degree registered nurse should not be delegated to the same aspects of nursing care. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.

Also, staff members differ in terms of their knowledge, skills, abilities and competencies. A staff member who has just graduated as a certified nursing assistant and a newly graduated registered nurse cannot be expected to perform patient care tasks at the same level of proficiency, skill and competency as an experienced nursing assistant or registered nurse. It takes time for new graduates to refine the skills that they learned in school.

Validated and documented competencies must also be considered prior to assignment of patient care. No aspect of care can be assigned or delegated to another nursing staff member unless this staff member has documented evidence that they are deemed competent by a registered nurse to do so. For example, a newly hired certified nursing assistant cannot perform bed baths until a supervising registered nurse has observed this certified nursing assistant provide a bed bath and has decided that they are now competent to do this task without direct supervision.

All healthcare facilities and agencies must assess and validate competency before total care or any aspect of care is performed by an individual without the direct supervision of another, regardless of their years of experience. Competency checklists are used to document the competency of the staff; they must be referred to as assignments are made. Care can be delegated to another only when that person is deemed competent to perform the role or task and this competency is documented.

Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians.

The job of the registered nurse is far from done after client care has been delegated to members of the nursing team. The delegated care must be followed up on and the staff members have to be supervised as they deliver care. The registered nurse remains responsible for and accountable for the quality, appropriateness, completeness, and timeliness of all of the care that is delivered.

The supervision of the care provided by others includes the monitoring the care, coaching and supporting the staff member who is providing the care, assisting the staff member with priority setting and time management skills, as indicated, educating the staff member about the proper provision of care, as indicated by a knowledge or skills deficit, and also praising and positively reinforcing the staff for a job well done.

Remember, the delegating registered nurse is still responsible and accountable for all of the client care that is delegated to others.

Registered nurses who assign, delegate and/or provide nursing care to clients and groups of clients must report all significant changes that occur in terms of the client and their condition. For example, a significant change in a client's laboratory values requires that the registered nurse report this to the nurse's supervisor and doctor.

They must also communicate and document all tasks that were completed and the client's responses to this treatment. As the old adage says, "If it wasn't documented, it wasn't done."

Time is finite and often the needs of the client are virtually infinite. Time management, organization, and priority setting skills, therefore, are essential to the complete and effective provision of care to an individual client and to a group of clients.

Priorities of care, as previously discussed, are established using a number of methods and frameworks including the ABCs, Maslow's Hierarchy of Needs and the ABCs/MAAUAR method of priority setting.

Some time management techniques, in addition to priority setting, that you may want to consider using to insure that you manage your workload and time effectively include:

• Clarifying your assignment as necessary
• Planning your work in an orderly and systematic manner knowing that priorities and clients' status change frequently
• Avoiding all unnecessary interruptions
• Learning how to say no to others when they ask you for help and you have priority patient needs that would not be addressed if you helped another

As previously discussed, all delegation may be based on the "Five Rights of Delegation" which are:

• The "right" directions and communication

In addition to the supervision of delegated tasks in terms of quality, appropriateness, and timeliness, the registered nurse who has delegated tasks must insure that the assigned activities have been correctly completed.

When assignments are made, the registered nurse must insure that the staff member will have ample time during the shift to complete the assignment and, then, the registered nurse must monitor and measure the staff members' progress toward the completion of assigned tasks throughout the duration of the shift.

This monitoring must be done in an ongoing and continuous manner and not at the end of the shift when it is too late to make corrections.

As previously discussed, staff members should have documented competency for all tasks that are assigned to them. All nursing team members have the responsibility, however, to refuse an assignment if they believe that they cannot do it properly. When this occurs, the registered nurse should either teach the staff member how to perform the task and then document their competency in terms of this assigned task or assign the task to another nursing team member who has documented competency and is sure that they can perform the task in a correct manner.

Part of supervision entails the ongoing evaluation of staff's ability by the registered nurse to perform assigned tasks using direct observations and with indirect observations of patient safety, the quality of the care provided, the appropriateness of care provided, and the timeliness of care provided. For example, the registered nurse can directly observe the performance of the nursing assistant while the client is being transferred from the bed to the chair; and the registered nurse can review the medication administration record to determine if the licensed practical nurse has administered medications in a timely manner which is an example of indirect observation.

The ability of a staff member to perform a specific task is not only based on their competency but it is also based on their:

• Legal scope of practice,
• Documented competency,
• Education and training,
• Past experiences,
• Position description which is also referred to as the job description and
• Healthcare facility specific policies and procedures.

All states throughout our nation have legally legislated scopes of practice for registered professional nurses, licensed practical or vocational nurses, and advanced nursing practice nurses; and they also have legal guidelines related to what an unlicensed, assistive staff member, such as a student nurse technician, patient care aide, patient care technician or nursing assistant, can and cannot legally perform regardless of whether or not the healthcare provider or the delegating nurse believes that they are competent to do.

Although these legal, legislated scopes of practice may vary a little from state to state, they share a lot of commonalities and similarities. For example:

• The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
• The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement and evaluate care under the direct supervision and guidance of the registered nurse.
• The scope of practice for an advanced practice nurse, such as a nurse practitioner, will most likely include the legal ability of the advanced practice registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation in addition to prescribing some medications.

Nurses violate scope of practice statutes, or laws, when they function in roles and aspects of care that are above, beyond and/or not included in their scope of practice. Permanent license revocation may occur when a nurse practices outside of the legally mandated scope of practice. Additionally, licensed nurses who have failed to either reapply for their license or have had it revoked as part of a state disciplinary action cannot and continue to practice nursing are guilty of practicing nursing without a license.

Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment and professional knowledge.

Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the nurse include:

• Assisting the client with their activities of daily living such as ambulation, dressing, grooming, bathing and hygiene
• Measuring and recording fluid intake and output
• Measuring and recording vital signs, height and weight
• The provision of nonpharmacological comfort and pain relief interventions such as establishing and maintaining an environment conducive to comfort and providing the client with a soothing and therapeutic back rub
• Observation and reporting changes in and the current status of the patient’s condition and reactions to care
• The transport of clients and specimens and other errands and tasks such as stocking supplies
• Assistance with transfers, range of motion, feeding, ambulation, and other tasks such as making beds and assisting with bowel and bladder functions

In addition to the legally mandated state scopes of practice, the registered nurse must also insure that the delegated tasks are permissible according to the nursing team members' position description which is also referred to as the job description, and the particular facility's specific policies and procedures relating to client care and who can and who cannot perform certain tasks.

For example, intravenous bolus and push medications may be permissible for only licensed registered nurses in certain areas of the healthcare facility such as the intensive care units; the administration of blood and blood components may be restricted to only registered nurses; and the care of a client who is receiving conscious sedation may be restricted to only a few registered nurses in the particular healthcare facility, according to these job descriptions, policies and procedures.

As previously mentioned, the registered nurse must allot a reasonable amount of time for staff members to complete their assignments when care and tasks are delegated. The staff should be able to complete their assignments within the allocated period of time. When an assignment is not done as expected, the delegating nurse should determine why this has occurred and they must take corrective actions to insure task completion.

One of the things that the delegating nurse will want to consider when an assignment is not completed within the allotted time frame is determining whether or not the staff member is organizing their work and using effective time management skills. If the staff member is not using effective time management skills, the nurse must teach and assist the staff member about better time management and priority setting skills.

RELATED NCLEX-RN MANAGEMENT OF CARE CONTENT:

• Advance Directives
• Assignment, Delegation and Supervision (Currently here)
• Case Management
• Client Rights
• Collaboration with Interdisciplinary Team
• Concepts of Management
• Confidentiality/Information Security
• Continuity of Care
• Establishing Priorities
• Ethical Practice
• Informed Consent
• Information Technology
• Legal Rights and Responsibilities
• Performance Improvement & Risk Management (Quality Improvement)

SEE – Management of Care Practice Test Questions

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Nursing School Assignments and Tips to Ace All of Them

If you are about to start nursing school or considering enrolling in a nursing program, you would want to know what to expect. You will write many papers in nursing school and do many other assignments. This is true whether you pursue ADN, BSN, MSN, DNP, or PhD in Nursing.

Before we delve into the types of assignments and papers to expect in nursing school, let us begin by dispelling the myth that nursing school is hell; it is NOT. Instead, it is a beautiful and exciting journey into a noble profession. It entails a commitment to life-long continuous learning for you to grow.

Nursing school writing assignments are an excellent way for students to understand concepts taught in the classroom. You might wonder what kinds of assignments nursing students do. These assignments come in various forms and help students build critical thinking, creativity, research, clinical reasoning, and problem-solving skills that are critical in clinical settings.

This blog post looks at the diverse assignments you should expect or will cover in nursing school, including some tips to help you ace them and get better grades.

Common Nursing School Writing Assignments

Classwork forms the core of most nursing programs. You must have high-quality assignment submissions to attain better grades in nursing school. As soon as you decide to become a nursing student, you sign up for a marathon of writing different types of papers.

Whether you love or hate it, you will write papers before graduating from nursing school; that is the norm. Although not so many, you will encounter a few homework and assignments where you must submit a well-researched, formatted, and organized nursing paper.

The typical nursing school assignments include essays, research papers, term papers, and case studies. Others are article critiques/reviews, critical appraisal, evidence synthesis tables (synthesis matrix), PowerPoint Presentations, posters, discussion posts/ responses, and policy analysis papers. Other advanced papers include nursing care plans, SBAR template papers, evidence-based papers, capstone projects, theses, dissertations, proposals, etc.

These assignments are submitted either individually or as a group. Let us expound on this so you have a clear picture.

Essays for nursing classes come in various forms, including admission essays , scholarship essays, descriptive essays, persuasive essays, speech essays, expository essays, and narrative essays.

Notably, nursing essays focus on a single perspective, argument, or idea, which constantly forms the thesis of the paper.

Nursing essays focus on various topics relating to nursing practice and the broader healthcare field. You can write an essay examining a nursing theory or non-nursing theory or discuss a nursing issue .

Some essays, such as reflective nursing essays, use reflective models to reflect, analyze, and understand personal and professional encounters during clinical practice.

Each nursing essay should demonstrate your understanding of the topic, critical analysis, and organization skills. Besides, you should use evidence from peer-reviewed scholarly sources to support your arguments and ideas.

Discussion Board Posts

If you pursue a hybrid or exclusively online nursing program, you will be assigned to write weekly discussion forum posts and responses. Discussion board posts are short essay-like assignments posted in a threaded format so students can discuss nursing and healthcare topics.

You will write an original discussion post, between 200 and 300 words long, and post it on the forum. You are also expected to write a peer-response post in response to or to comment on an original post done by your peers.

Discussion boards help nursing students advance theoretical concepts, learn from one another, share ideas, and get feedback that can help them advance their knowledge in clinical reasoning and practice.

Research Papers

Nursing practice is evidence-driven, translating evidence into practice to ensure quality, accessible, and affordable healthcare. As such, nursing research takes precedence during studies and when practicing.

Nursing professors assign nursing students to write research papers on various evidence-based practice topics. The students must prove their worth by researching, analyzing, and organizing facts.

Related Writing Guides:

• How to write a nursing school research paper.
• Systematic Reviews vs Literature Review

Research papers help student nurses to review literature, conduct research, implement solutions, and draw evidence-based conclusions.

Research papers are critical in developing research and writing skills, maintaining good communication, and fostering creativity and clinical reasoning.

Potential nursing research paper topics can be quality improvement, healthcare/nursing informatics , healthcare policies, practice privileges, nursing ethics, ethical dilemmas , pathophysiology, and epidemiology .

Term Papers

In nursing school, a term paper is a type of assignment completed and submitted toward the end of the semester.

Usually, a professor can assign you a specific term paper topic, or they can let you choose a topic and consult with them for approval.

Term papers can be done individually or as a group project. A term paper has an impact on your final grade.

You should use credible scholarly sources published within the last five years for recent information.

Besides, also ensure that you plan your time well, do everything as per the instructions, and submit the nursing term paper before the deadline.

A term paper can also be a nursing process change report that is expected to address an area that needs change.

Case Studies

Nursing school case study assignments are an essential learning tool.

Most professors assign hypothetical clinical case studies or case scenarios (snippets) to test your clinical reasoning skills.

As a nursing educational tool, nursing case studies help you to develop practical, theoretical knowledge by simulating real-world experiences.

When analyzing a case study, you must use concepts and knowledge from class and class text to assess a patient, plan and implement care, and evaluate the outcomes.

Sometimes, you encounter simulated or digital clinical experience case studies such as iHuman and Shadow Health .

You should be very keen when analyzing a case study and when writing the analysis report.

Case studies help you get beyond books and use your creativity, clinical reasoning, problem-solving, and analytical skills to apply theoretical knowledge to real-world problems.

Your professor can give you a case study of a patient presenting with a given condition and expect you to take them through the care planning process, including admission and discharge, as you would in a real healthcare setting.

Other times, you can be asked to develop a hypothetical case study of a patient presenting with a chronic disease or a disorder and then use the case study guidelines, including head-to-toe assessment , diagnosis , nursing care planning , and discharge planning.

Related Guides:

• How to write a great nursing case study.
• How to complete a case conceptualization report (for psychiatric nursing students)

Nursing Care Plans and SOAP Notes

A nursing care plan can be part of a case study or a stand-alone assignment. Nursing care plans are essential in nursing education as they help students develop effective nursing care planning. Formulating a nursing care plan for a patient scenario or case helps treat them as you define the guidelines and roles of nurses in caring for the patient.

You also develop solid action plans for focused and patient-centred care by documenting the patient's needs. When they are part of an assignment, you can tabulate the nursing care plan using columns so that you explore every aspect independently.

Remember to use evidence from peer-reviewed scholarly sources when giving rationale.

The SOAP notes are a clinical tool healthcare professionals use to organize patient information to minimize confusion and assess, diagnose, and treat patients. Check our comprehensive guide on developing good SOAP Notes in nursing school .

Concept Maps

Another common nursing school assignment is concept maps. Concept mapping helps you visually organize, compartmentalize, and categorize information about nursing care planning, medical diagnosis, pathophysiology, SBAR, nursing responsibilities, etc.

A nursing concept map assignment equips you with strong critical thinking, analytical, and problem-solving skills. You also hone your clinical reasoning skills in the process.

Whether it is part of an assignment or a stand-alone, learn how to write great concept maps to score the best grades.

Concept Analysis Papers

If you are taking BSN, MSN, or DNP, you will likely be assigned to write a concept analysis paper. Make sure to distinguish this from a concept paper that is a proposal. A concept analysis paper examines the structure and function of a nursing concept.

The process entails a review of the literature and creativity in coming up with borderline, related, contrast, inverted, and illegitimate cases.

You also explore the antecedents and consequences of the concept before finalizing with empirical referents.

If you need to learn about the structure of a good concept analysis paper, check out our nursing concept analysis guide . We have listed concepts you can analyze depending on your speciality, instructions, and passion.

Capstone Projects

At an advanced stage in nursing school, students are expected to submit longer research papers; capstone project papers. A nursing capstone project is a final project that allows students to demonstrate the skills, knowledge, and concepts gained throughout the nursing program.

In nursing education, the capstone project typically covers an evidence-based practice issue or problem. You can write a nursing change paper, look into a clinical process, problem, or issue, and then develop recommendations based on a study.

Most of the MSN and DNP capstone projects focus on clinical change or quality improvement. You will be expected to develop a PICOT question and formulate a research study to examine the issue, implement a change process using evidence-based models, and make recommendations.

Nursing capstone projects are individual research projects based on nursing topics either of your professional or personal interest. You have to demonstrate competency and commitment to improve health outcomes.

Apart from capstone projects, you will also write a nursing thesis and dissertation papers, which depend on the program requirements and your professor's preferences.

Check out these specific writing guides for advanced papers:

• How to write a nursing dissertation or thesis
• Tips for choosing the best nursing dissertation topic
• How to write an excellent capstone project paper
• List of capstone project topics for nursing school
• How to formulate a PICOT question
• PICOT question examples to inspire nursing students

Group Assignments

In nursing school and practice, collaboration and teamwork are highly recommended. You will encounter collaborative group assignments such as presentations (PowerPoint slides, Prezi, or other platforms), simulation assignments, writing nursing reports, and group research projects.

Group projects allow you to research, learn, and organize ideas together so that you can understand concepts better. It is essential to avoid social loafing in a group to gain more. Besides, plan your time well and avoid excuses.

You can also be assigned to work on simulation exercises as a group of nursing students. The aim of such exercises is to build a collaborative, teamwork, and decision-making spirit among the team.

When in such groups, expect to work with your peers to assess the hypothetical patient, communicate with your peers, formulate a care plan, and manage any arising issues as you would in clinical settings. Do not take such activities for granted; they contribute significantly to your grade.

Presentations

Your professor can assign you to design a PowerPoint Slide accompanied by speaker notes and send it for grading or present it online or in class. Under presentations, you will also be requested to design flyers, posters, and other visual documents to disseminate information.

It could be about a disease, health promotion, or nursing research. You must also make PowerPoint slides when presenting a thesis, dissertation, or capstone for assessments. Remember, this is the chance to bring out your creativity.

Expect other assignments such as dosage calculations, HESI test exams, skills checkoffs, electronic medical record documentation, nursing student portfolio, online quizzes, drug write-ups, process recordings, group drug presentations, etc.

In most cases, you will be given a template to use wisely and make it as appealing as possible.

Tips to Help You Ace Nursing Assignments

A lot goes into getting the best grades in nursing school. One of the main determinants of your nursing school grades is the assignments, which you are required to do and complete within set deadlines.

Even though many nursing students perform better on clinical, that needs to reflect in written assignments. Most students fear research and writing or do not take writing assignments seriously. Regardless of the assignment, here are some practical and effective tips to help you ace your nursing school writing assignments and surprise everyone, including yourself.

1. Plan your Time

The number one challenge for nursing students that inhibits them from completing assignments is the need for more time management.

Most students are juggling studies and work to make ends meet. It worsens when you have a massive workload from more than one class and a family to look after.

The simple trick to beat this is to manage your time well. You can schedule your assignments for periods when you are free and when you can concentrate and cover more. Assignments have deadlines ranging from hours to days or a few weeks.

To succeed, keep track of your assignments and other academic activities, such as mid-term and final examinations, so that you can plan your study periods. You can use online time management tools and apps to allocate your nursing school homework time.

With proper planning, you should be reassured about the last-minute rush to complete your assignment, which is responsible for the colossal failure we are experiencing in nursing schools.

2. Follow the Course Guidelines to the T

Guidelines, prompts, and reading materials accompany each writing assignment and homework. Sometimes a professor can be generous enough also to give you access to the Rubric, which breaks down how they will assess assignments. Ensure you read everything and note what is required before working on any paper.

Pay attention to these, read, and familiarize yourself with the course guidelines. Understand the formatting requirements preferred by your school, such as Vancouver, APA, or Harvard. Most nursing schools will specify this in the course documents. Also, check the databases and journal articles you can use when writing your nursing assignments.

Preparing in advance by reading the course materials to identify the recommended study materials. You will have a deeper understanding, knowledge, and skills to handle every nursing assignment correctly.

3. Have an Active Study Buddy

A nursing study buddy can be one of your classmates whom you study with. Study buddies offer mutual support, which comes in handy when completing assignments.

Select a bright and committed person with something to offer so you are not only giving. Set the study hours and have accountability follow-ups to ensure you cover much of the syllabus and concepts in time.

A study buddy can help you understand nursing concepts, theories, models, and frameworks. They can also help you review your written papers and give valuable feedback when editing and proofreading your nursing papers.

A knowledgeable, accountable, committed study partner can help you revamp your grades by submitting high-quality assignments.

4. Join a Study Group

A study group is a tried and tested means of completing nursing assignments. Apart from building your teamwork and collaborative skills, you can brainstorm ideas, critique one another, and learn more about the class assignments. With diversity in thoughts, you can get valuable insights and inputs for personal-level work.

Besides, you are also guaranteed to ace the nursing group assignments with ease. When doing group work, try to rotate into new groups so that you can appreciate the diversity of thoughts and reasoning. You can also identify individuals from your groups, those that are active, as your study buddies.

When you have accountability partners within the group, you commit to given tasks and make necessary follow-ups. If you are a part-time student, consider having students whose free time is similar to yours to benefit everyone.

5. Get Writing Assignment Help

As with other subjects in college and university, nursing students face challenges such as time management, complexity of assignments, too many assignments, and writer's block. When you feel overwhelmed with completing your nursing class assignments, you can always pay someone to handle the class for you or at least do your coursework or assignments.

One sure way to get assistance without drawing too much attention is by trusting assignment help websites like NurseMyGrade.com with your papers. Many students do not have time to complete assignments or find them challenging. Consequently, many hire nursing assignment helpers from nursing paper writing platforms.

If you feel like hiring the right professionals, use NurseMyGrade. We offer customized writing solutions to nursing students at different academic levels. Our nursing experts can complete short and lengthy assignments. You will have a well-researched and formatted paper written in Vancouver, APA, MLA, ASA, AMA, Harvard, or any citation style you choose.

You can use the tips and insights above to master nursing school assignments. We wish you all the best as you strive towards excellence. Don't worry about the many assignments. Instead, be grateful that they will equip you with knowledge, skills, and experience to make you the best nurse.

How Many Papers to Write in Nursing School

We have so far covered the general aspects of the types of assignments to expect in nursing school. Under the assignments, you may ask yourself if you must write many papers in nursing school.

While the answer depends on your professor, institutional curriculum requirements, and nursing level, you will undoubtedly write a couple of academic papers before graduating from nursing school. You will write research papers, essays, proposals, white papers, policy analysis papers, capstone project papers, case studies, scholarship essays, personal statements, quality improvement reports, etc.

Suppose you are pursuing a Licensed Practical Nurse (LPN) program. In that case, you will likely write between 13 and 15 papers during the LPN program, including short and long essays, reflective journals, essays, patient-based case studies, and others as your professor pleases.

If you are in a 2-year ADN program, expect to complete about 20 to 30 papers, including care plans, SBAR reports, essays, case studies analyses, research papers, reports, and other assignments.

For a 4-year Bachelor of Science in Nursing (BSN) program, you will write between 35 and 50 papers. If you are taking the online class program options, like the WGU BSN program, you might write more papers because they form the basis for your assessment.

BSN-level papers are demanding because you must strictly adhere to the formatting styles and be critical and organized in your presentation.

If you are taking a Master of Science in Nursing (MSN) program, an advanced-level study for registered nurses (RNs), you will do about 20-50 papers, given that it offers the foundation for nursing research. Again, at an advanced level, the MSN writing assignments are complex.

You need to plan well, research widely, and analyze facts thoroughly before drawing conclusions. During this level, expect to write papers such as MSN essays, discussion posts and responses, specialized case studies, research papers, clinical reports, advanced SOAP notes, nursing care plans, policy papers, position papers (white papers), dissertations, theses, capstone papers, project papers, and change project papers.

You are expected to show exquisite research skills for the Doctor of Nursing Practice (DNP) program, considered the highest level or terminal degree in nursing practice. At this level, you have specialized, advanced your knowledge, and have adequate experience.

Mostly, DNP papers are a little longer. You will write between 20-30 papers; depending on your nursing school curriculum and supervisor's preference, it could be less or more.

If you opt for the research route, you will write many research papers, technical papers, policy analysis papers, white papers, reflection papers, nursing dissertations, PICOT-based change project papers (DNP change project papers), and other assignments.

Finally, for the Doctor of Philosophy (PhD) in nursing programs, you should expect to write between 10 and 15 papers covering research-oriented topics.

Attaining this degree makes you the epitome of success in the field. You can advance into a nursing researcher, educator, leader, or manager.

We have writers that can help you handle all these types of papers regardless of the academic level. Our Online Nursing Writing pros are available for hire anytime and any day.

Having worked successfully with many nursing clients/students, we are confident to help you achieve your dreams.

Before you go …

There are many assignments and papers to complete in nursing school, including written assignments, quizzes, exams (oral and written), reflective journals, journal entries, e-Portfolio, integrative reviews, teaching plans, presentations, etc. Whether taking an LPN program or advancing your career by pursuing a Ph.D. in Nursing, you will do many nursing school assignments.

Do not take assignments as a punishment. Instead, consider them as tools to equip and shape you into a desirable nurse practitioner.

If you feel overwhelmed, stressed, and anxious about completing the assignments, you can hire our nursing writers to help you. We can help you ace nursing assignments online and ensure that you get 100% well-researched, organized, and proofread papers.

Our papers are 100% original and non-plagiarized. The writers understand how to structure nursing papers, formulate great paragraphs using the MEAN, PEEL, or TEEL formats, and write desirable papers consistently, scoring the best grades. You can call us your nursing assignment slayers or acers because, in a few hours, we will help you get it all behind you. We can help you ace online nursing classes and tests/quizzes .

Click on the Order button and fill out the form to get our writers started in making you a nursing paper that gives the best grade. No topic is challenging for us, and we allow you direct communication with the writer in the process of getting help.

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NurseMyGrades is being relied upon by thousands of students worldwide to ace their nursing studies. We offer high quality sample papers that help students in their revision as well as helping them remain abreast of what is expected of them.

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Common Assignments: Writing in Nursing

Although there may be some differences in writing expectations between disciplines, all writers of scholarly work are required to follow basic writing standards such as writing clear, concise, and grammatically correct sentences; using proper punctuation; demonstrating critical thought; and, in all Walden programs, using APA style. When writing in nursing, however, students must also be familiar with the goals of the discipline and discipline-specific writing expectations.

Nurses are primarily concerned about providing quality care to patients and their families, and this demands both technical knowledge and the appropriate expression of ideas (“Writing in nursing,” n.d). As a result, nursing students are expected to learn how to present information succinctly, and even though they may often use technical medical terminology (“Writing in nursing,” n.d.), their work should be accessible to anyone who may read it. Among many goals, writers within this discipline are required to:

• Document knowledge/research
• Demonstrate critical thinking
• Express creative ideas
• Explore nursing literature
• Demonstrate understanding of learning activities. (Wagner, n.d., para. 2)

Given this broad set of objectives, nursing students would benefit from learning how to write diverse literature, including scholarly reports, reviews, articles, and so on. They should aim to write work that can be used in both the research and clinical aspects of the discipline. Walden instructors often ask nursing students to write position and reflective papers, critique articles, gather and analyze data, respond to case studies, and work collaboratively on a project. Although there may be differences between the writing expectations within the classroom and those in the workplace, the standards noted below, though more common in scholarly writing, require skills that are transferrable to the work setting.

Because one cannot say everything there is to say about a particular subject, writers present their work from a particular perspective. For instance, one might choose to examine the shortage of nurses from a public policy perspective. One’s particular contribution, position, argument, or viewpoint is commonly referred to as the thesis and, according to Gerring et al. (2004), a good thesis is one that is “new, true, and significant” (p. 2). To strengthen a thesis, one might consider presenting an argument that goes against what is currently accepted within the field while carefully addressing counterarguments and adequately explaining why the issue under consideration matters (Gerring et al., 2004). The thesis is particularly important because readers want to know whether the writer has something new or worthwhile to say about the topic. Thus, as you review the literature, before writing, it is important to find gaps and creative linkages between viewpoints with the goal of contributing innovative ideas to an ongoing discussion. For a contribution to be worthwhile you must read the literature carefully and without bias; doing this will enable you to identify some of the subtle differences in the viewpoints presented by different authors and help you to better identify the gaps in the literature. Because the thesis is essentially the heart of your discussion, it is important that it is argued objectively and persuasively.

With the goal of providing high quality care, the healthcare industry places a premium on rigorous research as the foundation for evidence-based practices. Thus, students are expected to keep up with the most current research in their field and support the assertions they make in their work with evidence from the literature. Nursing students also must learn how to evaluate evidence in nursing literature and identify the studies that answer specific clinical questions (Oermann & Hays, 2011). Writers are also expected to critically analyze and evaluate studies and assess whether findings can be used in clinical practice (Beyea & Slattery, 2006). (Some useful and credible sources include journal articles, other peer-reviewed sources, and authoritative sources that might be found on the web. If you need help finding credible sources contact a librarian.)

Like other APA style papers, research papers in nursing should follow the following format: title, abstract, introduction, literature review, method, results, discussion, references, and appendices (see APA 7, Sections 2.16-2.25). Note that the presentation follows a certain logic: In the introduction one presents the issue under consideration; in the literature review, one presents what is already known about the topic (thus providing a context for the discussion), identifies gaps, and presents one’s approach; in the methods section, one would then identify the method used to gather data; and in the results and discussion sections, one then presents and explains the results in an objective manner, noting the limitations of the study (Dartmouth Writing Program, 2005). Note that not all papers need to be written in this manner; for guidance on the formatting of a basic course paper, see the appropriate template on our website.

In their research, nursing researchers use quantitative, qualitative, or mixed methods. In quantitative studies, researchers rely primarily on quantifiable data; in qualitative studies, they use data from interviews or other types of narrative analyses; and in mixed methods studies, they use both qualitative and quantitative approaches. A researcher should be able to pose a researchable question and identify an appropriate research method. Whatever method the researcher chooses, the research must be carried out in an objective and scientific manner, free from bias. Keep in mind that your method will have an impact on the credibility of your work, so it is important that your methods are rigorous. Walden offers a series of research methods courses to help students become familiar with the various research methods.

Instructors expect students to master the content of the discipline and use discipline- appropriate language in their writing. In practice, nurses may be required to become familiar with standardized nursing language as it has been found to lead to the following:

• better communication among nurses and other health care providers,
• increased visibility of nursing interventions,
• improved patient care,
• enhanced data collection to evaluate nursing care outcomes,
• greater adherence to standards of care, and
• facilitated assessment of nursing competency. (Rutherford, 2008)

Like successful writers in other disciplines and in preparation for diverse roles within their fields, in their writing nursing students should demonstrate that they (a) have cultivated the thinking skills that are useful in their discipline, (b) are able to communicate professionally, and (c) can incorporate the language of the field in their work appropriately (Colorado State University, 2011).

If you have content-specific questions, be sure to ask your instructor. The Writing Center is available to help you present your ideas as effectively as possible.

Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation . http://www.hcmarketplace.com/supplemental/3737_browse.pdf

Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm

Dartmouth Writing Program. (2005). Writing in the social sciences . http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml

Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing , 13 (1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html

Wagner, D. (n.d.). Why writing matters in nursing . https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/

Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html

Didn't find what you need? Email us at [email protected] .

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• South Dakota Nurse November 2018 issue is now available.

8 Steps for Making Effective Nurse-Patient Assignments

This article appears on page 14 of

South Dakota Nurse November 2018

Reprinted from American Nurse Today

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

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

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

1. Find a mentor

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

2. Gather your supplies (knowledge)

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

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

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

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

3. Decide on the process

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

4. Set priorities for the shift

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

5. Make the assignments

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

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

6. Adjust the assignments

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

7. Evaluate success

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

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

8. Keep practicing

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

What you need to know

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

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

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

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

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

Psychosocial support •    Emotional needs •    Familial support •    Intellectual needs

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

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

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

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

Choose your process

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

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

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

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

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

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

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

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Chapter 4 Nursing Process

4.1. nursing process introduction, learning objectives.

• Use the nursing process to provide patient care
• Identify nursing diagnoses from evidence-based sources
• Describe the development of a care plan
• Prioritize patient care
• Describe documentation for each step of the nursing process
• Differentiate between the role of the PN and RN

Have you ever wondered how a nurse can receive a quick handoff report from another nurse and immediately begin providing care for a patient they previously knew nothing about? How do they know what to do? How do they prioritize and make a plan?

Nurses do this activity every shift. They know how to find pertinent information and use the nursing process as a critical thinking model to guide patient care. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. This chapter will explain how to use the  nursing process  as standards of professional nursing practice to provide safe, patient-centered care.

4.2. BASIC CONCEPTS

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [ 1 ] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness:  Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity:  Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility:  Recognizing your intellectual limitations and abilities
• Nonjudgmental:  Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity:  Being honest and demonstrating strong moral principles
• Perseverance:  Persisting in doing something despite it being difficult
• Confidence:  Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings:  Wanting to explore different ways of knowing
• Curiosity:  Asking “why” and wanting to know more

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 ]  To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [ 3 ]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning  involves noticing cues, making generalizations, and creating hypotheses.  Cues  are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A  generalization  is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A  hypothesis  is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1 . [ 4 ]  Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Inductive Reasoning Includes Looking for Cues

Example:  A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoning  is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example:  Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2 ). [ 5 ]  The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgment  is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”  [ 6 ]  The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP)  is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [ 7 ]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [ 8 ]  The mnemonic  ADOPIE  is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process:  A ssessment,  D iagnosis,  O utcomes Identification,  P lanning,  I mplementation, and  E valuation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3 [ 9 ]  for an illustration of the nursing process.

The Nursing Process

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A: Using the Nursing Process [ 10 ]

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [ 11 ]  A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. [ 12 ]

The “Assessment” component of the nursing process is further described in the “ Assessment ” section of this chapter.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [ 13 ]  A nursing diagnosis is the nurse’s clinical judgment about the  client's  response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses. [ 14 ]

The “Diagnosis” component of the nursing process is further described in the “ Diagnosis ” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [ 15 ]  The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “ Outcomes Identification ” section of this chapter.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [ 16 ]  Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [ 17 ]

The “Planning” component of the nursing process is further described in the “ Planning ” section of this chapter.

NURSING CARE PLANS

Creating nursing care plans is a part of the “Planning” step of the nursing process. A  nursing care plan  is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “ Planning ” and “ Implementing ” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” [ 18 ]  Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed. [ 19 ]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment. [ 20 ]

The “Implementation” component of the nursing process is further described in the “ Implementation ” section of this chapter.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 21 ]  During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. [ 22 ]

The “Evaluation” component of the nursing process is further described in the “ Evaluation ” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of  nursing  as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [ 23 ]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The  art of nursing  is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” [ 24 ]

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Review how to provide culturally responsive care and reduce health disparities in the “ Diverse Patients ” chapter.

Caring and the nursing process.

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” [ 25 ]  Successful use of the nursing process requires the development of a care relationship with the patient. A  care relationship  is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of  rapport  and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being. [ 26 ] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. [ 27 ]  See Figure 4.4 [ 28 ]  for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Touch as a Therapeutic Communication Technique

Review how to communicate with patients using therapeutic communication techniques like active listening in the “ Communication ” chapter.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment. [ 29 ]

Read more about Dr. Watson’s theory of caring at the  Watson Caring Science Institute .

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

4.3. ASSESSMENT

Assessment  is the first step of the nursing process (and the first  Standard of Practice  set by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.” [ 1 ]

Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes. Patient data is considered either subjective or objective, and it can be collected from multiple sources.

Subjective Assessment Data

Subjective data  is information obtained from the patient and/or family members and offers important cues from their perspectives. When documenting subjective data stated by a patient, it should be in quotation marks and start with verbiage such as,  The patient reports.  It is vital for the nurse to establish rapport with a patient to obtain accurate, valuable subjective data regarding the mental, emotional, and spiritual aspects of their condition.

There are two types of subjective information, primary and secondary.  Primary data  is information provided directly by the patient. Patients are the best source of information about their bodies and feelings, and the nurse who actively listens to a patient will often learn valuable information while also promoting a sense of well-being. Information collected from a family member, chart, or other sources is known as  secondary data . Family members can provide important information, especially for individuals with memory impairments, infants, children, or when patients are unable to speak for themselves.

See Figure 4.5 [ 2 ]  for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Example.  An example of documented subjective data obtained from a patient assessment is,  “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Assessment Data

Objective data  is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results. See Figure 4.6 [ 3 ]  for an image of a nurse performing a physical examination.

Physical Examination

Example.  An example of documented objective data is,  “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data

There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results.

Interviewing

Interviewing includes asking the patient questions, listening, and observing verbal and nonverbal communication. Reviewing the chart prior to interviewing the patient may eliminate redundancy in the interview process and allows the nurse to hone in on the most significant areas of concern or need for clarification. However, if information in the chart does not make sense or is incomplete, the nurse should use the interview process to verify data with the patient.

After performing patient identification, the best way to initiate a caring relationship is to introduce yourself to the patient and explain your role. Share the purpose of your interview and the approximate time it will take. When beginning an interview, it may be helpful to start with questions related to the patient’s  medical diagnoses  to gather information about how they have affected the patient’s functioning, relationships, and lifestyle. Listen carefully and ask for clarification when something isn’t clear to you. Patients may not volunteer important information because they don’t realize it is important for their care. By using critical thinking and active listening, you may discover valuable cues that are important to provide safe, quality nursing care. Sometimes nursing students can feel uncomfortable having difficult conversations or asking personal questions due to generational or other cultural differences. Don’t shy away from asking about information that is important to know for safe patient care. Most patients will be grateful that you cared enough to ask and listen.

Be alert and attentive to how the patient answers questions, as well as when they do not answer a question. Nonverbal communication and body language can be cues to important information that requires further investigation. A keen sense of observation is important. To avoid making inappropriate  inferences , the nurse should validate any cues. For example, a nurse may make an inference that a patient is depressed when the patient avoids making eye contact during an interview. However, upon further questioning, the nurse may discover that the patient’s cultural background believes direct eye contact to be disrespectful and this is why they are avoiding eye contact. To read more information about communicating with patients, review the “ Communication ” chapter of this book.

A  physical examination  is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a patient’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid is present. Detailed physical examination procedures of various body systems can be found in the Open RN  Nursing Skills  textbook with a head-to-toe checklist in  Appendix C . Physical examination also includes the collection and analysis of vital signs.

Registered Nurses (RNs)  complete the initial physical examination and analyze the findings as part of the nursing process. Collection of follow-up physical examination data can be delegated to  Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) , or measurements such as vital signs and weight may be delegated to trained  Unlicensed Assistive Personnel (UAP)  when appropriate to do so. However, the RN remains responsible for supervising these tasks, analyzing the findings, and ensuring they are documented .

A physical examination can be performed as a comprehensive, head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the patient’s  Electronic Medical Record (EMR) , an electronic version of the patient’s medical chart.

Reviewing Laboratory and Diagnostic Test Results

Reviewing laboratory and diagnostic test results provides relevant and useful information related to the needs of the patient. Understanding how normal and abnormal results affect patient care is important when implementing the nursing care plan and administering provider prescriptions. If results cause concern, it is the nurse’s responsibility to notify the provider and verify the appropriateness of prescriptions based on the patient’s current status before implementing them.

Types of Assessments

Several types of nursing assessment are used in clinical practice:

• Primary Survey:  Used during every patient encounter to briefly evaluate level of consciousness, airway, breathing, and circulation and implement emergency care if needed.
• Admission Assessment:  A comprehensive assessment completed when a patient is admitted to a facility that involves assessing a large amount of information using an organized approach.
• Ongoing Assessment:  In acute care agencies such as hospitals, a head-to-toe assessment is completed and documented at least once every shift. Any changes in patient condition are reported to the health care provider.
• Focused Assessment:  Focused assessments are used to reevaluate the status of a previously diagnosed problem.
• Time-lapsed Reassessment:  Time-lapsed reassessments are used in long-term care facilities when three or more months have elapsed since the previous assessment to evaluate progress on previously identified outcomes. [ 4 ]

Putting It Together

Review Scenario C in the following box to apply concepts of assessment to a patient scenario.

Scenario C [5]

Ms. J. is a 74-year-old woman who is admitted directly to the medical unit after visiting her physician because of shortness of breath, increased swelling in her ankles and calves, and fatigue. Her medical history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). She takes 81 mg of aspirin every day, metoprolol 50 mg twice a day, furosemide 40 mg every day, and metformin 2,000 mg every day.

Ms. J.’s vital sign values on admission were as follows:

• Blood Pressure: 162/96 mm Hg
• Heart Rate: 88 beats/min
• Oxygen Saturation: 91% on room air
• Respiratory Rate: 28 breaths/minute
• Temperature: 97.8 degrees F orally

Her weight is up 10 pounds since the last office visit three weeks prior. The patient states, “I am so short of breath” and “My ankles are so swollen I have to wear my house slippers.” Ms. J. also shares, “I am so tired and weak that I can’t get out of the house to shop for groceries,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She confides, “I would like to learn more about my health so I can take better care of myself.”

The physical assessment findings of Ms. J. are bilateral basilar crackles in the lungs and bilateral 2+ pitting edema of the ankles and feet. Laboratory results indicate a decreased serum potassium level of 3.4 mEq/L.

As the nurse completes the physical assessment, the patient’s daughter enters the room. She confides, “We are so worried about mom living at home by herself when she is so tired all the time!”

Critical Thinking Questions

Identify subjective data.

Identify objective data.

Provide an example of secondary data.

Answers are located in the Answer Key at the end of the book.

4.4. DIAGNOSIS

Diagnosis  is the second step of the nursing process (and the second Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, problems, strengths, and issues are documented in a manner that facilitates the development of expected outcomes and a collaborative plan. [ 1 ]

Analyzing Assessment Data

After collection of assessment data, the registered nurse analyzes the data to form generalizations and create hypotheses for nursing diagnoses. Steps for analyzing assessment data include performing data analysis, clustering of information, identifying hypotheses for potential nursing diagnosis, performing additional in-depth assessment as needed, and establishing nursing diagnosis statements. The nursing diagnoses are then prioritized and drive the nursing care plan. [ 2 ]

Performing Data Analysis

After nurses collect assessment data from a patient, they use their nursing knowledge to analyze that data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for that patient according to their age, development, and baseline status. From there, nurses determine what data are “clinically relevant” as they prioritize their nursing care. [ 3 ]

Example.  In Scenario C in the “Assessment” section of this chapter, the nurse analyzes the vital signs data and determines the blood pressure, heart rate, and respiratory rate are elevated, and the oxygen saturation is decreased for this patient. These findings are considered “relevant cues.”

Clustering Information/Seeing Patterns/Making Hypotheses

After analyzing the data and determining relevant cues, the nurse  clusters  data into patterns. Assessment frameworks such as Gordon’s  Functional Health Patterns  assist nurses in clustering information according to evidence-based patterns of human responses. See the box below for an outline of Gordon’s Functional Health Patterns. [ 4 ]  Concepts related to many of these patterns will be discussed in chapters later in this book.

Example.  Refer to Scenario C of the “Assessment” section of this chapter. The nurse clusters the following relevant cues: elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, shortness of breath, a medical history of heart failure, and currently prescribed a diuretic medication. These cues are clustered into a generalization/pattern of fluid balance, which can be classified under Gordon’s Nutritional-Metabolic Functional Health Pattern. The nurse makes a hypothesis that the patient has excess fluid volume present.

Gordon’s Functional Health Patterns [ 5 ]

Health Perception-Health Management:  A patient’s perception of their health and well-being and how it is managed

Nutritional-Metabolic:  Food and fluid consumption relative to metabolic need

Elimination:  Excretory function, including bowel, bladder, and skin

Activity-Exercise:  Exercise and daily activities

Sleep-Rest:  Sleep, rest, and daily activities

Cognitive-Perceptual:  Perception and cognition

Self-perception and Self-concept:  Self-concept and perception of self-worth, self-competency, body image, and mood state

Role-Relationship:  Role engagements and relationships

Sexuality-Reproductive:  Reproduction and satisfaction or dissatisfaction with sexuality

Coping-Stress Tolerance:  Coping and effectiveness in terms of stress tolerance

Value-Belief:  Values, beliefs (including spiritual beliefs), and goals that guide choices and decisions

Identifying Nursing Diagnoses

After the nurse has analyzed and clustered the data from the patient assessment, the next step is to begin to answer the question, “What are my patient’s human responses (i.e., nursing diagnoses)?” A  nursing diagnosis  is defined as, “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” [ 6 ]  Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. The nurse should refer to a care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses to determine if additional in-depth assessment is needed before selecting the most accurate nursing diagnosis.

Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings. [ 7 ]  Currently, there are over 220 NANDA-I nursing diagnoses developed by nurses around the world. This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses retired that no longer have supporting evidence. A list of commonly used NANDA-I diagnoses are listed in  Appendix A . For a full list of NANDA-I nursing diagnoses, refer to a current nursing care plan reference.

NANDA-I nursing diagnoses are grouped into 13 domains that assist the nurse in selecting diagnoses based on the patterns of clustered data. These domains are similar to Gordon’s Functional Health Patterns and include health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development.

Knowledge regarding specific NANDA-I nursing diagnoses is not assessed on the NCLEX. However, analyzing cues and creating hypotheses are part of the measurement model used to assess a candidate’s clinical judgment. Read more about the NCLEX and Next Generation NCLEX in the “ Scope of Practice ” chapter.

Nursing diagnoses vs. medical diagnoses.

You may be asking yourself, “How are nursing diagnoses different from medical diagnoses?” Medical diagnoses focus on diseases or other medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Nursing diagnoses focus on the  human response  to health conditions and life processes and are made independently by RNs. Patients with the same medical diagnosis will often  respond  differently to that diagnosis and thus have different nursing diagnoses. For example, two patients have the same medical diagnosis of heart failure. However, one patient may be interested in learning more information about the condition and the medications used to treat it, whereas another patient may be experiencing anxiety when thinking about the effects this medical diagnosis will have on their family. The nurse must consider these different responses when creating the nursing care plan. Nursing diagnoses consider the patient’s and family’s needs, attitudes, strengths, challenges, and resources as a customized nursing care plan is created to provide holistic and individualized care for each patient.

Example.  A medical diagnosis identified for Ms. J. in Scenario C in the “Assessment” section is heart failure. This cannot be used as a nursing diagnosis, but it can be considered as an “associated condition” when creating hypotheses for nursing diagnoses. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. The nursing diagnosis in Scenario C will be related to the patient’s response to heart failure.

Additional Definitions Used in NANDA-I Nursing Diagnoses

The following definitions of patient, age, and time are used in association with NANDA-I nursing diagnoses:

The NANDA-I definition of a “patient” includes:

• Individual:  a single human being distinct from others (i.e., a person).
• Caregiver:  a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
• Family:  two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
• Group:  a number of people with shared characteristics generally referred to as an ethnic group.
• Community:  a group of people living in the same locale under the same governance. Examples include neighborhoods and cities. [ 8 ]

The age of the person who is the subject of the diagnosis is defined by the following terms: [ 9 ]

• Fetus:  an unborn human more than eight weeks after conception, until birth.
• Neonate:  a person less than 28 days of age.
• Infant:  a person greater than 28 days and less than 1 year of age.
• Child:  a person aged 1 to 9 years
• Adolescent:  a person aged 10 to 19 years
• Adult:  a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.
• Older adult:  a person greater than 65 years of age.

The duration of the diagnosis is defined by the following terms: [ 10 ]

• Acute:  lasting less than 3 months.
• Chronic:  lasting greater than 3 months.
• Intermittent:  stopping or starting again at intervals
• Continuous:  uninterrupted, going on without stop.

New Terms Used in 2018-2020 NANDA-I Diagnoses

The 2018-2020 edition of  Nursing Diagnoses  includes two new terms to assist in creating nursing diagnoses: at-risk populations and associated conditions. [ 11 ]

At-Risk Populations  are groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences.

Associated Conditions  are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis [ 12 ]

Types of Nursing Diagnoses

There are four types of NANDA-I nursing diagnoses: [ 13 ]

• Problem-Focused
• Health Promotion – Wellness

A  problem-focused nursing diagnosis  is a “clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community.” [ 14 ]  To make an accurate problem-focused diagnosis, related factors and defining characteristics must be present.  Related factors  (also called etiology) are causes that contribute to the diagnosis.  Defining characteristics  are cues, signs, and symptoms that cluster into patterns. [ 15 ]

A  health promotion-wellness nursing diagnosis  is “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.” These responses are expressed by the patient’s readiness to enhance specific health behaviors. [ 16 ] A health promotion-wellness diagnosis is used when the patient is willing to improve a lack of knowledge, coping, or other identified need.

A  risk nursing diagnosis  is “a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.” [ 17 ]  A risk nursing diagnosis must be supported by risk factors that contribute to the increased vulnerability. A risk nursing diagnosis is different from the problem-focused diagnosis in that the problem has not yet actually occurred. Problem diagnoses should not be automatically viewed as more important than risk diagnoses because sometimes a risk diagnosis can have the highest priority for a patient. [ 18 ]

A  syndrome diagnosis  is a “clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.” [ 19 ]

Establishing Nursing Diagnosis Statements

When using NANDA-I nursing diagnoses, NANDA-I recommends the structure of a nursing diagnosis should be a statement that includes the  nursing diagnosis  and  related factors  as exhibited by  defining characteristics . The accuracy of the nursing diagnosis is validated when a nurse is able to clearly link the defining characteristics, related factors, and/or risk factors found during the patient’s assessment. [ 20 ]

To create a nursing diagnosis statement, the registered nurse completes the following steps. After analyzing the patient’s subjective and objective data and clustering the data into patterns, the nurse generates hypotheses for nursing diagnoses based on how the patterns meet defining characteristics of a nursing diagnosis.  Defining characteristics  is the terminology used for observable signs and symptoms related to a nursing diagnosis. [ 21 ]  Defining characteristics are included in care planning resources for each nursing diagnosis, along with a definition of that diagnosis, so the nurse can select the most accurate diagnosis. For example, objective and subjective data such as weight, height, and dietary intake can be clustered together as defining characteristics for the nursing diagnosis of nutritional status.

When creating a nursing diagnosis statement, the nurse also identifies the cause of the problem for that specific patient.  Related factors  is the terminology used for the underlying causes (etiology) of a patient’s problem or situation. Related factors should not be a medical diagnosis, but instead should be attributed to the underlying pathophysiology that the nurse can treat. When possible, the nursing interventions planned for each nursing diagnosis should attempt to modify or remove these related factors that are the underlying cause of the nursing diagnosis. [ 22 ]

Creating nursing diagnosis statements has traditionally been referred to as “using PES format.” The  PES  mnemonic no longer applies to the current terminology used by NANDA-I, but the components of a nursing diagnosis statement remain the same. A nursing diagnosis statement should contain the problem, related factors, and defining characteristics. These terms fit under the former PES format in this manner:

Problem (P)  – the patient  p roblem (i.e., the nursing diagnosis)

Etiology (E)  – related factors (i.e., the  e tiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”

Signs and Symptoms (S)  – defining characteristics manifested by the patient (i.e., the  s igns and  s ymptoms/subjective and objective data) that led to the identification of that nursing diagnosis for the patient; phrased with “as manifested by” or “as evidenced by.”

Examples of different types of nursing diagnoses are further explained below.

Problem-Focused Nursing Diagnosis

A problem-focused nursing diagnosis contains all three components of the  PES format :

Problem (P)  – statement of the patient response (nursing diagnosis)

Etiology (E)  – related factors contributing to the nursing diagnosis

Signs and Symptoms (S)  – defining characteristics manifested by that patient

SAMPLE PROBLEM-FOCUSED NURSING DIAGNOSIS STATEMENT

Refer to Scenario C of the “Assessment” section of this chapter. The cluster of data for Ms. J. (elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, and shortness of breath) are defining characteristics for the NANDA-I Nursing Diagnosis  Excess Fluid Volume . The NANDA-I definition of  Excess Fluid Volume  is “surplus intake and/or retention of fluid.” The related factor (etiology) of the problem is that the patient has excessive fluid intake. [ 23 ]

The components of a  problem-focused nursing diagnosis  statement for Ms. J. would be:

Fluid Volume Excess

Related to excessive fluid intake

As manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, increased weight of 10 pounds, and the patient reports, “ My ankles are so swollen .”

A correctly written problem-focused nursing diagnosis statement for Ms. J. would look like this:

Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

Health-Promotion Nursing Diagnosis

A health-promotion nursing diagnosis statement contains the problem (P) and the defining characteristics (S). The defining characteristics component of a health-promotion nursing diagnosis statement should begin with the phrase “expresses desire to enhance”: [ 24 ]

Signs and Symptoms (S)  – the patient’s expressed desire to enhance

SAMPLE HEALTH-PROMOTION NURSING DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. demonstrates a readiness to improve her health status when she told the nurse that she would like to “learn more about my health so I can take better care of myself.” This statement is a defining characteristic of the NANDA-I nursing diagnosis  Readiness for Enhanced Health Management , which is defined as “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.” [ 25 ]

The components of a  health-promotion nursing diagnosis  for Ms. J. would be:

Problem (P):  Readiness for Enhanced Health Management

Symptoms (S):  Expressed desire to “learn more about my health so I can take better care of myself.”

A correctly written health-promotion nursing diagnosis statement for Ms. J. would look like this:

Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis

A risk nursing diagnosis should be supported by evidence of the patient’s risk factors for developing that problem. Different experts recommend different phrasing. NANDA-I 2018-2020 recommends using the phrase “as evidenced by” to refer to the risk factors for developing that problem. [ 26 ]

A risk diagnosis consists of the following:

As Evidenced By  – Risk factors for developing the problem

SAMPLE RISK DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. has an increased risk of falling due to vulnerability from the dizziness and weakness she is experiencing. The NANDA-I definition of  Risk for Falls  is “increased susceptibility to falling, which may cause physical harm and compromise health.” [ 27 ]

The components of a  risk diagnosis  statement for Ms. J. would be:

Problem (P)  – Risk for Falls

As Evidenced By  – Dizziness and decreased lower extremity strength

A correctly written risk nursing diagnosis statement for Ms. J. would look like this:

Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Syndrome Diagnosis

A syndrome is a cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To create a syndrome diagnosis, two or more nursing diagnoses must be used as defining characteristics (S) that create a syndrome. Related factors may be used if they add clarity to the definition, but are not required. [ 28 ]

A syndrome statement consists of these items:

Problem (P)  – the syndrome

Signs and Symptoms (S)  – the defining characteristics are two or more similar nursing diagnoses

SAMPLE SYNDROME DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Clustering the data for Ms. J. identifies several similar NANDA-I nursing diagnoses that can be categorized as a  syndrome . For example,  Activity Intolerance  is defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities.”  Social Isolation  is defined as “aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.” These diagnoses can be included under the the NANDA-I syndrome named  Risk for Frail Elderly Syndrome.  This syndrome is defined as a “dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.” [ 29 ]

The components of a  syndrome nursing diagnosis  for Ms. J. would be:

– Risk for Frail Elderly Syndrome

– The nursing diagnoses of  Activity Intolerance  and  Social Isolation

Additional related factor: Fear of falling

A correctly written syndrome diagnosis statement for Ms. J. would look like this:

Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling

Prioritization

After identifying nursing diagnoses, the next step is prioritization according to the specific needs of the patient. Nurses prioritize their actions while providing patient care multiple times every day.  Prioritization  is the process that identifies the most significant nursing problems, as well as the most important interventions, in the nursing care plan.

It is essential that life-threatening concerns and crises are identified immediately and addressed quickly. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns. In critical situations, the steps of the nursing process are performed through rapid clinical judgment. Nurses must recognize cues signaling a change in patient condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members. Most patient situations fall somewhere between a crisis and routine care.

There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions. See the infographic in Figure 4.7 [30]  on  The How To of Prioritization .

The How To of Prioritization

Maslow’s Hierarchy of Needs  is used to categorize the most urgent patient needs. The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety. See Figure 4.8 [31]  for an image of Maslow’s Hierarchy of Needs. You may be asking yourself, “What about the ABCs – isn’t airway the most important?” The answer to that question is “it depends on the situation and the associated safety considerations.” Consider this scenario – you are driving home after a lovely picnic in the country and come across a fiery car crash. As you approach the car, you see that the passenger is not breathing. Using Maslow’s Hierarchy of Needs to prioritize your actions, you remove the passenger from the car first due to safety even though he is not breathing. After ensuring safety and calling for help, you follow the steps to perform cardiopulmonary resuscitation (CPR) to establish circulation, airway, and breathing until help arrives.

Maslow’s Hierarchy of Needs

In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the patient’s condition is an acute or chronic problem. Acute, uncompensated conditions generally require priority interventions over chronic conditions. Additionally, actual problems generally receive priority over potential problems, but risk problems sometimes receive priority depending on the patient vulnerability and risk factors.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Four types of nursing diagnoses were identified for Ms. J.:  Fluid Volume Excess, Enhanced Readiness for Health Promotion, Risk for Falls , and  Risk for Frail Elderly Syndrome . The top priority diagnosis is  Fluid Volume Excess  because it affects the physiological needs of breathing, homeostasis, and excretion. However, the  Risk for Falls  diagnosis comes in a close second because of safety implications and potential injury that could occur if the patient fell.

American Nurses Association. (2021).  Nursing: Scope and standards of practice  (4th ed.). American Nurses Association.  ↵

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).  Nursing diagnoses: Definitions and classification, 2018-2020 . Thieme Publishers New York.  ↵

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).  Nursing diagnoses: Definitions and classification, 2018-2020.  Thieme Publishers New York.  ↵

Gordon, M. (2008).  Assess notes: Nursing assessment and diagnostic reasoning.  F.A. Davis Company.  ↵

NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms /  ↵

NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

NANDA International. (n.d.).  Glossary of terms.   https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

“The How To of Prioritization” by Valerie Palarski for  Chippewa Valley Technical College  is licensed under  CC BY 4.0   ↵

“ Maslow's hierarchy of needs.svg ” by  J. Finkelstein  is licensed under  CC BY-SA 3.0   ↵

4.5. OUTCOME IDENTIFICATION

Outcome Identification  is the third step of the nursing process (and the third Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the health care consumer, interprofessional team, and others to identify expected outcomes integrating the health care consumer’s culture, values, and ethical considerations. Expected outcomes are documented as measurable goals with a time frame for attainment. [ 1 ]

An  outcome  is a “measurable behavior demonstrated by the patient responsive to nursing interventions.” [ 2 ]  Outcomes should be identified before nursing interventions are planned. After nursing interventions are implemented, the nurse will evaluate if the outcomes were met in the time frame indicated for that patient.

Outcome identification includes setting short- and long-term goals and then creating specific expected outcome statements for each nursing diagnosis.

Short-Term and Long-Term Goals

Nursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.

The nursing care plan is a road map used to guide patient care so that all health care providers are moving toward the same patient goals.  Goals  are broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided. For example, in a critical care area, a short-term goal might be set to be achieved within an 8-hour nursing shift, and a long-term goal might be in 24 hours. In contrast, in an outpatient setting, a short-term goal might be set to be achieved within one month and a long-term goal might be within six months.

A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. had a priority nursing diagnosis of  Fluid Volume Excess.  A broad goal would be, “ Ms. J. will achieve a state of fluid balance. ”

Expected Outcomes

Goals are broad, general statements, but outcomes are specific and measurable.  Expected outcomes  are statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions. Nurses may create expected outcomes independently or refer to classification systems for assistance. Just as NANDA-I creates and revises standardized nursing diagnoses, a similar classification and standardization process exists for expected nursing outcomes. The Nursing Outcomes Classification (NOC) is a list of over 330 nursing outcomes designed to coordinate with established NANDA-I diagnoses. [ 3 ]

Patient-Centered

Outcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving.

Outcome statements should contain five components easily remembered using the “SMART” mnemonic: [ 4 ]

• M easurable
• A ttainable/Action oriented
• R elevant/Realistic

See Figure 4.9 [ 5 ]  for an image of the SMART components of outcome statements. Each of these components is further described in the following subsections.

SMART Components of Outcome Statements

Outcome statements should state precisely what is to be accomplished. See the following examples:

• Not specific:  “The patient will increase the amount of exercise.”
• Specific:  “The patient will participate in a bicycling exercise session daily for 30 minutes.”

Additionally, only one action should be included in each expected outcome. See the following examples:

• “The patient will walk 50 feet three times a day with standby assistance of one and will shower in the morning until discharge”  is actually two goals written as one. The outcome of ambulation should be separate from showering for precise evaluation. For instance, the patient could shower but not ambulate, which would make this outcome statement very difficult to effectively evaluate.
• Suggested revision is to create two outcomes statements so each can be measured: The patient will walk 50 feet three times a day with standby assistance of one until discharge. The patient will shower every morning until discharge.

Measurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met. It is important to use objective data to measure outcomes. If terms like “acceptable” or “normal” are used in an outcome statement, it is difficult to determine whether the outcome is attained. Refer to Figure 4.10 [ 6 ]  for examples of verbs that are measurable and not measurable in outcome statements.

Figure 4.10

Measurable Outcomes

See the following examples:

• Not measurable:  “The patient will drink adequate fluid amounts every shift.”
• Measurable:  “The patient will drink 24 ounces of fluids during every day shift (0600-1400).”

Action-Oriented and Attainable

Outcome statements should be written so that there is a clear action to be taken by the patient or significant others. This means that the outcome statement should include a verb. Refer to Figure 4.11 [ 7 ]  for examples of action verbs.

Figure 4.11

Action Verbs

• Not action-oriented:  “The patient will get increased physical activity.”
• Action-oriented:  “The patient will list three types of aerobic activity that he would enjoy completing every week.”

Realistic and Relevant

Realistic outcomes consider the patient’s physical and mental condition; their cultural and spiritual values, beliefs, and preferences; and their socioeconomic status in terms of their ability to attain these outcomes. Consideration should be also given to disease processes and the effects of conditions such as pain and decreased mobility on the patient’s ability to reach expected outcomes. Other barriers to outcome attainment may be related to health literacy or lack of available resources. Outcomes should always be reevaluated and revised for attainability as needed. If an outcome is not attained, it is commonly because the original time frame was too ambitious or the outcome was not realistic for the patient.

• Not realistic:  “The patient will jog one mile every day when starting the exercise program.”
• Realistic:  “The patient will walk ½ mile three times a week for two weeks.”

Time Limited

Outcome statements should include a time frame for evaluation. The time frame depends on the intervention and the patient’s current condition. Some outcomes may need to be evaluated every shift, whereas other outcomes may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, the outcomes will be assessed according to the time frame specified for evaluation. If it has not been met, the nursing care plan should be revised.

• Not time limited: “The patient will stop smoking cigarettes.”
• Time limited:  “The patient will complete the smoking cessation plan by December 12, 2021.”

In Scenario C in Box 4.3, Ms. J.’s priority nursing diagnosis statement was  Fluid Volume Excess related to excess fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”  An example of an expected outcome meeting SMART criteria for Ms. J. is,  “The patient will have clear bilateral lung sounds within the next 24 hours.”

4.6. PLANNING

Planning  is the fourth step of the nursing process (and the fourth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” The RN develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team. Elements of the plan are prioritized. The plan is modified according to the ongoing assessment of the health care consumer’s response and other indicators. The plan is documented using standardized language or terminology. [ 1 ]

After expected outcomes are identified, the nurse begins planning nursing interventions to implement.  Nursing interventions  are evidence-based actions that the nurse performs to achieve patient outcomes. Just as a provider makes medical diagnoses and writes prescriptions to improve the patient’s medical condition, a nurse formulates nursing diagnoses and plans nursing interventions to resolve patient problems. Nursing interventions should focus on eliminating or reducing the related factors (etiology) of the nursing diagnoses when possible. [ 2 ]  Nursing interventions, goals, and expected outcomes are written in the nursing care plan for continuity of care across shifts, nurses, and health professionals.

Planning Nursing Interventions

You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan?” There are several sources that nurses and nursing students can use to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient chart. Nurses can also refer to other care planning books our sources such as the Nursing Interventions Classification (NIC) system. Based on research and input from the nursing profession, NIC categorizes and describes nursing interventions that are constantly evaluated and updated. Interventions included in NIC are considered evidence-based nursing practices. The nurse is responsible for using clinical judgment to make decisions about which interventions are best suited to meet an individualized patient’s needs. [ 3 ]

Direct and Indirect Care

Nursing interventions are considered direct care or indirect care.  Direct care  refers to interventions that are carried out by having personal contact with patients. Examples of direct care interventions are wound care, repositioning, and ambulation.  Indirect care  interventions are performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care interventions are attending care conferences, documenting, and communicating about patient care with other providers.

Classification of Nursing Interventions

There are three types of nursing interventions: independent, dependent, and collaborative. (See Figure 4.12 [ 4 ]  for an image of a nurse collaborating with the health care team when planning interventions.)

Figure 4.12

Collaborative nursing interventions, independent nursing interventions.

Any intervention that the nurse can independently provide without obtaining a prescription is considered an  independent nursing intervention . An example of an independent nursing intervention is when the nurses monitor the patient’s 24-hour intake/output record for trends because of a risk for imbalanced fluid volume. Another example of independent nursing interventions is the therapeutic communication that a nurse uses to assist patients to cope with a new medical diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of an evidence-based independent nursing intervention is,  “The nurse will reposition the patient with dependent edema frequently, as appropriate.” [ 5 ]  The nurse would individualize this evidence-based intervention to the patient and agency policy by stating,  “The nurse will reposition the patient every 2 hours.”

Dependent Nursing Interventions

Dependent nursing interventions  require a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 6 ]  A  primary health care provider  is a member of the health care team (usually a physician, advanced practice nurse, or physician’s assistant) who is licensed and authorized to formulate prescriptions on behalf of the client. For example, administering medication is a dependent nursing intervention. The nurse incorporates dependent interventions into the patient’s overall care plan by associating each intervention with the appropriate nursing diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a dependent nursing intervention is,  “The nurse will administer scheduled diuretics as prescribed.”

Collaborative nursing interventions  are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint. [ 7 ]

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a collaborative nursing intervention is consulting with a respiratory therapist when the patient has deteriorating oxygen saturation levels. The respiratory therapist plans oxygen therapy and obtains a prescription from the provider. The nurse would document “ The nurse will manage oxygen therapy in collaboration with the respiratory therapist ” in the care plan.

Individualization of Interventions

It is vital for the planned interventions to be individualized to the patient to be successful. For example, adding prune juice to the breakfast meal of a patient with constipation will only work if the patient likes to drink the prune juice. If the patient does not like prune juice, then this intervention should not be included in the care plan. Collaboration with the patient, family members, significant others, and the interprofessional team is essential for selecting effective interventions. The number of interventions included in a nursing care plan is not a hard and fast rule, but enough quality, individualized interventions should be planned to meet the identified outcomes for that patient.

Creating Nursing Care Plans

Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans are legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. CMS guidelines state, “Residents and their representative(s) must be afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. This may include ensuring that residents, families, or representatives understand the comprehensive care planning process, holding care planning meetings at the time of day when a resident is functioning best and patient representatives can be present, providing sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident’s representative (such as conducting the meeting in-person, via a conference call, or video conferencing), and planning enough time for information exchange and decision-making. A resident has the right to select or refuse specific treatment options before the care plan is instituted.” [ 8 ]  The Joint Commission conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care. [ 9 ]

Many facilities have established standardized nursing care plans with lists of possible interventions that can be customized for each specific patient. Other facilities require the nurse to develop each care plan independently. Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each patient. See Figure 4.13 [ 10 ]  for an image of a standardized care plan.

Figure 4.13

Standardized Care Plan

Nursing care plans created in nursing school can also be in various formats such as concept maps or tables. Some are fun and creative, while others are more formal.  Appendix B  contains a template that can be used for creating nursing care plans.

4.7. IMPLEMENTATION OF INTERVENTIONS

Implementation  is the fifth step of the nursing process (and the fifth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse implements the identified plan.” The RN may delegate planned interventions after considering the circumstance, person, task, communication, supervision, and evaluation, as well as the state Nurse Practice Act, federal regulation, and agency policy. [ 1 ]

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing Implementation of Interventions

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least invasive actions are usually preferred due to the risk of injury from invasive options. Read more about methods for prioritization under the “ Diagnosis ” subsection of this chapter.

The potential impact on future events, especially if a task is not completed at a certain time, is also included when prioritizing nursing interventions. For example, if a patient is scheduled to undergo a surgical procedure later in the day, the nurse prioritizes initiating a NPO (nothing by mouth) prescription prior to completing pre-op patient education about the procedure. The rationale for this decision is that if the patient ate food or drank water, the surgery time would be delayed. Knowing and understanding the patient’s purpose for care, current situation, and expected outcomes are necessary to accurately prioritize interventions.

Patient Safety

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states,  “The nurse will ambulate the patient 100 feet three times daily.”  However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient. This decision and supporting assessment findings should be documented in the patient’s chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient’s change in condition.

Implementing interventions goes far beyond implementing provider prescriptions and completing tasks identified on the nursing care plan and must focus on patient safety. As front-line providers, nurses are in the position to stop errors before they reach the patient. [ 2 ]

In 2000 the Institute of Medicine (IOM) issued a groundbreaking report titled  To Err Is Human: Building a Safer Health System . The report stated that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors.  To Err Is Human  broke the silence that previously surrounded the consequences of medical errors and set a national agenda for reducing medical errors and improving patient safety through the design of a safer health system. [ 3 ]  In 2007 the IOM published a follow-up report titled  Preventing Medication Errors  and reported that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. This report emphasized actions that health care systems could take to improve medication safety. [ 4 ]

Read additional information about specific actions that nurses can take to prevent medication errors; go to the “Preventing Medication Errors” section of the “ Legal/Ethical”  chapter of the Open RN  Nursing Pharmacology  textbook.

In an article released by the Robert Wood Johnson Foundation, errors involving nurses that endanger patient safety cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall, and more. Some errors can be traced to shifts that are too long that leave nurses fatigued, some result from flawed systems that do not allow for adequate safety checks, and others are caused by interruptions to nurses while they are trying to administer medications or provide other care. [ 5 ]

The Quality and Safety Education for Nurses (QSEN) project began in 2005 to assist in preparing future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.” [ 6 ]  Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and assisting in implementing initiatives to resolve these gaps.  Quality improvement  is defined as, “The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 7 ]

Delegation of Interventions

While implementing interventions, RNs may elect to delegate nursing tasks.  Delegation  is defined by the American Nurses Association as, “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.” [ 8 ]  RNs are accountable for determining the appropriateness of the delegated task according to condition of the patient and the circumstance; the communication provided to an appropriately trained LPN or UAP; the level of supervision provided; and the evaluation and documentation of the task completed. The RN must also be aware of the state Nurse Practice Act, federal regulations, and agency policy before delegating. The RN cannot delegate responsibilities requiring clinical judgment. [ 9 ]  See the following box for information regarding legal requirements associated with delegation according to the Wisconsin Nurse Practice Act.

Delegation According to the Wisconsin Nurse Practice Act

During the supervision and direction of delegated acts a Registered Nurse shall do all of the following:

Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.

Provide direction and assistance to those supervised.

Observe and monitor the activities of those supervised.

Evaluate the effectiveness of acts performed under supervision. [ 10 ]

The standard of practice for Licensed Practical Nurses in Wisconsin states, “In the performance of acts in basic patient situations, the LPN. shall, under the general supervision of an RN or the direction of a provider:

Accept only patient care assignments which the LPN is competent to perform.

Provide basic nursing care. Basic nursing care is defined as care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.

Record nursing care given and report to the appropriate person changes in the condition of a patient.

Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.

Perform the following other acts when applicable:

Assist with the collection of data.

Assist with the development and revision of a nursing care plan.

Reinforce the teaching provided by an RN provider and provide basic health care instruction.

Participate with other health team members in meeting basic patient needs.” [ 11 ]

Read additional details about the scope of practice of registered nurses (RNs) and licensed practical nurses (LPNs) in Wisconsin’s Nurse Practice Act in  Chapter N 6 Standards of Practice .

Read more about the American Nurses Association’s  Principles of Delegation.

Table 4.7 outlines general guidelines for delegating nursing tasks in the state of Wisconsin according to the role of the health care team member.

General Guidelines for Delegating Nursing Tasks

Documentation of Interventions

As interventions are performed, they must be documented in the patient’s record in a timely manner. As previously discussed in the “Ethical and Legal Issues” subsection of the “ Basic Concepts ” section, lack of documentation is considered a failure to communicate and a basis for legal action. A basic rule of thumb is if an intervention is not documented, it is considered not done in a court of law. It is also important to document administration of medication and other interventions in a timely manner to prevent errors that can occur due to delayed documentation time.

Coordination of Care and Health Teaching/Health Promotion

ANA’s Standard of Professional Practice for Implementation also includes the standards  5A   Coordination of Care  and  5B   Health Teaching and Health Promotion . [ 12 ]   Coordination of Care  includes competencies such as organizing the components of the plan, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and holistic care by the interprofessional team.  Health Teaching and Health Promotion  is defined as, “Employing strategies to teach and promote health and wellness.” [ 13 ]  Patient education is an important component of nursing care and should be included during every patient encounter. For example, patient education may include teaching about side effects while administering medications or teaching patients how to self-manage their conditions at home.

Refer to Scenario C in the “Assessment” section of this chapter. The nurse implemented the nursing care plan documented in Appendix C. Interventions related to breathing were prioritized. Administration of the diuretic medication was completed first, and lung sounds were monitored frequently for the remainder of the shift. Weighing the patient before breakfast was delegated to the CNA. The patient was educated about her medications and methods to use to reduce peripheral edema at home. All interventions were documented in the electronic medical record (EMR).

4.8. EVALUATION

Evaluation  is the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 1 ]  Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed. [ 2 ]

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record.

Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:

• Did anything unanticipated occur?
• Has the patient’s condition changed?
• Were the expected outcomes and their time frames realistic?
• Are the nursing diagnoses accurate for this patient at this time?
• Are the planned interventions appropriately focused on supporting outcome attainment?
• What barriers were experienced as interventions were implemented?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
• Are different interventions required?

Refer to Scenario C in the “Assessment” section of this chapter and Appendix C . The nurse evaluates the patient’s progress toward achieving the expected outcomes.

For the nursing diagnosis  Fluid Volume Excess , the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:

The patient will report decreased dyspnea within the next 8 hours.

The patient will have clear lung sounds within the next 24 hours.

The patient will have decreased edema within the next 24 hours.

The patient’s weight will return to baseline by discharge.

Evaluation of the patient condition on Day 1 included the following data: “ The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves .” Based on this data, the nurse evaluated the expected outcomes as “ Partially Met ” and revised the care plan with two new interventions:

Request prescription for TED hose from provider.

Elevate patient’s legs when sitting in chair.

For the second nursing diagnosis,  Risk for Falls , the nurse evaluated the outcome criteria as “ Met ” based on the evaluation, “ The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred. ”

The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record.

4.9. SUMMARY OF THE NURSING PROCESS

You have now learned how to perform each step of the nursing process according to the ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are used when assessing the patient, creating a nursing care plan, and implementing interventions. Frequent reassessment, with revisions to the care plan as needed, is important to help the patient achieve expected outcomes. Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care and evaluating whether that care has been successful in achieving patient outcomes are essential for providing safe, professional nursing practice.

Video Review of Creating a Sample Care Plan [ 1 ]

4.10. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Instructions: Apply what you’ve learned in this chapter by creating a nursing care plan using the following scenario. Use the template in   Appendix B   as a guide.

The client, Mark S., is a 57-year-old male who was admitted to the hospital with “severe” abdominal pain that was unable to be managed in the Emergency Department. The physician has informed Mark that he will need to undergo some diagnostic tests. The tests are scheduled for the morning.

After receiving the news about his condition and the need for diagnostic tests, Mark begins to pace the floor. He continues to pace constantly. He keeps asking the nurse the same question (“How long will the tests take?”) about his tests over and over again. The patient also remarked, “I’m so uptight I will never be able to sleep tonight.” The nurse observes that the client avoids eye contact during their interactions and that he continually fidgets with the call light. His eyes keep darting around the room. He appears tense and has a strained expression on his face. He states, “My mouth is so dry.” The nurse observes his vital signs to be: T 98, P 104, R 30, BP 180/96. The nurse notes that his skin feels sweaty (diaphoretic) and cool to the touch.

Critical Thinking Activity:

Group (cluster) the subjective and objective data.

Create a problem-focused nursing diagnosis (hypothesis).

Develop a broad goal and then identify an expected outcome in “SMART” format.

Outline three interventions for the nursing diagnosis to meet the goal. Cite an evidence-based source.

Imagine that you implemented the interventions that you identified. Evaluate the degree to which the expected outcome was achieved: Met – Partially Met – Not Met.

• IV GLOSSARY

The act or process of pleading for, supporting, or recommending a cause or course of action. [ 1 ]

Unconditionally acceptance of the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care. [ 2 ]

Groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences. [ 3 ]

Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. [ 4 ]

Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable. [ 5 ]

A relationship described as one in which the whole person is assessed while balancing the vulnerability and dignity of the patient and family. [ 6 ]

Individual, family, or group, which includes significant others and populations. [ 7 ]

The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care. [ 8 ]

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.  [ 9 ]

Grouping data into similar domains or patterns.

Nursing interventions that require cooperation among health care professionals and unlicensed assistive personnel (UAP).

While implementing interventions during the nursing process, includes components such as organizing the components of the plan with input from the health care consumer, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and person-centered care by the interprofessional team. [ 10 ]

Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow. [ 11 ]

Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder.

“Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion.

Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis, or syndrome. This does not only imply those things that the nurse can see, but also things that are seen, heard (e.g., the patient/family tells us), touched, or smelled. [ 12 ]

The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome. [ 13 ]

Interventions that require a prescription from a physician, advanced practice nurse, or physician’s assistant.

Interventions that are carried out by having personal contact with a patient.

An electronic version of the patient’s medical record.

A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values. [ 14 ]

Statements of measurable action for the patient within a specific time frame and in response to nursing interventions. “SMART” outcome statements are specific, measurable, action-oriented, realistic, and include a time frame.

An evidence-based assessment framework for identifying patient problems and risks during the assessment phase of the nursing process.

A judgment formed from a set of facts, cues, and observations.

Broad statements of purpose that describe the aim of nursing care.

Employing strategies to teach and promote health and wellness. [ 15 ]

Any intervention that the nurse can provide without obtaining a prescription or consulting anyone else.

Interventions performed by the nurse in a setting other than directly with the patient. An example of indirect care is creating a nursing care plan.

A type of reasoning that involves forming generalizations based on specific incidents.

Interpretations or conclusions based on cues, personal experiences, preferences, or generalizations.

Nurses who have had specific training and passed a licensing exam. The training is generally less than that of a Registered Nurse. The scope of practice of an LPN/LVN is determined by the facility and the state’s Nurse Practice Act.

A disease or illness diagnosed by a physician or advanced health care provider such as a nurse practitioner or physician’s assistant. Medical diagnoses are a result of clustering signs and symptoms to determine what is medically affecting an individual.

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity. [ 16 ]

Specific documentation of the planning and delivery of nursing care that is required by The Joint Commission.

A systematic approach to patient-centered care with steps including assessment, diagnosis, outcome identification, planning, implementation, and evaluation; otherwise known by the mnemonic “ADOPIE.”

Data that the nurse can see, touch, smell, or hear or is reproducible such as vital signs. Laboratory and diagnostic results are also considered objective data.

A measurable behavior demonstrated by the patient that is responsive to nursing interventions. [ 17 ]

The format of a nursing diagnosis statement that includes:

Problem (P) – statement of the patient problem (i.e., the nursing diagnosis)

Etiology (E) – related factors (etiology) contributing to the cause of the nursing diagnosis

Signs and Symptoms (S) – defining characteristics manifested by the patient of that nursing diagnosis

Orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 18 ]

Information collected from the patient.

Member of the health care team (usually a medical physician, nurse practitioner, etc.) licensed and authorized to formulate prescriptions on behalf of the client. [ 19 ]

The skillful process of deciding which actions to complete first, second, or third for optimal patient outcomes and to improve patient safety.

The “combined and unceasing efforts of everyone — health care professionals, patients and their families, researchers, payers, planners, and educators — to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 20 ]

Developing a relationship of mutual trust and understanding.

A nurse who has had a designated amount of education and training in nursing and is licensed by a state Board of Nursing.

The underlying cause (etiology) of a nursing diagnosis when creating a PES statement.

Patients have the right to determine what will be done with and to their own person.

Principles and procedures in the discovery of knowledge involving the recognition and formulation of a problem, the collection of data, and the formulation and testing of a hypothesis.

Information collected from sources other than the patient.

Data that the patient or family reports or data that the nurse makes as an inference, conclusion, or assumption, such as  “The patient appears anxious.”

Any unlicensed personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. [ 21 ]

Obtaining Subjective Data in a Care Relationship

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 Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 4 Nursing Process.
• PDF version of this title (216M)

In this Page

• NURSING PROCESS INTRODUCTION
• BASIC CONCEPTS
• OUTCOME IDENTIFICATION
• IMPLEMENTATION OF INTERVENTIONS
• SUMMARY OF THE NURSING PROCESS
• LEARNING ACTIVITIES

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• PMID: 23232175
• DOI: 10.1097/NNA.0b013e3182785fff

Charge nurses have integral roles in healthcare organizations. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient assignments are made and proposes a framework to guide the process of patient assignments.

• Continuity of Patient Care
• Nursing Staff, Hospital / organization & administration*
• Nursing, Supervisory
• Patient Safety
• Personnel Staffing and Scheduling*
• Planning Techniques*
• United States

Help With Nursing Assignments

Nursing students face a range of challenges when it comes to completing their assignments. From understanding complex medical terminology to managing their time effectively, the demands of the nursing curriculum can be daunting.

That’s why many healthcare students turn to external sources for help with their nursing homeworks. Whether you’re struggling with a particular assignment or simply looking to improve your grades, there is a range of resources available to help you succeed in your studies.

What Is a Nursing Assignment

A nursing homework assignment is a piece of written work that is assigned to students as a part of their coursework . It is a way for instructors to assess the student’s understanding of the subject matter and their ability to apply it in a practical setting. Nursing assignments can come in a variety of forms, including essays , case studies, research papers, and care plans.

The purpose of a nursing assignment is to help students develop critical thinking skills, research skills, and the ability to communicate their findings clearly and concisely. These skills are essential for nursing professionals who must make important decisions in high-pressure situations while providing care to patients.

Nursing assignments typically require the student to analyze and evaluate a clinical scenario, and to develop a plan of care that addresses the patient’s specific needs. This may involve researching evidence-based practices and incorporating them into the care plan.

Completing these assignments can be challenging, as they require a thorough comprehension of the subjects and a significant amount of time and effort to complete. However, they are an essential component of the curriculum and play an important role in preparing students for their future careers.

The Main Reason Why Students Need Nursing Homework Help

Nursing students often face a multitude of challenges when it comes to completing their homework assignments. With a heavy workload and limited time, it can be overwhelming to keep up with the demands of coursework. Here are some of the main reasons why students need homework help :

⛔ Lack of Time

Nursing students often have a hectic schedule that includes attending classes, clinical rotations, and other responsibilities. This leaves them with limited time to complete their homework assignments. In such cases, asking someone to do your nursing homework or buying a paper from a reliable source can save you time and allow you to focus on other important tasks.

⛔ Difficult Subject Matter

Nursing is a complex field that requires a deep understanding of medical terminology and concepts. Students may struggle to comprehend the material or may not have the necessary background knowledge to complete the assignment. Failure in cases like this can damage one’s mental health, this is why you need writing assistance. Professional writers who are well-versed in the field can help students write their assignments with accuracy and understand the subject matter.

⛔ Language Barriers

International students may struggle with the English language, making it difficult for them to write a coherent paper with an excellent structure. In such cases, getting nursing homework assignment help from a professional writer who is a native English speaker can ensure that the assignment is written in clear and concise language.

⛔ Urgent Deadlines

Students may be given a short deadline to complete their assignments, leaving them with limited time to research and write the paper. In such cases, buying an essay paper from a professional writer can help them meet the deadline and submit a high-quality assignment.

⛔ Lack of Confidence

Students who lack confidence in their writing skills may feel overwhelmed by the prospect of writing a paper. In such cases, hiring homework help from a professional writer can provide them with the assurance that their assignment will be written to a high standard, giving them confidence in their ability to succeed.

There are many situations where it can be more profitable for students to get help for their papers rather than write them themselves. From lack of time to difficult subject matter, the reasons for seeking homework help are many.

It’s important to remember that buying a paper is not cheating, but rather a legitimate way for students to receive the help they need to succeed in their academic endeavors. As long as they choose a reliable and trustworthy source for help, students can rest assured that they will receive a high-quality paper that meets their academic standards.

Benefits of Seeking Nursing Assignment Help

Nursing is a complex field that requires students to have a deep understanding of medical procedures, patient care, and clinical practices. As a result, assignments can be challenging and time-consuming, leading many students to seek help from tutors or professional writers. In this response, we’ll explore the benefits of seeking online assignment help, including improving your grades, saving time, learning from experts, reducing stress, and accessing additional resources.

✅ Improve Your Grades

One of the primary benefits of seeking help with nursing assignment is that it can help you improve your grades. These assignments often require students to have a thorough understanding of complex medical concepts and procedures, which can be difficult to grasp without guidance. By working with a tutor or professional writer, you can receive personalized feedback on your assignments, learn new skills and techniques, and develop a deeper understanding of the material. This can ultimately lead to improved grades and a greater sense of academic achievement.

✅ Save Time

Nursing assignments can be incredibly time-consuming, requiring students to spend hours researching, writing, and editing their work. This can be especially challenging for students who have busy schedules or other responsibilities, such as work or family obligations. Seeking assignment solutions from a tutor or professional writer can save you valuable time, as they can help you streamline your research, develop an effective writing strategy, and ensure that your work is free from errors and inconsistencies.

✅ Learn from Experts

Getting nursing assignment writing help from a tutor or a professional writer can provide you with valuable insights and knowledge about the nursing field. Tutors and writers who specialize in these assignments typically have years of experience in the field and can offer unique perspectives and advice that can help you improve your understanding of the subject matter. They may also be able to provide you with practical tips and techniques for completing assignments more efficiently, such as how to organize your research or develop an effective writing style.

✅ Reduce Stress

Completing assignments can be stressful, especially if you’re struggling with the material or facing a tight deadline. Seeking help from a tutor or professional writer can help you reduce your stress and anxiety, allowing you to focus on other important tasks. By taking the pressure off of yourself to complete your assignments perfectly, you can free up mental space to devote to other aspects of your life, such as work, family, or personal hobbies.

✅ Access Additional Resources

Working with a tutor or pro writer can provide you with access to additional resources that can help you complete your assignments more effectively. For example, tutors may be able to recommend textbooks or research articles that are particularly relevant to your assignment or provide you with feedback on your research and writing strategies. Professional writers may also have access to specialized databases or research tools that can help you find relevant sources more efficiently.

If you need help with nursing assignment, getting a professional to assist you can provide a variety of benefits, from improving your grades to reducing your stress levels. Whether you’re struggling with the material, are short on time, or simply looking to improve your understanding of nursing, working with a tutor or professional writer can help you achieve your academic goals and succeed in your studies. If you’re considering seeking help with your nursing assignments, be sure to choose a reputable service that has a track record of providing high-quality work and excellent customer support.

What Kind of Nursing Homework Assignments We Can Offer

Nursing research homework help is a diverse and complex field that encompasses a range of topics and areas of study. As such, there are many types of assignments that students may encounter during their coursework.

Here are some of the most common types of nursing homework assignments that we can offer:

• Case Studies: A nursing case study is a detailed analysis of a patient’s medical history, diagnosis, and treatment. It requires students to use critical thinking skills to identify the patient’s needs and develop a plan of care that addresses their specific health concerns.
• Essays: Nursing essays require students to write a well-structured and well-researched paper on a specific topic related to nursing. The essay may require students to evaluate and analyze evidence-based practices and provide their insights on the topic.
• Care Plans: Care plans are detailed documents that outline the nursing care that a patient requires. They require students to assess the patient’s needs and develop a comprehensive plan that addresses all aspects of their care, including physical, emotional, and social needs.
• Research Papers: Nursing research papers require students to conduct original research on a specific topic and present their findings clearly and concisely. This may involve reviewing existing literature, collecting data, and analyzing the results.
• Nursing Reflections: A nursing reflection is a personal account of a student’s experience in a clinical setting. It requires students to reflect on their practice, identify areas of improvement, and evaluate their performance.
• Presentations: Nursing presentations require students to communicate their ideas and findings to an audience. This may involve developing a visual aid, such as a PowerPoint presentation, and presenting it to a group of peers.
• Online Quizzes: Nursing online quizzes are a quick and efficient way for students to test their knowledge on specialized topics. They may include multiple-choice questions, true/false questions, and other types of assessment.

Choosing a Nursing Assignment Help Service

At this point, if you’re wondering, who will do my nursing assignment or who can do my nursing school homework? There are dozens of experts available, however, it is important to choose a reliable and trustworthy service.

Here are some factors to consider when choosing a nursing assignment help service:

☝️ Reputation

The reputation of the assignment service is crucial in determining the quality of work you’ll receive. You should check reviews and testimonials from other students who have used a nursing student homework help service before you to gauge their experience. If the reviews are positive and speak highly of the service’s quality, timely delivery, and professionalism, then it’s a good sign that the service can provide high-quality work. On the other hand, if the reviews are negative, and many students complain about the quality of work, late delivery, or poor customer support, then it’s a red flag, and you should consider other options.

☝️ Experience

If you are looking for cheap nursing assignment writing help you still need to contact a service provider with the right experience. When choosing a nursing assignment service, it’s crucial to pick one that employs writers with experience in the field. Nursing assignments require specialized knowledge and expertise, so it’s essential to work with writers who have a background in the nursing profession. These writers can provide accurate and high-quality work that meets the expectations of your professors.

If you want to pay someone to give you nursing homework help, pricing is a critical factor to consider. You need to ensure that the service you choose offers competitive pricing that fits within your budget. However, be wary of writing services that offer prices that are too low, as they may provide low-quality work that could negatively impact your grades. Conversely, services that charge exorbitant prices may not necessarily provide high-quality work, so it’s essential to strike a balance between price and quality.

☝️ Customer support

When searching for expert nursing assignment help online a proper nursing assignment service that provides excellent customer support is important to ensure that you have a positive experience. Look for a service that offers 24/7 support and responds promptly to your inquiries and concerns. They should have multiple channels of communication, such as phone, email, and live chat, to ensure that you can get in touch with them whenever you need to.

☝️ Plagiarism-free guarantee

Plagiarism is a serious academic offense that can have severe consequences. Therefore, it’s essential to buy help from a service that guarantees 100% original work. The service should have robust measures in place to ensure that their writers provide original content that’s free from plagiarism.

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Considerations for nurse-to-patient assignment ratios during the covid-19 pandemic.

Changing how we assign staff may help preserve the health workforce

Nov 15, 2021, By: Crystal McLeod, Candace Collins

Takeaway messages

• Nurse-patient assignments are more equitable when workload, versus nurse-to-patient ratio, is accounted for.
• The COVID-19 pandemic appears to increase the workload of nurses. As such, the influence of COVID-19 should be considered by nursing leadership when creating nursing assignments.
• There is little literature on nurse-patient assignments, especially during the COVID-19 pandemic. The strategies outlined in this article for assignment creation are merely a stepping stone toward more concrete guidelines.

In the early days of the novel coronavirus disease (COVID-19) pandemic, experts worried how nurses could provide high-quality care in the face of rising acuity and patient volumes. The focus, rightfully, was placed on patients and their safety. In order to optimize staffing, alterations to nursing schedules, shifts and patient assignments were made (Catania et al., 2021; Kluger et al., 2020). Furthermore, some nurses were redeployed to completely new clinical settings to manage staffing inadequacies (Catania et al., 2021; Gao, Jiang, Hu, Li, & Hou, 2020). As a whole, the nursing profession courageously responded to their assignment changes with flexibility, resiliency and a sense of duty (Catania et al., 2021; Schroeder, Norful, Travers, & Aliyu, 2020).

Yet, over a year into the pandemic, there is a need to reassess how nurse-patient assignments are being created. Nursing staff are reporting increasing occupational burnout, trauma and even resignation from their positions in the health-care field (Andrew, 2021; Chen et al., 2021). We can both attest to observing the departure of wonderful, skilled nurses from the nursing profession entirely because of COVID-19 and the difficult sacrifices the pandemic caused them to make.

We argue in this article that the health-care field should not wait to address the exhaustion and hardship of the pandemic among nurses until these resignations grow and instead should think about how nursing assignments are contributing to the problem at hand. Ultimately, without losing sight of patient safety and infection control, this article focuses on creating nurse-patient assignments that consider the toll of COVID-19 and promote preservation of the workforce through workload. A discussion of other assignment-making pandemic considerations and lessons learned is also included.

Workload and nursing assignments

Nurse-patient assignments seek to equitably divide patient care among nurses and have been traditionally assessed in terms of nurse-to-patient ratios (Allen, 2015). As such, a low nurse-to-patient ratio implies that each nurse is caring for more patients than what is typical — for instance, because nursing resources are exceeded — and adverse patient outcomes could result (Allen, 2015). One of the most relevant adverse outcomes that is associated with inequitable staffing, which has occurred during the COVID-19 pandemic, is the spread of hospital-acquired infections, leading to unit outbreaks (Allen, 2015).

However, contemporary research shows that workload is a more accurate means of assessing nurse-patient assignments (Acar & Butt, 2016). Workload is defined as the total work a nurse must complete in an allotted time frame per patient (Acar & Butt, 2016). Factors that affect nursing workload include patient acuity, nurse competence, continuity of care, nursing interventions, environment and patient characteristics (Acar & Butt, 2016; Allen, 2015). Workload is a broad and complex concept to quantify, but specific examples may include the frequency of medication administration and patient agitation (Allen, 2015).

Currently, there is a paucity of literature examining how nurse-patient assignments affect organizational outcomes (Acar & Butt, 2016; Allen, 2015). What is known is that equitable assignments determined through a measure of workload can improve nursing satisfaction and retention (Allen, 2015). Likewise, researchers suspect that the downstream effects of fair nurse-patient assignments could extend to reduced lengths of stay, improved patient outcomes, higher patient satisfaction and overall lower health-care costs (Acar & Butt, 2016; Allen, 2015).

When less experienced nurses are aggregated in one area, there can be a loss of policy compliance and increased performance-related stress.

Does COVID-19 increase nursing workload?

The 1918 influenza pandemic saw an abrupt decline in nurse-to-patient ratios, especially among community nurses (Keeling, 2010). In some cases, nurses saw a tripling of patients under their care. A similar effect was anticipated during the COVID-19 pandemic but has been less reported on to date. Instead, an emphasis has been placed on how COVID-19 has disrupted nurse-patient assignments through workload.

Arguably, the most pronounced effect of COVID-19 on nursing workload has been in isolation settings, where confirmed and suspected patients under infection control procedures receive treatment (Gao et al., 2020). Nurses report the care of isolation patients as more demanding due to stringent infection control procedures, a lack of proximity to human resources, uptake of tasks previously assigned to other staff, fear of exposure to COVID-19 and sickness leading to staff shortages (Gao et al., 2020). This research struck a chord with us as we, too, have been required to assess, lift and mobilize COVID-19 patients without the assistance of other health-care professionals, who are unable or reluctant to enter the patient’s room.

Moreover, in nursing settings not directly impacted by the care of COVID-19 patients, workload is felt to have increased through the restructuring of resources. Restructuring may include staff shortages from redeployment, mass training and less experienced nurses caring for acutely ill patients (Catania et al., 2021). Higher rates of mental and physical fatigue, stress, confusion, grief and occupational burnout secondary to the changing workload are thought to further burden nurses contributing to pandemic efforts (Catania et al., 2021; Gao et al., 2020; Schroeder et al., 2020). Consequently, COVID-19 can be reasonably connected to greater work and stress within nurse-patient assignments across various clinical settings.

Assignment creation in a pandemic

There is no true guideline to creating nurse-patient assignments, and the majority of nursing leadership relies on the knowledge of organizational practices to create fair assignments. Assignment creation is also a time-restricted activity, with most nurse leaders reporting approximately 30 minutes to prepare an assignment (Acar & Butt, 2016). Metrics and tools to create electronic assignments have been proposed in the past that introduce new technology to nursing leadership. Yet these tools have been met with mixed reviews, and the process continues to be largely manual (Acar & Butt, 2016). This article does not seek to widely disrupt current practices, offer a new methodology for nurse-patient assignment creation, or ignore the complexity of making an assignment under usual health-care conditions. We argue that the detailed process of creating nurse-patient assignments should continue as normal but with greater attention to COVID-19 and the pandemic’s related effects.

Research on the relationship between COVID-19 and workload is limited. Yet, in recognizing that COVID-19 compounds the challenges of the nurse-patient assignment, the literature has offered a few strategies for nurse leaders. The authors, who have worked clinically during the pandemic and felt the challenges first hand, present these strategies as relevant to their personal experience and professional practices. That being said, unvalidated, these strategies may serve as only an opportunity to reflect and deliberate on future directions in assignment creation for COVID-19 or in future infectious disease outbreaks.

If changes on assignments are going to be made, much of the research reviewed for this article strongly encourages nurse leaders to obtain input from nursing staff before implementing such changes (Gao et al., 2020; Schroeder et al., 2020; Simpson, Whitt, & Berger, 2021).

COVID-19 nurse-patient considerations

Rotation of staff

At the most basic level, a balanced pandemic assignment should ensure rotating distribution of isolation rooms. Designating confirmed and suspected COVID-19 patients to one group of nurses is ideal for infection control, but the increased workload associated with these patients can make such a model unsustainable. In a study of non-COVID-19 patient-care settings, Kluger et al. (2020) found that nurses could safely rotate out of assignments in three-day blocks without increasing infection risk. Understanding what is an acceptable time frame for nurses working in COVID-19 isolation to rotate schedules and assignments in future research would greatly assist in implementing this strategy. Tracking or rotating nurses’ isolation assignments may be delegated as an individual or administrational task depending on the practice setting.

Beyond regularly rotating staff in and out of isolation, there are several other factors that add to the complexity of assignment creation in a pandemic. Lack of personal protective equipment (PPE) and medical accommodations required by some of the nursing staff reduce the pool of potential staff able to care for confirmed or suspected COVID-19 patients (Catania et al., 2020; Gao et al., 2020). However, nursing staff who are not able to care for isolated patients can minimize the workload of colleagues in isolation by taking on staff training, assisting less experienced staff or being assigned more complex non-COVID-19 patients. Everyday nursing interventions that make up a large part of the workload, such as patient admissions, wound dressings and blood product transfusions, are also excellent opportunities for these nursing staff to contribute (Allen, 2015).

A nuanced consideration, perhaps most helpful to organizations with primarily novice staff, is to ensure a skill mix across the patient-care setting. When less experienced nurses are aggregated in one area, there can be a loss of policy compliance and increased performance-related stress (Catania et al., 2021; Gao et al., 2020). Having senior nurses work alongside novice nurses can promote more efficient, safe, high-quality work (Gao et al., 2020). If few senior nurses are available, nursing leadership can improve the assignment by keeping in close contact with these less experienced staff (Gao et al., 2020).

Support staff

Just outside the realm of nurse-patient assignment creation is support staff; their utility can help strengthen sub-optimal assignments. Support staff, like personal support workers, Helping Hands or Pandemic Partners, can be instrumental in reducing nurse workload (Allen, 2015; Simpson et al., 2021). Depending on organizational policies, support staff can help alleviate workload by completing certain tasks and taking on other special assignments (Gao et al., 2020; Simpson et al., 2021). One study noted that support staff were especially helpful during the pandemic by connecting patients with family via iPads, Zoom and FaceTime (Simpson et al., 2021). In our own experiences, Helping Hands nurses during the third wave of the pandemic were invaluable to managing tasks outside the isolation room while primary nurses provided care inside.

Ride the waves, enjoy the reprieves

The waves of illness created by COVID-19 make for organic periods of higher and lower case numbers. It is important for nursing leadership to recognize lower case numbers as an opportunity for reprieve for nursing staff. Allowing time for nurses to participate in mental health, education and social initiatives may improve the quality and delivery of patient care in subsequent waves (Catania et al, 2021; Kluger et al., 2020). Also, clear communication of changes in policy or department procedures should continue to occur between waves as this can leave nurses feeling more prepared as cases begin to rise or fall (Gao et al., 2020; Schroeder et al., 2020). Finally, in the first wave of the COVID-19 pandemic, staff nurses felt solidarity with and appreciation for managers who were involved and readily available to staff as cases rose (Catania et al., 2021). Nurse leaders should exercise flexibility in their own schedules and commitments to uphold this standard for any impending waves of infectious disease.

Designating staff to aerosol-generating medical procedures?

Medical procedures such as tracheal intubation and bronchoscopy have been believed during the COVID-19 pandemic to increase the risk of disease transmission by aerosolizing the virus (Harding, Broom, & Broom, 2020). For nurses, who often assist in these procedures, the risk of inhaling and developing an infection is exacerbated by anxiety and a poor knowledge of clinical guidelines for aerosol-generating medical procedures (AGMPs). To resolve such concerns, the organization we work for has used dedicated staff, often termed the “intubation team,” to conduct AGMPs during the pandemic. These dedicated staff ensure strict compliance with AGMP guidelines and can prevent waste of PPE (Harding et al., 2020). Not much is known of the impact of working on these dedicated AGMP teams, but we would imagine similar assignment and workload considerations need to be given to these staff as to those working in clinical isolation settings.

Lessons learned

As the delta and other variants of COVID-19 continue to spread across Canada, uncertainty remains as to when the pandemic will end and what hospitalization rates can be expected going forward (Aziz, 2021). Resolution of the pandemic, although the best possible outcome, does not mean that infectious disease outbreaks will cease altogether either.

We hope that this article presents a guide to what has been learned from the COVID-19 pandemic about nurse-patient assignments and offers possible solutions to any similar scenario that arises in the future. So much has been learned in the health-care field from this unprecedented time in history, and we only wish to carry such learning forward to strengthen the nursing profession.

Acknowledging the informal nature of assignments, we wished to identify COVID-19 as an important consideration in nurse-patient assignment creation and prompt discussion of how this factor may be accounted for in the future. Strategies proposed for pandemic assignment are only a starting point from the initial literature, and our hope is that a larger conversation can be sparked in the nursing profession. Forthcoming research on nursing workload and infectious disease management should increase our understanding of how this pandemic changed nursing care, well-being, workplace morale and distribution of work. Additionally, nurses sharing how their own experiences and assignments have impacted them throughout the pandemic may provide better insitutional insights to assignment management in the future.

Acar, I., & Butt, S. E. (2016). Modeling nurse-patient assignments considering patient acuity and travel distance metrics.  Journal of Biomedical Informatics, 64 , 192-206. doi:10.1016/j.jbi.2016.10.006

Allen, S. B. (2015). The nurse-patient assignment: Purposes and decision factors.  Journal of Nursing Administration, 45 (12), 628-635. doi:10.1097/NNA.0000000000000276

Andrew, S. (2021, February 25).  Traumatized and tired, nurses are quitting due to the pandemic.  Retrieved from https://www.cnn.com/2021/02/25/us/nurses-quit-hospitals-covid-pandemic-trnd/index.html

Aziz, S. (2021, June 17).  Delta COVID-19 variant: A look at the risks, symptoms and impact on vaccines . Retrieved from https://globalnews.ca/news/7955721/delta-covid-variant-explainer/

Catania, G., Zanini, M., Hayter, M., Timmins, F., Dasso, N., Ottonello, G., … Bagnasco, A. (2021). Lessons from Italian front-line nurses’ experiences during the COVID-19 pandemic: A qualitative descriptive study.  Journal of Nursing Management, 29 (3), 404-411. doi:10.1111/jonm.13194

Chen, R., Sun, C., Chen, J.-J., Jen, H.-J., Kang, X. L., Kao, C.-C., & Chou, K.-R. (2021). A large-scale survey on trauma, burnout, and posttraumatic growth among nurses during the COVID-19 pandemic.  International Journal of Mental Health Nursing, 30 (1), 102-116. doi: 10.1111/inm.12796

Gao, X., Jiang, L., Hu, Y., Li, L., & Hou, L. (2020). Nurses’ experiences regarding shift patterns in isolation wards during the COVID-19 pandemic in China: A qualitative study.  Journal of Clinical Nursing, 29 (21-22), 4270-4280. doi:10.1111/jocn.15464

Harding, H., Broom, A., & Broom, J. (2020). Aerosol-generating procedures and infective risk to healthcare workers from SARS-CoV-2: The limits of the evidence.  Journal of Hospital Infection, 105 (4), 717-725. doi:10.1016/j.jhin.2020.05.037

Keeling, A. W. (2010). “Alert to the necessities of the emergency”: U.S. nursing during the 1918 influenza pandemic.  Public Health Reports, 125 (Suppl. 3), 105-125. doi:10.1177/00333549101250S313

Kluger, D. M., Aizenbud, Y., Jaffe, A., Parisi, F., Aizenbud, L., Minsky-Fenick, E., … Kluger, Y. (2020). Impact of healthcare worker shift scheduling on workforce preservation during the COVID-19 pandemic.  Infection Control & Hospital Epidemiology, 41 (12), 1443-1445. doi:10.1017/ice.2020.337

Schroeder, K., Norful, A. A., Travers, J., & Aliyu, S. (2020). Nursing perspectives on care delivery during the early stages of the COVID-19 pandemic: A qualitative study.  International Journal of Nursing Studies Advances , 2, 100006. doi:10.1016/j.ijnsa.2020.100006

Simpson, B. B., Whitt, M. O., & Berger, L. (2021). Patient care services staffing support during a pandemic.  Nurse Leader, 19 (2), 150-154. doi:10.1016/j.mnl.2020.07.005

Crystal McLeod is a registered nurse at London Health Sciences Centre and an independent researcher. Her research interests include pediatric nursing, geographic health disparities and childhood disease.

Candace collins is an acute care registered nurse and a nurse practitioner student at western university. she is passionate about nursing education, rural health and spending time with family., sign in to leave a comment, related articles, racism, microaggressions, and sexism: is this the welcome new graduates were expecting, from nurse to patient: the lessons i have learned about my career from the other side of the health-care ..., backlash won’t stop birgit umaigba from advocating for more equity and diversity in health care, extreme heat, fire, and flooding: how climate change can impact your patients, an evidence-based review on the safe and effective use of antiseptic agents in health-care environme ..., why establishing psychological safety is crucial while teaching in a post-pandemic health-care setti ..., a primer on ‘african diabetes’: what it is, how it can be treated, and why it’s important for your nursing ..., 5 questions you should ask to ensure you’re providing 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A new patient-acuity tool promotes equitable nurse-patient assignments

Have you ever struggled to classify a patient’s acuity level? If so, you’re not alone. Have you ever looked at your patient assignments and wondered, “Why are the assignments so unfair? How will I care for all my patients effectively?” Again, you’re not alone.

Most nurses expect patient assignments to be equitable, with each nurse bearing a fair share of the workload so all patients can receive excellent care.

Nurses’ job satisfaction depends partly on their workload and their perceived ability to deliver high quality care. Nurse-sensitive indicators (including pressure ulcers, falls, medication errors, nosocomial infections, pain management, and patient satisfaction) depend largely on nursing care and are affected by nurses’ ability to recognize and intervene when a patient’s condition changes. Nursing workloads directly influence a nurse’s ability to assess thoroughly and promote excellent patient outcomes. When patient assignments aren’t equitable, nurses may feel inadequate and frustrated.

Problems also can arise when all nurses are assigned the same number of patients without regard for acuity levels. Yet determining patients’ acuity to promote more equitable assignments can be challenging. Some hospitals or nursing units use an established acuity tool. Others rely on charge nurses’ judgments of patient acuity.

Our nurses were getting restless

At Indiana University Health Ball Memorial Hospital in Muncie, we moved our progressive care unit (PCU) to a newly constructed area of our regional medical center. A short time later, we noticed increases in patient volumes, comorbidities, device support, and overall acuity. The patients’ nursing-care requirements varied widely, so assigning the same number of patients to all nurses would mean unequal assignments.

Although were using an acuity assessment tool, our increasingly dissatisfied nurses deemed it ineffective. It called for nurses to rank each patient as a 1, 2, or 3 based on their individual perception of the patient’s status or difficulty of care required. But the tool wasn’t providing useful information because nurses’ perceptions varied; also the cultural norm tends to make nurses rate most patients a 2. In addition, when more staff nurses were needed, we lacked an objective measure to make a case for obtaining additional staff. When our hospital tested a new nurse-satisfaction survey, nurses’ discontent with their workload became apparent.

Then a PCU direct-care nurse approached the unit-based council (UBC) and asked for an evaluation of our acuity tool. The nurse manager and UBC agreed that equitable patient assignments and adequate unit staffing could be addressed by improving the tool. Following the Iowa model of evidence-based practice (EBP), the UBC formed a team of staff nurses, charge nurses, unit manager, clinical nurse specialist, and nurse researcher to explore the inquiry.

What the evidence told us

The team’s literature review found a limited amount of research pertaining to acuity tools for PCUs, even though hospital expenses decrease and high-quality nursing care increases when leaders are empowered with better, more detailed knowledge of patient acuity and nursing workloads. A recurrent theme in the literature: nurses’ voices add value to processes and nurses should be involved in assessing their own workloads and making decisions about resources. Evidence also suggested that involving staff in developing an acuity assessment tool would yield a valued, more efficient instrument that could improve nurse satisfaction and job retention.

Formulating a plan

During our literature review, we found a tool to adapt for our adult PCU. On a flip chart in the nurses’ lounge, we displayed our existing tool alongside the new tool we’d revised from the literature search. Staff viewed both tools and provided input into what made a patient’s care difficult, time-consuming, or complex. This gave us a better picture of PCU patients and helped us ensure all tasks were represented, from the least to the most time-consuming. Brainstorming meetings clarified key elements of acuity that guided continued evolution of the new tool.

Tool-development strategies

In our new tool, criteria categories included complicated procedures, education, psychosocial/therapeutic interventions, number of oral medications, and complicated I.V. drugs and other medications. Rating options on the tool run from 1 through 4, with 1 indicating low acuity and 4 indicating high acuity. Ratings are based on nursing time needed to complete a task, emotional and physical energy expenditure required, expertise required, frequency of tasks and interventions, and follow-up assessments related to a specific task. Ratings for all five criteria categories are summed up to obtain a total acuity score for each patient, ranging from 1 to 60. Then the total scores are clustered into acuity category scores, which range from 1 to 4, with 1 being the lowest acuity and 4 being the highest. (See Acuity criteria categories .)

Now we were ready to test the new tool. Initially, charge nurses from each shift tested it with the same patients on different shifts. When we found that scores between shifts weren’t congruent, we tested the tool again, with charge nurses on the same shift assessing the same patients separately. This trial yielded an inter-rater reliability of 85%—an acceptable congruency level across nurse raters.

This trial provided insight into acuity differences between shifts and helped determine how to use the tool. With our previous acuity tool, tasks and procedures of the rater’s shift determined acuity, with no consideration of upcoming tasks or procedures for the next shift. So for the new tool, the team and staff agreed nurses would proactively score acuity for the oncoming shift by calculating current and projected needs and medications.

Measuring outcomes

We identified three outcome measures as indicators of the effectiveness of the new acuity approach.

• First, the team developed an eight-item survey to measure nurse satisfaction with the new acuity assessment process, which nurses completed 1 month before the new process began and then 1 month, 6 months, and 12 months later.
• Next, the team identified items on the standardized annual employee engagement and satisfaction survey, specifically targeting workload and perception of quality of care delivered.
• Finally, we tracked nurse sensitive indicators affected by workload, including falls and hospital-acquired pressure ulcers.

Translating scores into patient assignments

To translate acuity scores into equitable patient assignments, charge nurses collected the acuity tools that direct-care nurses completed for each patient, and calculated total acuity scores and acuity category scores near the end of their shift. Then the charge nurses designed nurse-patient assignments by considering both the category score from 1 to 4 and the total acuity score of 0 to 60 for each patient, aiming to keep category scores balanced across nurses. Charge nurses also considered the geographic location of rooms on the unit, need for continuity of care, and congruency between nurses’ expertise and patient needs. (See Current acuity tool on last page .)

Unit-wide rollout

Before we rolled out the new tool, direct-care nurses on our team provided education to all PCU nurses. Teaching strategies included showing video clips of patient scenarios, presenting case studies so nurses could practice using the tool, and playing a game-show exercise to stimulate discussion of the benefits of acuity scoring. Nurses voiced favorable responses to the new tool, specifically the benefits of empowerment, assurance of quality care, patient safety and satisfaction, nurse retention, and equitable assignments. The team encouraged staff to provide feedback on the new process and expect revisions to ensure its effectiveness and sustainability.

To hardwire the new acuity assessment process, team members rounded on nurses each shift for 1 week and then three times monthly. The team answered questions, audited acuity scores, and coached nurses to achieve a highly standardized approach to scoring. During orientation, preceptors trained newly hired nurses to use the acuity assessment tool.

Charge nurses kept a log of assignments, acuity scores, and overall unit activities, overtime, and informal comments on workload. In huddles held daily for the first week, charge nurses and the nurse manager reviewed acuity scores and the process. A numerical benchmark emerged as an indicator for requesting more staffing, based on total acuity scores and acuity category scores of all patients on the unit.

Evaluation and sustainability

At the end of the first month, scores on surveys of nurse satisfaction with the new acuity assessment process showed marked improvement in nurses’ reports of the equity of patient assignments (7% satisfaction before rollout, 55% satisfaction after) and the consistency with which the acuity assessment process occurred (21% consistency before rollout, 89% consistency after). Almost 80% of nurses reported that completing the new acuity tool wasn’t a waste of time. The team implemented suggestions for refining the process and set a target goal of 85% nurse satisfaction by the 6-month evaluation.

The sustainability plan for year 1 calls for quarterly reevaluation of the acuity assessment process and semiannual reevaluation thereafter, including scoring processes, staffing level benchmarks, nurse satisfaction per survey, and nurse-sensitive outcomes. It also calls for nurses to review reports of outcome data regularly during staff meetings. When revisions are indicated, the team will provide additional education.

As the process of creating ideal nurse-patient assignments evolves, the team will explore the benefits of the synergy model, which matches nurses’ strengths and competencies with patient and family characteristics. The team may conduct qualitative research studies to better understand the complex judgments charge nurses make when creating nurse patient assignments, with the goal of standardizing the process for sustainability and optimal outcomes.

In evaluating the overall projects  experience, team members listed  lessons learned and captured key  ideas to use in future projects. (See  Acuity tool: Lessons learned by clicking the PDF icon above). The  team validated usefulness of the  Iowa model in developing the tool  and process, and recommended  adopting a model for translating evidence  into practice. Nurses on the  team reflected that a highly satisfying  aspect of the project was identifying  a clinical issue and playing an  active role in addressing it as valued  partners in the change process.

Selected references

Choi J, Choi JE, Fucile JM. Power up your staffing model with patient acuity. Nurs Manage . 2011;42(9):40-3.

Duffield C, Diers D, O’Brien-Pallas L, et al. Nursing staffing, nursing workload, the work environment and patient outcomes. Appl Nurs Res . 2011;24(4):244-55.

Fram N, Morgan B. Ontario: linking nursing outcomes, workload and staffing decisions in the workplace: the Dashboard Project. Nurs Leadersh (Tor Ont). 2012;25(Spec No 2012): 114-25.

Hardin SR, Kaplow R, eds. Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care . Sudbury, MA: Jones and Bartlett; 2005.

Harper K, McCully C. Acuity systems dialogue and patient classification system essentials.  Nurs Adm Q . 2007;31(4):284-99.

Titler MG, Kleiber C, Steelman VJ, et al. The IOWA model of evidence-based practice to promote quality care. Crit Care Nurs Clin  North Am. 2001;13(4):497-509.

The authors work at Indiana University Health Ball Memorial Hospital in Muncie. Michelle Kidd is a critical care clinical nurse specialist. Kimberly Grove, Melissa Kaiser, and Brandi Swoboda are direct- care nurses in the progressive care unit (PCU). Ann Taylor is nurse manager in the PCU.

29 Comments .

Hello, I would like to request permission to utilize the patient acuity tool in my DNP project.

Hello, I would like to request permission to use this tool as a reference in my BSN assignment.

Hello Kaitlynn, The authors of the article are happy to grant others permission to use the tool. Please be sure to credit the source. Best, Cheryl Mee MSN, MBA, RN, FAAN, Executive Editorial Director, American Nurse Journal

Would like permission to use this tool for our Acute Care Floor in northern MN. Having a lot of the same issues discuss prior to your implementing…. Assignment and staffing inconsistencies, teams of 5 plus, multiple unsafe staffing scenarios. Think this would be a huge help! Thank you!

Hi, Our unit (surgical unit) are currently doing brain storming and gathering ideas on how to improve our nurse:patient assignment. We are trying to develop a patient acuity tool which would suit our patient care environment. Hoping we could reference and use your tools with your permission.

Very much appreciated.

can you share your acuity tool. We are also trying to come up with a solution instead of the admin. staffing by census…..

Can you email me at [email protected] please to discuss? Thanks!

Yes, you may.

Hi, I would love to use this as a reference to adapt an appropriate acuity tool for the medical surgical unit at our hospital. I am hoping to be granted permission to use , with appropriate citations.

Dear Micaela,

The authors of the article are happy to grant others permission to use the tool. Please be sure to credit the source.

Cynthia Saver, MS, RN

Firstly, we would like to congratulate the authors of the New Tool and we wish to be granted to use the tool with citation of the authors. What about Chemotherapy, is it under the complicated IV drugs but it is not specified? Hope to be clarified about it. Thank you.

Ruhaina Ladja,

Thank you for your interest in the acuity tool. I would venture to say chemotherapy would be included in complicated IV drugs, but in the units for which we first developed this tool the nurses did not administer chemotherapy.

Thanks again, Michelle J Kidd, MS, APRN, ACNS-BC, CCRN-K

Hi there, I am seeking permission to utilize this patient acuity tool for our evidence-based project on our IMU/ICU unit. Thank you so much.

The authors of the article are happy to grant others permission to use the tool. Please be sure to credit the source. Cynthia Saver, MS, RN, Editorial director for American Nurse Journal

Does anyone have the contact information for the authors of this tool? I would like to use this tool for my DNP project and need permission to use.

I would like to request fro your permission to utilize this tool for a pilot project initiative in my department.

The authors of the article are happy to grant others permission to use the tool. Please be sure to credit the source. Cynthia Saver, MS, RN, Editorial director for American Nurse Journal.

I am requesting permission to use this tool Thank you

I am requesting permission to use this tool on my Med/Surg floor

Thank you, Tiffany Brisken, BSN, RN, PHN

I would love to use your tool on my floor which is cardiac. I am researching and hoping this will work for us.

Wendee, the author of the article is happy to grant permission for you to use the tool.

Cynthia Saver, MS, RN, Editorial director for American Nurse Journal.

Looking to obtain permission to use tool for QI project. Please let me know who to contact.

We did contact the authors, and they gave permission for the use of the tool. Thank you for your inquiry!

-Lydia Kim, Digital Content Editor at American Nurse Today

Hello Can you help me get an acuity tool that helps nurses?

Hello Ms. Kidd,

Can I get permission to use your acuity tool for my research? Hoping for your favorable response.

Kathy Carandang

I agree! I would love to see a follow up!

Any chance to see this “patient-acuity” tool? I am working on developing one for my unit.

Awesome, this is a HUGE help.

Would love to see the follow up on this article! The results only discuss nurse satisfaction after 1 month. What happened to the results from the other nurse-sensitive indicators discussed?

I would like to use your tool for my DNP project, how would I go about contacting the right person(s) to get permission? I would appreciate your feedback.

Comments are closed.

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