Nurse-patient assignments,

Transcription

1 Instructions for Continuing Nursing Education Contact Hours appear on page 82. The Nurse-Patient Assignment Process: What Clinical Nurses and Patients Think Stephanie Allen Nurse-patient assignments, the matching of a nurse with a patient for a specified period of time, are essential to inpatient nursing care. Assignments typically are made by the unit charge nurse or nurse manager, and have the potential to affect patient, nurse, and hospital outcomes. Under standing the specific characteristics of a nurse that match well with the unique needs of a patient could lead to improvements in patient safety, mortality, or hospital-acquired infections (Aiken et al., 2014; Yakusheva, Lindrooth, & Weiss, 2014). Nurse satisfaction and turnover could be improved by identifying the best unit work teams or the most equitable assignments (Leineweber et al., 2016; Van Oostveen, Braaksma, & Vermeulen, 2014). Additionally, identifying the most efficient and therapeutic assignments may lower hospital lengths of stay, and decrease adverse outcomes and costs (Hui, Chen, Yan, Haiyan, & Wenqin, 2015). Review of the Literature PubMed and CINAHL were search ed for articles published in Search terms included nurse-patient assignment, nurse-patient assignment AND nurse perception OR patient perception, and process AND assignment AND patient AND nurse. Twelve articles addressed the nursepatient assignment process. Each article was read to determine its relevance to the topic of clinical nurses and patients perceptions of the nurse-patient assignment process. Clinical nurses and hospitalized patients were interviewed to understand how they view the nurse-patient assignment process. Themes were identified based on responses and provided a unique perspective on the nurse s role and the assignment process. Six articles were determined to be relevant for inclusion in this review. Allen (2015) examined how the process is viewed by charge nurses and others who make assignments. Fourteen charge nurses from 11 unique inpatient units (e.g., Emergency Department, Neonatal Intensive Care, Surgical) at a large suburban hospital completed semistructured interviews. Charge nurses considered various purposes, such as providing best care, fairness, and equal workload, when making assignments. They also identified factors related to the patient (acuity, workload), nurse (experience, competence), and environment (available support, room location) before the assignment was made. Clinical nurses and patients were not asked their views of the nurse-patient assignment process. Kohr, Hickey, and Curley (2012) examined the feasibility of using the American Association of Critical- Care Nurses Synergy Model for Patient Care as a framework for a nursing productivity system. One research question addressed factors considered by charge nurses when making nurse-patient assignments. Thirty charge nurses participated in one of two focus groups. Research - ers guided data collection on the eight components of the Synergy Model, with charge nurses identifying 134 factors they considered when making nurse-patient assignments. Of those, 22 factors related to the Synergy Model component Patient and/or family participation in decision making and care. These factors identified characteristics of patient and/or family member, but not their preferences or wishes. Although charge nurses considered availability of ICU nurse resources and mentors on unit and ancillary staff available 24/7 (p. 425), they did not indicate they consider any factors related to characteristics of clinical nurses, or their input or preferences when making assignments. As part of the development of a computerized decision support system for making nurse-patient assignments, Dutch researchers identified factors nurses consider when making assignments (Van Oostveen et al., 2014). The project started with clinical nurse focus groups identifying an exhaustive Stephanie Allen, PhD, RN, NE-BC, is Assistant Professor, Pace University, Pleasantville, NY. March-April 2018 Vol. 27/No. 2 77

2 Background How clinical nurses and patients view the nurse-patient assignment process is not understood well. Although there is evidence on how charge nurses approach the process, no research explains how clinical nurses and patients view the nurse-patient assignment process. Purpose Identify clinical nurses and hospitalized patients perceptions of the nurse-patient assignment process. Methods Ten participants completed semi-structured interviews with the researcher in this descriptive qualitative study. Five female nurses, four female patients, and one male patient consented and were interviewed. Findings The researcher identified three themes from nurse responses: Consult the expert, Continuity is care, and Meeting the nurse s needs, too. Three themes for patient participants were identified: The nurse s role is unclear, I need a connection, and The assignment process isn t random? Conclusion This preliminary study was unique because clinical nurses and hospitalized patients were asked their perceptions of the nurse-patient assignment process. Results validated previously identified purposes and decision factors of the nurse-patient assignment process. Patients provided a unique perspective on the nurse s role and the assignment process. list of factors considered when making nurse-patient assignments. The list was presented to clinical and student nurses working on the two study units, and they were asked to rank the top 10 most important factors. The top 10 factors included patient acuity information from previous shift, patient (or family) preference, nurse experience with patient, student nurse assignment, patient/nurse language match, student s year of education, nurse s years of experience, nurse health (e.g., disabilities), location of patient on unit, and nurse mental health. Authors also sought to identify factors considered when making nurse-patient assignments. They asked clinical nurses as well as charge nurses. Sir, Dundar, Barker Steege, and Pasupathy (2015) surveyed clinical nurses (N=36) about workload to develop a nurse-patient assignment program that paired workload perceived by clinical nurses with information from a commercially available patient classification system. Their goal was to develop an assignment tool that balanced both assessments, making assignments more representative of the unit s workload. Developed with workload input from clinical nurses, their tool produced a balanced assignment with less perceived workload than the commercial patient classification system. Although their only role was their response about workload as a factor in making assignments, clinical nurses were an integral part of this study. Acar and Butt (2016) developed a software program to model nursepatient assignments based on patient acuity and observed distance traveled by the nurse due to patient room location. Authors defined acuity based on charge nurse constructs of acuity and workload; for example, was the patient transferred from a stepdown unit or receiving a high-risk medication (e.g., chemotherapy, heparin)? Although this study focused on the nurse-patient assignment, patients and clinical nurses were not included. Liang and Turkcan (2016) developed an oncology clinic nursepatient assignment program. The program used criteria, such as patient acuity, expected duration of treatment, and nurse skill level, to create assignments. They used multi-objective optimization models to reduce patient wait times, nurse overtime, and workload. Using retrospective data, authors determined numerous solutions to meet their objectives and developed a spreadsheet-based tool to assist charge nurses in assignment development. Only charge nurses were consulted; clinical nurses or patients were not involved in program development. Clinical nurses and patients represent the outcome of the assignment process, yet current research does not include them in its development and maximization. Gaps exist in the understanding of how the nursepatient assignment pro cess affects assignment recipients. They are an untapped resource and can provide a unique perspective on the process. Nurses satisfaction with their assignments can influence their overall job satisfaction, as well as patients satisfaction with care. Their feedback can improve the assignment process and may influence patient and nurse outcomes. Purpose The purpose of this qualitative descriptive study was to describe the nurse-patient assignment pro - cess from the perspective of clinical nurses and patients. Sample Two participant samples were sought: clinical nurses and hospitalized patients. The researcher used typical cases to allow participants to describe their understanding of the nurse-patient assignment process and its effect on them. Clinical nurse participants were registered 78 March-April 2018 Vol. 27/No. 2

3 The Nurse-Patient Assignment Process: What Clinical Nurses and Patients Think nurses employed on a medical or surgical unit who had never made nurse-patient assignments. A purposive sample was identified by a member of the hospital s Nursing Research Council, and potential participants were contacted through by the council member. If nurses were interested, the re - searcher contacted them through or by telephone and invited them to participate in the study. The researcher then scheduled the interview. All nurse interviews occurred at the hospital in the nurse s unit lounge or nurses station. Of the six nurses identified as meeting the criteria, five agreed to participate and were interviewed. Five patients participated in the study. They were age 18 or older and hospitalized for at least 24 hours. Patients hospitalized for more than 24 hours had been assigned to two or three nurses, potentially increasing their familiarity with the assignment process. This convenience sample was recruited after discussion with clinical nurses on each unit. The researcher asked the nurses which patients met the inclusion criteria. Patients who met the criteria were asked by the researcher to participate in the study. The researcher repeated the process on 5 separate days on three units, approaching 35 patients until a sample of five patients was obtained. Patients were reluctant to participate due to fatigue and presence of family members. Patients were interviewed in their hospital rooms. Ethics The study was conducted at a suburban community hospital in the northeastern United States. Institutional Review Board (IRB) approval was obtained from the researcher s university and the hospital s IRB committees. The re - searcher was the only person to have access to the digital recordings and electronic transcripts. The 10 participants provided informed consent before completing semistructured interviews with the researcher. Methods and Design Demographic data were collected, including age, gender identity, and level of education. The five nurse participants were Caucasian females with a baccalaureate degree in nursing. One nurse also held certification as a progressive care nurse. Four patient participants were female and one was male. One female participant was African- American and the other four pa - tients were Caucasian. Four patients were high school graduates while one had a bachelor s degree. Four patients had been hospitalized for 4 days and one was hospitalized for 10 days (mean hospitalization 5.2 days). Patients ranged in age from 57 to 96; average age was Questions asked of the clinical nurses included the following: When you have an assignment, what is your goal? What are you trying to accomplish? At the end of your shift, how do you know whether or not you met your goals? Think about your last assignment. Why do you think you were given that particular assignment? Were there any characteristics about you or the patient that made the assignment more logical or better? If you were asked to give advice about making nurse-patient assignments to a new charge nurse (or the person who makes your assignments), what advice would you give? Questions asked of the patient participants included the following: Why do you think you are assigned a nurse each day or shift? What does the nurse do to you or for you or with you? Why do you think this nurse was assigned to you? Was/is this nurse a good fit for you? Why or why not? Do you know how you are assigned a nurse? If yes, can you describe? If not, what do you think happens? Analysis Data were collected through semi-structured interviews and analyzed using Krippendorff s (2004) method for content analysis. Con - tent analysis includes five steps: data coding (highlighting text related to the study questions and nursepatient assignment process), data sorting (combining data by research question or content), data reduction (assigning categories and labels to the data), data inferring (defining the assigned labels), and narrating (explaining the results). The data identified during reduction were used to illustrate major themes. Trustworthiness In Krippendorff s (2004) content analysis, trustworthiness is assessed using reliability and validity. Reliability is the degree to which members of a designated community agree on the readings, interpretations, responses to, or uses of given texts or data (p. 212), and is concerned with stability, accuracy, and reproducibility. Validity is established through systematic critique of the research process and analysis of study findings within the context of current knowledge of the research topic. This reflects and aligns with the current thought of trustworthiness as credibility, transferability, dependability, and confirmability (Shenton, 2004). The researcher s familiarity with the nurse-patient assignment process provided credibility for the study. In addition, a colleague of the researcher familiar with the phenomenon of interest reviewed the data and completed coding and inferences from a nurse interview to verify accuracy. Transferability should be ap - proached cautiously. The research setting was a small community hospital in the Northeast and participants were not representative of the population in general. The patients were diverse enough in medical diagnosis, education, and place of residence to present varying and unique views. The patients ability to address the same themes and March-April 2018 Vol. 27/No. 2 79

4 present equal understanding of the nurse-patient assignment process contributed to the transferability of the findings. Depend ability was confirmed based on adherence to recognized procedures for data collection. Finally, confirmability was addressed through the use of semistructured interviews. Without a second data collection method, the interviews allowed participants to direct the inquiry based on their responses to open-ended questions. Confirma bility also was addressed by a second researcher coding the nurse interviews. The second researcher independently verified accuracy of interview data and preliminary nurse findings. The literature review supported the decision to conduct a descriptive study as current knowledge of the phenomenon is limited. Results related to purposes and decision factors of nurse-patient assignment process were supported by the current literature, strengthening the validity of the research. Findings The researcher identified three themes from nurse responses: Consult the expert, Cont inuity is care, and Meeting the nurse s needs, too. Patient responses also reflected three themes: The nurse s role is unclear, I need a connection, and The assignment process isn t random? Nurse-Identified Themes Consult the expert. Nurses expect to be consulted about the nursepatient assignment. Regarding charge nurses making assignments, one nurse stated, I would definitely tell them to check with the staff who has actually been working with them [the patients] to see if they think anything needs to be changed because they ll be the ones that know best. Clinical nurses know their patients better than the charge nurse and can alert the charge nurse to changes in acuity or workload. As one nurse explained the process on her unit, They come around and they ask every nurse how is your assignment, are you okay to give it to this person, do you have anyone who is going home? Another nurse described how patients are part of the assignment process on her unit, stating, The managers and the assistant manager try every shift to go around and to talk to all the patients so if there are any issues regarding the assignment they can pick up on that. Continuity is care. Clinical nurses were unanimous in stating they have continuity of care in their assignments. When nurses are working consecutive days, they receive the same patient assignment as their previous shifts: For continuing care, it s easier if the same people are back and have the same assignment. Another nurse stated, If a nurse is back, they ll get the same patients back unless there s some reason it needs to be changed. Continuity of care was important to the clinical nurses for two reasons. First, they indicated it made their workload lighter be cause they knew their patients histories and routine. Second, patients benefited from interacting with someone they knew already. One nurse stated, It s a benefit for the patient, first of all, and then for us. We know the routine and we re comfortable. We can be more efficient than just starting out new. When asked why continuity of care was important, another nurse said, I think it s easier because pain management is pretty big on our floor so if you ve done a lot of trial and error with all of the drug options they ve given you and you find what works for the patient, it s kind of like, okay, I know what s gonna make them comfortable. Meeting the nurse s needs, too. Clinical nurses were comfortable asking for their assignments to be changed. Although this was a rare instance, most nurses described scenarios when they would ask for their assignments to be changed. They would request a change if a patient was physically or emotionally challenging. [When] I was working 3 days in a row with a really challenging, emotionally draining patient, I have asked to switch, reported one clinical nurse. Another s response was more general and spoke to charge nurses support for assignment requests: If you have a patient that s very heavy or if you re having a lot of problems, I ve always been told that I can tell the charge nurse if I don t want this assignment back or if I don t want this specific patient back. One nurse spoke of a specific situation. There was one patient her situation was just so upsetting, she was so young, she was in so much pain; she was totally confused, it was just an emotional case and she also needed a lot of care. By the end of the night, I was just totally wiped. Went home and just collapsed; I was totally emotionally and physically exhausted I asked when I came back if I could take a break and not have her again. Patient-Identified Themes The nurse s role is unclear. Patients were asked about their understanding of the nurse s role to establish the connection between nurse s role and patient s needs, and their combined influence on the nursepatient assignment process. When asked what their nurse did for them or to them, patients responded with a variety of simple nursing tasks or a vague understanding of the role: She wants to keep me comfortable. A position change, or sometimes you have to remind them that you need certain medications. If there s anything that I need she ll get it for me. They always give me pills, or shots, [they re] always changing the saline and stuff like that. They bathe me, change me, and kind of attend to anything that comes up that I might ask them for. Patient subjects were unaware of or could not articulate the full scope of the nurse s role in the monitoring, surveillance, and care coordination of their conditions. If you have a problem, you should be able to tell them what it is and they should be able to relay it to their superior. This statement referenced surveillance and care coordination, al - though it failed to recognize the nurse s exact role as a member of the healthcare team. I need a connection. Patients 80 March-April 2018 Vol. 27/No. 2

5 The Nurse-Patient Assignment Process: What Clinical Nurses and Patients Think expected the nurse to establish a connection, an emotional bond, with them. They wanted a caring relationship. The nurse is somebody pleasant to talk to occasionally, and she lets me know that I m in the best hands. We bonded; they have an idea of who I am, I have an idea of who they are. I just want someone nice, gentle, to talk to me nicely and make me feel better. As long as you re getting along and friendly, that s all that s really needed. When asked why she thought the assigned nurse was a good fit for her, one patient stated, Because I m an old toughie and so is she. Patients wanted a relationship with their nurses. They wanted nurses to help them feel better, and to talk to them. The assignment process isn t random? Patients had little understanding of the nurse-patient assignment process. One patient stated, I didn t know there was a nurse that picked another nurse I thought it was purely random. When asked if they knew how nurses and patients were assigned, two patients replied, I have no idea and No, I don t. One patient said, Yes when asked if she thought it was random. Another patient suggested, Before they start, they should review the patient s file. Discussion Clinical nurses validated purposes and decision factors previously identified by charge nurses (Allen, 2015), including providing the best care, ensuring fairness, distributing workload equally, and facilitating a therapeutic nurse-patient relationship. Nurse participants identified the following purposes of the nursepatient assignment: equal workload, fairness, patient comfort, patient safety, continuity of care, and workload completion. Clinical nurses and patients also identified factors that should be considered during the nurse-patient assignment process, including continuity of care, nurse status (orientation, floater), acuity, workload, nursepatient relationship, admissions/ discharges/transfers, and psychological support. Allen also identified these factors previously. Those who make assignments and recipients of assignments appeared to agree about what is important to consider when nurse-patient assignments are made. Patients had a very narrow understanding of the nurse s role in the inpatient setting. Patients identified basic tasks for which nurses are responsible, such as medication administration, hygiene, and nutrition. They also identified the psychological support in the nursing role. Patients did not identify or seem to understand the tasks and responsibilities of the nurse outside the patient s room. Because of this, they appeared to feel a lack of engagement with their nurses. Finally, patients did not understand how nurse-patient assignments are made. Patients did not know they are assigned to a specific nurse. They thought the process was random, not realizing the importance of the nurse-patient match. Limitations Patients and clinical nurses were recruited using convenience and purposive sampling, respectively, although five of six nurses who met the criteria were interviewed. The small patient sample may not have been representative of all patients and only included patients on medical or surgical units. Although the sample was small, data saturation was achieved for both the clinical nurse and patient participants. By the fifth interview, no new themes were identified. Recommendations for Future Research Continuity of care and its potential effect on outcomes in the adult care setting need to be explored because of its implications for patients and clinical nurses. Nurses in this study expected continuity of care in their assignments; they indicated such assignments were easier because they knew patients histories, and better for patients because they had established a caring relationship. Nurses in this study also indicated they were able to change their assignments when they felt overwhelmed or needed a break. Another area for additional research is the impact of nurse-patient assignments on nurse satisfaction, which is unexplored. Nursing Implications Data from this study can be used to influence the assignment process to benefit patients and nurses. For example, clinical nurses routinely monitor changes in patient acuity and nursing care needs. This critically important knowledge should be a component of the assignment process as charge nurses consider acuity and workload when making assignments (Allen, 2015). Clinical nurses want and expect to be consulted about their patients. Charge nurses and others who make nursepatient assignments need to be aware of the expectation of consultation from clinical nurses and proactively solicit nurses feedback about their patients. Patients wanted to feel a connection with their nurses. They wanted nurses to establish a caring relationship. However, psychological and psychosocial needs of patients may be neglected as nurses prioritize to meet patients physiological needs (Jones, Hamilton, & Murry, 2015). Nurse leaders need to assess nurses psychological support and its impact on patient outcomes. Time to provide psychological support for patients should be included in the nurse s workload. Patients need better education on the nurse s role and tasks because it can improve overall quality of care and satisfaction with that care. For example, when patients understand nurses surveillance and care coordination roles, they will know to alert nurses to changes in their conditions and discuss concerns with their overall care. This may lead to better satisfaction with care. Better education of patients is needed so they understand the nurse-patient assignment process is not random. They also should March-April 2018 Vol. 27/No. 2 81

6 Instructions For Continuing Nursing Education Contact Hours The Nurse-Patient Assignment Process: What Clinical Nurses and Patients Think Deadline for Submission: April 30, 2020 MSN J1804 To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation through the AMSN Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to 2. Evaluations must be completed online by April 30, Upon completion of the evaluation, a certificate for 1.1 contact hour(s) may be printed. Learning Outcome After completing this learning activity, the learner will be able to describe an analysis of the nurse-patient assignment process from the perspective of clinical nurses and patients. Learning Engagement Activity Respond to the following self-assessment questions: Do patients in your work environment know they are assigned to a specific nurse? Would better education of patients in your work environment help them understand the nurse-patient assignment process? Is there a potential to use data from this study to influence the assignment process in your work environment? The author(s), editor, editorial board, con - tent reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article. This educational activity is jointly provided by Anthony J. Jannetti, Inc. and the Academy of Medical-Surgical Nurses (AMSN). Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Com - mission on Accreditation. Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP Licensees in the state of California must retain this certificate for four years after the CNE activity is completed. This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director. Fees AMSN Member: FREE Regular: $20 know they can have input into the assignment. Knowing their feedback is valued may encourage their participation in development of the nurse-patient relationship. Conclusion This study was unique in asking clinical nurses and hospitalized patients their perceptions of the nurse-patient assignment process. Results also validated previously identified purposes and decision factors of the nurse-patient assignment process (Allen, 2015). Larger patient samples in different types of hospitals (e.g., teaching, community) and settings (urban, rural) should be included in future studies to provide a more complete understanding of the impact of the assignment process on outcomes for patient and nurse. REFERENCES Acar, I., & Butt, S.E. (2016). Modeling nursepatient assignments considering patient acuity and travel distance metrics. Journal of Biomedical Informatics, 64, doi: /j.jbi Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R.,... Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. Lancet, 383(9931), doi: /s (13) Allen, S.B. (2015). The nurse-patient assignment: Purposes and decision factors. Journal of Nursing Administration, 45(12), doi: /nna Hui, J., Chen, L., Yan, G., Haiyan, L., & Wenqin, Y. (2015). Status of nurse staff - ing and nursing care delivery in Pudong, Shanghai. Contemporary Nurse, 50(1), doi: / Jones, T.L., Hamilton, P., & Murry, N. (2015). Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. International Journal of Nursing Studies, 52(6), Kohr, L.M., Hickey, P.A., & Curley, M.A.Q. (2012). Building a nursing productivity measure based on the Synergy model: First steps. American Journal of Critical Care, 21(6), doi: /ajcc Krippendorff, K. (2004). Content analysis: An introduction to its methodology (2nd ed.). Thousand Oaks, CA: Sage. Leineweber, C., Chungkham, H.S., Lindqvist, R., Westerlund, H., Runesdotter, S., Smeds Alenius, L., & Tishelman, C. (2016). Nurses practice environment and satisfaction with schedule flexibility is related to intention to leave due to dissatisfaction: A multi-country, multilevel study. International Journal of Nursing Studies, 58, doi: /j.ijnurstu Liang, B., & Turkcan, A. (2016). Acuity-based nurse assignment and patient scheduling in oncology clinics. Health Care Management Science, 19(3), doi: /s z Sir, M.Y., Dundar, B., Barker Steege, L.M., & Pasupathy, K.S. (2015). Nurse-patient assignment models considering patient acuity metrics and nurses perceived workload. Journal of Biomedical Inform - atics, 55, doi: /j.jbi Shenton, A.K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22(2), Van Oostveen, C.J., Braaksma, A., & Vermeulen, H. (2014). Developing and testing a computerized decision support system for nurse-to-patient assignment. CIN: Computers, Informatics, Nursing, 32(6), doi: /cin Yakusheva, O., Lindrooth, R., & Weiss, M. (2014). Economic evaluation of the 80% baccalaureate nurse workforce recommendation: A patient-level analysis. Medical Care, 52(10), doi: /mlr March-April 2018 Vol. 27/No. 2