Chapter 2 - Prioritization (2024)

2.1. PRIORITIZATION INTRODUCTION

Learning Objectives

• Prioritize nursing care based on patient acuity

• Use principles of time management to organize work

• Analyze effectiveness of time management strategies

• Use critical thinking to prioritize nursing care for patients

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

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

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

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

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

References

1.: Rochefort, C. M., Abrahamowicz, M., Biron, A., Bourgault, P., Gaboury, I., Haggerty, J., & McCusker, J. (2021). Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient‐level longitudinal study.Journal of Advanced Nursing,77(3), 1567-1577.↵10.1111/jan.14710 [PMC free article: PMC7898788] [PubMed: 33305473] [CrossRef]
2.: Hoeve, Y. T., Brouwer, J., Roodbol, P. F., & Kunnen, S. (2018). The importance of contextual, relational and cognitive factors for novice nurses' emotional state and affective commitment to the profession. A multilevel study.Journal of Advanced Nursing,74(9), 2082-2093.↵10.1111/jan.13709 [PubMed: 29754390] [CrossRef]

2.2. TENETS OF PRIORITIZATION

Prioritization

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

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

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

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

Scenario A

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

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

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

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

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

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

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

References

1.: Cho, S., Lee, J., You, S. J., Song, K. J., & Hong, K. J. (2020). Nurse staffing, nurses prioritization, missed care, quality of nursing care, and nurse outcomes.International Journal of Nursing Practice,26(1), e12803.↵10.1111/ijn.12803 [PubMed: 31850645] [CrossRef]
2.: Jessee, M. A. (2019). Teaching prioritization: “Who, what, & why?”Journal of Nursing Education,58(5), 302-305.↵10.3928/01484834-20190422-10 [PubMed: 31039266] [CrossRef]

2.3. TOOLS FOR PRIORITIZING

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

Acuity

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

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

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

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

Table 2.3

Example of a Patient Acuity Tool[4]

	1: Stable Patient	2: Moderate-Risk Patient	3: Complex Patient	4: High-Risk Patient
Assessment	Q8h VS A & O X 4	Q4h VS CIWA < 8	Q2h VS Delirium CIWA > 8	Unstable VS
Respiratory	Stable on RA	O2 < 2L NC	O2 > 2L NC	O2 via mask
Cardiac	VS	Temp < 98.7 F Pacemaker/AICD HR > 130	Change in BP Temp > 100.3 F	Unstable rhythm Afib
Medications	PO/IVPB	TPN, heparin infusion, blood glucose, PICC for blood draws	CBI 1 unit blood transfusion Fluid bolus	> 1 unit blood transfusion Chemotherapy
Drainage Devices	< 2 JP, hemovac, neph tube	Chest to water seal NG tube	Chest tube to suction Drain measured Q2 hrs	Drain measured Q1 hr CT > 100 mL/2 hrs
Pain Management	Pain well- managed with PO or IV meds Q4 hrs	PCA, nerve block Nausea/Vomiting	Q2h pain management	Uncontrolled pain with multiple pain devices
Admit/Transfer/Discharge	Stable transfer, routine discharge	Discharge to outside facility	New admission, discharge to hospice	Complicated post-op
ADLs and Isolation	Independent	Assist with ADLs Two-person assist out of bed Isolation	Turns Q2h Bedrest Respiratory isolation	Paraplegic Total care
Patient Score	Most = 1	Two or > = 2	Any = 3	Any = 4

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

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

Staffing Models and Acuity

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

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

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

Scenario B

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

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

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

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

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

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

Maslow’s Hierarchy of Needs

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

Figure 2.1

Maslow’s Hierarchy of Needs

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

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

Scenario C

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

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

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

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

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

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

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

ABCs

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

Scenario D

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

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

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

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

CURE

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

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

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

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

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

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

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

Data Cues

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

Acute Versus Chronic Conditions

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

Scenario E

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

Actual Versus Potential Problems

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

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

Scenario F

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

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

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

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

Unexpected Versus Expected Conditions

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

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

Handoff Report/Chart Review

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

Scenario G

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

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

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

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

Diagnostic Information

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

Scenario H

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

References

1.: Oregon Health Authority. (2021, April 29).Hospital nurse staffing interpretive guidance on staffing for acuity & intensity. Public Health Division, Center for Health Protection.https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/HEALTHCAREPROVIDERSFACILITIES/HEALTHCAREHEALTHCAREREGULATIONQUALITYIMPROVEMENT/Documents/NSInterpretiveGuidanceAcuity.pdf↵.
2.: Ingram, A., & Powell, J. (2018). Patient acuity tool on a medical surgical unit.American Nurse.https://www.myamericannurse.com/patient-acuity-medical-surgical-unit/↵.
3.: Kidd, M., Grove, K., Kaiser, M., Swoboda, B., & Taylor, A. (2014). A new patient-acuity tool promotes equitable nurse-patient assignments.American Nurse Today , 9(3), 1-4.https://www.myamericannurse.com/a-new-patient-acuity-tool-promotes-equitable-nurse-patient-assignments/↵.
4.: Ingram, A., & Powell, J. (2018). Patient acuity tool on a medical surgical unit.American Nurse.https://www.myamericannurse.com/patient-acuity-medical-surgical-unit/↵.
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6.: Maslow, A. H. (1943). A theory of human motivation.Psychological Review ,50(4), 370–396.↵ 10.1037/h0054346. [CrossRef]
7.: "Maslow's_hierarchy_of_needs.svg" byJ. Finkelsteinis licensed underCC BY-SA 3.0↵.
8.: Stoyanov, S. (2017).An analysis of Abraham Maslow's A Theory of Human Motivation(1st ed.). Routledge. 10.4324/9781912282517↵ 10.4324/9781912282517. [CrossRef] [CrossRef]
9.: Kohtz, C., Gowda, C., & Guede, P. (2017). Cognitive stacking: Strategies for the busy RN.Nursing2021, 47(1), 18-20. 10.1097/01.nurse.0000510758.31326.92↵ 10.1097/01.nurse.0000510758.31326.92. [PubMed: 28027129] [CrossRef] [CrossRef]
10.: Kohtz, C., Gowda, C., & Guede, P. (2017). Cognitive stacking: Strategies for the busy RN.Nursing2021, 47(1), 18-20. 10.1097/01.nurse.0000510758.31326.92↵ 10.1097/01.nurse.0000510758.31326.92. [PubMed: 28027129] [CrossRef] [CrossRef]
11.: Kohtz, C., Gowda, C., & Guede, P. (2017). Cognitive stacking: Strategies for the busy RN.Nursing2021, 47(1), 18-20. 10.1097/01.nurse.0000510758.31326.92↵ 10.1097/01.nurse.0000510758.31326.92. [PubMed: 28027129] [CrossRef] [CrossRef]
12.: Kohtz, C., Gowda, C., & Guede, P. (2017). Cognitive stacking: Strategies for the busy RN.Nursing2021, 47(1), 18-20. 10.1097/01.nurse.0000510758.31326.92↵ 10.1097/01.nurse.0000510758.31326.92. [PubMed: 28027129] [CrossRef] [CrossRef]

2.4. CRITICAL THINKING AND CLINICAL REASONING

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

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

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

References

1.: Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development.Nursing Education Perspectives,41(4), 215-221.↵10.1097/01.nep.0000000000000669 [PubMed: 32569111] [CrossRef]
2.: Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development.Nursing Education Perspectives,41(4), 215-221.↵10.1097/01.nep.0000000000000669 [PubMed: 32569111] [CrossRef]

2.4. CRITICAL THINKING AND CLINICAL REASONING

References

1.: Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development.Nursing Education Perspectives,41(4), 215-221.↵10.1097/01.nep.0000000000000669 [PubMed: 32569111] [CrossRef]
2.: Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development.Nursing Education Perspectives,41(4), 215-221.↵10.1097/01.nep.0000000000000669 [PubMed: 32569111] [CrossRef]

2.4. CRITICAL THINKING AND CLINICAL REASONING

References

1.: Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development.Nursing Education Perspectives,41(4), 215-221.↵10.1097/01.nep.0000000000000669 [PubMed: 32569111] [CrossRef]
2.: Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development.Nursing Education Perspectives,41(4), 215-221.↵10.1097/01.nep.0000000000000669 [PubMed: 32569111] [CrossRef]

2.7. LEARNING ACTIVITIES

Learning Activities

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

1.

The nurse is conducting an assessment on a 70-year-old male client who was admitted with atrial fibrillation. The client has a history of hypertension and Stage 2 chronic kidney disease. The nurse begins the head-to-toe assessment and notes the patient is having difficulty breathing and is complaining about chest discomfort. The client states, “It feels as if my heart is going to pound out of my chest and I feel dizzy.” The nurse begins the head-to-toe assessment and documents the findings. Client assessment findings are presented in the table below. Select the assessment findings requiring immediate follow-up by the nurse.

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

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

2.

The following nursing actions may or may not be required at this time based on the assessment findings. Indicate whether the actions are “Indicated” (i.e., appropriate or necessary), “Contraindicated” (i.e., could be harmful), or “Nonessential” (i.e., makes no difference or are not necessary).

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

3.

The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences amongCritical needs,Urgent needs,Routine needs, andExtras.

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

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

II. GLOSSARY

ABCs: Airway, breathing, and circulation.
Actual problems: Nursing problems currently occurring with the patient.
Acuity: The level of patient care that is required based on the severity of a patient’s illness or condition.
Acuity-rating staffing models: A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.
Acute conditions: Conditions having a sudden onset.
Chronic conditions: Conditions that have a slow onset and may gradually worsen over time.
Clinical reasoning: A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[1]
Critical thinking: A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[2]
CURE hierarchy: A strategy for prioritization based on identifying “critical” needs, “urgent” needs, “routine” needs, and “extras.”
Data cues: Pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition.
Expected conditions: Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.
Maslow’s hierarchy of needs: Prioritization strategies often reflect the foundational elements of physiological needs and safety and progr ess toward higher levels.
Ratio-based staffing models: A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.
Risk problem: A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.
Time estimation: A prioritization strategy including the review of planned tasks and allocation of time believed to be required to complete each task.
Time scarcity: A feeling of racing against a clock that is continually working against you.
Unexpected conditions: Conditions that are not likely to occur in the normal progression of an illness, disease, or injury.

References

1.: Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development.Nursing Education Perspectives, 41(4), 215-221. 10.1097/01.nep.0000000000000669↵ 10.1097/01.nep.0000000000000669. [PubMed: 32569111] [CrossRef] [CrossRef]
2.: Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development.Nursing Education Perspectives, 41(4), 215-221. 10.1097/01.nep.0000000000000669↵ 10.1097/01.nep.0000000000000669. [PubMed: 32569111] [CrossRef] [CrossRef]

FAQs

How to prioritize patients in NCLEX? ›

Nurses need to assess each client's current state and future goals in order to figure out which clients are most likely to benefit from additional attention. The ABCs of patient prioritization are Airway, Breathing, and Circulation, which are the three things that must be addressed in any medical situation.

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What are the levels of prioritization in nursing? ›

The steps to set priorities are divided into first-level, second-level and third-level priority problems. Designate high priority to first level priority problems, such as the ABC's; airway, breathing, and circulation, which are emergent and life-threatening.

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What are the ABCs of prioritization? ›

Airway, breathing, and circulation, otherwise known by the mnemonic “ABCs,” are another foundational element to assist the nurse in prioritization. Like Maslow's hierarchy, using the ABCs to guide decision-making concentrates on the most critical needs for preserving human life.

What is the nursing process of prioritization? ›

Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as the priority, then breathing, and finally circulation.

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What are the 4 P's of nursing prioritization? ›

What are the 4 ps to remember in prioritization? Purpose for care, current clinical picture, plan according to desired outcomes or results, part played by each team member for delegation or assignment.

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What are the 4 P's of prioritization? ›

In conclusion, the four Ps of time management (Prioritize, Plan, Prepare, and Perform) provide a useful framework for managing your time more efficiently and achieving your goals.

What are the 5 levels of prioritization? ›

These are the tasks that can't be left for when you have time because not doing them can have serious negative consequences. For this method, use the following priority levels: critical, high priority, neutral, low priority, unknown.

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What are the 5 Ds of Prioritisation? ›

What Are The 5 D's?

Do – urgent and important things.
Delegate – urgent and unimportant things.
Delay – important and not urgent things.
Delete- unimportant and not urgent thing.
Decide to call an accountability partner – to hold you to your decisions.

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How to determine patient priority? ›

Generally, you want to focus first on things that must be addressed right away (to prevent serious illness or harm). Then you can move on to things that should be addressed soon, and after that, issues to treat in the near future.

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How do you know which patient to see first? ›

Prioritization without the ABCs

We all know prioritizing is tied to the ABCs – airway, breathing, and circulation; technically, you are figuring out the client who has the higher chance of dying first.

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How to prioritize people in nursing? ›

Prioritise people

You put the interests of people using or needing nursing or midwifery services first. You make their care and safety your main concern and make sure that their dignity is preserved and their needs are recognised, assessed and responded to.

How would you prioritize your patients? ›

As a nurse or doctor, your priority is to provide care to your patients to ensure those basic needs at the bottom of the pyramid are met.

Physiological Needs. ...
Safety Needs. ...
Love and Belongingness Needs. ...
Esteem Needs. ...
Self-Actualization Needs. ...
Airway. ...
Breathing. ...
Circulation.

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