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Assignments Matter: Results from a Nurse-Patient Assignment Survey.

Clinical nurses attending a medical-surgical nursing conference responded to an online survey about nurse-patient assignments. Nurses reported their assignments were very important and extremely important to their overall job satisfaction. Over 90% of clinical nurses made assignments. Nurses learn to make assignments through informal means.

Hospital leaders continually look for ways to improve patient, nurse, and organizational outcomes. Because reimbursement no longer exists for adverse patient events, hospital units are driven to improve outcomes while containing costs (Kuhn, 2008). One area in which this is possible is the nurse-patient assignment process, which is an ideal process for quality improvement efforts (Choi & Miller, 2018).

Nurse-patient assignments involve the matching of the nurse and patients for a specified time for the provision of nursing care. Assignments provide the structure for nursing care delivery in most inpatient settings through identifying and matching individual nurse characteristics to specific patient needs. Positive outcomes can be achieved with nurse-patient assignments that reduce risk (Van Oostveen, Braaksma, & Vermeulen, 2014). Although nurse-patient assignments are made millions of times a day in hospitals around the world, little formalized knowledge exists about the process (Allen, 2012, 2015). The lack of formalized training related to making nurse-patient assignments was the impetus for this research.

Research Questions

The three research questions for this study were as follows: (1) What percentage of a sample of registered nurses (RNs) has ever made nurse-patient assignments? (2) How do RNs learn to make nurse-patient assignments? and (3) Is nurse satisfaction with assignments related to absenteeism and turnover?

Review of the Literature

A PubMed search using the terms nurs*, patient, and assignment generated 255 results for articles within the previous 5 years. Fifteen articles discussed nurse-patient assignments. After review of those articles' abstracts, three articles were found to model/describe the assignment-making process. However, none of these authors addressed how nurses learn to make nurse-patient assignments (Acar & Butt, 2016; Rogowski et al., 2015; Sir, Dundar, Barker Steege, & Pasupathy, 2015). To date research on the nurse-patient assignment process has been scarce; no research exists that actually describes the complex process of making nurse-patient assignments. Foundational research has begun to explore the most basic aspects of the nurse-patient assignment process (Allen, 2012, 2015). Purposes, decision factors, and steps of the process have been identified. Supplemental results from this research indicate the majority of charge nurses learn to make nurse-patient assignments through non-formalized methods (Allen, 2012).

The process of making nurse-patient assignments is not taught routinely in undergraduate education because beginner nurses do not make assignments. Issacson and Stacy (2004) described a single instance of senior nursing students making patient assignments for junior students during a medical-surgical clinical rotation. The process also is not taught in graduate curricula because nurse managers and administrators also do not make assignments. Nurse-patient assignments are identified as an activity of the charge nurse, but training programs and role descriptions do not identify how to make nurse-patient assignments (Admi & Moshe-Eilon, 2010; Eggenberger, 2012; Sherman, 2005; Thomas, 2012). Although charge nurses typically make assignments, no protocols have been found that address where they learn how to do so. No publications appear to describe if they receive guidance in the process.

Anecdotal and unpublished evidence suggests nurses learn this important process through on-thejob training (Allen, 2012). The effectiveness of this process is unknown. Without knowledge of how nurses are taught to make assignments, evidence-based practice changes to improve the process cannot be implemented.

Theoretical Framework

The conceptual framework for this study was the Nurse Planning Process (Allen, 2012). Planning for and delivering nursing care involves four sequential phases: budgeting, scheduling, staffing, and nurse-patient assignments (see Figure 1). During the initial budgeting phase, the number and skill mix of the nursing staff needed for the year is budgeted for a specific nursing service area. Resources include human resources records, financial reports, and nursing service staffing documentation. Data may incorporate historical and projected census and nursing hours per patient day, allocated financial resources, and/or historical staffing data.

Scheduling typically occurs 6-8 weeks before schedule implementation. Nurses assign budgeted nursing personnel to shifts for a set number of work weeks. Staffing is the third phase and occurs in the 2-24 hours before the beginning of the shift (Allen, 2012). The nurse manager or staffing coordinator uses some type of tool, usually based on census, to project nursing care needs. The fourth phase is the nurse-patient assignment, in which the unit nurse manager or charge nurse matches individual characteristics of the nurse and the patient to achieve the highest quality, safest nursing care. Nurses are assigned to specific patients. Key factors, such as patient acuity and nurse experience, are critical to the successful matching of nurse and patient and the provision of safe nursing care (Allen, 2015; Berbarie, 2010).

The process then repeats. Historical data of nurse-patient assignments from the previous year are used in the next year's budgeting process (Allen, 2012). Actual hours of nursing care received by each patient are determined. Historical patient and other hospital financial information is used to project patient characteristics for the next year. Patient projections in turn dictate specific nursing personnel needs for the next year.

Ethics

The project was approved by the university Institutional Review Board. Before completing the survey, each participant gave informed consent. Participants read the consent form online and needed to click Yes to confirm they understood the purpose of the research before accessing the survey. No personal identifying information was requested or collected during the survey. No data were recorded on paper. To safeguard electronic data, access to survey data was restricted to the researcher and statistician. Only the researcher was able to access the data online via a user-specific and password-protected Qualtrics account.

Sample Selection

The target population was RNs who work or have worked on inpatient medical or surgical nursing units. A convenience sample was drawn from attendees of the 2016 Academy of Medical-Surgical Nurses Annual Convention held September 29-October 2, 2016, in Washington, DC. The sample was recruited from a booth in the convention's exhibition hall. The researcher distributed flyers to attendees who passed the booth. Approximately 350 potential subjects were given a flyer with a link to the survey.

Design and Methods

Data were collected for this descriptive study using a 24-question Qualtrics computer-based survey. The survey was developed by the researcher based on previous findings (Allen, 2015, 2018). The survey was reviewed for content and face validity by a colleague with knowledge of nurse-patient assignments. It then was pilot tested for reliability with seven nurses. Group answers were consistent for questions and constructs.

Participants used personal electronic devices to access the Internet and enter the web address for the survey. In addition to basic demographic information (e.g., age, gender identity), participants were asked about their practice settings (unit type, number of beds) and professional history (academic achievements, years of practice). Some questions used Likert scales to gauge data importance (e.g., How important are nurse-patient assignments to your overall job satisfaction?). Other questions asked participants to rank-order items (e.g., Place the following factors used to make nurse-patient assignments in order of importance). Finally, open-ended questions were used to gather additional information about nurse-patient assignments (e.g., What advice would you give to a nurse learning how to make nurse-patient assignments?).

Most questions were descriptive in nature. For those questions, univariate data analysis was used to determine data frequencies, means, medians, ranges, and standard deviations. If the variable was continuous, mean, standard deviation, and minimum and maximum were calculated. If the variable was categorical, count and percentage were calculated. Chi-square analyses were used to assess an association between self-rated importance of nurse satisfaction with assignments and nurse absenteeism and turnover.

Findings

Based on the estimated 350 flyers distributed, the response rate was approximately 17%; 59 nurses gave informed consent and started the survey. Because participants were able to choose not to answer any question in the survey, some questions had fewer than 59 responses. Table 1 highlights the participants' demographic and workplace characteristics data. The average participant was a 44-year-old female with a baccalaureate degree. She had been a nurse for 17 years, practicing 16 of those years in an inpatient setting.

An overwhelming majority (91.4%, n=58) of nurses reported having made nurse-patient assignments. They made assignments for an average of 10 years (n=53, range 1-31 years). Participants then indicated how they learned to make nurse-patient assignments. Only 5.7% (n=3) said they learned in their primary degree programs and 8.6% (n=5) learned through a hospital-based course/training. More participants learned on their own (43.1%, n=25) and/or from a mentor/colleague (75.9%, n=44). Slightly less than 10% (n=5) of participants reported making nurse-patient assignments within 6 months of graduation. At 1 year after graduation, the percentage rose to 34% (n=18) of the sample. At 2 years after graduation, 58.5% (n=31) of the nurses were making assignments.

Participants were asked if they knew someone who has been absent from work or left work early because of an assignment he or she did not like. How often did this happen? Of the 58 respondents, 58.6% (n=40) said they knew of no one, 34.5% (n=20) said this happened one to two times a year, and 5.2% (n=3) said this happened two to five times a year; for 1.7% (n=1) of respondents, this happened more than 12 times a year. When asked if they knew someone who left a position (transferred to another unit, quit) because he or she was unhappy with the nurse-patient assignments, 25.9% (n=15) said they knew no one, 20.7% (n=12) said they knew one, and 53.4% (n=31) knew more than one. Finally, participants were asked how important their nurse-patient assignments were to their overall job satisfaction. Of respondents, 39.7% (n=23) indicated they were extremely important, 56.9% (n=33) noted they were very important, and 3.4% (n=2) identified them as moderately important.

Chi-square testing was used to identify associations between importance of daily patient assignment to overall satisfaction and absenteeism and turnovers. The dependent variable Importance of Daily Patient Assignment to Overall Job Satisfaction was compared individually to the four independent variables (Have you been absent from work or left work early because of an assignment you did not like or agree with? Have you ever left a position [transferred to another unit, quit] because you were unhappy with the nurse-patient assignments? Do you know someone who has been absent from work or left work early because of an assignment he or she did not like or agree with? Have you been absent from work or left work early because of an assignment you did not like or agree with?). No bivariate analyses between these variables showed statistical significance.

Participants also were asked how important they considered certain decision factors when making nurse-patient assignments. The majority indicated the following factors were extremely important or very important (first or second on a 5-point Likert scale): patient acuity, nurse-patient ratio, current staffing, patient workload, nurse competence, continuity of care, nurse-patient relationship, and support staff availability. When the nurses were told they could rely on only three pieces of information (factors) to make assignments, they chose patient acuity, nurse competence, and patient workload. They also were asked how important they considered various purposes of the nurse-patient assignment process (see Table 2). They chose best care (41.1%, n=23) as the primary purpose or outcome (see Table 3).

Discussion

Results indicated the clear majority of nurses is being tasked with making nurse-patient assignments early in their careers. With the high number of nurses making assignments, it became very important to know how nurses are learning to make assignments. The vast majority of nurses learned to make assignments from a colleague (76%). They also learned on their own (43%). The two ways that were least identified were formal hospital training (9%), and in their primary pre-licensure program (6%). Results show almost all nurses are making nurse-patient assignments yet there is a lack of formalized education and/or training on this crucial process.

Although no correlation was found between nurse satisfaction with assignments and absenteeism and turnover, 97% of nurses said their daily assignment was extremely or very important to their overall job satisfaction. There were additional results that support the importance of nurse-patient assignments in overall job satisfaction: 41% of nurses know someone who called out sick because of an assignment and 74% of nurses know someone who quit or transferred because of her nurse-patient assignment; 10% have quit or transferred themselves. Absenteeism and turnover are common in the inpatient setting. Both can contribute to short staffing, potentially impacting patient care quality. Additionally, there are financial implications for the organization related to nurse turnover. The cost to organizations ranges from $37,700 to $58,400 for each nurse who leaves a bedside nursing position (NSI Nursing Solutions, 2016).

Nurses who participated in the study also validated decision factors and purposes of the nurse-patient assignment process previously identified in the literature (Allen, 2012). The findings added new knowledge related to the crucial knowledge nurses need when making assignments. Nurses also validated the importance of best care as the primary purpose of the nurse-patient assignment process.

Limitations

Although nurses from 22 states and 19 nursing units were interviewed, the sample was small. Only nurses who worked on medical-surgical nursing units in hospitals were recruited to participate. Nurses who work in other inpatient and outpatient settings may have different experiences with nurse-patient assignments. The average participant has been a nurse for 17 years. However, less-experienced nurses may have different exposure to nurse-patient assignments and thus less competency in the assignment process, based on the evolving goals of prelicensure nursing programs (American Association of Colleges of Nursing, 2008).

Recommendations for Future Research

Study results suggest further areas of inquiry. A priority is to explore the link between nurse-patient assignments and job satisfaction with a larger, more diverse sample of nurses. There is also a need to understand how prelicensure nursing programs prepare nurses to make nurse-patient assignments. Finally, research is needed to describe the role of formal hospital training programs in facilitating the transition to making nurse-patient assignments.

Nursing Implications

Results of this study are especially important for inpatient nurses who make nurse-patient assignments. Assignments play a larger role in nurse job satisfaction than previously documented (Al Maqbali, 2015). Determining the nurse-patient assignment process that satisfies nurses and delivers best care is important. These findings can be used as a starting point for dialogue among unit nurses about the nurse-patient assignment process that meets their unit's needs.

Healthcare leaders have opportunities to develop formalized training and competencies for nurses and nursing students on the nurse-patient assignment process. Nurses start making assignments early in their careers. They need the resources to make assignments that meet goals for patients (best care), nurses (satisfying), and the organization (cost-effective).

Conclusion

Assignments matter to patients and nurses (Allen, 2018). Nurse-patient assignments are important to nurses and their overall job satisfaction. However, nurses often make assignments early in their careers without formal education on the process. Survey responses supported previous research that emphasized patient acuity and nurse competence as primary decision factors when making assignments. Nurses reinforced best care as the primary purpose of nurse-patient assignments.

Background

Nurse-patient assignments are made every day in hospitals around the world. These assignments can affect patients, nurses, and organizations alike. Although a common process, little formalized knowledge exists about making assignments. The lack of formalized training related to making nurse-patient assignments was the impetus for this research.

Aims

The specific aims were to learn who makes nurse-patient assignments, how they learn to make them, and if satisfaction with an assignment affects absenteeism and turnover.

Method

This descriptive study used a 24-question Qualmetrics computer-based survey launched from an exhibitor booth at the 2016 Academy of Medical-Surgical Nurses Annual Convention in Washington, DC.

Results

A clear majority (91%) of the registered nurse sample has made nurse-patient assignments. Respondents indicated they learned to make nurse-patient assignments in the following ways: primary undergraduate program - 6%, formal hospital training - 9%, colleague - 76%, on their own - 43%. No correlation was found between nurse satisfaction with assignments and absenteeism or turnover.

Limitations and Implications

Small sample and lack of diversity in nursing specialty and years of experience of nurses were limitations of the study. Formalized hospital training on nurse-patient assignments and inclusion of nurse-patient assignment process in prelicensure programs are recommended for nurses.

Conclusion

Although nurse-patient assignments are very important to overall job satisfaction, nurses are making assignments early in their careers without formal education on the process. Further research is needed to explore the link between assignments and job satisfaction with a larger sample.

REFERENCES

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

Admi, H., & Moshe-Eilon, Y. (2010). Stress among charge nurses: Tool development and stress management. Nursing Economics, 28(3), 151-158.

Al Maqbali, M.A. (2015). Factors that influence nurses' job satisfaction: A literature review. Nursing Management (Harrow), 22(2), 30-37. doi:10.7748/nm.22.2.30. e1297

Allen, S.B. (2012). The nurse-patient assignment: Purposes, decision factors and steps of the process. (Ph.D. 3506483), University of South Carolina, Columbia, SC. Retrieved from https://search.pro quest.com/openview/522bc40e1309a1b f25daf78a1ed5b76c/1?pq-origsite=g scholar&cbl=18750&diss=y

Allen, S.B. (2015). The nurse-patient assignment: Purposes and decision factors. Journal of Nursing Administration, 45(12), 628-635. doi:10.1097/nna.00000 00000000276

Allen, S.B. (2018). The nurse-patient assignment process: What clinical nurses and patients think. MEDSURG Nursing, 27(2), 77-82.

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.

Berbarie, T.L. (2010). Charge nurse program builder: Tools for developing unit leaders. Middleton, MA: HCPro, Inc.

Choi, J., & Miller, P. (2018). Registered nurse perception of patient assignment linking to working conditions and outcomes. Journal of Nursing Scholarship, 50(5), 530-539. doi:10.1111/jnu.12418

Eggenberger, T. (2012). Exploring the charge nurse role: Holding the frontline. Journal of Nursing Administration, 42(11), 502506. doi:10.1097/NNA.0b013e318271 4495

Isaacson, J.J., & Stacy, A. S. (2004). Nursing students in an expanded charge nurse role: A real clinical management experience. Nursing Education Perspectives, 25(6), 292-296.

Kuhn, H.B. (2008). Centers for Medicare & Medicaid Services Medicare payment policy for selected hospital acquired conditions (HACs). Baltimore, MD: Author.

NSI Nursing Solutions. (2016). 2016 national healthcare retention & RN staffing report. East Petersburg, PA: Author.

Rogowski, J.A., Staiger, D.O., Patrick, T.E., Horbar, J.D., Kenny, M.J., & Lake, E.T. (2015). Nurse staffing in neonatal intensive care units in the United States. Research in Nursing & Health, 38(5), 333-341. doi:10.1002/nur.21674

Sherman, R.O. (2005). Don't forget our charge nurses. Nursing Economic$, 23(3), 125-130.

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 Informatics, 55, 237-248. doi:10.1016/j.jbi. 2015.04.005

Thomas, P.L. (2012). Charge nurses as frontline leaders: Development through transformative learning. Journal of Continuing Education in Nursing, 43(2), 67-74. doi:10.3928/00220124-20111003-05

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), 276-285. doi:10.1097/CIN.000 0000000000056

Stephanie B. Allen, PhD, RN, NE-BC, is Assistant Professor, Pace University, Pleasantville. NY.

Caption: FIGURE 1. Nurse Planning Process
TABLE 1.
Participant and Participant Workplace Demographics

Age (n=54)                        Mean = 44.6 years (range = 24-
                                  62 years)

Gender Identity (n=55)            96.4% Female

Education (n=55)                  Associate degree - 16.4%
                                  Bachelor degree - 54.5%
                                  Master degree - 23.6%
                                  Doctorate of nursing
                                    practice - 3.6%
                                  Doctor of philosophy - 1.8%

State of Residence (n=56)         6 = Indiana
                                  5 = Pennsylvania
                                  4 = North Carolina, Ohio, Oregon
                                  3 = Maryland, New York, Virginia,
                                      Washington
                                  2 = California, Colorado, Florida,
                                      Georgia, Idaho, Illinois,
                                      Minnesota, Texas
                                  1 = Arizona, Kansas, Louisiana,
                                      New Hampshire, New Jersey

Years as a Nurse (n=58)           17.1 years (range 1-40 years)

Years Working in an Inpatient     16.4 years (range 1-40 years)
Setting (n=58)

Shift Typically Worked (n =58)    Day shift - 62%
                                  Night shift - 27.6%
                                  Evening shift - 6.9%
                                  Other combination - 3.4%

Workplace Setting (n=58)          23 = Medical unit
                                  18 = Surgical unit
                                  6 = Other
                                  4 = Orthopedic unit
                                  2 = Neuroscience unit
                                  1 = Cardiothoracic unit,
                                      gastroenterology unit, medical
                                      intensive care unit, oncology
                                      unit, transplantation unit

Number of Beds (n=58)             29.2 Beds (range 12-48 beds)

Average Length of Stay (n=55)     4.4 Days (range 1-15 days)

TABLE 2.
How Important Each Purpose/Outcome Is When Making Assignments

Purpose                         Value *

Safety                           4.73
Best Care                        4.66
Quality/Patient Satisfaction     4.29
Staff Well-being                 4.23
Equal Workload                   4.16
Fairness                         4.16
Continuity of Care               4.16
Maintaining the Workflow         4.11
Workload Completion              4.07
Care Coordination                3.96
Patient Advocacy                 3.84
Nurse/Patient Match              3.75
Nurse Development                3.63
Discharge Planning               3.54

* Extremely important = 5, Very important = 4, Moderately
important = 3, Slightly important = 2, Not at all important = 1

TABLE 3.
Primary Purpose of the Nurse-Patient Assignment

Purpose                            %

Best Care                        41.1
Safety                           28.6
Equal Workload                   12.5
Quality/Patient Satisfaction      8.9
Continuity of Care                3.6
Fairness                          3.6
Workload Completion               1.8
Total                           100
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Title Annotation:Research for Practice
Author:Allen, Stephanie B.
Publication:MedSurg Nursing
Article Type:Report
Date:Mar 1, 2019
Words:3603
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