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• South Dakota Nurse November 2018 issue is now available.

8 Steps for Making Effective Nurse-Patient Assignments

This article appears on page 14 of

South Dakota Nurse November 2018

Reprinted from American Nurse Today

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

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

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

1. Find a mentor

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

2. Gather your supplies (knowledge)

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

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

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

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

3. Decide on the process

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

4. Set priorities for the shift

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

5. Make the assignments

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

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

6. Adjust the assignments

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

7. Evaluate success

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

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

8. Keep practicing

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

What you need to know

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

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

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

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

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

Psychosocial support •    Emotional needs •    Familial support •    Intellectual needs

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

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

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

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

Choose your process

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

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

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

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

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

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

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

Home / NCLEX-RN Exam / The Therapeutic Environment: NCLEX-RN

The Therapeutic Environment: NCLEX-RN

Identifying external factors that may interfere with client recovery, making client room assignments that support the therapeutic milieu, providing a therapeutic environment for clients with emotional/behavioral issues.

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

• Identify external factors that may interfere with client recovery (e.g., stressors, family dynamics)
• Make client room assignments that support the therapeutic milieu
• Provide a therapeutic environment for clients with emotional/behavioral issues

Client recovery is negatively and positively impacted by a wide variety of intrinsic and internal client related factors and also with extrinsic and external forces and factors. For example, physical recovery from a biological illness or disease can be delayed, interrupted and otherwise negatively impacted when the client has a comorbidity such as diabetes which is an intrinsic factor; and physical recovery from a biological illness or disease can be facilitated when the patient has the support of the family and resources in the community which are extrinsic factors external to the client. Similarly, psychological recovery can be facilitated and enhanced when the client has a strong support system and psychological recovery can be impeded and interfered with when the patient is not compliant and adherent to their medication regimen.

Other factors that can interfere with the psychological recovery and psychosocial integrity include disrupted family dynamics, the inaccessibility and the lack of affordability of health care services and resources, levels of stress, social stigma, and the lack of culturally competent care.

Psychological recovery is enhanced when patients and significant others participate in group meetings for professional and peer support. For example, community meetings can help the client in terms of socialization skills enhancement, self care promotion groups, group therapy, and psychosocial peer support groups; and community group meetings are available to also facilitate psychological recovery for those affect with a common disease or disorder such as depression, and there are also peer support groups like Alcoholics Anonymous and Narcotics Anonymous meetings.

As much as possible, client room assignments should support the therapeutic milieu. For example, a client with violent and, or otherwise, disruptive behavior should not share a room with a client who triggers a client's inappropriate and/or violent dangerous behaviors, and a client at risk for suicide should have a room close to nursing station so that the client can be observed and monitored more closely and more frequently than would occur in a less trafficked and remote area.

Nurses establish, provide and maintain a therapeutically safe and supportive environment, which is referred to as a therapeutic milieu. Environments must be free of all physical safety hazards and also free of any hazards that could potentially jeopardize psychological wellbeing and safety. A therapeutic milieu eliminates as many stressors from the environment as possible. The goal of this environment is to facilitate the client's coping and recovery without the need to cope with these extraneous and avoidable stressors.

Some of the elements of a therapeutic milieu environment include consistency, client rules, limitations and boundaries, and client expectations, including contracts, relating to appropriate behavior.

RELATED CONTENT:

• Abuse and Neglect
• Behavioral Interventions
• Chemical and Other Dependencies/Substance Abuse Disorders  
• Coping Mechanisms
• Crisis Intervention
• Cultural Awareness and Influences on Health
• End of Life Care
• Family Dynamics
• Grief and Loss
• Mental Health Concepts
• Religious and Spiritual Influences on Health
• Sensory/Perceptual Alterations
• Stress Management
• Support Systems
• Therapeutic Communication
• The Therapeutic Environment (Currently here)

SEE – Psychosocial Integrity Practice Test Questions

• Recent Posts

A practical guide to making patient assignments in acute care

Affiliation.

• 1 Definitive Observation Unit, Kaiser Permanente San Diego Medical Center, CA, USA. [email protected]
• PMID: 23232175
• DOI: 10.1097/NNA.0b013e3182785fff

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

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

Nurse-Patient Assignments: A Fresh Look

As hospitals continue to try to reduce costs, improve operations and still provide quality care, one area that might benefit from an evidence-based practice review could be nurse-patient assignments.

There’s certainly no shortage of complaints and concerns about the process among nursing units.

Whether it’s concerns about favoritism leading to unfair nurse-patient assignments or whether it’s heavy workloads leading to frustration and burnout – nurse workloads and how they are created are gaining attention.

Even the training behind them is under scrutiny.

For example, in one limited study of 58 nurses, researcher Stephanie Allen of Pace University asked a group of nurses how they learned to make nurse-patient assignments. Six percent of the respondents said they learned in their primary undergraduate program, while another 9 percent said they got formal hospital training. But three out of four respondents (76%) said it was a colleague or learned on their own.

In addition, 9 out of 10 of the nurses surveyed said they had at some point made a nurse-patient assignment and the majority of them indicated that they began making assignments within 2 years of graduating from nursing school. 1

Perhaps more alarming, 74% of the nurses surveyed said they knew someone who transferred or left their position because of unhappiness with their nurse-patient assignments and almost all of them said that their daily nurse-patient assignment was extremely or very important to their overall job satisfaction.

Some other interesting findings from this particular study:

• 79% of the respondents said they made assignments for a shift other than their own
• 41% of nurses knew someone who called out sick because of an assignment
• 41% said if they could choose only one purpose when making assignments, it would be “best care”

IMPLICATIONS OF NURSE-PATIENT ASSIGNMENTS

What are the implications of this study and others related to workload and nurse-patient assignments?

There’s still much work to be done.

Whether it’s the result of insufficient nurse-patient ratios or cost-cutting measures, the evidence has been building that heavy nursing workloads can adversely affect the delivery of care. In addition, there’s also compelling evidence to suggest that matching the right nurse to the right patient in the “right environment” can lead to positive quality and safety outcomes. In another study where a computerized decision support system (CDSS) was implemented to assist nurses and nursing teams with their daily, recurring nurse-to-patient assignment process, the researchers concluded that creating well-balanced, high-quality assignments is crucial to “ensuring patient safety, quality of care, and job satisfaction for nurses.” 2

And yet, almost all nurse-patient assignments today in most hospitals are done manually and backed with little or no training.

Patient acuity tools haven’t proven to be all that helpful either.

While some EHR systems and patient classification systems have been moving towards trying to attach some kind of coding or numbering system to different acuities, problems surface.

For example, it’s not unusual for a patient acuity classification system coming out of the EHR to be more geared towards physicians and their needs instead of the needs of nurses, which makes it either unusable or cumbersome to try to customize.

Then there’s the problem of patient acuity or classification systems specifically geared towards nurses.

They might be able to code a patient’s condition and allow for a charge nurse to assign a particular nurse based on that coding. But it still doesn’t take into account a host of other factors that need to be considered when trying to match the right nurse to the right patient.

For example, what about geography AND patient acuity? How can those two be balanced?

Furthermore, what if you want to also try to factor in continuity? Now, instead of using just one criteria – patient acuity– you’re suddenly dealing multiple variables at once in a maddening juggling act that challenges even the most savvy and experienced nurse.

Imagine the difficulties of this patient-assignment task on a nurse with one to two years of experience. With little or no training and no viable tools, charge nurses and others are left to come up with balanced, fair and meaningful workloads at a time when budgets continue to be tightened and greater care is not only asked for, but demanded.

It’s an unfair battle.

No wonder frustration, burnout and even turnover is high. Charge nurses and others are being asked to do the impossible

Maybe it’s time to take a fresh look at nurse-patient assignments, especially since it can be argued (and the evidence supports it) that they are one of the pillars of quality inpatient nursing care.

1  Assignments Matter: Results From a Nurse-Patient Assignment Surve y. Stephanie B. Allen, PhD, MSN, MS, BSN, ASN. Lienhard School of Nursing, College of Health Professions, Pace University, Pleasantville, NY. 44TH Biennial Convention, Sigma Global Nursing Excellence

2  developing and testing a computerized decision support system for nurse-to-patient assignment: a multimethod study . van oostveen cj1, braaksma a, vermeulen h.comput inform nurs. 2014 jun;32(6):276-85. doi: 10.1097/cin.0000000000000056., get the latest updates and news delivered to your inbox..

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The Professional Regulation Commission (PRC) releases the list of room assignments for the May 2024 Nurse Licensure Exam (NLE) a few days before the exams.

The May 2024 Nursing board exams will be conducted on May 6-7, 2024, at PRC testing centers located in Metro Manila, Baguio, Butuan, Cagayan de Oro, Calapan, Cebu, Davao, Iloilo, Koronadal, Legazpi, Lucena, Pagadian, Palawan, Pampanga, Rosales, Tacloban, Tuguegarao and Zamboanga.

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The May 2024 Nursing licensure exam covered topics from community health nursing, care of healthy or at-risk mother and child, and care of clients with physiologic and psychosocial alterations.

As per the Board of Nursing, the tests draw basic knowledge, skills, and attitudes in the major subject areas, specifically in fundamentals of nursing, including professional adjustments, maternal and child nursing, community health and communicable disease nursing, nursing of adolescents, adults and aged, and mental health and psychiatric nursing.

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing Management and Professional Concepts [Internet].

• About Open RN

Chapter 4 - Leadership and Management

4.1. leadership & management introduction, learning objectives.

• Compare and contrast the role of a leader and a manager

• Examine the roles of team members

• Identify the activities managers perform

• Describe the role of the RN as a leader and change agent

• Evaluate the effects of power, empowerment, and motivation in leading and managing a nursing team

• Recognize limitations of self and others and utilize resources

As a nursing student preparing to graduate, you have spent countless hours on developing clinical skills, analyzing disease processes, creating care plans, and cultivating clinical judgment. In comparison, you have likely spent much less time on developing management and leadership skills. Yet, soon after beginning your first job as a registered nurse, you will become involved in numerous situations requiring nursing leadership and management skills. Some of these situations include the following:

• Prioritizing care for a group of assigned clients
• Collaborating with interprofessional team members regarding client care
• Participating in an interdisciplinary team conference
• Acting as a liaison when establishing community resources for a patient being discharged home
• Serving on a unit committee
• Investigating and implementing a new evidence-based best practice
• Mentoring nursing students

Delivering safe, quality client care often requires registered nurses (RN) to manage care provided by the nursing team. Making assignments, delegating tasks, and supervising nursing team members are essential managerial components of an entry-level staff RN role. As previously discussed, nursing team members include RNs, licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).[ 1 ]

Read more about assigning, delegating, and supervising in the “ Delegation and Supervision ” chapter.

An RN is expected to demonstrate leadership and management skills in many facets of the role. Nurses manage care for high-acuity patients as they are admitted, transferred, and discharged; coordinate care among a variety of diverse health professionals; advocate for clients’ needs; and manage limited resources with shrinking budgets.[ 2 ]

Read more about collaborating and communicating with the interprofessional team; advocating for clients; and admitting, transferring, and discharging clients in the “ Collaboration Within the Interprofessional Team ” chapter.

An article published in the  Online Journal of Issues in Nursing  states, “With the growing complexity of healthcare practice environments and pending nurse leader retirements, the development of future nurse leaders is increasingly important.”[ 3 ] This chapter will explore leadership and management responsibilities of an RN. Leadership styles are introduced, and change theories are discussed as a means for implementing change in the health care system.

4.2. BASIC CONCEPTS

Organizational culture.

The formal leaders of an organization provide a sense of direction and overall guidance for their employees by establishing organizational vision, mission, and values statements. An organization’s  vision statement  defines why the organization exists, describes how the organization is unique from similar organizations, and specifies what the organization is striving to be. The  mission statement  describes how the organization will fulfill its vision and establishes a common course of action for future endeavors. See Figure 4.1 [ 1 ] for an illustration of a mission statement. A  values statement  establishes the values of an organization that assist with the achievement of its vision and mission. A values statement also provides strategic guidelines for decision-making, both internally and externally, by members of the organization. The vision, mission, and values statements are expressed in a concise and clear manner that is easily understood by members of the organization and the public.[ 2 ]

Mission Statement

Organizational culture  refers to the implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture. Because individual organizations have their own vision, mission, and values statements, each organization has a different culture.[ 3 ]

As health care continues to evolve and new models of care are introduced, nursing managers must develop innovative approaches that address change while aligning with that organization’s vision, mission, and values. Leaders embrace the organization’s mission, identify how individuals’ work contributes to it, and ensure that outcomes advance the organization’s mission and purpose. Leaders use vision, mission, and values statements for guidance when determining appropriate responses to critical events and unforeseen challenges that are common in a complex health care system. Successful organizations require employees to be committed to following these strategic guidelines during the course of their work activities. Employees who understand the relationship between their own work and the mission and purpose of the organization will contribute to a stronger health care system that excels in providing first-class patient care. The vision, mission, and values provide a common organization-wide frame of reference for decision-making for both leaders and staff.[ 4 ]

Learning Activity

Investigate the mission, vision, and values of a potential employer, as you would do prior to an interview for a job position.

Reflective Questions

1. How well do the organization’s vision and values align with your personal values regarding health care?

2. How well does the organization’s mission align with your professional objective in your resume?

Followership

Followership  is described as the upward influence of individuals on their leaders and their teams. The actions of followers have an important influence on staff performance and patient outcomes. Being an effective follower requires individuals to contribute to the team not only by doing as they are told, but also by being aware and raising relevant concerns. Effective followers realize that they can initiate change and disagree or challenge their leaders if they feel their organization or unit is failing to promote wellness and deliver safe, value-driven, and compassionate care. Leaders who gain the trust and dedication of followers are more effective in their leadership role. Everybody has a voice and a responsibility to take ownership of the workplace culture, and good followership contributes to the establishment of high-functioning and safety-conscious teams.[ 5 ]

Team members impact patient safety by following teamwork guidelines for good followership. For example, strategies such as closed-loop communication are important tools to promote patient safety.

Read more about communication and teamwork strategies in the “ Collaboration Within the Interprofessional Team ” chapter.

Leadership and Management Characteristics

Leadership and management are terms often used interchangeably, but they are two different concepts with many overlapping characteristics.  Leadership  is the art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[ 6 ],[ 7 ] See Figure 4.2 [ 8 ] for an illustration of team leadership. There is no universally accepted definition or theory of nursing leadership, but there is increasing clarity about how it differs from management.[ 9 ]  Management  refers to roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[ 10 ] The overriding function of management has been described as providing order and consistency to organizations, whereas the primary function of leadership is to produce change and movement.[ 11 ] View a comparison of the characteristics of management and leadership in Table 4.2a .

Management and Leadership Characteristics[ 12 ]

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Not all nurses are managers, but all nurses are leaders because they encourage individuals to achieve their goals. The American Nurses Association (ANA) established  Leadership  as a Standard of Professional Performance for all registered nurses. Standards of Professional Performance are “authoritative statements of action and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”[ 13 ] See the competencies of the ANA  Leadership  standard in the following box and additional content in other chapters of this book.

Competencies of ANA’s Leadership Standard of Professional Performance

• Promotes effective relationships to achieve quality outcomes and a culture of safety

• Leads decision-making groups

• Engages in creating an interprofessional environment that promotes respect, trust, and integrity

• Embraces practice innovations and role performance to achieve lifelong personal and professional goals

• Communicates to lead change, influence others, and resolve conflict

• Implements evidence-based practices for safe, quality health care and health care consumer satisfaction

• Demonstrates authority, ownership, accountability, and responsibility for appropriate delegation of nursing care

• Mentors colleagues and others to embrace their knowledge, skills, and abilities

• Participates in professional activities and organizations for professional growth and influence

• Advocates for all aspects of human and environmental health in practice and policy

Read additional content related to leadership and management activities in corresponding chapters of this book:

• Read about the culture of safety in the “ Legal Implications ” chapter.

• Read about effective interprofessional teamwork and resolving conflict in the “ Collaboration Within the Interprofessional Team ” chapter.

• Read about quality improvement and implementing evidence-based practices in the “ Quality and Evidence-Based Practice ” chapter.

• Read more about delegation, supervision, and accountability in the “ Delegation and Supervision ” chapter.

• Read about professional organizations and advocating for patients, communities, and their environments in the “ Advocacy ” chapter.

• Read about budgets and staffing in the “ Health Care Economics ” chapter.

• Read about prioritization in the “ Prioritization ” chapter.

Leadership Theories and Styles

In the 1930s Kurt Lewin, the father of social psychology, originally identified three leadership styles: authoritarian, democratic, and laissez-faire.[ 14 ],[ 15 ]

Authoritarian leadership  means the leader has full power. Authoritarian leaders tell team members what to do and expect team members to execute their plans. When fast decisions must be made in emergency situations, such as when a patient “codes,” the authoritarian leader makes quick decisions and provides the group with direct instructions. However, there are disadvantages to authoritarian leadership. Authoritarian leaders are more likely to disregard creative ideas of other team members, causing resentment and stress.[ 16 ]

Democratic leadership  balances decision-making responsibility between team members and the leader. Democratic leaders actively participate in discussions, but also make sure to listen to the views of others. For example, a nurse supervisor may hold a meeting regarding an increased incidence of patient falls on the unit and ask team members to share their observations regarding causes and potential solutions. The democratic leadership style often leads to positive, inclusive, and collaborative work environments that encourage team members’ creativity. Under this style, the leader still retains responsibility for the final decision.[ 17 ]

Laissez-faire  is a French word that translates to English as, “leave alone.” Laissez-faire leadership gives team members total freedom to perform as they please. Laissez-faire leaders do not participate in decision-making processes and rarely offer opinions. The laissez-faire leadership style can work well if team members are highly skilled and highly motivated to perform quality work. However, without the leader’s input, conflict and a culture of blame may occur as team members disagree on roles, responsibilities, and policies. By not contributing to the decision-making process, the leader forfeits control of team performance.[ 18 ]

Over the decades, Lewin’s original leadership styles have evolved into many styles of leadership in health care, such as passive-avoidant, transactional, transformational, servant, resonant, and authentic.[ 19 ],[ 20 ] Many of these leadership styles have overlapping characteristics. See Figure 4.3 [ 21 ] for a comparison of various leadership styles in terms of engagement.

Leadership Styles

Passive-avoidant leadership  is similar to laissez-faire leadership and is characterized by a leader who avoids taking responsibility and confronting others. Employees perceive the lack of control over the environment resulting from the absence of clear directives. Organizations with this type of leader have high staff turnover and low retention of employees. These types of leaders tend to react and take corrective action only after problems have become serious and often avoid making any decisions at all.[ 22 ]

Transactional leadership  involves both the leader and the follower receiving something for their efforts; the leader gets the job done and the follower receives pay, recognition, rewards, or punishment based on how well they perform the tasks assigned to them.[ 23 ] Staff generally work independently with no focus on cooperation among employees or commitment to the organization.[ 24 ]

Transformational leadership  involves leaders motivating followers to perform beyond expectations by creating a sense of ownership in reaching a shared vision.[ 25 ] It is characterized by a leader’s charismatic influence over team members and includes effective communication, valued relationships, and consideration of team member input. Transformational leaders know how to convey a sense of loyalty through shared goals, resulting in increased productivity, improved morale, and increased employees’ job satisfaction.[ 26 ] They often motivate others to do more than originally intended by inspiring them to look past individual self-interest and perform to promote team and organizational interests.[ 27 ]

Servant leadership  focuses on the professional growth of employees while simultaneously promoting improved quality care through a combination of interprofessional teamwork and shared decision-making. Servant leaders assist team members to achieve their personal goals by listening with empathy and committing to individual growth and community-building. They share power, put the needs of others first, and help individuals optimize performance while forsaking their own personal advancement and rewards.[ 28 ]

Visit the Greenleaf Center site to learn more about  What is Servant Leadership ?

Resonant leaders  are in tune with the emotions of those around them, use empathy, and manage their own emotions effectively. Resonant leaders build strong, trusting relationships and create a climate of optimism that inspires commitment even in the face of adversity. They create an environment where employees are highly engaged, making them willing and able to contribute with their full potential.[ 29 ]

Authentic leaders  have an honest and direct approach with employees, demonstrating self-awareness, internalized moral perspective, and relationship transparency. They strive for trusting, symmetrical, and close leader–follower relationships; promote the open sharing of information; and consider others’ viewpoints.[ 30 ]

Characteristics of Leadership Styles

Outcomes of Various Leadership Styles

Leadership styles affect team members, patient outcomes, and the organization. A systematic review of the literature published in 2021 showed significant correlations between leadership styles and nurses’ job satisfaction. Transformational leadership style had the greatest positive correlation with nurses’ job satisfaction, followed by authentic, resonant, and servant leadership styles. Passive-avoidant and laissez-faire leadership styles showed a negative correlation with nurses’ job satisfaction.[ 31 ] In this challenging health care environment, managers and nurse leaders must promote technical and professional competencies of their staff, but they must also act to improve staff satisfaction and morale by using appropriate leadership styles with their team.[ 32 ]

Systems Theory

Systems theory  is based on the concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system. Efficient and functional systems account for these diverse influences and improve outcomes by studying patterns and behaviors across the system.[ 33 ]

Many health care agencies have adopted a culture of safety based on systems theory. A  culture of safety  is an organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. According to The Joint Commission, a culture of safety includes the following components[ 34 ]:

• Just Culture:  A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn by managers between human error, at-risk, and reckless employee behaviors. See Figure 4.4 [ 35 ] for an illustration of Just Culture.
• Reporting Culture:  People realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses. For example, nurses complete an “incident report” according to agency policy when a medication error occurs or a client falls. Error reporting helps the agency manage risk and reduce potential liability.
• Learning Culture:  People regularly collect information and learn from errors and successes while openly sharing data and information and applying best evidence to improve work processes and patient outcomes.

“Just Culture Infographic.png” by Valeria Palarski 2020. Used with permission.

The Just Culture model categorizes human behavior into three categories of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior[ 36 ]:

• Simple human error:  A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a patient. In this example, a root cause analysis reveals a system issue that must be modified to prevent future patient errors (e.g., change the labelling and storage of look alike-sound alike medications).[ 37 ]
• At-risk behavior:  An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the patient. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time.[ 38 ]
• Reckless behavior:  Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk. For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.[ 39 ]

These categories of errors result in different consequences to the employee based on the Just Culture model:

• If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes.[ 40 ] In the “simple human error” example above, system-wide changes would be made to change the label and location of the medications to prevent future errors from occurring with the same medications.
• Individuals committing at-risk behavior are held accountable for their behavioral choices and often require coaching with incentives for less risky behaviors and situational awareness.[ 41 ]In the “at-risk behavior” example above, when the nurse chose to ignore an error message on the barcode scanner, mandatory training on using barcode scanners and responding to errors would likely be implemented, and the manager would track the employee’s correct usage of the barcode scanner for several months following training.
• If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken.[ 42 ] In the “reckless behavior” example above, the manager would report the nurse’s behavior to the State Board of Nursing for disciplinary action. The SBON would likely mandate substance abuse counseling for the nurse to maintain their nursing license. However, employment may be terminated and/or the nursing license revoked if continued patterns of reckless behavior occur.

See Table 4.2c describing classifications of errors using the Just Culture model.

Classification of Errors Using the Just Culture Model

Systems leadership  refers to a set of skills used to catalyze, enable, and support the process of systems-level change that is encouraged by the Just Culture Model. Systems leadership is comprised of three interconnected elements:[ 43 ]

• The Individual:  The skills of collaborative leadership to enable learning, trust-building, and empowered action among stakeholders who share a common goal
• The Community:  The tactics of coalition building and advocacy to develop alignment and mobilize action among stakeholders in the system, both within and between organizations
• The System:  An understanding of the complex systems shaping the challenge to be addressed

4.3. IMPLEMENTING CHANGE

Change is constant in the health care environment.  Change  is defined as the process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[ 1 ] The outcomes of change must be consistent with an organization’s mission, vision, and values. Although change is a dynamic process that requires alterations in behavior and can cause conflict and resistance, change can also stimulate positive behaviors and attitudes and improve organizational outcomes and employee performance. Change can result from identified problems or from the incorporation of new knowledge, technology, management, or leadership. Problems may be identified from many sources, such as quality improvement initiatives, employee performance evaluations, or accreditation survey results.[ 2 ]

Nurse managers must deal with the fears and concerns triggered by change. They should recognize that change may not be easy and may be met with enthusiasm by some and resistance by others. Leaders should identify individuals who will be enthusiastic about the change (referred to as “early adopters”), as well as those who will be resisters (referred to as “laggers”). Early adopters should be involved to build momentum, and the concerns of resisters should be considered to identify barriers. Data should be collected, analyzed, and communicated so the need for change (and its projected consequences) can be clearly articulated. Managers should articulate the reasons for change, the way(s) the change will affect employees, the way(s) the change will benefit the organization, and the desired outcomes of the change process.[ 3 ] See Figure 4.5 [ 4 ] for an illustration of communicating upcoming change.

Identifying Upcoming Change

Change Theories

There are several change theories that nurse leaders may adopt when implementing change. Two traditional change theories are known as Lewin’s Unfreeze-Change-Refreeze Model and Lippitt’s Seven-Step Change Theory.[ 5 ]

Lewin’s Change Model

Kurt Lewin, the father of social psychology, introduced the classic three-step model of change known as Unfreeze-Change-Refreeze Model that requires prior learning to be rejected and replaced. Lewin’s model has three major concepts: driving forces, restraining forces, and equilibrium. Driving forces are those that push in a direction and cause change to occur. They facilitate change because they push the person in a desired direction. They cause a shift in the equilibrium towards change. Restraining forces are those forces that counter the driving forces. They hinder change because they push the person in the opposite direction. They cause a shift in the equilibrium that opposes change. Equilibrium is a state of being where driving forces equal restraining forces, and no change occurs. It can be raised or lowered by changes that occur between the driving and restraining forces.[ 6 ],[ 7 ]

• Step 1: Unfreeze the status quo.  Unfreezing is the process of altering behavior to agitate the equilibrium of the current state. This step is necessary if resistance is to be overcome and conformity achieved. Unfreezing can be achieved by increasing the driving forces that direct behavior away from the existing situation or status quo while decreasing the restraining forces that negatively affect the movement from the existing equilibrium. Nurse leaders can initiate activities that can assist in the unfreezing step, such as motivating participants by preparing them for change, building trust and recognition for the need to change, and encouraging active participation in recognizing problems and brainstorming solutions within a group.[ 8 ]
• Step 2: Change.  Change is the process of moving to a new equilibrium. Nurse leaders can implement actions that assist in movement to a new equilibrium by persuading employees to agree that the status quo is not beneficial to them; encouraging them to view the problem from a fresh perspective; working together to search for new, relevant information; and connecting the views of the group to well-respected, powerful leaders who also support the change.[ 9 ]
• Step 3: Refreeze.  Refreezing refers to attaining equilibrium with the newly desired behaviors. This step must take place after the change has been implemented for it to be sustained over time. If this step does not occur, it is very likely the change will be short-lived and employees will revert to the old equilibrium. Refreezing integrates new values into community values and traditions. Nursing leaders can reinforce new patterns of behavior and institutionalize them by adopting new policies and procedures.[ 10 ]

Example Using Lewin’s Change Theory

A new nurse working in a rural medical-surgical unit identifies that bedside handoff reports are not currently being used during shift reports.

Step 1: Unfreeze:  The new nurse recognizes a change is needed for improved patient safety and discusses the concern with the nurse manager. Current evidence-based practice is shared regarding bedside handoff reports between shifts for patient safety.[ 11 ] The nurse manager initiates activities such as scheduling unit meetings to discuss evidence-based practice and the need to incorporate bedside handoff reports.

Step 2: Change:  The nurse manager gains support from the Director of Nursing to implement organizational change and plans staff education about bedside report checklists and the manner in which they are performed.

Step 3: Refreeze:  The nurse manager adopts bedside handoff reports in a new unit policy and monitors staff for effectiveness.

Lippitt’s Seven-Step Change Theory

Lippitt’s Seven-Step Change Theory expands on Lewin’s change theory by focusing on the role of the change agent. A  change agent  is anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort. Change agents can be internal, such as nurse managers or employees appointed to oversee the change process, or external, such as an outside consulting firm. External change agents are not bound by organizational culture, politics, or traditions, so they bring a different perspective to the situation and challenge the status quo. However, this can also be a disadvantage because external change agents lack an understanding of the agency’s history, operating procedures, and personnel.[ 12 ] The seven-step model includes the following steps[ 13 ]:

• Step 1: Diagnose the problem.  Examine possible consequences, determine who will be affected by the change, identify essential management personnel who will be responsible for fixing the problem, collect data from those who will be affected by the change, and ensure those affected by the change will be committed to its success.
• Step 2: Evaluate motivation and capability for change.  Identify financial and human resources capacity and organizational structure.
• Step 3: Assess the change agent’s motivation and resources, experience, stamina, and dedication.
• Step 4: Select progressive change objectives.  Define the change process and develop action plans and accompanying strategies.
• Step 5: Explain the role of the change agent to all employees and ensure the expectations are clear.
• Step 6: Maintain change.  Facilitate feedback, enhance communication, and coordinate the effects of change.
• Step 7: Gradually terminate the helping relationship of the change agent.

Example Using Lippitt’s Seven-Step Change Theory

Refer to the previous example of using Lewin’s change theory on a medical-surgical unit to implement bedside handoff reporting. The nurse manager expands on the Unfreeze-Change-Refreeze Model by implementing additional steps based on Lippitt’s Seven-Step Change Theory:

• The nurse manager collects data from team members affected by the changes and ensures their commitment to success.
• Early adopters are identified as change agents on the unit who are committed to improving patient safety by implementing evidence-based practices such as bedside handoff reporting.
• Action plans (including staff education and mentoring), timelines, and expectations are clearly communicated to team members as progressive change objectives. Early adopters are trained as “super-users” to provide staff education and mentor other nurses in using bedside handoff checklists across all shifts.
• The nurse manager facilitates feedback and encourages two-way communication about challenges as change is implemented on the unit. Positive reinforcement is provided as team members effectively incorporate change.
• Bedside handoff reporting is implemented as a unit policy, and all team members are held accountable for performing accurate bedside handoff reporting.

Read more about additional change theories in the  Current Theories of Change Management pdf .

Change Management

Change management  is the process of making changes in a deliberate, planned, and systematic manner.[ 14 ] It is important for nurse leaders and nurse managers to remember a few key points about change management[ 15 ]:

• Employees will react differently to change, no matter how important or advantageous the change is purported to be.
• Basic needs will influence reaction to change, such as the need to be part of the change process, the need to be able to express oneself openly and honestly, and the need to feel that one has some control over the impact of change.
• Change often results in a feeling of loss due to changes in established routines. Employees may react with shock, anger, and resistance, but ideally will eventually accept and adopt change.
• Change must be managed realistically, without false hopes and expectations, yet with enthusiasm for the future. Employees should be provided information honestly and allowed to ask questions and express concerns.

4.4. SPOTLIGHT APPLICATION

Jamie has recently completed his orientation to the emergency department at a busy Level 1 trauma center. The environment is fast-paced and there are typically a multitude of patients who require care. Jamie appreciates his colleagues and the collaboration that is reflected among members of the health care team, especially in times of stress. Jamie is providing care for an 8-year-old patient who has broken her arm when there is a call that there are three Level 1 trauma patients approximately 5 minutes from the ER. The trauma surgeon reports to the ER, and multiple members of the trauma team report to the ER intake bays. If you were Jamie, what leadership style would you hope the trauma surgeon uses with the team?

In a stressful clinical care situation, where rapid action and direction are needed, an autocratic leadership style is most effective. There is no time for debating different approaches to care in a situation where immediate intervention may be required. Concise commands, direction, and responsive action from the team are needed to ensure that patient care interventions are delivered quickly to enhance chance of survival and recovery.

4.5. 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.)

Sample Scenario

An 89-year-old female resident with Alzheimer’s disease has been living at the nursing home for many years. The family decides they no longer want aggressive measures taken and request to the RN on duty that the resident’s code status be changed to Do Not Resuscitate (DNR). The evening shift RN documents a progress note that the family (and designated health care agent) requested that the resident’s status be made DNR. Due to numerous other responsibilities and needs during the evening shift, the RN does not notify the attending physician or relay the information during shift change or on the 24-hour report. The day shift RN does not read the night shift’s notes because of several immediate urgent situations. The family, who had been keeping vigil at the resident’s bedside throughout the night, leaves to go home to shower and eat. Upon return the next morning, they find the room full of staff and discover the staff performed CPR after their loved one coded. The resident was successfully resuscitated but now lies in a vegetative state. The family is unhappy and is considering legal action. They approach you, the current nurse assigned to the resident’s care, and state, “We followed your procedures to make sure this would not happen! Why was this not managed as we discussed?”[ 1 ]

1. As the current nurse providing patient care, explain how you would therapeutically address this family’s concerns and use one or more leadership styles.

2. As the charge nurse, explain how you would address the staff involved using one or more leadership styles.

3. Explain how change theory can be implemented to ensure this type of situation does not recur.

IV. GLOSSARY

The process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[ 1 ]

Anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort.

Organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. Just Culture is a component of a culture of safety.

The upward influence of individuals on their leaders and their teams.

A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless employee behaviors.

The art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[ 2 ],[ 3 ]

Roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[ 4 ]

An organization’s statement that describes how the organization will fulfill its vision and establishes a common course of action for future endeavors.

The implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture.

A set of skills used to catalyze, enable, and support the process of systems-level change that focuses on the individual, the community, and the system.

The concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system.

The organization’s established values that support its vision and mission and provide strategic guidelines for decision-making, both internally and externally, by members of the organization.

An organization’s statement that defines why the organization exists, describes how the organization is unique and different from similar organizations, and specifies what the organization is striving to be.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 4 - Leadership and Management.
• PDF version of this title (18M)

In this Page

• LEADERSHIP & MANAGEMENT INTRODUCTION
• BASIC CONCEPTS
• IMPLEMENTING CHANGE
• SPOTLIGHT APPLICATION
• LEARNING ACTIVITIES

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A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?

A client who has a history of dependent personality disorder.

A client who has moderate-stage Alzheimer's disease.

A client who has schizotypal personality disorder.

A client who has a history of alcohol use disorder.

Choice A rationale:

A client with a history of dependent personality disorder does not necessarily require close placement to the nurse's station for safety reasons. The primary concern in this case is not related to Alzheimer's or potential wandering, so placing this client closer to the nurse's station is not warranted.

Choice C rationale:

A client with schizotypal personality disorder may have unique care needs, but these typically do not require placement close to the nurse's station. The primary concern in this case is not related to the safety or wandering associated with Alzheimer's disease.

Choice D rationale:

A client with a history of alcohol use disorder may require monitoring and support but does not necessarily need to be placed close to the nurse's station solely based on this history. The primary concern is not related to Alzheimer's disease or safety due to wandering. In a healthcare setting, clients with Alzheimer's disease often experience confusion and may wander, creating a risk of harm to themselves. Placing a client with moderate-stage Alzheimer's disease close to the nurse's station allows for better supervision and prompt response to any safety concerns. Therefore, it is the most appropriate choice for close placement. .

Nursing Test Bank

Naxlex comprehensive predictor exams.

Related Questions

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?  

Correct answer is d, explanation.

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines? The correct answer is Choice D: Psychomotor retardation.

Significant weight loss may be a concerning symptom in a client with major depressive disorder, but it is not the top priority. Major depressive disorder can lead to changes in appetite, which may result in weight loss. However, psychomotor retardation, which is a significant slowing of physical and mental activities, is a more critical finding. It can be a sign of severe depression and even potential suicidal ideation. Reporting psychomotor retardation to other disciplines allows for a prompt evaluation of the client's safety.

Choice B rationale:

Markedly neglected hygiene is an important observation and may indicate the client's inability to perform self-care activities. While this should be addressed, psychomotor retardation takes precedence as it can indicate more severe symptoms associated with major depressive disorder.

Poor problem-solving skills are a common cognitive symptom of major depressive disorder, but they are not an immediate priority. Clients with depression often struggle with decision-making and problem-solving, but psychomotor retardation is a more severe and concerning symptom that warrants immediate attention.

Psychomotor retardation is the top priority finding in this scenario. It can be a sign of severe depression and may be associated with an increased risk of self-harm or suicide. Reporting psychomotor retardation allows the interprofessional team to assess the client's safety and initiate appropriate interventions promptly.

  A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?  

The correct answer is Choice D, sore throat.

Choice A rationale: Random blood glucose 130 mg/dL is not a priority finding for the nurse to report to the provider. This level is slightly above the normal range of 70 to 110 mg/dL, but it is not indicative of a serious condition such as diabetes mellitus or hyperglycemia. Clozapine can cause hyperglycemia in some patients, but this is usually a chronic effect that develops over months or years of treatment. Therefore, a single random blood glucose measurement of 130 mg/dL is not a cause for immediate concern or intervention. The nurse should monitor the client’s blood glucose levels regularly and educate the client on the signs and symptoms of hyperglycemia, such as increased thirst, urination, hunger, and fatigue. The nurse should also encourage the client to maintain a healthy diet and exercise regimen to prevent or manage hyperglycemia.

Choice B rationale: Nausea is not a priority finding for the nurse to report to the provider. Nausea is a common side effect of clozapine that usually occurs during the initial phase of treatment or after a dose increase. It is usually mild and transient and can be managed by taking the medication with food or water, using antiemetics, or reducing the dose if necessary. Nausea does not indicate a serious or life-threatening adverse reaction to clozapine, unless it is accompanied by other symptoms such as vomiting, abdominal pain, jaundice, or fever. The nurse should assess the client’s nausea and provide supportive care and education on how to cope with it.

Choice C rationale: Heart rate 104/min is not a priority finding for the nurse to report to the provider. This level is slightly above the normal range of 60 to 100 beats per minute, but it is not indicative of a serious condition such as tachycardia or cardiac arrhythmia. Clozapine can cause orthostatic hypotension, bradycardia, syncope, and cardiac arrest in some patients, but these are rare and serious adverse effects that require immediate medical attention. Therefore, a single heart rate measurement of 104/min is not a cause for immediate concern or intervention. The nurse should monitor the client’s vital signs regularly and educate the client on the signs and symptoms of orthostatic hypotension, such as dizziness, lightheadedness, or fainting when changing positions. The nurse should also advise the client to rise slowly from a lying or sitting position, avoid alcohol and other substances that can lower blood pressure, and drink plenty of fluids to prevent dehydration.

Choice D rationale: Sore throat is a priority finding for the nurse to report to the provider. Sore throat is a sign of infection, inflammation, or irritation of the throat, which can be caused by various factors such as viruses, bacteria, allergens, or irritants. However, in a client who is taking clozapine, sore throat can also indicate a serious and potentially fatal adverse effect of the medication: severe neutropenia. Neutropenia is a condition in which the number of neutrophils, a type of white blood cell that fights infection, is abnormally low. This increases the risk of developing serious and life-threatening infections, especially in the mouth, throat, and respiratory tract. Clozapine can cause neutropenia in some patients, especially during the first 18 weeks of treatment, and it is the most common reason for discontinuing the medication. Therefore, any client who is taking clozapine and develops a sore throat should be evaluated by the provider as soon as possible to rule out neutropenia and initiate appropriate treatment if needed. The nurse should also educate the client on the importance of regular blood tests to monitor the absolute neutrophil count (ANC) and the signs and symptoms of infection, such as fever, chills, weakness, or sore throat. The nurse should also instruct the client to avoid contact with people who are sick, practice good hygiene, and report any signs of infection immediately.

A nurse is caring for a client who has borderline personality disorder. Which of the following actions should the nurse take?

A nurse is assessing a client who is restless and constantly mutters to himself. which of the following findings should lead the nurse to suspect delirium, a nurse in a long-term care facility is caring for a client. the nurse should identify that which of the following conditions places the client at an increased risk for developing delirium, a nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. after a rapid assessment, which of the following actions should the nurse plan to take next, a nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. which of the following interventions should the nurse take first, a nurse is caring for a client who exhibits chronic physical symptoms that cannot be fully explained by medical conditions. these symptoms cause distress and impairment in the client's daily life. what term is used to describe this condition, a nurse is educating a patient with an eating disorder about the treatment options. which statement made by the patient indicates a need for further teaching, a nurse is caring for a client who has alzheimer's disease. which of the following findings should the nurse expect  .

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Understanding the charge nurse’s role in staffing

If you’re a charge nurse, you know making patient assignments is stressful. Call bells light up the hallways like Christmas trees, family members ask for patient updates, and nursing staff make specific assignment requests. All you want to do is take care of patients, but you have to consider such questions as, “What about all the new admissions?” “Where will all these patients go?” “Who’s going to take care of them?”

Every day, charge nurses face the daunting task of balancing the unit’s budget with ensuring safe patient care. At the same time, they’re aware of the organizational push to increase staff and patient satisfaction. Balancing these sometimes competing needs can be difficult.

Most people agree that nurse staffing aims to match registered nurse (RN) expertise with patients’ needs. But staffing is fluid, which creates a challenge not just for nurses but also for patients. Consider the patient who has a different nurse every day, missing out on continuity of care.

A solid staffing plan with proper communication is the basic tool for success, for both individuals and the organization. The American Nurses Association (ANA) outlines principles for nurse staffing in the following areas:

• characteristics of patients and family members
• characteristics of RNs and other staff
• organizational and workplace culture
• practice environment
• staffing evaluation.

Think of these five principles as tools you can apply to your staffing decisions and, on a larger plane, help ensure the organization’s overall staffing plan is effective.

1 Assess characteristics of patients and families

Each unit has a unique set of patients and their families. While making assignments, first consider each patient’s clinical needs (such as acuity and functional ability) and family needs, such as education. Also consider patients’ room locations to avoid (if possible) having nurses walk from one end of the unit to another.

Try to give patients the best experience possible. Determine what matters most to them. Most important, view the patient and family members as individuals.

2 Assess staff skills

Once you’ve identified patient needs, consider characteristics of each nurse. Keep in mind that each nurse has a unique set of clinical skills, personality, and strengths and expresses these characteristics differently. Consider completed competencies, years of experience, culture, and emotional intelligence. Patricia Benner’s stages of clinical competence from novice to expert can help guide this assessment and should factor into your assignments. For example, if a nurse has been in clinical practice for only 2 years, she is unlikely to be an expert, so she shouldn’t be assigned the most complicated patient on the unit.

Also assess the skills, personality, and strengths of other staff, such as certified nursing assistants and licensed practical nurses. In this case, it’s especially important to be aware of each staff member’s scope of practice.

Managing the various characteristics of bedside nurses and other staff can be challenging. It’s a developed talent that doesn’t come easily to everyone. Also, you may need to overcome a perception of favoritism toward certain staff members. Remember—your decisions may not always be popular, but being an effective leader doesn’t always mean you’ll be liked by all.

3 Understand the culture

As a charge nurse, you’re a frontline leader—the first reflection of your organization—and you need to ensure you are meeting the organization’s goals and values. Each unit functions differently, but the charge nurse’s role is to make the unit run smoothly. Organizational success depends on charge nurses to execute this function well and help ensure staff are competent. A competent staff makes patient assignments easier.

Of course, your organization has a responsibility to support you in your efforts by providing such elements as orientation, ongoing education, and time to supervise other staff.

4 Consider the practice environment

Practice environment can be considered from an organizational and an individual perspective. For example, your organization should create an environment where nurses can practice autonomously; but as a charge nurse, you’re also responsible for creating a safe, positive work environment. One way to accomplish this is to build strong relationships, based on trust, with nurses and other staff through open communication. Sometimes you may need to explain constraints related to assignments; most staff members aren’t familiar with such terms as care hours, earned hours, or actual hours. If you don’t know these terms, work with your supervisor to learn more about them.

In addition, the care environment should remain calm even in the midst of chaos. As a charge nurse, you must lead the tone for the unit and establish the appropriate environment. Remain calm and coach others to do the same.

The bottom line: Staff should feel they’re working in a safe and fair environment. If they do, they’ll be more likely to embrace their assignments.

5 Evaluate staffing plans

As we all know, patient census fluctuates regularly on nursing units, and patient acuity can change quickly. Your staffing plan for the shift needs to remain flexible; you should reevaluate it on a regular basis. As needed, tap into experts, such as shift supervisors.

The ANA staffing principles focus on a more global level, but you can help there as well. Consider working with your supervisor to help evaluate overall staffing plans based on such factors as patient outcomes, use of supplemental staffing, and nurse and patient satisfaction. You might also want to start an RN-driven staffing committee, which allows bedside nurses to voice their opinion and have a say in nursing productivity.

Meeting the challenge

Making patient assignments can be challenging for the charge nurse. Using the tools described in this article can help you make optimal assignments to benefit both staff and patients.

The authors work in Delray Beach, Florida. Sarah Siebert is director of nursing at Pinecrest Rehabilitation. Jennifer Chiusano is chief nursing officer at Delray Medical Center.

Selected references

American Nurses Association. Nurse Staffing. 2015. http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Nurse-Staffing

American Nurses Association. ANA’s Principles for Nurse Staffing . 2nd ed. ANA: Silver Spring, MD; 2012.

Marine K, Meehan P, Lyons AC, Curley MA. Inequity of patient assignments: fact or fiction. Crit Care Nurse . 2013;33(2):74-7.

Weston MJ, Brewer KC, Peterson CA. ANA principles: the framework for nurse staffing to positively impact outcomes. Nurs Econ . 2012;30(5):247-52.

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