critical care nursing practice

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Critical Care Nursing: Science and Practice (3 edn)

Chief Nurse

Independent Consultant

Consultant Nurse in Critical Care and Critical Care Outreach

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This textbook encompasses the knowledge, skills, and expertise needed to deliver excellent nursing care to critically ill patients. Emphasis is placed on a holistic and compassionate approach towards humanizing the impact of the environment, organ support, and monitoring, as well as critical illness itself. Chapters cover the general aspects of critical care such as the critical care environment or critical care continuum and specific organ systems and diseases. The structure of the systems chapters reminds the reader of the underlying anatomy and physiology as well as highlighting areas of particular relevance to critical care. The focus on priorities for management builds on the ABCDE assessment and offers insight into key interventions in urgent situations as well as outlining evidence-based practice. The book is ideal for those new to the critical care environment, but will also act as a reminder for more experienced nurses when faced with a new situation or when teaching/mentoring students. The patient and their family remain the centre of all This new edition brings the definitions, pathophysiology, and management of fast-changing and challenging areas such as ARDS, sepsis and multiple organ dysfunction, resuscitation, and acute kidney injury up to date as well as including any evidence-based changes associated with nursing practice in critical care. A new chapter covers major incident planning and management and the role of critical care in pandemic situations.

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Practice specialties, critical care nursing.

Critical care nursing, or intensive care unit (ICU) nursing, is a specialty focused on the care of unstable, chronically ill or post-surgical patients and those at risk from life-threatening diseases and injuries.

What do critical care nurses do?

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• an understanding of human anatomy and physiology.
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• ongoing education related to recommended ICU treatment options.

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Use this Critical Care Nursing Certification Review Course to study for the critical care nursing specialty certification from the American Association of Critical-Care Nurses (AACN), which grants the credential CCRN ® (Adult).

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Guidelines for Critical Care Nursing

Drafted FEBRUARY 24,2012

INTRODUCTION

The health care industry all over the world has been undergoing great changes over the past two decades and the Philippines has been part of these transformational events having great impact on the quality of nursing practice. There are new expectations in the way nurses and the nursing practices are to be delivered particularly now that there are many challenges that besiege the present time as a consequence of the complexities of globalization.

In the Philippines, the Professional Regulation Commission – Board of Nursing (PRC-BON) is committed to provide need-driven, effective and efficient specialty nursing care services of high standard and at international level within the obtainable resources. To respond to this mission and commitment, a PRC-BON Working Group in Developing the Nursing Specialty Framework was formed sometime in 1996 to take on the task of setting the process-based framework and guidelines for specialty nursing services. Working Group members comprise clinical nurse practitioners, nurse educators and nurse managers1.

However, the expanding healthcare and nursing knowledge together with new and evolving healthcare sites, structures, and technologies all have contributed to the need and desire for specialty nursing organizations like the Critical Care Nurses Association of the Philippines, Inc. (CCNAPI) to revisit the existing statement of its Standards of Nursing Practice in order to provide clear and updated statements regarding the scopes of practice and standards of critical care nursing. This will ensure continued understanding and acknowledgment of nursing's varied specialty professional contributions in today's healthcare environment.

Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems2. These problems deal dynamically with human responses to actual or potential life-threatening illnesses.

The framework of critical care nursing is a complex, challenging area of nursing practice which utilizes the nursing process applying assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The critical care nursing practice is based on a scientific body of knowledge and incorporates the professional competencies specific to critical care nursing practice and is focused on restorative, curative, rehabilitative, maintainable, or palliative care, based on identified patient need3. It upholds multi and interdisciplinary disciplinary collaboration in initiating interventions to restore stability, prevent complications, achieve and maintain optimal patient responses. The critical care nursing profession requires a clear description of the attributes, guidelines and nursing practice standards in guiding the critical care nursing practice to fulfill this purpose. The critical care nursing competencies statements developed in 2005 are aligned with the PRC-BON statement of the 11 Core Competencies for Entry Level for Safe and Quality Nursing Care. The CCNAPI Core Competencies of a Critical Care Nurse are stated according to the levels of expected behavior defining the actual knowledge, skills and abilities in the practice of critical care by a nursing professional. These statements cover expected behavior of a Nurse Clinician I, Nurse Clinician II and Nurse Specialist that will serve as the basis for assessing competence in critical care practice. In the CCNAPI Standards of Practice, there is no statement that covers the goals, scope of practice and procedural standards in the care of the critically ill. Hence, these are important aspects that should be covered in this working paper.

The focus of care for the critically ill patient is holistic. However, to organize statement in this paper physiological focus will be categorized under bodily functional systems such as pulmonary system, cardiovascular system, renal system, neurological system and other system.

The specific objectives of developing this paper are:

• To identify Critical Care Nursing Service characteristics and contributions of nurses to patient care in the specialty. 1.2 To develop specific competencies required for the delivery of nursing care in the critical care.
• To provide a framework for evaluation of nursing practice within the specialty of critical care.
• To provide a basis for the assessment of staff development needs in the critical care nursing.
• To http://pangeagiving.org/cheap/ guide the development of collaborative relationship with other members of the health care team.

This process-based framework not only describes the critical care nursing services in Philippines, but also assists critical care nurses to have a better understanding of what is expected of them from the organization and the public perspectives.

PHILOSOPHY OF CRITICAL CARE NURSING

Critical care nursing reflects a holistic approach in caring of patients. It places great emphasis on caring the bio-psycho-social-spiritual nature of human beings and their responses to illnesses rather than the disease process. It helps to maintain the individual patient's identity and dignity. The caring focus includes preventive care, risk factor modification and education to decrease future patient admission to acute care facilities.

The Critical Care Nurses of the Philippines, Inc. (CCNAPI) believes that as an organization of critical care nurses, it is conscious of its responsibility for the promotion of man's health and welfare for national development, and has the desire to give support for professional and personal growth and development. CCNAPI has organized itself into a national association committed to the ideals of service to the people, equality, justice and social progress.

In the Critical Care Units, each patient is viewed as a unique individual with dignity and worth. The critically ill patient should receive comfort and privacy in a highly technological environment. In collaboration with other health care team members, critical care nurses provide high level of patient care which includes patient and family education, health promotion and rehabilitation. To achieve this holistic care process, participation by the patient and his/her family is always emphasized. At the forefront of critical care science and technology, critical care nurses maintain professional competence based on a broad base of knowledge and experience through continuous education and evidence-based research.

With advances in sophisticated biomedical technology and knowledge, critical care nurses are able to continuously monitor and observe patients for physiological changes to confront problems proactively and to assist patients to achieve and maintain an optimum level of functioning or a peaceful death.

In other words, this nursing philosophy of the CCNAPI is accomplished by looking after critically http://www.dfwhindutemple.org/antibiotics-for-sale/ ill patient in an environment with specially trained nurses, appropriate equipment, adequate medical supplies and auxiliary health care personnel.

GOALS OF CRITICAL CARE NURSING

Critical or intensive care is a complex specialty developed to serve the diverse health care need of patients (and their families) with actual or potential life threatening conditions3. It is therefore important that a clear statement of what critical care nursing wish to achieve and provide should be articulated.

Goals of critical care nursing include the following: To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care so that the

physiological dysfunction as well as the psychological stress in the ICU are under control

To care for the critically ill patients with a holistic approach, considering the patient's biological, psychological, cultural and spiritual dimensions regardless of diagnosis or clinical setting.

To use appropriate and up-to-date knowledge, caring attitude and clinical skills, supported by advanced technology for prevention, early detection and treatment of complications in order to facilitate recovery.

To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to help http://carpha.org/pt/cialis-online-20mg.aspx the patients and families to go through the painful sufferings.

On the whole, critical care nursing should be patient-centered, safe, effective, and efficient. The nursing interventions are expected to be delivered in a timely and equitable manner.

SCOPE CRITICAL CARE NURSING

The scope of critical care nursing is defined by the dynamic interaction of the critically ill patient, the critical care nurse and the critical care environment in order to bring about optimal patient outcomes through nursing proficiency within an environment conducive to the provision of this highly specialized care.

Constant intensive assessment, timely critical care interventions and continuous evaluation of management through multidisciplinary efforts are required to restore stability, prevent complications and achieve optimal health. Palliative care should be instituted to alleviate pain and sufferings of the patient and family in situations where death is imminent.

Critical Care Nurses are registered nurses, who are trained and qualified to practice critical care nursing. They possess the standard critical care nursing competencies in assuming specialized and expanded roles in caring for the critically ill patients and their family. Likewise, the critical care nurse is personally responsible and committed to continues learning and updating of knowledge and skills. The critical care nurses carry out interventions and collaborates patient care activities to address life-threatening situations that will meet patient's biological, psychological, cultural and spiritual needs.

The critical care environment constantly supports the interaction between the critically ill patients, their family and the critical care nurses to achieve desired patient outcomes. It entails readily available and accessible emergency equipment, sufficient supplies and effective supporting system to ensure quality patient care as well as staff safety and productivity.

ROLES OF THE CRITICAL CARE NURSES

In response to changes and expansion within and outside the healthcare environment, critical care nurses have broadened their roles at both practice and advanced practice levels. Competencies of critical care nurses are honed and developed to achieve their roles as a practitioner, manager / leader and researcher.

PRACTIONER ROLE

ICU nurses execute their practice roles 24-hours a day to provide high quality care to the critically ill patient.

CARE PROVIDER

• Detects and interprets indicators that signify the varying conditions of the critically ill with the assistance of advanced technology and knowledge.
• Plans and initiates nursing process to its full capacity in a need-driven and proactive manner.
• Acts promptly and judiciously to prevent or halt deterioration when conditions warrant.
• Co-ordinates with other healthcare providers in the provision of optimal care to achieve the best possible outcomes.
• Understands family needs and provide information to allay fears and anxieties.
• Assists family to cope with the life-threatening situation and/or patient's impending death.

EXTENDED ROLES AS CRITICAL CARE NURSES

Critical care nurses have roles beyond their professional boundary. With proper training and established guidelines, algorithms, and protocols that are continuously reviewed and updated, critical care nurses also perform procedures and therapies that are otherwise done by doctors. Such procedures and therapies are:

• Sampling and analyzing arterial blood gases;
• Weaning patients off ventilations;
• Adjusting intravenous analgesia / sedations;
• Performing and interpreting ECGs;
• Titrating intravenous and central line medicated infusion and nutrition support; and
• Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular tachycardia.
• Removal of pacer wire, femoral sheaths and chest tubes
• Other procedures deemed necessary by their respective institution under a clinical protocol.
• Provides health education to patient and family to promote understanding and acceptance of the disease process and to facilitate recovery.
• Participates in the training and coaching of novice healthcare team members to achieve cohesiveness in the delivery of patient care.

PATIENT ADVOCATE

• Acts in the best interest of the patient.
• Monitors and safeguards the quality of care which the patient receives.

MANAGEMENT AND LEADERSHIP ROLE

The critical care nurse in her management and leadership role will be able to render the following responsibilities:

• Perform management and leadership skills in providing safe and quality care
• Accountability for safe critical care nursing practice
• Delivery of effective health programs and services to critically-ill patients in the acute setting
• Management of the critical care nursing unit or acute care setting
• Take lead and supervision among nursing support staff
• Utilize appropriate mechanism for collaboration, networking, linkage –building and referrals.

RESEARCHER ROLE

The critical care nurse in her researcher role will be able to render the following responsibilities:

• Engage self in nursing or other health –related research with or under supervision of an experienced researcher.
• Utilize guidelines in the evaluation of research study or report
• Apply the research process in improving patient care infusing concepts of quality improvement and in partnership with other team-players

ADVANCED PRACTICE LEVEL

This is the future direction in the Philippines and to be benched marked with other countries. For now, a thorough study of Advanced Practice Nursing in critical care will be pursued to align with the BON initiative on specialization framework.

The current healthcare environment demands intensive care nurses to have advanced knowledge and skills to provide the highest possible level of care to the critically ill patients.

EXPANDED ROLES

• Nurse Specialist / Clinical Nurse Specialist Typically, the education and preparation of the critical care nurse practitioner is provided by the respective hospital or institution without advanced educational preparation beyond that of the basic baccalaureate degree. Advanced educational preparation refers to the care nursing training program run by the university or Institute offering Advanced Nursing Studies or other recognized critical care program both local and overseas.A registered nurse, who is a nursing degree holder, should have more than more than __ years of uninterrupted practice experience in the critical care field and has attained advanced education and expertise in caring patients with critical problems can function as a critical care nurse specialist. He /She is also eligible to be accredited by the PRC- Board of Nursing as a Clinical Nurse Specialist. The Hospital Authority supports this accreditation.The critical care nurse specialist is responsible for building up nursing competencies in the ICU entity. He / She contributes to continuous improvement in critical care nursing through staff and clients education cialis online sales and uphold quality nursing guidelines and patient care through clinical research and refinement of ICU standards.
• Advanced Practice Nurse Advanced Practice Nurse (APN) in the critical care unit takes lead in developing practices to meet changing clinical needs and to facilitate patient care processes across professional and organizational boundaries. He /She should have the recommended number of post registration nursing experience, which are spent in the critical care field, exhibiting in-depth professional knowledge and skills. An APN (Critical Care) is a holder of a) clinical master degree in a clinical nursing specialty (Medical-Surgical) such as Critical Care Nursing OR b) master degree in nursing or related discipline / management together with recognized critical care training qualification(s). The Advanced Practice Nurse executes the nursing team leader's responsibilities as designated in the position of APN (NO) or APN (Ward/Unit Management).
• Outcomes Manager Outcome management has been introduced into the healthcare system to ensure achievement of quality and cost-effectiveness in the delivery of patient care. Some critical care units have adopted clinical pathways (e.g., Critical Pathways, Protocols, Algorithms and Orders) in the management of specific diseases such as Acute Myocardial Infarction and Cardio-thoracic Surgeries. Qualified nurse experts are involved in the development and implementation of patient outcomes management.

CHALLENES THAT CRITICAL NURSES WILL FACE

The challenging needs from the critical care nursing service and its environments demand the nurses:

• To develop, foster and maintain a level of knowledge about the norms, values, beliefs, patterns of ill health and care needs of the people;
• To analyze and evaluate specialist skills and criticize their evolving roles;
• To review current studies and researches and to examine contextual issues thus enabling evaluation and synthesis of new knowledge, traditionaltechniques, religious and cultural influences to be applied in nursing practice, particularly, evidence-based nursing practice; and
• To exercise professional judgments expected of them in the critical care clinical setting.

TRAINING OF NURSES FOR CRITICAL CARE SERVICES

The institution / hospital should provide training opportunities to ensure staff competencies. This will enable the nurses working in the critical care units to cope with the complexities and demands of the changing needs of the critically ill patients. The following training activities should be supported in order to maintain a high standard of care:

Orientation program / Preceptorship and mentoring program

New recruits to the critical care shall attend an orientation program and be given the opportunities to work under supervision. Experienced staff in the unit should be readily available for consultation.

IN-SERVICE TRAINING PROGRAM

• Unit / hospital based training courses / workshop / seminar at hospital level
• On-the-job training and bedside supervision

CRITICAL CARE NURSING PROGRAM (POST-GRADUATE SPECIALTY PROGRAM)

• Post-graduate Course in Critical Care Nursing / Cardiac Special Care Nursing / Cardiac Intensive Care Nursing shall be reviewed, evaluated and endorsed to PRC-BON by the CRITICAL CARE NURSES ASSOCIATION OF THE PHILIPPINES, INC for accreditation i. Advanced Critical Care Nursing (ACCN) Provider Course
• It is recommended that the WFCCN policy statement of education shall be used as a framework for designing a critical care program. (Please see declaration of Madrid, 2005)

CCNAPI recommends that all practicing CCN shall ensure that they continuously update their knowledge, skills and behavior through active participation in related critical care nursing education.

This shall include but not limited to the following adult and pediatric concepts on:

• Advanced Cardiac Life Support
• Basic Critical Care Course (BCCC)
• Cardiac Assessment
• Neurological Assessment
• Respiratory Assessment
• Continuous Renal Replacement Therapy
• Advanced Pharmacology
• Advanced Intravenous Therapy
• Others as may be deemed necessary to enhance critical care practice

LEVELS & CATEGORIES OF CRITICAL CARE PROVISIONS WITHIN PHILIPPINES

With respect to the physical set-up and supporting facilities of critical care units in the Philippines, the Department of Health (DOH) Standards requires the critical care units / intensive care unit to be a self-contained area, with the provisions for resources that will support critical care practice. Currently, the DOH is reviewing these standards to come-up with updated requirement.

Sometime in 2003, the Philippine Society of Critical Care Medicine (PSCCM), Society of Pediatric Critical Care Medicine (SPCCM) and the CCNAPI stratified into different levels and categories the care provisions in critical care practice to make it similar to its counterparts overseas with the goal of having effective utilization and organization of resources. Hence, as a guide, CCNAPI will incorporate these standards into this guideline.

LEVELS OF CARE PROVISION

The role of a particular critical care unit will vary, depending on staffing, facilities and support services as well as the type and number of patients it has to manage. Taking into account the guidelines of the Society of Critical Care Medicine, the critical care service provision in Philippines can be classified into 3 levels:

• Should be capable of providing immediate resuscitation for the critically ill and short term cardio-respiratory support because the patients are at risk of deterioration;
• Has a major role in monitoring and preventing complications in "at risk" medical and surgical patients;
• Must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring;
• Has a formal organization of medical staff and at least one registered medical officer available to the unit at all times;
• A certain number of nurses including the nurse in-charge of the unit should possess post-registration qualification in critical care or in the related clinical specialties; and
• Has a nurse: patient ratio of 1:1 for all critically ill patients.
• Should be capable of providing a high standard of general criitcal care for patients who are stepping down from higher levels of care or requiring single organ support/support post-operatively;
• Capable of providing sustainable support for mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring and equipment for critically ill patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery;
• Has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit at all times; The nurse in-charge and a significant number of nursing staff in the unit have critical care certification; and
• A nurse: patient ratio is 1:1 for all critically ill patients.
• Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This does not only include the management of patients requiring advanced respiratory support but also patients with multi-organ failure);
• Has a medical director with specialist critical / intensive care qualification and a duty specialist available exclusively to the unit and medical staff with an appropriate level of experience present in the unit at all times;
• A nurse in-charge and the majority of nursing staff have intensive care certification; and A nurse: patient ratio is at least 1:1 for all patients at all times.

CATEGORIES OF CRITICAL CARE NURSING

The Critical Care Unit can be categorized according to patients' age group or medical specialties.

In the existing environment, majority of the Critical Care Units in the Philippines provide service for patients of various specialties. They are labeled as General ICUs. In certain hospitals, the critical care unit / service is dedicated to the following specific groups:

• Cardio-thoracic
• Respiratory
• Neurosurgical

SYSTEM OPERATION OF CRITICAL CARE UNITS

The operation of critical care units can be classified into Open System and Closed System.

• Open System The admitting and other attending doctors dictate management, change management or perform procedures without consultation or communication with a Critical Care Specialist. A Critical Care Specialist may be available for advice or be consulted to provide interventional skills (optional). No one designated person assumes the "gatekeeper" role.
• Closed System Management is coordinated by a qualified Critical Care Specialist. The critical / intensive care specialist has clinical and administrative responsibility. There is a multi-disciplinary team of specially trained critical care staff. The "intensivist" is the final common pathway for all medical decision-making including the decision to admit or discharge.

Irrespective of the ICU "System" Operation, i.e. open system or closed system, or a mixture of the two, there should be a designated group of registered nurses under a unique management to provide highly specialized care to the critically ill patients. The nurse in-charge and the majority of nursing staff in each unit should have the relevant qualification in the specialty of the respective Unit.

Critical Care Nursing Workforce

The CCNAPI will adopt the Position Statement of the World Federation of Critical Care Nurses on the Provisions of Critical Care Nursing Workforce also called the Declaration of Buenos Aires ratified in the full council meeting last August 27, 2011 at the Sheraton Hotel, Buenos Aires, Argentina.

The declaration presents guidelines universally accepted by critical care professionals, which may be adapted to meet the critical care nursing workforce and system requirements of a particular country or jurisdiction. The declaration states the specific central principles governing the provision and provides for specific recommended critical care nursing workforce requirement. The complete declaration is attached as Annex to this guideline.

COMPETENCIES FOR CRITICAL CARE NURSES

The competence of critical care nurses together with established nursing standards and the identified core competencies for registered nurses will result to excellence in critical care nursing practice. This three pronged holistic framework ensures quality performance through an adherence to nursing standards, the application of competencies, and the integration of appropriate nursing model/s into the care delivery process.

To achieve safe and quality client-centered care, nurses working in the critical care units are envisioned to adopt not only the stated core competencies of registered nurses but also the specific competencies stipulated in the following eleven major key responsibility areas:

• Safe and Quality Nursing Care
• Management of Resources
• Legal Responsibilities
• Ethico-Moral Responsibilities
• Collaboration and Teamwork
• Personal and Professional Development
• Communication
• Health Education
• Quality Improvement
• Record Management

STANDARDS OF CRITICAL CARE NURSING PRACTICE

Critical care specialty addresses the management and support of patients with severe or life-threatening illness. The goal of critical care nursing is to promote optimal adaptation of critically ill patients and their families by providing highly individualized care, so that the critically ill patients adapt to their physiological dysfunction as well as the psychological stress in the Critical Care Unit or Intensive Care Unit (ICU). In order to achieve this, standards should be developed to serve as a guide for monitoring and enhancing the quality of intensive care nursing practice. Care standards for critical care nursing provides measures for determining the quality of care delivered, and also serves as means for recognizing the competencies of nurses in intensive care specialty. Procedures standards for critical care nursing practice provide a step-by-step guideline in guiding nurses to carry out day-to-day nursing procedure in a most appropriate manner. The following 11 are Standards are intended to furnish nurses with direction in providing quality care and excellence in Critical Care Nursing.

• The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing practice.
• The critical care nurse provides care to meet individual patient needs on a 24-hour basis.
• The critical care nurse practices current critical care nursing competently.
• The critical care nurse delivers nursing care in a way that can be ethically justified.
• The critical care nurse demonstrates accountability for his/her professional judgment and actions.
• The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff.
• The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients.
• The critical care nurse protects patients from developing environmental induced infection.
• The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the goals of care.
• The critical care nurse carries out health education for promotion and maintenance of health.
• The critical care nurse acts to enhance the professional development of self and others.

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Chapter 2 - Prioritization

2.1. prioritization introduction, learning objectives.

• Prioritize nursing care based on patient acuity

• Use principles of time management to organize work

• Analyze effectiveness of time management strategies

• Use critical thinking to prioritize nursing care for patients

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

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

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

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

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

2.2. TENETS OF PRIORITIZATION

Prioritization.

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

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

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

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

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

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

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

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

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

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

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

2.3. TOOLS FOR PRIORITIZING

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

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

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

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

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

Example of a Patient Acuity Tool [ 4 ]

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

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

Staffing Models and Acuity

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

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

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

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

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

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

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

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

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

Although acuity can a useful tool for determining care priorities, it is important to recognize the limitations of this tool and consider how other patient needs impact prioritization.

Maslow’s Hierarchy of Needs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Acute Versus Chronic Conditions

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

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

Actual Versus Potential Problems

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

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

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

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

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

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

Unexpected Versus Expected Conditions

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

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

Handoff Report/Chart Review

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

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

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

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

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

Diagnostic Information

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

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

2.4. CRITICAL THINKING AND CLINICAL REASONING

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

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

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

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

2.7. LEARNING ACTIVITIES

Learning activities.

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

The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among  C ritical needs,  U rgent needs,  R outine needs, and  E xtras.

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

II. GLOSSARY

Airway, breathing, and circulation.

Nursing problems currently occurring with the patient.

The level of patient care that is required based on the severity of a patient’s illness or condition.

A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.

Conditions having a sudden onset.

Conditions that have a slow onset and may gradually worsen over time.

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[ 1 ]

A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 2 ]

A strategy for prioritization based on identifying “critical” needs, “urgent” needs, “routine” needs, and “extras.”

Pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition.

Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.

Prioritization strategies often reflect the foundational elements of physiological needs and safety and progr ess toward higher levels.

A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.

A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.

A prioritization strategy including the review of planned tasks and allocation of time believed to be required to complete each task.

A feeling of racing against a clock that is continually working against you.

Conditions that are not likely to occur in the normal progression of an illness, disease, or injury.

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 2 - Prioritization.
• PDF version of this title (18M)

In this Page

• PRIORITIZATION INTRODUCTION
• TENETS OF PRIORITIZATION
• TOOLS FOR PRIORITIZING
• CRITICAL THINKING AND CLINICAL REASONING
• LEARNING ACTIVITIES

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Enhancing Critical Thinking in Clinical Practice

Implications for critical and acute care nurses.

Shoulders, Bridget MS, ACNP-BC, CCRN-CMC; Follett, Corrinne MS, FNP-BC, CCRN, RN-BC, RCIS; Eason, Joyce MS, ANP-BC, RN-BC

Bridget Shoulders, MS, ACNP-BC, CCRN-CMC , is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

Corrinne Follett, MS, FNP-BC, CCRN, RN-BC, RCIS, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

Joyce Eason, MS, ANP-BC, RN-BC, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Address correspondence and reprint requests to: Bridget Shoulders, MS, ACNP-BC, 31047 Whitlock Dr, Wesley Chapel, FL 33543 ( [email protected] ).

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patient condition. The interpretation and response to these events can greatly impact patient outcomes. Nurses caring for these complex patients are expected to use astute critical thinking in their decision making. The purposes of this article were to explore the concept of critical thinking and provide practical strategies to enhance critical thinking in the critical and acute care environment.

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patient condition. The interpretation and response to these events can greatly impact patient outcomes. The purpose of this article is to explore the concept of critical thinking and provide practical strategies to enhance critical thinking in the critical and acute care environment.

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patients’ condition. Caring for patients with complex conditions, decreased length of stay, sophisticated technology, and increasing demands on time challenges new and experienced nurses alike to use astute critical thinking in clinical decision making. The decisions made directly affect patient care outcomes. 1 Bedside nurses, preceptors, and nurse leaders play a pivotal role in the development of critical thinking ability in the clinical setting. The purposes of this article were to explore the concept of critical thinking and to provide nurses with practical strategies to enhance critical thinking in clinical practice.

WHAT IS CRITICAL THINKING?

Critical thinking is a learned process 2 that occurs within and across all domains. There are numerous definitions of critical thinking in the literature, often described in terms of its components, features, and characteristics. Peter Facione, an expert in the field of critical thinking, led a group of experts from various disciplines to establish a consensus definition of critical thinking. The Delphi Report, 3 published in 1990, characterized the ideal critical thinker as “habitually inquisitive, well-informed, trustful of reason…, diligent in seeking relevant information, and persistent in seeking results.” Although this definition was the most comprehensive attempt to define critical thinking 4 at the time, it was not nursing specific.

Scheffer and Rubenfeld 4 used the Delphi technique to define critical thinking in nursing. An international panel of expert nurses in practice, education, and research provided input into what habits of the mind and cognitive skills were at the core of critical thinking. After discussion and analysis, the panel provided the following consensus statement: “Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge.” This definition expanded on the consensus definition in the Delphi Report to include the additional components of creativity and intuition.

Skilled critically thinking nurses respond quickly to changes in patients’ conditions, changing priorities of care based on the urgency of the situation. They accurately interpret data, such as subtle changes in vital signs or laboratory values. 5 They are not just looking at the numbers but also assessing the accuracy and relevancy of the findings. Critical thinking helps the nurse to recognize events as part of the bigger picture and center in on the problem.

Lack of critical thinking is evident when nurses depend heavily on structured approaches, such as protocols, to make clinical decisions. These guidelines should not be viewed as mandates because the practice is always more complex than what can be captured by pathways and protocols. 6 Without critical thinking, nurses are merely performing task-oriented care.

One example of how nurses use critical thinking is with medication administration. This task may appear to be primarily a technical process, but it requires astute critical thinking. Eisenhauer and Hurley 7 interviewed 40 nurses to illustrate their thinking processes during medication administration. The nurses described communicating with providers, sharing their interpretation of patient data to ensure safe administration of medication. They used their judgment about the timing of as-needed medication (eg, timing pain medication before physical therapy). Nurses integrated their knowledge of the patient’s laboratory values or pattern of response to medication to determine the need for a change in the drug dose or time. They assessed whether a medication was achieving the desired effect and took precautionary measures in anticipating potential side effects. It is evident in these examples that safe administration of medication involves critical thinking beyond the 5 rights that nurses are taught in the academic setting .

INTEGRATING RESEARCH, EVIDENCE-BASED PRACTICE, AND CRITICAL THINKING

Nursing research is a scientific process that validates and refines existing knowledge and generates new knowledge that influences nursing practice. 8 Evidence-based practice integrates the best available research with clinical expertise and patient’s needs and values. Different types of evidence have different strengths and weaknesses in terms of credibility. The typical evidence hierarchy places meta-analysis of randomized clinical trials at the top and expert opinion at the bottom of what counts as good evidence. 6

It is important to recognize that nursing knowledge is not always evidence based. Nurses have historically acquired knowledge through a variety of nonscientific sources such as trial and error, role modeling, tradition, intuition, and personal experiences. 8 Although these sources have been “handed down” over the years and continue to influence nursing practice, nurses are expected to use the best available evidence to guide their decision making. Evidence-based practice redirects nursing from making decisions based on tradition to practicing based on the best research evidence.

Barriers for nurses to implement evidence-based practices include lack of knowledge of research, difficulty interpreting findings and applying to practice, lack of time, and lack of autonomy to implement changes. 9 Universities can overcome these barriers by incorporating nursing research throughout all clinical and nonclinical courses. Joint endeavors between hospitals and universities to educate nurses in the use of research will increase the level of comfort with evidence-based practice. 10 Specialized research departments devoted to promotion and education of staff nurses in research evaluation, utilization, and implementation would allow nursing staff to experience an increased level of support and awareness of the need for research utilization.

Nurse leaders need to create an environment that supports transformation from outdated practices and traditions. Nurses must feel empowered to question nursing practice and have available resources to support the search for evidence. Critical thinking and evidence-based practice must be connected and integrated for nurses, starting in their basic education programs and fostered throughout their lifetime. 11

THE NURSING PROCESS AND CRITICAL THINKING

The nursing process is the nurse’s initial introduction to a thinking process used to collect, analyze, and solve patient care problems. The steps of the nursing process are similar to the scientific method. In both processes, information is gathered, observations are made, problems are identified, plans are developed, actions are taken, and processes are reviewed for effectiveness. 8 The nursing process, used as a framework for making clinical judgments, helps guide nurses to think about what they do in their practice.

Chabeli 12 described how critical thinking can be facilitated using the framework of the nursing process. During the assessment phase, the nurse systematically gathers information to identify the chief complaint and other health problems. The nurse uses critical thinking to examine and interpret the data, separating the relevant from the irrelevant and clarifying the meaning when necessary. During the diagnosis phase, nurses use the diagnostic reasoning process to draw conclusions and decide whether nursing intervention is indicated. The planning and implementation of interventions should be mutual, research based, and realistic and have measurable expected outcomes. The evaluation phase addresses the effectiveness of the plan of care and is ongoing as the patient progresses toward goal achievement. The author concludes that when the nursing process is used effectively for the intended purpose, it is a powerful scientific vehicle for facilitating critical thinking.

HOW DO WE LEARN CRITICAL THINKING IN NURSING?

Nurses initially learn to think critically in the academic environment, using assessments designed to measure critical thinking. It is conceivable that a nurse could pass an examination in the classroom but have difficulty making the transition to think critically in the clinical setting. Improving critical thinking ability should be viewed as a process and, as with the development of any skill, requires practice. 13

Most nurses develop their critical thinking ability as they gain clinical expertise. Patricia Benner 14 described the development of clinical expertise, as nurses transition from novice to expert. The beginning, or novice nurse, has theoretical knowledge as a foundation and minimal practical experiences to draw from. As similar situations are encountered, experience is accrued over time as the nurse evolves toward competency. As proficiency is developed, the nurse is able to perceive situations as a whole and recognize the significant aspects. As the proficient nurse reaches toward expertise, decision making becomes automatic, drawing from the enormous background of experience acquired over the years. Experience is more than the passage of time and is required at each stage before progressing to the next level of clinical expertise. As nurses progress along the novice-to-expert continuum and gain competence, they develop their ability to think critically. 15

Preceptors play a significant role in transitioning nurses into professional practice. It is essential that preceptors have the necessary skills to facilitate the critical thinking development of new nurses. Forneris and Peden-McAlpine 16 investigated the impact of the preceptor’s coaching component of a reflective learning intervention on novice nurses’ critical thinking skills. The following coaching strategies were used to educate preceptors: context (eg, understanding the big picture), dialogue, reflection, and time (eg, the use of past experiences to discern change over time). After completing the educational intervention, the preceptors used these strategies to coach the novice nurses in the development of their critical thinking skills. This study found that these strategies stimulated the novice nurses to engage in an intentional, reflective dialogue. The preceptors acknowledged a change in their preceptor style, moving from describing critical thinking as prioritizing and organizing task to a dialogue to share thinking and understand rationale.

Nurses must have the necessary dispositions (eg, attributes, attitudes, habits of the mind) to be effective critical thinkers. 11 Finn 17 defined thinking dispositions that influence critical thinking. Open mindedness was described as the willingness to seek out and consider new evidence or possibilities. Fair mindedness referred to an unprejudiced examination of evidence that might question beliefs or a viewpoint contrary to the nurse’s own beliefs. Reflectiveness was described as the willingness to gather relevant evidence to carefully evaluate an issue, rather than making hasty judgments. Counterfactual thinking referred to the willingness to ponder what could or would happen if the facts were considered under different conditions or perspectives. The opposite thinking styles directed toward maintaining the status quo included being close minded, biased, and rigid.

Rung-Chaung et al 18 investigated the critical thinking competence and disposition of nurses at different rankings on the clinical ladder. Using Benner’s novice to expert model as their theoretical framework, a stratified random sampling of 2300 nurses working at a medical center were classified according to their position on the clinical ladder. Ten to fifteen percent of this population were randomly selected for each ladder group, with the final sample size totaling 269. Data were collected using a modified version of the Watson-Glaser Critical Thinking Appraisal tool, designed to assess critical thinking competence in the categories of inference, recognition of assumptions, deduction, interpretation, and evaluation. The participants’ cumulative average score for critical thinking competence was 61.8 of a possible score of 100, ranking highest in interpretation and lowest in inference. Participants completed a modified version of the California Critical Thinking Disposition Inventory, designed to measure the following characteristics of critical thinking: inquisitiveness, systematic analytical approach, open mindedness, and reflective thinking. Participants scored highest in reflective thinking and lowest in inquisitiveness.

Analysis of the data indicated that older nurses with more years of experience and a more prominent position on the clinical ladder were predictive of a higher critical thinking disposition. Overall, critical thinking was shown to be only partially developed. The authors recommended training programs, such as problem-based learning, group discussion, role-playing, and concept mapping be adopted to enhance nurse critical thinking skills.

Chang el al 19 examined the relationship between critical thinking and nursing competence, using the Watson-Glaser Critical Thinking Appraisal and the Nursing Competence Scale. A total of 570 clinical nurses participated in the study. These nurses scored highest in interpretation ability and lowest in inference ability. These findings were consistent with the results reported in the Rung-Chuang study. Analysis of the data indicated that critical thinking ability was significantly higher in older nurses and nurses with more than 5 years of experience. The findings of this study indicated that critical thinking ability, working years, position/title, and education level were the 4 significant predictors of nursing competence. There were significantly positive correlations between critical thinking ability and nursing competence, indicating that the higher the critical thinking ability, the better the nursing competence is.

STRATEGIES TO ENHANCE CRITICAL THINKING ABILITY

To improve critical thinking, the learning needs of nurses must first be identified. The Performance Based Development System, a scenario-based tool, was used in a study to identify critical thinking learning needs of 2144 new and experienced nurses. 20 Results were reported as either meeting (identifying the appropriate actions) or not meeting the expectations. Most participants (74.9%) met the expectations by identifying the appropriate actions. Of the approximately 25% who did not meet the expectations, the learning needs identified included initiating appropriate nursing interventions (97.2%), differentiating urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), understanding decision rationale (62.6%), and problem recognition (57.1%). As expected, nurses with the most experience had the highest rate of identifying the appropriate actions on the Performance-Based Development System assessment. These findings were consisted with Benner’s novice to expert framework. These types of assessment tools can be used to identify learning needs and help facilitate individualized orientation. The authors acknowledged that further research is needed to identify areas of critical thinking deficiency and to test objective, educational strategies that enhance critical thinking in the nursing population.

The Institute of Medicine report on the future of nursing 21 emphasized the importance of nursing residency programs to provide hands-on experience for new graduates transitioning into practice. According to the report, these programs have been shown to help new nurses develop critical competencies in clinical decision making (eg, critical thinking) and autonomy in providing patient care. Implementing successful methods to expedite the development of critical thinking in new nurses has the potential to improve patient safety, nurse job satisfaction, and recruitment and retention of competent nurse professionals. 22

Although critical thinking skills are developed through clinical practice, there are many experienced nurses who possess less than optimal critical thinking skills. 5 As part of an initiative to elevate the critical thinking of nurses on the frontline, Berkow et al 23 reported the development of the Critical Thinking Diagnostic, a tool designed to assess critical thinking of experienced nurses. The tool includes 25 competencies, identified by nursing leaders as core skills at the heart of critical thinking. These competencies were grouped into 5 components of critical thinking: problem recognition, clinical decision making, prioritization, clinical implementation, and reflection. The potential application of this tool may enable nurse leaders to identify critical thinking strengths and individualize learning activities based on the specific needs of nurses on the frontline.

The critical thinking concepts, identified in the Delphi study of nurse experts, were used to teach critical thinking in a continuing education course. 24 The objective of the course was to help nurses develop the cognitive skills and habits of the mind considered important for practice. The course focused on the who, what, where, when, why, and how of critical thinking, using the case study approach. The authors concluded that critical thinking courses should include specific strategies for application of knowledge and opportunities to use cognitive strategies with clinical simulations.

Journal clubs encourage evidence-based practice and critical thinking by introducing nurses to new developments and broader perspectives of health care. 11 Lehna et al 25 described the virtual journal club (VJC) as an alternative to the traditional journal club meetings. The VJC uses an online blog format to post research-based articles and critiques, for generation of discussion by nurses. Recommendations for practice change derived from the analysis are forwarded to the appropriate decision-making body for consideration. The VJC not only exposes the nursing staff to scientific evidence to support changing their practice but also may lead to institutional policy changes that are based on the best evidence. The VJC overcomes the limitations of the traditional journal clubs by being available to all nurses at all times.

The integration of simulation technology in nursing exposes nursing students and nurses to complex patient care scenarios in a safe environment. Kirkman 26 reported a study to investigate nursing students’ ability to transfer knowledge and skill learned during high-fidelity simulations to the clinical setting, over time. The sample of 42 undergraduate students were rated on their ability to perform a respiratory assessment, using observation and a performance evaluation tool. The findings indicated there was a significant difference in transfer of learning demonstrated by participants over time. These results provide evidence that students were able to transfer knowledge and skills from high-fidelity simulations to the traditional clinical setting.

Jacobson et al 27 reported using simulated clinical scenarios to increase nurses’ perceived confidence and skill in handling emergency situations. During a 7-month period, the scenarios were conducted a total of 97 times with staff nurses. Each scenario presented a patient’s evolving story to challenge nurses to assess and synthesize the clinical information. The scenarios included a critical point at which the nurses needed to recognize and respond to significant deterioration in the patient’s condition. Postproject survey data found that most of the nurses perceived an improvement in their confidence and skill in managing emergency situations. More than half of the nurses reported that their critical thinking skills improved because of participation in this project.

Individual nurses can enhance critical thinking by developing a questioning attitude and habits of inquiry, where there is an appreciation and openness to other ways of doing things. Nurses should routinely reflect on the care provided and the outcomes of their interventions. Using reflection encourages nurses to think critically about what they do in everyday practice and learn from their experiences. 28 This strategy is beneficial for nurses to validate knowledge and examine nursing practice. 5 Nurses must be comfortable with asking and being asked “why” and “why not.” Seeking new knowledge and updating or refining current knowledge encourage critical thinking by practicing based on the evidence. “We’ve always done it that way” is no longer an acceptable answer. A list of other useful strategies for enhancing critical thinking is included in Table 1 .

USING THE INTERACTIVE CASE STUDY APPROACH TO ENHANCE CRITICAL THINKING

Case studies provide a means to attain experience in high-risk and complex situations in a safe environment. The purpose of a case study is to apply acquired knowledge to a specific patient situation, using actual or hypothetical scenarios. Waxman and Telles 32 discussed using Benner’s model to develop simple to complex scenarios that match the learning level of the nurse. The case study should ideally provide all the relevant information for analysis, without directing the nurse’s thinking in a particular direction. Participants are encouraged to use thinking processes similar to that used in a real situation.

A well-developed case study defines objectives and expected outcomes. The questions should be geared toward the outcomes to be met. 30 The focus of the questions should be on the underlying thought processes used to arrive at the answer, rather than the answer alone. This helps nurses identify the reasons behind why a decision is made. In some cases, the case study may build on the information shared, instead of presenting all the information at one time. At the very least, case studies should have face validity or represent what they were developed to represent. 33

Case studies can be developed for specific purposes, such as analyzing data or improving the nurse’s skill in responding to specific clinical situations. 30 This strategy can be useful in building nurses’ confidence in managing complex or emergency situations. The case can be tailored to specific patient populations or clinical events. Covering the course of care that a patient receives over time is effective in putting together the whole picture. 31 For the purpose of improving patient outcomes, the case study should represent the overall patient experience. Case studies may be used to review specific actions that led to positive outcomes or the processes that led to negative outcomes. This can help determine if the care was the most appropriate for the situation. 34

The use of case studies with simulation technology provides nurses with the opportunity to critically think through a critical situation in a controlled setting. The latest human patient simulators (HPSs) are programmed to respond to the nurse’s intervention, with outcomes determined as a result of the intervention. Howard et al 35 compared the teaching strategies of HPSs and the traditional interactive case study (ICS) approach, using scenarios with the same subject matter. A sample of 49 senior nursing students were given pretest and posttest designed to measure the students’ knowledge of the content presented and their ability to apply that content to clinical problems. Participants in the HPS group scored significantly higher on the posttest than the ICS group did. Students reported that the HPS assisted them in understanding concepts, was a valuable learning experience, and helped to stimulate their critical thinking. There was no significant difference between the HPS and ICS groups’ responses to the statement that the educational intervention was realistic.

The Figure depicts an example of a heart failure case study with the objective of applying critical thinking to a common problem encountered in practice. Expert clinical nurses would be ideal to serve as facilitators of this learning experience. Their role would be to present the scenario, describe the physiological findings, ask open-ended questions that require thinking and analysis, and guide the discussion and problem-solving process. Discussion and questioning strategies that are helpful in eliciting reflective responses during the learning experience are included in Table 2 . This case study could be tailored to meet the learning needs of the target audience.

THE INFLUENCE OF THE WORKPLACE ENVIRONMENT

The workplace environment can enhance or hinder nurses’ motivation to develop their critical thinking abilities. Cornell and Riordan 36 reported an observational study that assessed workflow barriers to critical thinking in the workplace. A total of 2061 tasks were recorded on an acute care unit during 35.7 hours of observation. The activities found to consume nearly 70% of the nurses’ time included verbal communication, walking, administering medications, treatments, and documentation. Nurse workflow was characterized by frequent task switching, interruptions, and unpredictability. The authors recommended reallocating duties, delegating appropriate task to nonnursing personnel, reducing waste, deploying technology that reduces repetitive task, and continuing education and training to help nurses cope with the complex demands of nursing.

Factors in the work environment conducive to the development of critical thinking include an atmosphere of team support, staffing patterns that allow continuity of care, and exposure to a variety of patient care situations. Creating an environment where contributions are valued, nurses feel respected, and there is comfort with asking probing questions is very important in enhancing the development of critical thinking skills.

Critical thinking is an essential skill that impacts the entire spectrum of nursing practice. Studies have shown that the higher the critical thinking ability, the better the nursing competence is. It is essential that critical thinking of new and experienced nurses be assessed and learning activities developed based on the specific needs of the nurses. The concept of critical thinking should be included in orientation, ongoing education, and preceptor preparation curriculums. These educational offerings should be designed to help nurses develop the cognitive skills and habits of the mind considered important for practice.

Bedside nurses can integrate a critical thinking approach by developing clinical expertise, making a commitment to lifelong learning, and practicing based on the evidence. Nurses should routinely reflect on the care provided and the outcomes of their interventions.

Further research is needed to identify areas of critical thinking deficiency and evaluate strategies aimed at enhancing critical thinking. These strategies will ultimately lead to improved clinical decision making and patient outcomes. Bedside nurses, preceptors, and nurse leaders are encouraged to work together collaboratively to create a culture where critical thinking is an integral part of nursing practice.

Acute care; Critical thinking; Decision making

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Teaching nursing care effectively requires an integration of theoretical knowledge, evidence-based practices, simulation, and active learning techniques. This article examines critical components of nursing education, including the incorporation of theoretical models, the role of evidence-based practice, and the utilization of simulation and technology in training. The focus is on bridging theory and practice, enhancing cultural competence, and leveraging feedback for continuous improvement. This comprehensive approach aims to prepare nursing students for delivering high-quality, patient-centered care across diverse clinical settings.

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MoSCoW Prioritization

What is moscow prioritization.

MoSCoW prioritization, also known as the MoSCoW method or MoSCoW analysis, is a popular prioritization technique for managing requirements. 

  The acronym MoSCoW represents four categories of initiatives: must-have, should-have, could-have, and won’t-have, or will not have right now. Some companies also use the “W” in MoSCoW to mean “wish.”

What is the History of the MoSCoW Method?

Software development expert Dai Clegg created the MoSCoW method while working at Oracle. He designed the framework to help his team prioritize tasks during development work on product releases.

You can find a detailed account of using MoSCoW prioritization in the Dynamic System Development Method (DSDM) handbook . But because MoSCoW can prioritize tasks within any time-boxed project, teams have adapted the method for a broad range of uses.

How Does MoSCoW Prioritization Work?

Before running a MoSCoW analysis, a few things need to happen. First, key stakeholders and the product team need to get aligned on objectives and prioritization factors. Then, all participants must agree on which initiatives to prioritize.

At this point, your team should also discuss how they will settle any disagreements in prioritization. If you can establish how to resolve disputes before they come up, you can help prevent those disagreements from holding up progress.

Finally, you’ll also want to reach a consensus on what percentage of resources you’d like to allocate to each category.

With the groundwork complete, you may begin determining which category is most appropriate for each initiative. But, first, let’s further break down each category in the MoSCoW method.

Start prioritizing your roadmap

Moscow prioritization categories.

1. Must-have initiatives

As the name suggests, this category consists of initiatives that are “musts” for your team. They represent non-negotiable needs for the project, product, or release in question. For example, if you’re releasing a healthcare application, a must-have initiative may be security functionalities that help maintain compliance.

The “must-have” category requires the team to complete a mandatory task. If you’re unsure about whether something belongs in this category, ask yourself the following.

If the product won’t work without an initiative, or the release becomes useless without it, the initiative is most likely a “must-have.”

2. Should-have initiatives

Should-have initiatives are just a step below must-haves. They are essential to the product, project, or release, but they are not vital. If left out, the product or project still functions. However, the initiatives may add significant value.

“Should-have” initiatives are different from “must-have” initiatives in that they can get scheduled for a future release without impacting the current one. For example, performance improvements, minor bug fixes, or new functionality may be “should-have” initiatives. Without them, the product still works.

3. Could-have initiatives

Another way of describing “could-have” initiatives is nice-to-haves. “Could-have” initiatives are not necessary to the core function of the product. However, compared with “should-have” initiatives, they have a much smaller impact on the outcome if left out.

So, initiatives placed in the “could-have” category are often the first to be deprioritized if a project in the “should-have” or “must-have” category ends up larger than expected.

4. Will not have (this time)

One benefit of the MoSCoW method is that it places several initiatives in the “will-not-have” category. The category can manage expectations about what the team will not include in a specific release (or another timeframe you’re prioritizing).

Placing initiatives in the “will-not-have” category is one way to help prevent scope creep . If initiatives are in this category, the team knows they are not a priority for this specific time frame. 

Some initiatives in the “will-not-have” group will be prioritized in the future, while others are not likely to happen. Some teams decide to differentiate between those by creating a subcategory within this group.

How Can Development Teams Use MoSCoW?

  Although Dai Clegg developed the approach to help prioritize tasks around his team’s limited time, the MoSCoW method also works when a development team faces limitations other than time. For example: 

Prioritize based on budgetary constraints.

What if a development team’s limiting factor is not a deadline but a tight budget imposed by the company? Working with the product managers, the team can use MoSCoW first to decide on the initiatives that represent must-haves and the should-haves. Then, using the development department’s budget as the guide, the team can figure out which items they can complete. 

Prioritize based on the team’s skillsets.

A cross-functional product team might also find itself constrained by the experience and expertise of its developers. If the product roadmap calls for functionality the team does not have the skills to build, this limiting factor will play into scoring those items in their MoSCoW analysis.

Prioritize based on competing needs at the company.

Cross-functional teams can also find themselves constrained by other company priorities. The team wants to make progress on a new product release, but the executive staff has created tight deadlines for further releases in the same timeframe. In this case, the team can use MoSCoW to determine which aspects of their desired release represent must-haves and temporarily backlog everything else.

What Are the Drawbacks of MoSCoW Prioritization?

  Although many product and development teams have prioritized MoSCoW, the approach has potential pitfalls. Here are a few examples.

1. An inconsistent scoring process can lead to tasks placed in the wrong categories.

  One common criticism against MoSCoW is that it does not include an objective methodology for ranking initiatives against each other. Your team will need to bring this methodology to your analysis. The MoSCoW approach works only to ensure that your team applies a consistent scoring system for all initiatives.

Pro tip: One proven method is weighted scoring, where your team measures each initiative on your backlog against a standard set of cost and benefit criteria. You can use the weighted scoring approach in ProductPlan’s roadmap app .

2. Not including all relevant stakeholders can lead to items placed in the wrong categories.

To know which of your team’s initiatives represent must-haves for your product and which are merely should-haves, you will need as much context as possible.

For example, you might need someone from your sales team to let you know how important (or unimportant) prospective buyers view a proposed new feature.

One pitfall of the MoSCoW method is that you could make poor decisions about where to slot each initiative unless your team receives input from all relevant stakeholders. 

3. Team bias for (or against) initiatives can undermine MoSCoW’s effectiveness.

Because MoSCoW does not include an objective scoring method, your team members can fall victim to their own opinions about certain initiatives. 

One risk of using MoSCoW prioritization is that a team can mistakenly think MoSCoW itself represents an objective way of measuring the items on their list. They discuss an initiative, agree that it is a “should have,” and move on to the next.

But your team will also need an objective and consistent framework for ranking all initiatives. That is the only way to minimize your team’s biases in favor of items or against them.

When Do You Use the MoSCoW Method for Prioritization?

MoSCoW prioritization is effective for teams that want to include representatives from the whole organization in their process. You can capture a broader perspective by involving participants from various functional departments.

Another reason you may want to use MoSCoW prioritization is it allows your team to determine how much effort goes into each category. Therefore, you can ensure you’re delivering a good variety of initiatives in each release.

What Are Best Practices for Using MoSCoW Prioritization?

If you’re considering giving MoSCoW prioritization a try, here are a few steps to keep in mind. Incorporating these into your process will help your team gain more value from the MoSCoW method.

1. Choose an objective ranking or scoring system.

Remember, MoSCoW helps your team group items into the appropriate buckets—from must-have items down to your longer-term wish list. But MoSCoW itself doesn’t help you determine which item belongs in which category.

You will need a separate ranking methodology. You can choose from many, such as:

• Weighted scoring
• Value vs. complexity
• Buy-a-feature
• Opportunity scoring

For help finding the best scoring methodology for your team, check out ProductPlan’s article: 7 strategies to choose the best features for your product .

2. Seek input from all key stakeholders.

To make sure you’re placing each initiative into the right bucket—must-have, should-have, could-have, or won’t-have—your team needs context. 

At the beginning of your MoSCoW method, your team should consider which stakeholders can provide valuable context and insights. Sales? Customer success? The executive staff? Product managers in another area of your business? Include them in your initiative scoring process if you think they can help you see opportunities or threats your team might miss. 

3. Share your MoSCoW process across your organization.

MoSCoW gives your team a tangible way to show your organization prioritizing initiatives for your products or projects. 

The method can help you build company-wide consensus for your work, or at least help you show stakeholders why you made the decisions you did.

Communicating your team’s prioritization strategy also helps you set expectations across the business. When they see your methodology for choosing one initiative over another, stakeholders in other departments will understand that your team has thought through and weighed all decisions you’ve made. 

If any stakeholders have an issue with one of your decisions, they will understand that they can’t simply complain—they’ll need to present you with evidence to alter your course of action.  

Related Terms

2×2 prioritization matrix / Eisenhower matrix / DACI decision-making framework / ICE scoring model / RICE scoring model

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CCRN (Adult) – Direct Care Eligibility Pathway

CCRN ® (Adult) is a specialty certification. The Direct Care Eligibility Pathway is for nurses who provide direct care to acutely/critically ill adult patients regardless of their physical location. Nurses interested in this certification pathway may work in areas such as intensive care units, cardiac care units, trauma units or critical care transport/flight.

This certification is accepted by the Magnet Recognition Program ® .

Initial Eligibility Requirements & Fees

A current, unencumbered U.S. RN or APRN license is required. An unencumbered license is not currently being subjected to formal discipline by the board of nursing in the state(s) in which the nurse is practicing and has no provisions or conditions that limit the nurse’s practice. Provisions or conditions may include, but are not limited to, direct supervision of practice, drug administration limitations and/or practice area exclusions.

Candidates must complete one of the following clinical practice hour requirement options:

Two-Year Option

Practice as an RN or APRN for 1,750 hours in direct care of acutely/critically ill adult patients during the previous two years, with 875 of those hours accrued in the most recent year preceding application

Five-Year Option

Practice as an RN or APRN during the previous five years with a minimum of 2,000 hours in direct care of acutely/critically ill adult patients, with 144 of those hours accrued in the most recent year preceding application

• Must be completed in a U.S.-based or Canada-based facility or in a facility determined to be comparable to the U.S. standard of acute/critical care nursing practice.
• Are those spent actively providing direct care to acutely/critically ill adult patients or supervising nurses or nursing students at the bedside of acutely/critically ill adult patients, if working as a manager, educator, preceptor or APRN. The majority of practice hours for exam eligibility must be focused on critically ill patients.
• Are verifiable by your clinical supervisor or professional colleague (RN or physician). Contact information must be provided for verification of eligibility related to clinical hours, to be used if you are selected for audit.
• For complete eligibility requirements, refer to the CCRN Exam Handbook – Direct Care Pathway.

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