critical care nursing management

Critical Care Nursing

Diagnosis and Management

9th Edition - February 18, 2021
Editors: Linda D. Urden, Kathleen M. Stacy, Mary E. Lough
Language: English
Other ISBN: 9780443111143 9 7 8 - 0 - 4 4 3 - 1 1 1 1 4 - 3
Paperback ISBN: 9780323642958 9 7 8 - 0 - 3 2 3 - 6 4 2 9 5 - 8
Paperback ISBN: 9780323751476 9 7 8 - 0 - 3 2 3 - 7 5 1 4 7 - 6
eBook ISBN: 9780323694001 9 7 8 - 0 - 3 2 3 - 6 9 4 0 0 - 1

Winner of the 2nd-place American Journal of Nursing Book of the Year award in emergency/critical care nursing for 2021!**Selected for Doody’s Core Titles® 2024 with "Essential Pu… Read more

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Winner of the 2nd-place American Journal of Nursing Book of the Year award in emergency/critical care nursing for 2021! **Selected for Doody’s Core Titles® 2024 with "Essential Purchase" designation in Critical Care**

Prepare for success in today’s high acuity, progressive, and critical care settings! Critical Care Nursing: Diagnosis and Management, 9th Edition helps you understand and apply critical care nursing principles and concepts to clinical assessment, diagnostic procedures, and therapeutic management. Known for its comprehensive coverage, this leading textbook uses a logical, body systems organization to address the care of patients with physiological alterations. New to this edition are illustrated Patient-Centered Critical Care features aimed at "humanizing the ICU" as well as Next Generation NCLEX® Exam–style case studies to help you further develop your clinical judgment skills and prepare for the latest nursing licensure exam. Also ideal for CCRN® and PCCN® exam preparation, this book is a one-stop resource on the concepts and skills required for critical care nursing!

Time-tested, high-quality content addresses all aspects of today’s high acuity, progressive, and critical care nursing.
Consistent organization within each body-system unit provides an efficient framework for learning, for CCRN ® and PCCN ® certification preparation, and for reference in clinical practice.
Comprehensive, evidence-based content is highly referenced and includes internet resources for further research and study.
Enhanced Quality and Safety Education for Nurses (QSEN) integration links text content to QSEN competencies, through the addition of QSEN-related questions in case studies, QSEN-labeled features and boxes, QSEN content icons, and highlighted QSEN information.
Cover image
Table of Contents
Evolve Student Resources
About the Authors
Contributors
Organization
Diagnosis and Patient Care Management
Included in this Edition
New to this Edition
Changes in Terminology
Evolve Resources for Critical Care Nursing
Acknowledgments
Unit I: Foundations of Critical Care Nursing
1. Critical Care Nursing Practice
History of Critical Care
Contemporary Critical Care
Critical Care Nursing Roles
Critical Care Professional Accountability
Evidence-Based Nursing Practice
Holistic Critical Care Nursing
Complementary and Alternative Therapies
Technology in Critical Care
Interprofessional Collaborative Practice
Interdisciplinary Care Management Models and Tools
Quality, Safety, and Regulatory Issues in Critical Care
Healthy Work Environment
2. Ethical Issues
Morals Versus Ethics
Ethical Principles
Conflicting Principles, Paternalism, and Medical Futility
Professional Nursing Ethics and the Nursing Code of Ethics
Situational and Organizational Ethical Decision Making in Critical Care
Sfno Model for Deliberation of Ethical Problems
Strategies for the Promotion of Ethical Decision Making
3. Legal Issues
Administrative Law: Professional Regulation
Tort Law: Negligence and Professional Malpractice, Intentional Torts
Constitutional Law: Patient Decision Making
Legal Issues Looking Forward
4. Genetic Issues
Genetics and Genomics
Genetic And Genomic Structure And Function
Genetic Inheritance
Obtaining Information about Genetics and Genomics
Genetics in Critical Care
Genetics, Genomics, and Nursing
Human Genetics Key Terms
5. Facilitating Care Transitions
Care Transitions
Core Components to Any Care Transition
Special Considerations During Care Transitions
Models or Programs for Care Transitions
Additional Resources
6. Psychosocial and Spiritual Considerations
Alterations in Self-Concept
Compromised Dignity
Spiritual Responses
Psychosocial Support
Comorbid Psychiatric Disorders
Post–Intensive Care Syndrome
Self-Care for Nurses
7. Nutrition Alterations and Management
Nutrient Metabolism
Focused Assessment of Nutrition Status
Implications of Undernutrition for Sick or Stressed Patients
Nutrition Support
Nutrition and Cardiovascular Alterations
Nutrition and Pulmonary Alterations
Nutrition and Neurologic Alterations
Nutrition and Kidney Alterations
Nutrition and Gastrointestinal Alterations
Nutrition and Surgery
Nutrition and Endocrine Alterations
Evolution of Nutrition Science
8. Pain and Pain Management
Pain Assessment
Definition and Description of Pain
Pain Management
9. Sedation, Agitation, and Delirium Management
Alcohol Withdrawal Syndrome and Delirium Tremens
Collaborative Management
10. Palliative and End-of-Life Care
End-of-Life Experience in Critical Care
Ethical and Legal Issues
Comfort Care
Decision Making
Withdrawal or Withholding of Treatment
Palliative Care
Withdrawal of Mechanical Ventilation
Professional Issues
Organ Donation
Family Care
Collaborative Care
Unit II: Cardiovascular Alterations
11. Cardiovascular Anatomy and Physiology
12. Cardiovascular Clinical Assessment
Physical Examination
13. Cardiovascular Diagnostic Procedures
Hemodynamic Monitoring
Electrocardiography
LABORATORY TESTS
Diagnostic Procedures
14. Cardiovascular Disorders
Coronary Artery Disease
Myocardial Infarction
Sudden Cardiac Death
Heart Failure
Cardiomyopathy
Pulmonary Hypertension
Endocarditis
Valvular Heart Disease
Atherosclerotic Diseases of the Aorta
Peripheral Artery Disease
Carotid Artery Disease
Venous Thromboembolism
Hypertensive Emergency
15. Cardiovascular Therapeutic Management
Implantable Cardioverter Defibrillators
Fibrinolytic Therapy
Catheter-Based Interventions for Coronary Artery Disease
Cardiac Surgery
Mechanical Circulatory Support
Vascular Surgery
Cardiovascular Medications
Unit III: Pulmonary Alterations
16. Pulmonary Anatomy and Physiology
Conducting Airways
Respiratory Airways
Pulmonary Blood and Lymph Supply
Ventilation
Respiration
Ventilation/Perfusion Relationships
Gas Transport
17. Pulmonary Clinical Assessment
Focused Physical Assessment
Assessment Findings of Common Disorders
18. Pulmonary Diagnostic Procedures
Laboratory Studies
Bedside Monitoring
19. Pulmonary Disorders
Acute Lung Failure
Acute Respiratory Distress Syndrome
Aspiration Pneumonitis
Acute Pulmonary Embolism
Status Asthmaticus
Air Leak Disorders
Long-Term Mechanical Ventilator Dependence
20. Pulmonary Therapeutic Management
Oxygen Therapy
Artificial Airways
Invasive Mechanical Ventilation
Noninvasive Ventilation
Positioning Therapy
Thoracic Surgery
Pharmacology
Unit IV: Neurologic Alterations
21. Neurologic Anatomy and Physiology
Divisions of the Nervous System
Microstructure of the Nervous System
Central Nervous System
Peripheral Nervous System
Autonomic Nervous System
22. Neurologic Clinical Assessment and Diagnostic Procedures
Multimodal Bedside Monitoring
23. Neurologic Disorders and Therapeutic Management
Guillain-Barré Syndrome
Intracranial Hypertension
Pharmacologic Agents
Unit V: Kidney Alterations
24. Kidney Anatomy and Physiology
Macroscopic Anatomy
Vascular Anatomy
Microscopic Structure and Function
Nervous System Innervation
Urine Formation
Functions of the Kidneys
Fluid Balance
Electrolyte Balance
25. Kidney Clinical Assessment and Diagnostic Procedures
Additional Assessments
Laboratory Assessment
Urine Toxicology Screen
Imaging Studies
Kidney Biopsy
26. Kidney Disorders and Therapeutic Management
Acute Kidney Injury
Chronic Kidney Disease
Renal Replacement Therapy: Dialysis
Unit VI: Gastrointestinal Alterations
27. Gastrointestinal Anatomy and Physiology
Small Intestine
Large Intestine
Accessory Organs
28. Gastrointestinal Clinical Assessment and Diagnostic Procedures
29. Gastrointestinal Disorders and Therapeutic Management
Acute Gastrointestinal Hemorrhage
Acute Pancreatitis
Acute Liver Failure
Gastrointestinal Surgery
Therapeutic Management
Unit VII: Endocrine Alterations
30. Endocrine Anatomy and Physiology
Pituitary Gland And Hypothalamus
Thyroid Gland
Adrenal Gland
31. Endocrine Clinical Assessment and Diagnostic Procedures
Pituitary Gland
32. Endocrine Disorders and Therapeutic Management
Acute Neuroendocrine Response To Critical Illness
Hyperglycemia in Critical Illness
Insulin Management In Critically Ill Patients
Hypoglycemia Management
Nursing Management
Diabetes Mellitus
Diabetes Mellitus Diagnosis
Type 1 Diabetes
Type 2 Diabetes
Hyperglycemic Emergencies
Pituitary Gland Disorders
Diabetes Insipidus
Syndrome of Inappropriate Secretion of Antidiuretic Hormone
Thyroid Gland Disorders
Thyroid Storm
Myxedema Coma
Adrenal Gland Disorders
Oversecretion of Adrenal Hormones
Undersecretion of Adrenal Hormones
Additional resources
Unit VIII: Multisystem Alterations
Mechanism of Injury
Phases Of Trauma Care
Specific Trauma Injuries
Complications of Trauma
Special Considerations in Trauma
34. Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Shock Syndrome
Hypovolemic Shock
Cardiogenic Shock
Anaphylactic Shock
Neurogenic Shock
Sepsis and Septic Shock
Multiple Organ Dysfunction Syndrome
Anatomy and Functions of the Skin
Pathophysiology and Etiology of Burn Injury
Classification of Burn Injury
Initial Emergency Burn Management
Special Management Considerations
Burn Nursing Management
36. Organ Donation and Transplantation
Immunology of Transplantation
Immunosuppressive Medications
Transplant Candidate Evaluation
Heart Transplantation
Heart-Lung Transplantation
Single-Lung And Double-Lung Transplantation
Liver Transplantation
Kidney Transplantation
Pancreas Transplantation
37. Hematologic and Oncologic Emergencies
Overview of Coagulation and Fibrinolysis
Disseminated Intravascular Coagulation
Thrombocytopenia
Heparin-Induced Thrombocytopenia
Sickle Cell Anemia
Tumor Lysis Syndrome
Hospital-Acquired Anemia
Unit IX: Special Populations
38. The Obstetric Patient
Physiologic Alterations in Pregnancy
Physiologic Changes During Labor and Delivery
Cardiac Disorders in Pregnancy
Hypertensive Disease
Pulmonary Dysfunction
Postpartum Hemorrhage
Risks to Fetal Development
39. The Pediatric Patient
Respiratory System
Cardiovascular System
Nervous System
Gastrointestinal System, Fluids, and Nutrition
Psychosocial Issues of the Child and Family
40. The Older Adult Patient
Neurocognitive Age-Related Changes
Age-Related Changes of the Respiratory System And Pulmonary Disease
Age-Related Changes of the Cardiovascular System
Age-Related Changes of The Kidney System
Age-Related Changes Of The Liver
Age-Related Changes Of The Gastrointestinal System And Nutrition
Diabetes In Older Adults
Age-Related Changes In The Immune System
Age-Related Changes In The Skin And Integumentary System
Age-Related Changes In The Musculoskeletal System
Complications of Critical Care For Older Adults
Palliative and End-Of-Life Care For Older Adults
Appendix A. Patient Care Management Plans
Appendix B. Physiologic Formulas for Critical Care
Hemodynamic Equations
Pulmonary Formulas
Neurologic Formulas
Endocrine Formulas
Kidney Formulas
Nutritional Formulas
Appendix C. Canadian Laboratory Values
Special Features
Case Studies
Concept Maps
Data Collection
Patient and Family Education Plans
Patient Care Management Plans
Patient-Centered Critical Care
Pharmacologic Management
QSEN: Evidence-Based Practice
QSEN: Informatics
QSEN: Patient-Centered Care
QSEN: Quality Improvement
QSEN: Safety
QSEN: Teamwork and Collaboration
No. of pages : 1136
Language : English
Edition : 9
Published : February 18, 2021
Imprint : Elsevier
Other ISBN : 9780443111143
Paperback ISBN : 9780323642958
Paperback ISBN : 9780323751476
eBook ISBN : 9780323694001

Linda D. Urden

Kathleen m. stacy, mary e. lough.

‘Racism absolutely must not be tolerated’

STEVE FORD, EDITOR

You are here: Critical care

Essential critical care skills 1: what is critical care nursing?

18 October, 2021

Critical care nurses provide highly skilled, expert care for the most severely ill or injured patients. This introduction - part one of a six-part series – provides an overview of their role

In this first article of a six-part series on critical care nursing, we introduce the role and what it involves, as well as looking at how critical care nurses can support the whole patient, from a physical and psychosocial perspective. The importance of rehabilitation, assessment of risk of ongoing morbidity and delirium are also discussed. Part 2 describes the assessment of the critically ill patient.

Citation: Credland N et al (2021) Essential critical care skills 1: what is critical care nursing? Nursing Times [online]; 117: 11, 18-21.

Authors: Nicki Credland is reader in critical care, University of Hull; Louise Stayt is senior lecturer, Oxford Brookes University; Catherine Plowright is professional adviser, British Association of Critical Care Nurses; David Waters is associate professor, Birmingham City University.

This article has been double-blind peer reviewed
Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
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Introduction

Critical care nurses provide expert, specialist care to the most severely ill or injured patients in intensive care units and the wider hospital. They are highly trained and skilled safety-critical professionals working as part of a multidisciplinary team. Critical care is classified using four levels of patient acuity, as outlined in Table 1. Updated guidelines for the provision of intensive care services (Faculty of Intensive Care Medicine, 2019) recommend that level-3 patients should have a minimum registered nurse–patient ratio of 1:1 and level-2 patients must have a minimum nurse–patient ratio of 1:2.

To deliver highly skilled care, critical care nurses undertake postgraduate study and ongoing training. The Step Competency Framework underpins critical care nurse education; it recognises that, to be able to deliver high-quality care to patients, staff need the knowledge and skills so they can work at the highest level, with standardisation across all critical care units. Step 1 for adult critical care begins when a nurse with no previous experience of the specialty starts working in intensive care medicine. Steps 2 and 3 should be incorporated into academic intensive care programmes.

Critical care nurses also lead many outreach teams that identify, monitor and initiate timely treatment to prevent clinical deterioration, and support ward nurses (Department of Health, 2000). They offer advanced system assessment and rescue before irretrievable deterioration and cardiac arrest takes place.

This article is the first in a six-part series on essential critical care skills, which aims to explore essential critical care nursing competencies.

Managing organ dysfunction

Admission to a critical care unit is usually because of organ dysfunction or organ failure. Respiratory failure alone leads to around 100,000 annual admissions to critical care in the UK (FICM, 2019). The goal is to correct or provide support to these dysfunctional organs. Technological and medical advances over the past few decades have meant significant growth in treatments and interventions, and more-effective management of patients who need organ support.

The interventions most commonly used include mechanical ventilators, infusion devices and renal replacement therapy. Table 2 outlines the interventions used for different physiological systems.

Patient monitoring and documentation

It is crucial to gather accurate data on physiological parameters – such as oxygen saturation (SpO2), heart rate and fluid balance – at the bedside of the patient who is critically ill. Typically, each patient will have their own monitor that will display a range of clinical factors (Box 1) and provide real-time feedback to help evaluate critical care interventions, and detect any deterioration or emergency situations promptly.

Box 1. Clinical factors recorded by bedside monitors

Heart rhythm
Oxygen saturation
Respiratory rate
Exhaled carbon dioxide concentration/partial pressure
Non-invasive blood pressure
Arterial blood pressure
Central venous pressure
Temperature

Critical care nurses need technical skill and knowledge to effectively use and interpret bedside monitors. A further common technical resource is the clinical information system (CIS), which can record and process large amounts of data, such as:

Patient physiological observations;
Care or interventions delivered;
Medication plans.

The FICM (2019) highlights how a CIS can not only improve efficiency, but also reduce errors and improve compliance with standards or guidelines.

Psychosocial care

Holistic patient-centred care – as outlined by Jasemi et al (2017) – is vital in critical care, with effective psychosocial care, and cultural, spiritual and family care being of particular significance. Immediately on admission to a critical care setting, patients are subjected to an onslaught of physical and psychosocial stressors including:

Physical pain;
An unfamiliar environment; equipment and treatments;
Sensory disturbances;
Isolation from family;
Loss of autonomy;
Impaired communication;
Fear for their life (Kiekkas et al, 2010).

It can lead to severe emotional distress and the development of delirium, anxiety, depression and post-traumatic stress disorder (PTSD) (Hatch et al, 2018) – all of which may persist long after the patient’s physical recovery and discharge from hospital (Ewens et al, 2018).

Psychosocial care is often considered the touchstone to person-centred care and, in this setting, refers to supportive interventions that may mitigate the stressors associated with critical illness. Evidence-based measures that may all help include:

Providing information and explanations;
Regularly orientating the patient to date, time and place;
Reassurance;
Empathetic touch;
Early mobilisation;
Family visits;
Maintaining clear night and day routines;
Minimising noise (Bani Younis et al, 2021; Alaparthi et al, 2020; Parsons and Walters, 2019).

Delirium is of particular concern in patients who are critically ill, and has an incidence range of 45-87% (Cavallazzi et al, 2012). It is characterised by the acute onset of cerebral dysfunction, with a change or fluctuation in baseline mental status, inattention, disorganised thinking or an altered level of consciousness (NICE, 2019). Delirium is associated with significant increases in mortality, morbidity and hospital stay, as well as having long-term ramifications such as cognitive impairment, PTSD, anxiety and depression (Cavallazzi et al, 2012) so the prevention, early recognition and effective management of it is of paramount importance. The ABCDEF bundle of care may help:

A ssessment, prevention and management of pain;
Awakening the patient and doing a spontaneous B reathing trial;
C hoice of sedation and analgesia;
Assessment, prevention and management of D elirium;
E arly mobilisation;
F amily engagement (Marra et al, 2017) .

Cultural and spiritual care

A patient’s cultural and spiritual background influences many aspects of nursing in critical care, such as patient and family roles, communication, nutrition, values and beliefs towards health, care and treatments, and end-of-life care. Careful assessment of the patients’ health beliefs, communication needs, social networks and family dynamics, dietary requirements, religious practices and values, is essential to plan and deliver culturally sensitive and spiritual care that contributes to the quality of life, care and satisfaction of patients as well as their families (Willemse et al, 2020).

Family care

Family members of patients who are critically ill can play an important part – often acting as surrogate decision makers – and be essential in providing emotional and social support. However, relatives may experience extreme stress, fear and anxiety, both during and after the patient’s admission. Relatives are also vulnerable to ongoing psychological illnesses such as PTSD, anxiety and depression (Johnson et al, 2019). Nurses need to develop a collaborative relationship with them to effectively identify and address their immediate needs, as well as prepare them to cope with their loved one’s discharge and ongoing rehabilitation. Families need honest and timely information, assurance, proximity, comfort and support (Scott et al, 2019).

Rehabilitation

Critical illness can cause significant long-term physical and non-physical problems for patients, and rehabilitation is important to improve recovery. National guidelines, such as those by the FICM (2019) and the National Institute for Health and Care Excellence (2017), have supported this, with the aim of improving these patients’ physical, psychological and cognitive outcomes.

Patients should be assessed at the following key stages:

Within four days of admission to a critical care unit, or earlier if being discharged;
Just before discharge to ward-based care;
When receiving ward-based care;
Before discharge to their home or community care;
Two to three months after discharge from the critical care unit.

Rehabilitation should be patient centred, involve the whole multidisciplinary team and occur throughout the patient pathway, with plans updated as the patient’s condition changes (FICM, 2019). Physiotherapists, occupational therapists, dieticians, speech and language therapists, critical care nurses and doctors, as well as patients and their families, all have a role.

Short clinical assessments should be done with all patients in critical care to identify their risk of physical and non- physical morbidity. A short clinical assessment is applicable for patients who are expected to recover quickly, despite requiring initial level-3 care, and should assess a range of factors (Box 2). If the patient is deemed at risk, a comprehensive clinical assessment should be undertaken; this will also assess physical and non-physical risk (Box 3).

Box 2. Short clinical assessment

The following may indicate that the patient is at risk of physical/non-physical morbidity and needs further assessment:

Unable to get out of bed independently
Anticipated long duration of critical care stay
Obvious significant physical or neurological injury
Lack of cognitive functioning to continue exercise independently
Unable to self-ventilate on 35% of oxygen or less
Presence of pre-morbid respiratory or mobility problems
Unable to mobilise independently over short distances

Non-physical

Recurrent nightmares, particularly if the patient reports trying to stay awake to avoid them
Intrusive memories of traumatic events that occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks)
New or recurrent anxiety or panic attacks
Expressing a wish not to talk about their illness or changing the subject quickly

Box 3. Comprehensive clinical assessment

This assessment should be undertaken for all patients identified as being at risk of physical or non-physical morbidity.

Physical issues

Breathlessness
Tracheostomy
Artificial airway
Swallowing issues
Poor nutritional state
Minor assistance needed
Major assistance needed
Full assistance needed
Visual changes
Hearing changes
Altered sensations
Sedated/pain
Difficulties in speech
Changes in voice quality
Difficulty writing
Poor wound healing

Non-physical issues

Palpitations, irritability or sweating
Hallucinations, delusions
Flashbacks, withdrawal, traumatic memories of critical care
Loss of memory
Attention deficit
Sequencing problems
Lack of organisational skills
Disinhibition
Low self-esteem
Low self-image
Relationship difficulties
Difficulty sleeping

During the assessment of these patients, a range of tools may be used including the following:

Hospital Anxiety and Depression Score (Zigmond and Snaith, 1983);
Barthel Activities of Daily Living Index (Wade and Colin, 1988);
Chelsea Critical Care Physical Assessment Tool (Corner et al, 2013).

Many critical care units provide follow-up services for patients after discharge, giving them access to a range of health professionals, including critical care nurses, to assess physical and non-physical recovery (NICE, 2017). If these are not available, patients can be directed to ICU Steps (www.icusteps.org), which can help to support patients and families affected by critical illness.

This article aims to provide an overview of critical care and the critical care nurse role. The following articles in this series will explore in more detail key issues relating to the management of patients who are critically ill.

Critical care nursing is highly skilled, and requires postgraduate study and training
Critical care nurses provide outreach to support ward nurses who are caring for patients at risk of deterioration
Care of patients on critical care units often involves organ system support and close monitoring is needed
A holistic view of the patient – which takes into account physical and psychosocial matters – is vital, as is supporting families

Also in this series

Essential critical care skills 2: assessing the patient
Essential critical care skills 3: arterial line care
Essential critical care skills 4: airway assessment and management
Essential critical care skills 5: management of fluid balance
Essential critical care skills 6: arterial blood gas analysis

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Critical Care Nursing: Diagnosis and Management 9th Edition

Time-tested, high-quality content addresses all aspects of today’s high acuity, progressive, and critical care nursing.
Consistent organization within each body-system unit provides an efficient framework for learning, for CCRN® and PCCN® certification preparation, and for reference in clinical practice.
Comprehensive, evidence-based content is highly referenced and includes internet resources for further research and study.
Enhanced Quality and Safety Education for Nurses (QSEN) integration links text content to QSEN competencies, through the addition of QSEN-related questions in case studies, QSEN-labeled features and boxes, QSEN content icons, and highlighted QSEN information.
NEW! Updated content throughout reflects the latest changes in concepts, techniques, and technology of high acuity, progressive, and critical care nursing.
NEW! New Facilitating Care Transitions chapter explains how critical care nurses can ensure patient safety and provide family education through all phases and locations of care, during transitions to other units and departments within the facility, and during patient discharge to various sites (e.g., home, hospice, long-term care).
NEW! Illustrated Patient-Centered Critical Care boxes highlight a new emphasis on changing the culture of critical care by greater inclusion of the patient and family, with evidence-based discussions of topics such as family meetings, debriefing after a code, patient diaries, creating a calm environment, pet visitation, music therapy, the transition of care, and 24/7 ICU visitation.
NEW! 10 Next Generation NCLEX® Exam–style case studies are provided on the Evolve website to help prepare you for the changes in the nursing licensure exam.
NEW! Diagnosis and Patient Care Management boxes reflect a new focus on the International Classification of Nursing Practice (ICNP), providing a common language for patient problems using the evidence-based ICNP taxonomy.
NEW! Expanded coverage of key trends includes the use of personal protective equipment in light of the global COVID-19 pandemic, the opioid epidemic, special considerations for bariatric patients, oncology, and acute chest syndrome.
NEW! Additional coverage of the technology required to monitor the patient and other interprofessional team members assists in the management of the patient and the integration of other QSEN competencies.
NEW! Psychosocial and Spiritual Considerations chapter emphasizes the psychosocial and spiritual wellbeing of critical care clients.
NEW! Expanded coverage of self-care for healthcare professionals equips new critical care nurses to take the time to care for themselves as well as for their patients.
NEW! Updated illustrations improve understanding.
NEW! Inclusion of Canadian/SI units promotes an international understanding of common laboratory values, with a new Common Laboratory Values appendix.
NEW! CCN learning features include three new Concept Maps on protein-calorie malnutrition, burns, and pulmonary embolism; two new Case Studies on burns and facilitating care transition; and two new Patient Care Management Plans on stress overload and impaired spiritual status.
ISBN-10 0323642950
ISBN-13 978-0323642958
Edition 9th
Publisher Elsevier
Publication date March 25, 2021
Language English
Dimensions 8.5 x 1.3 x 10.8 inches
Print length 1136 pages
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Publisher ‏ : ‎ Elsevier; 9th edition (March 25, 2021)
Language ‏ : ‎ English
Paperback ‏ : ‎ 1136 pages
ISBN-10 ‏ : ‎ 0323642950
ISBN-13 ‏ : ‎ 978-0323642958
Reading age ‏ : ‎ 1 year and up
Item Weight ‏ : ‎ 4 pounds
Dimensions ‏ : ‎ 8.5 x 1.3 x 10.8 inches
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Lippincott ® NursingCenter ®

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?

What do critical care nurses need to know.

an understanding of human anatomy and physiology.
sharp clinical assessment skills.
vast knowledge about diseases and conditions.
ongoing education related to recommended ICU treatment options.

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Ten areas for ICU clinicians to be aware of to help retain nurses in the ICU

Jean-Louis Vincent 1 ,
Carole Boulanger 2 ,
Margo M. C. van Mol 3 ,
Laura Hawryluck 4 &
Elie Azoulay 5

Critical Care volume 26 , Article number: 310 ( 2022 ) Cite this article

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Shortage of nurses on the ICU is not a new phenomenon, but has been exacerbated by the COVID-19 pandemic. The underlying reasons are relatively well-recognized, and include excessive workload, moral distress, and perception of inappropriate care, leading to burnout and increased intent to leave, setting up a vicious circle whereby fewer nurses result in increased pressure and stress on those remaining. Nursing shortages impact patient care and quality-of-work life for all ICU staff and efforts should be made by management, nurse leaders, and ICU clinicians to understand and ameliorate the factors that lead nurses to leave. Here, we highlight 10 broad areas that ICU clinicians should be aware of that may improve quality of work-life and thus potentially help with critical care nurse retention.

The coronavirus disease 2019 (COVID-19) crisis has been followed by a serious increase in the shortage of intensive care unit (ICU) personnel, especially nurses, exacerbating a problem that pre-dated the pandemic… and this on a global scale. The reasons are not difficult to elucidate and primarily relate to the prolonged, excessive workload during the pandemic period, often with denial of vacation time; the significant emotional burden associated with the high patient death rate; and the moral distress associated with being unable to provide the usual high quality standard of care, because of the sheer numbers of patients being admitted [ 1 , 2 , 3 , 4 , 5 ]. Personal anxieties around catching the virus and/or passing it on to one’s family, and restrictions and limitations associated with the strict safety measures, including reduced communication and contact with patients and their relatives that resulted in a de-humanizing of care, added to the physical and mental exhaustion felt by healthcare staff [ 1 , 2 , 3 , 4 , 6 , 7 ]. In some hospitals, non-critical care-trained nurses or doctors were transferred to the ICU to fill nursing staff gaps, in ways that created a feeling that the skill set and knowledge of trained critical care nurses was devalued and that they could be easily replaced. In addition, at the beginning of the pandemic, there were visible signs of recognition and appreciation by the public for the extra work—indeed, in many countries, people came out of their homes to applaud the medical and nursing personnel at the same time every day—but this initial mark of gratitude soon lapsed and was replaced by complaints, threats from COVID deniers, protests, attacks on social media, and even legal claims by patients and especially their families, which certainly did not help improve morale.

As a profession already associated with high rates of stress and burnout [ 8 , 9 , 10 ], the additional pressures associated with the pandemic have led many nurses, especially those working on acute units with large numbers of COVID-19 patients, to become even more disillusioned so that many have left the ICU to work in other Departments and, worryingly, some have left the profession completely. Adequate staffing is recognized as being vital to ensure good patient care and, consequentially, outcomes [ 11 , 12 , 13 ]. There is therefore an urgent and ongoing need to cultivate and support strategies that help make critical care nursing attractive and reduce the pressures and stresses faced by nurses, to ensure that sufficient numbers of well-trained nurses are present on our units. Increasing wages may seem an obvious solution; indeed, in many countries, critical care nurses are paid at the same level as nurses without any additional specialized training, yet the responsibilities of critical care nurses are much greater. However, while financial incentives are necessary and may indeed help attract staff in the short-term, they will not be sufficient to retain staff if other aspects to improve job satisfaction are not tackled simultaneously; adequate pay must be seen as just one component of a suite of solutions [ 14 , 15 ].

Here we discuss—in no specific order of importance—10 broad areas that ICU clinicians should be aware of which may improve quality of work-life and thus potentially help with critical care nurse retention (Table 1 ). Of note, although the focus of this commentary is on the recruitment and retention of critical care nurses, burnout is significant among all members of the ICU team [ 16 , 17 ] and many of the aspects we propose here to help in the retention of critical care nurses may equally apply to the retention of other team members.

Recognition, respect, and value If the COVID-19 pandemic has taught us nothing else, it has highlighted the incredible worth and importance of critical care nurses. They are highly trained professionals, with specialized knowledge, and skills honed with every patient cared for. Such qualities are not replaceable; not everyone can perform the role of a critical care nurse. Non-critical care nurses and other healthcare providers may provide significant help and can relieve critical care nurses from performing tasks that are not ICU skill specific (e.g., patient hygiene, turning, suctioning), but how such personnel are recruited and deployed needs careful consideration for people to feel valued and supported. Such assistance may permit critical care nurses to really focus on what they trained for: critical thinking, crisis management, and situational awareness in caring for those with life-threatening illnesses. It is important to recognize and appreciate the important role of critical care nurses as skilled members of the ICU team, to thank them, and to see the person in the professional to make them feel they are valued colleagues. A lot of attention has been paid to humanizing medicine for the patients (and their families) that we treat. It is past time for attention to be paid to humanizing it for healthcare providers, especially those working in critical care. This may seem obvious and even unnecessary, but such acknowledgement is all too frequently overlooked—taken as understood among professionals—and yet is crucial for maintaining morale, decreasing stress and promoting a healthy, safe, and high performance workplace. Understanding and valuing the contribution of all ICU team members, including nursing staff, fosters a team approach to the significant difficulties faced.

Role and responsibility Within the ICU, each member of staff should have some responsibility, relative to his/her qualifications, interests, and experience. Nurses have knowledge and competences specific to their own professional domain and should take the lead in these aspects of ICU patient care. However, the degree of allowed responsibility varies considerably internationally. In most countries, nurses can, for example, initiate fluid challenges [ 18 ], perform electrolyte replacement, or titrate vasopressor agents while monitoring and assessing the patient’s response. They should be involved in checking sedation and analgesia levels are appropriate, adjusting feeding, and other essential aspects of patient management, helpfully summarized in the FAST-HUG mnemonic [ 19 ]. Within defined boundaries, which may differ in different units and in different countries, and with adequate support, nursing staff should be encouraged to use their clinical judgement and act on their own. These aspects should be discussed within each ICU team to determine which tasks nurses can perform and which skills nurses could be taught to achieve in the future to promote engagement, career development, and patient care. ICU teams should also discuss and share their experiences as a way of mentoring and supporting change, recognition, and promotion of the evolving critical care nursing role.

Intellectual stimulation and professional development It is well recognized that intellectual stimulation and feelings of self-accomplishment are an essential component of job satisfaction across professions. Each nurse should be able, and indeed encouraged and mentored, to develop expertise in one or several specific aspects of patient management, if they wish to do so. They could become the recommended contact for any question related to issues including but not limited to wound care, optimal feeding, renal replacement therapy, a continuous positive airway pressure (CPAP) system, a new piece of monitoring equipment, appropriate sedation, family liaison, and person-centered care. They could also participate in or be a designated resource for specific research trials if a research nurse is not readily available. Awareness of who holds these roles and valuing the associated expertise and input supports personal development and the sense of worth. A higher level of autonomy, leadership and broadening of the critical care nursing profession offers career-enhancing possibilities that may lead to reduced work-related stress and potentially help retain more nurses in our profession [ 20 ]. In hospitals where this applies, nurses should be provided with opportunities and encouragement for promotion within the ICU or outside the ICU borders, whether as an ICU representative or as a role model for others of what a career in intensive care can lead to.

Teaching opportunities Nurses of all levels should be given the opportunity to teach in their area(s) of expertise, not only to other nurses, but also to doctors (trainees and attending staff) and other allied healthcare professionals. Encouraging and supporting nurses to present at unit/team seminars, to participate in simulation, case-based teaching, gamification, to lead teaching on new policies, new equipment and new practices, and to present results of emerging research in ICU- or hospital-wide journal clubs or even at (inter)national congresses is another way to engage nurses and send a message to the entire ICU team, healthcare organization, and even ministries of health that the nurses are an integral and highly valued and respected part of the ICU team.

Good leadership and management Dynamic, motivated leaders and managers are important to provide a good example of what is possible and specific leadership patterns are linked to higher levels of job satisfaction among nursing staff [ 21 ]. Head nurses should be offered regular leadership and mentorship training and encouraged to listen to the concerns of their team members, to provide positive, constructive feedback rather than negative criticism, and to understand the career goals of their nursing staff while seeking opportunities to help fulfill these goals. Since critical care medicine is a collaborative specialty, it is also important for critical care physicians to consider how they too may help foster nurses at all stages of their career to achieve their goals, open doors to new opportunities, and provide mentorship. Such actions would make the ICU a supportive, encouraging environment, and facilitate both recruitment and retention.

Team work/collaborative practice Nurses are fundamental members of the ICU team and should be encouraged to actively contribute during clinical rounds and to other discussions regarding patient management; after all, they usually spend more time with the patient than the medical staff. Indeed, a team approach is essential for any professional activity, but is even more important in our discipline—people’s lives can literally depend on every team member feeling safe to raise concerns and/or share their perceptions of responses to treatments. ICUs must foster an inclusive, non-intimidating, collaborative work environment in which the contributions and opinions of all team members are valued.

Clinical discussion and exchange Although regular, planned formal discussions of clinical cases that engage key educational principles are valuable, impromptu, informal discussions of individual patients or relevant topics are also important. Nurses should feel empowered to initiate such discussions with other members of staff and to speak openly as equals. Indeed, all members of the team must feel they can raise any issue with their colleagues and that their questions and opinions are relevant and appreciated. Open dialogue with the nurse at the bedside promotes effective communication in the interests of patient care. Ideas from nursing staff to improve patient care, patient safety, and the functioning of the ICU should be listened to and actioned when possible and appropriate. Taking time to share concerns can help to ease the burden of care and ensure broad understanding, thereby reducing the risk of conflict within a team that can occur as a result of ineffective or absent communication.

Good work-life balance / wellness/rehumanizing the workplace The ICU is a very fast paced, challenging workplace environment and efforts to meet patient needs are often overwhelming. Given their firsthand knowledge of current workload, nurses can provide important input into decisions regarding admission triage of referrals or transfers from outside facilities, and what is possible to maintain patient safety and quality of care. Furthermore, when new tasks, such as implementation of new policies, procedures or equipment, are required, critical care professionals should ensure that the responsibilities are shared as much as possible and that one group, e.g., nurses, respiratory therapists,… are not disproportionately burdened. The same applies to the initiation of new research projects within the ICU environment. In addition, everyone needs time off, to relax and recuperate both mentally and physically, and to enjoy family life and leisure time. This is easy to say, but not so easy to put into action. However, small steps can help, such as ensuring sufficient rest periods between shifts; providing work schedules well ahead of time as much as possible; accepting that nurses can say no to staying late/working overtime; and respecting family and personal commitments and responsibilities. Finally, although part-time jobs have not been encouraged and in some places are not currently available for nurses, especially in an acute care setting, the flexibility they offer could play an important role in encouraging some nurses to stay. Wellness is not just a personal responsibility but needs to be incorporated into our work environment in practical ways to decrease stress and strain.

Psychological support The ICU is often an environment of life-death situations, and constantly caring for high-burden, critically ill patients can create considerable emotional and mental stress. Team debriefings after particularly difficult or distressing cases are important, but individual support from colleagues seems to be most valued and appropriate among nurses [ 7 ]. For example, WhatsApp groups during the COVID-19 pandemic worked well. Sometimes professional help is needed and should be freely available to all at all times, without stigmatizing those who do (or do not) make use of it. The expenses for such support will be more than compensated for by the positive effects on nurse morale and thus workflow. Resilience training, or similar programs to help manage stress, may also be beneficial [ 22 ].

Humane care Nursing activities are not limited to monitoring, feeding, and medication administration, but include providing continuing psychological support of the patients, and often their families. A perception that patients are not being cared for humanely or that care given is inappropriate [ 5 , 23 ] can promote disillusion and frustration. End-of-life care, in particular, is not always as good as it could or should be for ICU patients. Conflict in end-of-life decision making is associated with moral distress for critical care nurses [ 24 ]. Nurses should feel able to raise the need for a possible end-of-life decision with other members of staff if they feel it is relevant for a particular patient. Listening to their ideas for improvement and discussing and developing inclusive quality improvement initiatives can help. Nurse facilitators are one option to help improve end-of-life communication among staff members, the patient and their family [ 25 ].

The current nurse shortages in the ICU are not new, but have been amplified by the COVID-19 pandemic. It is more than time to acknowledge the need for change, at all levels of the healthcare system from the individual to the institutional to the broader governmental and societal level [ 26 ]. Insufficient nurse numbers impact not only patient safety and outcomes [ 11 , 12 , 13 ], but also create a vicious cycle—fewer nurses lead to increased workload, so there is greater pressure on remaining staff, leading to increased stress and burnout, which in turn leads to increased numbers of nurses leaving the specialty, thereby further increasing the workload. Adequate nurse staffing is thus of prime importance not only for hospital managers and nurse leaders, but for all members of the ICU team, including doctors. Having sufficient numbers of nursing staff with high job satisfaction will improve the quality of care delivered to patients and the quality of work-life for all on the ICU. Understanding and valuing the contribution of all ICU team members, including nursing staff, fosters a team approach to the significant difficulties faced. Awareness of ways in which medical staff can contribute to supporting their nursing colleagues ensures a team approach to the challenges of the fallout from the pandemic on the background of an already stretched nursing team.

The elements discussed herein may not be applicable or relevant to all hospitals or units but can serve as a general framework for further discussion to help understand why critical care nurses leave the profession and what strategies can be actively established and supported at a local level to encourage them to stay.

Availability of data and materials

Not applicable.

Abbreviations

Coronavirus disease 2019

Continuous positive airway pressure

Intensive care unit

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Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium

Jean-Louis Vincent

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Carole Boulanger

Department of Intensive Care Adults, Erasmus MC, University Medical Center, Rotterdam, The Netherlands

Margo M. C. van Mol

Critical Care Medicine, University Health Network, University of Toronto, Toronto, ON, Canada

Laura Hawryluck

Medical Intensive Care Unit, Famirea Study Group, Paris, France

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JLV and EA wrote the first draft; CB, MMCvM, and LH revised the text; all authors read and approved the final manuscript.

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Vincent, JL., Boulanger, C., van Mol, M.M.C. et al. Ten areas for ICU clinicians to be aware of to help retain nurses in the ICU. Crit Care 26 , 310 (2022). https://doi.org/10.1186/s13054-022-04182-y

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SITUATIONAL LEADERSHIP STYLE IN NURSING MANAGEMENT IN CRITICAL CARE UNITS

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leadership, style, nursing, critical care units

Leadership styles wield a profound influence on the dynamics of critical care units, shaping nursing workforce outcomes and patient care quality. Emphasizing the significance of transformational leadership and situational adaptability, this research explores the multifaceted impact of diverse leadership styles in nursing management. Investigating their effects on job satisfaction, intention to stay, and service provision, the study underscores the relevance of situational leadership in emergencies. As healthcare systems evolve, understanding these leadership dynamics becomes paramount for ensuring high-quality patient care amidst unprecedented challenges such as the COVID-19 pandemic, this study aims to explore the impact of nurse leadership philosophies—specifically transformational, transactional, and laissez-faire—on quality indicators in intensive care units. Through surveys, interviews, and patient data analysis, the research reveals that transformational leadership significantly enhances quality metrics, fostering increased patient satisfaction, reduced mortality rates, and improved cooperation among healthcare workers. The findings underscore the importance of nurse leadership development programs and emphasize the pivotal role of effective nursing leadership in delivering high-quality care, The study employed an integrated review technique, combining quantitative and qualitative findings on situational leadership in nursing management within critical care units. Adhering to Whittemore & Knafl's framework, the research involved problem identification, literature search, data evaluation, analysis, and findings presentation. Following PRISMA guidelines, the search strategy targeted studies published in English between 2000 and 2020, focusing on situational leadership in critical care units. Data collection involved extracting key study details, employing thematic analysis for qualitative data, and meta-analysis for quantitative data. Quality assessment utilized JBI checklists, identifying strengths and limitations, subsequently addressed through sensitivity analysis, In conclusion, situational leadership proves vital for nursing managers in dynamic critical care units, offering flexibility to address staff readiness levels effectively. The findings underscore the compatibility and effectiveness of transformational and situational leadership styles in promoting clinical leadership. Emphasizing collaborative leadership, shared values, and authentic behaviors, the studies highlight their positive impact on staff outcomes and care quality. Continuous training for nurse leaders is crucial for creating positive work environments, ultimately improving patient care and staff well-being.,

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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License .

All articles published in JPTCP are licensed under Copyright Creative Commons Attribution-NonCommercial 4.0 International License.

Waleed Saad Tulayhan Alshammari

King Khaled hospital in Hail ER staff.

Abdulsalam Salem Mohammad Alshammari

Tariq kareem dhaidan alshammari.

King Salman Specialist hospital in Hail oncology staff.

Rinad Aedh Abed Alresheedi

King Salman Specialist Hospital in Hail, ICU Nurse Staff.

Ohud Binyah Thayid Alshammari

King Salman Specialist Hospital in Hail.

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

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

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.

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.)

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

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

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

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.

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

II. GLOSSARY

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

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2.3 Tools for Prioritizing

Prioritization of care for multiple clients 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 clients 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 client safety.

Acuity and intensity are foundational concepts for prioritizing nursing care and interventions. Acuity refers to the level of client care that is required based on the severity of a client’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” client 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” client generally requires frequent or long periods of psychosocial, educational, or hygiene care from nursing staff members. High-intensity clients 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 clients benefits both the nurse and client by helping to ensure that client care needs do not overwhelm individual staff and safe care is provided.

Organizations use a variety of systems when determining client acuity with rating scales based on nursing care delivery, client stability, and care needs. See an example of a client 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 client requiring minimal individualized nursing care and intervention. A rating of 2 reflects a client with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex client who requires frequent intervention and assessment. This client might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk client. 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 client with a rating of 1 or 2. [3]

Table 2.3. Example of a Client Acuity Tool [4]

Read more about using a client 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 client 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 client assignments according to their acuity ratings. This means that when comparing client 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 client 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 clients.

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 clients during their shift. Ratio-based staffing models may be useful for administrators creating budget requests based on the number of staff required for client care, but can lead to an inequitable division of work across the nursing team when client acuity is not considered. Increasingly complex clients require more time and interventions than others, so a blend of both ratio and acuity-based staffing is helpful when determining staffing assignments. [5]

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 clients to start your day. The clients have the following acuity ratings:

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

Client B: 87-year-old client 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.

Client C: 63-year-old client 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.

Client D: 83-year-old client 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 client 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 clients 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, Client 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 client 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.

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 a while; I should probably find her something to eat.

All 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 client, it is important to immediately intervene to stop the bleeding and restore fluid volume. Stabilizing the client 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 client’s family and didn’t address the bleeding or dehydration – you might return to a severely hypovolemic client who has deteriorated and may be near death. In this example, prioritizing emotional needs above physiological needs can lead to significant harm to the client.

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 client well-being. Maslow’s hierarchy provides the nurse with a helpful framework for identifying and prioritizing critical client 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 client does not have a patent airway, is unable to breathe, or has inadequate circulation, very little of what else we do matters. The client’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 clients 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 506 has a 47-year-old woman who was hospitalized with new onset atrial fibrillation with rapid ventricular response. The client 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 client scenarios, it might be difficult to determine whom you should see first. Both clients are demonstrating needs in the foundational physiological level of Maslow’s hierarchy and require assistance. To prioritize between these clients’ physiological needs, the nurse can apply the principles of the ABCs to determine intervention. The client in Room 506 reports both breathing and circulation issues, warning indicators that action is needed immediately. Although the client in Room 504 also has an urgent physiological elimination need, it does not overtake the critical one experienced by the client in Room 506. The nurse should immediately assess the client in Room 506 while also calling for assistance from a team member to assist the client in Room 504.

Prioritizing what should be done and when it can be done can be a challenging task when several clients 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 client 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” client 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 clients’ critical needs is the correct prioritization of their time and energies.

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

The third part of the CURE hierarchy reflects “routine” client needs. Routine client needs can also be characterized as “typical daily nursing care” because the majority of a standard nursing shift is spent addressing routine client 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 client needs, they do not supersede critical or urgent client needs.

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

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

If we return to Scenario D regarding clients in Room 504 and 506, we can see the client 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 client in Room 506 is experiencing a critical need and takes priority. Recall that critical needs require immediate nursing action to prevent client deterioration. The clientin 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 clients’ 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 client’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 client’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 client’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 clients admitted to the medical-surgical unit complaining of pain in Scenario E in the following box.

As part of your client assignment on a medical-surgical unit, you are caring for two clients who both ring the call light and report pain at the start of the shift. Client A was recently admitted with acute appendicitis, and Client B was admitted for observation due to weakness. Not knowing any additional details about the clients’ conditions or current symptoms, which client would receive priority in your assessment? Based on using the data cue of acute versus chronic conditions, Client A with a diagnosis of acute appendicitis would receive top priority for assessment over a client with chronic pain due to osteoarthritis. Clients 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 client. A risk problem indicates the client 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 client 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 client as part of the care planning process. One nursing diagnosis for this client is Ineffective Airway Clearance . This nursing diagnosis is an actual problem because the client 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 client 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 client’s room and discovers the client is experiencing increased shortness of breath, nursing interventions to improve the client’s respiratory status receive top priority before attempting to get the client 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

Let’s apply this tool to the two clients previously discussed in Scenario E. As you recall, both Client A (with acute appendicitis) and Client B (with weakness and diagnosed with osteoarthritis) are reporting pain. Acute pain typically receives priority over chronic pain. But what if both clients are also reporting nausea and have an elevated temperature? Although these symptoms must be addressed in both clients, they are “expected” symptoms with acute appendicitis (and typically addressed in the treatment plan) but are “unexpected” for the client with osteoarthritis. Critical thinking alerts you to the unexpected nature of these symptoms in Client 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 client chart. These data cues can be used to establish a client’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 client admitted to the medical-surgical unit with pneumonia:

At the beginning of my shift, the client was on room air with an oxygen saturation of 93%. She had slight crackles in both bases of her posterior lungs. At 0530, the client 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 client 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 client on 2 L/minute of oxygen via nasal cannula. Within five 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 client may be experiencing a change in condition. Although these changes could be attributed to lack of lung expansion that occurred while the client was sleeping, there is enough information to indicate to the oncoming nurse that follow-up assessment and interventions should be prioritized for this client 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 client condition? Many nurses develop a habit of reviewing their clients’ charts at the start of every shift to identify trends and “baselines” in client condition. For example, a chart review reveals a client’s heart rate on admission was 105 beats per minute. If the client 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 client’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 client’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 client’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 clients.

You completed morning assessments on your assigned five clients. Client A previously underwent a total right knee replacement and will be discharged home today. You are about to enter Client 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 Client B. Rather than enter Client A’s room to perform discharge teaching, you immediately reprioritize your care. You call the primary provider to report Client B’s critical hemoglobin level and determine if additional intervention, such as a blood transfusion, is required.

Prioritization Principles & Staffing Considerations [13]

With the complexity of different staffing variables in health care settings, it can be challenging to identify a method and solution that will offer a resolution to every challenge. The American Nurses Association has identified five critical principles that should be considered for nurse staffing. These principles are as follows:

Health Care Consumer: Nurse staffing decisions are influenced by the specific number and needs of the health care consumer. The health care consumer includes not only the client, but also families, groups, and populations served. Staffing guidelines must always consider the client safety indicators, clinical, and operational outcomes that are specific to a practice setting. What is appropriate for the consumer in one setting, may be quite different in another. Additionally, it is important to ensure that there is resource allocation for care coordination and health education in each setting.
Interprofessional Teams: As organizations identify what constitutes appropriate staffing in various settings, they must also consider the appropriate credentials and qualifications of the nursing staff within a specific setting. This involves utilizing an interprofessional care team that allows each individual to practice to the full extent of their educational, training, scope of practice as defined by their state Nurse Practice Act, and licensure. Staffing plans must include an appropriate skill mix and acknowledge the impact of more experienced nurses to help serve in mentoring and precepting roles.
Workplace culture: Staffing considerations must also account for the importance of balance between costs associated with best practice and the optimization of care outcomes. Health care leaders and organizations must strive to ensure a balance between quality, safety, and health care cost. Organizations are responsible for creating work environments, which develop policies allowing for nurses to practice to the full extent of their licensure in accordance with their documented competence. Leaders must foster a culture of trust, collaboration, and respect among all members of the health care team, which will create environments that engage and retain health care staff.
Practice environment: Staffing structures must be founded in a culture of safety where appropriate staffing is integral to achieve client safety and quality goals. An optimal practice environment encourages nurses to report unsafe conditions or poor staffing that may impact safe care. Organizations should ensure that nurses have autonomy in reporting and concerns and may do so without threat of retaliation. The ANA has also taken the position to state that mandatory overtime is an unacceptable solution to achieve appropriate staffing. Organizations must ensure that they have clear policies delineating length of shifts, meal breaks, and rest period to help ensure safety in client care.
Evaluation: Staffing plans should be consistently evaluated and changed based upon evidence and client outcomes. Environmental factors and issues such as work-related illness, injury, and turnover are important elements of determining the success of need for modification within a staffing plan. [14]
Oregon Health Authority. (2021, April 29). Hospital nurse staffing interpretive guidance on staffing for acuity & intensity . Public Health Division, Center for Health Protection. https://www.oregon.gov/oha/ph/providerpartnerresources/healthcareprovidersfacilities/healthcarehealthcareregulationqualityimprovement/pages/nursestaffing.aspx ↵
Ingram, A., & Powell, J. (2018). Patient acuity tool on a medical surgical unit. American Nurse . https://www.myamericannurse.com/patient-acuity-medical-surgical-unit/ ↵
Kidd, M., Grove, K., Kaiser, M., Swoboda, B., & Taylor, A. (2014). A new patient-acuity tool promotes equitable nurse-patient assignments. American Nurse Today, 9 (3), 1-4. https://www.myamericannurse.com/a-new-patient-acuity-tool-promotes-equitable-nurse-patient-assignments / ↵
Welton, J. M. (2017). Measuring patient acuity. JONA: The Journal of Nursing Administration, 47 (10), 471. https://doi.org/10.1097/nna.0000000000000516 ↵
Maslow, A. H. (1943). A theory of human motivation. Psychological Review , 50 (4), 370–396. https://doi.org/10.1037/h0054346 ↵
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Stoyanov, S. (2017). An analysis of Abraham Maslow's A Theory of Human Motivation (1st ed.). Routledge. https://doi.org/10.4324/9781912282517 ↵
Kohtz, C., Gowda, C., & Guede, P. (2017). Cognitive stacking: Strategies for the busy RN. Nursing2021, 47 (1), 18-20. https://doi.org/10.1097/01.nurse.0000510758.31326.92 ↵
ANA. (2024). Principles for nurse staffing. Retrieved from https://www.nursingworld.org/practice-policy/nurse-staffing/staffing-principles/ ↵

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.

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

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

Airway, breathing, and circulation.

Pieces of clinical information that direct the nurse toward a potential “actual problem” or a change in condition.

Conditions having a sudden and severe onset.

Have a slow onset and may gradually worsen over time.

Nursing problems currently occurring with the patient.

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

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

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

Nursing Management and Professional Concepts 2e Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Effective January 1, 2025, new and revised emergency management requirements will apply to all Joint Commission–accredited nursing care centers. The Joint Commission began conducting a critical analysis of its “Emergency Management” (EM) chapter in late 2019. During the height of the COVID-19 pandemic, The Joint Commission received numerous inquiries pertaining to emergency plans and response procedures. Based on the work already being performed on the EM chapter and the questions and issues that arose during the pandemic, the entire EM chapter has been restructured to provide a meaningful framework for a successful emergency management program. The changes in the EM chapter include a new numbering system, elimination of redundant requirements, and the addition of new requirements. This restructuring resulted in a reduction in the number of elements of performance by 28% in the EM chapter for the nursing care center program.

Download R3 for New and Revised Emergency Management Standards for Nursing Care Centers Download R3 for New and Revised Emergency Management Standards for Nursing Care Centers

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Master’s in Healthcare Management Programs

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MHM Program Overview
Applying to an MHM Program
Program Accreditation

Are you ready to earn your online nursing degree?

Hospital manager in meeting with doctors

The healthcare sector continues to expand, as does the need for experts who can effectively lead healthcare organizations, systems, and teams. A master’s in healthcare management (MHM) prepares students for a variety of executive positions that require advanced strategic and decision-making skills.

According to the Bureau of Labor Statistics (BLS), medical and health services managers earned an annual median salary of $110,680 as of May 2023. The BLS also projects these fields to expand by an impressive 28% each year from 2022-2032 — far greater than the 3% national average.

Explore some of the nation’s best MHM degree programs, plus a career overview, academic requirements, and the information you need to stand out among other applicants.

Popular Online Healthcare Management Programs

Learn about start dates, transferring credits, availability of financial aid, and more by contacting the universities below.

How Do Master’s in Healthcare Management Programs Work?

While the structure of MHM programs varies by school, your goals, and other factors, these programs typically require 1-2 years of study. The MHM curriculum provides the knowledge, skills, and practical experience healthcare employers value.

An MHM curriculum requires 30-48 credits and covers topics, such as managerial finance and accounting, financial reporting and analysis, operations strategy, health law, and ethics. Programs can be in person, fully online, a hybrid of the two, or otherwise scheduled to accommodate working professionals.

Applying to a Master’s in Healthcare Management Program

Applicants must have a bachelor’s degree from a regionally accredited institution. Degree-seekers must begin by filling out an application form. Some MHM programs require an application fee, usually around $50-$70. You may also need to demonstrate a competitive GPA and relevant professional experience.

Admission Materials: Generally, these include academic transcripts, a CV or resume, personal statement, letters of recommendation, and evidence of 2-5 years of professional experience. Some programs no longer require GRE or GMAT scores.
GPA Requirement: 3.0 on a 4.0 grading system; 2.5-2.99 GPA is often considered on a provisional basis.

Why Is MHM Program Accreditation Important?

A regional or national accreditation ensures that academic programming meets stringent standards recognized by the U.S. Department of Education . These private accreditation groups establish evaluation criteria and conduct site visits to ensure schools measure up.

Accrediting organizations , such as the Higher Learning Commission (HLC), the Middle States Commission on Higher Education (MSCHE), and the New England Association of Schools and Colleges (NEASC) accredit institutions within specific geographic regions. For instance, the MSCHE accredits institutions in New Jersey and several other nearby states.

The Commission on Accreditation of Healthcare Management Education (CAHME) is the programmatic accreditation for healthcare management graduate programs.

Employers and educational institutions often require or strongly prefer accredited degrees, so graduating from an accredited program makes it easier to secure job opportunities and advance to a doctoral program in the future.

What Can I Do with a Master’s in Healthcare Management Degree?

A master’s in healthcare management prepares graduates for a variety of management-level roles in hospitals, outpatient clinics, doctors’ offices, and other healthcare organizations. Increased demand for healthcare services, along with a growing need for health information technology and informatics specialists, will translate into additional job opportunities.

Hospital Manager

Median annual salary: $128,740

Hospital managers oversee units and departments in hospitals, where they set budgets, schedule staff, and implement new policies. They may also ensure compliance with healthcare regulations and communicate long-term organizational goals to departments.

Nursing Home Administrators

Median annual salary: $97,490

Nursing home administrators manage long-term care facilities. They oversee admissions, the administrative side of patient care, and facilities maintenance. As the population continues to age, demand for nursing home administrators will likely increase.

Health Information Managers

Median annual salary: $110,680

Health information managers organize patient records and oversee databases that secure private information. They also review records for accuracy and implement security policies. Within health information management, professionals may also specialize in areas, such as informatics or cybersecurity.

Frequently Asked Questions About Master’s in Healthcare Management Programs

What is the role of healthcare management.

Healthcare management ensures the efficient and effective delivery of healthcare services. Healthcare managers typically oversee day-to-day operations, manage budgets and financial assets, lead and guide healthcare professionals and other staff, and ensure compliance with state and federal laws. They identify areas for improvement and plan and implement long-term organizational goals.

What is the difference between a master’s in healthcare administration and a master’s in healthcare management?

A master’s in healthcare administration (MHA) prepares administrators for the day-to-day management of healthcare programs, departments, and organizations. A master’s in healthcare management (MHM) can prepare institutional leaders to manage entire healthcare facilities, though it depends on the program and its outlined student learning outcomes.

Is a master’s in healthcare management worth it?

While nothing is guaranteed, graduates from MHM programs have a bright future. Relevant fields are growing fast, and wages are competitive. This trend should continue because of the aging baby boomer population, among other factors.

What degree is best for healthcare management?

Consider degrees like a master’s in healthcare management (MHM), a master of business administration (MBA) with a healthcare focus, or a master’s in healthcare administration (MHA) to qualify for managerial positions in healthcare settings.

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Trying to decide between furthering your career in nursing or healthcare management? Check out details on both to help you decide which might be right for you.

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College of Nursing

Barb St. Marie stands in front of a board full of papers, pointing and something and talking to a person whose back we see.

Barb St. Marie: Maximizing care to minimize pain

Choosing a career in healthcare, specifically nursing, was not an immediate or obvious decision for Barb St. Marie . She began college as a music major, but after experiencing a serious illness and being hospitalized, she changed her path and graduated with a Bachelor of Science in Nursing.

"Throughout the period that I was sick, there was a nurse holding my hand through the whole thing, and it just made me feel safe and comforted," St. Marie reflects. "And when I woke up the next morning, I told my family, that's what I want to do for others."

This realization set the foundation for her career in nursing, with a particular focus on pain management and critical care. Her goal became clear: to alleviate pain and support those battling severe illnesses.

"That's kind of been my career—providing comfort," says St. Marie. "Working with people with critical disease and pain has been my life's work. And with the opioids we use for pain, it comes with the responsibility of knowing how to help people who develop opioid use disorder or have pain and substance use disorder."

This commitment led her to work at the University of Minnesota Pain Clinic, where she treated patients with both pain and addiction. During this time St. Marie noticed a significant gap in the available training and resources for managing opioid use disorder. "The idea of opioid use disorder secondary to the development of pain was not well-defined or recognized," St Marie says.

"I decided to go back for my PhD to learn how to investigate, ask the right questions, and change our systems of care. This way, when we treat people with pain with opioids, we can help minimize the risk for misuse and development of opioid use disorder.”

St. Marie earned her PhD from the University of Wisconsin-Milwaukee while maintaining a clinical practice in Minnesota. She recalls being introduced to the University of Iowa by Dr. Joanne Eland, who invited her for a tour that left a lasting impression. “It was all very exciting to see,” she says, noting the research opportunities and faculty expertise. When a postdoctoral position at the University of Iowa College of Nursing became available, St. Marie jumped at the opportunity.

During her postdoc, St. Marie gained experience working alongside other researchers and observing how faculty balanced their roles in both clinical practice and academics. “It really allowed me to dive right in,” she says, adding that by the end of her postdoc she was eager to stay and continue her work. She joined the college faculty in 2014.

Teaching has become an integral part of St. Marie's career. Currently, she teaches pathophysiology, physiology, qualitative research, and pharmacology. She also mentors DNP and PhD students, guiding them in formulating research questions and designing projects to achieve meaningful results.

Outside of her teaching responsibilities, she is involved in two significant projects.

One is nearing completion after years of data collection on individuals with opioid use disorder being treated with buprenorphine. Her study investigates the effectiveness of a TENS (transcutaneous electrical nerve stimulation) unit in reducing cravings, withdrawals, and pain.

Additionally, last December St. Marie won a National Institute on Drug Abuse (NIDA) startup challenge . The initiative supports groundbreaking research ideas in substance use disorders to develop successful biotech startups. Through the challenge, St. Marie and her team received monthly lectures and mentoring sessions in company and product development. In June, the team pitched their device to challenge leadership and received $10,000 in startup funds.

St. Marie loves to hike when she's not working.

"That's my number one hobby. I love being outside. I try to get outside as much as possible, breathe the air, see the trees, and experience the weather," she says.

St. Marie has two adult children—one in Minneapolis and one in Milwaukee—three grandchildren and one granddog who all keep her busy.

Reflecting on her time at the College of Nursing, St. Marie values collegiality among faculty at the college and throughout the University of Iowa.

“Working with all nurses, whether undergraduate students, graduate or PhD students, or clinical practice nurses at the hospital or clinics, the collegiality is always there. Faculty are always willing to help each other. It speaks volumes to how wonderful it is to work here," she shares.

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VNJ Articles emergency and critical care hyperkalaemia metabolic acidosis nursing post-obstructive diruesis urethral obstruction

19 August 2024

Critical nursing care of feline urethral obstruction – A case study

Author: Cyndi Haslam RVN, GradCertAVN(ECC), CertVNECC. Cyndi is a weekend night emergency and critical care RVN at the Queen Mother Hospital for Animals at the Royal Veterinary College. She is passionate about emergency and critical care. Outside work, Cyndi loves spending time with her two children, two spaniels, two cats and husband, Paul.

ABSTRACT This case study describes a male domestic shorthair cat with urethral obstruction (UO). The cat was catheterised by its primary care practice, hospitalised for the day and then transferred to the out-of-hours (OOH) provider. On admission of the patient, a urine collection set was in place with the clamp closed, which occluded the urine flow. There was no evidence of urine in the system, despite it having been placed several hours previously. The patient was stuporous and had severe metabolic acidosis, and was given a grave prognosis. Unfortunately, due to the patient’s critical condition and financial constraints, it was euthanased within 1 hour of admission. The case highlights the importance of continuity of care when transferring patients to an OOH service. Key nursing points include a focus on metabolic acidosis and the monitoring of trends, and fluid therapy and the effect it can have on acidaemia in these cases. It also highlights the role of the veterinary nurse in monitoring patients with UO. Keywords urethral obstruction, metabolic acidosis, hyperkalaemia, post-obstructive diuresis, emergency and critical care, nursing

DOI: https://doi.org/10.56496/ZCQD3790

To cite this article: Critical nursing care of feline urethral obstruction – A case study. Haslam, C. (2024) VNJ 39 (3) pp 40-48. DOI: https://doi.org/10.56496/ZCQD3790

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What is Critical Care Nursing: A Guide to the Role
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Essential critical care skills 1: what is critical care nursing?
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Critical Care Nursing
Critical Care Nursing: Diagnosis and Management, 9th Edition helps you understand and apply critical care nursing principles and concepts to clinical assessment, diagnostic procedures, and therapeutic management. Known for its comprehensive coverage, this leading textbook uses a logical, body systems organization to address the care of patients ...
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A holistic view of the patient - which takes into account physical and psychosocial matters - is vital, as is supporting families. Essential critical care skills 2: assessing the patient. Essential critical care skills 3: arterial line care. Essential critical care skills 4: airway assessment and management.
American Association of Critical-Care Nurses
American Association of Critical Care Nurses is more than the world's largest specialty nursing organization. We are an exceptional community of acute and critical care nurses offering unwavering professional and personal support in pursuit of the best possible patient care. AACN is dedicated to providing more than 500,000 nurses with knowledge, support and resources to ensure optimal care ...
Nursing Management of Patients Requiring Acute ...
The critical care nurse plays a crucial role in managing patients receiving acute mechanical circulatory support devices and monitoring for potential complications. Purpose To review the anatomical placement and mechanics of each type of device so that nurses can anticipate patients' hemodynamic responses and avoid complications whenever ...
Critical Care Nursing: Diagnosis and Management
Critical Care Nursing: Diagnosis and Management, 9th Edition helps you understand and apply critical care nursing principles and concepts to clinical assessment, diagnostic procedures, and therapeutic management. Known for its comprehensive coverage, this leading textbook uses a logical, body systems organization to address the care of patients ...
Intensive and Critical Care Nursing
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Nursing in Critical Care
nursing practice, research, education or management. Critical care nursing is defined as the whole spectrum of skills, knowledge and attitudes utilised by practitioners in any setting where adults or children, and their families, are experiencing acute and critical illness. Such settings encompass general and specialist hospitals, and the ...
Nursing in Critical Care
Nursing in Critical Care is an international peer-reviewed journal covering any aspect of critical care nursing practice, research, education or management. Critical care nursing is defined as the whole spectrum of skills, knowledge and attitudes utilised by practitioners in any setting where adults or children, and their families, are expe-
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Many hospitals, schools, nursing organizations, states, and nurses themselves are seeking innovative solutions as the nursing profession faces challenges. Read more. Practice Pointers ... American Association of Critical-Care Nurses 27071 Aliso Creek Road Aliso Viejo, CA 92656. Tel: (800) 899-1712; Tel: (949) 362-2000; Facebook; Twitter ...
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R3 Report Issue 46: New and Revised Emergency Management Standards for
New and Revised Emergency Management Standards for Nursing Care Centers . Effective January 1, 2025, new and revised emergency management requirements will apply to all Joint Commission-accredited nursing care centers. The Joint Commission began conducting a critical analysis of its "Emergency Management" (EM) chapter in late 2019.
Master's In Healthcare Management Programs
A master's in healthcare administration (MHA) prepares administrators for the day-to-day management of healthcare programs, departments, and organizations. A master's in healthcare management (MHM) can prepare institutional leaders to manage entire healthcare facilities, though it depends on the program and its outlined student learning ...
Barb St. Marie: Maximizing care to minimize pain
Reflecting on her time at the College of Nursing, St. Marie values collegiality among faculty at the college and throughout the University of Iowa. ... This realization set the foundation for her career in nursing, with a particular focus on pain management and critical care. Her goal became clear: to alleviate pain and support those battling ...
2010 WOCN/WCET Joint Conference (June 12-16, 2010): Practice Innovation
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Critical nursing care of feline urethral obstruction
The case highlights the importance of continuity of care when transferring patients to an OOH service. Key nursing points include a focus on metabolic acidosis and the monitoring of trends, and fluid therapy and the effect it can have on acidaemia in these cases. It also highlights the role of the veterinary nurse in monitoring patients with UO.
PDF Health System Strengthening
4 Lewis (2005) and World Bank (2005). bilateral donors are all struggling for the best way to deal with this issue. The highly visible and politically charged debate on human resources for health has also recognized that human resources are one critical component of the overall objective of health systems' strengthening.

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