This module explores the nurse's role in safe and effective patient care through prioritization and delegation.
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Prioritization in Nursing
This module explores the nurse's role in safe and effective patient care through prioritization and delegation.
Upon completion of this module, learners should be able to:
- discuss the importance of prioritization in delivering patient care
- explore the application of various prioritization frameworks and principles of delegation for safe, effective patient care
- apply the concepts of various prioritization frameworks and principles of delegation to case scenarios
Nurses are responsible for offering high-quality, evidence-based care to optimize patient outcomes. As new treatments emerge, people are living longer, healthier lives. As the US population ages, more people live with chronic health conditions. These conditions have created a clinical environment that is more complex than ever before. The demands of the complex clinical environment require that nurses multitask, prioritize, delegate, and make sound clinical decisions when providing patient care. The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP; 2022) defines chronic diseases as conditions that last more than 1 year, require ongoing medical attention, and/or limit activities of daily living (ADLs). Chronic disease is the leading cause of death and disability in the US. An estimated 6 out of 10 American adults have at least one chronic disease, and 4 out of 10 have two or more chronic diseases. Chronic conditions such as heart disease, cancer, chronic lung disease, diabetes mellitus (DM), Alzheimer's disease, and chronic kidney disease (CKD) significantly contribute to the increasing complexity of care in the clinical environment (Manetti, 2019; NCCDPHP, 2022).
New graduate nurses entering the clinical setting encounter various challenges in delivering safe and effective patient care. It is estimated that only 8% of new graduate nurses are prepared to make entry-level clinical judgments, creating an education-to-practice gap. Poor clinical judgment can lead to poor patient outcomes. New graduate nurses must receive focused training and clinical insight into promptly and appropriately identifying and prioritizing patient needs. This skill set requires knowledge about medical conditions and disease processes, the principles of medication administration, pharmaco*kinetics, and adverse effects, as well as the ability to appropriately apply this information to meet individual patient needs. Experienced nurses have acquired and developed clinical judgment through their experience delivering patient care. Due to staffing and resource shortages, new graduate nurses are expected to hit the ground running, delivering safe and effective care in a fast-paced healthcare environment with high patient acuity, patient-to-nurse ratios, and complex clinical conditions despite their lack of experience. To ensure that new graduate nurses are prepared for these demands upon entering the clinical setting, nurses must assess the clinical environment and apply appropriate prioritization frameworks and principles of delegation. In addition, recurrent application and intentional practice of clinical judgment must occur during their education (Kavanagh & Szweda, 2017; Rose, 2020).
Prioritization in Nursing Care
Nursing programs devote significant time and attention to teaching nursing students how to prioritize their time to deliver safe and effective care. While in school, most clinical training involves caring for one or two patients with oversight from faculty and nurse preceptors. However, once the graduate nurse is in the clinical setting, they are often faced with a much higher patient load, and many things demand the nurse's attention. Prioritizing and managing time is vital for any successful novice or expert nurse. However, prioritizing and managing time is not necessarily information that can be memorized or easily taught in a textbook. Nurses must combine knowledge and skills to make safe decisions when delivering care to a group of patients. However, the increasing complexity of patient situations and high patient-to-nurse ratios have hindered new graduate nurses from successfully prioritizing care, leading to avoidable errors and poor patient outcomes. This education-to-practice gap has been attributed to a lack of clinical reasoning and judgment of new graduate nurses. As a result, the National Council for State Boards of Nursing will launch the NexGen NCLEX in 2023 as an intentional initiative to focus the pre-licensure assessment and determination of competency based on clinical reasoning and judgment skills (Jessee, 2019; Kavanagh & Szweda, 2017).
The quality of patient care depends on nurses who are prepared to recognize their needs and respond accordingly. Nursing judgment directly impacts the ability to apply EBP and to react to changes in the patient's condition. Hospitals have acknowledged the lack of new nurse preparedness for years and implemented extended orientations, preceptorships, mentoring programs, and nurse residency programs to bridge the gap between the education and practice settings. Despite organizational strategies to improve the safety and efficacy of patient care, preventable healthcare errors are the third leading cause of death in the US. The transition from novice nurse to an advanced beginner is filled with insecurities, a lack of experience, and a deficit of clinical judgment. Both patients and medical facilities benefit from nurses who can demonstrate competent clinical judgment. Lasater and colleagues (2015) found that only 13% of preceptors believed novice nurses could establish priorities and demonstrate safe nursing care. High-quality patient care depends on the nurse's competence and application of clinical judgment (Lasater et al., 2015). The National Council of State Boards of Nursing targets optimal outcomes for patients, nurses, and clinical organizations. Nurses should enter practice with the ability to make appropriate clinical decisions through clinical judgment (NCSBN, n.d.).
It is not unusual for a nurse working on a general medicine or surgical unit to be tasked with caring for up to 5 or 6 patients with serious illnesses in a given shift. When managing these multi-patient, complex care situations, nurses must be able to prioritize patient needs accurately to promote positive patient outcomes. Once the nurse receives their patient assignment, they must determine how to proceed with the shift and meet the multifaceted demands, including patient assessments, administration of medications, patient advocacy, the delegation of appropriate tasks to other members of the nursing team, facilitation of diagnostic testing, and family communication. Organizing all these demands can be challenging, and overlooking a step can lead to a medical error or a near-miss. While most nurses working consistently on the same unit will achieve competency of prioritization within their first year. However, there are situations when nurses may be asked to float to different units with different patient case mix. Managing patients and appropriately prioritizing care needs can be especially challenging in these situations. This difficulty may manifest as deficits in clinical reasoning and judgment, which can interfere with prioritizing and determining the most pressing issues (Kavanagh & Szweda, 2017).
- Clinical Judgment
- While several terms are used interchangeably to describe the competencies needed to deliver safe and effective patient care, they have different meanings; nursing leadership should understand the distinctions among them to foster clinical judgment for new graduate nurses (Alfaro-Lefevre, 2017). The following terms are interrelated and represent essential processes that lead to the comprehensive application of EBP (Alfaro-Lefevre, 2017; Con
