room assignment nursing may 2023

Category: Room Assignment

Room assignment —  may 2023 nursing licensure exam.

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The list of room assignments for the May 2023 Nursing Licensure Exam is released by the Professional Regulation Commission (PRC) weeks before the exams. See room assignments below!

Table of contents

Manila – added to list, manila – pwd, cagayan de oro, lucena – added to the list, rosales, pangasinan, tuguegarao – pwd, zamboanga – pwd, what to bring on exam day, what not to bring on exam day, what to wear on exam day, covid-19 protocols during the exam day, exam subjects and general instructions.

Disclaimer: WhatALife! is not in anyway affiliated with PRC. The information posted in this page is sourced from the official PRC website ( www.prc.gov.ph ).

The exams will be conducted in different parts of the Philippines, including NCR, Baguio, Butuan, Cagayan de Oro, Calapan, Cebu, Davao, Iloilo, Koronadal, Legazpi, Lucena, Pagadian, Palawan, Pampanga, Rosales, Tacloban, Tuguegarao, Zamboanga, and Palawan. The exam will take place on May 28 & 29, 2023.

The Board of Nursing, which is headed by Elsie A. Tee and has members Carmelita C. Divinagracia, Merle L. Salvani, Zenaida C. Gagno, Leah Primitiva S. Paquiz, Marylou B. Ong, and Elizabeth C. Lagrito, administers the exam.

Room Assignment — May 2023 Nursing Licensure Exam

Related information.

Here are the things to bring during the examination proper:

• Official Receipt of payment of application for examination
• Notice of admission
• One (1) piece metered-stamped window mailing envelope
• Two (2) or more pencils (No. 2)
• Ballpens with black ink only
• One (1) piece long brown envelope
• 1 piece long transparent/plastic envelope (for keeping your valuables and other allowed items)
• Health Forms (Pursuant to Joint Administrative Order No. 01 (s 2021))
• Negative RT-PCR Test Results,  if applicable, or Certificate of Quarantine or Certificate or copy of Vaccination Card for fully vaccinated examinees to the proctor on the examination day.
• Books, notes, review materials, and other printed materials containing coded data/information/formula 
• PROGRAMMABLE CALCULATORS, especially CASIO FX991ES and CASIO FX-991ES plus
• CELLULAR PHONES, EARPLUGS, TRANSMITTERS, PORTABLE COMPUTERS, SMART WATCHES, BLUETOOTH and other electronic gadgets/devices which may be used for communication purposes.
• Any type of bag
• Other examination aides not stated
• For male examinees, a tucked-in white polo shirt with collar (without any seal, logo, or mark) paired with decent pants or slacks.
• For female examinees, a tucked-in white blouse or shirt with collar (without any seal, logo, or mark) paired with decent pants or slacks.

During the PRC licensure exams, the following precautionary health and safety rules must be followed at all times:

• Observe physical distancing of at least two (2) meters between examinees.
• Examinees shall be restricted to their assigned seat;
• Wear face mask (at least 3-ply surgical mask, preferably N95 mask) and face shield at all times; 
• Bring 70% ethyl alcohol for hand disinfection;
• Avoid close contacts like “beso-beso”, hugging, handshake, and directly touching other persons;
• Avoid touching one’s eyes, nose, and mouth;
• When sneezing and/or coughing, facial tissues must be used to wipe the nose and mouth areas. Dispose of used facial tissues properly; and
• Don’t spitting in public, on floors, and along corridors. 

Good luck future Nurses! – WhatALife!

Also read: Room Assignment : Full List of Passers — May 2023 Nursing Licensure Exam (NLE)

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Philippine Updates

Nursing Board Exam (NLE) 2024 Schedule & Requirements

Students studying nursing still have to take the board exam after graduation to become fully pledged nurses. The Professional Regulation Commission along with the Professional Regulatory Board for Nursing conducts the Nursing Licensure Exam (NLE) twice a year.

This is in accordance with Republic Act No. 9173 or the Philippine Nursing Act of 2002. All applicants need to pass a written examination for a license to practice nursing.

Nursing Board Exam 2024

The PRC releases the schedule of board exams for the year 2024 . T he Nursing Licensure Exam (NLE) is scheduled on May 06 & 07, 2024 for the first batch and November 09 & 10, 2024 for the second batch.

Refer to the table below for the complete details.

Also Read: PRC Board Exams Schedule for 2024

What are the Qualifications?

In order to be admitted to the examination for nurses, an applicant must, at the time of filing his/her application, establish to the satisfaction of the Board that: 

(a) He/she is a citizen of the Philippines,

(b) He/she is of good moral character, and 

(c) He/she is a holder of a Bachelor’s Degree in Nursing from a college or university that complies with the standards of nursing education duly recognized by the proper government agency. 

How to apply for NLE online?

The PRC requires you to set an appointment online through LERIS before going to any PRC office. The LERIS stands for Licensure Examination and Registration Information System. You can set an appointment and pay the application fee through this link http://online.prc.gov.ph/ .

If you still don’t have an account in LERIS, you can read our guide or tutorial on how to make leris account .

What are the requirements?

Prepare your requirements as early as possible so you can apply early as well. According to the PRC website, you need these documents:

First-time takers

• PSA/NSO Birth Certificate (original and photocopy).
• For married female applicants, provide a copy of the PSA/NSO Marriage Contract.
• Transcript of Records with scanned photo and remarks “For board exam purposes”
• Duly Notarized copies of RLE, OR & DR cases (Minor Scrubs-3, Deliver Room Handled-3, Assisted-3, Cord Dressing-3, If under CMO 30- Certificate of Undertaking
• Notarized Certificate of Undertaking (CMO#14 series of 2009)
• Payment of 900 for complete while 450 for conditioned/ removal.

If you are a repeater, you need the exact requirement above except for the RLE and OR & DR Cases. The payment for the repeater is P450.

Nursing Board Exam Coverage

The Board determines the scope of the examination for the practice of nursing in the Philippines

The Philippine Nurses Licensure Examination consists of five parts: Nursing Practice 1 up to 5.

• I – Community Health Nursing
• II – Care of Healthy/At Risk Mother and Child
• III – Care of Clients with Physiologic and Psychosocial Alterations (Part A)
• IV –  Care of Clients with Physiologic and Psychosocial Alterations (Part B)
• V –  Care of Clients with Physiologic and Psychosocial Alterations (Part C)

In order to pass the examination, an examinee must obtain a general average of at least seventy-five percent (785%) with a rating of not below sixty percent (60%) in any subject.

If ever, an examinee obtains an average rating of seventy-five percent (75%) or higher but gets a rating below sixty percent (60%) in any subject, he/she must take the examination again but only in the subject or subjects where he/she is rated below sixty percent (60%). In order to pass the succeeding examination, an examinee must obtain a rating of at least seventy-five percent (75%) in the subject or subjects repeated. 

Good luck to our future Nurses!

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Prioritization, Delegation, and Assignment in Nursing NCLEX Practice Questions (100 Items)

In this NCLEX guide , we’ll help you review and prepare for prioritization, delegation, and assignment in your nursing exams. For this nursing test bank , improve your prioritization, delegation, and patient assignment skills by exercising with these practice questions. We will also be teaching you test-taking tips and strategies so you can tackle these questions in the NCLEX with ease. The goal of these practice quizzes and reviewers is to help student nurses establish a foundation of knowledge and skills on prioritization, delegation, and assignment.

Quiz Guidelines

Before you start, here are some examination guidelines and reminders you must read:

• Practice Exams : Engage with our Practice Exams to hone your skills in a supportive, low-pressure environment. These exams provide immediate feedback and explanations, helping you grasp core concepts, identify improvement areas, and build confidence in your knowledge and abilities.
• You’re given 2 minutes per item.
• For Challenge Exams, click on the “Start Quiz” button to start the quiz.
• Complete the quiz : Ensure that you answer the entire quiz. Only after you’ve answered every item will the score and rationales be shown.
• Learn from the rationales : After each quiz, click on the “View Questions” button to understand the explanation for each answer.
• Free access : Guess what? Our test banks are 100% FREE. Skip the hassle – no sign-ups or registrations here. A sincere promise from Nurseslabs: we have not and won’t ever request your credit card details or personal info for our practice questions. We’re dedicated to keeping this service accessible and cost-free, especially for our amazing students and nurses. So, take the leap and elevate your career hassle-free!
• Share your thoughts : We’d love your feedback, scores, and questions! Please share them in the comments below.

Prioritization, Delegation, and Assignment Practice Quiz

This section contains the practice questions to exercise your knowledge on nursing prioritization, delegation, and assignment. As with other quizzes, be sure to read and understand the question carefully. For prioritization, delegation, and assignment questions, read each choice carefully before deciding on your answer. Good luck and answer these questions at your own pace. You are here to learn.

Quizzes included in this guide are:

Nursing Prioritization, Delegation and Assignment Reviewer for Nurses

This is your guide to help you answer NCLEX priority, delegation, and assignment style questions.

NCLEX Tips for Nursing Prioritization, Delegation, and Assignment questions:

Here are six tips and strategies to help you ace NCLEX questions about delegation, assignment, and prioritization.

1. Do not make decisions based on resolutions

Do not make decisions concerning the management of care issues based on resolutions you may have witnessed during your clinical experience in the hospital or clinic setting. As a student nurse, you are constantly reminded that NCLEX questions are to be solved and responded to in the context of “Ivory Tower Nursing.” That is, if you only had one patient at a time, loads of assistive personnel, countless supplies, and equipment. This is what people mean when they refer to “ textbook nursing .” But when you’re in the real world without the time and resources, you adjust. Your clinical rotation in management may have been less than ideal but remember that in NCLEX, the answers to the questions are seen in nursing textbooks or journals. Always bear in mind, “Is this textbook nursing care?”

2. Never delegate the functions of assessment, evaluation and nursing judgment.

Throughout your nursing education, you learned that assessments, nursing diagnosis , establishing expected outcomes, evaluating care and any other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge are the responsibilities of the registered professional nurse. You cannot give these responsibilities to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides.

3. Identify tasks for delegation based on the client’s needs.

Delegate activities for stable patients because some of these needs are relatively predictable and more frequently encountered. These are somewhat routinized and without the need for high levels of professional judgment and skill. But if the patient is unstable, the needs are acute and become unpredictable, ever-changing, and rarely encountered based on the patient’s changing status. These needs should not be delegated.

4. Ensure the appropriate education, skills, and experience of personnel performing delegated tasks.

Delegate activities that involve standard, consistent, and unchanged systems and procedures. The care of a patient with chest tubes and chest drainage can be delegated to either another RN or a licensed practical nurse. Therefore, the authorizing RN must ensure that the nurse is qualified, skilled, and competent to perform this intricate task, observe the patient’s response to this treatment, and ensure that the equipment is operating suitably and accurately.

The care of a stable chronically ill patient who is comparatively stable and more anticipated than a seriously ill and unstable acute patient can be assigned to the licensed practical nurse, and assistance with the activities of daily living and basic hygiene and comfort care can be assigned and delegated to an unlicensed assistive staff member like a nursing assistant or a patient care technician. Activities that frequently occur in daily patient care can be delegated. Bathing, feeding , dressing, and transferring patients are examples.

Procedures that are complex or complicated should not be delegated, especially if the patient is highly unstable.

5. Remember priorities!

Recall and understand Maslow’s Hierarchy of Needs , the ABCs (Airway, Breathing, Circulation), and stable versus unstable. It is necessary to know and understand the priorities when deciding which patient the RN should attend to first. Remember that you can see only one patient or perform one activity when answering questions that require you to establish priorities.

Always keep in mind that improper and inappropriate assignments can lead to inadequate quality of care, unexpected care outcomes, the jeopardization of client safety, and even legal consequences. Right assignment of care to others, including nursing assistants, licensed practical nurses, and other registered nurses, is certainly one of the most significant daily decisions nurses make.

6. Additional Test Taking Tips and Strategies

• Questions using keywords such as “ best ,” “ essential ,” “ highest priority ,” “ primary ,” “ immediate ,” “ first ,” or “ initial response ” are asking for your prioritizing skills.
• Know the patient’s purpose of care, current clinical condition, and outcome of care in order to determine and plan priorities.
• Identify the priority patient based on the following: patient’s age, day of admission/ surgery , or the number of body systems involved.
• Unlicensed assistive personnel (UAP) such as nurses’ aides, certified nursing assistants, attendants, health aides are not allowed to delegate. Only a registered nurse can delegate tasks. 
• In some states, Licensed Practical Nurses ( LPN ) may delegate to a UAP depending on the state nursing practice.   
• Ensure the appropriate knowledge, skills, and experience of personnel performing the delegated tasks.
• Do not delegate teaching, assessment , planning , evaluating, and nursing judgment to an unlicensed nurse.
• A client with an unstable and unpredictable condition cannot be delegated to a UAP’s or LPNs.
• Delegate tasks that involve standard, simple procedures such as bathing, dressing, feeding, and transferring patients.
• Student nurses, float nurses, personal assistants, and other personnel may require levels of guidance and supervision.

Nursing Prioritization

Prioritization is deciding which needs or problems require immediate action and which ones could be delayed until later because they are not urgent. In the NCLEX, you will encounter questions that require you to use the skill of prioritizing nursing actions. These nursing prioritization questions are often presented using the multiple-choice format or via ordered-response format. For a review, in an ordered-response question format , you’ll be asked to use the computer mouse to drag and drop your nursing actions in order or priority. Based on the information presented, determine what you’ll do first, second, third, and so forth. Directions are provided with the question. To help you answer nursing prioritization questions, remember the three principles commonly used:

1. Remember ABC’s (airway, breathing, and circulation).

Patients with obvious respiratory problems or interventions to provide airway management are given priority.

2. Maslow’s Hierarchy of Needs

Use Maslow’s hierarchy of needs as a guide to prioritize by determining the order of priority by addressing the physiological needs first.

There are five different levels of Maslow’s hierarchy of needs:

• Physiological Needs. The basic physiological needs have the highest priority and must be met first. Some examples of physiological needs include oxygen, food, fluid, nutrition , shelter, sleep , clothing, and reproduction.
• Safety Needs. Safety can be divided into physical and physiological. These include health, property, employment, security of the environment, and resources.
• Social Needs. These include love, family, friendship, and intimacy.
• Esteem. These include confidence, self-esteem , respect, and achievement.
• Self-actualization. These include creativity, morality, and problem-solving.

3. Using the Nursing Process

The nursing process is a systematic approach to assess and give care to patients. Assessment should always be done first before planning or providing interventions.

Delegation in Nursing

Delegation is the transference of responsibility and authority for an activity to other health care members who are competent to do so. The “delegate” assumes responsibility for the actual performance of the task and procedure. The nurse (delegator) maintains accountability for the decision to delegate and for the appropriateness of nursing care rendered to the patient. The role of a registered nurse also includes delegating care, assigning tasks, organizing and managing care, supervising care delivered by other health care providers while effectively managing time! The NCLEX includes questions related to this unique nursing role of delegation.

5 Rights of Delegation in Nursing

The following are the five rights of delegation in nursing:

• Right Person. The licensed nurse and the employer and the delegatee are responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity.
• Right Tasks. The activity falls within the delegatees’ job description or is included as part of the nursing practice settings established written policies and procedures. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
• Each delegation situation should be specific to the patient, the licensed nurse, and the delegatee.
• The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee should ask any clarifying questions as part of two-way communication. This communication includes any data that needs to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation.
• The delegatee must understand the terms of the delegation and must agree to accept the delegated activity.
• The licensed nurse should ensure that the delegatee understands that she or he cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse.
• Right Circumstances. The health condition of the patient must be stable. If the patient’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation.
• The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating patient outcomes. The delegatee is responsible for communicating patient information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary.
• The licensed nurse should ensure appropriate documentation of the activity is completed.

Recommended Resources

Recommended books and resources for your NCLEX success:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

Illustrated Study Guide for the NCLEX-RN® Exam The 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. This study guide gives you a robust, visual, less-intimidating way to remember key facts. 2,500 review questions are now included on the Evolve companion website. 25 additional illustrations and mnemonics make the book more appealing than ever.

NCLEX RN Examination Prep Flashcards (2023 Edition) NCLEX RN Exam Review FlashCards Study Guide with Practice Test Questions [Full-Color Cards] from Test Prep Books. These flashcards are ready for use, allowing you to begin studying immediately. Each flash card is color-coded for easy subject identification.

Recommended Links

An investment in knowledge pays the best interest. Keep up the pace and continue learning with these practice quizzes:

• Nursing Test Bank: Free Practice Questions UPDATED ! Our most comprehenisve and updated nursing test bank that includes over 3,500 practice questions covering a wide range of nursing topics that are absolutely free!
• NCLEX Questions Nursing Test Bank and Review UPDATED! Over 1,000+ comprehensive NCLEX practice questions covering different nursing topics. We’ve made a significant effort to provide you with the most challenging questions along with insightful rationales for each question to reinforce learning.

10 thoughts on “Prioritization, Delegation, and Assignment in Nursing NCLEX Practice Questions (100 Items)”

Very helpful. A LPN graduate who has taken the nclex four times. It gives me a quick overview. Thanks

Love it!!! These made me think. They up there with ReMar and uWorld.

Very helpful thanks

In which order will the nurse perform the following actions as she prepares to leave the room of a client with airborne precautions after performing oral suctioning?

please your order for this question is wrong

I have learned a lot from the NursesLabs. Love it!

Nurse Pietro receives an 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take FIRST? First- Speak with parents as to how injury occurred??? Yes, this is going to take place but this the first thing to do? Perhaps the wording needs to change as I have been “textbook” taught, treat first, then question in cases of suspected abuse.

good questions which test your analyzing and critical thinking skils

Thank you for making this free. It is my additional resources. This has been very helpful. I really appreciate that you are helping all future nurses to be at their best .

I’m really grateful for this excercise which aids in preparing for the NCLEX. Thanks

This has help me pass my nclex !! Thanks

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Home / NCLEX-RN Exam / Assignment, Delegation and Supervision: NCLEX-RN

Assignment, Delegation and Supervision: NCLEX-RN

Identifying tasks for delegation based on client needs, the "right task" and the "right person": identifying tasks for delegation based on client needs, ensuring the appropriate education, skills, and experience of personnel performing delegated tasks, assigning and supervising the care provided by others, communicating tasks to be completed and report client concerns immediately, organizing the workload to manage time effectively, utilizing the five rights of delegation, evaluating delegated tasks to ensure the correct completion of the activity or activities, evaluating the ability of staff members to perform the assigned tasks for the position, evaluating the effectiveness of staff members' time management skills.

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

• Identify tasks for delegation based on client needs
• Ensure appropriate education, skills, and experience of personnel performing delegated tasks
• Assign and supervise care provided by others (e.g., LPN/VN, assistive personnel, other RNs)
• Communicate tasks to be completed and report client concerns immediately
• Organize the workload to manage time effectively
• Utilize the five rights of delegation (e.g., right task, right circumstances, right person, right direction or communication, right supervision or feedback)
• Evaluate delegated tasks to ensure correct completion of activity
• Evaluate the ability of staff members to perform assigned tasks for the position (e.g., job description, scope of practice, training, experience)
• Evaluate the effectiveness of staff members' time management skills

The assignment of care to others, including nursing assistants, licensed practical nurses, and other registered nurses, is perhaps one of the most important daily decisions that nurses make.

Proper and appropriate assignments facilitate quality care. Improper and inappropriate assignments can lead to poor quality of care, disappointing outcomes of care, the jeopardization of client safety, and even legal consequences.

For example, when a registered nurse delegates aspects of patient care to a licensed practical nurse that are outside of the scope of practice of the licensed practical nurse, the client is in potential physical and/or psychological jeopardy because this delegated task, which is outside of the scope of practice for this licensed practical nurse, is something that this nurse was not prepared and educated to perform. This practice is also illegal and it is considered practicing outside of one's scope of practice when, and if, this licensed practical nurse accepts this assignment. All levels of nursing staff should refused to accept any assignment that is outside of their scope of practice.

• How is the Scope of Practice Determined for a Nurse?
• Scope of Practice vs Scope of Employment
• RN Scope of Practice

Delegation, simply defined, is the transfer of the nurse's responsibility for the performance of a task to another nursing staff member while retaining accountability for the outcome. Responsibility can be delegated. Accountability cannot be delegated. The delegating registered nurse remains accountable for all client care despite the fact that some of these aspects of care can, and are, delegated to others.

Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs' position description or job descriptions, the employing facility's policies and procedures, and legal aspects of care such as the states' legal scopes of practice for nurses, nursing assistants and other members of the nursing team.

The " Five Rights of Delegation " that must be used when assigning care to others are:

• The "right" person
• The "right" task
• The "right" circumstances
• The "right" directions and communication and
• The "right" supervision and evaluation

In other words, the right person must be assigned to the right tasks and jobs under the right circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or job. The nurse supervises the person and determines whether or not the job was done in the correct, appropriate, safe and competent manner.

The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

Some client needs are relatively predictable; and other patient needs are unpredictable as based on the changing status of the client. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routinized and without the need for high levels of professional judgment and skill. Some client needs are acute, ever changing and/or rarely encountered; and other patient needs are chronic, relatively stable, more predictable, and more frequently encountered.

Based on these characteristics and the total client needs for the group of clients that the registered nurse is responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to.

For example, a new admission who is highly unstable should be assigned to a registered nurse; the care of a stable chronically ill patient who is relatively stable and more predictable than a serious ill and unstable acute client can be delegated to the licensed practical nurse; and assistance with the activities of daily living and basic hygiene and comfort care can be assigned and delegated to an unlicensed assistive staff member like a nursing assistant or a patient care technician. Lastly, the care of a client with chest tubes and chest drainage can be delegated to either another registered nurse or a licensed practical nurse, therefore, the registered nurse who is delegating must insure that the nurse is competent to perform this complex task, to monitor the client's response to this treatment, and to insure that the equipment is functioning properly.

The staff members' levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for. Some staff members may possess greater expertise than others. Some, such as new graduates, may not possess the same levels of knowledge, past experiences, skills, abilities, and competencies that more experienced staff members possess. Some may even be more competent in some aspects of client care than other aspects of client care. For example, a licensed practical nurse on the medical surgical floor may have more knowledge, skills, abilities, and competencies than a registered nurse in terms of chest tube maintenance and care because they may have, perhaps, had years of prior experience in an intensive care area of another healthcare facility before coming to your nursing care facility.

Delegation should be done according to the differentiated practice for each of the staff members. A patient care technician, a certified nursing assistant, a licensed practical nurse, an associate degree registered nurse and a bachelor's degree registered nurse should not be delegated to the same aspects of nursing care. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.

Also, staff members differ in terms of their knowledge, skills, abilities and competencies. A staff member who has just graduated as a certified nursing assistant and a newly graduated registered nurse cannot be expected to perform patient care tasks at the same level of proficiency, skill and competency as an experienced nursing assistant or registered nurse. It takes time for new graduates to refine the skills that they learned in school.

Validated and documented competencies must also be considered prior to assignment of patient care. No aspect of care can be assigned or delegated to another nursing staff member unless this staff member has documented evidence that they are deemed competent by a registered nurse to do so. For example, a newly hired certified nursing assistant cannot perform bed baths until a supervising registered nurse has observed this certified nursing assistant provide a bed bath and has decided that they are now competent to do this task without direct supervision.

All healthcare facilities and agencies must assess and validate competency before total care or any aspect of care is performed by an individual without the direct supervision of another, regardless of their years of experience. Competency checklists are used to document the competency of the staff; they must be referred to as assignments are made. Care can be delegated to another only when that person is deemed competent to perform the role or task and this competency is documented.

Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians.

The job of the registered nurse is far from done after client care has been delegated to members of the nursing team. The delegated care must be followed up on and the staff members have to be supervised as they deliver care. The registered nurse remains responsible for and accountable for the quality, appropriateness, completeness, and timeliness of all of the care that is delivered.

The supervision of the care provided by others includes the monitoring the care, coaching and supporting the staff member who is providing the care, assisting the staff member with priority setting and time management skills, as indicated, educating the staff member about the proper provision of care, as indicated by a knowledge or skills deficit, and also praising and positively reinforcing the staff for a job well done.

Remember, the delegating registered nurse is still responsible and accountable for all of the client care that is delegated to others.

Registered nurses who assign, delegate and/or provide nursing care to clients and groups of clients must report all significant changes that occur in terms of the client and their condition. For example, a significant change in a client's laboratory values requires that the registered nurse report this to the nurse's supervisor and doctor.

They must also communicate and document all tasks that were completed and the client's responses to this treatment. As the old adage says, "If it wasn't documented, it wasn't done."

Time is finite and often the needs of the client are virtually infinite. Time management, organization, and priority setting skills, therefore, are essential to the complete and effective provision of care to an individual client and to a group of clients.

Priorities of care, as previously discussed, are established using a number of methods and frameworks including the ABCs, Maslow's Hierarchy of Needs and the ABCs/MAAUAR method of priority setting.

Some time management techniques, in addition to priority setting, that you may want to consider using to insure that you manage your workload and time effectively include:

• Clarifying your assignment as necessary
• Planning your work in an orderly and systematic manner knowing that priorities and clients' status change frequently
• Avoiding all unnecessary interruptions
• Learning how to say no to others when they ask you for help and you have priority patient needs that would not be addressed if you helped another

As previously discussed, all delegation may be based on the "Five Rights of Delegation" which are:

• The "right" directions and communication

In addition to the supervision of delegated tasks in terms of quality, appropriateness, and timeliness, the registered nurse who has delegated tasks must insure that the assigned activities have been correctly completed.

When assignments are made, the registered nurse must insure that the staff member will have ample time during the shift to complete the assignment and, then, the registered nurse must monitor and measure the staff members' progress toward the completion of assigned tasks throughout the duration of the shift.

This monitoring must be done in an ongoing and continuous manner and not at the end of the shift when it is too late to make corrections.

As previously discussed, staff members should have documented competency for all tasks that are assigned to them. All nursing team members have the responsibility, however, to refuse an assignment if they believe that they cannot do it properly. When this occurs, the registered nurse should either teach the staff member how to perform the task and then document their competency in terms of this assigned task or assign the task to another nursing team member who has documented competency and is sure that they can perform the task in a correct manner.

Part of supervision entails the ongoing evaluation of staff's ability by the registered nurse to perform assigned tasks using direct observations and with indirect observations of patient safety, the quality of the care provided, the appropriateness of care provided, and the timeliness of care provided. For example, the registered nurse can directly observe the performance of the nursing assistant while the client is being transferred from the bed to the chair; and the registered nurse can review the medication administration record to determine if the licensed practical nurse has administered medications in a timely manner which is an example of indirect observation.

The ability of a staff member to perform a specific task is not only based on their competency but it is also based on their:

• Legal scope of practice,
• Documented competency,
• Education and training,
• Past experiences,
• Position description which is also referred to as the job description and
• Healthcare facility specific policies and procedures.

All states throughout our nation have legally legislated scopes of practice for registered professional nurses, licensed practical or vocational nurses, and advanced nursing practice nurses; and they also have legal guidelines related to what an unlicensed, assistive staff member, such as a student nurse technician, patient care aide, patient care technician or nursing assistant, can and cannot legally perform regardless of whether or not the healthcare provider or the delegating nurse believes that they are competent to do.

Although these legal, legislated scopes of practice may vary a little from state to state, they share a lot of commonalities and similarities. For example:

• The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
• The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement and evaluate care under the direct supervision and guidance of the registered nurse.
• The scope of practice for an advanced practice nurse, such as a nurse practitioner, will most likely include the legal ability of the advanced practice registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation in addition to prescribing some medications.

Nurses violate scope of practice statutes, or laws, when they function in roles and aspects of care that are above, beyond and/or not included in their scope of practice. Permanent license revocation may occur when a nurse practices outside of the legally mandated scope of practice. Additionally, licensed nurses who have failed to either reapply for their license or have had it revoked as part of a state disciplinary action cannot and continue to practice nursing are guilty of practicing nursing without a license.

Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment and professional knowledge.

Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the nurse include:

• Assisting the client with their activities of daily living such as ambulation, dressing, grooming, bathing and hygiene
• Measuring and recording fluid intake and output
• Measuring and recording vital signs, height and weight
• The provision of nonpharmacological comfort and pain relief interventions such as establishing and maintaining an environment conducive to comfort and providing the client with a soothing and therapeutic back rub
• Observation and reporting changes in and the current status of the patient’s condition and reactions to care
• The transport of clients and specimens and other errands and tasks such as stocking supplies
• Assistance with transfers, range of motion, feeding, ambulation, and other tasks such as making beds and assisting with bowel and bladder functions

In addition to the legally mandated state scopes of practice, the registered nurse must also insure that the delegated tasks are permissible according to the nursing team members' position description which is also referred to as the job description, and the particular facility's specific policies and procedures relating to client care and who can and who cannot perform certain tasks.

For example, intravenous bolus and push medications may be permissible for only licensed registered nurses in certain areas of the healthcare facility such as the intensive care units; the administration of blood and blood components may be restricted to only registered nurses; and the care of a client who is receiving conscious sedation may be restricted to only a few registered nurses in the particular healthcare facility, according to these job descriptions, policies and procedures.

As previously mentioned, the registered nurse must allot a reasonable amount of time for staff members to complete their assignments when care and tasks are delegated. The staff should be able to complete their assignments within the allocated period of time. When an assignment is not done as expected, the delegating nurse should determine why this has occurred and they must take corrective actions to insure task completion.

One of the things that the delegating nurse will want to consider when an assignment is not completed within the allotted time frame is determining whether or not the staff member is organizing their work and using effective time management skills. If the staff member is not using effective time management skills, the nurse must teach and assist the staff member about better time management and priority setting skills.

RELATED NCLEX-RN MANAGEMENT OF CARE CONTENT:

• Advance Directives
• Assignment, Delegation and Supervision (Currently here)
• Case Management
• Client Rights
• Collaboration with Interdisciplinary Team
• Concepts of Management
• Confidentiality/Information Security
• Continuity of Care
• Establishing Priorities
• Ethical Practice
• Informed Consent
• Information Technology
• Legal Rights and Responsibilities
• Performance Improvement & Risk Management (Quality Improvement)

SEE – Management of Care Practice Test Questions

• Recent Posts

The Benefits of Nurse-to-Patient Staffing Ratio Laws and Regulations

• For every patient added to a nurse’s workload, the risk of patient harm increases significantly.
• Mandated nurse-to-patient ratios are a proven way to save lives.
• California and Massachusetts are the only states with nurse-to-patient ratio laws.

Most healthcare facilities use staffing guidelines to decide a nurse’s assignment on a given shift. They may follow hospital-specific staffing ratios to ensure nurses have safe workloads. However, current staffing shortages are pushing nurse-to-patient ratios to the limit.

Could laws and regulations prevent nursing workloads from getting out of control? Learn how nurse staffing ratio laws and regulations can protect patients and nurses.

Why There’s a Push to Mandate Nurse Staffing

The nursing shortage has increased since COVID-19. Nurses have left the bedside because of nurse burnout , fatigue, and unsafe working conditions. This postpandemic nursing shortage creates heavier workloads for nurses.

Nurses remaining at the bedside are assigned higher volumes of sicker patients. As managers and charge nurses make patient assignments, they’re placed in a difficult position: How can one divide up so many patients among so few nurses?

Safe staffing mandates are the most effective way to hold hospitals accountable.

Current Safe Patient Ratio Laws

Currently, two states have laws concerning safe patient ratios. In 2014, Massachusetts enacted a law regulating how many patients a nurse can care for in the intensive care unit (ICU).

Nurses in Massachusetts should only care for one patient in the ICU. If they must accept a second patient, the nurse should use clinical judgment to determine if the assignment is safe. Nurses must complete an acuity tool to evaluate patients’ stability.

In 2004, California passed a law for numerical nurse staffing ratios. The law defines how many patients a nurse can care for in acute care, psychiatric, and specialty hospitals.

Here’s a guideline for standard nurse-to-patient ratios in California:

• 1:3 Step down
• 1:4 Emergency room
• 1:5 Medical-surgical

Since incorporating mandated nurse-to-patient ratios, California has seen improved patient outcomes and staff retention.

Popular MSN Programs

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

What Nurse Staffing Laws and Regulations Mean for Patients

The ultimate goal of staffing ratios is to ensure patients get the care they deserve. When there are limits to the number of patients in a nursing workload, nurses can spend more quality time with patients. Nurses can assess status changes and attend to patients’ needs better.

Improved Quality of Care

Linda Aiken, Ph.D., RN, conducted a study examining the correlation between nurse-to-patient ratios and patient outcomes.

In this study, patients in “well nurse resourced hospitals” had better outcomes. With adequate nurse staffing, patients had:

• Shorter hospital stays
• Less hospital-acquired infections
• Fewer ICU admissions
• Fewer deaths

The study found that adequate staffing ratios led to a better quality of care.

More Affordable Healthcare

The Centers for Medicare and Medicaid Services (CMS) uses a value-based approach to reimburse hospitals. This incentivizes hospitals to meet quality markers to receive reimbursements.

One example is the Hospital Readmissions Reduction Program (HRRP). Hospitals will not be reimbursed for a patient’s stay if they are readmitted to the hospital within 30 days of discharge.

Nurses do not have time to provide thorough discharge teaching during staffing shortages. Patients with complex health needs may be sent home with several medications and care instructions they don’t fully understand.

Aiken’s study found that readmission rates increased significantly for every extra patient added to a nurse’s workload. Patients admitted for acute myocardial infarction, heart failure, and pneumonia had readmission rates of 6-9% due to short staffing.

With mandated staffing ratios, nurses will have more one-on-one time with their patients. Patients will have more opportunities to ask questions about their care to avoid readmission.

Safe staffing ratios allow hospitals to be compliant with programs like HRRP. This adds funds to hospital budgets and may lower healthcare costs.

Greater Transparency

Patients deserve to know the nurse staffing ratios at hospitals. This may help guide their decision on where to go for a planned hospital stay. Transparent staffing ratios reassure patients that their health is safe in a hospital’s care.

Until staffing ratios are mandated in each state, hospitals can be transparent with patients by

reporting hospital staffing ratios to the public . States that mandate public reporting of hospital staffing include:

• Rhode Island

Aiken says the federal government has a responsibility to address nurse-to-patient ratios. She suggests, at a minimum, hospitals should report their ratios to the CMS in exchange for incentives like reimbursements.

What Nurse Staffing Laws and Regulations Mean for Nurses

Healthcare leaders are constantly evaluating strategies to address the nursing shortage . To take a root-cause approach, they should consider creating mandated staffing ratios. This can help retain nurses by creating a safer work environment.

Safer Working Conditions

In the aftermath of the pandemic, patients come to the hospital with increasingly complex needs. With current staffing shortages, nurses are assigned higher volumes of patients per assignment.

These two factors cause a major challenge for nurses. By limiting the number of patients a nurse can oversee, there is less margin for error for nurses .

Nurses will have more opportunities to focus on the complex needs of a typical patient load.

Staffing ratios create a safer workplace, which leads to nurse retention . National Nurses United found that staff turnover is significantly lower in states with mandated ratios than in states without regulation.

Staff turnover is costly for healthcare facilities. Many hospitals use travel nurses during staffing shortages, which is also expensive.

Hospitals will save money on training new or temporary nurses by using strategies to promote staff retention. This may open up funds to increase wages for staff nurses .

Healthcare leaders who commit to safe staffing ratios promise to value nurses. This is leadership’s way of saying they support nurses by giving them the tools to do their job. They’re telling staff that they’re committed to patient safety.

Better Work-Life Balance

Would you like to work less overtime? With mandatory staffing ratios, managers will be accountable for adequately staffing your unit each shift. You’ll be able to enjoy your days off without being pressured to come in to cover short shifts.

How to Advocate for Safe Nurse Staffing in Your State

Lawmakers are currently advocating for safe patient ratios. In May 2021, Illinois Representative Janice Schakowsky introduced a safe staffing bill to Congress.

The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act would require hospitals to limit the number of patients a nurse cares for on a given shift.

Nurses would be legally protected to refuse unsafe assignments — and hospitals could be fined for breaking ratios. The bill has not moved past its introduction in 2021.

You can bring attention to nurse staffing issues in your state by contacting your local constituents .

Here are a few other organizations you can get involved with:

• Academy of Medical-Surgical Nurses
• National Nurses United
• Nurse Advocacy Association

Until federal mandates are placed for nurse-to-patient ratios, you can advocate for safe staffing by joining staffing committees within your hospital. This is a productive way for nurses to have a say in patient workloads within your healthcare setting.

You might be interested in

How Short-Staffing and Unsafe Patient Ratios Led to the Sentencing of Former Nurse Christann Gainey

Nurse Christann Ganiey pleaded guilty for the 2018 death of 84-year-old Herbert R. McMaster Sr. Short-staffing, a high patient-to-nurse ratio, and lack of administration support are also to blame.

How States Are Addressing the Nursing Shortage

The pandemic has highlighted many ongoing issues in the nursing profession, especially the shortage of nurses. Review what states are doing to manage the deficit and address the issue looking forward.

Supporting Nurses’ Mental Health: An Open Letter to Nurse Leaders During COVID-19

Find out how one nurse leader has handled the pressures of the pandemic and advice on supporting nurses’ mental health.

Patient acuity tool on a medical-surgical unit

Use a tool for consistent, objective, and quantifiable patient assignments..

• Patient assignments can lead to dissatisfaction among nursing staff, especially when they’re not consistent, objective, and quantifiable.
• Dissatisfaction can create barriers to the adaptability and teamwork that are critical to good patient care.
• The patient acuity tool addresses the important issue of unbalanced nurse-patient assignments and helps nurses influence decision-making in their organizations.

Patient assignments can lead to dissatisfaction among nursing staff, especially when they’re not consistent, objective, and quantifiable. This dissatisfaction can create barriers to the adaptability and teamwork that are so critical to good patient care.

In 2016, three RNs on a complex 23-bed medical-surgical unit at Durham VA Health Care System identified a recurring complaint by nursing staff that patient assignments were inconsistent and unequal. An average of five RNs and one charge nurse were assigned five patients per nurse per shift. The nursing assignment system included placing patients in one of two categories: “standard patient” or “involved care” patient. The problem was the subjectivity of these terms; they had no supporting evidence. The result was frustrated nurses, which prompted the unit to develop a process improvement project.

Standardizing handoff communication

The Bedside Mobility Assessment Tool 2.0

Hours per patient day: Understanding this key measure of productivity

Purpose and goals

We used evidence-based information to create an objective acuity tool to establish patient assignments. The tool uses both clinical patient characteristics and workload indicators to score patients from 1 to 4 based on acuity level. This approach gives nurses the power to score their patient, then report to the charge nurse so that RN assignments for the oncoming shift are quantifiable and equitable. It also gives them the opportunity to assess the level of patient safety risk.

The goals of the tool are to:

• increase nurse satisfaction with their patient assignment
• increase nurse perception of patient safety by assigning patients with high acuity scores equitably.

The patient acuity tool

Each patient is scored on a 1-to-4 scale (1, stable patient; 2, moderate-risk patient; 3, complex patient; 4, high-risk patient) based on the clinical patient characteristics and the care involved (workload.) Each nurse scores his or her patients, based on acuity, for the upcoming shift and relays this information to the charge nurse, who then assigns patients before the shift change. The handoff report between RNs allows each to validate patients’ current acuity and care needs. (See Patient acuity tool .)

Methodology

Anecdotal reports by the RN staff and our observations prompted the collection of data from staff. Some of the staff comments about the current system included:

• “Why are my patient assignments so unfair?”
• “How will I care for all of my patients effectively?”
• “Involved care is a subjective term.”

We conducted a literature review and eventually combined two existing tools and restructured them to create our acuity tool. Before implementing the process improvement project, we used the newly created tool to assess the current average distribution of total acuity among nurse assignments, and we asked RNs to complete a 10-question survey to measure their satisfaction with patient assignments and perceptions of patient safety. We then taught the RNs how to use the tool and placed color-coded, laminated copies at every nursing computer.

The tool was pilot tested for 28 days. After the first 14 days, we conducted an audit to assess compliance, which revealed that average compliance among all four shifts was 35%. We then collected data on the average distribution of total acuity among nurse assignments. Progress e-mails were sent to staff, and individual follow-ups were held to promote compliance. At the end of the 28 days, we conducted another compliance audit, which revealed an average compliance among all four shifts of 77%, an increase of 220%.

At the end of the pilot study, we reviewed patient assignments before and after implementing the acuity tool to assess their equality, and we surveyed RNs about the two goals we set for the project: improve nurse satisfaction and increase nurse perception of patient safety.

Equality of patient assignments

To determine the equality of nurses’ assignments within a shift, the difference in total acuity between the highest and lowest scoring assignments was obtained. (See RN assignments using acuity tool .)

Before implementing the acuity tool, the average distribution of total acuity between highest and lowest nurse assignments for each shift was 4.83 (using a scale of 1 = lowest acuity and 4 = highest acuity). After implementation, the average distribution of total acuity between highest and lowest nurse assignments was 3.06, a 36.6% improvement in equality and accuracy.

Goal 1: Improve nurse satisfaction

Three of the 10 questions in the nurse survey were aimed at nurse satisfaction, including RN perception of patient assignment equality, having input into making assignments, and frequency of feeling overwhelmed with patient assignments. The most significant change occurred with the question “Please rate how frequently you feel overwhelmed with your patient assignment.” Response options were never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). According to the survey, the weighted average of nurse satisfaction was 3.19 before implementing the acuity tool and 2.84 (11% improvement) after.

Goal 2: Increase nurse perception of patient safety 

When asked to respond to the statement “I feel like patient safety is a concern when I accept my patient assignment,” RN staff chose from the following options: never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). The weighted average was 3.38 pre-implementation and 3.21 post-implementation, a 5% improvement in RNs’ perception of patient safety. After reviewing the annual performance improvement data, we found no direct correlation between using the acuity tool and patient safety measurements (rate of falls, medication errors, and restraint use). However, by distributing high-acuity patients among nurses, this tool, used in conjunction with other current actions, can reduce the need for patient safety measures such as using sitters and frequent rounding.

We attributed many of the challenges faced during the implementation of this project to staff assignment changes during some 24-hour periods. Sometimes patient assignments changed every 4 hours because of differences in nurse shift length, which left the staff with no consistent communication between shifts. The charge nurse would also occasionally take a patient assignment when patient acuity was high and RN census was low, resulting in outliers in data.

Another challenge included RN staff changes during the pilot study, leading to gaps in education about proper use of the tool, decreased feedback, and less data in post-implementation than pre-implementation. As part of our sustainment plan, we’ll incorporate education on the tool in new staff orientation, adapt it to other medical-surgical units in the hospital, and continue quarterly audits to assess compliance.

Given the original concern by staff that assignments were unequal, one of the strengths of this acuity tool is that it allows nurses to become stakeholders in making patient assignments. In addition, it also gives the charge nurse an objective way to justify assignment rationale. The tool costs no money to implement and requires no special technology. In addition, it’s noninvasive to the unit’s workflow, easy to implement, and easily adapted to different units and their specific needs. We’ve also found that the tool enhances the shift-to-shift handoff report and that it can be used to assign patients based on nurse competence (novice nurses, expert nurses, etc.).

Striking a balance

The patient acuity tool addresses the important issue of unbalanced nurse-patient assignments and helps nurses influence decision-making in their organizations. Our research found that an objective patient acuity tool on a medical-surgical floor could increase assignment equality, improve nurse satisfaction, and improve nurse perception of patient safety. The tool is now being piloted on other units at this facility, and we’ve received consults from other facilities in the Veterans Affairs Health Care System.

Andrea Ingram is a medical-surgical certified nurse at the VA Health Care System in Durham, North Carolina. Jennifer Powell is a neonatal intensive care unit nurse at Novant Health Hemby Children’s Hospital in Charlotte, North Carolina.

Selected references

Chiulli KA, Thompson J, Reguin-Hartman KL. Development and implementation of a patient acuity tool for a medical-surgical unit . Academy of Medical-Surgical Nurses. 2014;23(2):1, 9-12.

Kidd M, Grove K, Kaiser M, Swoboda B, Taylor A. A new patient-acuity tool promotes equitable nurse-patient assignments . American Nurse Today. 2014;9(3):1-4.

24 Comments .

Hello, I am working on my DNP project and wondering if I could utilize the PAT here during my study citing it appropriately?

Thank you Nikki

would like to know more about this classification tool, is it still in use or has it been revised? can it be used without copywrite restrictions? is it electronically available

Yes, you can use it but must source the tool appropriately.

I am interested to know how to utilize this acuity tool. I have several nurses complain about assignments, this might be something that our unit could utilize to better assignments.

My name is Tijuana L Parker and we want to use your tool on our unit to see if we can balance the assignments better and improve nurse satisfaction.

Hi Mrs. Andrea Ingram, and Jennifer Powell,

I would like to ask if there is any educational material on how di you roll out your acuity tool.

Dear Mrs. Andrea Ingram, and Jennifer Powell

My name is Myriam Valdema, a DNP student. Thank you for such a fantastic study. I am writing my final project on a patient-acuity tool’s effect on job satisfaction in a medical-surgical Unit. We are currently using the block method to make assignments, and it is not working well for the nurses. With your permission, I would like to use the tool to provide better patient assignments while improving patients’ safety.

Sincerely, Myriam Valdema BSN, RN

Thank you for the great article Andrea Ingram and Jennifer Powell. I am writing to seek permission to reuse the tool for our tertiary hospital. Let me know the psychometric properties of the tool or Has it been tested for validity and reliability. Sincerely Dr.Asha Raj Sudha

Dear Mrs. Andrea Ingram, and Jennifer Powell, Thank you for a very intersting study. We are interested in implementing it in our hospital. May we ask : 1) Is it applicable to all types of patient population or restricted to medical surgical as the the title of the article suggests? 2) Has it been tested for validity and reliability and can be safely used to assess the patients acuity. 3) Has it been successfuly in other hospitals? 4) Is there a copyright if want to use?

We started a project on my unit about four years ago using EPIC to created a tool for our surgical trauma progressive care. Working with our EMR nurse team, we were able to customize the tool to fit our patient population. If you would like more information, please let me know.

Patrice, I would love to know how you utilized EPIC to create an acuity tool. I am currently working on finding or creating one for my department. I would love if you could reach out to me. My personal email is wiels1987 at gmail. Thank you.

Interesting article, thank you for acknowledging and taking action to help improve a system. It would be ideal to have a universal acutiy tool that all units can adapt to their speciality. I was wondering how you than use this tool to decide how many staff you require on the ward? If you have so many orange and red level patients, are you able to aquire more staff? Or are you only using this tool to allocate patients equitably between the 5 staff you have?

I was wondering if we would be able to reference the acuity tool in an EVB project we are doing?

This is an interesting article, but I think the use of quantitative measures such as means on ordinal scales is incorrect. First, the score (1, stable patient; 2, moderate-risk patient; 3, complex patient; 4, high-risk patient) is made to be ordinal, therefore, the interpretation “the average distribution of total acuity between highest and lowest nurse assignments for each shift was 4.83” is not appropriate and should not be used. The difference between “stable patient”, “moderate-risk patient” and “complex patient” are not equal. In other words, one cannot assume that the difference between responses is equidistant even though the numbers assigned to those responses are. The same interpretive problem is present for the question “Please rate how frequently you feel overwhelmed with your patient assignment”. The response options were never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). The comment : “the weighted average of nurse satisfaction was 3.19 before implementing the acuity tool and 2.84 (11% improvement) after.”, is also incorrect. I would suggest reporting the percentage of each classes and the median (1). This would be transparent and avoid false interpretations if the answers were clustered at the high and low extremes.

Secondly, I understand the need to have an objective tool and I also chase this goal, but when I read the table “RN assignments using acuity tool”, I come to the conclusion that it is not at all objective and that the nurse’s classification is completely subjective. Either the tool needs to be less interpretation-free and have more quantitative criterias or the nurses need to have the same interpretation of each criteria before using the tool.

I want to thank you for your work as it is a great start and hope you continue to enhance this potentially powerful tool.

Vincent Morissette-Thomas, Statistician and Data Scientist

1. Sullivan, Gail M., and Anthony R. Artino Jr. “Analyzing and interpreting data from Likert-type scales.” Journal of graduate medical education 5.4 (2013): 541-542.

Nice article on acuity. Many years I developed numerous acuity systems from P.I.C.U., to ED and Psychiatric units.

I am interested in using a Patient Acuity tool for my DNP project. Can I use this tool? Thank you. Catherine Bell MSN RNC

Dear Mrs. Andrea Ingram, and Jennifer Powell, I am interested in using a Patient Acuity tool for my project. Can I use this tool? Thank you.

Thank you Great article. I was wanting to contact author about the possibility of using this tool.

I am writting in regards to “patient acuity tool on a medical surgical unit” I am currently connected with a regional hospital (government owned) here in the philippines with a bed capacity of 800 but in reality it is way more than that since we are not allowed to refuse a patient since we are the end refferal hospital in our region.. my hospital have not adapted any tool on patient assignment that most often led to nurse job unsatisfaction and burnt out. And i think your study will be of great help. But before my hospital can adapt this, it has to be grounded with a study and so I will be making a study on this and would like to use also your survey with some revisions that is applicable to us if you could allow me. Thank you in advance.

Thank you all for the responses to the article! I am sorry it has taken me this long to respond, but I would love to provide the survey used. Unfortunately, I’m only able to find 6 of the 10 questions (my account used for the online survey was deleted) but I hope these questions help you.

Re: Liz Doll, I’m so glad you would find this tool helpful. You are more than welcome to adapt our tool to fit your patient population. I hope it works out well for your staff!

1. How long have you been a nurse? 2. How long have you been a nurse on 6A? (the name of our unit) 3. In my opinion, I feel that patient assignments are equal between nursing staff. (Strongly agree, agree, neutral, disagree, strongly disagree.) 4. In my opinion, I feel like I have input into making the nursing assignments. (Strongly agree, agree, neutral, disagree, strongly disagree.) 5. Please rate how frequently you feel overwhelmed with your patient assignment. (Frequently, sometimes, rarely, never.) 6. I feel like patient safety is a concern when I accept my patient assignment. (Every shift, frequently, sometimes, rarely, never.)

Loved this study and was wondering if there’d be a way to get a copy of the survey used? Thank you!

Is there a way to get a copy of the survey questions used? This is a great article!

Thank you for this insightful article. Our hospital is expanding beds and we have been using this tool to ensure our new units are properly staffed. With your permission, our team would like to make slight modifications to this tool to better fit our unique patient population. Please let me know your thoughts!

I am writing in regards to “Patient acuity tool on a medical-surgical unit” (Morrow and Powell, 2018). I believe patient acuity is a critical aspect to take into consideration when looking at staffing and nursing assignments. I agree with method the article used, creating a tool to score patient acuity. It is important to have an objective way to determine the acuity and fairly assign patients to a nurse. Having a balanced assignment benefits not only nurses by decreasing their workload, but also extends to the patients by giving them better outcomes. As a bedside nurse I have experienced overwhelming, unbalanced patient assignments. Being stretched thin forces me to be more task-oriented rather than patient centered, as I would prefer. Several months ago the unit I work for started utilizing a tool similar to the one mentioned in the article. By giving us an objective way to rate the acuity of a patient it lead to more balanced the assignments. It gave us more of a say in the assignments, the charge nurses ask us our opinions on our patient group and if they need to be separated for the next shift. This makes us feel as though we have a voice and give the charge nurse an objective way to fairly make assignments (Morrow, 2018). Overall, RNs who rated their assignments as appropriate were more likely to be satisfied with their jobs, intend to stay on their current units, and deliver quality care to patients than those who rated their assignments as inappropriate. Registered nurses who said that their assignments were appropriate are more likely have higher job satisfaction and deliver higher quality care to patients as opposed to nurses who said their patient assignments were inappropriate and unbalanced (Choi, 2018). I find that in my own practice, a balanced mix of acuity within an assignment group I am able to spend more face-to-face time with each patient as opposed to having a group of patients who are all considered high acuity. Utilizing a patient classification system is a low cost tool that nurse leaders can ensure that nurses are receiving equal assignments.

Sincerely, Carrie Young, RN

References Choi, J (2018). Registered Nurse Perception of Patient Assignment Linking to Working Conditions and Outcomes. Journal of Nursing Scholarship, 50(5). Retrieved from https://doi-org.liblink.uncw . edu/10.1111/jnu.12418

Morrow, A. & Powell, J. (2018). Patient acuity tool on a medical-surgical unit. American Nurse Today, 13(4). Retrieved from https://www.myamericannurse.com/patient-acuity-meidcal-surgical-unit

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U.S. reporter Evan Gershkovich has now spent a whole year jailed in Russia

MOSCOW — Friday marks one year since Wall Street Journal reporter Evan Gershkovich was detained by Russian security forces on spying allegations — the first such detention of an American journalist on espionage charges in Russia since the latter days of the Cold War.

The Journal — which vehemently rejects the charges — observed the somber anniversary with an #IStandWithEvan tribute.

Family, friends and journalists across the media landscape took part in a marathon reading of Gershkovich's articles — penetrating vignettes of contemporary Russia that highlighted his deep knowledge of the country, its politics and its people.

Gershkovich, 32, the son of Russian Jewish émigrés who was born and raised in New Jersey, had grown up in a dual-language household absorbing American and Russian cartoons, books and pop culture.

Whether that background, his sharp reporter's eye or something else may have played a role in his arrest remains unclear.

What is certain is that his detention is yet another irritant in U.S.-Russian relations already at Cold War-like lows following the Kremlin's full-scale invasion of Ukraine in February 2022. The Biden administration has said securing Gershkovich's freedom is a priority.

His arrest has only further highlighted Western suspicion of a growing pattern of "hostage diplomacy" in Moscow — one in which Russian authorities are accused of ensnaring Americans on spurious legal charges to see what deals emerge.

A journalist detained

Gershkovich was on a reporting assignment in Russia's Ural mountain city of Yekaterinburg in March of last year when he was detained by agents from Russia's Federal Security Service, the FSB, at a downtown steakhouse.

Witnesses at the Bukowski Grill reportedly had little time to even see who was the target when government agents suddenly stormed the restaurant. Within seconds, they had pulled Gershkovich's sweater over his head and frog-marched him out into an unmarked van.

The next day, Gershkovich reappeared in a Moscow court and was formally charged with trying to obtain state secrets — a penalty for which he faces up to 20 years in jail if convicted.

A journalist, not a spy

Gershkovich and the Journal immediately rejected the spying allegations, saying Gershkovich was working in Russia with official press accreditation from the Foreign Ministry.

In fact, he'd been reporting on the country since 2017 — initially for The Moscow Times and then the Agence France-Presse (AFP) before taking a job with the Journal in 2022. His credentials had been subject to repeat security reviews by the Russian government.

Yet none of that appeared to matter. The Russian government insisted Gershkovich was guilty of the espionage charges — without providing any evidence. Instead, they saw his journalist status as possible proof of his guilt.

"Unfortunately, it's not the first occasion when the status of a 'foreign correspondent,' a journalist visa and accreditation have been used by foreigners in our country to cover up activities that aren't journalism," Foreign Ministry spokesperson Maria Zakharova wrote on social media shortly after Gershkovich's arrest.

"It's not the first famous Westerner we've caught red-handed."

The U.S. government moved quickly to label Gershkovich "wrongfully detained" — a designation that makes him a hostage in the eyes of the U.S. government.

Cold War replay

Gershkovich's arrest echoed Moscow's detention of another American reporter — decades prior in what seems like a different era.

In 1986, Nicholas Daniloff, a correspondent with U.S. News & World Report , was arrested in a KGB sting operation in Moscow. Like Gershkovich, Daniloff was of Russian heritage. He and his publication, too, rejected the charges as a sham.

The American spent 14 days in Moscow's Lefortovo Prison before negotiations between President Ronald Reagan and Soviet Premier Mikhail Gorbachev — then the USSR's new reform-minded leader — cut a deal to set him free.

"Time in Lefortovo was mental torture," Daniloff wrote in an article later, recalling his repeat sessions with a KGB interrogator.

"He played with my emotions, posing alternatively as a 'good cop' and a 'bad cop.' He controlled all information that reached me. He controlled my food, my exercise, my life. [By] the time I was freed, he had made me feel guilt where there was none."

There are also Daniloff's accounts of conditions in a cell "measured five-paces long, three-paces wide."

"There were three steel cots painted blue, a small table for each prisoner, a washbowl and primitive toilet with a wooden cover just high enough to be uncomfortable. The place was clean, but there was a distinctive smell," Daniloff wrote.

Nearly four decades later, recent prisoners say little has changed .

Life on hold

The past year has seen a continuous loop of closed-court hearings in which judges have extended Gershkovich's pretrial detention time and again.

The judges have rejected cash bail offers by the Journal's parent company, Dow Jones. They have also denied appeals to move him to house arrest pending a trial, whose date never seems to come.

Yet Gershkovich's family and friends say he remains strong — with his letters full of his trademark optimism and humor.

"We currently have a joke going back and forth about this framed photo of him," his sister, Danielle Gershkovich, said in an interview with NPR's All Things Considered last October.

"And I'm joking about where I should put it in the apartment, and he recently suggested, put it directly in front of the TV so you can see his face," she said.

Evan Gershkovich has also taken advantage of one of Lefortovo's few benefits: a decent library collection of Russian classics by the likes of Leo Tolstoy, Fyodor Dostoevsky and other literary giants.

"He's read a lot of books. And he told us maybe he will write some good novel at the end of this story, about himself," his Russian lawyer Tatiana Nozhkina told NPR following a hearing last April.

But there's no denying the slow grind of a year spent awaiting trial with no immediate court date in sight.

This week, a judge extended his detention by another three months — until late June. Again, no indication of when Gershkovich might expect trial.

U.S. Ambassador to Russia Lynne Tracy called the latest ruling "particularly painful" — noting the journalist had spent a year awaiting charges that were "fiction" from the outset.

"Evan's case is not about evidence, due process, or rule of law. It is about using American citizens as pawns to achieve political ends," the ambassador said in a statement Tuesday.

Tracy specifically pointed to the case of Paul Whelan , another American the U.S. has designated "wrongfully detained."

But there are others languishing in Russian prisons, including Alsu Kurmasheva , a Russian American journalist with the U.S.-government funded Radio Free Europe/Radio Liberty news service, and Marc Fogel , an American schoolteacher.

Prisoner trade rumors

If there's an upside amid the current situation, it's that prisoner exchanges between Moscow and Washington remain possible despite current hostilities.

Trevor Reed, a former Marine who says he was wrongly convicted of assaulting a Russian police officer, was released by Russia in April 2022.

Brittney Griner , a WNBA basketball star sentenced to nine years on drug possession, was freed later that same year.

In each case, the price was steep: The Biden administration released Viktor Bout, a convicted arms dealer, for Griner. Reed was traded for Konstantin Yaroshenko, a pilot convicted of narcotics smuggling.

White House officials defended the moves as difficult — but necessary — decisions.

Detractors argued the trades merely encouraged more detentions. Perhaps even that of a Wall Street Journal reporter.

Either way, few, including the U.S. government, expect much from a Russian justice system in which over 99% of all criminal cases end in conviction.

And so the Biden administration says it continues to make offers aimed at securing the release of Gershkovich and others.

In turn, Russian President Vladimir Putin has indicated Moscow is open to a swap provided circumstances are right.

Asked about the Gershkovich case in a February interview with former Fox News host Tucker Carlson, Putin was even more explicit. The Russian leader strongly suggested he would be willing to trade Gershkovich for Vadim Krasikov, a suspected FSB assassin currently serving a life sentence for murder in Germany.

Further muddying the picture: Multiple news reports allege that German authorities had tied Krasikov's potential release to the Kremlin leader agreeing to free the jailed Russian opposition leader Alexei Navalny.

Neither U.S. nor German officials have verified those accounts. And Navalny died under still unexplained circumstances in a remote Arctic prison last month, making any potential deal impossible.

In the meantime, Gershkovich remains in Lefortovo prison, reading, writing, waiting — his story like one he himself would report on in ordinary times.

"Evan has displayed remarkable resilience and strength in the face of this grim situation," said Ambassador Tracy in her statement this week.

"But it is time for the Russian government to let Evan go."

Copyright 2024 NPR. To see more, visit https://www.npr.org.

Room Assignments

Here you can find the list of room assignments for the board licensure exam conducted by the Professional Regulation Commission (PRC) and other Philippine government agencies.

ROOM ASSIGNMENTS: April 2024 Physician Licensure Exam (PLE)

PLE ROOM ASSIGNMENTS 2024 – The Professional Regulation Commission (PRC) releases the list of room assignments for the April 2024 Physician Licensure Exam a few days before the exams.

The April 2024 Physician board exams will be conducted on April 7-8 & 14-15, 2024, at PRC testing centers located in NCR, Baguio, Cagayan de Oro, Cebu, Davao, Iloilo, Legazpi, Lucena, Pampanga, Rosales, Tacloban, Tuguegarao and Zamboanga. The Board of Medicine is led by its Chairman, Dr. Zenaida L. Antonio, and its members, Dr. Godofreda V. Dalmacion, Dr. Eleanor B. Almoro, Dr. Martha O. Nucum, Dr. Efren C. Laxamana and Dr. Joanna V. Remo.

List of Room Assignments

Examinees are advised to verify the room assignments through the links below or the notices and announcements posted on the PRC official website. Here is the list of room assignments for the April 2024 Physician licensure exams.

• Manila (PWD)
• Cagayan de Oro

You can follow us on our Facebook and Twitter pages or join us at the Board Exam Results Broadcast Channel to receive updates through chat.

Examinees shall report before 5:30 in the morning on the said date because late comers will not be admitted.

What to bring on the day of exams?

Here are the things to bring during the examination proper:

• Notice of Admission
• Official Receipt
• Two (2) or more pencils (No. 2)
• Ball pens (black ink only)
• One (1) piece long brown envelope
• One (1) piece long transparent/plastic envelope (for keeping your valuables and other allowed items)

What to wear on examination day?

Here are the specified dress codes from PRC:

• All examinees shall wear their school uniform.

What are not allowed during board exams?

• Books, notes, review materials, and other printed materials containing coded information or formulas
• Calculators which are programmable or with embedded functions, especially CASIO FX991ES and CASIO FX-991ES plus
• Apple, Samsung, and other smartwatches, cellular phones, ear plugs, transmitters, portable computers, Bluetooth, and other electronic devices that may be used for communication purposes;
• Bags of any kind

PRC added that they will not be responsible for any lost personal belongings.

Coverage of Exams

• Biochemistry
• Anatomy and Histology
• Microbiology and Parasitology
• Legal Medicine, Ethics and Medical Jurisprudence
• Pharmacology and Therapeutics
• Surgery and Ophthalmology, Otolaryngology and Rhinology
• Obstetrics and Gynecology
• Pediatrics and Nutrition
• Preventive Medicine and Public Health

Other Story

• How to Pass Licensure Exam? Tips from Board Passers
• Program for Physician licensure exams for April 2024 PLE from PRC

For inquiries, you may reach the PRC Licensure Exam Division through the following email contacts:

• [email protected]

We encourage our readers to visit the commission’s official website for the latest and most trustworthy updates and announcements regarding the physician board exams in 2024.

Feel free to post any comments or reactions related to this article in the section below.

• Privacy Policy

U.S. reporter Evan Gershkovich has now spent a whole year jailed in Russia

MOSCOW — Friday marks one year since Wall Street Journal reporter Evan Gershkovich was detained by Russian security forces on spying allegations — the first such detention of an American journalist on espionage charges in Russia since the latter days of the Cold War.

The Journal — which vehemently rejects the charges — observed the somber anniversary with an #IStandWithEvan tribute.

Family, friends and journalists across the media landscape took part in a marathon reading of Gershkovich's articles — penetrating vignettes of contemporary Russia that highlighted his deep knowledge of the country, its politics and its people.

Gershkovich, 32, the son of Russian Jewish émigrés who was born and raised in New Jersey, had grown up in a dual-language household absorbing American and Russian cartoons, books and pop culture.

Whether that background, his sharp reporter's eye or something else may have played a role in his arrest remains unclear.

What is certain is that his detention is yet another irritant in U.S.-Russian relations already at Cold War-like lows following the Kremlin's full-scale invasion of Ukraine in February 2022. The Biden administration has said securing Gershkovich's freedom is a priority.

His arrest has only further highlighted Western suspicion of a growing pattern of "hostage diplomacy" in Moscow — one in which Russian authorities are accused of ensnaring Americans on spurious legal charges to see what deals emerge.

A journalist detained

Gershkovich was on a reporting assignment in Russia's Ural mountain city of Yekaterinburg in March of last year when he was detained by agents from Russia's Federal Security Service, the FSB, at a downtown steakhouse.

Witnesses at the Bukowski Grill reportedly had little time to even see who was the target when government agents suddenly stormed the restaurant. Within seconds, they had pulled Gershkovich's sweater over his head and frog-marched him out into an unmarked van.

The next day, Gershkovich reappeared in a Moscow court and was formally charged with trying to obtain state secrets — a penalty for which he faces up to 20 years in jail if convicted.

A journalist, not a spy

Gershkovich and the Journal immediately rejected the spying allegations, saying Gershkovich was working in Russia with official press accreditation from the Foreign Ministry.

In fact, he'd been reporting on the country since 2017 — initially for The Moscow Times and then the Agence France-Presse (AFP) before taking a job with the Journal in 2022. His credentials had been subject to repeat security reviews by the Russian government.

Yet none of that appeared to matter. The Russian government insisted Gershkovich was guilty of the espionage charges — without providing any evidence. Instead, they saw his journalist status as possible proof of his guilt.

"Unfortunately, it's not the first occasion when the status of a 'foreign correspondent,' a journalist visa and accreditation have been used by foreigners in our country to cover up activities that aren't journalism," Foreign Ministry spokesperson Maria Zakharova wrote on social media shortly after Gershkovich's arrest.

"It's not the first famous Westerner we've caught red-handed."

The U.S. government moved quickly to label Gershkovich "wrongfully detained" — a designation that makes him a hostage in the eyes of the U.S. government.

Cold War replay

Gershkovich's arrest echoed Moscow's detention of another American reporter — decades prior in what seems like a different era.

In 1986, Nicholas Daniloff, a correspondent with U.S. News & World Report , was arrested in a KGB sting operation in Moscow. Like Gershkovich, Daniloff was of Russian heritage. He and his publication, too, rejected the charges as a sham.

The American spent 14 days in Moscow's Lefortovo Prison before negotiations between President Ronald Reagan and Soviet Premier Mikhail Gorbachev — then the USSR's new reform-minded leader — cut a deal to set him free.

"Time in Lefortovo was mental torture," Daniloff wrote in an article later, recalling his repeat sessions with a KGB interrogator.

"He played with my emotions, posing alternatively as a 'good cop' and a 'bad cop.' He controlled all information that reached me. He controlled my food, my exercise, my life. [By] the time I was freed, he had made me feel guilt where there was none."

There are also Daniloff's accounts of conditions in a cell "measured five-paces long, three-paces wide."

"There were three steel cots painted blue, a small table for each prisoner, a washbowl and primitive toilet with a wooden cover just high enough to be uncomfortable. The place was clean, but there was a distinctive smell," Daniloff wrote.

Nearly four decades later, recent prisoners say little has changed .

Life on hold

The past year has seen a continuous loop of closed-court hearings in which judges have extended Gershkovich's pretrial detention time and again.

The judges have rejected cash bail offers by the Journal's parent company, Dow Jones. They have also denied appeals to move him to house arrest pending a trial, whose date never seems to come.

Yet Gershkovich's family and friends say he remains strong — with his letters full of his trademark optimism and humor.

"We currently have a joke going back and forth about this framed photo of him," his sister, Danielle Gershkovich, said in an interview with NPR's All Things Considered last October.

"And I'm joking about where I should put it in the apartment, and he recently suggested, put it directly in front of the TV so you can see his face," she said.

Evan Gershkovich has also taken advantage of one of Lefortovo's few benefits: a decent library collection of Russian classics by the likes of Leo Tolstoy, Fyodor Dostoevsky and other literary giants.

"He's read a lot of books. And he told us maybe he will write some good novel at the end of this story, about himself," his Russian lawyer Tatiana Nozhkina told NPR following a hearing last April.

But there's no denying the slow grind of a year spent awaiting trial with no immediate court date in sight.

This week, a judge extended his detention by another three months — until late June. Again, no indication of when Gershkovich might expect trial.

U.S. Ambassador to Russia Lynne Tracy called the latest ruling "particularly painful" — noting the journalist had spent a year awaiting charges that were "fiction" from the outset.

"Evan's case is not about evidence, due process, or rule of law. It is about using American citizens as pawns to achieve political ends," the ambassador said in a statement Tuesday.

Tracy specifically pointed to the case of Paul Whelan , another American the U.S. has designated "wrongfully detained."

But there are others languishing in Russian prisons, including Alsu Kurmasheva , a Russian American journalist with the U.S.-government funded Radio Free Europe/Radio Liberty news service, and Marc Fogel , an American schoolteacher.

Prisoner trade rumors

If there's an upside amid the current situation, it's that prisoner exchanges between Moscow and Washington remain possible despite current hostilities.

Trevor Reed, a former Marine who says he was wrongly convicted of assaulting a Russian police officer, was released by Russia in April 2022.

Brittney Griner , a WNBA basketball star sentenced to nine years on drug possession, was freed later that same year.

In each case, the price was steep: The Biden administration released Viktor Bout, a convicted arms dealer, for Griner. Reed was traded for Konstantin Yaroshenko, a pilot convicted of narcotics smuggling.

White House officials defended the moves as difficult — but necessary — decisions.

Detractors argued the trades merely encouraged more detentions. Perhaps even that of a Wall Street Journal reporter.

Either way, few, including the U.S. government, expect much from a Russian justice system in which over 99% of all criminal cases end in conviction.

And so the Biden administration says it continues to make offers aimed at securing the release of Gershkovich and others.

In turn, Russian President Vladimir Putin has indicated Moscow is open to a swap provided circumstances are right.

Asked about the Gershkovich case in a February interview with former Fox News host Tucker Carlson, Putin was even more explicit. The Russian leader strongly suggested he would be willing to trade Gershkovich for Vadim Krasikov, a suspected FSB assassin currently serving a life sentence for murder in Germany.

Further muddying the picture: Multiple news reports allege that German authorities had tied Krasikov's potential release to the Kremlin leader agreeing to free the jailed Russian opposition leader Alexei Navalny.

Neither U.S. nor German officials have verified those accounts. And Navalny died under still unexplained circumstances in a remote Arctic prison last month, making any potential deal impossible.

In the meantime, Gershkovich remains in Lefortovo prison, reading, writing, waiting — his story like one he himself would report on in ordinary times.

"Evan has displayed remarkable resilience and strength in the face of this grim situation," said Ambassador Tracy in her statement this week.

"But it is time for the Russian government to let Evan go."

Copyright 2024 NPR. To see more, visit https://www.npr.org.

2023 Documentation Guideline Changes for ED E/M Codes 99281-99285

On July 1, 2022, the American Medical Association (AMA) released a preview of the 2023 CPT Documentation Guidelines for Evaluation and Management (E/M) services. These changes reflect a once-in-a-generation restructuring of the guidelines for choosing a level of emergency department (ED) E/M visit impacting roughly 85 percent of the relative value units (RVUs) for typical members. Since 1992, a visit level was based on a combination of history, physical exam, and medical decision-making elements. Beginning in 2023, the emergency department E/M services will be based only on medical decision making.

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Explore This Issue

The American College of Emergency Physicians (ACEP) represents the specialty in the AMA current procedural technology (CPT) and AMA/Specialty Society RVS Update Committee (RUC) processes. In fact, they are your only voice in those arenas. The AMA convened a joint CPT/RUC work group to refine the guidelines based on accepted guiding principles. Although the full CPT code set for 2023 has not yet been released, the AMA recognized that specialties needed to have access to the documentation guidelines changes early to educate both their physicians on what to document and their coders on how to extract the elements needed to determine the appropriate level of care based on chart documentation. Additionally, any electronic medical record or documentation template changes will need to be in place prior to January 1, 2023, to maintain efficient cash flows and ensure appropriate code assignment.

ACEP was able to convince the Joint CPT/RUC Workgroup that time should not be a descriptive element for choosing ED levels of service because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. It would be nearly impossible to track accurate times spent on every patient under concurrent active management.

The prior requirements to document a complete history and physical examination will no longer be deciding factors in code selection in 2023, but instead the 2023 Guidelines simply require a medically appropriate history and physical exam. That leaves medical decision making as the sole factor for code selection going forward. These changes are illustrated by the 2023 ED E/M code descriptors, which will appear as follows:

The 2023 E/M definitions have been updated to reflect simply Medical Decision Making determining the level.

• 99281: ED visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
• 99282: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
• 99283: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical decision making.
• 99284: ED visit for the evaluation and management of a patient which requires a medically appropriate history and/or examination and moderate medical decision making.
• 99285: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high medical decision making.

Pages: 1 2 3 | Single Page

Topics: 2023 guidelines Coding CPT guidelines Practice Management Reimbursement & Coding

Medicare’s Reimbursement Updates for 2024

Workplace Violence and Mental Health in Emergency Medicine

Maryland Implements Value-Based Alternative Payment Model

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ACEP Now: Vol 43 – No 03 – March 2024

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Nursing professional development evidence-based practice.

Barbara A. Brunt ; Melanie M. Morris .

Affiliations

Last Update: March 4, 2023 .

• Introduction

Evidence-based practice is “integrating the best available evidence with the healthcare educator’s expertise and the client’s needs while considering the practice environment. [1] One of the roles of the NPD practitioner in the 2022 edition of the Nursing Scope and Standards of Practice is a champion for scientific inquiry. In this role, the NPD practitioner promotes a spirit of inquiry, the generation and dissemination of new knowledge, and the use of evidence to advance NPD practice, guide clinical practice, and improve the quality of care for the healthcare consumer/partner. Scholarly inquiry is a standard of practice within that role. It is defined as “The nursing professional development (NPD) practitioner integrates scholarship, evidence, and research findings into practice” (p. 104).

There is often confusion between quality improvement, evidence-based practice, and research. A seminal article by Shirey and colleagues. [2]  differentiated these three topics. Evidence-based practice is a systematic problem-solving approach that is evidence-driven and translates new knowledge into clinical, administrative, and educational practice. Institutional Review Board (IRB) approval is usually not required unless outcomes are intended for publication, or the project could potentially expose individuals to harm.

The EBP process, as defined by Melnyk and Fineout-Overholt, includes seven steps:         

• Encouraging and supporting a spirit of inquiry
• Asking questions
• Searching for evidence
• Appraising the evidence
• Integrating evidence into practice
• Evaluating outcomes
• Sharing results

Implementing EBP in practice has been shown to lead to a higher quality of care and better patient outcomes, but nurses encounter many barriers when implementing EBP. NPD practitioners can facilitate the implementation of EBP by ensuring a supportive environment for EBP, providing educational sessions to nurses about the EBP process, being role models, and mentoring nurses.

• Issues of Concern

PICOT Question

The foundation of EBP is developing a PICOT question, which identifies the terms to be used to search for the best evidence to answer a burning clinical question. [3] This framework breaks down the question into keywords. P stands for patient/population; I refers to Intervention; C stands for comparison/control; O stands for the outcome; and T refers to the time frame. When looking at the population, it is important to consider the relevant patients, including age, sex, geographic location, or specific characteristics that would be important to the question.

The intervention examines the management strategy, diagnostic test, or exposure of interest. There may not always be a comparison in the PICOT analysis. If there is, this would be a control or alternative management strategy compared to the intervention. Outcomes should be measurable, as the best evidence comes from rigorous studies with statistically significant findings. The time factor looks at what period should be considered. There are a variety of clinical domains that PICOT questions can evaluate, such as intervention, diagnosis, etiology, prevention, prognosis/prediction, quality of life, or therapy. Writing a good PICOT question for an effective search and making robust, evidence-based recommendations to improve care and outcomes is critical.

The Evidence

While there are multiple ways to evaluate and rank evidence in the literature, one of the most widely used in nursing in the United States uses seven levels. These seven accepted levels of evidence are assigned to studies based on the methodological quality of the design, validity, and application to patient care. In addition, these levels provide the “grade” or strength of the recommendation.

• Level I –  Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on a systematic review of RCTs or three or more RCTs of decent quality with comparable results.
• Level II -  Evidence obtained from at least one well-designed RCT
• Level III – Evidence obtained from well-designed controlled trials without randomization
• Level IV -  Evidence from well-designed case-control or cohort studies        
• Level V - Evidence from a systematic review of descriptive and qualitative studies (meta-syntheses)
• Level VI – Evidence from a single or descriptive or qualitative study              
• Level VII - Evidence from the opinion of authorities and/or reports of expert committees.

Roe-Prior discussed the strength of evidence by comparing it to a murder trial. A suspect’s conviction should require more than the testimony of one witness. If a crowd of people all agree that the suspect was the perpetrator or there was DNA evidence, that evidence is much stronger. Studies without a comparative group, methodologically weak studies, or poorly controlled studies could be likened to one witness. Roe Prior encouraged individuals to also look at non-nursing research findings since research centered on other disciplines, like psychology or education, could be appropriate.

Other frameworks for identifying levels of evidence include The Oxford Centre for Evidence-Based Medicine Levels of Evidence and Burns framework. [4] The Oxford Centre describes five levels with various subparts as listed here:

• 1a           Systematic review of RCTs
• 1b           Individual RCT
• 2a           Systematic review of cohort studies
• 2b           Individual cohort study
• 2c           Outcomes research
• 3a           Systematic review of case-control studies
• 3b           Individual case-control study
• 4             Case series
• 5             Expert opinion

Burns uses three levels to differentiate the strength of the evidence presented:

• I             At least 1 RCT with proper randomization
• II.1         Well-designed cohort or case-control study
• II.2         Time series comparisons or dramatic results from uncontrolled studies
• III           Expert opinions

Roe Prior outlined guidelines for the literature review. [5] Use keywords from the PICOT question to perform simple, then more complex searches in reliable databases, preferably limited to the past five years, although landmark studies can be included. Limit the review to peer-reviewed and research articles and use caution when including only full-text articles, as some key papers may be missed. Check the validity of any online sources and use original research where possible. Remember that textbooks are often obsolete by their publication date, and books are considered secondary sources.

The Cochran Library is comprised of multiple databases where systematic reviews on healthcare topics can be found. Using the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) Guidelines to evaluate a systemic review or meta-analysis can help the individual ensure the findings are valid and reliable. Findings from the literature review are put into an evidence-based table. There are various formats for these tables, but they all include information about the source, design, sample, summary of findings, and level of evidence for each of the articles included.

The most frequently used EBP models are the Iowa Model, the Advancing Research and Clinical Practice through Close Collaboration (ARCC) Model, the Star Model of Knowledge Transformation, and the John Hopkins Nursing Evidence-based Practice (JHNEBP) Model. The IOWA Model focuses on implementing evidence-based practice changes, and the ARCC model on advancing EBP in systems by using EBP mentors and control and cognitive behavioral therapies. The Star Model provides a framework for approaching EBP, and the John Hopkins Model is a problem-based approach to clinical decision-making accompanied by tools to guide its use.

The Iowa model was revised and updated in 2017 by the Iowa Model Collaborative. [6]  Changes in the healthcare environment, such as a focus on implementation science and emphasis on patient engagement, prompted a reevaluation, revision, and validation of the model. This model differs from other frameworks by linking practice changes within the system. Model changes included an expansion of piloting, implementation, patient engagement, and sustaining change.

Support for the ARCC Model was outlined in an article by Melnyk and colleagues in a study exploring how an evidence-based culture and mentorship predicted EBP implementation, nurse job satisfaction, and intent to stay. [7] This model involves assessing organizational culture and readiness for EBP using EBP mentors who work with clinicians to facilitate the implementation of evidence-based practice.

A concept analysis of feelings of entrapment during the COVID-19 pandemic, using the ACE Star Model, was completed by Lee and Park. The ACE Star model is used to understand the cycle, nature, and characteristics of knowledge used in various aspects of EBP. The model consists of five steps: discovery research, evidence summary, translation to guidelines, practice integration, and process and outcome evaluation.

The JHNEBP Model is a problem-solving approach to clinical decision-making with user-friendly tools to guide individual or group use. It is explicitly designed to meet the needs of the practicing nurse and uses a three-step process called PET: practice question, evidence, and translation. In a study conducted by Speroni and colleagues on using EBP models across the United States, this was the second most frequently used model by the 127 nurse leaders who responded to the questionnaire. [8]

EBP Competence and Implementation

NPD practitioners are instrumental in implementing EBP. Harper and colleagues conducted a national study to examine NPD practitioners’ beliefs and competencies, frequency of implementing EBP, and perceptions of organizational culture and readiness for EBP. [9] The Association for Nursing Professional Development (ANPD) collaborated with the Center for Transdisciplinary Evidence-Based Practice at The Ohio State University to explore the NPD practitioners’ beliefs and experiences with EBP, as well as to explore relationships among NPD practitioner characteristics and healthcare organizational outcomes such as nursing sensitive quality indicator scores and core measures. A total of 253 NPD practitioners from 43 states and the District of Columbia participated in this study. Findings indicated that NPD practitioners need to develop personal competence in EBP, become involved in shared governance, collaborate with others to facilitate the implementation of EBP, and become comfortable with using quality metrics to demonstrate the effectiveness of NPD activities.

The Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare of the Ohio State University developed an Evidence-Based Practice Certificate, which was approved by the Accreditation Board for Specialty Nursing Certification in 2018. There are 24 EBP competencies; 13 for practicing registered nurses and an additional 11 competencies for practicing advanced practice nurses and EBP experts. These competencies are outlined in an article by Melnyk et al. [10]

Although these competencies were initially written for nurses, they apply to other interprofessional team members who have received advanced EBP education. In addition to demonstrating completion of the EBP coursework, applicants must demonstrate current EBP knowledge through content review and successful testing and submit a portfolio to review that shows an EBP practice change project before receiving a certificate.

In 2020, ANPD worked with the Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare to develop a curriculum for the Nursing Professional Development EBP Academy. [11] The program consists of live webinars, 26 asynchronous modules, and the completion of an EBP change initiative/project. This Academy curriculum aligns with the EBP Certificate educational requirements.

There are numerous resources available for NPD practitioners on evidence-based practice. There is a peer-reviewed journal published by Sigma Theta Tau International, Worldviews on Evidence-based Nursing, which includes original research with recommendations applicable to use as best practices to improve patient care. ANPD has a year-long evidence-based fellowship consisting of theory and completion of an evidence-based project. The Nursing Professional Development Evidence-Based Practice (EBP) Academy is a 12-month mentored program designed to guide the NPD practitioner through creating PICOT questions, gathering and critically appraising literature, and EBP implementation, evaluation, dissemination, and sustainment. Participation in the EBP Academy enhances the evidence-based competencies of nursing professional development practitioners to enable them to fulfill their role as champions of scientific inquiry and mentor other healthcare professionals in implementing EBP practices.

EBP in Action

One organization evaluated the use of evidence-based practice in clinical practice after nurses attended a formal evidence-based practice course. [12]  Nurses who attended the organization’s EBP course were invited to participate in focus groups to provide additional qualitative data. Data from two focus groups highlighted the impact of the EBP course, areas for further development, and potential barriers to the use of EBP. The nurses indicated that the course changed their way of thinking and enhanced their patient care. They stated there was a need for mentoring and that time was a significant barrier to EBP. That information was used by organizational leadership to help identify areas needing consideration for educational offerings and support mechanisms.

Another large academic medical center evaluated the implementation of an EBP program. [13]  They noted that although their approach to educating professional staff on EBP provided initial benefits, holding the gains over a one-year period was difficult. The “train-the-trainer” model envisioned by the team was not realistic, as the participants did not feel well-versed enough to teach others. They concluded future efforts require attention to participant feedback and the implementation of measures to decrease the barriers to implementing EBP.

There are numerous examples in the literature of individuals/organizations using evidence-based principles to develop programs in a variety of settings. McGarity and colleagues examined frontline nurse leaders oriented with only on-the-job training questioning whether their level of competence is improved with a professional development program. [14] This project used a pre-and post-survey design to evaluate a leadership development curriculum. The intervention was an evidence-based leadership curriculum that consisted of twelve four-hour classes. The fact that all 38 frontline nurse leaders who participated in this project improved their competencies reinforced the need for formal professional development. The outcome of this training program showed that all 38 frontline nurse leaders who attended it were more confident in their skills and improved their competence in leading effective teams, reinforcing the need for education.

Ydrogo and colleagues discussed a multifaceted approach to strengthening nurses’ EBP capabilities in a comprehensive cancer center. [15] They created a program designed to promote a spirit of inquiry, strengthen EBP facilitators, overcome barriers to EBP, and expand nurses’ knowledge of EBP. The program consisted of a blended interactive seminar with leader-directed discussion on promoting a spirit of inquiry, a seven-week course on retrieving, reading, analyzing, and evaluating research papers, and a monthly challenge emailed to staff, posted to the hospital intranet, and included in a weekly nursing newsletter. Both leadership and staff gained increased confidence and a foundation to initiate two research projects and one EBP project shortly after completing the course.

Integrating EBP into an emergency department nurse residency program was the subject of an article by Asselta. [16] In addition to extensive training in the core competencies of emergency nursing, this 6-month program included exemplars in EBP and its positive impact on patient care and/or ED workflow. One of the requirements for this program was for the nurses to participate in developing an EBP project specific to emergency nursing practice. An example of a project comparing intravenous (IV) push medications versus IV piggyback medications was shared. This project demonstrated the advantages of the IV push route of administration, which yielded significant cost savings for the organization.

Pediatric nurses were the focus of a project described by Cline et al. [17] They evaluated nurses’ perceptions of barriers, facilitators, confidence, and attitudes toward research and evidence-based practice. There were 369 nurses who completed the survey during the baseline data collection period, 288 nurses completed the 6-month survey, and 284 nurses completed the 12-month survey. The results indicated that implementation of a curriculum focused on research and EBP may be most successful when implemented with the availability of mentors, in a research-supported environment, with grant funding support for novice researchers, and with an ample amount of time allotted to complete a research study.

Many nurses work in long-term care. Higuchi and colleagues described a study that examined the impact of EBP practice change in ten long-term care (LTC) settings in Canada. [18] Introducing and sustaining practice changes that enhance the quality of care is a significant challenge in LTC facilities. A full-day workshop that included identifying success stories, describing current practice challenges, building a case for change, seizing the moment, and identifying an action plan was presented at each site. Participants completed a questionnaire at the end of the workshop, and all participants were invited to participate in semi-structured interviews five months after the program. The benefits identified in the follow-up interviews were initiating the change process and enhancing team collaboration. This study demonstrated that an interactive workshop had important positive effects on LTC staff.

Clinical nurse educators were the focus of a study conducted by Dagg and colleagues. [19]  Centralization of a new clinical nurse educator (CNE) role created role confusion and poor role outcomes. An evidence-based quality improvement project was completed to integrate the ANPD practice model and transition to the practice fellowship program. An ANPD competency assessment survey tool was selected because it included information specific to the CNE role expectations. The nurse-sensitive indicators selected were fall rates and indwelling urinary catheter rates. Self-assessed competencies and nurse-sensitive quality outcomes of the CNEs were measured before and after the ANPD practice model was integrated into their daily practice. There were only 5 CNEs who completed both the pre-and post-assessment, but results supported that CNEs influenced patient quality outcomes and improved their self-assessed competency.

Phan and Hampton described an evidence-based project focused on promoting civility in the workplace by addressing bullying in new graduate nurses using simulation and cognitive rehearsal. [20]  Nurse bullying (NB) has been a problem for many years, and this can threaten the safety of patients, nurses, and organizations. This study used a mixed-methods, quasi-experimental design.

The NPD Scope and Standards were used to assess, plan, implement, and evaluate the project. In addition to the demographic data collected at baseline, participants completed the Clark Workplace Civility Index (CWCI) at baseline and three times after the intervention (immediately, 2.5 months, and five months). The sample included 36 new graduate nurses (NGNs). The intervention consisted of 2.75 hours of didactic, polling, reflection, simulation role-play, and debriefing. The training was developed virtually on the Zoom platform, and breakout rooms facilitated small group discussions and role-playing. Although there was no statistically significant increase in civility scores, the qualitative data indicated the participants could apply knowledge and skills from the intervention to improve communication, peer relationships, teamwork, patient safety, and care.

• Clinical Significance

Evidence-based practice falls under the champion for scientific inquiry role of the NPD practitioner. According to the NPD scope and standards of practice, the NPD practitioner promotes a spirit of inquiry and assists with generating and disseminating new knowledge. The NPD practitioner also uses evidence to advance the specialty of NPD and guide practice.

The ultimate goal is to promote the quality of care for the healthcare consumer. Competencies for scholarly inquiry include acting as a champion for inquiry, generating new knowledge, and integrating the best available evidence into practice. In addition, the standards include disseminating inquiry findings, including evidence-based practice and quality improvement activities, through educational and professional development activities.

• Enhancing Healthcare Team Outcomes

The healthcare consumer is the ultimate recipient of NPD practice. Therefore, NPD practitioners collaborate with the interprofessional team to ensure quality care, leading to optimal care outcomes and population health. Interprofessional partnerships are critical factors in achieving safe, effective, high-quality care.

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Disclosure: Barbara Brunt declares no relevant financial relationships with ineligible companies.

Disclosure: Melanie Morris declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Brunt BA, Morris MM. Nursing Professional Development Evidence-Based Practice. [Updated 2023 Mar 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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