Digital Repository Masters Projects Spring 2023 Patient Acuity, Nurse-To-Patient Ratios, and Job Satisfaction Adela Webb Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Webb, A. 2023. Patient acuity, nurse-to-patient ratios, and job satisfaction. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Patient Acuity, Nurse-To-Patient Ratios, and Job Satisfaction Project Title by Adela Webb Student’s Name A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 2nd, 2023 Date Adela Webb BSN, RN April 2nd, 2023 Student Name, Credentials Date (electronic signature) 04/27/2023 DNP Project Faculty (electronic signature) Date 04/27/2023 Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Date 1 Patient Acuity, Nurse-To-Patient Ratios, and Job Satisfaction Adela Webb, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing 2 Abstract This MSN project analyzes the themes of nurse-to-patient ratios, patient acuity, and their effect on nurse workload and job satisfaction. The project aims to provide the latest evidencebased research to show the positive and negative outcomes correlated with varying patient acuity and nurse-to-patient ratios. The current problem in the Medical-Surgical unit at AllianceHealth Durant is the need for a patient acuity tool to determine if the nurse workload is evenly distributed amongst the staff. The nurse-to-patient ratios can vary from six patients to as high as eight patients per nurse. The main objectives are to determine whether having a patient acuity tool to appropriately determine patient acuity levels and a consistent maximum number of six patients per nurse would improve the nurse’s job satisfaction and decrease workload. The implications for practice are to reduce the workload for nurses and increase job satisfaction to avoid nurse burnout and nurses leaving the bedside. Research shows that the number of nurses leaving the bedside has increased. The recommendations are to have the interdisciplinary team work cohesively and transparently with one another to gain trust and accountability, improve teamwork to increase knowledge, increase the quality of patient care, and create a healthier work environment that is effective and beneficial for nursing staff. Research and evidence-based practice show that having a clearly defined patient acuity in which the nurse workload can be evenly distributed along with a consistent maximum of nurse-to-patient ratios increases job satisfaction and decreases overall workload. Keywords: nurse-to-patient ratios, patient acuity, job satisfaction, nurse workload 3 Patient Acuity, Nurse-To-Patient Ratios, and Job Satisfaction Nurses are integral to the healthcare system's day-to-day patient care operations. Collaboratively, they utilize their expertise, skills, and ability to perform multiple functions to support health outcomes. However, in juggling most of these tasks to care for patients effectively, many nurses may become overwhelmed and stressed due to low staffing and high patient acuities, leading to decreased job satisfaction in the workplace (Van den Oetelaar et al., 2021). Senek et al. (2020) found that nurse demoralization was one of the leading root causes of issues in understaffing, with high nurse-to-patient ratios and an inability to provide adequate care within their shift due to high patient acuity. The factors of patient acuity, nurse-to-patient ratios, and their effect on job satisfaction are worth further exploring to advance the nursing workforce's stability and sustainability. Patient acuity is a core staffing model used in determining appropriate staffing levels and nurse workloads to maximize the care given to patients safely and provide a high quality of care (American Nurses Association, n.d.a). The American Nurses Association (n.d.b) also delineates that one of the core components to successful staffing for nurse-to-patient ratios is to consider the time needed to perform quality patient care associated with a patient acuity tool. Many variations of acuity tools are adjusted to the workplace in which they are used. For example, in a hospital setting, an acuity tool-based assignment assists nurse leaders in allocating nurses’ tasks for the shift. It is based on a scoring system of one being the lowest level in acuity up to four, which is the highest level of patient acuity. This patient model assigns rooms for patients according to the severity of the condition, required care, and the decision to move other patients to different units for accommodation purposes related to staffing needs (Ageiz & El-Mageed, 4 2020). A nurse's ability to effectively utilize the acuity model can impact the workload of the nurse providing care and the unit's workflow. Nurse-to-patient ratios are a highly debated topic. Considering the acuity of patients in the care of nurses, it is also imperative to determine whether the number of patients assigned to a nurse is adequate for the nurse to carry. Nurses continue to advocate for safe nurse-to-patient ratios for reasons ranging from nurse burnout to patient safety. According to Shin et al. (2018), increased nurse-to-patient ratios indicated statistically significant adverse outcomes but clarified the need for additional research regarding appropriate ratios. Statement of Problem Nurses currently provide care for patients at varying ratios and with minimal or no assistive personnel, which can increase job dissatisfaction within the workplace (Senek et al., 2020). The nurse-to-patient ratios vary by facility, type of organization, and there is currently no standard nurse-to-patient ratio, only a recommended guideline based on staffing levels (Driscoll et al., 2018). Tenorio et al. (2021) noted a statistical significance in the impact of nurse-to-patient ratios and increased rate of missed care with an odds ratio of 1.3, 95% CI, and a P value of 0.037. Chen et al. (2019) reported in their meta-analysis of 13 cross-sectional studies that nurses with higher nurse-to-patient ratios showed an increased risk for job dissatisfaction. A suggested mediation model of a standardized daily nurse-to-patient ratio showed a statistically significant positive correlation with job dissatisfaction (Chen et al., 2019). Also, patient acuity needs to be consistently considered; otherwise, an excessive workload between nurses and increasing adverse patient outcomes may occur. In addition, increased nursing workloads correlate with decreased job satisfaction (Chen et al., 2019). Driscoll et al. (2018) noted that to address appropriate staffing levels, nurse managers must 5 consider patient acuity and the number of staff needed when making staffing decisions. In the 205 surveys collected by Ivziku et al. (2021), 114 indicated that their patients' acuity level heavily impacted nurses. These results were statistically significant in identifying this as a variable to consider when assessing nurse workload. Van den Oetelaar et al. (2021) further delve into the definition of patient acuity and its impact on nurse workload, noting how it affects job dissatisfaction. The recommendation was a method to objectively measure nurse workload that is more conducive to even workload distribution. Ways Project Contributes to Intended Recipients The primary goal of this project is to bring to the forefront the latest evidence-based practices regarding patient acuity staffing tools and current practices in nurse-to-patient ratios within a hospital setting. DiClemente (2018) noted that implementing a standardized acuity tool could improve nurses’ productivity and patient outcomes by allowing nurses more autonomy and empowerment in how patients are assigned to them. Secondly, this project aims to implement consistent patient acuity assessments before the end of each shift to maintain fixed nurse-to-patient ratios at AllianceHealth Durant on the Medical-Surgical unit. In research from Ruiz Colon et al. (2022), implementing a patient acuity score assisted nurses in objectively assessing the patient’s needs and level of care required for staffing adjustments to be made based on patient acuity levels. Third, this project aims to showcase the latest evidence-based practices to implement consistent nurse-to-patient ratios within the Medical-Surgical department and evaluate their effectiveness in job satisfaction. Ruiz Colon et al. (2022) also noted that having appropriate staffing to meet patient needs results in a balanced workload associated with increased job satisfaction and lower turnover rates. 6 The intended recipients of this project are nurse leaders, nurses, and hospital management within the Medical-Surgical department. This project will guide them in effectively using a patient acuity tool in the Medical-Surgical department to assess patients during their shift, guided by the latest evidence-based practice (Ingram & Powell, 2018). In addition, the assessment, development, planning, implementation, and evaluation of the research performed at AllianceHealth Durant may add value to the nursing profession for other organizations to implement. Rationale for the Importance of Project Job satisfaction is critical in nurse retention, lower turnover rate, lower burnout, and better perception of the quality of care (Al Sabei et al., 2019). Al Sabei et al. (2019, Predictors of Nurses’ Turnover Intention, Burnout, and Perceived Quality of Care) also noted that adequate staffing created an 81% reduction rate decrease in the self-reported low or average quality of care given to patients (p=.003, 95% CI = 0.06–0.56). In addition, the implementation of an acuity tool assisted in reducing unbalanced workloads for nurses, justified higher level of care assignments based on clinical criteria, and objectively determined an accurate level of care to ensure that the proper amount of nursing staff needed to care for patients was available for current patient’s needs (Ruiz Colon et al., 2022). Although there is evidence-based research regarding nurse-to-patient ratios and patient acuity assignments with nurse staffing affecting job satisfaction, further research is needed to combine these themes. Research examining the stated topics can provide a clear outline of how to assign a set nurse-to-patient ratio based on a specific patient acuity tool designated for the Medical-Surgical unit, with the long-term goal of increasing nurse job satisfaction. For example, research by Meyer et al. (2020) showed that a patient acuity tool generated from the patient’s electronic 7 health records and nurse-to-patient ratios created an accurate real-time indicator for nurse staffing needs that showcased best practice for staffing and increased patient safety, nurse satisfaction, and appropriate use of resources for patient care. In addition, relationships among patient acuity, nurse staffing, workplace satisfaction, and the contribution to patient outcomes are critical issues with nurse staffing (Van den Oetelaar et al., 2021). Literature Review and Framework A project intended to create change within a facility’s unit to add evidence-based best practices and transform the knowledge into practices requires a model to guide proposed changes. This MSN project aimed to find a nursing model best suited to correctly guide these changes into practice. In analyzing several different models and frameworks, one was selected and found to be best suited for the project based on its easy-to-follow guidelines and transition from knowledge into practice. Framework The John Hopkins Nursing Model is the evidence-based practice change model selected to guide this MSN project. This model is described by Melnyk and Fineout-Overholt (2019) as a standard by which bedside nurses can implement the latest evidence-based research and carry out into practice. This model is ideal for this MSN project due to interpreting the best evidence regarding patient acuity, nurse-to-patient ratios, and job satisfaction and then applying the information gathered for the bedside nurses working within the Medical-Surgical unit at AllianceHealth Durant. John Hopkins Medicine (2022) describes its model as a three-part approach in which inquiry is initiated and processed: formulating a practice question, accumulating evidence, and translating research into practice. Virginia Commonwealth University (2022) created a guide 8 specifically reviewing the three phases of the Johns Hopkins evidence-based practice model to give nurses a simplified yet effective resource to carry out the steps. The first part of this model is developing an answerable practice question. Then, with a question in place, a leader is chosen to spearhead the newly formed team of interprofessional members (Melnyk & Fineout-Overholt, 2019). Next, John Hopkins Medicine (2022) recommends that a PICO-style question be formulated in order for the team to identify indicators correctly and subsequently reference back if needed. For this MSN project, the question focuses on adjusting patient acuity assignments and nurse-to-patient ratios at AllianceHealth Durant’s Medical-Surgical nursing staff to examine the nursing workload. In the second portion of the model, the research literature is reviewed and categorized by its quality and hierarchy of strength in evidence. This MSN project has a wide variety of research and evidence ranging in multiple higher-tiered levels of strength and quality, including systematic reviews and meta-analysis research articles. In the final step, translating, all evidence is amalgamated to be used in day-to-day practice (John Hopkins Medicine, 2022). Strengths and Limitations This model is tailored to be used for nursing practice. The strength of the Johns Hopkins Nursing Model is its ability to guide bedside nurses into creating a culture of transforming research into practice (Melnyk & Fineout-Overholt, 2019). This strength aligns directly with the goal of this project. However, further analysis of the Johns Hopkins Model determined that each of the three stages presented multiple steps which could delay implementation efforts (John Hopkins Medicine, 2022). Analysis of Literature 9 Nurses play a pivotal role within the healthcare team, bringing their collective expertise, skills, and ability to perform multiple functions to support patient health outcomes. For nurses in an acute care setting, close attention to factors such as patient acuity, patient care, and available resources will structure how the next twelve hours flow while caring for patients. The most important of these factors is the acuity of the patients in their care and how much current staff is available to assist in managing patients. These factors affect the intensity of the nurse’s workload responsibilities. Nurse-to-patient ratios are a highly debated topic. Nurses have advocated for safe nurseto-patient ratios for various reasons, from nurse burnout to patient safety. Research shows, as analyzed by Shin et al. (2018), that increased nurse-to-patient ratios showed statistically significant adverse outcomes but clarified the need for additional research regarding appropriate ratios. Further research may explain whether other factors contribute to the negative results or if it is specific to nurse/patient ratios only. The weight of increased nurse-to-patient ratios and high patient acuity can increase the nursing workload and become detrimental to a nurse's job satisfaction and subsequent nurse burnout (Ivziku et al., 2021). Ivziku et al. (2021) noted that current evidence strengthens the rationale that patient acuity and staffing are significant factors to consider when determining the nurse's workload and appointing appropriate nurse-to-patient ratios. Senek et al. (2020) found that nurse demoralization was due to four themes, which further outlined the issues of understaffing, patient/nurse ratio, and inability to get work done within those themes. The factors of patient acuity and nurse/patient ratios and their effect on nurse workload and job satisfaction are worth further exploring to advance the nursing workforce's stability and sustainability. This literature review aims to highlight the current evidence supporting a standardized patient acuity 10 method and encourages a fixed nurse-to-patient ratio to decrease the nursing workload and increase nurses' job satisfaction. Search Strategies The database used for research regarding this topic was Weber State University's Stewart Library's ONESearch and PubMed Central, with a refined advanced search to include only fulltext articles that were scholarly and peer-reviewed, had full access, and were published between 2018 and 2022. The keywords used to find specific articles relating to the topic were patient acuity, nurse job satisfaction, nurse-to-patient ratios, and nurse workload. In addition, using the themes searched together allowed for a more defined search of the topics. It produced specific research on patient acuity, nurse workload, nurse job satisfaction, and nurse workload. Inclusion criteria were Medical-Surgical units and hospitals. Nurse-to-Patient Ratios and Nurse Workload The nurse's workload depends on how many patients they have, with the addition of each patient increasing the workload by the number of hours spent per patient (Abed Al Ahad et al., 2021). Therefore, nurse-to-patient ratios are correlated to the nurse's workload. Abed Al Ahad et al. (2021) conducted a longitudinal study of 90 registered nurses (RNs) in a hospital setting. They were asked to fill out a daily questionnaire over a period of 91 days, which produced a total of 1,303 responses (Abed Al Ahad et al., 2021). The nurse workload factor was divided between day and night shifts, with a reported mean nurse-to-patient ratio of 5.90 during the day versus 9.54 at night. In comparison, the day shift reported a mean of 6.75 in nurse workload versus a mean of 5.89 on the night shift. McHugh et al. (2020) showed similar disparities between day and night shifts, with nurse-to-patient ratios in hospitals (n=68) showing a mean of 5.07 patients per nurse 11 during the day and 7.38 during the night shift. These results highlight the imbalance of nurse workload and nurse-to-patient ratios seen between shifts, an essential factor for leaders to consider when planning assignments. Patient Acuity and Nurse Workload Juvé-Udina et al. (2020) define patient acuity as how much care a nurse must provide to meet the safety needs of the patient. The accurate evaluation of patient acuity is a core staffing model for determining appropriate assignment levels for nurses and nurse workloads (DiClemente, 2018). In the surveys collected by Ivziku et al. (2021), 114 out of 205 surveys indicated that nurses were heavily impacted due to patient acuity. Results were statistically significant in identifying this as a variable to consider when assessing nurse workload. With this in mind, nurse leaders should be conscientious regarding implanting patient acuity when assigning patients for the upcoming shift to help lighten the burden and fairly distribute workloads. As the patient acuity increases, so does the nurse's workload. Several studies showed high patient acuity increased nursing workload and adverse patient outcomes. Juvé-Udina et al. (2020) focused on Medical-Surgical floors, noting an average of 5.6 required RN hours per patient day; however, the available RN hours the nurses could reach was only 50% of the hours to meet the needs of the patients. Of the 416 RN responses, "73.4% of RNs reported excessive workload and 90.7% reported insufficient staffing in the wards" (Juvé-Udina et al., 2020, Results, para. 4). In contrast, Van den Heede et al. (2020) acknowledge that patient acuity must be assessed based on the complexity of the patient’s needs. Patient acuity measurement is rarely applied due to documented differences in patient numbers, staffing, and acuity levels from one shift to the next (Van den Heede et al., 2020). Meyer et al. (2020) acknowledge the patient acuity problem 12 and showcase one effort using an electronic health record to factor in the nurse workload by updating patient acuity and condition changes every six hours, as well as factoring in the nurse competency in handling the specified workload. Meyer et al. (2020) state that for a nursing assignment tool to implement acuity scores in determining appropriate workload, the unit and its leaders must work together to implement the practice. Patient Acuity and Job Satisfaction Higher patient acuity can add stress and increase nurse errors, leading to job dissatisfaction and nurse burnout (Van den Oetelaar et al., 2021). Van den Oetelaar et al. (2021) discuss that patient acuity is one type of perceived workload that is based on the unit level, which with increased patient acuity, affects job dissatisfaction, burnout, and medication errors. Van den Oetelaar et al. (2021) noted that nurses are expected to provide high-quality care despite an increased risk of high acuity and demand. Chaboyer et al. (2020) created an overview of twenty-two systematic reviews. They found that one of the factors affecting missed care was patient acuity, with associated detrimental nurse job satisfaction. Juvé-Udina et al. (2020) had a sample of 89,724 patient episodes, with 36,797 patient episodes in Medical-Surgical units (26,221 in medical units, 41,596 in surgical units). Juvé-Udina et al. (2020) reported that 77.9% of patients admitted into the medical wards had intermediate and pre-intensive acuity profiles averaging six RN hours per patient day. In the same three units, 14.9% of medical, 14.8% of surgical, and 19.1% of Medical-Surgical unit nurses desired to leave their job. They also analyzed that all three units reported a higher mean in an unexpected rise in patient acuity within their units. Nurse-To-Patient Ratios and Job Satisfaction 13 McHugh et al. (2020) analyzed 4372 Medical-Surgical nurses, 146,456 patients, and 68 public hospitals that measured outcomes, including nurse-to-patient ratios and job dissatisfaction. Results showed that for each assignment of an additional patient to a nurse, 12% higher odds of 30-day mortality were seen and 14% higher odds of job dissatisfaction. These results were statistically significant, with a 95% CI. In their meta-analysis of thirteen cross-sectional studies, Chen et al. (2019) reported that nurses with a higher nurse-to-patient ratio showed an increased risk for job dissatisfaction. A suggested mediation model of a standardized daily nurse-to-patient ratio showed a statistically significant positive correlation with job dissatisfaction with a p-value of <0.001 (Chen et al., 2019). Based on the p-value, there is a statistical significance between higher nurse-to-patient ratios and increased job dissatisfaction. Summary of Literature Review Findings and Application to the Project Relationships among patient acuity, nurse staffing, workplace satisfaction, and the contribution to patient outcomes are critical issues with nurse staffing. The overall sustainability of the healthcare industry will weaken and even potentially collapse with the rising aging population and shortage of nurses due to various factors, including the themes discussed above. The changes needed must be done with others. These changes require multi-disciplinary effort from all members within an organization to produce the real progress required. Limitations noted throughout the research articles were the lack of more rigorous research (Ivziku et al., 2021), nurse staffing may not guarantee good outcomes (McHugh et al., 2020), and the lack of clear policies to guide staffing issues (Van den Heede et al., 2020). Van den Oetelaar et al. (2021) define patient acuity, noting its effect on perceived nurse workload and job dissatisfaction. Their recommendation is to objectively measure nurse workload to ensure its distributed appropriately. 14 Overall, a substantial amount of current evidence is present to take these issues with the seriousness it deserves. Project Methodology The intended goal of this MSN project is to assess whether maintaining a consistent nurse-to-patient ratio and implementing a standardized patient acuity system will positively affect job satisfaction, create a fair nurse workload amongst staff, and assign proper patient acuity levels within the Medical-Surgical unit at AllianceHealth Durant. The proposed plan for change will be a two-part process that addresses both issues. Initially, the goal is to implement a set nurse-to-patient ratio (six patients to one nurse) to be upheld consistently. Secondly, a project deliverable as a patient acuity tool will be taught to all staff nurses during monthly meetings to be used at the end of each shift. Additionally, the patient acuity tool checklist will remain at the nurse’s station to assist nurses in identifying the criteria to properly rate patients’ acuity levels without keeping track of where the checklist is. Finally, periodic check-ins to assess compliance, fair assignment distribution, and cap on nurse-to-patient ratios will be implemented monthly and formatted as a questionnaire. Description and Development of Project Deliverables Two items were formulated to properly implement this MSN project, with subsequent detailed descriptions of how each was created and intended goals for use. Two educational components are also added to assist staff and nurse leaders in understanding and acknowledging the project deliverables. Patient Acuity Tool Checklist The project material will be in the format of a physical copy of a Patient Acuity Tool (see Appendix A). This form has been specifically tailored to apply to the Medical-Surgical unit at 15 AllianceHealth Durant. Current examples of patient acuity tools, such as the American Nurse Today (2014), included cardiac drips, insulin drips, peritoneal dialysis, vent, restraints, and rectal tubes. These criteria did not pertain to the Medical-Surgical department at AllianceHealth Durant. However, they served as an inspiration in which a new tool could be formulated and beneficial for this project. Another example of a patient acuity tool intended for a MedicalSurgical unit was created by Ingram and Powell (2018). The criteria were more suitable for the department, but their acuity levels were rated from one to four, unlike AllianceHealth Durant, where their acuity level is from one to three. This personalized project deliverable will assist RNs in determining what factors categorize a patient into a certain acuity level and the proposed workload for the nurse. Educational Teachings During Staff Meetings Teaching strategies will consist of an initial introduction at the monthly mandatory staff meeting, where a thorough explanation of the Patient Acuity Tool will be reviewed, and any suggestions or questions can be answered at this time. Kidd et al. (2014) noted that a recurrent theme within the literature shows that nurses' additional input and active participation added value in assessing their workloads and participating in the decision-making process. Therefore, this educational teaching aims to increase nurses’ involvement in the proposed change so they may be more willing to use the project deliverables and address any staff questions. Questionnaire An evaluation concerning the general understanding and implementation of the Patient Acuity Tool and gauging the nurse’s feelings regarding its use will be gathered via a sevenquestion questionnaire at the end of the meeting (See Appendix B). Research evidence shows a correlation that staff involved in developing a patient acuity assessment tool leads to an efficient 16 tool that effectively improves nurse satisfaction and job retention (Kidd et al., 2014). The same seven questions listed above will be used within the monthly re-assessment intervals to monitor if any changes, suggestions, or further teaching interventions are required. Understanding how using an acuity score by the level of care is beneficial to creating a balance in nurse staffing for efficient and appropriate deliverance in optimal patient care (Ruiz Colon et al., 2022). Research has also shown that having input from nurses to determine actual and perceived workload correlates with job satisfaction and subsequent turnover rates (Ruiz Colon et al., 2022). Nurse Leader Evidence-Based Practice Education The second portion entails meeting with the unit manager and house supervisor regarding maintaining a nurse-to-patient ratio of six patients per nurse. Education is to be done in person by educating the unit manager and house supervisor on the latest evidence-based research showing how increased nurse-to-patient ratios show statistically significant adverse patient outcomes (Shin et al., 2018) and increased risk for job dissatisfaction from nurses (Chen et al., 2019). Increased workloads for each patient added to their care (Abed Al Ahad et al., 2021). Further education can also be provided to nurse leaders from other departments that frequently round on patients in the Medical-Surgical department so that they can understand how the unit operates. Plan and Implementation Process This MSN project would require the approval of the Medical-Surgical unit manager. Due to the proposed change being to adhere strictly to a nurse-to-patient ratio of six patients to one nurse, further approval will need to be sought by the unit director. Once permission has been granted, further approval would need to be sought by the unit director. The current cap within the Medical-Surgical unit is six patients to one nurse; however, if the administration deems the 17 emergency department too overcrowded, they will assign additional patients. Oklahoma has no Safe Harbor Law to protect nurses from unsafe nursing assignments (Buppert, 2019). Initial meetings would be held within the facilities’ conference room for administration. In contrast, meetings with staff to educate on proposed changes can be held in the break room during unit meetings. Each of these meetings is an opportunity to educate, create an environment for open communication, and gain support for changes within the unit. Further support will need to be garnered from the staff RNs within the Medical-Surgical Unit to use and implement the proposed project deliverables in their daily routines. During each meeting, any barriers to implementing this MSN project may be addressed and discussed as a multidisciplinary team to achieve resolution and move forward. In addition, the questionnaire will be handed out during unit meetings for staff, following an explanation of the questions and creating another opportunity for open discussion. Finally, the nurses within the unit will begin implementing the Patient Acuity Tool while acknowledging the strict adherence to maintaining a max of six patients per nurse. Interdisciplinary Teamwork The implementation of this MSN project depends upon multiple AllianceHealth Durant members to actively participate, encourage, and accept the proposed changes to succeed. This project aims to accurately identify patients’ acuity levels with a subsequent focus on creating evenly distributed workloads and improving job satisfaction. This project also aims to allow for nurse autonomy, self-governance, and empowerment through the ability to hold consistent nurseto-patient ratios with appropriate workloads for more efficiency and increased satisfaction. Neither aspect of this project is achievable without the support and approval of the following interdisciplinary team members. 18 Chief Nursing Officer. The Chief Nursing Officer at AllianceHealth Durant holds an MSN degree. She is primarily responsible for significant changes, including enforcing the cap of six nurses to one patient, which this MSN project intends to implement and evaluate. In addition, this individual must approve the MSN project for full implementation within the unit. Nurse Leaders. The nurse leaders perform their leader rounding in the Medical-Surgical department. They directly garner patient feedback regarding their care and provide insight into the nurse's workload. These nurse leaders can collaborate and even assist nurses in tasks that can reduce the workload and enhance quality care while improving conditions within the unit which would benefit nurse morale. Medical-Surgical Manager. The Medical-Surgical manager is also an MSN RN with direct department staff involvement. This manager must also approve the MSN project before implementation can occur. Additionally, the manager must be willing to allow time within staff meetings to propose changes within this project, allow for educational periods within the meetings, and garner support for compliance in implementing the Patient Acuity Tool. The manager will also oversee that the responses to the questionnaires provided to staff are given back promptly and that any additional feedback/concerns are addressed in the following unit monthly meeting. House Supervisor. The house supervisor directly assigns patients to each unit and monitors the patient census and how many nurses are available for the current and upcoming shifts. They are mainly responsible for enforcing the nurse-to-patient ratio of six patients per nurse. It will take critical thinking, planning, and staff projection to consistently maintain the proportion of six patients per nurse cap for the upcoming shifts, with subsequent additional planning for call-ins or absences. 19 Medical-Surgical Nurses. The Medical-Surgical department staff nurses are at the forefront of these proposed changes for this MSN project. They will be primarily responsible for consistently implementing the Patient Acuity Tool and resilience in advocating for the max ratios to remain at six patients per nurse. The nurses will also be responsible for giving feedback via the provided questionnaires during unit meetings. They will also conduct frequent check-ins to evaluate how the proposed changes affect them (either positively or negatively) within the unit. These check-ins will allow for a review of nurse workload, job satisfaction, and proper assignments based on the Patient Acuity Tool. Timeline The proposed timeline will assist everyone within the interdisciplinary team in monitoring the progression of changes outlined in this MSN project. For this MSN project to be correctly implemented, the multidisciplinary care team at AllianceHealth Durant must complete coordination, assessment, and re-assessment. Therefore, the initial meeting will be held with the Chief Nursing Officer and Medical-Surgical Manager to obtain approval. In addition, all project deliverables and educational information are to be distributed at this time to educate and detail what the proposed changes are included for this MSN project. This meeting should take one hour, with any proposed follow-up meetings for progress updates to be done monthly, lasting a half-hour. Before the initial meetings, the deliverables will be produced, handed out, and available within one business day. The project implementation may then be instituted within the unit with formal approval from CNO and Medical-Surgical Director. The initial meeting with staff will occur at the next monthly unit meeting post-approval, where the proposed changes are to be presented to staff, along with the questionnaire assessing the understanding of the MSN project 20 changes. This initial meeting would take an estimated hour, and two-time slots will be provided to accommodate both night-shift and day-shift nursing staff. The full implementation at the department level is expected to occur within one month of the initial unit meetings with staff members. After that, feedback from initial and subsequent questionnaires will be conducted at the monthly meetings, each taking an hour. Complete project implementation from beginning to completion will be six months, with final meetings to address findings at the end of the MSN project (See Appendix C). All data gathered will be presented to both shifts at the unit meeting. A secondary meeting will be conducted with nurse leaders and administration to submit data regarding the project. Plan for Evaluation of Project The evaluation of this MSN project will be determined by analyzing the baseline data regarding nurses’ job satisfaction, nurse-to-patient ratios, nurse workload, and consistency in the use of a patient acuity tool. Comparing initial responses from the first questionnaire with subsequent responses will also assist in evaluating whether the implementation of the proposed project was successful. Finally, a summary of findings will be presented to all within the interdisciplinary team to show this MSN project's effectiveness (or ineffectiveness) within AllianceHealth Durant’s Medical-Surgical department. Ethical Considerations A few ethical considerations are to be considered regarding this MSN project. The first concern would be reliant upon the administration’s willingness to adhere to creating the nurse-topatient ratio consistently at six patients per nurse with no additional patients assigned from other units unless there is an additional support staff that would assist in the workload (e.g., an additional nurse was called in to help with holds in the Emergency department). 21 The second potential issue that one may encounter in implementing this project will be the adherence, willingness, and general attitude nursing staff have in consistently using the Patient Acuity Tool. If there is a positive outlook on the proposed changes by nursing staff, they will generally be more compliant with instituting the Patient Acuity Tool in practice. However, they may also resent it, feeling that this is additional work to be done on top of their other daily tasks. This can be combated with open communication between nurse managers and staff, nurse leaders assisting nurses in reducing workload if needed, and staff education regarding the Patient Acuity Tool. Finally, the last ethical consideration regarding this project will be creating an open and honest environment. This can be assessed during each meeting with staff and administration. Those who choose not to participate will not be penalized, and all factors that may identify a patient when determining acuity levels will be omitted during patient assignments. Discussion The following section highlights how the MSN project will be distributed for implementation, the significance of this project concerning the advancement of the nursing practice, as well as strengths and limitations of this project. Recommendations to overcome hurdles and improve this project are also noted, with an overall conclusion regarding the main objectives for the design of this MSN project and its potential benefit for future use in the nursing profession. Evidence-based Solutions for Dissemination Dissemination is vital in converting new evidence-based solutions and applying them to the point of care (Dudley-Brown, 2019). Dudley-Brown (2019) details dissemination as occurring on a multi-level scale, with internal dissemination once the translation project is 22 completed to a grander scale on an institutional level, accomplished through committees and organizations within hospitals (ex: AllianceHealth Durant). Multiple methods through which dissemination can occur include posters, presentations, and papers to inform and educate regarding policies that may need to be changed (Dudley-Brown, 2019). The main format that will be used to share essential project findings will be via a poster, publication of the MSN project paper in Portfolium, and a presentation to peers and faculty at Weber State University. The purpose is to raise awareness of the problem addressed in this paper, sharing the latest evidence-based practice regarding the subjects covered, the plan (with project deliverables) that will be used to implement changes, and evaluation methods to monitor either the success or failure of stated changes and obtain feedback from the staff at AllianceHealth Durant. In addition, the patient acuity tool could benefit other Medical-Surgical Units and could be further altered to suit the needs of other units. Significance to Advance Nursing Practice This MSN project is meant to benefit the nursing profession by addressing the current issues of a variable or increased nurse-to-patient ratio, causing increased workload to nurses and adding to the increase of nurse burnout, job dissatisfaction, and leaving bedside nursing. RNs are leaving the bedside at an increasing rate, with hospitals losing 2.47% of their RN employees (The National Health Care Retention & RN Staffing Report, 2022). Multiple factors noted by ITA Group (2023) explain why there is such an increased rate of nurses leaving the bedside, including but not limited to: nurses feeling overworked, overstressed, lack of support, and poor communication between upper-level management regarding significant concerns needing to be addressed. 23 This project also aims to have a detailed patient acuity tool that can be used specifically for Medical/Surgical units. There are multiple patient acuity tools available seen in research. However, this particular acuity tool is meant to reflect what is seen in a rural hospital's Medical/Surgical unit. Implications The prospective strength of this project is the cumulative research in the latest evidencebased practice which outlines the outcomes of increased nurse workloads from disproportionate patient acuities and an increase in assigned patients per nurse, causing decreased job satisfaction and burnout. Another strength is the low cost of implementation and application of this project. The main adjustments will be primarily by staff and administration, with a more educational and collaborative approach to the proposed changes outlined in this MSN project. The limitations of this project will come primarily from staff participation, accountability from both nurse managers and staff, and a willingness to change the current workflow process to accommodate the collaborative effort needed to assess patient acuities for the upcoming shift. In addition, nurse managers and house supervisors must strictly uphold the maximum of six patients per nurse, planning for call-ins, future scheduling, and proper assignment of patients from the emergency department to the Medical/Surgical unit. Hospital administration comes together during their meetings to assess any potential issues regarding critical staffing shortages. Leaders are required to take patients if there is an unavoidable shortage in the foreseeable future. A strong nurse leader (preferably the nurse manager directly over staff) must be actively involved in the process from inception until completion to combat the obstacles of participation and accountability. The nurse leader’s involvement allows staff to have a point of contact with whom they can ask questions directly and be held accountable for any potential lax involvement. 24 In addition, creating a positive workforce encourages participation. It informs nursing staff of why the proposed changes are being made and possible future benefits that could be the determining factors that increase participation. The implementation of the project supports the knowledge regarding the determination of patient acuity levels by nursing intervention needs, appropriate nurse-to-patient ratios, and factors that contribute to nursing job dissatisfaction and workload. The goal of the implementation of this project is to enhance the nursing profession by creating a more proportionate, manageable, and fair workload for patients while maintaining a consistent nurseto-patient ratio. Recommendations Recommendations for improving the project can be to increase the length of time the project is to be completed, collect more data, and strengthen the findings with additional research. Current gaps related to the problem of varying nurse-to-patient ratios are from a state and legislative stance where significant changes would have to be made on these levels to enact standardized nurse-to-patient ratios. Further examination of patient acuity tools can be explored to identify what applies to Medical/Surgical departments, as there are few currently in nursing research. Conclusions In conclusion, this MSN project's overall focus was to showcase the latest evidence-based practices regarding how patient ratios, nursing workloads, patient acuity, and job satisfaction directly affect each other and can either positively or negatively affect nurses. The literature review highlighted the newest research available within the last five years regarding the topics covered in this MSN project. The main objectives of this project were to address what is being 25 seen at the bedside, particularly in the Medical/Surgical department at AllianceHealth Durant, and how this project can assist nurses in correctly identifying patient acuity levels while maintaining an appropriate nurse-to-patient ratio to increase job satisfaction and lessen nurse workload. 26 References Abed Al Ahad, M., Elbejjani, M., Simon, M., Ausserhofer, D., Abu‐Saad Huijer, H., & Dhaini, S. (2021). Variability, shift‐specific workloads and rationed care predictors of work satisfaction among registered nurses providing acute care: A longitudinal study. Nursing Open, 9(2), 1190–1199. https://doi.org/10.1002/nop2.1160 Ageiz, M. W., & El-Mageed, H. H. A. (2020). Nurses' satisfaction related to implementing patient acuity tool-based assignment. American Journal of Nursing Research, 8(4), 452462. https:// doi.org/10.12691/ajnr-8-4-5 Al Sabei, S. D., Labrague, L. J., Miner Ross, A., Karkada, S., Albashayreh, A., Al Masroori, F., & Al Hashmi, N. (2019). Nursing work environment, turnover intention, job burnout, and quality of care: The moderating role of job satisfaction. Journal of Nursing Scholarship, 52(1), 95–104. https://doi.org/10.1111/jnu.12528 American Nurses Association. (n.d.a). Nurse Staffing. https://www.nursingworld.org/practicepolicy/nurse-staffing/ American Nurses Association. (n.d.b). Nurse Staffing Measures. https://www.nursingworld.org/practice-policy/nurse-staffing/nurse-staffing-measures/ Buppert, C. (2019). A ‘safe harbor’ for unsafe nursing assignments. Medscape. https://www.medscape.com/viewarticle/912200 Chaboyer, W., Harbeck, E., Lee, B., & Grealish, L. (2020). Missed nursing care: An overview of reviews. The Kaohsiung Journal of Medical Sciences, 37(2), 82–91. https://doi.org/10.1002/kjm2.12308 27 Chen, Y., Guo, Y., Chin, W., Cheng, N., Ho, J., & Shiao, J. (2019). Patient–nurse ratio is related to nurses’ intention to leave their job through mediating factors of burnout and job dissatisfaction. International Journal of Environmental Research and Public Health, 16(23), Article 4801. https://doi.org/10.3390/ijerph16234801 Colon, G. D., Sullivan, K. M., Albaniel, M., Britt, P., & Shieh, L. (2022). Assessment of level of care recommendations and nursing acuity scores following an appropriateness of care intervention. BMJ Open Quality, 11(2), Article e001688. https://doi.org/10.1136/bmjoq2021-001688 DiClemente, K. (2018). Standardizing patient acuity: A project on a medical-surgical/ cancer care unit. MedSurg Nursing, 27(6), 355-387. https://www.proquest.com/openview/7b8dbc7257006d95a335f2e9272c95d0/1?pqorigsite=gscholar&cbl=30764 Driscoll, A., Grant, M., Carroll, D., Dalton, S., Deaton, C., Jones, I., Lehwaldt, D., McKee, G., Munyombwe, T., & Astin, F. (2018). The effect of nurse-to-patient ratios on nursesensitive patient outcomes in acute specialist units: A systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6–22. https://doi.org/10.1177/1474515117721561 Dudley-Brown, S. (2019). Dissemination of evidence. In Translation of Evidence into Nursing and Health Care, 3rd ed. (pp. 255–267). Springer Publishing Company. https://doi.org/10.1891/9780826147370.0012 Ingram, A., & Powell, J. (2018). Patient acuity tool on a medical-surgical unit. American Nurse Today, 13(4), 1–9. https://www.myamericannurse.com/patient-acuity-medical-surgicalunit/ 28 ITA Group. (2023). 7 Things That Cause Nurse Turnover (and 8 Things That Stop It). Blue Compass Interactive, Des Moines, Iowa, www.bluecompass.com. https://www.itagroup.com/insights/employee-experience/7things-cause-nurse-turnover-8-things-to-stop-it Ivziku, D., Ferramosca, F., Filomeno, L., Gualandi, R., de Maria, M., & Tartaglini, D. (2021). Defining nursing workload predictors: A pilot study. Journal of Nursing Management, 30(2), 473–481. https://doi.org/10.1111/jonm.13523 Johns Hopkins Medicine. (2022). Evidence-Based Practice. https://www.hopkinsmedicine.org/nursing/center-nursing-inquiry/nursinginquiry/evidence-based-practice.html Juvé‐Udina, M., González‐Samartino, M., López‐Jiménez, M., Planas‐Canals, M., Rodríguez‐ Fernández, H., Batuecas Duelt, I., Tapia‐Pérez, M., Pons Prats, M., Jiménez‐Martínez, E., Barberà Llorca, M., Asensio‐Flores, S., Berbis‐Morelló, C., Zuriguel‐Pérez, E., Delgado‐ Hito, P., Rey Luque, S., Zabalegui, A., Fabrellas, N., & Adamuz, J. (2020). Acuity, nurse staffing, and workforce missed care and patient outcomes: A cluster‐unit‐level descriptive comparison. Journal of Nursing Management, 28(8), 2216–2229. https://doi.org/10.1111/jonm.13040 Kidd, M., Grove, K., Kaiser, M., Swoboda, & Taylor, A. (2014). A new patient-acuity tool promotes equitable nurse-patient assignments. American Nurse Today, 9(3), 1– 4. https://www.myamericannurse.com/wp-content/uploads/2014/03/ant3-WorkforceManagement-Acuity-304.pdf 29 McHugh, M., Aiken, L., Windsor, C., Douglas, C., & Yates, P. (2020). Case for hospital nurseto-patient ratio legislation in Queensland, Australia, hospitals: an observational study. BMJ Open, 10(9), e036264. https://doi.org/10.1136/bmjopen-2019-036264 Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in Nursing & Healthcare: A guide to best practice (4th ed.). Wolters Kluwer. Meyer, K., Fraser, P. & Emeny, R. (2020). Development of a nursing assignment tool using workload acuity scores. JONA: The Journal of Nursing Administration, 50(6), 322–327. https://pubmed.ncbi.nlm.nih.gov/32427663/ NSI Nursing Solutions, Inc. (2022). 2022 NSI National Health Care Retention & RN Staffing Report. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_ Care_Retention_Report.pdf Ruiz Colon, G. D., Sullivan, K. M., Albaniel, M., Britt, P., & Shieh, L. (2022). Assessment of level of care recommendations and nursing acuity scores following an appropriateness of care intervention. BMJ Open Quality, 11(2), e001688. https://doi.org/10.1136/bmjoq2021-001688 Senek, M., Robertson, S., Ryan, T., King, R., Wood, E., Taylor, B., & Tod, A. (2020). Determinants of nurse job dissatisfaction - findings from a cross-sectional survey analysis in the UK. BMC Nursing, 19(1), Article 88. https://doi.org/10.1186/s12912-020-00481-3 Shin, S., Park, J., & Bae, S. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), 273–282. https://www.sciencedirect.com/science/article/abs/pii/S0029655417302658 Tenorio, M. R., Aletreby, W. T., Al Shammari, B., Almuabbadi, B., Mwawish, H., & Montegrico, J. (2021). The interrelation between nurse-to-patient ratio, nurse engagement, 30 and missed nursing care in King Saud Medical City: Basis for development of nurse– patient quality of care. Saudi Journal for Health Sciences, 10(2), 116. https://doi.org/10.4103/sjhs.sjhs_74_21 Van den Heede, K., Cornelis, J., Bouckaert, N., Bruyneel, L., van de Voorde, C., & Sermeus, W. (2020). Safe nurse staffing policies for hospitals in England, Ireland, California, Victoria, and Queensland: A discussion paper. Health Policy, 124(10), 1064–1073. https://doi.org/10.1016/j.healthpol.2020.08.003 Van den Oetelaar, W., Roelen, C., Grolman, W., Stellato, R., & Van Rhenen, W. (2021). Exploring the relation between modelled and perceived workload of nurses and related job demands, job resources and personal resources; A longitudinal study. PLOS ONE, 16(2), Article e0246658. https://doi.org/10.1371/journal.pone.0246658 Virginia Commonwealth University. (2022). Evidence-Based Practice Portfolio. https://guides.library.vcu.edu/c.php?g=283853&p=4033440 31 Appendix A Personalized Patient Acuity Tool Patient Acuity Tool for AllianceHealth Durant’s Medical/Surgical Department The following chart is a specialized acuity tool designated for the patient’s needs seen within this department. Rating options are ranked 1 through 3, from lowest to highest patient acuity. Ratings are based on the scores from the categories listed below. These show how much nursing time is required to care for a patient. Total scores range from 1 to 64. Acuity Category Oral Medications Complicated IV Medications 1 2 3 1-5 6-10 11-15+ 2-5 IV medications >5 IV medications Bumex drip Heparin Insulin coverage TPN Blood products Tube feedings/meds Patient Care Requirements Foley Assist with ADLS x1 BiPAP Telemetry NG tube Wound Care Incontinent Assist with ADLS x2+ Central line /PICC Fall Risk Continuous pulse ox HFNC PCA maintenance Fall Risk (not alert and oriented) PCA initiation CBI Chest Tube Neuro checks New Admission Total Acuity Category Scores: Patient Rating of 1: 1-15 Patient Rating of 2: 16-30 Patient Rating of 3: 31+ Total 32 Appendix B Questionnaire 1. Do you understand how to use the Patient Acuity tool at the end of each shift? 2. If not, what specific part of the Patient Acuity Tool do you need help understanding? 3. Would you be willing to assist other nurses in using and holding them accountable for using the Patient Acuity Tool? 4. Do you have any objections or reservations about implementing this Patient Acuity Tool within your daily practice at the end of the shift? If so, what are they? 5. Do you think the consistent use of the Patient Acuity Tool would be beneficial in assisting the nurse (or charge nurse) make fair and equal patient assignments for nurses? 6. Do you have any suggestions on making this Patient Acuity Tool work better for your unit? 7. How satisfied are you with your job concerning patient acuity, current nurse-to-patient ratios, and nurse workloads? Please describe in terms of (extremely dissatisfied, dissatisfied, neutral, satisfied, or extremely satisfied). 33 Appendix C Time Frame for Implementation of MSN Project Project Implementation Timeline Day 1 Produce all deliverables and teaching information to be ready for distribution at all initial meetings Week 1 Meet with MedicalSurgical Manager, CNO, and nurse leaders to discuss MSN project and distribute project deliverables End of Month 1 Initial unit meeting with staff regarding projected changes Distribution of project deliverables (Patient Acuity Tool and Questionnaire) Month 2-5 Feedback and additional reinforcement teaching to be conducted at unit meetings with staff Month 6 Collect data from questionnaires and feedback from staff. Present all data to all within the interdisciplinary team