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Assignments Matter: Results from a Nurse-Patient Assignment Survey

Article  in  Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses · March 2019

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Stephanie Allen
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 Research for Practice
Assignments Matter: Results from a
Nurse-Patient Assignment Survey
ospital leaders continually
H look for ways to improve
patient, nurse, and organi-
zational outcomes. Because reim-
bursement no longer exists for
adverse patient events, hospital
units are driven to improve out-
comes while containing costs
(Kuhn, 2008). One area in which
this is possible is the nurse-patient
assignment process, which is an
ideal process for quality improve-
ment efforts (Choi & Miller, 2018).
Nurse-patient assignments in-
volve the matching of the nurse and
patients for a specified time for the
provision of nursing care. Assign-
ments provide the structure for nurs-
ing care delivery in most inpatient
settings through identifying and
matching individual nurse charac-
teristics to specific patient needs.
Positive outcomes can be achieved
with nurse-patient assignments
that reduce risk (Van Oostveen,
Braaksma, & Vermeulen, 2014).
Although nurse-patient assignments
are made millions of times a day in
hospitals around the world, little
formalized knowledge exists about
the process (Allen, 2012, 2015). The
lack of formalized training related
to making nurse-patient assign-
ments was the impetus for this
research.
Research Questions
The three research questions for
this study were as follows: (1) What
percentage of a sample of registered
nurses (RNs) has ever made nurse-
patient assignments? (2) How do
RNs learn to make nurse-patient
assignments? and (3) Is nurse satis-
faction with assignments related to
absenteeism and turnover?
March-April 2019 • Vol. 28/No. 2
Stephanie B. Allen
Clinical nurses attending a medical-surgical nursing conference
responded to an online survey about nurse-patient assignments.
Nurses reported their assignments were very important and
extremely important to their overall job satisfaction. Over 90% of
clinical nurses made assignments. Nurses learn to make assign-
ments through informal means.
Review of the Literature through non-formalized methods
(Allen, 2012).
A PubMed search using the
The process of making nurse-
terms nurs*, patient, and assignment
patient assignments is not taught
generated 255 results for articles
routinely in undergraduate educa-
within the previous 5 years. Fifteen
tion because beginner nurses do not
articles discussed nurse-patient
make assignments. Issacson and
assignments. After review of those
Stacy (2004) described a single
articles’ abstracts, three articles were
instance of senior nursing students
found to model/describe the assign-
making patient assignments for
ment-making process. However,
junior students during a medical-
none of these authors addressed
surgical clinical rotation. The
how nurses learn to make nurse-
process also is not taught in gradu-
patient assignments (Acar & Butt,
ate curricula because nurse man-
2016; Rogowski et al., 2015; Sir,
agers and administrators also do
Dundar, Barker Steege, & Pasu-
not make assignments. Nurse-
pathy, 2015). To date research on
patient assignments are identified
the nurse-patient assignment pro-
as an activity of the charge nurse,
cess has been scarce; no research
but training programs and role
exists that actually describes the
descriptions do not identify how to
complex process of making nurse-
make nurse-patient assignments
patient assignments. Foundational
(Admi & Moshe-Eilon, 2010; Eggen-
research has begun to explore the
berger, 2012; Sherman, 2005;
most basic aspects of the nurse-
Thomas, 2012). Although charge
patient assignment process (Allen,
nurses typically make assignments,
2012, 2015). Purposes, decision fac-
no protocols have been found that
tors, and steps of the process have
address where they learn how to do
been identified. Supplemental re-
so. No publications appear to
sults from this research indicate the
describe if they receive guidance in
majority of charge nurses learn to
the process.
make nurse-patient assignments
Stephanie B. Allen, PhD, RN, NE-BC, is Assistant Professor, Pace University, Pleasantville,
NY.
119
Research for Practice

Scheduling typically occurs 6-8

Background weeks before schedule implementa-
Nurse-patient assignments are made every day in hospitals around the tion. Nurses assign budgeted nurs-
world. These assignments can affect patients, nurses, and organizations ing personnel to shifts for a set
alike. Although a common process, little formalized knowledge exists number of work weeks. Staffing is
about making assignments. The lack of formalized training related to the third phase and occurs in the 2-
making nurse-patient assignments was the impetus for this research. 24 hours before the beginning of
the shift (Allen, 2012). The nurse
Aims manager or staffing coordinator
The specific aims were to learn who makes nurse-patient assignments, uses some type of tool, usually
how they learn to make them, and if satisfaction with an assignment based on census, to project nursing
affects absenteeism and turnover. care needs. The fourth phase is the
nurse-patient assignment, in which
the unit nurse manager or charge
Method
nurse matches individual character-
This descriptive study used a 24-question Qualmetrics computer-based istics of the nurse and the patient to
survey launched from an exhibitor booth at the 2016 Academy of achieve the highest quality, safest
Medical-Surgical Nurses Annual Convention in Washington, DC. nursing care. Nurses are assigned to
specific patients. Key factors, such
Results as patient acuity and nurse ex-
A clear majority (91%) of the registered nurse sample has made nurse- perience, are critical to the suc-
patient assignments. Respondents indicated they learned to make nurse- cessful matching of nurse and
patient assignments in the following ways: primary undergraduate pro- patient and the provision of safe
gram – 6%, formal hospital training – 9%, colleague – 76%, on their own nursing care (Allen, 2015; Berbarie,
– 43%. No correlation was found between nurse satisfaction with assign- 2010).
ments and absenteeism or turnover. The process then repeats. His-
torical data of nurse-patient assign-
Limitations and Implications ments from the previous year are
used in the next year’s budgeting
Small sample and lack of diversity in nursing specialty and years of expe- process (Allen, 2012). Actual hours
rience of nurses were limitations of the study. Formalized hospital train- of nursing care received by each
ing on nurse-patient assignments and inclusion of nurse-patient assign- patient are determined. Historical
ment process in prelicensure programs are recommended for nurses. patient and other hospital financial
information is used to project
Conclusion patient characteristics for the next
Although nurse-patient assignments are very important to overall job sat- year. Patient projections in turn dic-
isfaction, nurses are making assignments early in their careers without tate specific nursing personnel
formal education on the process. Further research is needed to explore needs for the next year.
the link between assignments and job satisfaction with a larger sample.
Ethics
The project was approved by
the university Institutional Review
Anecdotal and unpublished evi- and delivering nursing care in- Board. Before completing the sur-
dence suggests nurses learn this volves four sequential phases: vey, each participant gave informed
important process through on-the- budgeting, scheduling, staffing, and consent. Participants read the con-
nurse-patient assignments (see sent form online and needed to
job training (Allen, 2012). The
click Yes to confirm they under-
effectiveness of this process is Figure 1). During the initial budget-
stood the purpose of the research
unknown. Without knowledge of ing phase, the number and skill mix
before accessing the survey. No per-
how nurses are taught to make of the nursing staff needed for the
sonal identifying information was
assignments, evidence-based prac- year is budgeted for a specific nurs- requested or collected during the
tice changes to improve the process ing service area. Resources include survey. No data were recorded on
cannot be implemented. human resources records, financial paper. To safeguard electronic data,
reports, and nursing service staffing access to survey data was restricted
documentation. Data may incorpo- to the researcher and statistician.
Theoretical Framework rate historical and projected census Only the researcher was able to
The conceptual framework for and nursing hours per patient day, access the data online via a user-
this study was the Nurse Planning allocated financial resources, and/or specific and password-protected
Process (Allen, 2012). Planning for historical staffing data. Qualtrics account.

120 March-April 2019 • Vol. 28/No. 2

 Assignments Matter: Results from a Nurse-Patient Assignment Survey

FIGURE 1. in nature. For those questions, uni-

Nurse Planning Process
Nurse Budgeting
The number and mix of nursing
staff is determined for a defined
period (year, quarter, etc.).
Nurse-Patient Assignment
Nurse Scheduling
Individual nurses are matched
Nursing staff is assigned to work
to a patient or group of patients
particular shifts for a defined
for the shift (0-2 hours before
period (2, 4, or 6 weeks, etc.).
shift).
Nurse Staffing
Nursing staff is called in, called
off, or floated to another area to
meet the defined nursing needs
for a particular shift (2-24 hours
before the start of the shift).
Source: Allen, 2012
Sample Selection reliability with seven nurses. Group
answers were consistent for ques-
The target population was RNs
tions and constructs.
who work or have worked on inpa-
Participants used personal elec-
tient medical or surgical nursing
tronic devices to access the Internet
units. A convenience sample was
and enter the web address for the
drawn from attendees of the 2016
Academy of Medical-Surgical Nurses survey. In addition to basic demo-
Annual Convention held September graphic information (e.g., age, gen-
29 - October 2, 2016, in Washington, der identity), participants were
DC. The sample was recruited from a asked about their practice settings
booth in the convention’s exhibi- (unit type, number of beds) and
tion hall. The researcher distributed professional history (academic
flyers to attendees who passed the achievements, years of practice).
booth. Approximately 350 potential Some questions used Likert scales to
subjects were given a flyer with a link gauge data importance (e.g., How
to the survey. important are nurse-patient assign-
ments to your overall job satisfac-
tion?). Other questions asked par-
Design and Methods ticipants to rank-order items (e.g.,
Data were collected for this Place the following factors used to
descriptive study using a 24-ques- make nurse-patient assignments in
tion Qualtrics computer-based sur- order of importance). Finally, open-
vey. The survey was developed by ended questions were used to gath-
the researcher based on previous er additional information about
findings (Allen, 2015, 2018). The nurse-patient assignments (e.g.,
survey was reviewed for content What advice would you give to a
and face validity by a colleague with nurse learning how to make nurse-
knowledge of nurse-patient assign- patient assignments?).
ments. It then was pilot tested for Most questions were descriptive
variate data analysis was used to
determine data frequencies, means,
medians, ranges, and standard devi-
ations. If the variable was continu-
ous, mean, standard deviation, and
minimum and maximum were cal-
culated. If the variable was categori-
cal, count and percentage were cal-
culated. Chi-square analyses were
used to assess an association between
self-rated importance of nurse satis-
faction with assignments and nurse
absenteeism and turnover.
Findings
Based on the estimated 350 fly-
ers distributed, the response rate
was approximately 17%; 59 nurses
gave informed consent and started
the survey. Because participants
were able to choose not to answer
any question in the survey, some
questions had fewer than 59 re-
sponses. Table 1 highlights the par-
ticipants’ demographic and work-
place characteristics data. The aver-
age participant was a 44-year-old
female with a baccalaureate degree.
She had been a nurse for 17 years,
practicing 16 of those years in an
inpatient setting.
An overwhelming majority
(91.4%, n=58) of nurses reported
having made nurse-patient assign-
ments. They made assignments for
an average of 10 years (n=53, range
1-31 years). Participants then indi-
cated how they learned to make
nurse-patient assignments. Only
5.7% (n=3) said they learned in
their primary degree programs and
8.6% (n=5) learned through a hospi-
tal-based course/training. More par-
ticipants learned on their own
(43.1%, n=25) and/or from a men-
tor/colleague (75.9%, n=44). Slight-
ly less than 10% (n=5) of partici-
pants reported making nurse-
patient assignments within 6
months of graduation. At 1 year
after graduation, the percentage
rose to 34% (n=18) of the sample. At
2 years after graduation, 58.5%
(n=31) of the nurses were making
assignments.
Participants were asked if they
knew someone who has been

March-April 2019 • Vol. 28/No. 2 121

Research for Practice

TABLE 1.
Participant and Participant Workplace Demographics

Age (n=54) Mean = 44.6 years (range = 24-62 years)

Gender Identity (n=55)
Education (n=55)
State of Residence (n=56)
96.4% Female
Associate degree - 16.4%
Bachelor degree - 54.5%
Master degree - 23.6%
Doctorate of nursing practice - 3.6%
Doctor of philosophy - 1.8%
6 = Indiana
5 = Pennsylvania
4 = North Carolina, Ohio, Oregon
3 = Maryland, New York, Virginia, Washington
2 = California, Colorado, Florida, Georgia, Idaho, Illinois, Minnesota, Texas
1 = Arizona, Kansas, Louisiana, New Hampshire, New Jersey

Years as a Nurse (n=58) 17.1 years (range 1-40 years)

Years Working in an Inpatient
Setting (n=58)
Shift Typically Worked (n =58)
Workplace Setting (n=58)
Number of Beds (n=58)
Average Length of Stay (n=55)
16.4 years (range 1-40 years)
Day shift - 62%
Night shift - 27.6%
Evening shift - 6.9%
Other combination - 3.4%
23 = Medical unit
18 = Surgical unit
6 = Other
4 = Orthopedic unit
2 = Neuroscience unit
1 = Cardiothoracic unit, gastroenterology unit, medical intensive care unit,
oncology unit, transplantation unit
29.2 Beds (range 12-48 beds)
4.4 Days (range 1-15 days)

absent from work or left work early
because of an assignment he or she
did not like. How often did this
happen? Of the 58 respondents,
58.6% (n=40) said they knew of no
one, 34.5% (n=20) said this hap-
pened one to two times a year, and
5.2% (n=3) said this happened two
to five times a year; for 1.7% (n=1)
of respondents, this happened more
than 12 times a year. When asked if
they knew someone who left a posi-
tion (transferred to another unit,
quit) because he or she was unhap-
py with the nurse-patient assign-
ments, 25.9% (n=15) said they
knew no one, 20.7% (n=12) said
they knew one, and 53.4% (n=31)
knew more than one. Finally, par-
ticipants were asked how important
their nurse-patient assignments
were to their overall job satisfac-
tion. Of respondents, 39.7% (n=23)
indicated they were extremely impor-
tant, 56.9% (n=33) noted they were
very important, and 3.4% (n=2) iden-
tified them as moderately important.
Chi-square testing was used to
identify associations between im-
portance of daily patient assign-
ment to overall satisfaction and
absenteeism and turnovers. The
dependent variable Importance of
Daily Patient Assignment to Overall
Job Satisfaction was compared indi-
vidually to the four independent
variables (Have you been absent
from work or left work early
because of an assignment you did
not like or agree with? Have you
ever left a position [transferred to
another unit, quit] because you
were unhappy with the nurse-
patient assignments? Do you know
someone who has been absent from
work or left work early because of
an assignment he or she did not like
or agree with? Have you been
absent from work or left work early
because of an assignment you did
not like or agree with?). No bivari-
ate analyses between these variables
showed statistical significance.
Participants also were asked
how important they considered cer-
tain decision factors when making
nurse-patient assignments. The
majority indicated the following
factors were extremely important or
very important (first or second on a
5-point Likert scale): patient acuity,
nurse-patient ratio, current staffing,
patient workload, nurse compe-

122 March-April 2019 • Vol. 28/No. 2

 Assignments Matter: Results from a Nurse-Patient Assignment Survey

TABLE 2. training (9%), and in their primary

How Important Each Purpose/Outcome Is When Making Assignments pre-licensure program (6%). Results
show almost all nurses are making
Purpose Value* nurse-patient assignments yet there
Safety 4.73 is a lack of formalized education
and/or training on this crucial
Best Care 4.66 process.
Quality/Patient Satisfaction 4.29 Although no correlation was
Staff Well-being 4.23 found between nurse satisfaction
with assignments and absenteeism
Equal Workload 4.16 and turnover, 97% of nurses said
Fairness 4.16 their daily assignment was extreme-
Continuity of Care 4.16 ly or very important to their overall
job satisfaction. There were addi-
Maintaining the Workflow 4.11 tional results that support the
Workload Completion 4.07 importance of nurse-patient assign-
Care Coordination 3.96 ments in overall job satisfaction:
41% of nurses know someone who
Patient Advocacy 3.84 called out sick because of an assign-
Nurse/Patient Match 3.75 ment and 74% of nurses know
Nurse Development 3.63 someone who quit or transferred
because of her nurse-patient assign-
Discharge Planning 3.54
ment; 10% have quit or transferred
*Extremely important = 5, Very important = 4, Moderately important = 3, Slightly themselves. Absenteeism and turn-
important = 2, Not at all important = 1 over are common in the inpatient
setting. Both can contribute to
short staffing, potentially impact-
ing patient care quality. Addi-
TABLE 3. tionally, there are financial implica-
Primary Purpose of the Nurse-Patient Assignment tions for the organization related to
nurse turnover. The cost to organi-
Purpose % zations ranges from $37,700 to
Best Care 41.1 $58,400 for each nurse who leaves a
bedside nursing position (NSI
Safety 28.6 Nursing Solutions, 2016).
Equal Workload 12.5 Nurses who participated in the
Quality/Patient Satisfaction 8.9 study also validated decision factors
and purposes of the nurse-patient
Continuity of Care 3.6 assignment process previously iden-
Fairness 3.6 tified in the literature (Allen, 2012).
Workload Completion 1.8 The findings added new knowledge
related to the crucial knowledge
Total 100 nurses need when making assign-
ments. Nurses also validated the
importance of best care as the pri-
mary purpose of the nurse-patient
tence, continuity of care, nurse- Discussion assignment process.
patient relationship, and support
Results indicated the clear
staff availability. When the nurses
majority of nurses is being tasked
were told they could rely on only Limitations
with making nurse-patient assign-
three pieces of information (factors)
ments early in their careers. With Although nurses from 22 states
to make assignments, they chose
the high number of nurses making and 19 nursing units were inter-
patient acuity, nurse competence,
assignments, it became very impor- viewed, the sample was small. Only
and patient workload. They also
tant to know how nurses are learn- nurses who worked on medical-sur-
were asked how important they
ing to make assignments. The vast gical nursing units in hospitals were
considered various purposes of the
majority of nurses learned to make recruited to participate. Nurses who
nurse-patient assignment process
assignments from a colleague work in other inpatient and outpa-
(see Table 2). They chose best care
(76%). They also learned on their tient settings may have different
(41.1%, n=23) as the primary pur-
own (43%). The two ways that were experiences with nurse-patient
pose or outcome (see Table 3).
least identified were formal hospital assignments. The average partici-

March-April 2019 • Vol. 28/No. 2 123

Research for Practice
pant has been a nurse for 17 years.
However, less-experienced nurses
may have different exposure to
nurse-patient assignments and thus
less competency in the assignment
process, based on the evolving goals
of prelicensure nursing programs
(American Association of Colleges
of Nursing, 2008).
Recommendations for
Future Research
Study results suggest further
areas of inquiry. A priority is to
explore the link between nurse-
patient assignments and job satis-
faction with a larger, more diverse
sample of nurses. There is also a
need to understand how prelicen-
sure nursing programs prepare nurs-
es to make nurse-patient assign-
ments. Finally, research is needed to
describe the role of formal hospital
training programs in facilitating the
transition to making nurse-patient
assignments.
Nursing Implications
Results of this study are espe-
cially important for inpatient nurses
who make nurse-patient assign-
ments. Assignments play a larger
role in nurse job satisfaction than
previously documented (Al Maqbali,
2015). Determining the nurse-
patient assignment process that sat-
isfies nurses and delivers best care is
important. These findings can be
used as a starting point for dialogue
among unit nurses about the nurse-
patient assignment process that
meets their unit’s needs.
Healthcare leaders have oppor-
tunities to develop formalized train-
ing and competencies for nurses
and nursing students on the nurse-
patient assignment process. Nurses
start making assignments early in
their careers. They need the re-
sources to make assignments that
meet goals for patients (best care),
nurses (satisfying), and the organi-
zation (cost-effective).
Conclusion
Assignments matter to patients
and nurses (Allen, 2018). Nurse-
124
View publication stats
patient assignments are important
to nurses and their overall job satis-
faction. However, nurses often
make assignments early in their
careers without formal education
on the process. Survey responses
supported previous research that
emphasized patient acuity and
nurse competence as primary deci-
sion factors when making assign-
ments. Nurses reinforced best care
as the primary purpose of nurse-
patient assignments.
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