Recognition and prioritization of patient problems is an essential skill but an ongoing challenge for new graduate nurses (Kavanagh & Szweda, 2017). Mastery of clinical skills requires multiple opportunities for practice, yet mastering prioritization is difficult given that clinical experiences often prioritize completion of time-dependent tasks and provide limited opportunities for managing care for multiple patients (Jessee, 2016). Multipatient simulation engages students in prioritization of care for multiple patients but requires multiple sessions and additional faculty time (Mager & Roberto, 2018; Sullivan, Goldstein, Lucas, & Ockimey, 2019). Further, there is minimal inquiry addressing nurse prioritization activities and best practices for teaching the skill of prioritization (Hendry & Walker, 2004; Suhonen et al., 2018). Teaching strategies that focus on recognition of risk potential, familiarize students with common prioritization frameworks, and engage students in multiple opportunities to practice prioritizing patient care may improve students' ability to intervene on highest risk problems first, to reduce avoidable negative patient outcomes. The purpose of this manuscript is to present a simple, targeted, theoretically supported strategy to teach prioritization of patient care that can be implemented without significant change to curricula or clinical education structure.
When managing care for multiple, complex patients in the acute care setting, new graduate nurses struggle to accurately prioritize patient needs and intervene to promote positive outcomes (Kavanagh & Szweda, 2017). Increasingly complex patient situations and high patient-to-nurse staffing ratios hinder new graduate nurses' successful management of patient care, contributing to avoidable patient decline and death (Brooks Carthon et al., 2019; Griffiths et al., 2018). This phenomenon is often attributed to the persistent deficit in clinical reasoning and judgment of new graduate and novice nurses (Kavanagh & Szweda, 2017). As a result, the National Council for State Boards of Nursing started the NextGen NCLEX® initiative to modify the licensure examination for more direct assessment of clinical reasoning and judgement abilities (National Council for State Boards of Nursing, 2017). Therefore, it is imperative that educators focus on improving strategies to ensure students are prepared. Sound prioritization requires accurate foundational knowledge and understanding of essential nursing prioritization frameworks, including the ABCs (airway, breathing, and circulation), Maslow's Hierarchy of Needs, and time-sensitive indicators relevant to the acute care setting (e.g., medication administration, provider orders), recall of knowledge, interpretation of patient data, ranking of patient risks, and problems for action. Because nursing students and most novice nurses use rule-based analytic thinking rather than intuitive thinking processes characteristic of expert nurses, initial teaching of prioritization may be best approached as a structured process (Cader, Campbell, & Watson, 2005) that highlights risks that contribute to patient decline and significance of interventions to reduce risk of adverse patient outcomes.
The “Who, What, & Why?” exercise is supported by the integrated clinical education theory, which posits that clinical education should occur in a supportive sociocultural context, include multiple opportunities for practice, engage students in discourse and meaningful feedback during interactions with peers and instructors, and foster continued reflection to promote deep learning (Jessee, 2018). Consistent use of “Who, What, & Why?” within clinical experiences provides students with repeated practice prioritizing actual patient situations, promotes collaborative discourse with peers, and fosters metacognition within a supportive environment guided by coaching from the instructor.
Design and Implementation
The “Who, What, & Why?” exercise is designed to facilitate student learning of the prioritization process for care of hospitalized patients with three scaffold levels designed to target the learning for beginner, intermediate, and advanced students. Identification of patient problems using concepts such as oxygenation or perfusion, or nursing diagnoses such as ineffective airway clearance or ineffective coping, is more relevant when approached by the risks those problems pose to patient outcomes if that problem worsens or fails to improve. “Who, What, & Why?” uses a risk-based framework and builds on specific foundational knowledge including (a) essential nursing prioritization frameworks (ABCs, Maslow's Hierarchy of Needs, time-sensitive tasks) and (b) concepts or disorders students are asked to consider during the exercise. Notably, and contrary to Maslow's Hierarchy of Needs, attention to psychological and educational needs often pose a greater risk than a physiologic problem if left unattended and should take priority in those situations (Jones, 2016). Existing clinical pre- or postconferences are the ideal context for use since students are likely already examining patient data and discussing plans of care or concept maps with their instructor and peers. Maximizing the meaning of these existing experiences with the inclusion of this prioritization activity is an easy step to enrich clinical learning experiences.
Level 1: Concept-Based Approach
Three simple steps characterize this approach. The concept of oxygenation provides as an example.
Step 1: Simple Patient Report. Each student verbalizes a simple report and prioritization plan to the peer group about their individual patient's situation, while peers document each patient's information using the provided tool. The report should include the history of present illness, underlying problem or diagnosis, current oxygenation needs and delivery methods, interventions used to improve oxygenation and maintain safety, patient responses to the interventions, and educational needs. A presentation of a prioritized list of risks with rationale for order of priority follows the simple report. Peers consider the thought process that informed each student's choice for prioritization of their patient's risks, and then identify how their own thought process is similar or different. Students end Step 1 with a group of patients and risks for which to consider prioritization of nursing actions.
Step 2: Concept-Based Discussion. The instructor facilitates a concept-based discussion about similarities and differences in each patient's risks (e.g., how underlying pathology, comorbidities, and immobility influence oxygenation), and how students make prioritization decisions about nursing and medical interventions for each situation (e.g., ABCs, Maslow's Hierarchy of Needs, time-sensitive tasks). The facilitated discourse with peers in Step 2 promotes students' recognition of nuanced differences among multiple patient situations that indicate subtle changes in prioritization of care.
Step 3: “Who, What, & Why.” The instructor asks students, “If you were the nurse arriving on the hospital unit to care for this group of patients, which patient would you see first (Who is at risk), what are the risks and appropriate nursing actions (What), and why do those risks make that patient the priority (Why)?” This question is crucial to help novice students begin to learn to prioritize care for multiple patients and engages students in making difficult decisions about actual patient care within the safety and support of their instructor and peers.
Level 2: Holistic Approach
This approach requires student knowledge of a wider range of topics and is ideal for use when the clinical experience objective is the integration of multiple concepts or problems. The same steps as the concept-based approach are used but are inherently more complex, given that students identify a holistic picture of each patient's situation.
Step 1: Complex Patient Report. Each student verbalizes a report to the peer group about the individual patient's situation and risks as identified in the concept-based approach, but from a holistic, total-body approach as opposed to a simple one-concept view. This report may indicate the patient problems by body system (e.g., mental status, respiratory, cardiac) or concepts (e.g., oxygenation, perfusion, fluid and electrolytes, safety), and a prioritized list of risks with rationale for order of priority.
Step 2: Problem or Concept-Based Discussion. The instructor guides discussion as students compare and contrast their prioritization decisions with those of their peers.
Step 3: “Who, What, & Why.” Students are again asked “If you were the nurse arriving on the hospital unit to care for this group of patients, which patient would you see first (Who is at risk), what are the risks and appropriate actions (What), and why do those risks make that patient the priority (Why)?” The more complex discussions in this holistic approach, and the comparison and contrast of thought processes driving the prioritization decisions of peers, contributes to students' repertoire of cognitive scripts (Norman, 2005), or pictures of what to expect and how to respond in similar situations. This contributes to development of intuitive patterns of thinking used by expert nurses. This level increases in complexity to further challenge the advancing student with inclusion of prioritization for the full list of current provider orders, scheduled nursing care, laboratories, tests, activities of daily living, and educational and safety needs.
Level 3: Nursing Shift-Based Approach
This level provides opportunities for individual student practice with prioritization of care for multiple patients and is ideal for use with students preparing to enter practice and care for multiple complex patients.
Step 1: Complex Patient Report. Each student verbalizes a complex, holistic report as in the Level 2 exercise, but also adds provider orders, scheduled nursing care, laboratories, tests, activities of daily living, and educational and safety needs. Rather than the reporting student sharing risk identification and prioritization decisions, each student listens to each patient report, then makes his or her own decisions about priority risk and order of care delivery for each patient. Additionally, each student identifies tasks appropriate for delegation for each patient, including to whom, and the responsibility for follow up by the nurse.
Step 2: Prioritization and Delegation Discussion. The instructor guides discussion as students compare and contrast their prioritization and delegation decisions for the group of patients with those of their peers.
Step 3: “Who, What, & Why.” Students work as a group to prioritize care for that group of patients throughout a typical nursing shift. This starts with the same question: “If you were the nurse arriving to the hospital unit to care for this group of patients, which patient would you see first (Who is at risk), what are the risks and appropriate actions (What), and why do those risks make that patient the priority (Why)?” This question is followed with “Who would you see next and why?” until the prioritization of all patients is determined. This multipatient approach offers students the opportunity to practice organizing care for multiple patients, to consider delegation and leadership as a nurse working with unlicensed assistive personnel, and to work as a team to make collective decisions to promote positive patient outcomes.
The Level 3 Nursing Shift-based Approach is made even more challenging by instructor insertion of unexpected events (e.g., a rapid response, a patient having a panic event, a patient being discharged who needs education) that create the need to revisit and modify the prioritization plan. The inclusion of other points for consideration, such as social, ethical, or legal issues requiring resource assessment and communication with other members of the health care team creates additional opportunity for learning.
The “Who, What, & Why?” exercise began in the fall of 2014 with 150 baccalaureate-level prelicensure students in groups of six students with one instructor. To date, it has been used with 600 students in postconference sessions after fundamental clinical experiences in the fall; pediatric, obstetric, and adult medical-surgical experiences in the spring; and a summer capstone in which students care for multiple patients. The exercise took approximately 1 to 1.5 hours, depending on the number of patients discussed. Instructors and students found the exercise enriched student learning and meaning making during postconference sessions. Instructors were better able to assess students' thought processes about prioritization of problems and reduction of risk for adverse outcomes. Student discussions were more focused on risk recognition and how pathophysiology, activity level, and other factors influenced differences in risks. Students more readily proposed modification of interventions to meet individual patient needs based on those risks. As clinical rotations progressed, students demonstrated more appropriate prioritization during clinical experiences. Students used the language of the exercise in their student–instructor clinical coaching sessions (Jessee & Tanner, 2016), such as “I think we should assess Patient A first because they are at greater risk for respiratory depression due to their opioid pain medication,” or “We should assess Patient B first because they were admitted with suicidal ideation.” Overall, instructors found the exercise simple to incorporate into their current clinical conference teaching strategies.
Students appreciated considering how their thinking about priority risks was similar or different from their peers and expressed that this prompted them to consider alternative patterns of prioritization. Some students expressed the exercise created a desire to “dig deeper” into pathophysiology and ask more questions of their patients so that they were better able to tailor interventions to each patient. Other students were intimidated when peers better understood concepts, but ongoing coaching by the instructors helped focus each student on recognizing his or her strengths and opportunities for growth. Overall, students identified increased confidence for recognizing problems and risks, and ability to prioritize care for their hospitalized patients.
Implications for Nursing Education
Success of “Who, What, & Why?” depends on several key factors. First, instructors must have adequate knowledge to recognize when students have faulty or deficient knowledge in order to accurately guide and respond to students' thought processes and decisions and ensure new knowledge gained from this experience is sound. Second, instructors must manage the boundaries of a group discussion, keeping it on topic and maintaining civil discourse among participants to promote the supportive environment students perceive as facilitative to learning (Jessee & Tanner, 2016). Third, the continued, scaffolded use of this exercise across the clinical education curriculum as students gain more knowledge and experience, as opposed to use only during an individual clinical rotation, will promote continued development of the skill of prioritization (Jessee, 2018).
The difficulty of new graduate nurses' management of care for multiple complex patients may indicate that the ability to prioritize interventions for one patient, as learned in clinical education experiences as students, does not readily transfer to successful prioritization of care for multiple complex patients. Purposeful inclusion of clinical activities that foster prioritization skill is essential, and requires swift, targeted action by nurse educators. Facilitating students' ability to prioritize using a risk-based framework to plan care that promotes patient safety, may contribute to development of clinical reasoning, and a reduction in morbidity and mortality. The “Who, What, & Why?” exercise provides a theoretically supported, evidence-based method to make minor modifications to existing clinical education curricula that may result in major effects on students' ability to provide safe patient care.
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