Matching Nursing Assignment to Patients' Acuity Level: The Road to Nurses' Satisfaction

Abstract

Background and Purpose
Nurses face many healthcare challenges, such as high turnover, workload, and unfair assignments, that lead to nurses' dissatisfaction. Linking nursing shift assignment to patients' acuity scores may increase the workload balance, achieving equitable nursing assignment and nurses' satisfaction. This article aimed to (a) describe the effectiveness of the Perroca patient acuity tool (PAT) by measuring nurses' satisfaction with workload and standard of care pre and post the acuity tool application, and (b) measure nurses' satisfaction about the implemented patients' acuity tool.

Methods
Quasi-experimental (one group pre- and postdesign) was used. Donabedian's structure-process-outcome (SPO) model was followed as a conceptual model to guide the implementation process of this study. A convenience sample of 64 nurses participated in the study. Two scales were used to measure nurses' satisfaction with workload and with standard of care. Perroca's scale was used to measure nurses' satisfaction about patient acuity level.

Results
Significant differences were found on nurse's total satisfaction level, satisfaction with workload, and satisfaction with standard of care between the two times, pre- and post–Perroca PAT application. The majority of nurses had positive impressions of the tool.

Conclusion
This study concludes that linking PAT to nursing shift assignment has several positive outcomes. It increases nurses' satisfaction and serves as managers' voice for important staffing decisions like recruitment, assignment distribution, employing new staff, and improving quality of care.

Full text

Journal of Nursing Measurement, Volume 27, Number 1, 2019
Matching Nursing Assignment to
Patients’ Acuity Level: The Road to
Nurses’ Satisfaction
Ghadeer Al-Dweik, PhD
Applied Science Private University, Amman, Jordan
Muayyad Ahmad, PhD, RN
The University of Jordan, Amman, Jordan
Background and Purpose: Nurses face many healthcare challenges, such as high turnover,
workload, and unfair assignments, that lead to nurses’ dissatisfaction. Linking nurs-
ing shift assignment to patients’ acuity scores may increase the workload balance,
achieving equitable nursing assignment and nurses’ satisfaction. This article aimed to
(a) describe the effectiveness of the Perroca patient acuity tool (PAT) by measuring
nurses’ satisfaction with workload and standard of care pre and post the acuity tool
application, and (b) measure nurses’ satisfaction about the implemented patients’ acu-
ity tool. Methods: Quasi-experimental (one group pre- and postdesign) was used. Don-
abedian’s structure-process-outcome (SPO) model was followed as a conceptual model
to guide the implementation process of this study. A convenience sample of 64 nurses
participated in the study. Two scales were used to measure nurses’ satisfaction with work-
load and with standard of care. Perroca’s scale was used to measure nurses’ satisfac-
tion about patient acuity level. Results: Significant differences were found on nurse’s
total satisfaction level, satisfaction with workload, and satisfaction with standard of
care between the two times, pre- and post–Perroca PAT application. The majority of
nurses had positive impressions of the tool. Conclusion: This study concludes that link-
ing PAT to nursing shift assignment has several positive outcomes. It increases nurses’
satisfaction and serves as managers’ voice for important staffing decisions like recruit-
ment, assignment distribution, employing new staff, and improving quality of care.
Keywords: nursing assignment; nurses’ satisfaction; nursing workload acuity; patient
acuity tools; patient classification systems
Nurses consistently report a high level of dissatifaction with their workload envi-
ronment due to the inequity of assignment distribution (Acar, 2010; Kidd, Grove,
Kaiser, Swoboda, & Taylor, 2014). A focus on balancing workload among sched-
uled nurses through patient assignments can help to alleviate the chance of assigning exces-
sive workloads to one or more nurses during a shift, which enhances the level of nurses’
satisfaction and quality of care (QoC) (Acar, 2010; Kidd et al., 2014).
Jordanian nurses reported that their levels of job satisfaction and intention to stay are
on the borderline (Abu Al Rub, 2010; Mrayyan, 2007). Poor work conditions such as
stress, dissatisfaction, and unsupportive work environment were reported by nurses in
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Nursing Assignment and Patients’ Acuity Level E35
Jordan (Abu Al Rub, 2010). Thus, turnover rate among Jordanian nurses is high (Abu Al
Rub, 2007).
It is difficult in nursing assignment to know exactly how to assign and distribute nurses
to patients in a dynamic clinical workplace. The traditional method of organizing the
distribution of nurses for optimum delivery of patient care is the nurse-to-patient ratio
(Kidd et al., 2014; Welton, 2007). While this method is practical to some extent, no one can
define with certainty how many patients a single nurse can care for, due to the unexpected
needs of patients (Kidd et al., 2014).
Liang and Turkcan (2015) reported that lower nurse-to-patient ratios lead to higher
adverse incidents. Developing an effective staffing plan that addresses unique patient needs
is one of the most important duties of nurse managers (Bell, 2015). Nursing workload
directly influences nurses’ assessment ability and inequitable assignment among nurses,
which may lead to frustration due to the feeling of a lack of fairness (Kidd et al., 2014). The
head nurse tries to solve the problem of inequitable assignment among nurses by distribut-
ing the same number of patients, but this does not solve the problem due to the varying
needs of patients with different acuity levels (Kidd et al., 2014).
A patient acuity tool (PAT) is defined as “the classification and categorization
of patients based on assessment of nursing care requirement and patient needs”
(Harper & McCully, 2007, p. 284). Doing assignment based on an acuity tool help
to regulate the number of nurses in a shift according to patient needs, not num-
bers (Harper & McCully, 2007). Patients in medical/surgical wards may vary from
needing low-level basic care to high and complex nursing care for advanced cases.
Therefore, identifying each patients need may assist nurses to prioritize and achieve
the individualization of care for each patient in each shift assignment (Harper &
McCully, 2007).
Perroca PAT is considered an important tool for nursing in the Brazilian healthcare sys-
tem (Riboldi et al., 2016). In the state of Sao Paulo, the new version of Perroca PAT was
used for 105 adult patients. Thirteen nurses participated in this study; results confirmed
that it is recommended to use Perroca’s tool to identify patients’ care needs effectively to
guide decisions of nurses and nurses’ managers in care planning, care effectiveness, and
staff management (Perroca, Jericó, & Paschoal, 2014). Another study conducted in Swedish
hospitals to measure the degree of nurses’ satisfaction with Perroca PAT also showed that
nurse managers were satisfied in their use of PAT in their wards (Perroca & Ek, 2007b).
The problem addressed in this article is the need to implement nursing assignment based
on a valid and reliable PAT. The proofs from the previous studies indicated that nurses are
in need to apply evidence in the process of nursing assignment (Fagerstrom & Rauhala,
2007; Perroca & Ek, 2007a; Riboldi et al., 2016; Tomic, 2017; Vortherms, Spoden, &
Wilcken, 2015). Sustained efforts have been made in Jordan to improve staffing plans. The
Jordanian Nursing Council (JNC, 2008) developed a guideline entitled “Minimum Nurse
to Patient Ratio” to be applied nationwide in nursing assignment process and staffing plan.
This guideline is based on patients’ numbers and nurse-to-patient ratio and cited in the
JNC website (JNC, 2008). Nursing assignments in all Jordanian hospitals are still lacking
evidence-based acuity tools; most hospitals depend on the head nurse’s or the charge nurse’s
personal judgment for nursing assignment process, and this leads to negative staffing and
consequences for patients. Therefore, that conducting this study has importance stems from
the fact that it is the first in Jordan addressing nursing assignment based on patients’ acuity
in medical/surgical clinical settings.
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E36 Al-Dweik and Ahmad
STUDY PURPOSE
The purpose of this study is to apply Perroca’s patient acuity rating tool for nurses’ assign-
ment in medical/surgical wards. Specifically, this article aims to describe the effectiveness
of the Perroca tool from nursing perspectives by measuring nurses’ satisfaction with work-
load and standard of care pre and post applying the Perroca tool, and measuring nurses’
satisfaction about the implemented Perroca PAT.
PAT IN JORDAN
The idea of applying PAT and considering its results in nursing assignment is considered
new in Jordan. This is the first study aimed to introduce a valid and a reliable PAT in
Jordanian hospitals for staffing purposes and nursing assignment.
Nursing assignments in most Jordanian hospitals are still lacking evidence-based acuity
tools. One of the largest healthcare centers in Jordan implements different acuity tools, but
they lack the appropriate provenance of development in terms of scientific evidence and
the evaluation of psychometric properties.
THEORETICAL FRAMEWORK
Donabedian’s structure-process-outcome (SPO) model (is the conceptual model which
guided this study. Donabedian’s model is well known to those involved in healthcare qual-
ity research; Avedis Donabedian described a framework for assessing QoC that is flexi-
ble enough to be applied to many situations (Donabedian, 1980). As explained by Makary
et al. (2006), “structure is how we organize care, process is what we do, and outcomes are
what we achieve.”
Structure Process Outcomes
•฀Training฀and฀nursing฀฀education
•฀Acuity-based฀฀nursing฀assignment฀฀decision
•฀Implementation
฀฀process฀of฀patient฀฀acuity฀tool•฀Nurses฀Satisfaction฀฀toward฀workload฀and฀฀standard฀of฀care•฀Balance฀workload•฀Patient฀Acuity•฀Nursing฀care฀needs฀฀and฀activities
•฀Complexity฀of฀cases
Figure 1. Study conceptual model (Donabedian’s quality framework).
The concept of acuity can be considereda structure of care; matching the patients’ acuity level to
nursing assignment decisions can be considered a process of care. The matching processes have the
potential to increase nurses’ satisfaction and balance the nursing workload among nurses, which are
the outcomes of care.
Pdf_Folio:E36

Nursing Assignment and Patients’ Acuity Level E37
According to Donabedian’s model (Figure 1), the concept of acuity can be considered
a structure of care; measuring the patients’ acuity and applying the data from the acuity
tool in nursing assignment decisions can be considered a process of care. Nurse staffing
decisions and nursing assignment based on patient acuity have the potential to increase
nurses’ satisfaction and balance the nursing workload among available nurses, which are
the outcomes of care.
METHODS
Design and Setting
A quasi-experimental (one group pre and post) design was used in this study. This study
was conducted in medical/surgical wards at a private hospital in Jordan established in 1996;
it is a teaching hospital with a capacity of 250 beds. It is located in Amman to serve patients
from Jordan and the surrounding areas.
Sampling Process
A convenience sampling process over three phases was used. Phase one: The pretest phase,
in whicha sample was recruited to complete Nurses Satisfaction Surveys by registered
nurses (RNs), charge nurses, and head nurses who were working in the medical/surgical
wards. Phase two: All participating nurses attended an education program about how to
utilize Perroca PAT to categorize and classify their patients. Phase three: All participating
nurses completed the Satisfaction Surveys as posttest, and Perroca surveys that measure
the nurses’ satisfaction about Perroca PAT.
Sample Size
The sample size, based on conventional power analysis of paired t-test with medium effect
size, indicates a power of 0.80 and a level of significance at 0.05 (Cohen, 1992); the mini-
mum needed sample size was 64 participants. The principal investigator (PI) distributed 75
surveys to all registered nursed and head nurses of medical/surgical wards. Sixty-six partic-
ipants from RN and head nurses of medical surgical wards accept to participate by signing
the informed consent. Two of nurses were excluded because they resigned suddenly before
the completion of the study duration, making the response rate of the study equal 85%. The
participants were asked to fill the measure of job satisfaction (MJS) pre and post applying
the Perroca tool and to fill the Perroca scale post applying the Perroca PAT.
Eligibility Criteria
All participating nurses had at least a bachelor’s degree in nursing, male or female, and
worked in medical/surgical wards. Practical nurses were excluded because the nature of
this study is out of their scope of practice.
Procedure
After obtaining ethical approval from the relevant Institutional Review Board, the PI for-
mally met the hospital administrators, director of nursing, supervisors, quality coordina-
tors, and the head nurses to introduce the study to them. Then, the PI announced in the
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E38 Al-Dweik and Ahmad
medical/surgical wards about the study plan and confirmed that the participation is volun-
tary. The PI contacted the human resource manager and obtained a list of employee num-
bers and names for all RNs who work in medical/surgical wards. All RNs who met the
inclusion criteria were invited to participate in the study either through personal invitation
by the PI, or by the head nurses of their ward.
An envelope that includes the invitation letter was distributed to all RNs, charge nurses,
and head nurses of medical/surgical wards. Then, the PI met the participants in their work-
place setting to clarify and answer any question. In the first phase, the selected partici-
pants were asked to complete a socio-demographic sheet and the two subscales of MJS
survey (pre-test) within 5–10 minutes. The second phase was implementing 2-hour train-
ing sessions about the PAT and how to utilize its scores in nursing shift assignment in
the ward. In this phase, the director of nursing distributed an announcement to all medi-
cal/surgical departments asking from them to follow the patient acuity guideline and use
it for their nursing assignment process. The new version of Perroca PAT was used and
adapted; it is written in English and appropriate to RNs’ level and scope of practice. The
third phase was after 3 months of the second phase, measuring the outcomes using the MJS
survey and Perroca scale. According to the required time before reevaluation (postimple-
mentation process), the previous literature indicated that some trials applied the evaluation
after 2 weeks (Harper & McCully, 2007), 1 month (Kidd et al., 2014), or 43 days (Silva,
Echer, & Magalhaes, 2016). Most previous studies that implemented PATs reported that
the outcomes of the tool application can be evaluated after a short time of implementa-
tion because the nature of PAT indicators are very close to nurses’ activities, which facili-
tates the understanding and makes the application process easy. However, the authors did
the evaluation process after 3 months from the application of the tool when they achieved
the objectives from the project and ensured that nurses effectively applied the tool on
their wards.
Nurses continued the use of Perroca PAT on their wards after finishing the study plan
and showed their enthusiasm to disseminate the idea of linking PAT scores to nursing shift
assignment to other departments in the hospital.
Inter-Rater Reliability
The major problem reported by the nurses in previous literatures about PATs was the sub-
jectivity of the assessment. Nurse managers recommended the necessity to undertake PAT
reliability as a manner to guarantee appropriate levels of inter-rater reliability.
In this study, inter-rater reliability of PAT was assessed in medical/surgical wards. The
Perroca tool was implemented with 15 patients chosen by the medical/surgical ward head
nurse and by two raters of nurses from the same unit. Every nurse assessed the same patient
independently. The total score of the patients’ acuity level was recorded for the two raters
for the purposes of comparisons. Correlation coefficient and Pearson correlation were com-
puted to verify the level of inter-rater agreement concerning the different care categories
(minimum, intermediate, semi-intensive, and intensive). The agreement level was 0.94.
INSTRUMENTS
Perroca PAT
The new version of the Perroca PAT was adapted and implemented in five medical and
surgical wards at one private hospital. The tool is based upon individual needs for nursingPdf_Folio:E38

Nursing Assignment and Patients’ Acuity Level E39
care and is intended for adult patients. The tool consists of nine care areas (nursing care
requirements for patients): (a) care process planning and coordination, (b) investigation
and monitoring, (c) personal hygiene and eliminations, (d) skin integrity, (e) nutrition and
hydration, (f) locomotion or activity, (g) therapeutics, (h) emotional support, and (i) health
education (Perroca, 2013). Each of the care areas is scored from 1 to 4, with higher scores
indicating increasing care complexity levels. The acuity tool was administered in English;
no translation was conducted because it was appropriate and clear to RNs’ level and was
done on a paper scoring tool and recorded into data reports by supervisors, head nurses, or
charge nurses. Perroca (2013) reported the psychometric properties of Perroca PAT. The
findings provide evidence that the new scale is a reliable and valid tool. Cronbach’s alpha
coefficient of the acuity tool is 0.87, and construct validity was conducted; all variables
chosen to compose the new instrument were important and participated in effective dis-
crimination of patients’ care needs and care categories.
MEASURE OF JOB SATISFACTION
This measure of job satisfaction (MJS) was developed by Traynor’s survey (Traynor &
Wade, 1993). It is composed of seven subscales, which when combine give a measure of
“overall job satisfaction.” The MJS includes 43 items; all of them are scored in a range of
very satisfied (5) to very dissatisfied (1).
In this study, the researchers used two subscales from MJS. Nurses’ job satisfaction
with their workload, which includes eight items with 0.88 Cronbach alpha as reported in
the literature; and nurses’ job satisfaction with standards of care, which includes six items
with 0.90 Cronbach alpha. The internal consistency for the overall instrument is equal to
0.83 (Traynor & Wade, 1993); the instrument is open access and available to the public. In
this study Cronbach’s alpha for MJS with workload equal 0.86 and MJS with standards of
care equal 0.90.
NURSES’ SATISFACTION ABOUT THE PAT
Nurses’ satisfaction about the implemented PAT was measured by a scale developed by
Perroca and Ek (2007a, 2007b). This scale includes 20 statements using five-point Likert
scale responses. The statements focused on characteristics of the PAT (simplicity of use
and objectivity), reliability (interpretation and adequacy of classification), purposes of use,
and acceptance. The Cronbach’s alpha coefficient for the scale was 0.85 as cited in Perroca
and Ek (2007b) and 0.84 as reported in this study. The most positive response was scored
as five, and a score of one was given to the most negative response.
INSTRUMENTS VALIDITY
The researcher requested from seven participants to review carefully the 14 items from MJS
questionnaires, 20 items related to the Perroca and Ek (2007b) scale, and nine indicators
of Perroca PAT, and to report if there were ambiguities in any aspect of the study, content
of questionnaires, time required to fill it, clarity, readability, and acceptability.Pdf_Folio:E39

E40 Al-Dweik and Ahmad
The participants indicated that the items of all instruments were clear, comprehensive,
and appropriate to their aim and that the contents of statements were written in simple
language. The time needed to complete the questionnaires ranged from 5 to 10 minutes for
14 items of MJS and Perroca PAT and 5 minutes for the Perroca 2007 scale.
Data Analyses
Statistical Package for Social Sciences (SPSS) for Windows, version 21 (IBM, 2010) was
used to analyze the data. The analyses included descriptive statistics for the demographic
data. Paired t-test was used to compare the differences between nurses’ job satisfaction
scores at baseline and subsequent application of the PAT. Frequencies and percentages of
responses were used to analyze participants’ responses about their Perroca PAT satisfaction
level.
RESULTS
Most participants were female (n= 47, 73.4%). The majority (85%) were between the
ages of 20 and 29 (n= 55). Only one nurse (1.6%) had a master’s degree. Demographic
characteristics are presented in Table 1.
The Effect of Using Perroca PAT on Nurses’ Job Satisfaction
There was significant increase in nurse’s satisfaction total score post applying Perroca PAT,
t(63) = 2.57, p= .012. There was significant increase in nurses’ satisfaction with workload
post applying Perroca PAT, t(63) = 2.41, p= .019. There was significant increase in nurses’
satisfaction with standard of care post applying Perroca PAT, t(63) = 2.456, p= .017.
TABLE 1. Demographic Characteristics of Nurses’ Satisfaction Scores Pre- and
Post-PAT Implementation N= (64)
Variable Category Frequency (%)
Gender Female 47 73.4
Male 17 26.6
Age 20–29 55 85.9
30–39 8 12.5
40–49 1 1.6
Education Bachelor’s degree 63 98.4
Master’s degree 1 1.6
Experience Less than 1 year 22 34.4
From 1 year to 5 years 34 53.1
From 6 years to 10 years 3 4.7
From 11 years to 15 years 4 6.3
More than 15 years 1 1.6
Position Title Registered nurses 36 56.3
In-charge nurses 22 34.4
Head nurses 6 9.4
Note. PAT = patients acuity tool.
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Nursing Assignment and Patients’ Acuity Level E41
Pdf_Folio:E41
According to the satisfaction with workload mean difference in each single item
(Table 2), significant differences were found on item numbers 4 (Overall staffing
levels), 5 (The amount of time available to finish everything that I have to
do), 6 (What I have accomplished when I go home at the end of the day),
7 (The hours I work), and 8 (The time available for patient/client care) (Table 3).
According to the satisfaction with standard of care mean difference in each single item
(Table 4), significant differences were found on items 3 (The way that patients/clients are
cared for), 4 (The standard of care that I am currently able to give), and 5 (The general
standard of care given in this unit) (Table 5).
TABLE 2. Means of Pre- and Post-PAT Items on Nursing Satisfaction Scores With
Their Workload
Item
Number Question Mean (pre/post)
8 The time available for patient/client care 3.64/4.04
5 The amount of time available to finish
everything that I have to do
3.63/3.94
1 The time available to get through my work 3.76/3.90
6 What I have accomplished when I go home at
the end of the day
3.46/3.81
2 The amount of time spent on administration 3.62/3.70
4 Overall staffing levels 3.33/3.70
3 My workload 3.50/3.67
7 The hours I work 3.26/3.60
Note. PAT = patient acuity tool.
TABLE 3. Paired-Samples t-test of the Nursing Satisfaction Scores With Their
Workload
Item Number Question t-statistics
*p< .05.
1 The time available to get through my work 1.07
2 The amount of time spent on administration 0.56
3 My workload 1.03
4 Overall staffing levels 2.05*
5 The amount of time available to finish
everything that I have to do
1.97*
6 What I have accomplished when I go home
at the end of the day
2.12*
7 The hours I work 2.27*
8 The time available for patient/client care 2.56*

E42 Al-Dweik and Ahmad
NURSES’ SATISFACTION ABOUT THE PAT
The PI distributed (Perroca, 2007) surveys to all 64 nurses who participated in the study.
This instrument aimed to measure the nurses’ satisfaction about the PAT that was used
in their ward. The instrument consisted of 20 statements using a five-point Likert scale
response. The highest means were reported to item numbers 12 (Is easy to be used) and 17
(It is possible to make decisions based on the classification system used). The lowest means
were reported to item numbers 5 (Determines if the unit is understaffed) and 6 (Measures
the quality of the nursing care).
DISCUSSION
The results of this study provide direction for improving nursing job satisfaction through
the usage of a PAT in nursing shift assignment in medical/surgical wards. The findings of
Pdf_Folio:E42
TABLE 4. Means of Pre- and Post-Survey Items on Nursing Satisfaction Scores
With Standard of Care
Item Number Question Mean (pre/post)
6
5
4
2
3
1
TABLE 5. Paired-Samples t-test of the Nursing Satisfaction Scores With Standard
of Care
Item Number Question t-Statistics
*p< .05.
3.90/4.20
3.56/4.13
3.67/4.03
3.92/4.02
3.73/4.00
3.75/3.97
Patients are receiving
the care that they need
The general standard of
care given in this unit
The standard of care
that I am currently able
to give
The standard of care
given to patients/clients
The way that
patients/clients are
cared for
The quality of work
with patients/clients
1 The quality of work with patients/clients 1.30
2 The standard of care given to patients/clients 0.63
3 The way that patients/clients are cared for 2.28*
4 The standard of care that I am currently able to give 2.42*
5 The general standard of care given in this unit 3.81*
6 Patients are receiving the care that they need 1.76

Nursing Assignment and Patients’ Acuity Level E43
this study showed significant differences in nurses’ satisfaction with their workload and
standard of care pre- and post-Perroca PAT application.
The idea behind the utilization of PAT in the clinical setting was to create balanced nurs-
ing shift assignments, which potentially increase nursing job satisfaction toward workload
and standard of care. This result is consistent with a study by DeLisle (2009), who con-
cluded that establishing and using a PAT effectively captures the complexity of patients and
their related care, thus it promotes equitable nursing shift assignments and increases nurs-
ing job satisfaction. A recent study supported our findings on the link between patient acu-
ity application and nurses’ workload. Sir, Dundar, Steege, and Pasupathy (2015) reported
that PAT achieved a balanced assignment and lower workload in comparison to the tradi-
tional assignment. Also, Tomic (2017) stated that implementing a valid and reliable patient
acuity instrument when determining nursing shift assignments can ultimately affect nurs-
ing workload and hence increase nursing job satisfaction (Tomic, 2017).
Furthermore, another recent study reported that the PAT of Perroca is considered an
important tool for nursing in the Brazilian healthcare system to sort the care complexity
or patient acuity. This tool, in addition, provides better care planning and allows adequate
staff sizing, with direct effect on workload control (Riboldi et al., 2016).
Many literature reported that applying PAT can improve the utilization of nursing
resources and improve nursing satisfaction and retention (Harper & McCully, 2007; Kidd
et al., 2014; Tufanaru, 2015). Our results indicated a significant enhancement in the nurses’
satisfaction toward the standard of care that the nurses were able to give and in the QoC
given in their wards post applying the acuity tool. Furthermore, our results revealed that
after the implementation of PAT, an improvement occurred in the nurses’ satisfaction
toward the standard of care. These findings are consistent with many studies that reported
better patient care when applying nursing assignment based on the acuity tool (Harper &
McCully, 2007; Kidd et al., 2014; Tufanaru, 2015). Knowledge of patients’ care needs
allows for effective care and discharge planning, patient distribution across units, and care
quality assessment, and strengthens arguments on the need for additional nursing staff (Gio-
vannetti, 1979; Malloch & Conovaloff, 1999; Perroca, 2011).
The idea from applying Perroca PAT to promote the patients’ outcomes was supported
by Cicolini, Comparcini, and Simonetti (2014), who stated that implementing interven-
tions that promote staffing conditions should be given high priority at the organizational
administrative level. Adequate nursing staff and balanced workload have a positive impact
on nursing satisfaction, which effectively influences the quality of patient care and patient
satisfaction (Cicolini et al., 2014). The implementation of Perroca PAT has led to improve-
ment in the standard and the quality of care that the nurses give in their wards. This result is
consistent with literature that reported better patient care with applied nursing assignment
based on acuity tools (Harper & McCully, 2007; Kidd et al., 2014; Tufanaru, 2015).
Matching the Perroca PAT to assignment process enhanced nurses’ focus, concentra-
tion, performance level, and QoC. These results were congruent with Harper and McCully
(2007), who stated that measuring patient acuity is the essential component in the provision
of competent patient care. Furthermore, our findings about patients’ outcomes are con-
sistent with evidence suggested that acuity-based assignment in nursing can affect patient
safety, productivity, patient outcomes, and QoC (Barton, 2013; Kidd et al., 2014; Llies,
Wilson, & Wagner, 2009).
Vortherms et al. (2015) were consistent with the current study’s findings regarding
acuity-based assignment; they stated that the key elements in acuity-based assignment are
clear communication, fairness distribution, and assignment transparency. Thomasos et al.Pdf_Folio:E43

E44 Al-Dweik and Ahmad
(2015) also reported that acuity-based staffing improved workload balance, satisfaction,
and employee engagement.
According to nurses’ satisfaction about Perroca PAT as a classification system, the find-
ings from this study revealed that most of the nurses were satisfied with the application of
the tool. This finding was consistent with a Swedish study to assess nurses’ opinion toward
two types of patient classification in 18 Swedish hospitals (Perroca & Ek, 2007b). Overall,
nurses seemed to have high satisfaction with the utilization of the PAT for workload and
staff planning. The nurses’ responses showed an overall satisfaction toward Perroca PAT
in use on their wards. The simplicity of use revealed a high level of satisfaction among
nurses. They also seemed to be satisfied with the tools to identify changes in the patients’
needs, workload, and staff planning. However, the areas of dissatisfaction among nurses
regarding Perroca PAT were reported as the tool’s inability to measure the quality of nurs-
ing care. Quality is considered a complex and multidimensional concept and nurse staffing
is just one of its several dimensions. Applying the PAT with allocation of nursing staff
permitted a more efficient utilization of the resources and performance controlling of the
ward which, theoretically, should enhance the QoC (Currie, Harvey, West, McKenna, &
Keeney, 2005; Mark, Harless, McCue, & Xu, 2004).
Furthermore, nurses revealed certain dissatisfactions with the time required to complete
the tool. The adoption of a computerized documentation system will facilitate the process
of capturing patient acuity and minimize the required time to fill the acuity tool (Hustad,
Helleso, & Andersen, 2015).
LIMITATION
Several limitations were observed and reported by the researchers and participants during
the application of this study. The sample size may have been small in this study. Observed
limitations included resistance to change from some participants at the beginning of the
study; a shortage of nurses in one of the medical/surgical departments, which led nurses to
follow the functional nursing care delivery method in some shifts; infrastructure building
of the hospital, such as long distance between the rooms; and patients’ gender preferences
barriers. More time was required to implement the study for other purposes such as bench-
mark and patient outcomes.
Another limitation in the study was the hospital documentation system, which was not
computerized and depended on paperwork. Using computerized health record helps the
healthcare provider to integrate the acuity tool into the medical health system.
IMPLICATION AND RECOMMENDATIONS
The PAT results can be applied in practice and for important managerial decisions; they
can be used for endorsement procedure at the beginning of each shift. The results can be
used for internal or external benchmark of the acuity level in the same hospital units and
department or between hospitals; the benchmark results can be used in important staffing
decisions such as hiring, motivation, retention, and education plans. Creating a policy that
links the nursing assignment with PAT is recommended. Encouraging the nursing staff in
the hospital to be involved in the development process of a new PAT will facilitate the
process of application and utilization.Pdf_Folio:E44

Nursing Assignment and Patients’ Acuity Level E45
Integrating the acuity tool into electronic health record systems and repeating the same
study for future research by supporting computerized documentation systems will allow
for much simplicity and efficiency when utilizing the acuity tool and calculating the total
scores.
Studies that focus on the developing and evaluation of new PATs can generate new
knowledge to nursing research. To conduct studies with larger sample size and to be in
different hospitals are recommended.
CONCLUSION
The implementation of Perroca PAT provided direction for the nursing workplace environ-
ment and healthcare institutions. Implementing the tool at organizational level will yield
better nursing assignments, and that will be a road for better nursing and patients’ outcomes.
Overall, this study offered a valuable direction for future research on the utilization of a
PAT within the clinical setting as a way to improve nursing shift assignments and nursing
satisfaction. However, this study needs to be implemented as a longitudinal research design
for more and better evaluation. The use of the Donabedian framework for the study was
appropriate.
This study was welcomed by the staff, managers, and administrators and offered a
desired positive change in clinical practice. Introduction of the acuity tool gave adminis-
trators insight into the concept of nursing assignment, nursing satisfaction, and evidence-
based decision, and enhanced and improved the QoC toward patients.
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Disclosure.The authors have no relevant financial interest or affiliations with any com-
mercial interests related to the subjects discussed within this article.
Acknowledgments. The authors acknowledge the support from the University of Jordan and Applied
Science Private University.
Correspondence regarding this article should be directed to Ghadeer Al-Dweik, PhD, Applied Sci-
ence Private University, Faculty of Nursing, 11931-166, Amman, Jordan. E-mail: ghadeerdweik
@yahoo.com
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