Prioritization: Helping New Nurses Transition into Practice

Damion Jenkins, MSN, RN

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When I've interviewed new graduate nurses about what they find most difficult as they transition from student nurse to professional nurse, many admit that they struggle with prioritization. This is because new nurses are often eager to please their manager and/or supervisor, while also learning how to manage the care of their patients. The mastery of prioritization includes deciding which patients to see first, as well as which task or skill should be implemented before the next. In many cases, prioritization can be very difficult to master as patients, families, and other members of the healthcare team are complex, ever changing, and require varying levels of attention and care from the Registered Nurse.

Considering that new grad nurses are just learning how to identify when patients need intervention, or when they require the consultation of a another member of the healthcare team, this may contribute to additional stress to the transitioning nurse. One thing to remember is that nursing is not a one person job. It takes an entire team to safely and effectively care for patients. Since it is essential for nursing to remain a team effort, it is vial that the new nurse master strategies for safe and effective prioritization. To assist new nurses in better managing their patient care needs, let's look at three tips for mastering prioritization:

Start with Priority Ranking: Think Maslow's

Do you remember Maslow's Hierarchy of Needs? Well, it wasn't just a tool nursing professors used to create really complicated exams. In fact, you will ALWAYS consider Maslow's throughout your entire nursing career. When considering which patient requires your immediate attention - whether it be assessment, or intervention, you should start with priority ranking. Always start with the ABCs (Airway, Breathing, Circulation). Without a stable airway, a patient cannot breathe. If a patient cannot breathe, the body will not receive adequate levels of oxygen. If a person's circulation is compromised (bleeding, blockage, etc), then the tissues beyond the decreased circulation will die due to lack of oxygen and nutrients. Majority of the time, prioritization ranking doesn't necessarily involve the ABCs for your patients because they are otherwise stable. However, still using Maslow's, you would then rank priority based on nutrition, hydration, pain, knowledge, etc. For example, if a patient's pain is not managed well, they will not ready to learn new information about their surgery or disease process. Therefore you should always begin prioritization by using Maslow's Hierarchy of Needs to rank which patient needs the attention of the RN first.

Identify Who You Need to See First

As a nursing student, you probably only had one or two patients at a time during your clinical rotations. However, in real-world practice nurses will have double, or even more depending on the specialty setting. To help you prioritize the care of each of your patients, you have to think about who needs you the MOST. Here are some things you should consider when deciding:

What is the age of the patient? Older patients are at a higher risk to develop complications, and are often risks for falls, skill impairment, and delirium. Therefore, if all major considerations are the same, you'll want to see the oldest patient FIRST.
Are they newly admitted? Recent admissions are more likely to be at risk for a change in status. A strange environment, knowledge deficits, and acute illness or injury places patients at greater risk for complications. Therefore, if all major considerations are the same, you'll want to see the most recently admitted patient FIRST.
When was their surgery? The more recent the time of surgery, the higher acuity and risk for potential complications. Therefore, if all major considerations are the same, you'll want to see the most recent surgical patient FIRST.
How many comorbidities does the patient have? Chronic kidney disease patients are a great example of patients who typically have multiple comorbidities due to systemic metabolic changes that are influenced by the kidney disease. Diabetes, uncontrolled Hypertension, and Fluid Overload are common comorbidities that accompany chronic kidney disease. Therefore, if medical complexity is present and all other major considerations are the same, then you'll want to see this patient FIRST.

Listen to your Gut and Intuition and Act Accordingly

It's important to listen to your gut and intuition about how your patients are doing. If you sense something that is not quite right, but you are unable to identify what the issue is, you need to investigate further and quickly determine if you should assess or intervene.

Sometimes it's as simple as performing a quick assessment or interview to determine what is wrong with the patient. In other cases, you may need to call upon other members of the healthcare team, such as a physician, to help you identify what the issue is. Either way, you should always investigate further when the little voice inside your head tells you "Something isn't quite right about this patient."

An example would be that sympathetic nervous system stimulation is not an expected finding in patients recovering from surgery. Elevated heart rate, pale skin color, and sweaty skin with normal blood pressure are all EARLY signs of shock. As a new nurse, you may not identify these findings as an early indicator of shock, however, you would know that the signs observed are not normal, and you would become concerned by these findings. In this case, you could call a rapid response, notify the physician, or seek out the advice of another experienced RN.

What's most important is that you would recognize and understand the significance of these findings, and alert members of the healthcare team so that necessary interventions can be initiated to rescue and preserve the safety and well-being of the patient.

If you have any additional tips for effective and safe prioritization, please feel free to share your thoughts in the comments section below!

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Prioritization: Helping New Nurses Transition into Practice

Start with Priority Ranking: Think Maslow's

Identify Who You Need to See First

Listen to your Gut and Intuition and Act Accordingly

About Damion Jenkins, MSN, RN

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