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What works: Equitable nurse-patient assignments using a workload tool

By: Amanda L. O’Connell, MSN, RN; Rita M. Nettleton, MSN, RN; Dawn R. Bunting, EdD, MSN, CNE, FAADN; and Susan Eichar, EdD, APRN

One unit’s experience developing and implementing a process change.


  • Implementation of a workload tool can promote equitable workloads and improve perceived nurse satisfaction.
  • Continuous collaboration within the multi-levels of leadership and bedside nurses is essential to improve compliance.
  • Sufficient time is needed to allow the workload tool to be incorporated into standard practice.

Nurses on a 36-bed medical/surgical telemetry unit in a metropolitan hospital expressed frustration with their nursing workload. Many of them felt that the time needed to safely care for their patients wasn’t always considered when nurse-patient shift assignments were made. The nurses also voiced concerns about unfair assignments.

To address this problem, two bedside nurses (O’Connell and Nettleton), launched a project to understand the problem of unsafe and unfair patient assignments and the benefits of using a workload tool to equalize them. During our literature review, we discovered a simple one-page tool (Kidd and colleagues, 2014,, see the second page of the article) that classifies nursing workload into a rating system that the charge nurse uses before change of shift to make assignments based on individual patient scores. Here is how we successfully adapted and implemented the tool to improve staff satisfaction.

Uncovering the evidence

Over the past 15 years, advances in technology and documentation have added to nursing responsibilities. Research shows that extensive workloads can cause nurses to feel a loss of control, overwhelmed, and stressed. Improved workload management may reduce stress and its negative impact on nurses, leading them to work with a higher level of integrity and loyalty to their organization.

Research indicates that using a workload tool can help promote equitable nurse-patient assignments, which may improve nurse job satisfaction. During our literature search, we discovered several studies found that nurses believed their assignments were more fair after implementing a workload tool. For example, a study by Firestone-Howard and colleagues suggests that nurse input on their assignments improved verbal communication and increased job satisfaction. When management engages nurses to participate in patient assignments, they feel their value is being acknowledged and that they’re part of a team, which can enhance unit camaraderie.

What we did

We introduced the 2014 paper acuity tool to the unit nurses, giving them ample time to review it. We then deployed an email survey via to evaluate nurses’ perceived workload distribution and job satisfaction. Included in the survey were open-ended questions asking about their current nursing assignments and suggestions for revising the sample tool to make it unit specific.

After reviewing the presurvey results, we revised the initial workload tool to meet the staff’s suggestions by deleting and adding tasks pertinent to the unit. After revisions were made, we led brief educational sessions on the unit at various times to accommodate all shifts. In these sessions, we taught nurses how to use the revised workload tool and used a case scenario to demonstrate its proper use. In our check-ins during the initial training, we found that bedside nurses were excited and willing to be actively involved in the entire change process, which at times led us to make additional unit-specific revisions to the tool.

Throughout the 12-week project, nursing staff shared suggestions for improving the tool and identified the need for an additional revision to it, including the addition of another level to the scoring system. At the end of the 12 weeks, we deployed another survey to re-evaluate nurses’ perceived workload distribution and job satisfaction.


Before implementing the workload tool, 28% of nurses felt their assignments were fair and equal compared to 57% postimplementation. The tool was being used nearly 52% of the time; when it was used, 70% of nurses felt that it helped equally distribute nurse-patient assignments. Postimplementation data analysis demonstrated a 34% increase in satisfaction with the distribution of patient workload in nurses’ daily assignments.

Initial successes and challenges

The high level of staff nurse and leader engagement in this project was remarkable, which suggests two things. First, the problem of unfair and unsafe patient assignments is a shared and prevalent problem. Bedside nurses who feel the stress of burdensome workloads were invested in trying to fix the problem. Second, management wanted to hear from them.

Bedside nurses are crucial to patient safety, so they must be included in any change process. Their input and engagement can make all the difference in the success of a project. Involving them helps improve nurse satisfaction, communication, and collaboration, all of which has an impact on patient safety.

Although the workload tool improved nurse satisfaction, some nurses felt that because it was on paper it added to their already busy schedules. We know this can lead to nonadherence, so the next step will be to see if the tool can be incorporated into the electronic health record.

We also may have initially underestimated the fear that change can produce. Implementing any new project can make staff feel uneasy. Anticipating this uneasiness, we used engagement strategies—such as acknowledging the staff’s involvement in the change process, remaining transparent throughout, and providing support when needed—to get ready for the change ahead, but we realize that more effort in this area would have been helpful.

What we learned

Collaboration between bedside nurses and all levels of leadership was essential to successfully implement the workload tool. We don’t know yet whether it will be fully adopted on our unit, but we gained some unexpected knowledge about change and its effects on staff.

We were reminded to be patient and understanding. Sufficient time is key for change to be incorporated into standard practice. When relationships are built based on trust and respect, participants will reciprocate with honest feedback. Including bedside nurses in decisions about future change will promote an eagerness to participate in creating a stronger community on the unit.

Nurses’ time is valuable, so education and training should accommodate their schedules. Using email, SurveyMonkey, and the TigerText app made communication easy and allowed us to reach nurses who couldn’t attend trainings or check-ins on their off days.

With collaboration, patience, trust, respect, and open communication, the change process can result in improved care quality and nurse work satisfaction.

Amanda L. O’Connell is a float pool nurse at Trinity Health Of New England Saint Francis Hospital and Medical Center in Hartford, Connecticut. Rita M. Nettleton is a medical/surgical staff nurse at Charlotte Hungerford Hospital in Torrington, Connecticut. Dawn R. Bunting is an adjunct professor at the University of Hartford in West Hartford, Connecticut, and nursing division director at Capital Community College in Hartford, Connecticut. Susan Eichar is an associate professor at the University of Hartford in West Hartford,  Connecticut.


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