Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2019


Doctor of Nursing Practice (DNP)

Primary Advisor

Pearl Zhou, RN, PhD; Karen Whitt, PhD, FNP-C, AGN-BC


Background: Assigning the correct nursing resources to hospitalized patients positively impacts patient outcomes. The current process for matching nurses to patients is highly variable and involves a combination of simple ratios, historical workload data, and expert opinion but lacks objective measurement of the patient’s condition.

Objectives: This project evaluated change in selected quality indicators and the daily unit-level management of nursing resources after implementing the Troubled Outcome Risk (TOR) into existing nursing staffing methodology in a Department of Veterans Affairs hospital.

Methods: TOR provides objective measurement of individual patient allostatic load. Daily calculation of TOR scores for each patient on the study unit and nursing staffing methodology were used by charge nurses to determine assignments. Nursing sensitive indicators including length of stay, transfers to intensive care unit, hospital acquired pressure ulcer (HAPU), 30-day readmissions, and nursing surveillance indicators including rapid response team activation and cardiac arrests were compared before and after implementing TOR.

Results: There was a reduction of HAPU rates that exceeded the stated goal after implementation of TOR. Other indicators did not meet project goals. Prior to implementation of TOR, nurse assignments clustered in specific locations; after implementation 16.7% were without regard to location. None of the results were statistically significant; yet we observed a small-medium effect size between intervention and assignment change.

Conclusions: The implementation of TOR did not result in significant differences in nursing sensitive outcomes, however charge nurses appear to have changed staff nurse assignments using TOR as an addition to existing methodology. Future study with a larger sample over a longer period of time may yield different results.

Open Access




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