Concept Analysis on Acuity Nursing Essay Example

The focus of this concept analysis paper is acuity. On the surface, “acuity” appears to be a precisely defined concept because of its prevalent use in health sciences-related literature. For instance, many authors have acknowledged the rising patient acuity in the course of the last three decades. Moreover, numerous tools have been developed to quantitatively measure patient acuity. Some of these tools include the Revised Easley-Storfjell Patient Classification Instrument, the Can Slyck and Associated Acuity System, the Injury Severity Score, the National Therapeutic Intervention Scoring System, the Acute Physiology, Age, Chronic Health Evaluation instrument, and the Resource Utilization Group Classification System. Despite the existence of several measurement tools for patient acuity, the literature is inconsistent with respect to the definition and measurement of the concept.

This concept analysis paper has the main aim of evaluating the definitions of acuity in various disciplines, concepts related to patient acuity, usages of the concept, antecedents of patient acuity, and the consequences of patient acuity. A personal definition of the concept is also provided along with a conceptual model. Before analyzing the concept of acuity, there is the need to have valid measurements, which emphasize on the clarity of the concept being measured. Regardless of the fact that “acuity” is frequently used, the inconsistent definition and measurement tools of the concept have made it impossible to make a cross-comparison of acuity measurements in diverse settings. In addition, this inconsistency has increased the difficulty of exploring the relationship between acuity and its respective outcomes. As a result, there is the need to perform a concept analysis in order to clarify the meaning and move towards the development of standardized definitions as well as measurements as it relates to acuity.

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The concept analysis was guided by the Morse’s concept classification method (Morse, 1995). According to Morse (1995), a concept will rarely seem well described and mature, which can be attributed to vast literature covering the concept that provides comprehensive descriptions, clinical empirical evidence as well as quantitative tools used in measuring the concept. However, a closer look reveals inconsistent definitions and several rival implicit theories, which is the case with the concept of patient acuity. The concept clarification method recommended by Morse (1995) encompasses performing a review of literature, and content analysis of literature with respect to the underlying values. In addition, the concept analysis process involves analyzing the attributes of the concept including the consequences and antecedents.

A search for the term “acuity” was performed in the abstract and titles of papers published in the English language in electronic databases and citation indexes such as Google Scholar, PsycINFO, MEDLINE, CINAHL, and PubMed. The Oxford and Merriam-Webster English Dictionaries were also searched. A complementary Internet search using Google was performed. The searches yielded about 100 papers. Only one published report on the topic of concept analysis of patient acuity was found. An inclusion and exclusion criteria was employed in order to filter the papers to remain with relevant resources. Specifically, papers with the term “acuity” in the abstract or title were incorporated in the concept analysis whereas papers that lacked the term were excluded. The reason for the exclusion of the papers lacking the term “acuity” in the abstract and title was the possibility that no novel information regarding the concept of acuity could be obtained from these sources.

Definitions of Acuity

The Miriam-Webster dictionary defined acuity as “the ability to understand, hear or see something easily.” In this light, acuity denotes the keenness associated with perception. The Oxford English Dictionary defines acuity as “keenness or sharpness of hearing, vision or thought.” In literature, there are several definitions of acuity that vary across discipline. For instance, Hebasevich (2012) defined acuity in healthcare settings as the intensity of care needed for a patient determined by a registered need. In this respect, six categories exist that range from minimal care to intensive care. In healthcare settings, when acuity increases, there is the need to allocate more nursing resources in order to guarantee safe care. Hughes (2008) defines patient acuity as the patient requirements for nursing care, which are used in the management of nursing quality, costs and personnel resources.

In psychology, acuity has been defined as the sharpness of the mind, which depends on a number of factors including understanding, concentration and focus. An elderly individual with Alzheimer’s Disease is considered to have low mental acuity since he/she is unlikely to remember the events that happened during their youth. In addition, the elderly individual is unlikely to have a precise memory of when and how something occurred. He/she may be slow in understanding relatively simple things like operating a remote control. A person can enhance his/her mental acuity using activities that engage the mind such as mental puzzles.

Gorman and Campbell (1995) also defined mental acuity as the sharpness of the mind in terms of understanding, concentration, memory and focus. However, mental acuity is not concerned with intelligence. Mental acuity denotes how well or poorly an individual’s brain is functioning and not his/her ability to undertake complex tasks. A number of factors have irreversible impacts on mental acuity such as the onset of Alzheimer’s disease, encephalitis and prolonged substance abuse. Moreover, some short-term conditions that lessen mental acuity also exist such as high stress and fatigue levels, distractions, external and external interruptions. Table 1 below illustrates the various definitions of acuity as found in the review of literature.

Education, Medicine, Psychology, and Nursing

Despite the fact that there are some different terminologies and views in the definition of acuity in the various disciplines, a common theme that spans across all the definitions of acuity is that the concept measures something. In all of the definitions, it is evident that acuity denotes the degree to which something being described by the various disciplines manifests itself. For instance, in medicine, acuity denotes the degree to which an illness is severe, or the extent to which an illness requires urgent medical attention. Visual acuity refers to the range to which a person is capable of seeing clearly at a certain distance (Pelosini et al., 2012). In the context of nursing, acuity refers to the aggregate of the nursing services required, which may be in the form of the level of difficulty of the nursing care needs (Buerhaus, 2009), the level of demand for the nursing skills and service (Boudreaux, Friedman, Chansky, & Baumann, 2004), the level of patient’s dependence on the nursing staff (Hughes, 2008), the amount of time required to offer nursing care, and the amount of nursing care (Arling, Kane, Mueller, & Lewis, 2007).

Similarly, in psychology it is evident that acuity denotes the amount of the psychological element being defined; for instance, acuity may denote the severity of the psychological distress, cognition and memory, and sharpness of the mind (Turnage, Kennedy, Smith, Baltzley, & Lane, 1992). A similar approach is evident in the definition of acuity in the field of education. From all the definitions, acute represents the smallest degree of whatever is being defined. For instance in medicine, a disease that requires the most urgent medical attention is considered acute. Similarly, a serious psychological distress can be considered acute such as acute depression, implying that it is severe. In mental or intellectual acuity, people with high degrees of sharpness, concentration can be considered to have acute intelligence.

Among the various definitions of acuity in the various fields, it is evident that the field of nursing offers the most comprehensive definition of acuity. The definition of acuity in nursing spans focuses on complexity, workload and nursing care needs, which all represent intensity. The nursing care needs represent the amount and concentration of nursing care required – high acuity demands more nursing care and vice versa. Nursing workload with respect to acuity represents the time required in offering the nursing care as well as the level to which a patient relies on nursing staff. Complexity symbolizes the degree of difficulty of the care requirements and the demand for the nursing skills and services. Overall, the definition of nursing is multi-dimensional, as opposed to the definition of acuity in other disciplines, which focus only on a single aspect.

Concept Use

In order to provide a further clarification of the concept of acuity, it is necessary to examine the different uses and situations involving the usage of the concept. In order to delineate the use of the concept of acuity, it is imperative to establish the attributes associated with the concept. In this respect, the attributes associated with acuity revealed four uses and situations where “acuity” could be applied, which included patient-related acuity, non-patient related acuity, provider-related acuity, and system-related acuity (Hughes, 2008; Boudreaux, Friedman, Chansky, & Baumann, 2004; Cherry, 2003; Chin & Muramatsu, 2003).

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Patient-related acuity emphasizes on the onset of an illness or the timing of the medication intervention such as the treatment of a disease. For instance, high patient acuity could be used when a patient requires urgent medical attention. Patient-related acuity can also be used in differentiating care facilities in terms of those providing long-term care and acute care facilities. Acute care facilities attend to patients with high patient acuity; that is, those requiring urgent medical attention. This is in contrast to long-term care facilities that attend to patients with low acuity. Acute care can also involve the patient receiving active albeit short-term treatment to severe injury. Acute care is in contrast to longer-term care or chronic care.

Patient-related acuity can also be used in describing the severity of the illness. An example of the inflammatory acuity, which denotes the extent of the actual inflammatory process, or with respect to a particular illness such as chronic kidney disease or an acute cold. Emergency departments use the term injury acuity for triage purposes. In addition, psychological acuity can be used to represent the severity of a psychological disease such as acute depression. It is evident that in patient-related acuity, the use of acute implies the highest level of severity, requiring urgent attention, and nursing care administered on a short-term basis. This is in contrast with chronic, which represents the need for long-term care. Chronic and acute are on the opposite ends of the patient condition spectrum (Abualrub, 2007).

In the context of patient-related acuity, the intensity of nursing care and illness severity can be used in determining the level of patient acuity. It is imperative to note that intensity and severity aspects of acuity are similar, and their uses overlap. Intensity and severity can be utilized interchangeably to refer to the type, duration and amount of nursing care needs required by a particular group of patients. Intensity and severity can also refer to the seriousness of the illness (Abualrub, 2007).

The concept of acuity can also be used in non-medical settings to represent keenness or sharpness in various domains including sensation, social intellectual, and coming to a point. With respect to sensation, there are numerous uses of acuity including visual acuity (Pelosini, et al., 2012), tactile acuity, spatial acuity, sensory acuity (Turnage, Kennedy, Smith, Baltzley, & Lane, 1992), proprioceptive acuity, perceptual acuity, olfactory acuity, and auditory acuity (Cherry & Reed, 2007). Visual acuity is the most commonly used in the non-patient acuity and refers to the clearness and acuteness of one’s vision. Auditory acuity refers to the ability to trace a sound in a given space (Rischbieth, 2006). Essentially, auditory acuity places emphasis on localization acuity.

With respect to coming to a point, papers that used this description of the concept of acuity referred to positioning or repositioning of the sense acuity. These papers had the main objective of determining a quantitative error of measure in regards to the positioning of joints in order to relive pain, facilitate a motion range, and come up with diagnostic techniques as well as rehabilitation programs that can be applied to joint-related injuries. In the intellectual domain, intellectual acuity is mostly used when referring to memory and cognition (Cherry, 2003). An example of this could be the strategies that are utilized in helping elderly people maintain their mental capacities and capabilities during aging, and interventions and medicines utilized improving attentiveness and memory among others. Social acuity is used to refer to keenness, sensibility and social awareness with respect to one’s ability to interact with other individuals socially (Salvia, Ysseldyke, & Bolt, 2012; Rischbieth, 2006).

Provider-related acuity refers to the intensity of nursing care required for a patient. In this case, intensity represents the care burden that a patient imposes on the nursing staff in regards to surveillance, mental concentration, skills and time in order to satisfy the needs of the patient. The intensity aspect of acuity can be looked at in three ways: in terms of complexity, workload, and care needs (Boudreaux, Friedman, Chansky, & Baumann, 2004; Chin & Muramatsu, 2003; Pelosini, et al., 2012). Complexity in provider-related acuity refers to the level of difficulty of the medical and nursing care needs of the patient, which involves physicians and nurses’ surveillance, concentration and skill needed to offer care services for patient(s). Workload is an attribute of acuity, whereby high patient acuity requires a high nursing workload. In this respect, high patient acuity is described by a decrease in the period of stay for patients and an escalation in the illness severity (Hughes, 2008). Nursing workload usually denotes a surge in the demand for nursing skills and services, and measures the nursing requirements to satisfy the needs of a patient (Arling, Kane, Mueller, & Lewis, 2007; Cherry & Reed, 2007). With respect to nursing care needs, it is evident that the severity of the illness often determines the nursing care needs; as a result, there is a close relationship between the intensity and severity aspects of acuity. Seriousness of the illness can be perceived as the amount of nursing resources and care utilized by the patient. Intensity can be looked at in terms of the amount of time needed to offer care to the patient. Some of the measures of nursing intensity could include the nursing intensity weights, and the nursing hours per patient per day (Abualrub, 2007). Other aspects of provider related acuity include the extent to which the patient depends on the nursing staff for their health care needs, which is sometimes referred to as nursing dependency. Patient severity could also be used to describe the nursing interventions and the amount and type of nursing care activities (direct and indirect) that are needed for the patient. Other measures of patient severity aspect of provider-related acuity can include patient debility and functional status. With respect to provider-related acuity, based on the review of literature, it can be argued that high acuity requires more nursing care, an increased workload, and complex patient needs; the case is the oppose for low acuity patients.

System-related acuity is concerned with the pairing of attributes of acuity with other concepts. The uses of system-related acuity include triage/urgency, classification system and case mix. Urgency/triage are used in emergency medicine settings in ascertaining the severity of illness in order to ensure that the patient is matched with the suitable nursing and medical requirements (Abualrub, 2007; Craig & Huber, 2007; Rischbieth, 2006). Classification systems are used in pairing acuity with nursing costs. In this context, acuity denotes the amount of care required. This often involves measuring the patient characteristics in order to ascertain the amount of nursing resources required and determine the nursing assignments. In addition, the classification systems can be used to match and predict staffing needs with respect to the patient needs. Case-mix is also an aspect of system-related acuity and is concerned with the number of patients in a given hospital who can be put in the same group depending on their nursing care needs. The case mix determines the resource utilization needed by a patient grouped in every category (Abualrub, 2007). Patients can also be grouped in accordance with the illness severity and the intensity of care. Acuity measurements can also be utilized in a number of other predictions such as the assignment of patients to nurses or case managers, budgeting, staffing, costs of care, mortality and morbidity (Abualrub, 2007).

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Antecedents

The nursing work environment is continuously evolving, which as a result has increased the demands placed on nurses while at the same time increasing the distance between the nurse and patient, requiring the presence and attention of nurses. There is widespread agreement in the literature that patient acuity is rising, which can be attributed to a number of factors. The first factor is the shortened length of patient stay in hospitals as hospitals embark on reengineering their workflows in order to lessen delays. This reengineering has focuses on nursing care and nurses through various. For instance, a hospital can adopt a screening tool aimed at enabling nurses to recognize patients who may require physical therapy as well as produce early consultation to be undertaken with the physical therapy department. Moreover, other hospitals are modifying their discharge procedures in order to make sure that the discharge takes place early during the day in order to accommodate patients being transferred from emergency rooms and surgery. Moreover, other hospitals have embarked on enhancing multidisciplinary rounds in order to make sure that all departments within the hospital have adequate information in a timely manner.

It is evident that all of these changes have resulted in novel demands of the nursing staff’s time and has lessened the nurse-time for lower-intensity patients. An increase in throughput results in a high rate of admissions, which increases the demands placed on the nurses’ time. In addition, the durations of patient stay are also being reduced because of the fact that patients are being discharged at a faster rate to post-acute care in home health and skilled nursing facilities. The outcome of faster discharge is an increase in patient acuity in both hospitals and patients placed under post-acute care. Therefore, nursing in post-acute care and hospital care are handling higher acuity patients. According to Lang, Hodge, Olson, Romano, & Kravitz (2004), the rising patient acuity and the novel work demands posed by the modified workflow cannot be addressed using higher nursing staffing levels; instead, there is the need to change the manner in which nursing staff use their time.

The second factor contributing to patient acuity is an increase in demand for nursing services because of the aging of the population. It is projected that from 2000 through 2020, the population will grow by 18% (Duffield & O’Brien-Pallas, 2003; Lang, Hodge, Olson, Romano, & Kravitz, 2004). In addition, the population growth for the over-65 population will be 54%, which translates to an increase in healthcare needs by this population. Studies have affirmed that the population is aging, and that elderly people comprise a considerable and growing percentage of people being admitted in hospitals and emergency departments. Elderly people usually develop complex health illnesses that are likely to result in chronic diseases. In addition, in hospital settings, elderly patients have reported relatively higher adverse events rates as well as higher chances of becoming deconditioned. According to Duffield & O’Brien-Pallas (2003), nurses must use all means necessary to avoid prolonging the duration of stay in hospitals for older patients, which requires the use of care models that shun deconditioning while at the same time promoting functioning. In addition, it is imperative to note that an increase in the demand for acute services has increased consistently during the last decades, with older people comprising of the fastest increasing population of those admitted for acute services.

Lankshear, Sheldon, & Maynard (2005) notes that the increased demand for acute services goes hand in hand with the decrease in the number of available acute hospital beds as well as the increased use of early patient discharge models. The clinical needs and problems of elderly patients are significantly different from the needs and problems presented by younger people (Craig & Huber, 2007; Mazzocco, Feigenson, & Halberda, 2011). A majority of elderly patients are often admitted with either sub-acute or acute illness that manifests itself ambiguously and is likely to be characterized by functional and mental deterioration. In addition, elderly patients are likely to have multifaceted social needs and several co-morbidities. Studies have shown that elderly have a lesser likelihood of being cleared from acute units. Moreover, when they are admitted, they are more likely to stay in the hospital for longer durations. Elderly patients also have higher rates of readmission (Abualrub, 2007).

The healthcare cost pressure has also been associated with the increase in patient acuity. The increase in the use of managed care during the 1990s played a pivotal role in increasing the cost pressure, especially in hospitals employing large numbers of registered nurses. During the 1990s, places with higher enrollments of managed care were characterized by slower employment growth and wage growth for registered nurses when compared to places having lower enrollments. With the spread of managed care, the employment and wage growth for registered nurses fell at the national level in the late 1990s (Hall, Doran, & Pink, 2004). This resulted in changes in hospital payment systems in order to lower spending and reduce the duration of patient stay in hospitals. Therefore, registered nurses in hospitals treat patients who are averagely sick although the intensity of their work increased, contributing to patient acuity (Lankshear, Sheldon, & Maynard, 2005; Rischbieth, 2006).

The nursing work environment and workload have also been linked to patient acuity. As a response to the increasing cost pressure, hospitals embarked on cutting the staffing levels and adopted mandatory overtime policies aimed at ensuring the availability of nurses during unanticipated increases in the number of patients admitted. The outcome has been an increase in nursing workload. In addition, this has resulted in a reduced nurses’ control with respect to weekend and night work. A direct implication of the increased workload could have been an increase in the wages of nurses; however, their wages have actually remained constant, which can be attributed to the increased competition in the healthcare industry. Increased workload contributes to high patient acuity in two ways. First, it reduces the nursing time and resources available to a patient. Second, it contributes to nursing shortage since it discourages people from entering or remaining in the nursing profession. Studies have affirmed that nurses with higher patient loads (workloads) report higher burnout and dissatisfaction.

Consequences

Numerous studies have reported a significant relationship between the levels of nursing staffing (patient acuity) and the quality of care for patients in both nursing homes and hospitals. For instance, a study conducted by Unruh (2003) reported that increasing the number of hours of nursing care per day per patient is related to improved health outcomes such as reduced duration of stay; reduced rates of illnesses including cardiac arrest, pneumonia, gastrointestinal bleeding, and urinary tract infections; and reduced mortality associated with complications. Another study by Lankshear, Sheldon, & Maynard (2005) revealed that increasing the number of patients per nurse (patient load) increases the probability of patients dying. Specifically, the study reported that, for each patient increased for each nurse, there is a 7% increased chance of death within one month of admission. The researchers also indicated that, for each patient increased per nurse, there is a 7% increase in the probability of dying from complications. In the context of nursing homes, studies have also reported a relationship between the quality of care and staffing levels (patient acuity) (Lankshear, Sheldon, & Maynard, 2005).

Studies have also documented the outcomes associated with increased nursing workload, which is an attribute of patient-related acuity (Hall, Doran, & Pink, 2004; Hall, Doran, & Pink, 2004; Hughes, 2008). The workload on nurses can be grouped into three categories including the unit, job, and patient levels. At the unit level, the nurse-patient ration is often used in measuring the level of nurse workload. Studies have reported that increased nursing workloads (lower nurse-patient ratio) can negatively affect patient outcomes. As a result, it has been suggested that increasing the number of nursing staff in a unit and reducing the number of patients that are assigned to a single nurse can help in enhancing patient care (Unruh, 2003). Nevertheless, these suggestions are not feasible because of nursing shortages and costs. At the job level, the extent of the nursing workload is determined by the specialty such as operating nurse versus Intensive Care Unit nurse. Studies have reported a relationship between job-level nursing workload and nursing outcomes like job satisfaction and stress. At the patient level, the extent of the workload depends on the patient’s clinical condition. Several empirical studies have explored relationship between nursing workload and patient outcomes (Duffield & O’Brien-Pallas, 2003; Hughes, 2008).

Increased nurse workload is associated with sub-optimal patient outcomes as well as lessened patient satisfaction (Rothberg, Abraham, Lindenauer, & Rose, 2005; Unruh, 2003). The majority of the research studies exploring the effect of nursing workload on patient outcomes have placed an emphasis on the nursing staffing levels – an attribute of patient acuity. For instance, reduced levels of nursing staffing has been associated with increased rates of pneumonia. In this regard, Unruh (2003) reported that increasing the number working hours of nurses by 1 hour per patient day results in an 8.9% increase in the likelihood of surgical patients developing pneumonia. The study also reported that higher pneumonia rates for units that staff fewer nurses. The levels of nursing staffing have also been reported to have an effect on nosocomial infections. In this respect, increasing the number of nursing hours for a patient resulted in a decrease in the rates of urinary tract infection (Hall, Doran, & Pink, 2004). The understaffing of nursing personnel has also been associated with an increase in the prevalence of E cloacae (Rischbieth, 2006). Evidence also suggests that nurse-staffing levels have an effect on mortality and failure to rescue. For instance, increasing the number of hours of registered nurses care per day resulted in reduced rates of failure to rescue. In addition, lower nurse-patient rations have been associated with an increase in the length of stay for admitted patients; specifically, a nurse patient ratio of 1:2 for the case of evening shifts results in a 20% increase in the duration of stay (Duffield & O’Brien-Pallas, 2003). Moreover, increased working hours are associated with a reduction in the duration of stay (Buerhaus, 2009).

Nursing workload does not only affect patient outcomes but nursing hours as well. There is no doubt that nursing workload has an impact on the time available for a nurse allocate for the various tasks. When the workload is high, nurses are unlikely to have adequate time in undertaking tasks having a direct impact on patient outcome. In addition, increased workload for nurses is likely to lessen the time that nurses spend communicating with other physicians, monitoring patients, and make use of safe practices. For instance, nurses may have no time to conform medications. Increased workload for nurses also resulted in decreased motivation and dissatisfaction, which can lead to reduced morale, increased absenteeism, increased organizational turnover, reduced job performance, and poor quality of care. Stress and burnout have also been associated with increased workload for nurses, which can contribute to medical errors because of the reduced attention that nurses put on performing critical tasks. Nursing workload has also been associated with work-around and violations among nursing staff. Violations comprise of nurses intentionally deviating from established practices that are necessary to guarantee safe operations and improved health outcomes. In this respect, increased nursing workload has been established to increase the difficulty of nurses adhering to guidelines and rules, which in turn can compromise quality of care and patient safety. An example of violation is insufficient hand washing. Moreover, increased nursing workload increases the probability of making errors during decision-making; this is because high workload increases high cognitive workload, which can result in mistakes, lapses or slips. An example of this is nurses forgetting to administer drugs to patients.

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Rationale for Antecedents, Criteria and Consequences Selection

The antecedent healthcare cost pressure was excluded from the table because it has no direct impact on patients. It is evident that the cost pressures on hospitals can be attributed to the competitive nature of the healthcare industry rather than patient-related and nurse-related factors. Nurses and patients are only on the receiving end in the sense that hospitals have to respond to cost pressures by cutting staffing levels, which ultimately affects patients, albeit indirectly. Essentially, because of the cost pressures, hospitals have changed their payment systems in order to cut spending and reduce the duration of patient stay in hospitals. Therefore, registered nurses in hospitals treat patients who are moderately sick although the intensity of their work has increased, contributing to patient acuity. The underlying argument is that, although they indirectly affect patient acuity, they cannot be used in determining the nursing care requirements by patients. In included shortened length of stay, high demand for nurses because of an aging population and nursing workload because they have a direct effect on the amount of nursing care resources allocated to a patient.

The criteria intensity of nurse work and clinical condition of the patient were used because they are measures that can be used in determining the staffing levels – an attribute of patient acuity. In addition, the nurse-patient ratio was included as a criterion because it is a measure of the nurse workload – also an attribute of patient acuity.

Increased patient acuity was included in the consequences because of the resulting effect associated with increased demand for nurses and shortened length of patient stay.
In addition, I synthesized the negative patient outcomes associated with nursing workload as poor health outcomes, and negative nurse outcomes such as poor job satisfaction, low motivation and morale, and increased burnout and stress, which are all linked to higher patient acuity.

Personal Definitions of Concept

The severity aspect of acuity can be used to refer to the patient’s psychological and physical status, which is the clinical condition of the patient. The intensity aspect of acuity represents the nursing care requirements and needs of the patient, which can be used to refer to the nursing workload for a particular patient or a group of patients. Therefore, the nursing workload depends on the intensity of care needs, which further depends on the illness severity. From this, acuity can be defined as the degree of illness severity and the corresponding workload intensity that required for the patient. It is imperative note that this definition incorporates both patient needs and the corresponding care required from the nurse. The association between intensity and severity aspect of patient acuity can be both non-linear and linear. For instance, Lankshear, Sheldon, & Maynard (2005) pointed out that a direct positive relationship exists between patient acuity and the intensity of nursing care, which suggests that, with an increase in the severity of illness, the nursing care needs increase. Nevertheless, the association between intensity of care and illness severity can also be influenced by the treatment goals. For instance, the nursing care requirements for a patient who have undergone a bone marrow transplant is likely to increase with respect to illness severity in instances where the treatment plan draws upon curative care when compared to a treatment plan that draws upon palliative care (Arling, Kane, Mueller, & Lewis, 2007). The association between intensity of care and illness severity is linear to a degree to which the patient decides to decline further treatment. At this point, the nursing care requirements are significantly reduced whereas the severity of the illness remains high. In the same light, patients needing long-term care may need complex interventions and therapies despite the fact that their illness severity is relatively stable relative to a patient that requires short-term care (high acuity patient) (Rothberg, Abraham, Lindenauer, & Rose, 2005).

In order to further clarify the concept of acuity, it is imperative to develop an operational definition that can be used in measuring acuity. In this regard, two attributes of acuity can be measured including provider-related and patient-related acuity. Provider-related acuity focuses on the measures intensity, which can be measured using nursing care needs in terms of amount, nursing care needs in terms of time, workload and complexity of care. The nursing care needs measured in terms of the amount, can be assessed by counting data about the number of tasks/activities accomplished for a single patient within 24 hours (Buerhaus, 2009). Nursing Intensity Weights can also be used in assessing the nursing care needs, which is based on a scale that ranges from 1 to 5 based on the nursing care requirements with higher scores indicating higher requirements (Abualrub, 2007). The nursing care needs in terms of time can be measured using the nursing hours per patient day (HPPD) and the minutes needed for particular indirect and direct care activities. Workload can be determined by using count data relating to nursing needs indicators. The care complexity is a categorical variable that depends on primary diagnosis, needs of the patient, and the case manager activities. Patient-related acuity can be measured using the Acute Physiology, Age, Chronic, Health Evaluation (APACHE), which is a weighted score relating to the patient physiological status including chronic health and age (Craig & Huber, 2007).

Conceptual Framework

This concept analysis of acuity has a number of implications for nursing research and practices. For nursing researchers, it is imperative to distinguish the acuity attribute that is being researched between severity (patient-related acuity) and intensity (provider-related). With respect to practices, it is evident that there are no consistent tool that is being used in measuring acuity, especially when measuring provider-related acuity. This is because the developers of these tools were not precise regarding the acuity attribute being measured. Therefore, these tools used in measuring acuity were not helpful in clinical situations. It is imperative to develop the tools for measuring acuity by drawing upon sound conceptual framework in order to affirm their relevance as well as validity for a specific patient population. From this concept analysis paper, I have discovered that patient acuity is a multifaceted concept that should be analyzed from both the provider and patient perspective, after which the two perspectives should be reconciled in order to match the patient requirements with the amount of nursing care provided in terms of amount and time.