Ranking actions

Judge each action independently

NHS England states that ranking options are discrete actions and “should not be thought of as chronological”. An action does not become better because you imagine taking another listed action before it.

Ask: “How appropriate is this action as written, given this scenario?” Do not require every option to solve the whole scenario; a useful partial response may still deserve a high position.

A practical sorting method

1. Find the clearest options. Look for an action that addresses the main problem well and one that causes harm or leaves an important duty unmet. Some questions won’t have an obvious best or worst action.
2. Sort into rough groups: good, acceptable but limited, and poor. This mirrors NHS England’s description of options as a mix of good, acceptable and poor responses.
3. Compare adjacent options. Explain why one is preferable using a fact from the stem and a difference in wording.
4. Place every option once. Check the direction of the scale and that no rank is missing or repeated.
5. Check the middle ranks. Make sure your explanation doesn’t rely on an imagined sequence, an added promise or an invented fact.

Ask what the action would achieve

Options that involve talking can have very different effects. Talking to the patient may establish their wishes; talking to a registrar may obtain urgent assistance; talking to an uninvolved colleague may spread confidential information.

Similarly, escalation can provide essential protection or be unnecessarily punitive. Check who you’re contacting, why and how urgently. “Senior” alone is not a reason to rank an option higher.

Three common ranking errors

Adding an unwritten action: “This option only tells the colleague to rest, but I would cover all their patients first.” Judge what’s written and what it necessarily involves.

Expecting each action to solve everything: “Asking a useful question does not solve everything, so it must rank low.” A focused action can be appropriate even if further work would be required.

Applying a fixed rule: “Direct conversation always beats senior advice.” That ignores situations where the concern is urgent, the person has power over you, or a private approach would be unsafe.

Explain your choice in one sentence

A ranks above B because [fact from the scenario] makes [specific benefit or risk] more important here.

For example: “Getting urgent senior support ranks above offering advice about tomorrow’s rota because today’s workload is already leaving patients without required reviews.”

If your explanation is only “more professional”, identify the action that creates that impression. If you can’t, use the close-option comparison.

References

• NHS England: ranking format