Validation of a new method for patient classification, the Oulu Patient Classification

Workload and short sickness absences in a cohort of Finnish hospital employees

This article used register data on day-to-day working hours of hospital employees combined with patient characteristics at work unit (wards) level to measure workload and its implications for short, self-certified sickness absences. We measured statistically the average nursing treatment burden of different patient mixes in hospital wards, and then analyzed the overall workload (intensity) of working days by comparing it to the actual available nursing workforce. We found that a significant part of the workload variation occurred between working days, and it was related to unexpected changes in the number of employees. In atypical situations a long work shift was associated with caring for patients with fewer resources. The high workload of a day increased the risk of short sickness absences along the following 3-week period. The results show that managing short-term workload variability should be a key aim from the perspective of well-being at work, and that combining different data sources can provide novel, important insights to the measurement of workload.

Measuring perceived adequacy of staffing to incorporate nurses' judgement into hospital capacity management: a scoping review

BACKGROUND

Matching demand and supply in nursing work continues to generate debate. Current approaches focus on objective measures, such as nurses per occupied bed or patient classification. However, staff numbers do not tell the whole staffing story. The subjective measure of nurses' perceived adequacy of staffing (PAS) has the potential to enhance nurse staffing methods in a way that goes beyond traditional workload measurement or workforce planning methods.

OBJECTIVES

To detect outcomes associated with nurses' PAS and the factors that influence PAS and to review the psychometric properties of instruments used to measure PAS in a hospital setting.

DESIGN AND METHODS

A scoping review was performed to identify outcomes associated with PAS, factors influencing PAS and instruments measuring PAS. A search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Business Source Complete and Embase databases identified 2609 potentially relevant articles. Data were independently extracted, analysed and synthesised. The quality of studies describing influencing factors or outcomes of PAS and psychometric properties of instruments measuring PAS were assessed following the National Institute for Health and Care Excellence quality appraisal checklist and the COnsensus-based Standards for the selection of health Measurement INstruments guidelines.

RESULTS

Sixty-three studies were included, describing 60 outcomes of PAS, 79 factors influencing PAS and 21 instruments measuring PAS. In general, positive PAS was related to positive outcomes for the patient, nurse and organisation, supporting the relevance of PAS as a staffing measure. We identified a variety of factors that influence PAS, including demand for care, nurse supply and organisation of care delivery. Associations between these factors and PAS were inconsistent. The quality of studies investigating the development and evaluation of instruments measuring PAS was moderate.

CONCLUSIONS

Measuring the PAS may enhance nurse staffing methods in a hospital setting. Further work is needed to refine and psychometrically evaluate instruments for measuring PAS.

Developing and testing a Korean patient classification system for general wards based on nursing intensity

Aim

To develop a new general wards patient classification tool based on the nursing intensity level that reflects patients’ clinical characteristics and indirect nursing activities.

Design

A cross‐sectional design was adopted. This methodological study developed a patient classification system to sort general ward patients based on the intensity of their nursing needs and verified the validity and reliability of this classification system.

Methods

Thirteen experts verified the tools’ content validity. Data collectors and head nurses classified 150 patients from two hospitals with four general wards and various nurse staffing levels. Inter‐rater reliability was analysed. Staff nurses classified 846 patients following the Korean patient classification system on nursing intensity scores that reflected patients’ clinical status. Content validity was verified based on the classification results. Using K‐group cluster analysis, score ranges for four groups were identified.

Results

The developed tool includes 8 domains, (symptom management, infection control, nutrition and medication, personal hygiene and secretion, activity, sleep and rest, guidance in nursing/emotional support, nursing activity planning and coordination, indirect activity), 24 subdomains, 66 nursing activities and 124 criteria. Inter‐rater reliability showed high agreement.

Integrative literature review of patient classification tools for nursing intensity evaluation: Focusing on comparison of South Korean and international tools

AIM

This study aimed to review the literature on patient classification tools (PCTs) for assessing nursing strength and to compare South Korean and international tools.

DESIGN

Integrative literature review.

METHODS

We searched the relevant literature published from 2000-2017 in PubMed and two electronic databases in Korea in March 2017. Twenty-five published studies were reviewed.

RESULTS

In most Korean studies, patients were classified by PCT, which were tested to ensure validity and reliability, followed by measurement of nursing time and development of the conversion index. In international studies, PCTs used were simpler than those in Korean studies; the results of estimation for optimum nurse staffing were reported. Most studies insufficiently reflected indirect nursing needs and patients' non-clinical factors. The current PCTs used in Korean studies inadequately reflect the reality of nursing field. Therefore, development of new PCTs reflecting nursing intensity based on direct and indirect nursing activities is necessary.

The transcultural adaptation and the validity and reliability of the Turkish Version of Perroca's Patient Classification Instrument

AIM

This study examines the transcultural adaptation and the reliability and validity of the Turkish version of Perroca's Patient Classification Instrument.

BACKGROUND

Nurse managers need valid and reliable patient classification tools for determining patients' acuity or dependency levels on nursing care for measuring nursing workloads.

METHODS

This study was conducted in two stages in a private hospital in Istanbul, Turkey. First, the instrument was translated, and its content validation was analysed. In the second stage, data were gathered from 300 hospitalized patients and were analysed by factor analyses, Cronbach's alpha and Cohen's kappa.

RESULTS

Validity testing with ten experts revealed a scale-content validity index of 0.93. Exploratory factor analysis revealed a two-dimensional instrument with distinct factor loadings and a variance of 66.97%. The confirmatory factor analysis revealed that the fit indices were satisfactory. This instrument had an overall Cronbach's alpha coefficient of .86 and Cohen's kappa coefficient of .826.

CONCLUSION

The study provides evidence that the Turkish version of Perroca's Patient Classification Instrument is a valid and reliable tool to determine patients' acuity levels on nursing care.

IMPLICATIONS FOR NURSING MANAGEMENT

This instrument may be used by nurse managers to determine acuity levels of patients and measure nursing workload.

Balancing workload of nurses: Linear mixed effects modelling to estimate required nursing time on surgical wards

Aim

Quantifying the relation between patient characteristics and care time and explaining differences in nursing time between wards.

Design

Academic hospital in the Netherlands. Six surgical wards, capacity 15-30 beds, 2012-2014.

Methods

Linear mixed effects model to study the relation between patient characteristics and care time. Estimated marginal means to estimate baseline care time and differences between wards.

Results

Nine patient characteristics significantly related to care time. Most required between 18 and 35 min extra, except "two or more IV/drip/drain" (8) and "one-on-one care" (156). Care time for minimum patient profile: 44-57 min and for average patient profile: 75-88 min. Sources of variation: nurse proficiency, patients, day-to-day variation within patients. The set of characteristics is short, simple and useful for planning and comparing workload. Explained variance up to 36%. Calculating estimated means per ward has not been done before. Nurse proficiency is an important factor.

Mapping nurses' activities in surgical hospital wards: A time study

Background

Balancing the number of nursing staff in relation to the number of patients is important for hospitals to remain efficient and optimizing the use of resources. One way to do this is to work with a workload management method. Many workload management methods use a time study to determine how nurses spend their time and to relate this to patient characteristics in order to predict nurse workload.

Objective

In our study, we aim to determine how nurses spend their working day and we will attempt to explain differences between specialized surgical wards.

Setting

The research took place in an academic hospital in the Netherlands. Six surgical wards were included, capacity 15 to 30 beds.

Method

We have used a work sampling methodology where trained observers registered activities of nurses and patient details every ten minutes during the day shift for a time period of three weeks.

Results

The work sampling showed that nurses spend between 40.1% and 55.8% of their time on direct patient care. In addition to this, nurses spend between 11.0% and 14.1% on collective patient care. In total, between 52.1% and 68% of time spent on tasks is directly patient related. We found significant differences between wards for 10 of the 21 activity groups. We also found that nurses spend on average 31% with the patient (bedside), which is lower than in another study (37%). However, we noticed a difference between departments. For regular surgical departments in our study this was on average 34% and for two departments that have additional responsibilities in training and education of nursing students, this was on average 25%.

Conclusions

We found a relatively low percentage of time spent on direct plus indirect care, and a lower percentage of time spent with the patient. We suspect that this is due to the academic setting of the study; in our hospital, there are more tasks related to education than in hospitals in other study settings. We also found differences between the wards in our study, which are mostly explained by differences in the patient mix, nurse staffing (proportion of nursing students), type of surgery and region of the body where the surgery was performed. However, we could not explain all differences. We made a first attempt in identifying and explaining differences in nurses’ activities between wards, however this domain needs more research in order to better explain the differences.

Using a new interrater reliability method to test the modified Oulu Patient Classification instrument in home health care

Aim

To test the interrater reliability of the modified Oulu Patient Classification instrument, using a multiple parallel classification method based on oral case presentations in home health care in Norway.

Design

Reliability study.

Methods

Data were collected at two municipal home healthcare units during 2013-2014. The reliability of the modified OPCq instrument was tested using a new multiple parallel classification method. The data material consisted of 2 010 parallel classifications, analysed using consensus in per cent and Cohen's kappa. Cronbach's alpha was used to measure internal consistency.

Results

For parallel classifications, consensus varied between 64.78-77.61%. Interrater reliability varied between 0.49-0.69 (Cohen's kappa), the internal consistency between 0.81-0.94 (Cronbach's alpha). Analysis of the raw scores showed 27.2% classifications had the same points, 39.1% differed one point, 17.9% differed two points and 16.5% differed ≥3 points.

Exploring nurse managers' perception of using the RAFAELA system as a management tool in a Norwegian hospital setting

Aim

The aim of the study, being part of a Norwegian evaluation project of the RAFAELA system, was to explore nurse managers’ perception of the RAFAELA system as a management tool in a Norwegian hospital setting.

Design

We applied an explorative qualitative design using focus group interviews.

Methods

Two focus group interviews were performed with 12 nurses in different management positions during autumn 2013. The principles of qualitative content analysis were used for analysing data.

Results

Three themes emerged. The informants experienced the RAFAELA system to be a basis for a precise and common langue. Furthermore, the informants considered it to be a system defining quality standards of nursing care. Finally, the RAFAELA system provided daily documentation of nursing intensity and thus was considered an important management tool for balancing patient needs with appropriate staff.

Human resource information systems in health care: a systematic evidence review

Objective: This systematic review aimed to: (1) determine the prevalence and scope of existing research on human resource information systems (HRIS) in health organizations; (2) analyze, classify, and synthesize evidence on the processes and impacts of HRIS development, implementation, and adoption; and (3) generate recommendations for HRIS research, practice, and policy, with reference to the needs of different stakeholders.

Methods: A structured search strategy was used to interrogate 10 electronic databases indexing research from the health, social, management, technology, and interdisciplinary sciences, alongside gray literature sources and reference lists of qualifying studies. There were no restrictions on language or publication year. Two reviewers screened publications, extracted data, and coded findings according to the innovation stages covered in the studies. The Critical Appraisal Skills Program checklist was adopted to assess study quality. The process of study selection was charted using a Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) diagram.

Results: Of the 6824 publications identified by the search strategy, 68, covering 42 studies, were included for final analysis. Research on HRIS in health was interdisciplinary, often atheoretical, conducted primarily in the hospital sector of high-income economies, and largely focused uncritically on use and realized benefits.

Discussion and Conclusions: While studies of HRIS in health exist, the overall lack of evaluative research raises unanswered questions about their capacity to improve quality and efficiency and enable learning health systems, as well as how sociotechnical complexity influences implementation and effectiveness. We offer this analysis to decision makers and managers considering or currently implementing an HRIS, and make recommendations for further research.

Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO): CRD42015023581. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015023581#.VYu1BPlVjDU.

The Criterion Validity, Reliability, and Feasibility of an Instrument for Assessing the Nursing Intensity in Perioperative Settings

Patient classification systems generate information for staff allocation based on a patient's care needs. This study aims to test further the instrument for assessing nursing intensity (NI) in perioperative settings. Nine operating departments from five university hospitals were involved. The perioperative nurses gathered data from patients (N = 876) representing different fields of surgery. Reliability was tested by parallel classifications (n = 144). Also, the users' (n = 40) opinions were surveyed. The results support the predictive validity and interrater reliability of the instrument. The nurses considered the instrument feasible to use. The patients' low ASA class did not automatically signify low NI; however, high ASA class was more frequently associated with high intraoperative NI. Intraoperative NI indicated the length of the postanaesthesia care and the type of the follow-up unit. Parallel classifications ensured the homogenous use of the instrument. The use of the instrument is recommended.

A multicentre, randomised controlled, non-inferiority trial, comparing nasal high flow with nasal continuous positive airway pressure as primary support for newborn infants with early respiratory distress born in Australian non-tertiary special care nurseries (the HUNTER trial): study protocol

INTRODUCTION

Nasal high-flow (nHF) therapy is a popular mode of respiratory support for newborn infants. Evidence for nHF use is predominantly from neonatal intensive care units (NICUs). There are no randomised trials of nHF use in non-tertiary special care nurseries (SCNs). We hypothesise that nHF is non-inferior to nasal continuous positive airway pressure (CPAP) as primary support for newborn infants with respiratory distress, in the population cared for in non-tertiary SCNs.

METHODS AND ANALYSIS

The HUNTER trial is an unblinded Australian multicentre, randomised, non-inferiority trial. Infants are eligible if born at a gestational age ≥31 weeks with birth weight ≥1200 g and admitted to a participating non-tertiary SCN, are <24 hours old at randomisation and require non-invasive respiratory support or supplemental oxygen for >1 hour. Infants are randomised to treatment with either nHF or CPAP. The primary outcome is treatment failure within 72 hours of randomisation, as determined by objective oxygenation, apnoea or blood gas criteria or by a clinical decision that urgent intubation and mechanical ventilation, or transfer to a tertiary NICU, is required. Secondary outcomes include incidence of pneumothorax requiring drainage, duration of respiratory support, supplemental oxygen and hospitalisation, costs associated with hospital care, cost-effectiveness, parental stress and satisfaction and nursing workload.

ETHICS AND DISSEMINATION

Multisite ethical approval for the study has been granted by The Royal Children's Hospital, Melbourne, Australia (Trial Reference No. 34222), and by each participating site. The trial is currently recruiting in eight centres in Victoria and New South Wales, Australia, with one previous site no longer recruiting. The trial results will be published in a peer-reviewed journal and will be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614001203640; pre-results.

Quality of nursing intensity data: inter-rater reliability of the patient classification after two decades in clinical use

AIMS

The aim of this study was to measure the inter-rater reliability of the Oulu Patient Classification and to discuss existing methods of reliability testing.

BACKGROUND

The Oulu Patient Classification, part of the RAFAELA^® System, has been developed to assist nursing managers with the proper allocation of nursing resources. Due to the increased intensity of inpatient care during recent years, there is a need for the reliability testing of the classification, which has been in clinical use for 20 years.

DESIGN

Retrospective statistical study.

METHODS

To test inter-rater reliability, a pair of nurses classified the same patients, without knowledge of each other's ratings, as a part of annually conducted standardization. Data on the parallel classifications (n = 19,997) was obtained from inpatient units (n = 32) with different specialties at a university hospital in Finland during 2010-2015. Parallel classification practices were also analysed. The reliability of the overall classification and its subareas were calculated using suitable statistical coefficients.

RESULTS

Inter-rater reliability coefficients were a reliable or almost perfect means of considering the nursing intensity category and various practices, but there were detectable differences between subareas. The lowest agreement levels occurred in the subareas 'Planning and Coordination of Nursing Care' and 'Guiding of Care/Continued Care and Emotional Support'.

CONCLUSIONS

There is a need to develop the descriptions of subareas and to clarify the related concepts. Precise nursing documentation can promote a high level of agreement and reliable results. The traditional overall proportion of agreement does not provide an adequate picture of reliability - weighted kappa coefficients should be used instead.

Balancing nurses' workload in hospital wards: study protocol of developing a method to manage workload

INTRODUCTION

Hospitals pursue different goals at the same time: excellent service to their patients, good quality care, operational excellence, retaining employees. This requires a good balance between patient needs and nursing staff. One way to ensure a proper fit between patient needs and nursing staff is to work with a workload management method. In our view, a nursing workload management method needs to have the following characteristics: easy to interpret; limited additional registration; applicable to different types of hospital wards; supported by nurses; covers all activities of nurses and suitable for prospective planning of nursing staff. At present, no such method is available.

METHODS/ANALYSIS

The research follows several steps to come to a workload management method for staff nurses. First, a list of patient characteristics relevant to care time will be composed by performing a Delphi study among staff nurses. Next, a time study of nurses' activities will be carried out. The 2 can be combined to estimate care time per patient group and estimate the time nurses spend on non-patient-related activities. These 2 estimates can be combined and compared with available nursing resources: this gives an estimate of nurses' workload. The research will take place in an academic hospital in the Netherlands. 6 surgical wards will be included, capacity 15-30 beds.

ETHICAL CONSIDERATIONS

The study protocol was submitted to the Medical Ethical Review Board of the University Medical Center (UMC) Utrecht and received a positive advice, protocol number 14-165/C.

DISCUSSION

This method will be developed in close cooperation with staff nurses and ward management. The strong involvement of the end users will contribute to a broader support of the results. The method we will develop may also be useful for planning purposes; this is a strong advantage compared with existing methods, which tend to focus on retrospective analysis.

Healthcare professionals' views on the mutual consistency of the Finnish Classification of Nursing Interventions and the Oulu Patient Classification

BACKGROUND

Various classification schemes have been used for clinical and administrative purposes, but their concepts have seldom been cross-mapped. Cross-mapping is a formal method that can be used for examining existing classifications' validity.

AIM

The aim was to cross-map two nursing classifications - the Finnish Classification of Nursing Interventions (FiCNI, version 3.0), developed for structured nursing documentation, and the Oulu Patient Classification (OPCq), created for daily assessment of nursing intensity - and evaluate their mutual consistency. The objective was to obtain information on the content equivalence of the two classifications and the consistency of the concepts used, to inform further development of both.

METHODS

The Delphi method was utilised, with a panel of experts that included terminology developers, researchers, teachers and nurses (n = 16). Four Delphi rounds were required. In these, panellists selected the most relevant content from the OPCq subareas (n = 6) for each FiCNI main category and subcategory (n = 307). In cases of doubt, respondents were asked to justify their choices.

RESULTS

Response rates ranged from 68.8 to 93.8% in the Delphi rounds. After three rounds, 81.4% of the FiCNI categories were cross-mapped with sufficient consensus. A fourth round was needed for 57 FiCNI categories (18.6%). Most FiCNI categories (29.3%) were cross-mapped to the OPCq's subarea 2. Deficiencies in the concepts' clarity and in the OPCq's content areas complicated the cross-mapping. The most unambiguous categories of the FiCNI were found in the respiratory, cardiac and activity components. The components showing greatest ambiguity were skin integrity, mental balance and safety.

CONCLUSION

The content and concepts used in both classifications need further development. The cross-mapping results can be utilised for developing reuse of structured nursing data in assessment of nursing intensity and in decision-making in human-resources planning.

Factors determining the patients' care intensity for surgeons and surgical nurses: a conjoint analysis

Background

Surgeons and nurses sometimes perceive a high workload on the surgical wards, which may influence admission decisions and staffing policy. This study aimed to explore the relative contribution of various patient and care characteristics to the perceived patients’ care intensity and whether differences exist in the perception of surgeons and nurses.

Methods

We invited surgeons and surgical nurses in the Netherlands for a conjoint analysis study through internet and e-mail invitations. They rated 20 virtual clinical scenarios regarding patient care intensity on a 10-point Likert scale. The scenarios described patients with 5 different surgical conditions: cholelithiasis, a colon tumor, a pancreas tumor, critical leg ischemia, and an unstable vertebral fracture. Each scenario presented a mix of 13 different attributes, referring to the patients’ condition, physical symptoms, and admission and discharge circumstances.

Results

A total of 82 surgeons and 146 surgical nurses completed the questionnaire, resulting in 4560 rated scenarios, 912 per condition. For surgeons, 6 out of the 13 attributes contributed significantly to care intensity: age, polypharmacy, medical diagnosis, complication level, ICU-stay and ASA-classification, but not multidisciplinary care. For nurses, the same six attributes contributed significantly, but also BMI, nutrition status, admission type, patient dependency, anxiety or delirium during hospitalization, and discharge type. Both professionals ranked ‘complication level’ as having the highest impact.

Discussion

The differences between surgeons and nurses on attributes contributing to care intensity may be explained by differences in professional roles and daily work activities. Surgeons have a medical background, including technical aspects of their work and primary focus on patient curation. However, nurses are focused on direct patient care, i.e., checking vital functions, stimulating self-care and providing woundcare.

Conclusions

Surgeons and nurses differ in their perception of patients’ care intensity. Appreciation of each other’s differing interpretations might improve collaboration between doctors and nurses and may help managers to match hospital resources and personnel.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1052-4) contains supplementary material, which is available to authorized users.

Factors and models associated with the amount of hospital care services as demanded by hospitalized patients: a systematic review

BACKGROUND

Hospitals are constantly being challenged to provide high-quality care despite ageing populations, diminishing resources, and budgetary restraints. While the costs of care depend on the patients' needs, it is not clear which patient characteristics are associated with the demand for care and inherent costs. The aim of this study was to ascertain which patient-related characteristics or models can predict the need for medical and nursing care in general hospital settings.

METHODS

We systematically searched MEDLINE, Embase, Business Source Premier and CINAHL. Pre-defined eligibility criteria were used to detect studies that explored patient characteristics and health status parameters associated to the use of hospital care services for hospitalized patients. Two reviewers independently assessed study relevance, quality with the STROBE instrument, and performed data analysis.

RESULTS

From 2,168 potentially relevant articles, 17 met our eligibility criteria. These showed a large variety of factors associated with the use of hospital care services; models were found in only three studies. Age, gender, medical and nursing diagnoses, severity of illness, patient acuity, comorbidity, and complications were the characteristics found the most. Patient acuity and medical and nursing diagnoses were the most influencing characteristics. Models including medical or nursing diagnoses and patient acuity explain the variance in the use of hospital care services for at least 56.2%, and up to 78.7% when organizational factors were added.

CONCLUSIONS

A larger variety of factors were found to be associated with the use of hospital care services. Models that explain the extent to which hospital care services are used should contain patient characteristics, including patient acuity, medical or nursing diagnoses, and organizational and staffing characteristics, e.g., hospital size, organization of care, and the size and skill mix of staff. This would enable healthcare managers at different levels to evaluate hospital care services and organize or reorganize patient care.

Predicting patient acuity from electronic patient records

BACKGROUND

The ability to predict acuity (patients' care needs), would provide a powerful tool for health care managers to allocate resources. Such estimations and predictions for the care process can be produced from the vast amounts of healthcare data using information technology and computational intelligence techniques. Tactical decision-making and resource allocation may also be supported with different mathematical optimization models.

METHODS

This study was conducted with a data set comprising electronic nursing narratives and the associated Oulu Patient Classification (OPCq) acuity. A mathematical model for the automated assignment of patient acuity scores was utilized and evaluated with the pre-processed data from 23,528 electronic patient records. The methods to predict patient's acuity were based on linguistic pre-processing, vector-space text modeling, and regularized least-squares regression.

RESULTS

The experimental results show that it is possible to obtain accurate predictions about patient acuity scores for the coming day based on the assigned scores and nursing notes from the previous day. Making same-day predictions leads to even better results, as access to the nursing notes for the same day boosts the predictive performance. Furthermore, textual nursing notes allow for more accurate predictions than previous acuity scores. The best results are achieved by combining both of these information sources. The developed model achieves a concordance index of 0.821 when predicting the patient acuity scores for the following day, given the scores and text recorded on the previous day.

CONCLUSIONS

By applying language technology to electronic patient documents it is possible to accurately predict the value of the acuity scores of the coming day based on the previous daýs assigned scores and nursing notes.

The oncology acuity tool: a reliable, valid method for measuring patient acuity for nurse assignment decisions

BACKGROUND AND PURPOSE

Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments.

METHODS

Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events.

RESULTS

Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls.

CONCLUSIONS

The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Explaining the amount of care needed by hospitalised surgical patients: a prospective time and motion study

Background

Hospitals provide care for patients with a variety of diseases, co-morbidities and complications. The actual amount of care these patients need is unclear. Given the recent developments such as ageing, multi-morbidity and budgetary restraints, a practical explanatory model would avail healthcare professionals and managers in determining the demand and costs for clinical care.

Methods

Six surgical wards in a Dutch university hospital participated in this prospective time and motion study. Surgeons, nurses and paramedics recorded the time spent on patient care 24/7 by means of PDAs. The investigators extracted possible determining characteristics from a previous systematic review and expert focus group. Total amount of care needed by the patients was expressed as costs involved in medical and nursing time, surgical interventions and diagnostics. Afterwards the investigators applied linear regression analysis to detect significant independent characteristics.

Results

174 Surgical patients were monitored during their hospital stay. Characteristics significantly influencing the consumed amount of care were: medication during hospitalisation, complications, co-morbidity, medical specialty, age, as well as undergoing surgery and length of stay. Median costs for care were €8.446 per patient admission.

Conclusions

The investigators developed a model that explains the total demand and costs of care needed for surgical patients in a university hospital. The input for this instrument can be derived from readily available data in hospital databases. This makes it a relatively easy instrument to help healthcare professionals and managers appreciate the amount of care needed on (surgical) wards and may be used to appreciate trends in time.

Development and content validity of the new version of a patient classification instrument

The purpose of this study was to reconstruct Perroca's patient classification instrument; and to assess the content validity of the new version. A group of experts comprising ten nurses appraised the instrument, using the Delphi technique. Data collection took place from March 2008 to February 2009 by means of structured questionnaires sent by electronic mail. The new version contained nine nursing care areas. Agreement levels on the instrument structure amounted to > 90%, and ranged between 80 and 96% in the nursing care areas. The refinement of classification instruments is of great importance to generate valid and reliable data, supporting management decision making on nursing care planning as well as nursing workload measurement.

Evidence-based human resource management: a study of nurse leaders' resource allocation

AIMS

The aims were to illustrate how the RAFAELA system can be used to facilitate evidence-based human resource management.

BACKGROUND

The theoretical framework of the RAFAELA system is based on a holistic view of humankind and a view of leadership founded on human resource management.

METHODS

Nine wards from three central hospitals in Finland participated in the study. The data, stemming from 2006-2007, were taken from the critical indicators (ward-related and nursing intensity information) for national benchmarking used in the RAFAELA system. The data were analysed descriptively.

RESULTS

The daily nursing resources per classified patient ratio is a more specific method of measurement than the nurse-to-patient ratio. For four wards, the nursing intensity per nurse surpassed the optimal level 34% to 62.2% of days. Resource allocation was clearly improved in that a better balance between patients' care needs and available nursing resources was maintained.

CONCLUSIONS

The RAFAELA system provides a rational, systematic and objective foundation for evidence-based human resource management.

IMPLICATIONS FOR NURSING MANAGEMENT

Data from a systematic use of the RAFAELA system offer objective facts and motives for evidence-based decision making in human resource management, and will therefore enhance the nurse leaders' evidence and scientific based way of working.

Time in care for older people living in nursing homes

In order to measure actual care needs in relation to resources required to fulfill these needs, an instrument (Time in Care) with which to evaluate care needs and determine the time needed for various care activities has been developed with the aim of assessing nursing intensity in municipal care for older people. Interreliability (ICC = 0.854) of time measurements (n = 10'546) of 32 nursing activities in relation to evaluated care levels in two nursing homes (staff n = 81) has been determined. Nursing intensity for both periods at the two nursing homes comprised on average a direct care time of 75 (45%) and 101 (42%) minutes, respectively. Work time was measured according to actual schedule (462 hours per nursing home during two weeks). Given that the need for care was high, one must further investigate if the quality of care the recipients received was sufficiently addressed.

Measuring care of the elderly: psychometric testing and modification of the Time in Care instrument for measurement of care needs in nursing homes

Background

Aging entails not only a decrease in the ability to be active, but also a trend toward increased dependence to sustain basic life functions. An important aspect for appropriately elucidating the individual's care needs is the ability to measure them both simply and reliably. Since 2006 a new version of the Time in Care needs (TIC-n) instrument (19-item version) has been explored and used in one additional municipality with the same structure as the one described in an earlier study.

Methods

The TIC-n assessment was conducted on a total of 1282 care recipients. Factor analysis (principal component) was applied to explore the construct validity of the TIC-n. Cronbach's alpha was calculated to test reliability and for each of the items remaining in the instrument after factor analysis, an inter-rater comparison was carried out on all recipients in both municipalities. Independently of each other, a weighted Kappa (K_w) was calculated. Results. The mean of each weighted Kappa (K_w) for the dimensions in the two municipalities was 0.75 and 0.76, respectively. Factor analysis showed that all 19 items had a factor loading of ≥ 0.40. Three factors (General Care, Medical Care and Cognitive Care) were created.

Conclusion

The TIC-n instrument has now been tested for validity and reliability in two municipalities with satisfactory results. However, TIC-n can not yet be used as a golden standard, but it can be recommended for use of measurement of individual care needs in municipal elderly care.

Measuring the intensity of nursing care: Making use of the Belgian Nursing Minimum Data Set

BACKGROUND

The Belgian Nursing Minimum Data Set (B-NMDS) is a nationwide registration of 23 nursing activities. It was developed for the measurement of nursing care in acute hospitals. It is used to support healthcare management & policy decision making such as hospital financing and nurse staffing decisions.

OBJECTIVE

To develop a measure of the intensity of nursing care based on information that is available in the B-NMDS. DESIGN-SETTING-PARTICIPANTS: Retrospective analysis of the B-NMDS from all Belgian acute hospitals (n=115) for the year 2003. The sample included 690,258 inpatient days for 298,691 patients that were recorded from 1637 acute care nursing units.

METHODS

The 23 nursing activities were synthesized into one new latent variable by PRINQUAL analysis. This variable was evaluated as a measure of nursing care intensity using key characteristics of the San Joaquin patient classification system, which was designed to measure the intensity of nursing care.

RESULTS

The main NMDS component from the PRINQUAL analysis accounted for 26.8% of the variance. The distribution of inpatient days over all four San Joaquin categories is: 11.1% (self-care); 40.4% (average care); 30.8% (above average care); 17.7% (intensive care). In 97.5% of the nursing units the intensity of nursing care score of the B-NMDS (main NMDS component) followed the ordinality of the San Joaquin classification system. Furthermore, the San Joaquin categories alone explained more variability--70.2% in the intensity of nursing care measure (main NMDS component) than did other determinants, such as department type, age, diagnostic-related groups (DRG) and severity of illness, hospital type and hospital size together.

CONCLUSION

The B-NMDS is an instrument that produces a measure of the intensity of nursing care in acute hospitals.

Benchmarking in nursing care by the RAFAELA patient classification system - a possibility for nurse managers

AIM

The aim of the study was to explore the possibilities of benchmarking with the RAFAELA system. In this study, comparisons are made between: (1) costs for one nursing care intensity point; (2) the nursing care intensity per nurse; (3) the relationship between nursing care intensity per nurse and (4) the optimal nursing care intensity.

BACKGROUND

During the period from 1994 to 2000 a new system for patient classification, the RAFAELA system, was developed in Finland.

METHODS

86 wards from 14 different hospitals in Finland took part in the study.

RESULTS

The costs for one nursing care intensity point on the adults' wards were on average 7.80euro. The average workload was 25.2 nursing care intensity points per nurse. The optimal nursing care intensity was exceeded during 49.5% of the days and under during 20% of the days.

CONCLUSIONS

The study shows that benchmarking with the RAFAELA system provides many opportunities for the nurse managers' resource allocation and their personnel administration.

What degree of work overload is likely to cause increased sickness absenteeism among nurses? Evidence from the RAFAELA patient classification system

AIM

This paper reports a study examining whether nurses' work overload is associated with increased sick leave and quantifying the loss of working days from work overload.

BACKGROUND

The RAFAELA patient classification system indicates nursing care intensity in relation to an optimum and is one of the few validated monitoring instruments of patient-associated workload among nurses. However, it is not clear whether work overload is a risk factor for increased sickness absenteeism, an important occupational problem in health care.

METHOD

An observational cohort study was carried out with 877 nurses, 31 wards and five Finnish hospitals. Patient-associated workload scores from the RAFAELA system were based on a 6-month monitoring period in 2004. Records of 12-month self certified (1-3 days) and medically certified (>3 days) periods of sick leave in the same year were obtained from employers' registers.

FINDINGS

The mean workload was 9% (sd = 8%) above the optimum. There was a linear trend between increasing workload and increasing sick leave (P < or = 0.006). Among nurses with workload > or =30% above the optimum the rate of self certified periods of sick leave was 1.44 (95% CI 1.13-1.83) times higher than among those with an optimum workload. The corresponding rate ratio for medically certified sick leave was 1.49 (1.10-2.03). These excess rates of sickness absence resulted in 12 extra sick leave days per person-year.

CONCLUSION

Measuring nurses' workload may be an important part of strategic human resource management of nurses to reduce sick leave among nurses.

Are nurses? assessments of their workload affected by non-patient factors? An analysis of the RAFAELA system

AIMS

To identify (1) the contribution of non-patient factors to patient classification systems and (2) the explanatory power of nursing care intensity and non-patient factors to Professional Assessment of Optimal Nursing Care Intensity Level workload.

BACKGROUND

In the Rainio, Fagerström and Rauhala (RAFAELA) patient classification system, nursing care intensity per nurse is measured daily by the Oulu Patient Classification/Qualisan instrument. The optimal nursing care intensity is determined using Professional Assessment of Optimal Nursing Care Intensity Level instrument. However, nurses' workload may be affected by factors other than nursing care intensity. Therefore, RAFAELA contains 12 non-patient questions.

METHODS

A retrospective study of all 22 somatic wards of a secondary healthcare hospital in Finland.

RESULTS

Non-patient questions were answered in 26% of 4870 questionnaires. They added to workload in 62%. Eight questions were grouped into four factors: administration; staff resources and mental stress; co-operation within and between units. The explanatory value between Oulu Patient Classification/Qualisan and Professional Assessment of Optimal Nursing Care Intensity Level had a median of 0.45. Including the non-patient questions raised it to 0.55.

CONCLUSIONS

Non-patient factors affect the nurses' assessments of their workload, but less than nursing care intensity. They contribute valuable information on the functioning and problems of wards.

Towards automated classification of intensive care nursing narratives

BACKGROUND

Nursing narratives are an important part of patient documentation, but the possibilities to utilize them in the direct care process are limited due to the lack of proper tools. One solution to facilitate the utilization of narrative data could be to classify them according to their content.

OBJECTIVES

Our objective is to address two issues related to designing an automated classifier: domain experts' agreement on the content of classes Breathing, Blood Circulation and Pain, as well as the ability of a machine-learning-based classifier to learn the classification patterns of the nurses.

METHODS

The data we used were a set of Finnish intensive care nursing narratives, and we used the regularized least-squares (RLS) algorithm for the automatic classification. The agreement of the nurses was assessed by using Cohen's kappa, and the performance of the algorithm was measured using area under ROC curve (AUC).

RESULTS

On average, the values of kappa were around 0.8. The agreement was highest in the class Blood Circulation, and lowest in the class Breathing. The RLS algorithm was able to learn the classification patterns of the three nurses on an acceptable level; the values of AUC were generally around 0.85.

CONCLUSIONS

Our results indicate that the free text in nursing documentation can be automatically classified and this can offer a way to develop electronic patient records.

Reconsidering the conceptualization of nursing workload: literature review

AIM

This paper reports a literature review that aimed to analyse the way in which nursing intensity and patient dependency have been considered to be conceptually similar to nursing workload, and to propose a model to show how these concepts actually differ in both theoretical and practical terms.

BACKGROUND

The literature on nursing workload considers the concepts of patient 'dependency' and nursing 'intensity' in the realm of nursing workload. These concepts differ by definition but are used to measure the same phenomenon, i.e. nursing workload.

METHOD

The literature search was undertaken in 2004 using electronic databases, reference lists and other available literature. Papers were sourced from the Medline, Psychlit, CINAHL and Cochrane databases and through the general search engine Google. The keywords focussed on nursing workload, nursing intensity and patient dependency.

FINDINGS

Nursing work and workload concepts and labels are defined and measured in different and often contradictory ways. It is vitally important to understand these differences when using such conceptualizations to measure nursing workload. A preliminary model is put forward to clarify the relationships between nursing workload concepts.

CONCLUSION

In presenting a preliminary model of nursing workload, it is hoped that nursing workload might be better understood so that it becomes more visible and recognizable. Increasing the visibility of nursing workload should have a positive impact on nursing workload management and on the provision of patient care.

Data warehouse approach to nursing management

AIM

This article describes a data warehouse approach when designing an information system to meet nursing management needs in acute hospital setting.

BACKGROUND

The rapidly changing health care environment has created new challenges for nursing leaders and requires appropriate, accurate and timely data for decision-making.

METHOD

Key aspects of current information needs were identified by a nursing expert group. A data warehouse-based Nursing Management Information System was produced and piloted in nine wards. A survey and interviews were conducted to evaluate the piloting.

RESULTS

Data from the patient administrative system together with nursing rostering data and measures for nursing care intensity brought new opportunities for nursing management.

CONCLUSIONS

A Nursing Management Information System is suggested to be built using data warehouse model. Successful implementation of a Nursing Management Information System requires systematic data quality checks. An information analyst is essential for interpreting and communicating nursing data to multi-professional management groups.

Measuring nursing workload in neonatal intensive care

AIM

To determine if a suitable method of measuring nursing workload could be developed in neonatal intensive care units (NICUs).

BACKGROUND

Nursing is a multifunctioning activity and previous methods measuring the demand for nurses do not put enough emphasis on the individual capabilities. The reporting of NICU activity has traditionally been related to bed occupancy and the number of infants requiring ventilator support. A classification system based on activity, hours of care and nursing staff ratios has been used; however, it does not consider the clinical ability of the individual nurses.

METHODS

A 5-month prospective study was undertaken in which nurses in two NICUs scored their patients' level of dependency and professional assessment of the level of intensity of care required by the infants in each shift. In addition, serial measures of severity of illness scores for each patient were collected.

KEY ISSUES

The study identified methods of measuring workload that consider the individual nurse's ability and contributing organizational factors. We found that the estimates of nursing hours using the two traditional dependency measures did not match the current practice or take into account the skill of the nurses. A method in which the nurses indicated the intensity of nursing care required by their patients was suitable one for capturing their individual capabilities. System factors were also found to contribute to the nursing workload.

CONCLUSIONS

It is not sufficient to use patient acuity or severity of illness alone. Other factors such as the nurse's assessment of the intensity of care required and the organizational factors are important components of workload estimates.

Assessment of nursing management and utilization of nursing resources with the RAFAELA patient classification system - case study from the general wards of one central hospital

BACKGROUND

RAFAELA is a new Finnish PCS, which is used in several University Hospitals and Central Hospitals and has aroused considerable interest in hospitals in Europe.

AIMS AND OBJECTIVES

The aim of the research is firstly to assess the feasibility of the RAFAELA Patient Classification System (PCS) in nursing staff management and, secondly, whether it can be seen as the transferring of nursing resources between wards according to the information received from nursing care intensity classification.

METHODS

The material was received from the Central Hospital's 12 general wards between 2000 and 2001. The RAFAELA PCS consists of three different measures: a system measuring patient care intensity, a system recording daily nursing resources, and a system measuring the optimal nursing care intensity/nurse situation. The data were analysed in proportion to the labour costs of nursing work and, from that, we calculated the employer's loss (a situation below the optimal level) and savings (a situation above the optimal level) per ward as both costs and the number of nurses.

RESULTS

In 2000 the wards had on average 77 days below the optimal level and 106 days above it. In 2001 the wards had on average 71 days below the optimal level and 129 above it. Converting all these days to monetary and personnel resources the employer lost 307,745 or 9.84 nurses and saved 369,080 or 11.80 nurses in total in 2000. In 2001 the employer lost in total 242,143 or 7.58 nurses and saved 457,615 or 14.32 nurses. During the time period of the research nursing resources seemed not have been transferred between wards.

CONCLUSIONS

RAFAELA PCS is applicable to the allocation of nursing resources but its possibilities have not been entirely used in the researched hospital. The management of nursing work should actively use the information received in nursing care intensity classification and plan and implement the transferring of nursing resources in order to ensure the quality of patient care.

RELEVANCE TO CLINICAL PRACTICE

Information on which units resources should be allocated to is needed in the planning of staff resources of the whole hospital. More resources do not solve the managerial problem of the right allocation of resources. If resources are placed wrongly, the problems of daily staff management and cost control continue.

Determining optimal nursing intensity: the RAFAELA method

BACKGROUND

RAFAELA is a modern system of patient classification. In the last few years the system has become widely used in Finland and has aroused international interest. It comprises three parts: (1) The Oulu Patient Classification (OPC) instrument and (2) a file on nurse resources. Using these, the daily nursing care intensity, expressed as OPC points per nurse, can be calculated. The existing nursing care intensity can then be compared with the optimal by using the third instrument, (3) the Professional Assessment of Optimal Nursing Care Intensity Level (PAONCIL). This is a daily questionnaire that nurses complete in a 2-month period at intervals every few years. The daily workload is scored from -3 to +3, where zero is the optimal level. The optimal nursing care intensity per nurse is then defined by using linear regression analysis. No expensive time studies are needed.

AIMS

This paper reports on a study which aimed to identify the minimum requirements for determining optimal nursing care intensity that allow the results to be accepted as correct, in terms of: length of the PAONCIL examination period, PAONCIL questionnaire response rate, explanatory power of the regression analysis and mean values of the OPC and PAONCIL instruments.

DESIGN

The results of analyses of optimal nursing care intensity from 61 wards in eight Finnish hospitals for the period 1997-2001 are presented. The data do not contain any information about the identity of the patients.

METHODS

Linear regression analysis, one-way analysis of variance, t-tests and correlation analysis were used, as well as parameters of distribution of the data.

RESULTS

The results of the analysis of optimal nursing care intensity can be regarded as reliable if the PAONCIL response rate is above 70%, the period of examination is at least 3-4 weeks, the mean PAONCIL value is below 0.65 and the explanatory power is above 25%.

CONCLUSION

On the basis of the RAFAELA system, the optimal nursing care intensity of a ward can be reliably determined. The prerequisites for achieving reliable results were clear and mostly fulfilled. Because a study period shorter than that which has previously been the practice is enough, the use of this system will be easier than before. The credibility and usefulness of the RAFAELA system have thus received considerable additional confirmation.

Initial validation of the perioperative nursing data set in Finland

PURPOSE

To explore the relevance of the Perioperative Nursing Data Set (PNDS) in Finland.

METHODS

A three-round Delphi technique (10 participants) and content analysis of 134 articles from the Journal of the Finnish Operating Room Nurses Association.

FINDINGS

All the PNDS outcomes, 86% of the diagnoses, and 87% of the interventions were found to be relevant. The Delphi panel suggested, and content analysis revealed, 6 new outcomes, 43 new diagnoses, and 11 new interventions. Consensus was achieved on 77%. The phrases used in perioperative articles corresponded with those of PNDS 56%-78% of the time.

CONCLUSIONS

PNDS can be used to describe perioperative nursing in Finland. Further conceptualization and validation are needed before using the data set in perioperative practice.

IMPLICATIONS FOR PRACTICE

Although PNDS cannot be implemented in Finland as is, it is a valid structure for further development of the terminology, contents, methods, and practice of Finnish perioperative documentation.