Constructing a nursing budget using a patient classification system

Content validation of an instrument for medical record audits

OBJECTIVE

To build and validate the content of an instrument to conduct medical record audits; to conduct a pre-test.

METHODS

Methodological study conducted from May/2020 to May/2021 in three stages: 1) development of the instrument by bibliographic survey and benchmarking; 2) content validation using the Delphi technique; 3) application of the instrument and descriptive analysis in a sample of 200 medical records.

RESULTS

An instrument was constructed with 11 domains containing sub-items that characterize the quality of care. Two stages of the Delphi technique were necessary to reach a content validity index higher than 0.90. For each domain, a graduated scale with a numerical value from 1 to 4 points was attributed, reflecting the quality of its completion. The average time of application was 35 minutes per record.

CONCLUSIONS

The tool proved to be viable to support clinical audits to identify the level of excellence and reveal opportunities for improvement in care processes.

Adaptation and validation of an adult patient classification instrument with emphasis on the family dimension

Objectives:

to adapt and validate an instrument for classifying adult patients that emphasizes the family support network in the demand for nursing care.

Methods:

methodological study, carried out in three phases: adaptation of an instrument considering the reality of adult patients; content validation with seven experts and assessment of measurement properties (construct validity and internal consistency) with 781 hospitalized patients.

Results:

in content validation, the indicators reached the values established for the Content Validity Index (0.85-1.00). In the confirmatory factor analysis, the 11 indicators were distributed in three domains and presented average variance extracted and factor loading greater than 0.5. Composite reliability was greater than 0.7.

Conclusions:

the present study adapted and made available, with evidence of validity and reliability, an instrument for classifying adult patients that considers the family support network in the demand for nursing care.

Adaptação e validação de instrumento de classificação de paciente adulto com ênfase na dimensão familiar

RESUMO Objetivos: adaptar e validar um instrumento para classificação de pacientes adultos que enfatiza a rede de suporte familiar na demanda de cuidados de enfermagem. Métodos: estudo metodológico, realizado em três fases: adaptação de um instrumento considerando a realidade de pacientes adultos; validação de conteúdo com sete especialistas e avaliação das propriedades de medida (validade de construto e consistência interna) com 781 pacientes internados. Resultados: na validação de conteúdo, os indicadores alcançaram os valores estabelecidos para o Índice de Validade de Conteúdo (0,85-1,00). Na análise fatorial confirmatória, os 11 indicadores foram distribuídos em três domínios e apresentaram variância média extraída e carga fatorial superiores a 0,5. A confiabilidade composta foi superior a 0,7. Conclusões: o presente estudo adaptou e disponibilizou, com evidências de validade e confiabilidade, um instrumento para classificação de pacientes adultos que considera a rede de suporte familiar na demanda de cuidados de enfermagem.

Critical care nursing service costs: Comparison of the top-down versus bottom-up micro-costing approach in Brazil

AIM

To estimate the nursing service costs using a top-down micro-costing approach and to compare it with a bottom-up micro-costing approach.

BACKGROUND

Accurate data of nursing cost can contribute to reliable resource management.

METHOD

We employed a retrospective cohort design in an adult intensive care unit in São Paulo. A total of 286 patient records were included. Micro-costing analysis was conducted in two stages: a top-down approach, whereby nursing costs were allocated to patients through apportionment, and a bottom-up approach, considering actual nursing care hours estimated by the Nursing Activities Score (NAS).

RESULTS

The total mean cost by the top-down approach was US$1,640.4 ± 1,484.2/patient. The bottom-up approach based on a total mean NAS of 833 ± 776 points (equivalent to 200 ± 86 hr of nursing care) yielded a mean cost of US$1,487.2 ± 1,385.7/patient. In the 268 patients for whom the top-down approach estimated higher costs than the bottom-up approach, the total cost discrepancy was US$4,427.3, while for those costed higher based on NAS, the total discrepancy was US$436.9. The top-down methodology overestimated costs for patients requiring lower intensity of care, while it underestimated costs for patients requiring higher intensity of care (NAS >100).

CONCLUSIONS

The top-down approach may yield higher estimated ICU costs compared with a NAS-based bottom-up approach.

IMPLICATIONS FOR NURSING MANAGEMENT

These findings can contribute to an evidence-based approach to budgeting through reliable costing methods based on actual nursing workload, and to efficient resource allocation and cost management.

The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

Background

The Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The Safer Nursing Care Tool is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care.

Objectives

To determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure.

Design

This was an observational study on medical/surgical wards in four NHS hospital trusts using regression, computer simulations and economic modelling. We compared the effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff re-deployed/hired to meet fluctuations in demand.

Setting

Medical/surgical wards in four NHS hospital trusts.

Main outcome measures

The main outcome measures were professional judgement of staffing adequacy and reports of omissions in care, shifts staffed more than 15% below the measured requirement, cost per patient-day and cost per life saved.

Data sources

The data sources were hospital administrative systems, staff reports and national reference costs.

Results

In total, 81 wards participated (85% response rate), with data linking Safer Nursing Care Tool ratings and staffing levels for 26,362 wards × days (96% response rate). According to Safer Nursing Care Tool measures, 26% of all ward-days were understaffed by ≥ 15%. Nurses reported that they had enough staff to provide quality care on 78% of shifts. When using the Safer Nursing Care Tool to set establishments, on average 60 days of observation would be needed for a 95% confidence interval spanning 1 whole-time equivalent either side of the mean. Staffing levels below the daily requirement estimated using the Safer Nursing Care Tool were associated with lower odds of nurses reporting ‘enough staff for quality’ and more reports of missed nursing care. However, the relationship was effectively linear, with staffing above the recommended level associated with further improvements. In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. Cost savings were small when high temporary staff availability was assumed. ‘High’ establishments were associated with substantial reductions in understaffing and improved outcomes but higher costs, although, under most assumptions, the cost per life saved was considerably less than £30,000.

Limitations

This was an observational study. Outcomes of staffing establishments are simulated.

Conclusions

Understanding the effect on wards of variability of workload is important when planning staffing levels. The Safer Nursing Care Tool correlates with professional judgement but does not identify optimal staffing levels. Employing more permanent staff than recommended by the Safer Nursing Care Tool guidelines, meeting demand most days, could be cost-effective. Apparent cost savings from ‘flexible (low)’ establishments are achieved largely by below-adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability that are required to make such policies function.

Future work

Research is needed to identify cut-off points for required staffing. Prospective studies measuring patient outcomes and comparing the results of different systems are feasible.

Trial registration

Current Controlled Trials ISRCTN12307968.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 16. See the NIHR Journals Library website for further project information.

Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion

Background

The importance of nurse staffing levels in acute hospital wards is widely recognised but evidence for tools to determine staffing requirements although extensive, has been reported to be weak. Building on a review of reviews undertaken in 2014, we set out to give an overview of the major approaches to assessing nurse staffing requirements and identify recent evidence in order to address unanswered questions including the accuracy and effectiveness of tools.

Methods

We undertook a systematic scoping review. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews.

Results

The published literature is extensive and describes a variety of uses for tools including establishment setting, daily deployment and retrospective review. There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. Tools generally attempt to match staffing to a mean average demand or time requirement despite evidence of skewed demand distributions. The largest group of recent studies reported the evaluation of (mainly new) tools and systems, but provides little evidence of impacts on patient care and none on costs. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. Although there is evidence that staffing assessments made using tools may correlate with other assessments, different systems lead to dramatically different estimates of staffing requirements. While it is evident that there are many sources of variation in demand, the extent to which systems can deliver staffing levels to meet such demand is unclear. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect.

Conclusions

Despite the importance of the question and the large volume of publication evidence about nurse staffing methods remains highly limited. There is no evidence to support the choice of any particular tool. Future research should focus on learning more about the use of existing tools rather than simply developing new ones. Priority research questions include how best to use tools to identify the required staffing level to meet varying patient need and the costs and consequences of using tools.

Tweetable abstract

Decades of research on tools to determine nurse staffing requirements is largely uninformative. Little is known about the costs or consequences of widely used tools.