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

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 patient acuity and nursing care needs in South Korea: application of a new patient classification system

BACKGROUND

An accurate and reliable patient classification system (PCS) can help inform decisions regarding adequate assignments for nurse staffing. This study aimed to evaluate the criterion validity of the Asan Patient Classification System (APCS), a new tertiary hospital-specific PCS, by comparing its rating and total scores with those of KPCS-1 and KPCS-GW for measuring patient activity and nursing needs.

METHODS

We performed a retrospective analysis of the medical records of 50,314 inpatients admitted to the general wards of a tertiary teaching hospital in Seoul, South Korea in March, June, September, and December 2019. Spearman's correlation and Kappa statistics according to quartiles were calculated to examine the criterion validity of the APCS compared with the KPCS-1 and KPCS-GW.

RESULTS

The average patient classification score was 28.3 points for APCS, 25.7 points for KPCS-1, and 21.6 points for KPCS-GW. The kappa value between APCS and KPCS-1 was 0.91 (95% CI:0.9072, 0.9119) and that between APCS and KPCS-GW was 0.88 (95% CI:0.8757, 0.8810). Additionally, Spearman's correlation coefficients among APCS, KPCS-1, and KPCS-GW showed a very strong correlation. However, 10.8% of the participants' results were inconsistent, and KPCS-1 tended to classify patients into groups with lower nursing needs compared to APCS.

CONCLUSION

This study showed that electronic health record-generated APCS can provide useful information on patients' severity and nursing activities to measure workload estimation. Additional research is needed to develop and implement a real-world EHR-based PCS system to accommodate for direct and indirect nursing care while considering diverse population and dynamic healthcare system.

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.

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.

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.

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.

Pre-implementation studies of a workforce planning tool for nurse staffing and human resource management in university hospitals

AIM

To investigate the reliability, validity and feasibility of the RAFAELA workforce planning system (including the Oulu patient classification system - OPCq), before deciding on implementation in Dutch hospitals.

BACKGROUND

The complexity of care, budgetary restraints and demand for high-quality patient care have ignited the need for transparent hospital workforce planning.

METHODS

Nurses from 12 wards of two university hospitals were trained to test the reliability of the OPCq by investigating the absolute agreement of nursing care intensity (NCI) measurements among nurses. Validity was tested by assessing whether optimal NCI/nurse ratio, as calculated by a regression analysis in RAFAELA, was realistic. System feasibility was investigated through a questionnaire among all nurses involved.

RESULTS

Almost 67 000 NCI measurements were performed between December 2013 and June 2014. Agreement using the OPCq varied between 38% and 91%. For only 1 in 12 wards was the optimal NCI area calculated judged as valid. Although the majority of respondents was positive about the applicability and user-friendliness, RAFAELA was not accepted as useful workforce planning system.

CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT

Nurses' performance using the RAFAELA system did not warrant its implementation. Hospital managers should first focus on enlarging the readiness of nurses regarding the implementation of a workforce planning system.

[Use of patients' classification instruments: analysis of the brazilian production of knowledge]

OBJECTIVE

To analyze the production of scientific knowledge about the use of patients' classification instruments in care and management practice in Brazil.

METHOD

Integrative literature review with databases search in: Latin American and Caribbean Literature on Health Sciences (LILACS), Medical Literature Analysis and Retrieval System on-line (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and SCOPUS, between January 2002 through December 2013.

RESULTS

1,194 studies were found, 31 met the inclusion criteria. We observed a higher number of studies in the category care plans and workload (n=15), followed by the category evaluation of psychometric properties (n=14).

CONCLUSION

Brazilian knowledge production has not yet investigated some purposes of using instruments for classifying patients in professional nursing practice. The identification of unexplored areas can guide future research on the topic.


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.

Construção e validação de um instrumento de classificação de pacientes pediátricos

OBJETIVO: Construir, validar o conteúdo e verificar a confiabilidade interavaliadores de um instrumento para a classificação de pacientes pediátricos. MÉTODOS: Estudo misto com referencial quantitativo, sendo o delineamento descritivo exploratório para a validação do conteúdo do instrumento realizado pela Técnica Delphi seguido por desenho correlacional para avaliar a confiabilidade interavaliadores. RESULTADOS: Após quatro fases da Técnica Delphi, o instrumento ficou constituído por 11 indicadores de demanda de cuidado e cada um por quatro situações graduadas refletindo o aumento da necessidade de enfermagem. Obteve-se nível de confiabilidade ótimo para cinco indicadores; bom para cinco e apenas um indicador com fraco nível de confiabilidade. CONCLUSÃO: Foi construído e validado o conteúdo do instrumento para classificar pacientes pediátricos em cinco categorias de cuidados com confiabilidade satisfatória.

[The evaluation of an instrument for pediatric oncology patient classification]

The objectives of this study were to assess the interrater reproducibility of the instrument to classify pediatric patients with cancer; verify the adequacy of the patient classification instrument for pediatric patients with cancer; and make a proposal for changing the instrument, thus allowing for the necessary adjustments for pediatric oncology patients. A total of 34 pediatric inpatients of a Cancer Hospital were evaluated by the teams of physicians, nurses and nursing technicians. The Kappa coefficient was used to rate the agreement between the scores, which revealed a moderate to high value in the objective classifications, and a low value in the subjective. In conclusion, the instrument is reliable and reproducible, however, it is suggested that to classify pediatric oncology patients, some items should be complemented in order to reach an outcome that is more compatible with the reality of this specific population.

[Pediatric Patient Classification System: construction and validation of care categories]

Patient classification is essential for managing a hospital unit. Literature, however, does not present conceptualizations of pediatric patient categories. The objectives of this study were to define and validate pediatric patient care categories, according to the level of dependency of the nursing team. The care categories were defined based on a literature review, and the content of the proposed categories was validated by a group of judges involved in managing and providing care in a pediatric unit, and by judges involved in pediatric education and research as well as in the construction of patient instruments. Five care categories were established and validated: Minimal, Intermediate, High dependency, Semi-intensive and Intensive. The validation of the care categories were the basis for constructing a system for the classification of pediatric patients, that may contribute with the decision making process of nurses working in management and health care.

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.

Does daily nurse staffing match ward workload variability? Three hospitals' experiences

PURPOSE

Nurse shortage and rising healthcare resource burdens mean that appropriate workforce use is imperative. This paper aims to evaluate whether daily nursing staffing meets ward workload needs.

DESIGN/METHODOLOGY/APPROACH

Nurse attendance and daily nurses' workload capacity in three hospitals were evaluated. Statistical process control was used to evaluate intra-ward nurse workload capacity and day-to-day variations. Statistical process control is a statistics-based method for process monitoring that uses charts with predefined target measure and control limits. Standardization was performed for inter-ward analysis by converting ward-specific crude measures to ward-specific relative measures by dividing observed/expected. Two charts: acceptable and tolerable daily nurse workload intensity, were defined. Appropriate staffing indicators were defined as those exceeding predefined rates within acceptable and tolerable limits (50 percent and 80 percent respectively).

FINDINGS

A total of 42 percent of the overall days fell within acceptable control limits and 71 percent within tolerable control limits. Appropriate staffing indicators were met in only 33 percent of wards regarding acceptable nurse workload intensity and in only 45 percent of wards regarding tolerable workloads.

RESEARCH LIMITATIONS/IMPLICATIONS

The study work did not differentiate crude nurse attendance and it did not take into account patient severity since crude bed occupancy was used. Double statistical process control charts and certain staffing indicators were used, which is open to debate.

PRACTICAL IMPLICATIONS

Wards that met appropriate staffing indicators prove the method's feasibility. Wards that did not meet appropriate staffing indicators prove the importance and the need for process evaluations and monitoring. Methods presented for monitoring daily staffing appropriateness are simple to implement either for intra-ward day-to-day variation by using nurse workload capacity statistical process control charts or for inter-ward evaluation using standardized measure of nurse workload intensity. The real challenge will be to develop planning systems and implement corrective interventions such as dynamic and flexible daily staffing, which will face difficulties and barriers.

ORIGINALITY/VALUE

The paper fulfils the need for workforce utilization evaluation. A simple method using available data for daily staffing appropriateness evaluation, which is easy to implement and operate, is presented. The statistical process control method enables intra-ward evaluation, while standardization by converting crude into relative measures enables inter-ward analysis. The staffing indicator definitions enable performance evaluation. This original study uses statistical process control to develop simple standardization methods and applies straightforward statistical tools. This method is not limited to crude measures, rather it uses weighted workload measures such as nursing acuity or weighted nurse level (i.e. grade/band).

The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis

OBJECTIVE

To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals.

STUDY SELECTION

Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol.

DATA SYNTHESIS

Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86).

CONCLUSIONS

Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.

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.