Methodological integrative review of the work sampling technique used in nursing workload research

Barriers and enablers to embedding fundamental nursing care for older patients-Implications of a mixed methods study for nursing leadership

AIMS

To understand the enablers and barriers for delivering fundamental care to hospitalized older patients.

DESIGN

Explanatory sequential mixed methods design, with qualitative data used to elaborate quantitative results.

METHODS

Set in one medical and one surgical unit of a tertiary hospital in southeast Queensland, Australia. Observations of nursing practice using the Work Sampling Technique were conducted over two 2-week periods in 2019. Data were analyzed and presented to groups of nurses who appraised the findings of the observations.

RESULTS

There were 1176 and 1278 observations of care in the medical unit over two time periods and 1380 and 1398 observations over the same period in the surgical unit. Fundamental care activities were recorded in approximately 26% (i.e. medical) and 22% (i.e. surgical) of all observations. Indirect care was highest, recorded in 41% (i.e. medical) and 43% (i.e. surgical) of observations. Nurses prioritized the completion of reportable activities, which is perceived as a potential enabler of fundamental care. Potential barriers to fundamental care included frequent delays in indirect care and difficulty balancing care requirements across a group of patients when patients have high fundamental care needs.

CONCLUSION

The cultural acceptance of missed nursing care has the potential to erode public confidence in health systems, where assistance with fundamental care is expected. Relational styles of nurse leadership should focus on: (1) making fundamental care important work in the nurses' scope thereby offering an opportunity for organizational change, (2) promoting education, demonstrating the serious implications of missed fundamental care for older patients and (3) investigating work interruptions.

IMPACT

Fundamental care is necessary to arrest the risk of functional decline and associated hospital-acquired complications in older patients. However, nurses commonly report fundamental care as missed or omitted care. Understanding the challenges of implementing fundamental care can assist in the development of nurse leadership strategies to improve older patients' care. Fundamental care was observed between 22% (i.e. surgical) and 26% (i.e. medical) of all observations. Nurses explained that they were focused on prioritizing and completing reported activities, experienced frequent delays when delivering indirect care and found balancing care requirements across groups of patients more challenging when patients had fundamental care needs. Clinical nurses working in acute health services with increasing populations of older patients can lead improvements to fundamental care provision through relational leadership styles to demonstrate how this work is in nurses' scope of practice, promote education about the serious implications of missed fundamental care and investigate the root cause of work interruptions.

A systematic review of activities undertaken by the unregulated Nursing Assistant

AIM

To identify activities performed by Nursing Assistants in acute and primary healthcare.

DESIGN

Systematic review.

DATA SOURCES

The databases MedLine/PubMed, ProQuest and Google Scholar were searched for empirical studies published in the English language between 2008 and 2018 that addressed the work of Nursing Assistants.

REVIEW METHODS

From an initial yield of 2,944 publications, 71 publications were retained for full text review and 20 publications included in this review. Activities undertaken by Nursing Assistants from eight countries were extracted and categorized into one of six categories.

RESULTS

Over 200 activities were identified as being delegated to Nurse Assistants globally. Many of these activities are beyond the training of the Nurse Assistant and are being performed with limited Registered Nurse supervision.

CONCLUSION

Patient safety is at risk. Nurse Assistants' roles vary widely, with some seeing their role as similar to that of a regulated nurse, while recognizing their need for additional training.

IMPACT

Over 31% of activities delegated to Nurse Assistants require skill and comprehension beyond their level of training. Patients and regulated nurses need to have confidence that Nursing Assistants responsible for care provision are appropriately trained and practicing within regulatory standards.

How much time do nurses spend using electronic devices at work?

Results of the Patient Care and Tracking Increasing Electronics in Nurses' Use of Time (PATIENT) study.

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.

Methods used to examine technology in relation to the quality of nursing work in acute care: A systematic integrative review

AIMS AND OBJECTIVES

To systematically locate, assess and synthesise research to describe methods used to examine technology in relation to the quality of nursing work in acute care. Specific objectives were to (a) describe the types of nursing work examined; (b) describe methods used to examine technology in nursing work; (c) identify outcomes used to evaluate technology in relation to the quality of nursing work; and (d) make recommendations for future research.

BACKGROUND

New technologies can offer numerous benefits to nurses; however, it is challenging to evaluate health information technologies in relation to the quality of nurses' complex day-to-day work.

DESIGN

A systematic integrative review using a five-step process.

METHODS

Five databases were searched using search terms "nurs*," "workload," "task," "time." Data screening, extraction and interpretation were conducted independently by at least two authors and agreement verified by discussion. Data extraction followed PRISMA guidelines.

RESULTS

Of the 41 studies included, most (87.8%, n = 36) examined physical dimensions of nursing work; 31.7% (n = 13) organisational dimensions; 17.1% (n = 8) cognitive dimensions; and only 12.2% (n = 5) emotional dimensions. More than half (58.5%, n = 24) examined only one dimension; one captured all four dimensions. Most frequently examined technologies were electronic medical/health records (36.5%) and electronic medication management (19.5%). Direct observation (58.8%, n = 28) and multiple methods (19.5%, n = 8) were the most common methods; nurse tasks, frequency, duration and time distribution were variables most often measured.

CONCLUSIONS

Examinations of technology in nursing work often failed to capture the multiple dimensions of this work nor did they recognise the complexity of day-to-day nursing work in acute care. There is a paucity of literature to inform how and what technology should be measured in relation to the quality of nursing care.

RELEVANCE TO CLINICAL PRACTICE

The outcomes inform useful research methods to comprehensively examine technology to enhance the quality of complex nursing work.

Development of an accurate nursing program based on function in chronic venous leg ulcers: protocol for matching function status with nursing interventions using the Delphi survey

Objective

Venous leg ulceration (VLU) is one of the complications of lower extremity venous reflux and reflux disorder of severe diseases, with many adverse effects on patient’s work and life. Nowadays, more and more patients with VLU accept wound care in community setting. Clinical nurses generally take care of the patients based on their own experiences. Healing in VLU is an incredibly complex process, which puzzles even experts. The majority of general nurses do not have this level of expertise, especially those nurses serving in community. Function is the basis of nursing activities. Patients always show different clinical manifestations and self-care abilities due to various function states, which cannot be reflected completely by the existing nursing practice. How to describe nursing practice standardized in order to demonstrate the effectiveness of interventions and facilitate interdisciplinary communication is another urgent problem. Therefore, the aim of this project is to develop an accurate nursing program based on function in chronic venous leg ulcers, which can both satisfy the needs of patients and promote nursing revolution.

Methods

This study will use International Classification of Functioning Disability and Health as a framework to choose suitable functions and to filter function classification standards of chronic venous leg ulcers through evidence-based systematic research. Nursing interventions related to VLU are selected based on Nursing Interventions Classification, adding other nursing activities by methods of evidence-based systematic review and clinical observation. Then, nursing interventions and function status are matched through steering committee. Finally, the Delphi survey method is adopted to make nursing program native and scientific.

Conclusions

This study is expected to be very significant and meaningful in using standardized nursing terminology. The nursing program established could better meet the needs of both patients with chronic venous leg ulcers and clinical nurses, promoting the development of wound specialist and standardized nursing language.

NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis

Background

Policy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings.

Objectives

The review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’.

Design

A realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing.

Participants

NHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory.

Results

Workforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose.

Limitations

The evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public.

Conclusions and recommendations

The synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory.

Study registration

This study is registered as PROSPERO CRD42016038132.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Clinical staff work sampling in a neurorehabilitation hospital and its relationship to severity of disease

Aim

Study aimed to analyse how rehabilitation staff spends working time on specific activities in a neurorehabilitation hospital and to determine the number of direct activities received by patients with different levels of disease severity.

Background

Few studies have investigated how clinical staff spends their time on activities in rehabilitation hospitals without considering at the same time all working categories and without reporting the number of direct activities received by patients with respect to their disease severity.

Design

Self‐reported observational study.

Method

Work Sampling Technique was used to record direct, indirect, unit‐related and personal activities every 5 min for 2 days.

Results

Total of 6,974 activities were recorded over 581 working hours. Physiotherapists and nurses spent 75.2% and 54.8% of their time in direct activities and medical doctors only 25.4%. Total time of direct activities was significantly different among worker categories (p = 0.001) and depended on patients’ disease severity (p = 0.020) in a different manner among worker categories (interaction: p = 0.010). This time ranged from almost 4 hr up to 6½ hr for the most severely affected patients.

Conclusion

Type of work differed among professionals. Workload greatly depended on degree of patients’ disability.

Implications for Nursing Management

Nurses and therapists spent most of their time in direct activities with patients. Economic burden of neurorehabilitation may vary greatly depending on disease severity.

Work-Time Distribution of Physicians at a German University Hospital

BACKGROUND

The effective utilization of staff resources is of decisive importance for the adequate, appropriate, and economical delivery of hospital services. The goal of this study was to determine the distribution of working time among doctors in a German university hospital-in particular, in terms of type of activities and time of day.

METHODS

The distribution of working time was determined from 14-day samples taken in seven clinical departments of the Medical Center-University of Freiburg. In each 14-day sample, the activities being carried out at multiple, randomly chosen times were recorded.

RESULTS

A total of 250 doctors (participation rate: 83%) took part in the study. A total of 20 715 hours of working time was analyzed, representing twelve years of full-time employment. Overall, 46% of working time in the inpatient sector was spent in direct contact with patients, with relevant differences among the participating clinical departments: for instance, the percentage of time taken up by patient contact was 35% in pediatrics and 60% in oral and maxillofacial surgery. Patient contact was highest (over 50% overall) in the period 8 a.m. to 12 noon.

CONCLUSION

The amount of working time taken up by activities other than direct patient contact was found to be lower than in previous studies. It remains unclear what distribution of working time is best for patient care and whether it would be possible or desirable to increase the time that doctors spend in direct contact with patients.

Nursing Administration Research Priorities: Findings From a Delphi Study

OBJECTIVE

The aim of this study is to determine the priorities for nursing administration research (NAR) in the United States.

BACKGROUND

Previously known as the Council of Graduate Educators in Administrative Nursing, CGEAN provides an avenue for researchers and educators focused on NAR to partner, dialogue, obtain funding resources, and present their findings at a biennial International Nursing Administration Research Conference (INARC). In late 2013, with a goal of building consensus, CGEAN convened an INARC postconference to initiate the process of establishing critical NAR priorities for the future.

METHODS

Data from a 3-staged Delphi study were used to identify relevant research topics and determine administrative research priorities.

RESULTS

Eight final categories of NAR were determined.

CONCLUSIONS

This study found economic valuing of nursing and designing effective future healthcare delivery systems to be high priorities for NAR.

Managers' use of nursing workforce planning and deployment technologies: protocol for a realist synthesis of implementation and impact

INTRODUCTION

Nursing staffing levels in hospitals appear to be associated with improved patient outcomes. National guidance indicates that the triangulation of information from workforce planning and deployment technologies (WPTs; eg, the Safer Nursing Care Tool) and 'local knowledge' is important for managers to achieve appropriate staffing levels for better patient outcomes. Although WPTs provide managers with predictive information about future staffing requirements, ensuring patient safety and quality care also requires the consideration of information from other sources in real time. Yet little attention has been given to how to support managers to implement WPTs in practice. Given this lack of understanding, this evidence synthesis is designed to address the research question: managers' use of WPTs and their impacts on nurse staffing and patient care: what works, for whom, how and in what circumstances?

METHODS AND ANALYSIS

To explain how WPTs may work and in what contexts, we will conduct a realist evidence synthesis through sourcing relevant evidence, and consulting with stakeholders about the impacts of WPTs on health and relevant public service fields. The review will be in 4 phases over 18 months. Phase 1: we will construct an initial theoretical framework that provides plausible explanations of what works about WPTs. Phase 2: evidence retrieval, review and synthesis guided by the theoretical framework; phase 3: testing and refining of programme theories, to determine their relevance; phase 4: formulating actionable recommendations about how WPTs should be implemented in clinical practice.

ETHICS AND DISSEMINATION

Ethical approval has been gained from the study's institutional sponsors. Ethical review from the National Health Service (NHS) is not required; however research and development permissions will be obtained. Findings will be disseminated through stakeholder engagement and knowledge mobilisation activities. The synthesis will develop an explanatory programme theory of the implementation and impact of nursing WPTs, and practical guidance for nurse managers.

TRIAL REGISTRATION NUMBER

CRD42016038132.