ASSESS USE, COMPLIANCE AND EFFICACY NURSING WORKLOAD MEASUREMENT TOOLS

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1 PROPOSITION À L APPUI DUPLAN STRATÉGIQUE DE MISE EN ŒUVRE DES RECOMMANDATIONS DU COMITÉ CONSULTATIF CANADIEN SUR LES SOINS INFIRMIERS COLLABORATEURS ACADEMY OF CHIEF EXECUTIVE NURSES ASSOCIATION CANADIENNE DES ÉCOLES DE SCIENCES INFIRMIÈRES FÉDÉRATIO N CANADIENNE DES SYNDICATS D INFIRMIÈRES ET D INFIRMIERS ASSOCIATION CANADIENNE DES SOINS DE SANTÉ ASSOCIATION DES INFIRMIÈRES ET INFIRMIERS DU CANADA ASSOCIATION DES INFIRMIÈRES ET INFIRMIERS AUXILIAIRES DU CANADA ASSOCIATION DES INFIRMIÈRES ET INFIRMIERS PSYCHIATRIQUES DU CANADA WORKFORCE MANAGEMENT OBJECTIVE A ASSESS USE, COMPLIANCE AND EFFICACY NURSING WORKLOAD MEASUREMENT TOOLS Authors: Fran Hadley Kathleen Graham Mary Flannery THE RECOMMENDATIONS CONTAINED IN THIS REPORT ARE THOSE OF THE AUTHORS AND DO NOT NECESSARILY REFLECT THOSE OF THE COLLABORATING ORGANIZATIONS OR THE PROJECT STEERING COMMITTEE. 31 March 2004 Page 1

2 Copyright 2005 Canadian Nurses Association Canadian Nurses Association 50 Driveway Ottawa, Ontario, Canada K2P 1E2 31 March 2004 Page 2

3 EXECUTIVE SUMMARY The Canadian Nursing Advisory Committee, (CNAC) report Our Health, Our Future: Creating Quality Workplaces for Canadian Nurses, listed recommendations to create healthy workplace environments for nurses. To address selected recommendations, a collaborative working group funded through Health Canada, directed a number of projects including the Nursing Workload Measurement system (WMS) project. Nursing workload is defined as the amount of care allocated to patients based on an assessment of their nursing needs and the care they require. WMS tools provide a system for collecting the specifics of each patient s care needs and the standard times required to complete the care in relation to the available staff time. Data generated by WMS provide managers and clinicians with information to support decision-making. The project objectives were to assess utilization, compliance, and efficacy of WMS tools for registered nurses, (RNs), licensed/registered practical nurses, (LPNs) and registered psychiatric nurses, (RPsychNs) across hospital and community health care settings, and to identify elements of effective WMS tools for nurses. A pan-canadian approach was selected to compile this Workload Measurement System tool (WMS) report. The research methods included an extensive literature search and review, key informant interviews, a web-based survey of front line staff and managers and focus groups with front line staff. Findings from the survey, focus groups and key informant interviews were consistent with the information gathered through the literature review. Participants repeatedly reported dissatisfaction with WMS tools and believe that the current WMS tools are outdated and do not reflect: changes in hospital-based health care, care needs of the evolving patient profile, the increased proportion of higher acuity in in-patients, and adequate tracking and measures of complexity, multi-tasking, and staff-mix elements of the nurses work environment. From the assessment of utilization of WMS tools, the conclusions are as follows. WMS tools were mainly used in the acute care hospital sector with the greatest concentration in teaching hospitals. Limited initial and on-going orientation negatively impacted understanding and use of the tool. Licensed Practical Nurses reported not using WMS tools but expressed a desire to actively participate and be involved in the input of their own data. From the assessment of compliance of WMS tools, the conclusions are as follows. 31 March 2004 Page 3

4 The single strongest reoccurring theme was inadequate time or no time to complete the tool. There is strong support for online recording of WMS data from electronic records in real time at the point of care. Critical that WMS tools be integrated into nurses usual work (assessment/planning/interventions/diagnostics/evaluation). The lack of technology and the costs of acquiring hardware and software and providing training were seen as significant barriers. Nurses not involved in the development of the WMS tools were less compliant, had no ownership of the tool and did not feel it reflected their practice. Greater levels of orientation and ongoing support yielded greater understanding of the specific tool, the purpose and potential benefits of WMS. Nurses were less likely to comply with accurate recording of data and more likely to manipulate the data to their advantage if they had had negative experiences (especially true where WMS data had been used to reduce staffing or where the nature of the tools and their organizations was punitive). The perceptions of managers and staff may vary and suggest the need for further study. The variation may be a function of their experience with and use of WMS. Managers may overestimate compliance, validity and reliability of the results. Staff information suggests that there may be significant issues with completion (time, access to computers, understanding and inclination to select particular scores or values). From the assessment of the efficacy of WMS tools, the conclusions are as follows. Efficacy was the least well understood and discussed element. Most respondents understood that the purpose of a WMS tool is for mandatory reporting and for staffing decisions. They were unable to provide examples where the tool was used to support staffing decisions, other than examples of staffing reductions and efficiencies that were not perceived to enhance care or quality of work life. Misunderstanding was common related to concepts such as validity and reliability, sampling, distribution and probability. There was limited discussion and understanding of WMS tools. A lack of clear language and commonly accepted definitions was identified as a barrier. No benefit was identified for patient care or staffing but there was a belief that if the tool was to be effective it must be unit-specific. All groups reported greater acceptance with retrospective tools than with prospective tools. While some recognized the limitations with documenting assessments and tasks that were done versus what should have been done, retrospective WMS tools were clearly preferred. 31 March 2004 Page 4

5 Front line nurses did not see the report(s) or identify any subsequent results or consequences. First level managers said they did not see meaningful reports and that the information seldom resulted in needed staffing additions. The critical elements of an effective WMS tool as identified in the findings of this project are clustered in two main areas. Human Resource Elements, including: Adequate initial and on-going orientation; Adequate scheduled time to complete the tool; Include all nurses (RN, RPsychN, LPN); Prompt, easily understood summaries and reports shared with staff; Clear, timely responses to results (staffing adjusted); Support for dedicated staff and education resources for chart development/updating/validation; and Include all elements of clinical nursing practice (not just tasks). Information Technology Elements, which include: Adequate access to computers; Recording and reporting in real time; Reporting at point of care (e.g., personal digital assistant); Electronic (e-health Record with an imbedded WMS tool); and Resource support for computer use (e.g., replace keyboards with touch screens, timely resolution of technical problems, etc.). 31 March 2004 Page 5

6 TABLE OF CONTENTS WORKFORCE MANAGEMENT OBJECTIVE A... 1 EXECUTIVE SUMMARY... 3 TABLE OF CONTENTS INTRODUCTION APPROACH AND METHODOLOGY CONSTRAINTS OR LIMITATIONS SUMMARY OF FINDINGS ANALYSIS CONCLUSIONS RECOMMENDATIONS APPENDIX A - LITERATURE REVIEW APPENDIX B WEB-BASED SURVEY DEMOGRAPHIC AND SURVEY QUESTIONS APPENDIX C WEB-BASED SURVEY NOTICE OF INTENT, INTRODUCTORY LETTER APPENDIX E WEB-BASED SURVEY DATA TOOLS APPENDIX F FOCUS GROUP DATA TABLE APPENDIX G ABBREVIATIONS APPENDIX H BIBLIOGRAPHY March 2004 Page 6

7 1 Introduction 1.1 Context Financial constraints, nursing workload/overload, accountability, clinical decision-making and reporting are driving the need to address workload measurement issues in the Canadian nursing workforce. Nursing workload is defined as the amount of care allocated to patients based on an assessment of their nursing needs and the care they require. Workload Measurement System (WMS) tools help collect the specifics of each patient s care needs and the standard times required to complete the care in relation to the available staff time. Data generated by WMS provide managers and clinicians with information to support decision-making. Automated clinical- decision support is still evolving; most Canadian health care organizations do not use computer-based WMS. The Steering Committee selected a mixed method of online survey, focus group and key informant strategies for this project. Nurse managers and front-line nurses across hospital and community health care settings were the target groups for information-gathering activities. Nurses and students in all areas of practice (clinical, education, management and research) across the country were invited to participate in various activities. Results of the literature review, surveys, focus groups and data analysis are reported in this document on nursing WMS tools. 1.2 Project Objective As Project Manager for this collaborative study, the Canadian Nurses Association contracted Hadley Health Administration Services Ltd. (HHAS) to undertake the Workload Measurement System (WMS) tool project. The project goal was to assess use, compliance and efficacy of WMS tools for registered nurses (RNs), licensed/registered practical nurses (LPNs) and registered psychiatric nurses (RPNs) across hospital and community health care settings. 1.3 Definitions Workload Measurement System Tools A nursing Workload Measurement System (WMS) tool determines, validates and monitors individual patient-care needs over time. WMS tools provide a system for collecting specific data about each patient s needs and the standard times required to complete the care. The tool helps nurse managers decide where to allocate nurses Health Care Providers: RN/LPN/RPN Nursing includes three regulated occupational groups that work in a variety of roles and organizations across the continuum of health services. In this report, the following 31 March 2004 Page 7

8 abbreviated definitions are used to describe these nursing groups, as well as to define nurse managers: RNs are licensed/registered nurses who practise within their province or territory. An RN uses the nursing process of assessment, diagnosis, planning, implementation and evaluation to serve persons of all ages and at varying levels of illness or wellness. They practise in a variety of settings, including hospitals, long-term care facilities, the community, etc. (CNA - LPNs, known as registered practical nurses in Ontario, are licensed/registered practical nurses who assess and treat health conditions, promote health, prevent illness, and help individuals, families and groups achieve an optimal state of health. (CPNA, RPNs are licensed/registered psychiatric nurses who are regulated as a distinct category in British Columbia, Alberta, Saskatchewan and Manitoba. RPNs use a holistic approach to provide psychiatric nursing services to individuals, groups, families and communities whose primary care needs are related to mental and developmental health. (RPNC - ) For this survey, nurse managers are nurses in a first-level administrative position who manage staff providing direct nursing care. 2 APPROACH AND METHODOLOGY 2.1 Approach Using an inclusive, pan-canadian approach, the study sought input from all three regulated occupational groups of nurses RNs, LPNs and RPNs who were in staff nurse and nurse manager positions, as well as from key informant nursing leaders. Research included an extensive literature search and review, interviews, a web-based survey and focus groups. In collaboration with the Canadian Nursing Informatics Association (CNIA) and others, and in keeping with the directions of the Steering Committee, the study addressed the following themes: existence of workload measurement tools; format of the tool (paper or electronic); nature of the tool (prospective or retrospective); easier ways to complete the tool; perceptions of tool s validity; date of tool s last update/revision; dissemination (internal and external) and use of workload measurement data; completion/compliance rate of the tool; how the data are used to support decision-making; 31 March 2004 Page 8

9 any other factors/information used to supplement workload management decisions; perceptions of the data s usefulness; and existence of and frequency of use of mechanisms to validate quality of data. 2.2 Methodology Literature Search and Review Method A literature search and review informed the survey, teleconference/interview and focus group activities. The body of literature related to health human resource is extensive; the most relevant 54 articles and reports were selected for in-depth review. The literature review sources of information included: Cumulative Index Nursing and Allied Health Literature (CINAHL) database; online resources; Medline, Medscape; and ehealth Resource Centre Database. Key words for searching included workload measurement systems, patient classification systems, WMS tools, managing nursing resources, vendors of WMS and nursing informatics. These references were reviewed to identify existing WMS tools, how data are used to support management decisions, data gaps and other relevant issues. Highlights of the review are presented in the Summary of Findings section and the full review of the literature is in Appendix A Key Informants Interview Method The Steering Committee, the project co-ordination team and the project consultants developed a list of possible key informants. Individuals were then selected from these sources, invited to participate and interviewed Survey Method Web-Based Workload Measurement Surveys for Nurse Managers and Front-Line Staff Two main groups of interest were identified for the survey, nurse managers and front-line registered nursing staff. Intended respondents included registered nurses (RNs), licensed practical nurses (LPNs) and registered psychiatric nurses (RPNs) from across the country in a wide variety of workplace settings. Recognizing the broad range of respondents, the survey was deliberately structured to evoke responses that were as inclusive and as clear as possible. The survey included issues related to demographics, as well as the key questions from the Steering Committee. The Steering Committee reviewed the survey, which was then translated and posted on a dedicated website. Given the web-based format and need to compile and summarize the data, the questionnaire featured predominantly forced choices with several options to add comments in free-text form (Appendix B - Demographics for Nurse Managers and Nurses and Survey Questions). An invitation to participate in the survey was mailed and sent via (Appendix C Notice of Intent and Invitation). The potential respondents were invited to participate through direct mail or through the communication network of their respective 31 March 2004 Page 9

10 association. The following associations were approached to disseminate the study information and invitation to participate: Academy of Chief Executive Nurses, Canadian Association of Schools of Nursing, Canadian Federation of Nurses Unions, Canadian Health Care Association, Canadian Nurses Association, Canadian Practical Nurses Association, Canadian Public Health Association and Registered Psychiatric Nurses of Canada. CNA hosted the website for all letters/surveys and compiled the survey data. To ensure optimal response rates, reminder letters and reminder s were issued one week after the initial invitation. Survey results were provided in summary tables. The electronic surveys were completed on a voluntary basis and respondents had the option to identify themselves. This approach created a convenience sample. The webbased survey response rate was more positive than expected and consequently, significantly more qualitative and quantitative data were collected than expected. Demographic information was collected for all participants (type of nursing registration, type of work setting and province) to describe the sample and to support analysis of results by selected demographic elements Focus Group Methods Focus groups held across the country between January and mid-march 2004 solicited qualitative feedback from front-line nurses. Generally, about six to eight people took part in each focus group, although some groups comprised individual interviews and up to 19 participants. To augment the robustness of the findings, the project consultants planned, implemented and reported on a greater number of focus groups than this assignment required. This increased the front-line staff results significantly. Preliminary information describing the context of the discussion, as well as a brief outline of the topics to be reviewed, was circulated in advance to the participants. Discussions were taped, transcribed and categorized by themes to capture the richness of participants comments. The focus groups included participants from all three regulated nursing occupational groups (RNs, LPNs and RPNs) and from across all health care sectors (hospitals, long-term care, community-based care, mental health, rehabilitation, etc.). The Atlantic, Central and Western regions were all represented. There were no focus groups for nurse managers. The focus group questions were based on key questions developed by the Steering Committee, as well as the literature review and questions in the electronic survey. These questions were constructed around the following areas: level of orientation to the tool, understanding of the tool and its purpose, rank/rate, the use and impact of information collected, quality of the data/information, methods used to fill in information, perceived difference in care practice and barriers to using the tool (Appendix D). To optimize efficiencies and to minimize nurse survey and focus group fatigue, the consultants piggybacked the focus group activity for this project onto other planned focus groups. This approach was acceptable as these two target groups shared homogeneous characteristics (from across Canada, three regulated nursing groups, broad section of health care sectors). The two studies were the WMS study and a national study on recruitment and retention in nursing. The participants expressed 31 March 2004 Page 10

11 satisfaction with this approach as it provided an opportunity to share their opinions on these timely topics. 3 CONSTRAINTS OR LIMITATIONS 3.1 Method Constraint Discussion findings from focus groups usually generate most of the questions for a survey. However, due to time constraints, focus groups and the survey ran at the same time. To minimize this constraint, the authors prepared questions by collecting and consolidating the key issues from the literature review, using discussions with key informants and drawing upon their own expertise. 3.2 Response Rate Constraint Focus group participants frequently stated they did not use a WMS. While numerous opportunities to discuss WMS were available, these participants were unable to speak to certain key questions. This gap in the focus groups was also evident in the nurses survey; 35 of the 72 respondents stated they did not have or use a WMS. Information about WMS use obtained through the literature review supports these findings. 3.3 Specific Population Segment Constraint The Steering Committee identified target response rates and specific pan-canadian demographics to be included in the survey and focus group results. Regrettably, representation from the francophone nursing sector was limited. While several specific focus groups for francophone nurses were scheduled, three were cancelled due to competing union priorities and/or insufficient attendance. Sixty-four nurses responded in French to the French-language web-based survey. Their responses were integrated into the data collection report. 3.4 Sample Constraints The web-based survey required some computer skills and access to Internet services. Responses were voluntary and based on mail solicitation. This created a convenience sample, which limited the external validity of the findings. While the total number of respondents exceeded Steering Committee targets, respondent characteristics such as province and type of workplace varied disproportionately. As a result, readers should be cautioned against generalizing the findings to the wider population of nurses across Canada. The same constraint applies to the focus group findings. 31 March 2004 Page 11

12 4 SUMMARY OF FINDINGS 4.1 Literature Review Key Findings As early as 1937, nursing leaders concluded that a system was needed to objectively determine the number of care hours required for each patient according to a given category. However, this proposed system did not include a process to determine staffing requirements. Almost 67 years later, we are still unable to consistently describe and predict patient care needs and nursing workload effort. In the 1950s, studies and investigations focussed on classifying patients according to medical needs and nursing care requirements. In the 1960s, social medicine continued to grow, forcing administrators to evaluate cost effectiveness. This led to renewed awareness of the need for a patient classification system. Throughout the 1970s, resources were scarce relative to increasing demands. Thus the demand for effective WMS tools became a priority. Three major issues hindered credible data collection: inability to capture high-level, cognitive portions of nursing work; impact of multi-tasking; and caregiver variability. In the 1980s, with the introduction of the Management Information System (MIS) Guidelines, hospitals established WMS committees, allocated resources and measured nursing resource intensity to predict nursing staff requirements. For the most part, the systems were paper-based and labour intensive. The information was predominantly used to limit staffing resources. Documented patterns of unmet patient-care needs were required before staffing increases would be addressed. In the early 1990s, nursing faced large-scale layoffs that resulted in increased workloads. Consequently, as reported staff shortages based on WMS often did not result in staffing increases, nurses became less enthusiastic about recording workload data. Overworked nurses found themselves in a vicious cycle. They lacked time to complete the documentation, which produced data that did not substantiate the qualitative anecdotal reports. They feared losing already insufficient resources if the documentation did not support the allocation. Compounding this situation was the reduction in dedicated resources to coordinate, monitor, and evaluate the data collection. This furthered the scepticism of staff and managers about the validity and ultimate fairness of WMS. The evolution of Patient Classification Systems (PCS) in the United States was initially similar to the development and implementation of WMS in Canada. In the 1980s, however, the introduction of managed care in the US began to transform the American health care system into a more business-focussed model. American health care organizations invested heavily in informatics and adopted new technologies to support and facilitate evidence-based decisions and support billings in a for-profit dominated delivery model. This resulted in American PCS/WMS that could monitor productivity, quality performance, staffing and compliance with regulatory agencies. In the last decade, senior Canadian stakeholders recognized the need for information and began to address required systems to support decision-making in all health care 31 March 2004 Page 12

13 environments. Momentum in all levels of Canadian government toward this goal is evident in the plethora of research literature describing an increasing level of Information and Communications Technologies (ICT) activity. The Federal/Provincial/Territorial Tactical Plan for a pan-canadian health infostructure is one example of how stakeholder groups tried to further the quality and sustainability of the Canadian health care system Existence of WMS and tools There is a clear difference in the focus of the Canadian and American literature on WMS. The mixed private and public funding arrangement for American health care demanded systems and tools to track resource use. In response, multiple informationgathering systems, including WMS, were developed. The momentum to meet this information need is reflected in the extensive volume of American literature reviewing WMS and tools. For its part, the Canadian literature from the early 1990s was prolific in WMS research and descriptions on new WMS tools. Fiscal constraints and health care restructuring in the second half of the 1990s in Canada limited the availability of resources; this negatively affected support for existing WMS tools, as well as for significant further development of WMS tools. Information on use of WMS and tools in Canada is limited; however, researchers in British Columbia reported on a tool used in conjunction with a WMS. An excellent example of a broad workload measurement tool, it measures the level of complexity, decision-making and clinical judgment required to meet patient-care needs and more accurately reflects nurses work. The tool, which objectively measures patient requirements, was designed to capture patient care requirements not identified by existing WMS (Fulton & Wilden, Victoria, BC 1998). The literature frequently comments on the gaps/limitations in current WMS. The third generation Patient Classification Systems (3PCS) prototype moved from examining multiple discrete nursing tasks to a holistic perspective that includes both empirical and intuitive knowledge. Terminology varies on the subject with the Americans using the term PCS where Canadians would use WMS (Malloch K. et al., 1999). A second documented set of limitations was the need for the tool to be specific to selected client groups. At the Rehabilitation Institute in Chicago, a prototype PCS assists with staffing decisions, monitors productivity, analyses trends, and supports the budgeting process. Sarnecki et al. report that the development of a specific classification instrument for patients undergoing rehabilitation and the resultant system have significantly enhanced the delivery of quality rehabilitative care (Sarnecki et al., 1998). In a long-term care facility, researchers evaluated the relationship between the GRASP WMS tool and the Resource Utilization Group Classification (RUGS III), both nursing workload projections tool. The findings suggested that nursing home managers could move to one standardized tool that measures self-care deficits and staffing resource needs (MDS and RUGS) (Adams- Wendling L., 2003). 31 March 2004 Page 13

14 4.1.2 Vendors There are numerous vendors of WMS tools. Of the 19 reviewed, seven were selected for their relevance to this project. Consumer and expert opinions were reviewed from a variety of sources, including Internet bulletin board/discussion groups. The vendors efforts reflect a keen awareness of the critical issues from the clinicians perspective. The tools are consistently portrayed in the vendors marketing material as adaptable to any setting and staff mix. Details of reviewed WMS products are located in Appendix A. 4.2 Key Informants Interview Findings The key informant group was comprised of administrators from across the country. Most were vice-presidents of community and teaching hospitals, while others were senior managers from regional health authorities including primary care. Four interviewees reported using GRASP and one used Medicus. Their input was consistent with both the literature and with what the staff and managers reported in the web-based survey. However, the breadth of the interviewees comments reflected a more strategic orientation. Their comments focussed more on the health care system as a whole, which reflected a senior management perspective. The current situation was succinctly summarized. The nurses working with the patients do not understand how WMS is used. Nor do nurses understand its relationship to their work and their resources. They see it as paperwork and not as a tool for them. But (they) see WMS as a tool used against them. Because of our history implementing WMS, they don t like it or trust that action will be taken to address WMS issues. This group of interviewees shared a historical perspective related to the changes in workload. They referred to the need to identify workload changes and measure all aspects. We keep saying acuity level is so much higher that higher levels of intervention are what is driving acuity. Technology has made our lives easier, improved technologies help the patient more, but technological advances that move less acute patient to out-patient and day-care treatments leave the more acute in hospital beds and these require more nursing hours. The current WMS tools are outdated and are not tracking the more complex care needs. The use and possible misuse of WMS was a concern. The WLM Tool can be used by the finance side of the table and it can be used against you, because it (WMS) doesn t really have any way of validating the targets e.g., after hours (coverage requirements for a) minimum number of staff in terms of safety and scheduling (limitations). They will say there is no interrelated reliability between and among the tools. The government would never want us to have a tool that we could all document, and compare and contrast and put information together. They wouldn t like the results (unmet needs, resource implications). 31 March 2004 Page 14

15 4.3 Survey Findings Survey Participant Profile A total of 301 nurses responded to the web-based survey. This convenience sample was comprised of 72 staff nurses and 229 nurse managers. Total responses per question varied since not all respondents answered all questions. Both actual values and percentages have been reported in many of the tables. Variations in total percentages are due to rounding errors. Given the sampling, data from nurse managers and front-line nurses are consolidated in the body of the report. Manager and front-line data are provided separately in full sets of data tables found in Appendix E Location by Province The largest response by province was from Alberta with 29 per cent of total respondents, followed by Ontario, British Columbia and New Brunswick. Figure Location by Province Area of Employment Province Total % Alberta 86 29% Ontario 73 24% British Columbia 36 12% New Brunswick 26 9% Nova Scotia 21 7% Manitoba 20 7% Saskatchewan 20 7% Newfoundland/Labrador 7 2% Territories 4 1% Prince Edward Island 4 1% Yukon 3 1% Quebec 1 0% Grand Total % Sixty-two percent of respondents identified their area of employment as either a teaching or community hospital. 31 March 2004 Page 15

16 Figure Area of Employment Area of Employment Total % Teaching Hospital % Community Hospital 57 19% Regional Health Authority 25 8% Long-Term Care 22 7% Home Care 16 5% Public Health 14 5% Community Health Centres 10 3% Mental Health 8 3% Other 6 2% Rehabilitation 3 1% Community Rehabilitation 3 1% Community Mental Health 3 1% Grand Total % Professional Designation The sample was comprised of registered nurses (97 per cent or 281), registered psychiatric nurses (three per cent or 8) and licensed practical nurses or registered practical nurses (one per cent or 2) Position Title Two-hundred-and-seventy respondents selected a position title. The top three responses comprised 67 per cent of all respondents: nurse managers (28 per cent), program managers (20 per cent) and patient-care managers (19 per cent). Staff nurses formed 16 per cent of the sample with team leaders and clinical nurse specialists adding six per cent and two per cent respectively to the total. 31 March 2004 Page 16

17 Figure Position Title Position Title Total % Clinical Nurse Specialist 6 2% Case Manager 36 13% Nurse Manager 76 28% Patient Care Manager 51 19% Program Manager 55 20% Staff Nurse 43 16% Team Leader 8 3% Grand Total % Years in Current Title Sixty-five percent of respondents had held their title for more than four years, 42 per cent for six years or more, and 23 per cent from four to six years. Twelve percent had held their title for less than one year. Figure Years in Current Title Age Years in Current Title Total % 6 plus % 4 to % 1 to % Less than % Grand Total % Sixty-nine per cent of respondents reported they were over 40 years old. Five per cent were 30 years old or younger. 31 March 2004 Page 17

18 Figure Age Age in Years Total % % % % % % % % % % Grand Total % 4.4 Survey Results Readers should be cautious about making any general conclusions. Due to limited sample size and convenience sampling, the statistical difference between subgroups of respondents those with and without WMS or managers and staff nurses could not be compared. The Canadian Nurses Association Highlights of 2002 Nursing Statistics provides a profile of the population of interest prepared by the Policy Health Division in September 2003 (Canadian Institute for Health Information (CIHI), Workforce Trends of Registered Nurses in Canada, 2002). The authors deliberately chose to retain incomplete questionnaires as a way to respect the time and effort of those who did participate, as well as to increase the response rate per question. Since not all respondents chose to answer all questions, the total number of responses per question varies. The complete results of the survey items in table form have been included for reference (Appendix E) Organizations with and without WMS One hundred and-sixty-six respondents (56.3 per cent) indicated they had a nursing workload measurement system while 129 (43.7 per cent) did not have a WMS. Of those with WMS, 62.7 per cent were employed in hospitals, 8.4 per cent in regional health authorities, 7.4 per cent in long-term care, and 5.4 per cent in home care. 31 March 2004 Page 18

19 Figure Organizations with and without WMS WMS Tool Yes No Teaching Hospital Community Hospital Regional Health Authority Long-Term Care 8 14 Home Care 6 10 Public Health 4 4 Community Health Centre 4 6 Mental Health 3 3 Other 3 11 Community Rehabilitation 2 1 Community Mental Health 1 2 Rehabilitation 0 3 Total by Yes / No Type of WMS Tools GRASP and QuadraMed/Medicus accounted for almost 70 per cent of the total. Slightly more tools were electronic (89 or 53.6 per cent) than paper-based (77 or 46.4 per cent). Most were retrospective in nature (87 or 53.7 per cent), while 24 per cent (39) were prospective and 22.2 per cent (36) were almost equally balanced between retrospective and prospective tools in their respective organizations. Figure Tool Type Tool Type Total % GRASP % QuadraMed/Medicus % In-House Tool % NISS % Other Commercial % PRN 1 0.6% Grand Total % 31 March 2004 Page 19

20 4.4.3 Areas Using WMS Tools Of the 160 respondents who answered the question about where the tools were used in their organizations, 52.5 per cent (84) indicated their organizations used the tool in most areas, 35 per cent (56) in all areas and 12.5 per cent (20) in some areas Validity and Reliability of WMS Of the 161 respondents who answered the question about how often they validated WMS, 44.1 per cent (71) reported doing so within the last year, 34.2 per cent (55) more than two years ago, and 21.7 per cent (35) in the past two years. Of the 162 respondents who answered the question about whether the tools were used in accordance with agency protocols, 58.6 per cent (95) said most of the time, 24.1 per cent (39) said all of the time and 17.3 per cent (28) said some of the time. Of the 165 respondents who answered the question about staff compliance with completing each tool, 46.7 per cent (77) called compliance good, 44.9 per cent (74) called it fair, while 8.5 per cent (14) called it poor. Of the 165 respondents who answered the question about the perceptions of the WMS validity, 42.4 per cent (70) said it was basically valid, 30.9 per cent (51) said it was somewhat valid, 15.8 per cent (26) said it was not valid and 10.9 per cent (18) said it was very valid. With the methodological limitations in the data identified, there may be an interesting difference in responses between managers and staff that is beyond the scope of this report. Future studies might ask about the perceptions of managers and staff with respect to staff compliance with following policy, completing the tool, and self-report of WMS validity. Given limitations of the sample, this report draws no conclusions about the responses between managers and staff WMS Use WMS reports are routinely provided in a variety of frequencies; respondents could select any of the options. The selections in descending order were: monthly (72 or 48.7 per cent), quarterly (33 or 22.3 per cent), daily (31 or 21 per cent) and weekly (12 or 8.1 per cent). Data from the WMS reports are routinely used to support a range of decisions. Again, respondents could select as many options as they wished. Both the manager and staff groups selected the same items in the same rank order. 31 March 2004 Page 20

21 Figure How Results Used WMS Support How Used Total % Meet Mandatory Requirements % Forecast Staffing % Analyse Benchmark % Compare And Adjust % Monitor And Adjust % Model Scenarios 7 5.0% Grand Total % Support to develop, audit, compile and consults on the tools and results were reported as generally sufficient by 39 per cent of the nurses (62), limited by 37.7 per cent (60) and not really available by 23.3 per cent of respondents (37). Almost 40 per cent (62 or 39.5) reported that inadequate resources were provided for software and hardware to support WMS, while 31.9 per cent (50) reported resources somewhat adequate and 28.7 per cent (45) reported adequate resources. There was a nearly equal split on responses related to dedicated resources for staff orientation and education on WMS. Figure Dedicated Resources Suggestions Dedicated Resources Total % Yes % Some % Not Really % Grand Total % An open-ended question invited respondents to suggest ways to make WMS tool completion easier. The themes from the suggestions are summarized in Table The additional comments are provided in A. Selected excerpts are provided in section March 2004 Page 21

22 Figure Suggestions Suggestions Electronic/have better computer access Manager and Nurse Frequency Staff Nurse Frequency Manager Frequency Real time online input No reports received 4 4 Clerical staff to input data Adjust for more mature staff, language barriers 1 1 Do retrospective only Standardize for typical patients to make completion easier Lack of time/time consuming/waste of time Useless no money to reduce workload. Everyone use same tool to make comparisons; include outpatients Figure A Other Comments Other Comments Favourable comments about having electronic point-of-care access Favourable staffing results with WMS Did standardize for typical patients and recommended (ER) Has helped situation Too task-focussed, no recognition of judgment Too specialized to be comparable e.g., maternity, ICU Frequency 4 managers 1 manager 1 manager 1 manager 1 staff 1 staff 2 managers Selected Excerpts The current reality reflecting a unit/departmental focus 31 March 2004 Page 22

23 Workload measurement is not a valuable tool for nurse managers or staff; changes in patient acuity/census fluctuate quicker than workload can be calculated, especially in emergency room. In small facilities, workload is shared by pulling from another area, and this often does not reflect in workload. If there is only one person in ER all night, what would that workload tell you for tomorrow? The competing priorities and tension of managers I perform the duties of the front-line management position of the [identifiers removed to protect anonymity] unit, and when we are short of staff, which is occurring with more and more regularity, especially in the rural sector, I am working as a staff nurse on the unit. This then leaves very little time to be a manager/leader or to do the duties of a manager/leader. When I speak with other nursing managers/nursing leaders, they have much the same story to tell. A visionary seeking balance Computerized system and program with Palm Pilots, so that the data collection is done as soon as the care/intervention is completed, and then the program does the necessary tabulations to create a report on a daily basis. Only this way will we have true measurements to help us improve. However, healthy work life is more than measurements. 4.5 Focus Group Findings For ease of reading, the following figures contain only pertinent data related to key areas of interest. A full set of data tables is found in Appendix F Focus Group Participant Profile Fifteen focus groups were conducted across Canada with RN, LPN and RPN groups representing all health care sectors (hospitals, long-term care, community-based care, mental health, rehabilitation, etc.). The 101 participants were comprised of 29 RNs, 55 LPNs, 16 RPNs and 1 with RN/RPN registration. Participants were asked to complete a profile sheet. The total responses per question varied since not all respondents answered all questions. Actual values and/or percentages were reported in many of the tables. Variations in total percentages are due to rounding errors Location by Region More than half of the participants (50) came from the Atlantic provinces followed by the western provinces (33) and central Canada (18). Findings from a number of planned focus groups could not be included as there was insufficient attendance and/or the invited participants had no experience with WMS tools. 31 March 2004 Page 23

24 Figure Participant Profile by Region Region Western Central Atlantic Totals Registered Nurse Licensed Ppractical Nurse Registered Ppsychiatric Nnurse Total Area of Employment Nurses from nine sectors of nursing work environments participated. The long-term care sector had the highest representation, comprising 27 per cent of all focus group participants. Twenty-one per cent were from teaching hospitals, 15 per cent from community hospitals and 13 per cent from regional health authorities. Seven per cent were from forensic/correctional institutional services, with the remaining 17 per cent equally distributed among community health/health centres, home care, rehabilitation, mental health, nursing station and other sectors. LPNs represented the largest proportion of participants. In the area of employment, 38 per cent of LPNs worked in long-term care. This percentage is similar to the Canada-wide statistics that report 36.4 per cent of LPNs work in long-term care/nursing homes. (CIHI, 2003) Figure Count of Setting Employed Employed as RN LPN RPN Grand Total Long-Term Care/Nursing Home Teaching Hospital Community Hospital Regional Health Authorities Forensic Services/Correctional Institution Community Health/Health Centre Home Care Mental Health Centre 3 3 Rehabilitation 3 3 Nursing Station March 2004 Page 24

25 Employed as RN LPN RPN Grand Total Other 2 2 Grand Total Employment Sector by Region The Atlantic provinces had the single largest group of participants, as well as the single largest group for one sector, representing 73 per cent of participants working in longterm care. The Western provinces represented 40 per cent of participants from the hospital sector. Representation for forensic service/correctional and mental health services was mainly in the western provinces (80 per cent); all were RPNs. Figure Employment Sector by Region Count of Region by Sector Western Central Atlantic Grand Total Long-term Care/Nursing Home Teaching Hospital District Regional Health Community Hospital Forensic Services/Correctional Ins Community Health/ Health Centre Home Care Rehabilitation 3 3 Mental Health Centre 3 3 Other Nursing Station 1 1 Grand Total Education Level LPNs had either a certificate (39) or diploma (16). Of the 29 RNs, 15 had either a diploma or certificate, five reported having a post-registered nurse diploma, five had undergraduate degrees in nursing, two were nurse practitioners and two had baccalaureates in science of mental health. In the final group, 17 RPNs reported having a general diploma. 31 March 2004 Page 25

26 Figure Count of Education Level Education Total Licensed/RPN Certificate 39 Licensed/RPN Diploma 16 RPN General Diploma 17 Registered Nurse Diploma 9 Certificates 6 Post-Registered Nurse Diploma 5 Bac. in Nursing 5 Nurse Practitioner 2 Bac. in Science of Mental Health 2 Grand Total Years of Nursing Experience Number of years employed in nursing ranged from one to 43 years. Fifty-five per cent of participants reported between 20 to 40-plus years of experience, 27 per cent reported 10 to 20 years, 13 per cent had five to 10 years and five per cent had five years or fewer. Figure Years of Nursing Experience Years of Nursing Count Years of Nursing Experience by Sector Nurses with one to 10 years of experience were found exclusively in the following sectors: long-term care (17 per cent), teaching hospitals (18 per cent), regional health authorities (40 per cent), community hospitals (23 per cent) and forensic services (14 per cent). Certain care sectors had a significant number of nurses in the 11 to 30 years of experience group. These sectors reported a larger proportion of nurses: long-term care (71 per cent), teaching hospitals (65 per cent), community health centres (67 per cent), regional health authorities (47 per cent) and community hospitals (38 per cent). Home care, rehabilitation, mental health centres and other had between per cent within the 31 to 40 years of experience group. The profile in the convenience sample may or may not reflect the profile of all nurses by sector. 31 March 2004 Page 26

27 Figure Years of Nursing Experience by Sector Years of Nursing Service Long-Term Care/Nursing Home Grand Total Teaching Hospital District Regional Health Community Hospital Forensic Services/ Correctional Institution Community Health / Health Centre Home Care Mental Health Centre Rehabilitation Nursing Station 1 1 Other Employment Status Seventy-six per cent (70) of participants who responded to the employment status question reported permanent full-time positions. Eighteen per cent (17) of participants were in permanent part-time positions and the rest (five per cent) were in casual and temporary part-time positions. 31 March 2004 Page 27

28 Figure Count by Employment Status Employment Status Total Permanent Full-time 70 Permanent Part-time 17 Term Part-time contract 1 Casual 4 Grand Total Focus Group Results Focus Group Results by Region For this report, individual comments were aggregated into statements that reflect the frequency and strengths of themes generated by participants. The focus group questions related to the following: orientation to the tool, understanding the tool, rating the tool, quality of data and barriers. For ease of review, the responses were aggregated into use, compliance and efficacy categories. The findings have been reported by region (West, Central and Atlantic). West (British Columbia, Saskatchewan, Manitoba RN/LPN/RPN) British Columbia: RPNs Use Believes the tool determines the appropriateness of the patient on the unit/determines acuity levels. Evaluates nurse s ability to assess new admissions. Supports budget decisions related to amount of supplies, staffing, staff mix, etc. Suggests managers use the tool to reduce staff positions or demonstrate they were not working hard enough. RPNs in two focus groups report they don t use a tool in their community/mental health settings. Compliance Feels use of the tool is futile, as the data are not used. Feels the tool is a burden; they were barely getting patient care completed. They most often make patient care a priority over paperwork. Tool is redundant; we are duplicating, unnecessary repetitive reporting. Managers need education on how to use it. We get no support. It s manual; we need an electronic way to enter data, but lack computers and physical space for computers. 31 March 2004 Page 28

29 Have to do it, so am doing it. Don t have enough time, do it quickly, whip through it as it means nothing, mimic what was checked off the previous day. In hospital, we input twice a shift and more frequently if it s a 12-hour shift. This is especially true if you have frail elderly patients with many changes during your shift. Efficacy Feel if they had a good tool 10 years ago, it would have identified the overall increases in caregiver workload. Difficult to assess the quality of the data, as we don t know where the information goes or its use. Quality is compromised because of insufficient orientation. Automated staffing tool that identifies need for staff, but replaces with the least expensive staff type leads to a poor staff mix. Saskatchewan: RNs Use Tool is the Nursing Information System Saskatchewan (NISS), which is used in hospital sectors (acute rural and urban) not in long-term care or community sectors. NISS needs updating. System was old and out of date, not user friendly, difficult to use by nurses who do not have computer and/or keyboarding skills. Believe the tool was used for patient assignments. They reported using the tool as a reminder and charted against it. Tool used for care planning. One rural hospital reported the tool was a legal part of the chart. Input divided between manual/automated. Keyboarding is a barrier, half done prospectively and the other retrospectively. Cannot comment on which is better as no results are evident. Compliance Useless tool, not being used as it should for staffing. Waste of time. Have filled it out for 10 years and nothing happens/no changes noted. Not specific to our patients in mental health sector, as items are missing that reflect what we do. Staff in surgery unit report that tool does not fit their changing patient profiles. More and more off-service (medicine) patients are admitted to their surgical unit. Limited compliance to complete forms because it is time consuming and subject to interpretation. This constraint caused inconsistent data collection. Don t know how data are used, as they don t see any related reports. No one fills them out properly or at all. No repercussions if you don t; managers encourage us to do it, but don t follow up/enforce. Takes away time from the patient. Efficacy 31 March 2004 Page 29

30 No quality data, as the forms are not completed accurately. Information related to staffing is not acted on. No consistency as tool is subject to interpretation. Saskatchewan: LPNs Use LPNs report use of tool in acute and rehabilitation hospital settings, but not throughout the hospital. Report only RNs input; done twice a day. Believe that the tool does not collect their workload data. Compliance State they are frustrated as staff mix information is not included and therefore related decisions are inaccurate. Access to computers is/will be a problem. Efficacy Do not see any changes because when the tool reports we need extra help, it doesn t happen. Believe there is rigid adherence to the old patterns of staffing. Also not flexible enough to provide extra staff when major changes in demand occur. Tool needs to be updated to reflect the current patient profile. Saskatchewan: RPNs Use RPNs from the hospital sector report NISS is used in their health region. However, only the RNs input the data and this is done at the end of the day. Data input is by hand, but they started the Saskatchewan Health Information Network. They report this will automate data, improving input. Compliance Frustrated because they believe the report of their workload is not included. Efficacy Never see reports so cannot assess if the tool leads to changes. Central: (Ontario/Quebec RN/LPN) Ontario/Quebec: RNs Use Hospitals were only sector using WMS tools (Medicus and an in-house tool). They understand the tool is used for staffing and budgeting. Some community health centres use an encounters -based system that records activity, but their tool did not incorporate a time element. Other sectors, including public health and long-term care, use a system that tracks activity. However, these systems do not meet the definition of a WMS tool. 31 March 2004 Page 30

31 Compliance Participants use a manual system, view the tool as a burden. They believe managers underestimate staffing needs because of incomplete information generated by the tool. They report non-compliance related to insufficient time to complete the tool. At one centre, where the tool was computerized, the staff had sufficient time to input the data. Lack of time to complete the tool and weak keyboarding skills to record the data were barriers. Accessibility of computers was problematic in a tertiary hospital, whereas in a community hospital they had dedicated computers for WMS tools. Insufficient orientation and ongoing training affect the ease of using the tool. Lack of automated definitions and classifications is a barrier. Efficacy Feel that managers responded to the information and would hire extra staff when warranted. Nurses who had used GRASP noted that the customized WMS tool did not include certain elements such as patient teaching and emotional support. Consequently, nurses felt these critical components of care were devalued. Lack of clear definitions and insufficient orientation with respect to WMS compromised quality of data. Insufficient resources preclude regular validity and reliability audits. Previously this group had benefited from WMS support resources; presently the participants report these resources are inadequate. Ontario: LPNs Use At times, participants used the term GRASP as a generic label to identify their WMS tools. They perceived the tool was used for staffing purposes. This group identified reliability and validity as a process of matching their work schedule and patient assignments to completed WMS forms. Compliance Suspected the tool was vulnerable to manipulation because they believe it is highly subjective. Retrospective input of the data was the usual. Half the group identified accessibility to computers as a problem. However, the entire group was comfortable using computers. Efficacy This group cannot comment on the quality of the data due to the lack of feedback or reports. As well, they could not identify changes that resulted from the WMS tool information. East: (New Brunswick, Nova Scotia RN/LPN) New Brunswick: LPNs in Acute Care 31 March 2004 Page 31

32 Use Only RNs directly input data into the GRASP WMS tool. Believe the tool is used for staffing and budgeting. Compliance The RN records the data with no input from the LPNs. Even though this group does not record data directly into the WMS tool, they believe that keyboard skills, computer access, and orientation could all be barriers. Insufficient time to complete the tool causes the RNs to input the data after the end of their shift. Efficacy Do not feel the tool is accurate as it does not record recurring tasks or additional time needed to care for confused patients. It neglects multi-tasking, an intrinsic part of nursing care. When it is determined that additional staff are required, managers most often hire additional RNs. The tool does not appear to support appropriate staff-mix decisions. Nova Scotia: RNs Use Only the hospital sector uses a WMS tool, and in this group s work environment, they use GRASP. Felt the tool attempted to apply science to measure the amount of nurses work and was focussed on staff requirements. Felt the data are used for accountability reports to the ministry. Some caregivers explained the charge nurse completed the WMS tool. Believe it could be used for staffing if the tool was unit-specific. Compliance While one centre helped develop the WMS tool, the majority had little or no input and therefore did not value the system. Only three of eight participants have access to a computer; location of the computer was also problematic. Felt that nurses are not typists and this is a barrier to complying with automated systems. Efficacy Strong feeling that when the tool is used prospectively, it is inaccurate because it is not updated throughout the shift. The tool does not have the ability to record the frequency of a given task. Tool is only used on weekdays, hence incomplete data compromise data quality. Believe that the tool needs frequent updating as unit services and patient careprofiles change. Nova Scotia: LPNs Use Only use WMS (GRASP ) in teaching hospitals. 31 March 2004 Page 32

33 Only RNs directly input data into the WMS tool. Believe that RNs dislike WMS tool and that managers use the data to support compensation rates for RNs. Believe the tool is used to track work hours needed for patient care. Compliance Lack of available computers would be a barrier if an electronic system were adopted. Reported that they do not see the information on their unit as only the charge nurse records data. Efficacy Felt that, regardless of WMS reports about numbers of staff needed, managers did not respond. Believe the tool is highly subjective, which leads to inconsistencies and inaccuracies. Feel data would be more reliable if all caregivers were inputting the data. 5 ANALYSIS 5.1 Analysis of Web-Based Survey Participants Organization Type by Province The table below lists all respondents to describe the distribution by organization and provincial/territorial location. In descending order, the largest numbers of respondents were: Ontario teaching hospitals, Alberta teaching hospitals, Ontario community hospitals, British Columbia teaching hospitals, Manitoba teaching hospitals, followed by a tie between New Brunswick teaching hospitals and Alberta community hospitals. 31 March 2004 Page 33

34 Figure Organization Type by Province Organization Type By Province AB BC MB NB NL NS NT ON PE QC SK YT Teaching Hospital Community Hospital Regional Health Authority Long-Term Care Home Care Public Health Community Health Centre Mental Health Other Community Rehabilitation Community Mental Health Rehabilitation Total by Province Analysis of Survey Results Total Org n The same caveats are offered as previously identified in Section 3 of this report for the survey results. Readers should be cautious about reaching any conclusions about statistical difference or generalizing the results. Due to limited sample size and convenience sampling, the authors could not calculate the statistical difference of results between subgroups of respondents e.g., those with and without WMS or by type of WMS tool. The Canadian Nurses Association Highlights of 2002 Nursing Statistics provides a profile of the population of interest and distributions of selected factors. The Policy Health Division prepared the report in September 2003 based on the 2002 CIHI report, Workforce Trend of Registered Nurses in Canada. The authors deliberately chose to retain incomplete questionnaires as a way to respect the time and effort of those who did participate, as well as to increase the response rate per question. Since not all respondents chose to answer all questions, the total number of responses per question varies Organizations with/without WMS by Province/Territory The results were tabulated to describe the existence of WMS by location (province/territory). In descending order, the highest percentage of respondents from 31 March 2004 Page 34

35 provinces with WMS was: Ontario (76.7 per cent), Alberta (69.8 per cent), New Brunswick (65.4 per cent), Saskatchewan (55 per cent) and Nova Scotia (52.4 per cent). Figure Organization With/Without WMS by Province Have WMS AB BC MB NB NL NS NT ON PE QC SK YT Total Yes No Total by Province WMS Data Uses and Type of WMS Tool Most commonly, the tool was used to meet mandatory reporting requirements; this held true for all types of tools. Tool and Uses Figure WMS Data Uses and Type of WMS Tool Analyse Benchmark Compare and Adjust Forecast Staffing Mandatory Requirement Model Scenarios Monitor and Adjust Total Tool Type Grasp Quadra Med In-House Tool NISS Other Commercia l PRN 1 1 Total Type of Use Perceived Validity of WMS Results and Compliance with Agency Protocols for Tool Completion The single largest group of respondents reported its WMS was basically valid (69 or 42.9 per cent). Those who reported their tools were basically valid also most frequently reported compliance with agency protocols for tool completion most of the time (43). The second largest group of respondents report described their WMS as somewhat valid (48 or 29.8 per cent), while 31 selected reported compliance with completion protocols most of the time. 31 March 2004 Page 35

36 Figure Perceived Validity/Results and Compliance Validity and Protocol Compliance All Time Most Time Some Time Total Results Validity % Validity Very Valid % Basically Valid % Somewhat Valid % Not Valid % Total Compliance % Compliance 23.60% 59.01% 17.39% Perceived Validity of WMS Results and Staff Compliance with Completing Each Tool/Chart The single largest group of respondents reported that WMS was basically valid (70 or 42.7 per cent). Those who reported their tools were basically valid also reported that staff compliance with completing each tool or chart was good (35) or fair (34). The second largest group of respondents reported that WMS was somewhat valid (50 or 30.5 per cent). Those who reported their tools were somewhat valid also reported that staff compliance with completing each tool or chart was fair (27), good (19), or poor (4). Figure Perceived Total Validity/Staff Compliance Validity and Completion Good Fair Poor Total Validity % Completion Very Valid % Basically Valid % Somewhat Valid % Not Valid % Total Compliance % Validity 46.34% 45.12% 8.54% 5.3 Focus Groups Analyses Focus Groups Analyses by Region Due to the nature of qualitative data collected during focus groups, descriptive analyses follows. For ease of reading, the analyses have been reported by region (West, Central 31 March 2004 Page 36

37 and Atlantic). The analysis is structured around the three nursing occupational groups and types of health care sectors. West (British Columbia, Saskatchewan, Manitoba RN/LPN/RPN) British Columbia: RPNs Representation in this group included participants from long-term care, acute hospitals and psychiatric facilities. However, only the hospital sector had adopted a WMS tool. General impressions Participants varied in their understanding of the tool and its intended purpose. Compliance is affected by their perception that using the tool is futile and an administrative burden that reduces time with patients. Feel they need feedback, need to be involved in planning, and implementing. Managers need to be educated about the process and to support staff in implementation and training. Schedule time in the workday to complete the tool. The efficacy of the tool was directly affected because of the frequently reported inadequate staff orientation and the inability to use the tool to identify mental health or off-service patient care needs accurately. Saskatchewan: RN/LPN/RPN The RNs use NISS (The Nursing Information System Saskatchewan). However, the WMS tool has not been updated in 20 years. While new staff receives eight hours of orientation, older staff had limited orientation varying from one hour to a half day; the sessions were informal and often provided by peers on the unit. Again, initial and ongoing orientation were limited key factors in the understanding and use of the tool. General impressions Would rather focus on patient care instead of completing more paperwork and would like to discard the tool. No value in the data; prospective/retrospective aspects are irrelevant. Do not think it influences their practice. Tool does not reflect patient care needs, hence the information generated is inaccurate, which compromises the efficacy. LPN and RPNs stated they give their information to the RN at the end of the shift as they are not permitted to input data into the tool. They believe it is used for staffing. However, when the tool reports that extra staff is required, the request is not addressed. This group expressed a desire to be included in recording WMS data. Central: (Ontario/Quebec RN/RPN) Ontario/Quebec: RNs Several health care sectors were represented in this focus group; only the hospital sector used a WMS tool, however. The non-hospital sectors had significantly different understanding of the purpose and function of WMS tools. General impressions Insufficient time to complete the tool in the manual format contrasted with the report by the nurses using an automated tool. This focus group overall was enthusiastic regarding improving the WMS tool and positive about its potential value. As well, participants indicated that management was supportive and there were dedicated budget resources to implement and improve the tool s usability. 31 March 2004 Page 37

38 Participants repeated the caution that insufficient orientation and resources to support the tool would compromise the accuracy and efficacy of the tool. Ontario: LPNs Ontario LPNs are unique compared to other practical nurses as they input data on their assigned patients. Similar to all focus groups, participants indicated orientation was limited, informal and that they learned the application from peers. General impressions Compared to other practical nurse groups, this group had a more positive attitude towards WMS tools and this is possibly due to their direct involvement. East: (New Brunswick, Nova Scotia RN/LPN) New Brunswick: LPNs in Acute Care LPNs do not input data into the tools; however, they expressed a desire to be included in using the WMS tool. General impressions This group perceived that insufficient time to record data during the shift would affect compliance. The WMS information needs to be integrated into existing documentation requirements. Nova Scotia: RNs This focus group had broad representation from all sectors. GRASP was identified as the WMS tool. Unfortunately, for community hospitals, the regionalization of services had resulted in discarding the WMS tool after many years of data collection. As in other areas, orientation was limited to a few hours and often was provided by peers informally. General impressions Believed that an electronic health record (EHR) would facilitate the collection of WMS data as a by-product of routine information collection. Reliability and validity tasks are completed regularly. Nonetheless, insufficient resources to respond to the information generated by the tool will compromise its efficacy. Nova Scotia: LPNs Although some focus group participants did not use a WMS tool, they were aware of it and its difficulties and wished to share this information. General impressions Most felt that an automated system would facilitate compliance. Possible use of personal digital assistant (PDA, e.g.,palm Pilot) technology to document events at point-of-care. Believe that ownership in the development would ensure tools are unit-specific, which they believe affects compliance and efficacy. 31 March 2004 Page 38

39 6 CONCLUSIONS Conclusions will be presented as a compilation of the literature review, survey and focus group findings and analyses. The respondents from the web-based survey were mainly nurse managers, mainly from acute care and almost all registered nurses. The focus groups were comprised of nurses only; the largest group was LPNs and the sector most represented was long-term care. Findings from the survey and focus groups were consistent with the information gathered through the literature review. The authors identified distinct trends during the assessment of use, compliance and efficacy of WMS tools used by the three occupational groups across hospital and community health care settings. Results of the survey and focus group were consistent with the themes and recommendations identified in the literature. Participants repeatedly reported dissatisfaction with WMS tools. They believe the current WMS tools are outdated and do not reflect the changes in hospital-based health care. Existing tools do not reflect care needs of the evolving patient profile. These new patient profiles result from changing demographics, improved technology and constrained fiscal resources that force reduced length-of-stay. Higher acuity in inpatients affects nurses workload. Existing WMS tools are not adequately tracking and measuring the complexity, multi-tasking, and staff-mix elements of the nurses work environment. 6.1 Assessment of use WMS tools as defined in this document were mainly used in the acute-care hospital sector with the greatest concentration in teaching hospitals. As identified in the literature, most nurses in the focus and survey groups were familiar with the uses of WMS tools. One theme identified consistently was that limited initial and ongoing orientation negatively affected understanding and use of the tool. LPNs frequently reported they were not using WMS tools. The LPN group expressed a desire to actively participate in the development of WMS tools and to be directly involved in the input of its own data. 6.2 Assessment of Compliance The strongest recurring theme was there was inadequate time or no time to complete use of the tool. There was strong support for online recording of WMS data from electronic records in real time at the point-of-care. It is critical that WMS tools be integrated into nurses usual work (assessment/planning/interventions/diagnostics/evaluation). Anything less is seen as needless duplication, more work, more bureaucracy, insensitivity to nurses workloads and ultimately a lack of respect for the nurses trying to care for their patients. More than one nurse described recording WMS as a waste of time that takes nurses away from the patients. The lack of technology and costs of acquiring hardware, software and training were seen as significant barriers. 31 March 2004 Page 39

40 Nurses who were not involved in the development of the WMS tools were less compliant as they had no ownership of the tool and did not feel it reflected their practice. Other factors that impact compliance included insufficient orientation and insufficient ongoing resources, including dedicated staff to support the tool. Greater levels of orientation and ongoing support yielded greater understanding of the specific tool, its purpose and potential benefits and can be attributed to improving compliance. Nurses were less likely to comply with accurate recording of data and more likely to manipulate the data to their advantage if they had had negative experiences. This was especially true where WMS data had been used to reduce staffing or where they felt the nature of the tools and their organizations was punitive. The perceptions of managers and staff may significantly vary as a function of their experience with and use of WMS. Managers may overestimate the compliance, validity and reliability of results since the staff information suggests significant issues may exist with completion (time, access to computers, understanding and inclination to select particular scores or values). 6.3 Assessment of Efficacy Efficacy (the power to produce an effect) was the area that was the least well understood and discussed. Most nurses understood a WMS tool was for mandatory reporting. They also identified a role for WMS in staffing decisions, but were often at a loss to provide actual examples where use of the tool information actually supported staffing decisions. Their examples were overwhelmingly focussed on staffing reductions and efficiencies that were not perceived to enhance care or quality of work life. Misconceptions around concepts such as validity and reliability further hindered efficacy. The conceptual challenge was itself further hindered by the lack of clear and commonly accepted language and definitions. Other concepts such as sampling, distribution and probability also limited discussion and understanding. Clearly, if a nurse does not understand or believe that the data fit a pre-selected distribution, then the nurse will not trust anything less than complete documentation as accurate. Many did not see any benefit to WMS for either patient care or staffing, but did believe the tool must be unitspecific to be effective. All groups reported greater acceptance with retrospective tools than with prospective tools. This may partly reflect the underlying mistrust and misunderstanding about the validity and reliability of the data. While some recognized the limitations in documenting assessments and tasks that were done (retrospective WMS) compared to what should have been done (prospective WMS), retrospective WMS was clearly preferred. An added element when assessing the tools effectiveness relates to observing outcomes. Most staff did not see the report(s) or identify any subsequent results or consequences. Many managers said they do not see meaningful reports and that the information seldom results in needed staffing additions. 6.4 Critical Elements in a WMS-tool The critical elements of an effective WMS tool are clustered into two main areas, human resources and information technology. Human Resource Elements 31 March 2004 Page 40

41 Adequate initial and ongoing orientation Adequate scheduled time to complete the tool Inclusion of all nurses (RN, RPN, LPN) Easily understood summaries and reports shared promptly with staff Clear, timely responses to results (staffing added) Support for dedicated staff and education resources for chart development/updating/validation Inclusion of all elements of clinical nursing practice (not just tasks) Information Technology Elements Adequate access to computers Recording and reporting in real time Reporting at point-of-care (e.g., PDA) Electronic (e-health Record with an imbedded WMS tool) Resource support for computer use (e.g., replace keyboards with touch screens, timely resolution of technical problems, etc.) 31 March 2004 Page 41

42 7 RECOMMENDATIONS 7.1 Key Findings The legacy of suspicion and mistrust surrounding WMS requires that future initiatives build a transparent process with results that staff will value. There are clear messages from the literature, focus groups and the survey respondents about the lack of time and supports to collect WMS data coupled with the perception about the lack of results for the effort involved. Clearly, nursing is demanding a much different approach if WMS tools are to succeed. The preceding section identified critical elements for successful WMS tools. Skipping or skimping on any of these elements will impede the ability of a WMS to accurately reflect patients needs, nurses care delivery and optimal resource distribution. 7.2 Recommendations This WMS tool study generated several recommendations based on findings from the literature review, the survey, the focus groups and interviews with key informants. The order of the recommendations is not intended to imply importance or priority Data, Information and Decision-Making Select and standardize data elements and data collection to permit valid comparisons and benchmarking ( Information Highway, minimum data sets). Software must match specifications for integration into the Information Highway. Create a clearinghouse to share the tools, information and network to support decision-makers. This clearinghouse might be national or international given the market and use of WMS in other countries. Investigate whether WMS could be sufficiently standardized and validated so that WMS can be included in formulas for case weights; obtain adequate resources. Create, pilot and disseminate decision-support models that address and evaluate changes in patient mix and staff mix. Critically evaluate and develop a generic business case to substantiate an investment of scarce resources (time, money, forgone opportunities) in the WMS to benefit the patients and nurses. Nurse leaders could use and adapt this business case to support both institution- and system-based decisions e.g., CIHI. Everyone needs a clear return on investment staff nurse, manager, hospital, administration, patient, funders and taxpayers. 31 March 2004 Page 42

43 7.2.2.Acceptance by Practitioners Develop comprehensive strategy to address negative past experiences with WMS and the notable gap in understanding the internal and external validity of the tools. This recommendation will hopefully influence critical reflection about the current preference for retrospective tools and the perceived need for highly specific unit-based tools. Investigate an interdisciplinary tool that captures the holistic aspect of patient-care needs. Ensure that WMS reports clear results and that appropriate resources are provided in response to results (funding to adjust staffing, adequately trained and resourced nurses, adequately trained and resourced administrators). Ensure human and IT resources for support (dedicated staff, tool orientation, computer skills training, ongoing monitoring, audits for reliability/validity and hardware and software). Ensure adoption of electronic solutions by addressing the possible aversion to computers through use of intuitive systems, training and support. Implement and sustain change. The plan must involve staff in all phases within organizations as part of the promotion and marketing strategies. The plan should include how to embed WMS into the organizational fabric so there is ongoing support and review. Develop tools that are sensitive to issues that nurses identify as affecting their workload: 1) patient frailty or acuity index, or a system that recognizes care differences between patient profiles; 2) nurse indexes sensitive to the aging work force, lack of equipment, staff mix issues, etc. 31 March 2004 Page 43

44 APPENDIX A - LITERATURE REVIEW Introduction This literature search investigates the utilization, compliance and efficacy of workload management tools for registered nurses (RNs), licensed practical nurses (LPNs), and registered psychiatric nurses (RPNs), across hospital and community health care settings. The review sources of information include: CINAHL database; on-line resources (CIHI, OHIH, HC, CNIA, CNA, NRU and others); Medline, Medscape; and ehealth Resource Centre Database. Key words for searching included workload measurement systems, patient classification systems, tools for WMS, managing nursing resources, vendors of WMS, and nursing informatics. These references were reviewed to identify existence of WMS tools, how data is used to support management decisions, data gaps and relevant issues. Financial constraints, nursing workload/overload, accountability, clinical decision making and reporting are some of the driving forces behind the need to address issues in the Canadian Nursing Workforce regarding workload measurement. Clinical decision support is still in the early stages of its evolution. While some Canadian health care organizations have implemented computer based WMS; the majority have low use of information and technology. The 2001 updated Tactical Plan of the Advisory Committee on Health Infostructure (ACHI) reflects a consensus achieved by federal, provincial and territorial jurisdictions on strategic first actions needed to implement the pan-canadian health infostructure. The MIS Guidelines are national reporting standards; however, only Ontario has mandated provincial reporting of nursing workload measurement. In the 2003 budget, the federal government allocated millions of new dollars to ICT-related initiatives. There is no shortage of vendors that can supply WMS tools with plug-in modules to address data collecting for performance analysis; staff planning tools; and integrated budget management tools. At issue for many organizations is the lack of technology infrastructure or infostructure to adequately implement computer-based WMSs. Another important issue is the need for dedicated human resources to implement, monitor and provide education resources for the WMS. The federal government has taken on a number of initiatives to address the development of a pan-canadian infostructure and is funding pilot projects to test predictive modelling for nursing human resources. This review of the literature while extensive is not all-inclusive as the subject matter is vast and relates to numerous human health care issues and delivery of service. One information gap noted in completing this review was access to information for some nursing web sites that limited entry to organization members. 31 March 2004 Confidential Page 44

45 Historical development of WMS Canadian Workload Measurement Systems In 1937, The National League of Nursing Education concluded that a system was needed to determine objectively the number of patient care hours required for each patient according to a given category. This did not, however, determine staffing requirement.. Almost 67 years later we are unable to consistently predict this beyond 24 hours. In 1947, the same organization attempted to group patients by severity of illness. The 1950s were a period of studies and investigations that focused on classifying patients according to medical needs and nursing care requirements. While many systems were attempted, they faded into oblivion. The 1960s were a time when social medicine increased. Administrators were obliged to evaluate cost effectiveness, which resulted in a resurgence of the need for a patient classification system. Doctors completed prototype evaluations and nurses used a multi-criterion list. Unfortunately, to reach an agreement between the two groups required nurses to reduce their list to physical care tasks. Emotional and psychosocial well being of the patients was not considered and this system became ineffective. Studies were done to determine the appropriate mix of RNs to LPNs and orderlies and aids were responsible for non-nursing tasks. Throughout the 1970s resources were scarce due to rising costs, which ultimately pushed some of the more expensive and less urgent health groups into outpatient settings and the private sector. While the balance between RNs and LPNs improved, administrators recognized that standard care hours based on census was not relevant. Thus the demand for an effective WMS became a priority. Consequently, a proliferation of studies ensued that resulted in numerous patient classification system (PCS) and WMSs. Many of these systems were adapted from industrial time and motion models. Three major issues hindered credible data collection: inability to capture high-level cognitive portions of nursing work, impact of multi-tasking, and care giver variability. The 1980s saw the introduction of the Management Information System (MIS) Guidelines, which provided a national framework to collect and record financial and statistical data. Resource Intensity Weights (RIW) measure expected resource use by patient grouping according to diagnosis called Case Mix Groups (CMG). Workload measurement is an essential component of the MIS Guidelines. Throughout the eighties hospitals established WMS committees, allocated resources (financial and human), and implemented systems to measure nursing resource intensity to predict nursing staff requirements. For the most part the systems were paper-based and labour intensive. In the early 1990s nursing was faced with large-scale layoffs that ultimately resulted in increased workloads. Consequently, nurses became less enthusiastic with recording workload data because reported staff shortages based on WMSs often did not result in staff increases. As well, there was a reduction in dedicated resources to coordinate, monitor, and evaluate the data collection. Computer technologies significantly impacted opportunities for advancement of information gathering, analysis and decision-making. In the second half of the nineties the information technologies revolution exploded providing tremendous opportunities for data collection and implementation of effective WMSs. However, there was a concurrent need for an analytical framework; government involvement to develop regulation and policies for use and distribution; as well as, government to provide implementation and ongoing funding. 31 March 2004 Confidential Page 45

46 Only Ontario has mandated provincial reporting of nursing workload measurement. The Joint Policy and Planning Committee, (JPPC) a partnership between the Ontario Hospital Association, (OHA) and the Ministry of Health, is responsible for coordinating the implementation of the MIS Guidelines in Ontario. In 1996 the Nursing Professional Advisory Working Group, (NPAWG) was established to advise on issues related to nursing data collection and reporting. Since 1997 the federal government has invested over 1.5 billion dollars in a variety of health care projects involving information and communication technology (ICT). In the 2003 budget, the federal government allocated millions of new dollars to ICT-related initiatives. Clinical decision support is still in the early stages of its evolution in Canada. Coupled with low use of information and technology generally by health care providers, there is still limited availability of clinical decision support tools. Where they are available, they are still not well integrated with professional practice. While there are recognized leaders in Canada promoting the use of clinical decision support tools there are gaps in the public policy required to support evidence-based care and accountability. (For more information visit: and search for Office of Health and Information Highway.) American Patient Classification Systems The evolution of PCS in the United States was similar to the experience in Canada until the 1980s. The introduction of managed care began to transform health care into a business. The federal implementation of diagnosis-related groups (DRGs) in 1983 dramatically affected management of inpatient services. Outpatient services began to increase, and accrediting organizations mandated patient classification systems. As well, the Joint Commission on Accreditation of Healthcare Organization, (JCAHO) utilized DRGs as a basis for funding and accreditation. Organizations invested heavily in technology and informatics. Numerous PCS were introduced to monitor productivity, quality staffing and to comply with regulatory agencies. For example, acute care hospitals in California are required by both the JCAHO and California Title 22 to have a reliable and valid patient classification. In May of 2003 Senator Daniel Inouye (D-Hawaii) introduction the Registered Nurse Safe Staffing Act of 2003, federal legislation that aims to ensure that patients receive safe, quality nursing care in hospitals and other health care institutions. The legislation mandates the development of staffing systems that require the input of direct-care RNs and provides whistle-blower protections for RNs who speak out about patient care issues. The advent of new technologies are leading to the development of PCS in which nurses carry a transponders, to record patient data while at the bed side. They are then able to transmit this data to workstations or access embedded system devices at the patients bedside, which can be tracked by software that produces real-time work activity charts. Definitions: RN, LPN, RPN Nursing includes three regulated occupational groups that work in a variety of roles and organizations across the continuum of health services. These include registered nurses (RN), licensed practical nurses (LPN), and registered psychiatric nurses (RPN). In 1999, there were 256,544 RNs (76%), an estimated 66,100 LPNs (22%), and 5,408 RPNs (2%). The delivery of nursing care is also supported by a number of unregulated workers such as nursing aides. [Canadian Institute for Health Information. Supply and Distribution of Registered Nurses in Canada, (2000), Ottawa, ON. 31 March 2004 Confidential Page 46

47 RN: A registered nurse is a nurse who is licensed or registered to practice within his/her province or territory. This requires that the nurse s practice is consistent with legislation, professional nursing standards and the code of ethics of the profession. Registered nursing practice requires the application of an appropriate conceptual model or models and utilizes the nursing process of assessment, diagnosis, planning, implementation and evaluation. A registered nurse may practice within the domains of clinical, research, administration, policy and education. Registered nurses provide services to individuals, families, communities and populations. They serve persons of all ages and at varying levels of illness or wellness. Registered nurses practise in a variety of settings including hospitals, outpost stations, clinics, homes, long term care facilities, community health centres, prisons, schools, workplaces, government, etc (CNA). LPN/RPracN: Licensed practical nurse (sometimes known as registered practical nurse); the practise of practical nursing is the provision of nursing services for the purpose of assessing and treating health conditions, promoting health, preventing illness, and assisting individuals, families and groups to achieve an optimal state of health. (CPNA, 2001, Licensed Practical Nurse Act in Manitoba). RPsychN: (Registered Psychiatric Nurse) Psychiatric nursing is regulated as a distinct profession in Canada in the provinces of Alberta, British Columbia, Manitoba and Saskatchewan. Registered Psychiatric Nurses use a holistic approach in providing psychiatric nursing services to individuals, groups, families and communities whose primary care needs are related to mental and developmental health. At the core of the practice of psychiatric nursing is the therapeutic relationship and a commitment to the promotion, restoration and maintenance of optimal health. RPsychNs focus on understanding the relationship between the physical, spiritual, cultural and psychosocial aspects of individuals. Interventions are planned, implemented and evaluated within the context of the therapeutic relationship. RPsychNs practise in a variety of settings and with various populations, including community mental health with children, adolescents or adults; in psychiatric units/hospitals; in psychogeriatric programs; in forensic units; and in crisis services (Registered Psychiatric Nurses of Canada). Nursing Informatics in Canada Nursing informatics organizations include: Canadian Institute for Health Information (CIHI), Canadian Nursing Informatics Association (CNIA) and Office of Health and Information Highway (OHIH) who hosted a national workshop for all funding recipients under the Canada Health Infostructure Partnerships Program (CHIPP). Other important contributors to nursing informatics include: Canadian Nurses Association (CNA) Canadian Nursing Advisory Committee (CNAC), Canadian Nurses Federation (CNFU), National Nursing Informatics Project (NNIP) and Ontario Nursing Informatics Group (ONIG). Health Infostructure Atlantic (HIA) Western Health Information Collaborative (WHIC). More than 15 federal funding initiatives/programs have been identified. These initiatives/programs in total have funded more than 153 ICT-related projects. The Health Infostructure Support Program (HISP), by sponsoring more than 35 projects, is the largest funding program in terms of the number of projects sponsored, and the Canadian Health Infostructure Initiative (CHI), which received more than $112,500,000 (between 1999 to 2002), is the largest in terms of the amount of money spent. Pan-Canadian Health Infostructure 31 March 2004 Confidential Page 47

48 The 2001 updated Tactical Plan of the Advisory Committee on Health Infostructure (ACHI) reflects a consensus achieved by federal, provincial and territorial jurisdictions on strategic first actions needed to implement the pan-canadian health infostructure. At federal, provincial and territorial levels, this has been translated into numerous health information and technology initiatives. Varying considerably in scope and size, these include local systems planning projects to ambitious pan-canadian initiatives aimed at addressing pressing information needs or introducing new technologies to improve service delivery. Many relevant information and technology initiatives are currently underway in Canada, both at a local and national level. Almost all federal, provincial and territorial governments across Canada have a strategic information systems initiative. HealthNet/BC, Alberta Wellnet, Saskatchewan Health Information Network, Manitoba Health Information Network, Smart Systems for Health, Inforoute Santé, Nova Scotia Telehealth Network and PEI's IslandNet are all examples of these initiatives. At the federal level, Health Canada has the Canadian Health Network, Network for Health Surveillance in Canada, First Nations and Inuit Health Information System (FNIHIS) and the HISP/CHIPP projects; Industry Canada and CANARIE support ehealth and network infrastructure, and together CIHI, Health Canada and Statistics Canada have the Health Information Roadmap initiative underway. Clinical Decision Support Data Analysis and Reporting The use of the health data holdings for analysis and reporting is a critical requirement. There are significant efforts in the different jurisdictions across Canada to use health data for identifying potential health risks, as well as for planning, research and evaluation purposes. Further, there has been a very focused and successful effort by CIHI to improve the reporting of health status and health system performance to the Canadian public. Apart from the limitations of the data currently available, the major gaps include data analysis and reporting for evidence based decision-making in clinical, public health, research and management settings, as well as for health system accountability. Human Resources Linked to the change management is the need to educate health human resources in the use of health information and technology. Canada suffers from a severe shortage of health informaticians to support clinicians and other users in the implementation of electronic health record and telehealth solutions. There are currently Health Informatics programs in some Canadian colleges and universities,but there is a serious lack of accessible health informatics programs for health professionals who are already in the workplace. Health Information: Nursing Components Information concerning aspects of nursing care that affect client outcomes must be included in existing and future databases on client-centred information. Although the information is available on the client's documents, none of the data are abstracted from the records and saved in a permanent database of health care information. There is no overall system in place, either nationally or provincially, to collect, retain and retrieve information which reflects nursing care. Health Information: Nursing Components (HI:NC) data that could represent nursing's contribution to a larger system of client-centred health information. HI:NC is information that represents the most important pieces of data 31 March 2004 Confidential Page 48

49 about the nursing care provided to a client during a health care episode. Another term for HI:NC is Nursing Minimum Data Set. International Classification for Nursing Practice CNA believes data involving identifiable health information should only be used with the consent of the individual. Based on achieving these objectives, CNA endorses testing, through demonstration and other projects, by the International Classification for Nursing Practice (ICNP ) for use in Canada as a foundational classification system for nursing practice in Canada. (CNA Policy Statement 1993) CNA endorses testing, through demonstration and other projects, by the ICNP for use in Canada as a foundational classification system for nursing practice in Canada. There is national data from provincial/territorial registration files on the supply of registered nurses but there is no data on what nurses do in terms of health interventions, little data on the utilization of nursing resources by patients, and little data on patient outcomes that are relevant to nurses. With changes being made to CIHI s national coding systems, there are opportunities to formalize a data collection process for nursing within the larger health care information system. The International Council of Nurses (ICN) began its work over 10 years ago to lead the development of a universal language for defining and describing nursing practice -the ICNP. The purpose of ICNP is to provide a tool for describing and documenting key elements that represent clinical nursing practice. ICNP provides nursing with a framework that facilitates cross mapping of existing nursing vocabularies and classifications to enable comparison of nursing data across organizations and health sectors, and among countries. The nursing care elements of HI:NC (i.e., client status, nursing intervention and client outcome) are included in ICNP. (CNA Position Statement 2001) International Nursing Minimum Data Set (i-nmds) The i-nmds is composed of the essential, minimum data elements to be collected in the course of providing nursing care. These data provide information to describe, compare, and examine nursing practice. Work toward the i-nmds is intended to build on the efforts already underway in individual countries. It is imperative that the national health care infrastructure supports the collection and reuse of nursing data. The contribution of nursing care and nurses is essential to health care globally. The i-nmds as a key data set will support: Describing the human phenomena, nursing interventions, care outcomes, and resource consumption related to nursing services Improving the performance of health care systems and the nurses working within these systems worldwide Enhancing the capacity of nursing and midwifery services Addressing the nursing shortage, inadequate working conditions, poor distribution and inappropriate utilization of nursing personnel, and the challenges as well as opportunities of global technological innovations Testing evidence-based practice improvements Empowering the public internationally 31 March 2004 Confidential Page 49

50 and 31 March 2004 Confidential Page 50

51 Existence of Workload Measurement Systems What Form There are many WMSs and the exact number of organizations using WMSs in Canada is at present unknown. However, the Nursing Professional Advisory Working Group of the JPPC conducted a survey in 1997 that reported three systems predominate in Ontario. GRASP /GRASP-like, NISS, and Medicus. While some centres are using automated or semi-automated systems the majority remain paper-based. Shaw 2003, reported on three centres that are using computerized clinical decision support systems. University Health Network (UHN); St. Michael s Hospital in Toronto; and at the McGill University Health Centre (MUHC) in Montreal. All three institutions are producing both clinical and financial advantages for themselves and their patients through decision-making that is supported by a computer system. UHN uses a Misys Data Warehouse, and MUHC uses the latest Gold version of the Eclipsys Sunrise Decision Support Manager product that allows for access to the data through their Intranet. At St Michael s, decision-support does care costing for all outpatient visits. Their system provides fully-costed patient visits data, which include 30,000 in-patients, 60,000 emergency patients, and now 500,000 ambulatory whose visits are also fully costed. Patient Requirements for Nursing Care: The development of an Instrument Fulton & Wilden, Victoria, BC (1998) Patient Requirements for Nursing Care (PRNC) A tool to be used in conjunction with WMSs. Five distinct components: instability; clinical judgement; educational needs; emotional support and physical care. Patient care needs as a determination of nursing staff mix. Incorporates components of nursing work beyond performance of tasks because it includes measuring level of complexity, decision making and clinical judgement required to meet patient care needs and therefore accurately reflects nurses work. The PRNC differentiates between the complex, unstable patient requiring a high level of nursing care and those patients that are less complex, more stable and have more predictable outcomes. This system was implemented in a medical-surgical unit. This tool objectively measures patient requirements and was not designed to replace a WMS but to capture patient care requirements that are not identified by existing WMS. Workload/Outcome Measurement for Hospital Educators: Confirming the Value of Education Vancouver Hospital and Health Sciences Centre Prociuk, J.; Beetstra, J. (1998) Vancouver Hospital and Health Sciences Centre, the education department has implemented a workload/outcome measurement system. The system is unique in that it considers the costs in terms of the time and money necessary to produce an educational product in relationship to the benefits of that product to the organization. This independent study offering is appropriate for nurses engaged in any aspect of nursing staff development. The learner will achieve the following objectives: 1. Identify the elements necessary to deliver educational services; 2. Describe a system to monitor workload and identify outcomes of education. 31 March 2004 Confidential Page 51

52 Monitoring workloads can assist new educators in understanding their role in the organization and can help set work priorities and adjust work activities. Outcome measurement, the more significant of the two, can provide justification for workloads and can acknowledge the importance of removing system barriers and of providing ongoing support in the workplace to achieve higher level outcomes. Patient classification systems (PCSs), also known as patient acuity systems; The Third Generation Providence St. Peter Hospital, Olympia, Washington Malloch K. et al PCS Providence: This third-generation model is designed to address the lack of sensitivity to the unique holistic nature of patients, fluctuations in economies of scale, and variability in caregivers. The 3PCS includes five elements: 1) standardized, researchedbased, interventions and outcomes categories; 2) descriptions of patient care in "comprehensive units of service"; 3) identified caregiver roles; 4) patient medical record documentation forms; and 5) caregiver competency profiles. Development of the 3PCS moved the staff from examining multiple discrete tasks to a holistic perspective that includes both empirical and intuitive knowledge reflective of the multiple dimensions of the health experience. The following nine advantages can be attributed to the new system. A more accurate reflection of the holistic nature of the human health experience. It considers the multidimensional, interactive essence of both the quantitative and qualitative aspects of care, as well as the specific context of care. A more accurate representation of professional nursing practice than an activitybased patient classification system. Interactions of clinical, psychosocial, environmental, and health management issues are considered in 3PCS. Research based. Information from the University of Iowa Nursing Interventions and Outcomes Classification project, and Benner's care-giver novice-to-expert classifications are incorporated in the model. Easily automated using generic spreadsheet software. A relatively simple method for collecting trend information. Accommodates a patient-centred model with multiple care-giver roles-the new system is able to respond efficiently to patient care delivery system changes in skill mix and labour cost. Emphasizes accountability, information sharing, professional expertise, and care-giver competence. Access to crucial patient care information enhances care-giver ability to get things done, to mobilize resources, and to meet goals. Provides opportunities for cost savings. Savings should be realized from the streamlined evaluation process. The elimination of extensive auditing of task processes and data collection decreases labour costs and the associated system support. Decreases competition for resources between staff and management. Design and Implementation of a Patient Classification System for Rehabilitation Nursing The need for a well-developed PCS in the rehabilitation setting has increased Sarnecki et al. (1998) 31 March 2004 Confidential Page 52

53 Division of Nursing at Rehabilitation Institute of Chicago (RIC) Development of a prototype patient classification (PCS) instrument designed specifically for rehabilitation patients. The primary advantage of this new model is that it provides more direct professional nursing care to patients on a shift-by-shift basis, as required by the increased acuity of patients. There are three major types of patient classification instruments: the factor instrument, nursing task documents, and the prototype instrument. The prototype instrument involves designation of several levels of nursing intensity reflecting demands for nursing care requirements and criteria for each level. The prototype instrument is a form of triage and can incorporate all aspects of the nursing process. Nursing task instrument systems reflect work sampling and time and motion methods seen in industrial settings. The critical indicators approach or factor evaluation system involves the listing of indicators representing clusters of care activities. In the United States, prototype systems practically were abandoned for the more objective systems. The scope of nursing practice captured by task systems is limited to those very visible activities of nurses. Task systems tend to portray nurses as technicians, while ignoring assessment, diagnosis, planning, coordinating, and evaluation, the high-level cognitive/judgmental portion of nursing work that is the essence of discretionary professional nursing practice. Clocking Care Hours with WLM Tools Current Management literature focuses on redefining existing nursing resource measurement rather than inventing new PCS Adams-Wendling L. (2003) Kansas, USA An evaluation of the relationship between the GRASP WLM tool and the Resource Utilization Group Classification (RUGS III) nursing workload projections tool. Management can rely on one workload assessment tool that measures self-care deficits and move to one mandated standardised tool (MDS Minimum Data Set and RUGS) Each facility in the study also completed the mandated MDS assessment and the LOL assessment. Due to this duplication, the researcher wanted to identify whether or not the MDS RUGS nursing staff time measurements (hours per resident per day) would be similar or related to the LOL nursing staff time measurements (hours per resident per day). The results of this analysis of these two workload systems suggests that it is legitimate to consider similar hours of care estimates of one system from the other. This study supports the staff time measurements used by the CMS to develop the RUGS for nursing facilities, which accurately reflect the nurse staffing needs in nursing facilities similar to an established workload estimate tool such as the GRASP methodology. What, exactly, does this mean for long-term care nurse leaders? Managers can rely on one workload assessment tool that measures self-care deficits and move to one mandated standardized tool (MDS and RUGS) that integrates financial data, clinical data, reimbursement data, and nursing workload projection. They can adjust their daily practice to eliminate the duplication of two systems, as long as they continue to evaluate the relationship and accuracy of staff time nursing workload projections provided by the CMS with other established nursing workload measurement tools. The RUG-III Case Mix Classification System for Long-Term Care Nursing Facilities: Is It Adequate for Nurse Staffing? Mueller C., (2000) Minnesota, Minneapolis 31 March 2004 Confidential Page 53

54 Using the nationally mandated resident assessment instrument, the Minimum Data Set (MDS), Medicare residents of LTC facilities are classified into a case mix group associated with the Resource Utilization Group Version III (RUG-III) case mix classification system to determine the payment the nursing home will receive for providing their care. Means to determine the nursing care needs and associated nursing time for the residents' care, selected RUG-III groups were simulated by using the items on the MDS to describe residents classified into a case mix group. A description included information about the residents' cognition, sensory deficits, mood and behaviour, physical functioning, elimination patterns, clinical conditions, nutrition patterns, and medications. Before implementing the study, content validity and test/retest reliability were demonstrated for the study instruments (12 resident descriptions and descriptions of two nursing units). Content validity was conducted and established using the expertise of two nurses in the Health Care Financing Administration National Case Mix Demonstration Project state project offices who worked intensively with the MDS and the RUG-III system. Test/retest reliability was established for the resident descriptions and the descriptions of the nursing units with reliability coefficients of 0.73 and 0.95, respectively. Although more attention has been focused on the adequacy of nurse staffing in nursing facilities, nursing research is needed to test staffing methodologies in LTC facilities, to evaluate care delivery systems in relation to staffing, and to investigate clinical and cost outcomes associated with different staffing models. A Comparison of Two Patient Classification Instruments in an Acute Care Hospital To compare the predictive validity of two types of PCS Seago J., (2003) California California Hospitals are required by both the JCAHC and California Title 22 to have reliable and valid PCS. Two types are summative and critical incident. There is modest research demonstrating the validity and reliability of different PCS but none regarding predictive values. The findings indicate that there are virtually no differences in the predictive ability of criterion versus summative PCS. More importantly managers should select a system that uses the fewest nursing resources possible and that at least one full time equivalent is allocated to maintain validity and reliability of the PCS. MIS Resource Doc. For costing, workload should ideally be expressed in retrospective units of service. It is recognized, however, that many nursing workload systems are designed to collect workload prospectively in order to assist with staffing decisions. Prospective workload measurement systems also facilitate the identification of gaps in service provision or failure to meet performance expectations. If it is expected that each patient will receive a full bed bath each day, for example, this will be predicted and documented as workload in a prospective system. If the unit is short staffed on a particular day, only a partial bath may be provided but the full workload value would still remain. This failure to meet the standard would result in a productivity ratio, which is greater than 93%. This is not to be interpreted as efficiency but as failure to meet performance expectations. 31 March 2004 Confidential Page 54

55 Perceptions Validity of the tool Validity can be defined as the extent to which a Workload Measurement System measures what it is designed to measure, that is, the ability to quantify and/or predict requirements for nursing resources (Hernandez, 1996). Validity is a matter of degree, not an all or none property, and the process of validation is unending (Giovanetti, 1984). In today s changing environment validity must be measured at regular intervals to ensure that the system continues to reflect current practice, process, time, procedures, activities and technology (Hernandez, O Brien Pallas, 1996). Redesign of the measurement tool may be necessary on a regular basis. There are several levels in the validation of a workload measurement tool. The first is related to the process for measuring the workload. The second is the validation of content. Do activities and times reflect current practice? The type of system in use will determine how much of the validity maintenance is the responsibility of the vendor and how much of the system can validated at the facility level (Hernandez, O Brien Pallas, 1996). In a workload system based on task identification with facility developed times, the validation of the tool is primarily the responsibility of the facility. These systems are very flexible and can be adapted easily to reflect the rapid changes occurring in our current health care system. Measurement systems, which require all changes by the vendor, may be less responsive (Hernandez, O Brien Pallas,1996). Reliability of an instrument is the degree of consistency with which it measures the attribute it is supposed to be measuring. Inter-rater reliability refers to the extent to which data is reproducible. It is important that different nurses using the same WMS, to measure the same individual, at the same time, derive a consistent result. A reliable system shows consistent data no matter who takes the measurement (Hernandez, O Brien Pallas, 1996). Inter-rater results below the target indicate a need for reeducation, redesign of the tool or the instructions on how to use the tool. The frequency and number of checks should be related to the use of the data and the importance of the resulting decisions. It is useful to test reliability both within a unit and between units (Hernandez, O Brien Pallas, 1996). Dissemination and Utilization of Workload Management Data The Use of Information Generated by a Patient Classification System The Use of PCS-information by nursing departments in eastern Wisconsin Botter, (2000) Findings indicated that the most common use of PCS information was to assist the nursing department with staffing decisions. Most respondents indicated interest in using PCS information to develop nursing personnel budgets and to cost out nursing care. Medicus PCS is used in more than 400 US hospitals. One manager said, "PCS wouldn't be the first thing for me to go and show them because... I don't think the staff has much faith in PCS." However, the direction, intensity, and interaction of these relationships need to be investigated. Research regarding the costs and benefits of these systems is essential as well. The actual cost of purchasing a PCS is known, but no empirical data exist regarding the impact of use or non-use of PCS information in terms of cost per patient-day. Studies exploring the relationships between PCS information use in decision-making and the cost, quality, and outcomes of care would provide valuable information for nurse administrators. 31 March 2004 Confidential Page 55

56 Improving Staffing with a Resource Management Plan Change from a crisis to a proactive mode for staffing, scheduling, resource pool utilization, information management and unit workload Kirkby et al. (1998) Ann Arbor, Michigan In September 1995, the nursing leaders at St. Joseph Mercy Hospital (SJMH) were struggling to have the right mix of staff on hand during each shift. The outcome of the project was a detailed plan for responding to resource needs either because of service demands (patient volume) or deficit demands (lower-than-needed staffing). The foundation of the plan was to stabilize the unit core staffing so that it would meet the unit s staffing model every shift and thus provide care for the expected number of patients. In the plan, the nursing leaders decide the desired census for a unit, budget for it, hire into an ideal position complement, keep the positions filled, prepare schedules that meet model every shift, and make adjustments every shift. The resource pool is used for deficit demands (leave of absence, unscheduled absence, posted vacancies) and for service demands (patient volume). When demands are higher than budgeted, extra shifts, prescheduled overtime, and travelers are used. When demands really peak, agency staff, incentives, and mandatory overtime are used. 31 March 2004 Confidential Page 56

57 Types of Tools Selected Vendors There are numerous vendors of WMS and PCS see appendix 2. However for the purpose of this review the following have been selected. Descriptions are based on information from the vendors. GRASP The GRASP Methodology was first developed and used 25 years ago in the United States, designed by Grace Hospital, Morgan Town, NC. Today, four privately held companies make up The GRASP Systems International Companies. They provide automated work measurement and consulting services to a variety of health care facilities in three countries, the United States, Canada, and the United Kingdom. Corporate headquarters are based in the United States, in Colorado. By 1980, it was becoming clear that automation was needed to help facilities better implement The GRASP Methodology. By 1987, many more facilities had computerized. To meet client needs GRASP introduced MIStro Software to provide a more sophisticated level of automation. The GRASP suite of PC-based software products includes DataWorks, StaffWorks, and Interfaces. DataWorks saves costly time by automating the definition, collection, reporting, and quality monitoring of workload information. No other product offers such a powerful and broad scope of functionality for workload collection. Nowhere else will you get the kind of reports that give you the tools to analyse workload patterns, make equitable workload distribution assignments, analyse workload by caregiver, analyse intervention specific usage, and provide data for true performance improvement. StaffWorks Automates the conversion of workload hours into staffing requirements specifically modeled for your organization. StaffWorks projects the cost associated with staffing decisions allowing the manager to make truly informed staffing decisions, as well as providing the data to create department specific budgets. Clients can also collect quality measures for each unit/department and report those out in a variety of management reports for analysis of staffing trends, utilization, and quality measures. Interfaces A variety of interfaces are available to import and export data to and from each of our MIStro modules. Below is a complete list of available interfaces. ADT Interfaces Two Admission, Discharges and Transfers (ADT) interfaces (batch and HL7 interfaces) for DataWorks Acuity Import Import of GRASP workload from a mainframe HIS system to StaffWorks Staffing Export Export of workload data from DataWorks to a variety of staff scheduling systems and costing systems Scheduling Import Import of staff hours to StaffWorks from any scheduling or payroll system QuadraMed (formerly Medicus) QuadraMed is dedicated to improving health care delivery by providing innovative health care information technology and services. From clinical and patient information management to revenue cycle and health information management, QuadraMed delivers real-world solutions that help health care professionals deliver outstanding patient care with optimum efficiency. Behind the products and services is a staff of more 31 March 2004 Confidential Page 57

58 than 850 professionals who provide support to more than 1,900 health care provider facilities. Information Systems with Affinity Affinity is an industry-leading health care information system that integrates clinical, financial, and patient information around a single, patient-centred scalable database. With its open technology and powerful suite of client-focused products it is easy to implement and even easier to use. Information Management with Quantim With the multi-dimensional Quantim application, provides access to the full breadth of health information management, skills, software, and services. Their suite of modular and integrated tools eliminates the duplication of records and streamlines the billing process so that users can process and deliver the most appropriate patient care. Compliance Solutions with Complysource Complysource provides powerful software tools to ensure a strong compliance program that protects patients and the ongoing viability of the organization. With the growing complexity of health care laws and federal regulations, having the right tools and services in place for a truly effective compliance program is now more important than. Financial Management with Chancellor Chancellor financial products and services enable organizations to improve cash flow and deliver the in-depth data analysis that is crucial to managing budgets of any size. With a spectrum of solutions, organizations can perform a wide range of tasks from accelerating collections to identifying outstanding receivables that are vital to the bottom line. ENEPCS: ENEPCS is a contemporary model that incorporates all activities and care needs of the patient. ENEPCS is customized by the caregivers in each organization to reflect actual workload requirements rather than using pre-set standards. Caregivers actively participate in the development of the system and in the ongoing monitoring of the effectiveness of the model. In most situations, a quick and obvious revitalization of the registered nurse s professional accountability for interventions and outcomes occurs. Professional accountability is emphasized and reinforced in the ENEPCS model with the use of standardized intervention language developed by the University of Iowa Nursing Interventions Classification project. ENEPCS Reflects the complexity of patient care and considers patients needs from a holistic perspective using the Comprehensive Unit of Service (CUS). Identifies the uniqueness of each patient using eight categories of care: 1. Cognitive Status 2. Self-care Status 3. Emotional PsychoSocial Support needs 4. Comfort/Pain Management needs 5. Family information and support needs 6. Treatment needs7. Interdisciplinary coordination, patient teaching, and documentation needs 31 March 2004 Confidential Page 58

59 8. Transition planning needs. Is based on professional nursing judgment, not a task-based model, using the expert knowledge and experience of nurses delivering the care Can be used in multiple clinical settings by multiple caregiver roles Identifies the skill mix and cost of labour for each patient Creates a valid and reliable system for your organization Transitions the benefits of current industrial based PCS to ENEPCS Meets regulatory requirements of Medicare Conditions of Participation, JCAHO, California-Title 22, and ANA Principles of Staffing Can be computerized or used manually Provides a simplistic method for information trending, calculation of labour cost each shift, labour cost per patient day, and overall productivity monitoring using a generic spreadsheet application. Catalyst Catalyst is the leading provider of data-based solutions that enable health care organizations to make precise staffing-related decisions. The EVALISYS tools, methodologies, and systems have proven their value time and again in health care organizations of all types and sizes. EVALISYS Patient Classification System (PCS) is a family of valid, reliable workload measurement tools and processes that set the standard for clear-sighted staffing solutions. With its unique ability to capture care complexity, EVALISYS PCS allows flexible, acuity-based staffing for all care disciplines. EVALISYS PCS Plus combines leading-edge analytic and observational methods to make workload and problematic staffing patterns visible. PCS Plus takes the guesswork out of staffing and skill-mix changes. EVALISYS Patient Classification/Staff Activity Study (Study) process offers comprehensive, enterprise-wide evaluation of staff utilization patterns and workload for all clinical disciplines, no matter what patient classification system you use. This objective process illuminates ways to ensure that the right care is provided to the right patient by the right staff. With Catalyst, you have the knowledge-based foresight to make tough decisions with greater ease and confidence. You can see what your needs really are and make changes that are responsible, informed, and more precise than ever before. Labour Resource Management System (LRMS) For Patient Care Decision Making The LRMS created by Applied Management Systems, Inc. provides for shift, daily, weekly and monthly reports, or can look at any desired timeframe to help quickly understand the operational status of various nursing areas. Designed to run on an IBM compatible personal computer, LRMS provides concise, meaningful management reports at the department and division levels. It takes data that is typically captured and organizes it into relevant information sets that describe at-a-glance how each unit, department or 31 March 2004 Confidential Page 59

60 division is performing. This easy-to-use tool provides essential information to support decision-making as well as reports to management. Patient care managers need reports that combine relevant indicators of workload and calculate required hours for comparison to actual hours. This tool is highly flexible, and forms and reports can be adapted to the unique needs of any area within an organization inpatient, outpatient, surgical suite and so on. More important, it gives accurate, timely information to help manage budget, adjust actual to required staffing levels, adjust staffing mix and assess productivity. An affordable tool that's designed to run on the hardware and software typically found in health care organizations, LRMS is an essential tool for patient care managers. Tenet Information Services, Inc Tenet provides software (EDNet32, Intellichart), consulting services, and system solutions to Emergency, In-patient Nursing, and Out-patient Nursing departments as well as other hospital departments and clinics. As a leader in health care information system and management engineering solutions for clinicians, nurses, and therapists, they make a positive impact on patient care by improving efficiency, containing costs, and minimizing risk. Tenet Software Products EDNet32 A Computerized Patient and Data Management System for the Emergency Department Intellichart A Computerized Patient and Data Management System for In-Patient Nursing Units P.E.R.F.O.R.M.: A Hospital Productivity Monitoring System QuikStaf: The Quality Staffing System RES-Q Workload and Productivity Management Founded in 1979, RES-Q has implemented hundreds of computerized applications for enterprise-wide employee staff scheduling, nurse scheduling, patient classification, productivity management, operating room scheduling, and surgery department management throughout the U.S., Canada and Europe. RES-Q Healthcare Systems is a leading provider of labour management and employee scheduling software for the health care industry. The RES-Q family of software products include applications for enterprise-wide employee scheduling, nurse scheduling, patient classification, productivity management, credentialing, operating room scheduling, and surgery department management. RES-Q Healthcare Systems' Labour Resource and Workload Management System is a modular PC-based client/server software application for performance and productivity management. The system includes capabilities to support enterprise-wide employee scheduling, personnel management, workload staffing, department labour budgeting, as well as other functional areas. 31 March 2004 Confidential Page 60

61 Nursing Workload Related Issues in Other Countries East Switzerland, Centre for Informatics and Managed Care Fischer, in Switzerland, has been examining PCS issues and theory. He proposes independent application of PCSs for each professional sector-clinical, nursing, and support services. ISE's Institute for Health and Economics NURSING data project aims to set up a national nursing information system that covers all three health care sectors home care, nursing homes, and hospitals as well as Switzerland's four linguistic regions and all medical specialities. This system has to be compatible with other Swiss systems, such as National Health Statistics, health or disease classifications (ICD-10), medical and nursing pricing systems, etc., and will also have to allow for international comparisons, taking in account national legislation on data protection. In 2001, the project entered the second and operational phase. The Institute is in charge of the following projects and activities. The management of the Swiss APDRG project (All Patient Diagnosis Related Groups), mandated by the Swiss APDRG group The management of the NURSING data project The management of the FARMED health network, mandated by its Joint Commission The secretariat of the Intercantonal Technical Commission of PLAISIR The operational secretariat of the Swiss Working Group on Patient Classification Systems (CST-PCS). New Zealand Ministry of Health Nursing Sector Update August 2002 In June 2000 the Ministry piloted a project to determine the applicability of a nurse workload measurement and planning system in New Zealand s public hospitals. The system used for the pilot was TrendCare Systems Limited, Australia which was piloted in six DHBs:Auckland, Capital and Coast, West Coast, Bay of Plenty, Taranaki, and Wairarapa DHBs. The Ministry received the final report in September 2001 and has been analysing the findings. Implementing the recommendations contained in the report will require indepth information on nursing workload management within DHBs. The Ministry has sought international peer review of the report from Professor Donna Diers (Yale School of Nursing, US). In order to gain an understanding of the information that is currently available in the sector, the Ministry contracted the New Zealand Health Information Service to undertake a stock take of current systems in DHBs that are conducive to collecting, measuring and reporting on nursing workload information. We also sought to establish the capacity of existing systems for medications. We have now received the stock take and international peer review and are developing a work program to proceed with this work. New Zealand Ministry of Health Acute Mental Health 31 March 2004 Confidential Page 61

62 Nursing Workload Measurement in Acute Mental Health Inpatient Units. February 2002 There is currently no means of estimating the nursing requirements of consumers, or the nursing workload in acute mental health inpatient units in New Zealand. A team of researchers from South Auckland Health (SAH) and the University of Auckland undertook this project. The project addressed issues of nursing workload measurement, the infrastructure necessary to meet nursing workload requirements, and the terminology for national consistency in managing mental health nursing workload. This report details a project aimed at establishing an acuity system at a national level, appropriate to multiple acute mental health inpatient settings. Measurement of nursing workload is a complex process aimed at providing a range of data, which will enable rational decision making in allocating resources to nursing, and in allocating nursing resources to consumers. Determining the distinction between nursing and non-nursing work, and linking this to an ideal skill mix, is an essential requirement for nursing workload measurement. Key findings of the literature review Health funding restraint and development of community mental health care has restricted inpatient use to those with as high level of clinical acuity. All systems for consumer care attempt to standardize the nursing resource needed for hours of care for consumer type. Most of the systems reviewed have been developed in general hospitals and few studies have been carried out in mental health settings. Two systems in current use, Trendcare, and PANDA were identified for further consideration. Recommendations Future work for New Zealand requires rigorous prospective evaluation of PANDA and/or Trendcare, measuring their impact on key nursing, economic and consumer outcomes. This should be carried out in the context of nationwide infrastructure limitations, and the concern expressed by DHB staff of the ways in which an instrument may be used. Such an analysis would need to consider the compatibility of these systems with existing information systems. That future studies aimed at matching consumer needs to nursing skill mix are focused on nursing workload rather than clinical acuity. That the issue of nursing infrastructure is further investigated, particularly the problems of recruitment, retention, and skill mix. 31 March 2004 Confidential Page 62

63 Research Bibliography 1. Arthur T, James N. (1994). Determining nurse staffing levels: a critical review of the literature. J Adv Nurs 19(3), Adams-Wendling, L. (2003). Clocking care hours with workload measurement tools. Nursing Management August, 34 (8), Benton D. (2003). On the front line: David Benton describes a new system for managing the deployment of front-line staff. Nurs Manage (Lond) Sep 10 (5), Bolton LB, Aydin CE, Donaldson N, Brown DS, Nelson M, Harms D. (2003). Nurse Staffing and Patient Perceptions of Nursing Care. JONA, 33 (11), Botter M L. (2000). The Use of Information Generated by a Patient Classification System. J Nurs Adm 30 (11), Burke TA, McKee JR, Wilson HC, Donahue RMJ, Batenhorst AS, Pathak DS. (2000). A comparison of time-and-motion and self-reporting methods of work measurement. J Nurs Adm 30 (3), Curtin LL. (1995). Nursing productivity: from data to definition. Nurs Manage Apr 26, 4, 25, 28-9, Darmoni SJ, et al. Horoplan: Computer-Assisted Nurse Scheduling Using Constraint- Based Programming. Internet: 9. Gaudine AP. (2000). What do nurses mean by workload and work overload? Can J Nurs Leadersh, 13 (2), Fulton TR. Wilden BM. (1998). Patient Requirements for nursing care; the development of an Instrument,. Can J Nurs Adm, 11(1), Houser J. (2003). A model for evaluating the context of nursing care delivery. J Nurs Adm, 33 (1), Park JH. Recent Publications of Jung Ho Park. Internet Hughes M. (1999). Nursing workload: an unquantifiable entity. J Nurs Manage, 7(6), Johnson, Nolan, MT. (2000). A Guide to Choosing Technology to Support the Measurement of Patient Outcomes. J Nurs Adm, 30 (1), Kirkby MP, Dost P, Holdwick CC, Poskie M, Glaser D, (1998). Improving staffing with a resource management plan Sage M. J Nurs Adm,DM 28 (11), Koivula M, Paunonen M, Laippala P. (1998). Prerequisites for quality improvement in nursing. J Nurs Manage, 6 (6), Malloch K & Conovaloff A. (1999). Patient Classification Systems, Part 1: The third Generation. J Nurs Adm, 29 (7/8), Malloch K, Neeld A P, McMurry, C, Meeks L, Wallach M, Williams S, Conovaloff A. 31 March 2004 Confidential Page 63

64 (1999). Patient Classification Systems, Part 2: The third Generation. J Nurs Adm, 29 (9), Manthey M. (1989). The role of the LPN or... the problem of two levels. Nurs Manage, 2 (3), Mark BA, Salyer J, Harless DW. (2002). What explains nurses' perceptions of staffing adequacy? J Nurs Adm, 32 (5), Martorella C. (1996). Implementing a patient classification system. Nurs Manage, 27 (12), Mueller C. (2003). The RUG-III Case Mix Classification System for Long-Term Care Nursing Facilities: Is It Adequate for Nurse Staffing? J Nurs Adm, 30 (11), O Brien-Pallas L. Baumann A. (2000). Toward evidence-based policy decisions: a case study of nursing health human resources in Ontario, Canada, Nursing Inquiry, 7, O Brien-Pallas L. Baumann A. Donner G. Tomblin Murphy G. Lochhaas-Gerlach J. Luba M. (2001) Forecasting models for human resources in health care. Journal of Advanced Nursing, 33 (1), O Brien-Pallas L. Irvine D. Peerboom E. Murray M. (1997). Measuring Nursing Workload: Understanding the Variability. Nursing Economics, 15 (4), O Brien-Pallas L. Thomson D, Alksnis C. Luba M. Pagnielllo A. Ray K. Meyer R. (2003). Stepping to Success and Sustainability: An Analysis of Ontario s Nursing Workforce. NHR, Prociuk JL, Beetstra J. (1998). Workload/outcome measurement for hospital educators. Confirming the value of education. J Nurs Staff Dev, 14 (1), Rosenfeld P, McEvoy MD, Glassman K. (2003). Measuring practice patterns among acute care nurse practitioners. J Nurs Adm,DM 33 (3), Sarnecki AJ, Haas S, Stevens K A, Willemsen J A. (1998). Design and Implementation of a Patient Classification System for Rehabilitation. J Nurs Manage, 28 (3), Seago J. (2002). Comparison of two patient classification instruments in an acute care hospital. J Nurs Adm, 32 (5), Seago JA. (2002). Nurse Staffing, Models of Care Delivery, and Interventions. University of California, San Francisco School of Nursing, Shaw A. (2003). Decision support systems can help hospitals reduce costs and improve patient care. Canadian Healthcare Technology November/December. Iinternet: Simpson RL. (2000) In our hands? The future of health care technology. Nurs Manage, 31(12), Walsh E. (2003) Get real with workload measurement: this innovative technique accurately determines the hours needed for comprehensive patient care. Nurs Manage, 34 (2 part1 ), March 2004 Confidential Page 64

65 Reports and Studies 1. A report for the Mental Health Research and Development Strategy Nursing Workload Measurement in Acute Mental Health Inpatient Units. Ministry of Health of New Zealand, February A Report on The Nursing Strategy for Canada, Advisory Committee Health Delivery and Human Resources, 2003, Health Canada. 3. Canadian Institute for Health Information. Supply and Distribution of Registered Nurses in Canada, , Ottawa, ON. 4. Canadian Institute for Health Information. Workforce Trends of Nurses in Canada, , Ottawa, ON. 5. Canadian Nurses Advisory Committee. Our Health, Our Future: Creating Quality Workplaces for Canadian Nurses. Final Report Canadian Nurses Association & Canadian Federation of Nurses Union Country Report for The International Council of Nurses Workforce Forum. Ottawa, Canada September 17-18, Canadian Nurses Association & Office of Health and Information Highway. Vision 2020 Workshop on Information and Communications Technology in Health Care from the Perspective of the Nursing Profession. Ottawa, Ontario, March 21, Canadian Nurses Association. Measuring Nurses Workload. Nursing Now Issues and Trends in Canadian Nursing March 2003, Number Canadian Nurses Association. What is Nursing Informatics and Why is it so Important? Nursing Now Issues and Trends in Canadian Nursing September 2001, Number Canadian Nurses Association. Health Informatics: Nursing Components. CNA Policy Statement, November Canadian Nurses Association. Collecting Data to Reflect the Impact of Nursing Practice. CNA Position Statement, November Canadian Nursing Informatics Association (CNIA) launches the national study Educating tomorrow s nurses: Where s nursing informatics? News Release, September F/P/T Advisory Committee on Health Infostructure Blueprint and Tactical Plan for a pan-canadian Health Infostructure. A Report on F/P/T Collaboration for the Planning of the Canadian Health Infostructure. Office of Health and the Information Highway. Health Canada, December F/P/T Advisory Committee on Health Infostructure. Tactical Plan for a pan-canadian Health Infostructure, Update Office of Health and the Information Highway. Health Canada, November Faculty of Nursing, University of Toronto. A Study on the Impact of Nursing Staff Mix Modules and Organizational Change Strategies on Patient, System and Nurse Outcomes. Principal Investigators: McGillis Hall L & Irvine Doran D. 31 March 2004 Confidential Page 65

66 16. Future Development of Information to Support the Management of Nursing Resources: Recommendations. Canadian Institute for Health Information, Health and Community Services Human Resource Sector Study. Recruitment and Retention in the Health System: A Discussion Paper, How Do Health Human Resources Policies and Practices Inhibit Change? A Plan for the Future. October 2002 Discussion Paper, Number 30, Tomblin Murphy G. O Brien- Pallas L. 19. Information and Communications Technologies in the Canadian Health System: An Analysis of Federally-Funded ICT-Related Projects. Office of Health and the Information Highway, Health Canada, Joint Commission on the Accreditation of Healthcare Organizations Accreditation Manual for Hospitals. Volume I Standards. Oakbrook Terrace, IL: Joint Commission on the Accreditation of Healthcare Organizations; MIS: Nursing Resource Consumption. Prepared by the Professional Advisory Working Group of the JPPC, August Nursing Workload Measurement in Acute Mental Health Inpatient Units. A report for the Mental Health Research and Development Strategy. February 2002 Ministry of Health, Auckland New Zealand. 23. Ontario Guide to Case Costing, version 2.0. Ontario Case Costing Initiative, Chapter 9, Departmental Case Costing Standards, List of companies that provide Nursing Workload Measurement Systems BDM Information Systems Cerner Combeck Computer Design Crystal Decisions Delphic Medical Systems Ltd. Dynaworks Eclipsys GRASP Systems HBO & Company Health Information Systems HealthVISION Corporation Healthware Technologies Inc. Med2020 Meditech NISS Ormed Home Page 31 March 2004 Confidential Page 66

67 Per-Se - since bought out by Misys Phoenix Solutions Ulticare 31 March 2004 Confidential Page 67

68 APPENDIX B WEB-BASED SURVEY DEMOGRAPHIC AND SURVEY QUESTIONS DEMOGRAPHICS WORKLOAD MEASUREMENT SURVEY Directed at Nurse Managers What best describes your area of employment: (choose only one of the following options to 1.12) Facility-Based 1.1 Teaching Hospital 1.2 Community Hospital 1.3 Rehabilitation 1.4 Mental Health 1.5 Long-term Care Community-Based 1.6 Home Care e.g. VON, St. Elizabeth s, Centre Local de Services Communautaires (CLSC), Community Access Care Centre (CCAC), Red Cross 1.7 Public Health 1.8 Community Health Centre 1.9 Rehabilitation 1.10 Mental Health 1.11 District/Regional Health Authority 1.12 Other: (please specify) (input field) Province/Territory you work in: (drop down list) Your professional designation is: Registered Nurse (RN) Registered Psychiatric Nurse (RPN) Licensed/Registered Practical Nurse (LPN/RPN) Approximate number of nursing staff in your organization: (choose one number for each type of staff) RN < >250 RPN(Psych) < >250 LPN/RPN < >250 RN: Registered Nurse, RPN: Registered Psychiatric Nurse, LPN/RPN: Licensed/Registered Practical Nurse 31 March 2004 Confidential Page 68

69 Your present age is: <25 years > What is your gender: Female Male What is your title within the organization: (choose one) Patient/Client/Resident-Care Manager Clinical Services Manager Nurse Manager Program Manager Manager Other (please specify) (input field) How many years have you held your current title: <1 year 1-3 years 4-6 years > 6 years What level of education have you completed: (select the highest) Diploma Certificate(RPN-Psych, LPN/RPN) Baccalaureate Masters Ph.D. 31 March 2004 Confidential Page 69

70 Directed at Nurses What best describes your area of employment: (choose only one of the following options to 1.12) Facility-Based 1.1 Teaching Hospital 1.2 Community Hospital 1.3 Rehabilitation 1.4 Mental Health 1.5 Long-term Care Community-Based 1.6 Home Care e.g. VON, St. Elizabeth s, Centre Local de Services Communautaires (CLSC), Community Access Care Centre (CCAC), Red Cross 1.7 Public Health 1.8 Community Health Centre 1.9 Rehabilitation 1.10 Mental Health 1.11 District/Regional Health Authority 1.12 Other: (please specify) (input field) Province/Territory you work in: (drop down list) What is your professional designation: Registered Nurse (RN) Registered Psychiatric Nurse (RPN) Licensed/Registered Practical Nurse (LPN/RPN) Approximate number of nursing staff in your organization: (choose one number for each type of staff) RN < >250 RPN (Psych) < >250 LPN/RPN < >250 RN: Registered Nurse, RPN: Registered Psychiatric Nurse, LPN/RPN: Licensed/Registered Practical Nurse What is your present age: <25 years >60 What is your gender: March 2004 Confidential Page 70

71 Female Male What is your title within the organization: (choose one) Staff Nurse Team Leader Clinical Nurse Specialist Other (please specify) (input field) How many years have you held your current title: <1 year 1-3 years 4-6 years > 6 years What level of education have you completed: (select the highest) Diploma Certificate( RPN-Psych, LPN/RPN) Baccalaureate Masters Ph.D. 31 March 2004 Confidential Page 71

72 APPENDIX C WEB-BASED SURVEY NOTICE OF INTENT, INTRODUCTORY LETTER Notice of intent: Canadian Nurses Association, Canadian Practical Nurses Association, Registered Psychiatric Nurses of Canada, Canadian Association of Schools of Nursing, Canadian Federation of Nurses Unions, Canadian Health care Association, and Academy of Chief Executive Nurses are undertaking a collaborative project to facilitate the implementation of recommendations contained in the final report of the Canadian Nursing Advisory Committee (CNAC). The report was released by federal / provincial / territorial governments in It includes 51 recommendations designed to create quality workplaces for nurses. There has been some action in response to the majority of the CNAC recommendations. This new collaborative project, funded through Health Canada, will focus on those recommendations where there has been little or no action. The project includes literature reviews, surveys, focus groups and data analysis. Nurses in all communities of practice (clinical, education, management and research) and students across the country will be invited (randomly chosen) to participate in various activities. ALL RESPONSES WILL BE KEPT CONFIDENTIAL. We encourage you to participate. Your voice is important. 31 March 2004 Confidential Page 72