2. Workload Measurement System

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1 A Overview of Nurses Worload Measuremet Systems ad Worload Balace Carolie Teoh Sheu Siew School of Distace Educatio, Uiversiti Sais Malaysia, 800 USM, Peag, Malaysia Noraida Abdul Ghai School of Distace Educatio, Uiversiti Sais Malaysia, 800 USM, Peag, Malaysia Abstract. Healthcare orgaizatios eed to overcome urses shortage issue by reviewig the curret worload measuremet system. May worload measuremet systems have bee developed to meet patiet care eeds i specified areas. This paper provides a overview of the worload measuremet systems ad its applicatio. A model to balace urses worload i Neoatal Itesive Care is discussed Mathematics Subect Classificatio: 90C0 Keywords: worload measuremet, patiet classificatio system, acuity system, worload balace.. Itroductio Issues i ursig worload measuremet have bee widely proposed, especially i wester coutries. A survey of 500 registered urses usig Broos Quality Nursig Wor Life suggested that ursig worload was too heavy ad they have ot eough time to carry out their ob properly. Nurses ot oly had little eergy left after wor, they were also uable to balace their wor ad family lives, ad the rotatig schedules affected their lives i a egative way [2]. Nearly half of urses pla to chage their ob withi the ext two years accordig to the survey from CareerBuilder.com (CareerBuilder.com is a olie ob site i U.S). The reasos give by the urses are because their facilities are uderstaffed, cotributig to high stress levels, compromised patiet care, departmet overcrowdig ad closig of beds [6]. Tarow-Mordi et al. [20] measured itesive care uit (ICU) worload per shift durig each patiet s stay for all admissios betwee 992 ad 995 to see if hospital mortality is idepedetly related to ursig requiremet ad other measures of worload, after adustmet for ris usig APACHE II (Acute Physiology ad Chroic Health Evaluatio) equatio. They cocluded that hospital mortality may partly be explaied by excess ICU worload such as iadequate umbers of ursig or medical staff, traiig, supervisio, or equipmet. I additio, a study i [2] measured staff s worload i Itermediate Care ad foud that icreasig staffig levels i facilities with high iury rates ad low staffig ratios ca actually decrease iuries ad time-loss rates.

2 The Caadia Nurses Associatio [3] defied ursig worload measuremet system as a ey compoet of ay process to measure ursig resource itesity. The obective of a worload measuremet system, as stated by the Nursig Professioal Advisory Worig Group of the Joit Policy ad Plaig Committee (JPPC) [4], is to provide the basis for expressig the volume of patiet care activity of a service, i terms of a stadardized uit of activity or productive persoel time. It is iteded to reflect the ursig resources required to accomplish all tass performed by ursig persoel i a give fuctioal cetre. This is measured ad recorded as a uit of service. This paper will review some of the wors o worload measuremet system ad discussed its applicatio i balacig the worload of urses. 2. Worload Measuremet System The worload measuremet ca be broadly categorized ito two types: activity based ad depedecy based, as illustrated i [3] ad [9]. The activity based measures characteristic of ursig care activities ad assigs a time value for them. The stregth of activity based systems lie i their ability to measure the tass that urses actually do i the course of their wor. The maor limitatio of activity based systems is that they focus o care give ad igore the umet eeds of the patiet. Depedecy based systems o the other had, assig cosumers to groups o the basis of critical idicators. These idicators are o a scale of oe to four or five where each level deotig a icreasig demad o ursig care time over a 24 hours period. Patiet depedecy tools, sometimes ow as caseloadweightig tools, usually focus o tass. Examples of tass iclude the eed for hygiee ad physical care such as iectios. Depedecy based, however, ca overloo the psychological care or the support eeds of carers, which are importat cosideratios i ursig care [6]. Depedecy is ofte referred to as classificatio, thus Patiet Classificatio System (PCS) is a example of depedecy systems [6]. There are thousads of patiet classificatio systems, ad they are categorized as prototype or factor systems. The prototype system uses a descriptio of characteristics typical to a patiet, placig them i appropriate categories, whereas the factor classificatio system uses a list of critical idicators, treatmets ad descriptors of patiet care give [5]. The Dutch Patiet Classificatio System [8] that categorizes patiets accordig to the type of care eeded, the expected umber of visits per wee ad the total legth of the service provided is a example of a prototype system. While the eoatal acuity system [5] discussed i sectio 3 is a example of a factor classificatio system. The PCS have bee developed sice the 960 s ad became the maor method to measure patiet eeds ad cliicia ivolvemets required to meet up with the eeds. Although the PCS system uses may differet methodologies to arrive at the groupigs, the itet of this system is to group patiets who cosume similar resources [4]. Malloch ad Coovaloff [9] described the growth of PCS as a four geeratioal progressio. The first geeratio PCSs developed before 970 s, were iteded to supply miimum staffig levels based o gross historical factors. These were calculated maually to estimate ratios (patiets per urses). I this

3 geeratio, the systems made oly gross iequities betwee specialty areas ad dealt with istabilities i worload by overstaffig. Durig the 980 s researchers saw the itroductio of care related to diagostic groups. More emphasis was give to commuity care due to the icreased use of computers, equipmet ad iformatics. Relievig ad agecy staffs were employed to provide more adaptable resposes to variatios i worload. However, there was still little cocetratio o sill combiatio. Techology ad research icreased sigificatly i the 990 s, ad there was a move towards greater cosumer ad family participatio. More sesitive patiet classificatio systems were developed due to frequet pressures from the society. The challege for this geeratio was to calculate ursig worload o a shift basis i a practical way, but to this poit this has ot bee attaied. Moreover, sortig of ursig sill level, which is elemetal for a fully resposive patiet classificatio system, has ot bee achieved. I the fourth geeratio, the system s obective is to be able to use techology to forecast ursig care eeds i real hours with a specific sill combiatio, ad to create extesive statistical iformatio for the orgaizatio. Speculatio about fourth geeratio icludes use of techology ot presetly available, for this reaso system developmet is still fully focused o the requiremets of third geeratio systems. A classificatio system i the evaluatio of a patiet with chroic low bac pai was described by [0]. The classificatio system was used to develop a supervisio program for a 55-year-old patiet with a medical diagosis of lumbar spie ad was istructed i symptom reducig strategies for positioig ad fuctioal movemet. [4] gives a implemetatio of Patiet Classificatio System while [] focuses o redefiig existig ursig resource measuremets, with a eye towards cotemporary issues such as severity measuremet, productivity ad cliical decisio maig. Assorted stadard measurig tools to measure ursig resource itesity have bee discussed ad ca be used to predict overall ursig staff requiremets i certai departmets. However, research aalysis performed over the years show that while worload measuremet systems ca assume to support the urse maagers i taig his/her verdicts, o tools have bee show to aswer all queries regardig worforce maagemet [8]. The viability of usig a acuity system is weighed dow with problems because acuity methodology does ot iclude may of the activities ivolved with patiet s actual care. For example, a elderly perso diagosed with peumoia is allotted a specific umber of care hours, but the same patiet may eed assistace with dressig, feedig, bathig ad other activities that require supplemetary care time i additio to the peumoia care pla [7]. Moreover, may of the early worload data was also captured maually ad was ot lied to payroll data, patiet registratio data, or health records. The process for capturig worload maually was time cosumig, susceptible to error ad limited the use of worload data. As such, worload iformatio was ot shared with admiistrators or staff urses ad iteral treds i worload were ot routiely available. Worload data was also ot compared across ursig uits ad comparative data across hospitals was ot available [7]. Nevertheless, there are still advatages i usig worload measuremet tools to provide decisios to support proposals for urses schedulig ad as a basis for orgaizatioal ad fudig decisios. If the iputs are precise, a ursig

4 worload measuremet system with restrictios ca provide a tool to support ursig resource cosumptio decisios whe used with quality data, other tredig data ad the qualitative reports of direct care urses [2]. 3. Model of Balacig Worload PCS, patiet cesus, staff turover rate, patiet acuity, ad sill mix ca be used collectively to develop a profile of the practice settig, to idetify eeded resources ad to demostrate the impact of worload o patiet ad urses outcomes [7]. The model discussed i this sectio ad obtaied from [5] deals with the daily assigmet of worload to staff urses i a itesive care ursery that provides health care for critically ill ifats. The obective of the model is to balace the ursig worloads with costraits by assigig a equal amout of patiet acuity to all urses i charged. I usig this model, a detailed eoatal acuity system was first developed. The eoatal acuity system cosisted of fourtee modules. The acuity score for each module is calculated i the followig maer. For example, i module, if a free flowig device is used to admiister oxyge to a ifat, ad is assessed every two hours, the the acuity score of module is twety four hours divided by the frequecy of the assessmet, that is 24/2=2. The patiets acuity score is the tae as the sum of the acuity score of each module. A statistical experimet was carried out to evaluate the iter-rater reliability of the acuity score by usig a balaced radomized complete bloc desig with patiets treated as blocs. The secod tas is to develop a mathematical model (iteger liear program) that assigs patiets to urses subect to costraits with the assumptio that the patiet acuity score have bee tabulated ad the umber of urses is give. The mathematical model for the problem is as give below: p Miimize ( Y,max Y,mi ) Subect to m x i = p z = = = i =... () = =... m (2) ( u ) sici i Y,max i= =... m, =... p (3) sici i Y,mi ( u ) i= =... m, =... p (4) si i B Z ( u ) i= =... m, =... p (5) si xi b z u i= =... m, =... p (6)

5 Y s C a u i i i i=, max A... p =... m, =... p (7) = (8) Variables if patiet i assiged urse x i if urses assiged zoe z i Y = maximum assiged acuity of zoe,max Y = miimum assiged acuity of zoe,mi Parameters if patiet i is i zoe s i if urse is admit urse u A = specified upper boud o the total o admit acuity of zoe a = specified upper boud o the total admit acuity of zoe B = specified upper boud o the umber of patiets fort o admit urses i zoe b = specified upper boud o the umber of patiets for admit urses i zoe C = acuity of patiet i i The obective fuctio miimizes the sum of rages over all zoes, thus balacig urse worload. Costrait () assures that each patiet is assiged to exactly oe urse, while (2) assures that each urse is assiged to exactly oe zoe. Costrait (3) establishes as the maximum assiged acuity amog Y,max o-admit urses i zoe, while (4) establishes Y,mi as the miimum. These two costraits iteract with the obective fuctio to miimize the rage i zoe. Costrait (5) assures that a o-admit urse is assiged o more tha a specified umber of patiets, while (6) assures the same for admit urses. It also guaratees that each admit urse will be assiged at least oe patiet. This is ecessary sice admit urse acuity is ot icluded i the rage computatios, ad thus it is possible that a admit urse would receive o assigmet. Costrait (7) assures that the total amout of acuity assiged to a admit urse does ot exceed a specified threshold, while (8) does the same for o-admit urses. This model distributes the urses amog zoes so that the optimal assigmet of patiets to urses is possible. To simplify this problem, a zoed-based heuristic was developed. This heuristic used bi pacig heuristic first fit decreasig (FFD) to assigs urses to zoes while the secod step computes patiet assigmets withi each zoe. 4. Coclusio

6 To develop the best PCS, the system must recogize its uique patiet populatio, be valid ad reliable, go beyod measurig tass, icorporate the caregiver s owledge, support the facility s missio ad visio, ad lastly remai applicable to various types of patiet care delivery models []. Worload measuremet system that provided reliable data ad iformatio ca support the cliicias i taig their decisios or actios for cost budgetig, schedulig, daily assigmet, maagemet ad patiet supervisio program. Refereces [] A. W. Lida. Clocig care hours with worload measuremet tools, Nursig Maagemet, 34, 8(2003), [2] B. A. Broos ad M. A. Aderso. Nursig Wor Life i Acute Care, Joural of Nursig Care Quality, 9, 3 (2004), [3] Caadia Nurses Associatio, Measurig Nurses Worload, March ( f). Accessed 5 th November [4] C. Martorella. Implemetig a Patiet Classificatio System, Nursig Maagemet, 27, 2 (996), [5] C. Mulliax ad M. Lawley. Assigig Patiets to Nurses i Neoatal Itesive Care, Joural of Operatioal Research Society, 53, (2002), [6] C. M. Begley, A. M. Brady, G. Byre, C. Macgregor, C. Griffiths ad P. Hora. A Study of the Role ad Worload of the Public Health Nurse i the Galway Commuity Care Area, April ( Uit/ResearchLibrary/d3227). Accessed 20 th October [7] E. Walsh. Get real with worload measuremet, Nursig Maagemet, 32, 2 (2003), [8] J. T. Algera-Osiga, R. Halfes, A. Hasma ad D. Wiersma. A Dutch Patiet Classificatio System for Commuity Care, Joural of Nursig Admiistratio, 34, 7/8 (994), [9] K. Malloch ad A. Coovaloff. Patiet classificatio systems, Part : the third geeratio, Joural of Nursig Admiistratio, 29 (999), [0] K. S. Maluf, S. A. Sahrma ad L. R. Va Dille. Use of a classificatio system to guide osurgical maagemet of a patiet with chroic low bac pai, Physical Therapy, 80 (2000), [] L. O Brya, J. Krueger ad R. Lus. Rewor the worload, Nursig Maagemet, 33, 3(2002), [2] M. Cohe, J. Village, A. S. Ostry, P. A. Rater, Y. Cvitovich ad A. Yassi. Worload as a Determiat of Staff Iury i Itermediate Care, It J Occup Eviro Health, 0 (2004), [3] M. Hughes. Nursig worload: a uquatifiable etity, Joural of Nursig Maagemet, 7 (999), [4] Nursig Professioal Advisory Worig Group of the JPPC, MIS: NURSING resource cosumptio, 997. ( Accessed 6 th October [5] N. MacNaughto. Emergecy departmet patiet classificatio system, Nursig Maagemet, 26, 0 (995), [6] Obesity, Fitess & Welless Wee editors. Staffig; Survey shows early half of urses pla to chage obs i 2 years, Obesity, Fitess & Welless Wee, 20 August 2005, 34.

7 [7] RNAO Practice Committee. Worload Measuremet, RNAO Practice Page, 4 (2004), 4. [8] Scottish Executive Health Departmet, Nursig & Midwifery Worload & Worforce Plaig Proect, ( Accessed 6 th October [9] S. R. Edwardso ad P. B. Giovaetti. Nursig worload measuremet systems, Aual Review of Nursig Research, 2 (994), [20] W. O. Tarow-Mordi, C. Hau, A. Warde ad A. J. Shearer. Hospital mortality i relatio to staff worload: A 4-year study i a adult itesivecare uit, The Lacet, 356, 9225 (2000),

CMA Physician Workforce Survey, National Results for Anesthesiologists.

CMA Physician Workforce Survey, National Results for Anesthesiologists. CMA Physicia Workforce Survey, 2017. atioal Results for Aesthesiologists. Q2. Geder Geder Female Male Other R All Physicias 29.1% 70.1% 0.6% 0.3% 100% 3590 otes: R=o respose. These demographics represet