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UBC Theses and Dissertations

Study of the modification of workload index staffing tool Jackson, Marion Ruth, 1940- 1973

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to STUDY OF THE MODIFICATION OF A WORKLOAD INDEX STAFFING TOOL by MARION RUTH JACKSON B.Sc.N., U n i v e r s i t y of Saskatchewan, 1963 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School of Nursing We accept t h i s t h e s i s as conforming to the re q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1973 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver 8, Canada 11 ABSTRACT This d e s c r i p t i v e study was designed to evaluate what m o d i f i c a t i o n s of an e x i s t i n g workload index s t a f f i n g t o o l were necessary f o r p r a c t i c a l a p p l i c a t i o n i n an extended care h o s p i t a l . Two a c t i v i t y s t u d i e s were conducted con-c u r r e n t l y i n a 63 bed extended care u n i t . The Inroom A c t i v i t y Study measured the amount and k i n d of care p a t i e n t s r e c e i v e d on each s h i f t . P a t i e n t s were c l a s s i f i e d i n t o two ca t e g o r i e s of n u r s i n g care needs - average and above average care. The I n d i r e c t Work Sampling Study i d e n t i f i e d how n u r s i n g s t a f f spent t h e i r time during t h e i r e i g h t hour tour of duty. A random s e l e c t i o n of the days of the week and the s h i f t to be observed was undertaken to s e l e c t times t h a t would be r e p r e s e n t a t i v e of the t o t a l week days. The data f o r the Inroom A c t i v i t y Study was c o l l e c t e d by continuous observations of n u r s i n g care given to p a t i e n t s during an e i g h t hour p e r i o d , and i n c l u d e d 10 p a t i e n t s from each category on each s h i f t . The data f o r the I n d i r e c t Care Study was c o l l e c t e d by making f i f t e e n minute spot checks on a l l n u r s i n g personnel throughout an e i g h t hour tour of duty. Observa-t i o n s were made throughout 5 day s h i f t s , 5 evening s h i f t s , and 4 n i g h t s h i f t s . Four questions were answered i n t h i s study. Data i i i i v analysis of Question 1 revealed that there was a difference i n the average amount of d i r e c t nursing care time that each category of patient received on days, and the average amount of time each category of patient received on evenings. There was no difference i n the average amount of time each category of patient received on nights. Data analysis of Question 2 revealed that there was a d i r e c t r a t i o between the amount of care a l l patients received on days, the average amount of time a l l patients received on evenings, and the average amount of time a l l patients received on nights. Data analysis of Question 3 revealed that weighting factors could be established to determine the amount of care received by each category of patient on each s h i f t . Data analysis of Question 4 showed the per-centage of time nursing personnel were able to spend i n givin g d i r e c t patient care during an eight hour s h i f t . The study concludes with consideration of the implications and recommendations f o r use of the workload index s t a f f i n g t o o l , and suggests further research as to refinement of the t o o l . 82 pages ACKNOWLEDGEMENTS My thanks are expressed to my Committee Chairman, Professor Mary Cruise, and Committee members Professor Helen E l f e r t and L i l l i a n McLean f o r t h e i r time and e f f o r t i n providing h e l p f u l suggestions} to the nursing s t a f f and patients who so w i l l i n g l y took part i n t h i s study? and to both my colleague, Eleanor Heieren, and my parents f o r t h e i r encouragement and i n s p i r a t i o n . v TABLE OF CONTENTS Page ACKNOWLEDGEMENTS v LIST OF TABLES v i i i LIST OF FIGURES i x CHAPTER I. INTRODUCTION TO THE STUDY 1 Introduction . . . . . « . . « « . • • • 1 The Purpose of the Study . . . . . . . . 4 The Problem . . . . . . . . . . . . . . 4 Assumptions . . . . . . . . 7 D e f i n i t i o n s • • . . • • • • « • « • • * 8 Limitations of the Study . . . . . . e . 1 0 I I . REVIEW OF THE LITERATURE 1 2 Conceptual Framework . . . . . . . . . . 1 2 Patient C l a s s i f i c a t i o n Studies . . . . . 2 0 Measurements of Patient Care Workload 2 6 I I I . METHOD 3 6 Overview . . . . . . . . . . . 3 6 Sample . . . . * . . . . . . « > < * • « 3 7 Patient C l a s s i f i c a t i o n . . . 3 8 The Inroom A c t i v i t y Study Data Co l l e c t i o n . . . . . . . . . . . . . . 3 9 The Indirect Care A c t i v i t y Study Data Co l l e c t i o n M v i v i i CHAPTER Page IV. ANALYSIS OP THE DATA . . . . Analysis of the Inroom A c t i v i t y Study 44 Analysis of the Indirect Care Study . . . 54 S t a f f i n g Guide Using the Workload Index 57 V. SUMMARY, CONCLUSIONS, RESEARCH IMPLICATIONS AND RECOMMENDATIONS 6 l Summary • • • « i ? . i . f e c e . . # . 6 l Conclusions • • • • • ; . . f . * * i . , 63 Research Implications . . . . . . . . . . 69 Recommendations 70 BIBLIOGRAPHY 71 APPENDICES . . . . 76 A. Patient C l a s s i f i c a t i o n Tool . . . . . 77 B. Direct Observation of Patient Data Form • • • • • . . 80 C. Work Sampling Data C o l l e c t i o n Form 82 LIST OP TABLES TABLE Page 1. Number of Patients Observed . . * . . . . , , kk 2. Average Minutes of Direct Nursing Care per Patient Category per S h i f t . . . . . . k$ 3. Relationship Between Amount of Care Received per Patient Category per S h i f t k5 k. Average Minutes of Direct Nursing Care per Patient per S h i f t • • • • • • k6 5. Ratios of Direct Nursing Care Time Received . . . . . . . . . . . . . . . . . k6 6. Number of St a f f Observed . . . . . . . . . . 5k 7. Total Observations Recorded 55 8. Percent of S t a f f Time Spent on Each A c t i v i t y per S h i f t 55 9. Conversion of Workload Index to Required S t a f f . . . . . • • 59 • • • v i i i LIST OF FIGURES FIGURE Page 1. Conceptual Framework • • . « 14 2. Average Direct Nursing Care Time by Patient Category and Type of Function* • . 51 3« Average Direct Nursing Care.Time by Patient Category and Level of Staff . 53 4, Calculation of Workload Index and Estimation of Required Staff Numbers f o r October, 1972 6? 5. Graphical Representation of Workload Index Calculation f o r October, 1972 . . . 68 i x CHAPTER I INTRODUCTION TO THE STUDY I. INTRODUCTION One of the most d i f f i c u l t aspects of the management role i n nursing service i s that of s t a f f i n g to meet the 1 needs of the patient. To be e f f e c t i v e the nurse manager must be able to assess the s t a f f i n g needs of each unit,, provide f l e x i b i l i t y i n s t a f f i n g by the a l l o c a t i o n of s t a f f according to workload, indicate trends i n patient care load from month to month, compare workloads between wards, and predict future s t a f f requirements when submitting annual 2 operational budgets. In the past a l l o c a t i o n of s t a f f has been determined, primarily, by patient census and the subjective judgement of experienced directors of nursing, supervisors, and head nurses. Far too often emphasis has been placed on patient census. Census can be misleading i f i t i s used as the sole 1 "Statement on Nursing S t a f f Requirements f o r In-patient Health Care Services," prepared by the Committee on Nursing Services, American Nurses' Association, American  Journal of Nursing, v o l . 67, no. 5, (May, 1967), pp 1029 -1030. 2 Margaret Street, " S t a f f i n g Problems i n Nursing Service," Canadian Nurse, v o l . 6 l , no. 2, (February, 1967), PP 91 - 93. 1 2 basis f o r judging workload, since each patient has varying degrees of nursing care requirements. The subjective judgements of nursing supervisors within the same i n s t i t u t i o n may vary greatly because of t h e i r i n d i v i d u a l differences i n both experience and education. To achieve consistency and to provide s t a f f i n g which w i l l meet the needs of the patients, nursing requires a method f o r objectively a r r i v i n g at a measure of nursing care workload, and an associated s t a f f i n g 3 guide. Since A p r i l , 1969t as Director of Medical Nursing at University Hospital, Saskatoon, Saskatchewan, the writer had been moving s t a f f between the four medical wards f o r which she was responsible. The assessment of s t a f f i n g requirements was a subjective assessment made by the Director, a f t e r consultation with the Head Nurse, on each of the wards. In A p r i l , 1970, at University Hospital, an objective method f o r numerically assessing workloads, and f o r c a l c u l a t i n g the number of required nursing s t a f f was developed out of the 4 nursing research i n progress. Use of the patient workload 3 Eugene Levine, "Nurse S t a f f i n g i n Hospitals," American Journal of Nursing, v o l . 6 l , no. 9, (September, 1961), pp 65 - 68. 4 K. Sjoberg and P. B i c k n e l l , Nursing Study Phase I I i  A P i l o t Study to Implement and Evaluate the Unit Assignment  System, Hospital Systems Study Group, University of Sask-atchewan, Saskatoon, Saskatchewan, December, 1969, 3 5 index t o o l made these decisions much more objective. The workload index was calculated d a i l y f o r each s h i f t , on each ward. S t a f f were then allocated to best meet patients* needs. The writer found that the workload index was an objective and accurate reference to use when compiling monthly and annual reports. I t was also a valuable t o o l to use when dealing with operational budgets when requesting or r e c l a s s i f y i n g nursing s t a f f p o s i t i o n s . Subsequent use of the workload index s t a f f i n g t o o l by other directors of the c l i n i c a l services i n t h i s same hosp i t a l resulted i n a more consistent o v e r a l l approach to s t a f f i n g the t o t a l nursing service department, and i n the a l l o c a t i o n of part time personnel assigned from a central l o c a t i o n at the beginning of each s h i f t . This approach to s t a f f i n g appears to provide consistency i n the provision of patient care, o b j e c t i v i t y i n e s t a b l i s h i n g s t a f f i n g p r i o r o t i e s , increased s t a f f s a t i s f a c t i o n by l i m i t i n g the wide fluctuations i n the nurse's d a i l y assignment of patients, and i n d i c a t i o n of cost reduction 5 P. B i c k n e l l , S t a f f i n g by Patient Care Workload. Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, December, 1970. 6 Communications between the Nursing Administrator and the Directors of C l i n i c a l Services, University Hospital, Saskatoon, Saskatchewan, 1970 - 1971. 4 7 i n providing nursing care by using a f l e x i b l e approach. I I . THE PURPOSE OF THE STUDY The purpose of the study was to obtain data on s t a f f u t i l i z a t i o n and the amount and type of nursing care being provided. Direct patient care a c t i v i t i e s of the nursing personnel were explored as well as the nursing personnel's i n d i r e c t patient care a c t i v i t i e s . I t i s intended that the study w i l l contribute to the knowledge of nursing s t a f f u t i l i z a t i o n by providing an instrument that w i l l a s s i s t nursing directors of extended care units to s t a f f more e f f e c t i v e l y . I I I . THE PROBLEM Statement of the Problem What modifications of an e x i s t i n g workload index s t a f f i n g t o o l are necessary to provide an e f f e c t i v e s t a f f i n g guide f o r u t i l i z a t i o n i n an extended care setting? In order to solve t h i s problem four questions must be answered. They includet (1) Is there a difference i n the average amount of di r e c t nursing care time that each category of patient receives on days, the average amount of time Marion Jackson, Annual Report - Medical Nursing  Department, submitted to the Nursing Administrator, University Hospital, Saskatoon, Saskatchewan, December, 1970. 5 each category of patient receives on evenings, and the average amount of time each category of patient receives on nights?, (2) Is there a d i r e c t r a t i o between the average amount of d i r e c t nursing care time that a l l patients receive on days, the average amount of time a l l patients receive on evenings, and the average amount of time a l l patients receive on nights?, (3) Can weighting factors be established from the relat i o n s h i p of d i r e c t nursing care time received by each category of patient on each s h i f t , and the r a t i o between the d i r e c t care patients receive on each s h i f t ? W i l l these weighting factors d i f f e r from those i d e n t i f i e d i n the acute care center?, and (4) W i l l the number of d i r e c t nursing care hours that nursing personnel provide i n an extended care se t t i n g d i f f e r from the number of d i r e c t care hours that nursing personnel provide i n the acute care setting? S p e c i f i c Objective of the Study The s p e c i f i c objective of the study i s to esta b l i s h the values f o r c a l c u l a t i o n of the workload index which can provide p r a c t i c a l a p p l i c a t i o n i n an extended care s e t t i n g by» (1) c l a s s i f i c a t i o n of patients into categories of care according to t h e i r needs f o r nursing care, (2) i d e n t i f i c a t i o n of the time nursing personnel spend giving d i r e c t care to each category of patient on each s h i f t , and (3) i d e n t i f i c a t i o n of the time nursing personnel spend on a c t i v i t i e s away from the patient's bedside. Significance of the Problem That the costs of health care services are r i s i n g 6 yearly i s indisputable. An important area to examine i s the question of what proportion of available f i n a n c i a l resources should be a l l o t t e d to nursing service to maintain a safe l e v e l of patient care with maximum e f f i c i e n c y ; The very d e f i n i t e need to relate s t a f f i n g to workload has been well 8 documented and recommended. Quantitative standards developed by s p e c i f i c hospitals cannot, and should not, be applied d i r e c t l y to other i n s t i t u t i o n s providing health services. This would r e s u l t i n a defeat of t h e i r i n i t i a l purpose and a loss of 9 t h e i r p o t e n t i a l f o r effectiveness. The tools f o r measuring quantitative needs can only be used when they are adjusted to 1 0 meet the needs of a p a r t i c u l a r nursing service department. However, the investigator believes that mueh time and e f f o r t can be saved by the modification of e x i s t i n g tools rather than the development of separate tools f o r each i n s t i t u t i o n i The acute care settings throughout Canada have gained through research. V i r t u a l l y no research of t h i s 8 Task Force Reports on Cost of Health Services i n Canada, v o l . 2 , Hospital Services, Queen's Pr i n t e r f o r Canada, Ottawa, 1 9 7 0 . 9 Margaret G i f f i n , "Your S t a f f i n g Situation i s Diff e r e n t , " American Journal of Nursing, v o l . 5 2 , no. 1 1 , (November, 1 9 5 2 ) , pp 1 3^8 - 1 3 5 1 . 1 0 Clara Hardin, "Using the Studies of Nursing Functions," American Journal of Nursing, v o l . 5 7 , noi 5 , (May, 1 9 5 7 ) , PP 6 2 2 - 6 2 3 . 7 11 kind has been conducted i n extended care f a c i l i t i e s . On January 1, 1972, i n B r i t i s h Solumbia, 27 extended care f a c i l i t i e s were providing care to 2,104 patients. The projected number of beds available f o r the end of 1972 was 3000. This was only a 75 per cent estimation of 12 required needs. Studies must be conducted i n extended care f a c i l i t i e s to i d e n t i f y the nursing needs of the patients, and to provide appropriate s t a f f i n g to meet those needs. Because of a l l these factors a study, conducted to determine what modifications of an e x i s t i n g workload index s t a f f i n g t o o l are necessary f o r a p p l i c a t i o n i n an extended care f a c i l i t y , was warranted, IV. ASSUMPTIONS This study i s based on the following assumptionsi (1) the c l a s s i f i c a t i o n system used i s a r e l i a b l e and v a l i d t o ol f o r assessing the patients* needs f o r nursing care, and (2) a quantitative measure of nursing care can be used as an estimate of the care the patients a c t u a l l y require. 11 Personal Communication with Mrs. L i l l i a n McLean, Director of Nursing, Louis B r i e r Home and Hospital, March, 1972. 12 I b i d i V. DEFINITIONS 8 Patient C l a s s i f i c a t i o n Patient c l a s s i f i c a t i o n i s a system of organizing patients* needs f o r nursing care into one of four categories. The categories include minimal care, average care, above average care, and intense carei Minimal Care The patient i s p h y s i c a l l y capable of caring fox; himself, but requires minimal support plus treatments or 13 monitoring by the nurse every four hours. Average Care The patient requires an average amount of nursing care and medical supportj e i g . he i s past the acute stage 14 of h i s disease. Above Average Care The patient requires a greater than average amount of care, medical support and use of special equipment; e.g. .15 af t e r the acute phase of CVA with residual p a r a l y s i s i Intense Care The patient requires continuous nursing care and 13 K. Sjoberg and P. B i c k n e l l , Patient C l a s s i f i c a t i o n  Study. Hospital Systems Study Group, University of Saskatchewan, September, 1968. 14 I b i d , p. 8. 15 Ib i d , p. 8. 9 close supervision by medical personnel with support from technical equipment} e.g. patient with multiple s c l e r o s i s on a rocking bed. Acute Care Setting An i n s t i t u t i o n designed f o r patients who are ser-i o u s l y i l l regardless of diagnosis, who require constant professional s k i l l e d nursing care and observation, d a i l y medical attention,reassessment, and observation! and f o r those patients who require special diagnostic and treatment 17 f a c i l i t i e s only available i n an acute h o s p i t a l . Extended Care Setting This i s an i n s t i t u t i o n designed f o r persons of a l l ages who do not require acute h o s p i t a l care and treatment, nor an intensive or comprehensive programme of a c t i v a t i o n and r e h a b i l i t a t i o n ; This l e v e l i s r e s t r i c t e d to those with severe impairment and who require regular and continuing medical attention as well as s k i l l e d nursing provided under graduate nurse supervision on a 24 hour basis. These patients should be treated i n the extended care unit 18 of an acute h o s p i t a l , or i n an extended care h o s p i t a l . 16 K. Sjoberg and P. B i c k n e l l , Patient C l a s s i f i c a t i o n  Study, Hospital Systems Study Group, University of Sask-atchewan, Saskatoon, Saskatchewan, September, 1968. 17 B.C.H.I.S., Defi n i t i o n s of Levels of Care, sent with form l e t t e r to B r i t i s h Columbia Hospitals, September, 1972. 18 I b i d . 10 Nursing Personnel This includes a l l personnel g i v i n g d i r e c t care to the p a t i e n t s . I t includes reg i s tered nurses and nurs ing a ides . Weighting Factors Weighting factors represent numerical values that have s i g n i f i c a n t r e l a t ionsh ip s to one another. Workload Index A numerical value that i s representat ive of the pat ient care load fo r the ent i re pat ient populat ion of a u n i t , ward, or h o s p i t a l . D i rec t Nursing Care This represents a l l care that i s given d i r e c t l y to the pat ient by the nursing personnel such as bathing, feeding, and administer ing medications. Ind i rec t Care This represents a l l i n d i r e c t care performed by the nurs ing personnel for the benef i t of the pa t i ent , and a l l a c t i v i t i e s which do not a f fec t the pat ient d i r e c t l y , but f u l f i l l the needs of the i n s t i t u t i o n such as the r e q u i s i t i o n -ing of supp l ie s . Y I . LIMITATIONS OF THE STUDY The study i s subject to the fo l lowing l imitat ionss (1) The study considered only numerical values which represented the amount of care that the pat ients a c t u a l l y rece ived , and not the nurs ing care required by the pa t ient s , 11 and (2) the study was conducted i n only.one extended care f a c i l i t y i n Vancouver, B r i t i s h Columbia. CHAPTER II REVIEW OF THE LITERATURE Review of the l i t e r a t u r e has been d iv ided into three sect ions i n c l u d i n g a conceptual izat ion of a l l of the var iab le s i n the s t a f f i n g of nursing u n i t s , a review of the s i g n i f i c a n t studies on pat ient c l a s s i f i c a t i o n , and a review of s i g n i f i c a n t studies that have developed indices fo r s t a f f i n g based on pat ient care loads • I . CONCEPTUAL FRAMEWORK The attempt to s t a f f nurs ing uni t s i n order to meet pa t ient needs i s a very r e a l concern to nurs ing adminis tra tors . The many var iab les i n s t a f f ing must be del ineated to substantiate a quant i ta t ive approach to the study of the problem. The volumes of l i t e r a t u r e concerned with s t a f f i n g problems are so numerous that a concise review of the l i t e r a t u r e i s imposs ible . Furthermore, the amount of research that has been car r i ed out i n the area of s t a f f i n g continues at a rap id pace. A review of the approaches to s t a f f i n g , prepared by the Canadian Nurses* As soc ia t ion , 1 gives c l ea r evidence of t h i s . The attempt, i n t h i s f i r s t 1 Canadian Nurses' As soc ia t ion , H i s t o r i c a l Overview  of Approaches to S ta f f ing the Hospi ta l Nursing Service'  Department, Canadian Nurses* As soc ia t ion . 50 The Driveway, Ottawa 4, 1966. 12 13 section of the l i t e r a t u r e review, w i l l be to i d e n t i f y a l l the intervening variables by a synthesis of much of the l i t e r a t u r e concerned with s t a f f i n g . Figure 1 i l l u s t r a t e s schematic representation of the conceptual framework. Influence of Soc i a l Factors 2 The r i s i n g cost of health services has a most profound a f f e c t on s t a f f i n g nursing u n i t s . The largest single item of expenditure i n a hospital's operational budget i s a l l o t t e d to the nursing service department. Although the estimates vary from h o s p i t a l to ho s p i t a l , some authors have stated that from one-half to one-third of a l l h o s p i t a l s a l a r i e s go to nursing personnel. This f a c t alone makes j u s t i f i c a t i o n of nursing budgets e s s e n t i a l . Nursing having had no control over the type of patients being admitted plus having no tools to i d e n t i f y patient workload has tended to s t a f f f o r projected maximum work-2 Task Force Reports on Cost of Health Services i n Canada, v o l . 2, Hospital Services, Queen's Pr i n t e r f o r Canada, Ottawa, 1970. 3 Margaret G i f f i n , "Your S t a f f i n g Situation i s Diff e r e n t , " American Journal of Nursing, v o l . 52, no. 11, (November, 1952), pp 1348 - 1351. 4 Measurement of Nursing Care, no. 9, Operational Research Unit, Oxford Regional Hospital Board, Old Road, Headington, Oxford, 19^7 • 14 SOCIAL INFLUENCES COST OF 1 ^HEALTH CARE SERVICES RAPID GRCWTH MEDICAL TECHNOLOGY OF HOSPITALS GROWTH NURSING HEALTH CARE VIEWED SHORTAGE AS A PUBLIC RIGHT <- -> NURSING SERVICE ORGANIZATION STAFFING POLICIES QUALITY OF AND PRACTICES ADMINISTRATION METHOD OF ASSIGNMENT / STAFF FUNCTIONS STAFF RESOURCES PROFESSIONAL DEVELOPMENT EMPLOYMENT POLICIES TIME FACTORS NURSE SATISFACTION PATIENT POPULATION EFFECTIVE STAFFING UNIFORMITY AND OBJECTIVITY IN COMMUNICATION FEEDBACK ON PATIENT NEEDS BY 1. C L A S S I F I C A T I O N 2. QJdKHinv OF CARE -dj.ie.ct. -i.ndi.ie.ct 3 . QUALITY Of CARE ADMISSIONS DISCHARGES LENGTH OF HOSPITAL STAY DEGREE OF DEPENDENCE AMOUNT AND KIND OF CARE FLUCTUATING DAILY NEEDS QUANTITY AND QUALITY CONTINUITY OF CARE I STANDARD OF CARE SWINGS IN WORKLOAD TIME CONSUMED PER PATIENT PATIENT SATISFACTION FACILITIES TO MEET PATIENT NEEDS PHYSICAL PLANT 1 — UNIT SIZE 1 1 EQU I^ PMENT 1 SUPPLIES ^ M E D I C A L STAFF SCOPE OF NUMBER OF ACTIVITIES PHYSICIANS PHYSICIAN SATISFACT ON Figure 1 - Conceptual Framework 15 5 loads which i s economically unsound. I t i s recognized that as medical technology ex-pands, and as the general public's knowledge and demand fo r health care increases, the number of hospitals increase. These factors lead n a t u r a l l y to an increased demand f o r nursing personnel. The shortage of nursing personnel, r e a l or imagined, i s not d i f f i c u l t to understand i n today's society. Women have many more alte r n a t i v e occupations from which to choose a career. Thus fewer women i n the population are l i k e l y to enter nursing i n comparison with the proportion of women 6 i n the population f i f t e e n years ago. The shorter work day, work week, increased vacation time, and other employee benefits further decrease the l i k l i h o o d of meeting the 7 demands. However, simply increasing the number of nursing personnel may not solve the problem, as was indicated i n a 5 Eleanor Heieren, Nursing Service Research Report -Workload Index, prepared f o r the Hospital Systems Study Group Third Annual I n s t i t u t e , University of Saskatchewan, Saskatoon, Saskatchewan, September 29, 1971* 6 "Statement on Nursing S t a f f Requirements f o r In-patient Health Care Services," prepared by the Committee on Nursing Services, American Nurses' Association, American  Journal of Nursing, v o l . 67, no. 5, (May, 1967)» pp 1029 -1030. 7 Elmina Priee, S t a f f i n g f o r Patient Care. Springer Publishing Company, Inc., New York, 1970. 16 8 study conducted by Abdellah and Levine. A study by 9 Aydelotte further indicated that increasing the number of personnel did not necessarily improve the care of the patients; E f f e c t i v e u t i l i z a t i o n of present resources would appear to be a more r a t i o n a l approach to deal with the shortage of nursing personnel. Organization of Nursing Service Sjoberg, Heieren and Jackson noted that the philosophy and objectives of the nursing service department, and the q u a l i t y of the senior nursing personnel d i r e c t l y a f f e c t the s t a f f i n g of nursing u n i t s . These factors are determinants f o r s t a f f i n g p o l i c i e s , nursing procedures, method of assignment, defined functions of nursing personnel, opportunity f o r professional development and advancement, and consistency i n the nurses' d a i l y r e s p o n s i b i l i t i e s . I f these factors are p o s i t i v e l y directed, they are l i k e l y to 8 Faye Abdellah and Eugene Levine, E f f e c t of Nurse  S t a f f i n g on S a t i s f a c t i o n with Nursing Care, Chicago. I l l i n o i s i American Hospital Association, Hospital Monograph, Series no. 4, 1958. 9 Myrtle Aydelotte, "The Use of Patient Welfare as a C r i t e r i o n Measure," Nursing Research, v o l . 11, (1962), p. 10. 10 K. B. Sjoberg, E. L. Heieren, and M. R. Jackson, "Unit Assignment A Patient-Centered System," Nursing  C l i n i c s of North America, v o l . 6, no. 2, (June, 1971)» PP 333 - 342. 17 increase the nurses' job s a t i s f a c t i o n which should decrease the rate of s t a f f turnover. Frequent turnover of s t a f f makes s t a f f i n g inconsistent, i s l i k e l y to increase costs, and most important, a f f e c t the q u a l i t y of care given to patients. A f i v e year nursing study at University Hospital i n Saskatoon, Saskatchewan, which dealt with many of these factors, resulted i n more e f f i c i e n t s t a f f i n g , increased job s a t i s f a c t i o n , and indicated a substantial saving i n 11 operational costs. Patient Population In determining how much s t a f f i s necessary* consider-ation of patient census, number of admissions and discharges d a i l y , and the average length of the patients* h o s p i t a l stay i s e s s e n t i a l . Census, alone, w i l l not e f f e c t i v e l y 12 determine s t a f f i n g needs. I d e n t i f i c a t i o n of the degree of each patient's needs i s the important determinant. This dependence should be assessed d a i l y because the patient's nee 13 may fluctuate from day to dayi 11 K. B. Sjoberg, E. L. Heieren, and M. R, Jackson, "Unit Assignment: A Patient-Centered System," Nursing  C l i n i c s of North America, v o l . 6, no. 2, (June, 1971)# PP 333 - 342. 12 Ruth Preston, "Add Meaning to Your Hospital Census," Nursing Outlook, v o l . 10, no. 7* (July, 1962), pp 466 - Wo~. 13 I b i d . 18 In addition the amount and kind of care to be given to the patient should be c l e a r l y established. Abdellah and others have suggested three categories of care which include sustenal, remedial, and r e s t o r a t i v e . Both q u a l i t y and quantity of s t a f f w i l l determine the type of care that 15 the nurse i s able to administer. Based on the preceeding discussion the investigator believes that the established s t a f f i n g pattern of any h o s p i t a l w i l l determine the standard of care and the time consumed per patient. Both these factors a f f e c t , to a great extent, the patient's comfort and s a t i s f a c t i o n . F a c i l i t i e s to Meet Patient Needs The following generalizations regarding i n t e r n a l and external forces a f f e c t i n g s t a f f i n g are sunbstantiated by the studies conducted by the Hospital Systems Study Group at the University of Saskatchewan, Saskatoon, Saskatchewan. 0 The physical plant and the size of each unit a f f e c t s t a f f i n g needs. Generally, the smaller the unit the greater 14 F. G. Abdellah, et a l , Patient-Centered Approaches  to Nursing. The MacMillan Company, New York, I960. 15 Margeurite Paetznick, A Guide f o r S t a f f i n g a  Hospital Nursing Service. Public Health Papers, World Health Organization, Geneva, 1966. 19 16 the cost i s i n s t a f f i n g . The a v a i l a b i l i t y , quantity, and the q u a l i t y of supplies and equipment w i l l also a f f e c t the s t a f f i n g of a 17 nursing u n i t . I f the nurse must t r a v e l varied distances, and frequently, to obtain supplies and equipment, more time i s consumed r e s u l t i n g i i i the need f o r more s t a f f and 18 i n the i n e f f e c t i v e u t i l i z a t i o n of professional nurses. Obviously, the structure of the medical s t a f f w i l l a f f e c t nurse s t a f f i n g . The number of physicians p r a c t i c i n g i n the ho s p i t a l , the scope of t h e i r a c t i v i t i e s , and t h e i r expectations f o r the nursing care of t h e i r patients w i l l determine, to some extent, the number and category of nursing personnel i n the i n s t i t u t i o n . 16 B. A. Holmund, Nursing Study - Phase I - University Hospital. Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, September, 1967, 17 K. Sjoberg and P, B i c k n e l l , Nursing Study - Phase  IIi--A-Pilot ..Study to Implement and Evaluate the Unit  Assignment System. Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, Deeefliber, 1969, 18 K. Sjoberg, E. Heieren, and P. B i c k n e l l , Nursing  Study - Phase IIIV Implementation and Evaluation of Unit  Assignment m a MUlti-Ward Setting, Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, August, 1971. 20 Discussion Exploration of the many variables that a f f e c t s t a f f i n g of the ho s p i t a l nursing service departments indicates that much research i s necessary to examine the many variables involved. How can e f f e c t i v e u t i l i z a t i o n of nursing s t a f f be achieved? O b j e c t i v i t y and Uniformity i n communication between a l l sources concerned with s t a f f i n g to meet patient needs w i l l r e s u l t i n e f f e c t i v e u t i l i z a t i o n of available s t a f f . To reach t h i s optimal state, standardized methods of i d e n t i f y i n g both quantitative and q u a l i t a t i v e measures of care are e s s e n t i a l . The methods of communication must be such that i t i s l o g i c a l to nurses, physicians, business administrators, and the p u b l i c . I I . PATIENT CLASSIFICATION STUDIES Since quantitative nursing care i s more e a s i l y studied, the s t a r t i n g point has been time studies to determine how much care the patient i s receiving. At f i r s t , time studies dealt with averages of time that care was given to a l l patients regardless of t h e i r i n d i v i d u a l needs. Recently, c l a s s i f i c a t i o n of the patient, according to his needs f o r 19 nursing care, have made time studies more d e f i n i t i v e . 19 K., Sjoberg and P. B i c k n e l l , The Development of a  Research Tool to Evaluate and Compare the Standard of Patient  Care. Hospital Systems Study Group, University of Sask-atchewan, Saskatoon, Saskatchewan, A p r i l , 1971, Unpublished; 21 The inves t i ga tor fee l s that more s p e c i f i c information on quant i ty of care i s needed. Hopeful ly , further study on the quant i ta t ive measurements of pat ient care w i l l a s s i s t i n the i d e n t i f i c a t i o n of improved methods for the measurement of q u a l i t a t i v e pat ient care . C l a s s i f i c a t i o n of pa t ient s , according to t h e i r needs 20 for nurs ing care, was suggested as f a r back as 1937* The major work that was done i n t h i s area was p r i m a r i l y i n the late; 1950's and 196o»s. Review of the s i g n i f i c a n t studies on pat ient c l a s s i f i c a t i o n w i l l include those of the past f i f t e e n years . 21 In 1955» Flanagan and Herdan analyzed the nursing requirements of neuro log ica l and neurosurgical pa t i en t s . The pat ients were grouped into four categories of care according to t h e i r degree of phys i ca l independence. Observers recorded the amount of time d i r e c t care was g iven . The s t a t i s t i c a l approach revealed that , on the average, pat ients 20 Committee on Studies of the National League o f Nursing Education, "A Study of the Nursing Service i n F i f t y Selected H o s p i t a l s , " Reprinted from The Hosp i ta l  Survey from New York. The United Fund of New York, 1937. 21 E . Flanagan and I . Herdan, "A Prel iminary Study and Analys i s of Nursing Care Requirements i n Neurological and Neurosurgical Nurs ing , " Canadian Nurse, v o l . 51* no. 11, (November, 1955), pp 855 - 8 o X 22 received 3*7 hours of d i r e c t care per 24 hours. This average was f o r a l l patients regardless of t h e i r category. The researchers estimated the i n d i r e c t care as 1 hour i n a 24 hour period. This was an estimation only, not a timed f a c t o r . One of the most s i g n i f i c a n t studies originated at 22 the John Hopkins Hospital under the d i r e c t i o n of F l a g l e . A c l a s s i f i c a t i o n system was developed which divided the patients into three groups of care based on the elements of nursing care. I t was further developed by Connor and 23 others from the John Hopkins Research Center, Their studies indicated the importance of categorizing patients according to nursing care needs. The c l a s s i f i c a t i o n consisted of a ch e c k l i s t of 25 items, and put the patient into one of three categories of care - intensive, i n t e r -mediate, and minimal, 24 CASH (Commission f o r Administrative Services i n 22 C, D, Flagle, et a l , Optimal Organization and  F a c i l i t y f o r a Nursing Unit, Operations Research D i v i s i o n , The John Hopkins Hospital, Baltimore, 1959, 23 R. J . Connor, et a l , " E f f e c t i v e Use of Hospital Resources! A Research Report," Hospitals, JAHA, v o l , 35. no, 5, (May 1, 1961), pp 30 - 39. 24 Nursing Service« Staff U t i l i z a t i o n and Control  Program Orientation Report, May, 1964, Commission f o r Administrative Services i n Hospitals, CASH, 23 H o s p i t a l s ) , i n 1964, published a report on s t a f f u t i l i z -a t ion and a program for c o n t r o l . Nursing personnel were categorized according to what procedures they performed for pa t ient s , and the pat ients were c l a s s i f i e d as s e l f care, intermediate care, and intens ive care . 25 In 1965, MacDonell and Murray at Deer Lodge H o s p i t a l , i n Winnipeg, Manitoba, introduced a three l e v e l care ca tegor iza t ion of pa t i en t s . These included l e v e l I -i n v e s t i g a t i v e , convalescent} l e v e l II - intermediate, extended; and l e v e l III - in tens ive , acute. Placement of the pat ient involved a check-off l i s t of 55 items to describe the p a t i e n t . The program was most extensive and appeared to meet d e f i n i t i v e c r i t e r i a of pat ient needs. To be used d a i l y on a un i t was f e l t by some nursing profess ional s 26 to be too time consuming to be of p r a c t i c a l va lue . In 1964 the research un i t i n Headington, Oxford, observed care received by pat ients c l a s s i f i e d into s e l f care, 27 intermediate care, and intensive care . The i r methods of 25 J . A . K. MacDonell and G. B. Murray, "An Index of Care , " Medical Services Journal , Canada, v o l . XXI, no. 8, (September 8, 1965), pp 499 - 517. 26 K. Sjoberg and P. B i c k n e l l , Pat ient C l a s s i f i c a t i o n  Study, Hospi ta l Systems Study Group, Univer s i ty of Sask-atchewan, Saskatoon, Saskatchewan, December, 1968. 27 Measurement of Nursing Care, no. 9, Operational Research Uni t , Oxford Regional Hospi ta l Board, Old Road, Headington, Oxford, 1967. zk research added more knowledge to the s ign i f i cance of pat ient c l a s s i f i c a t i o n , and the time consumed per pat ient i n each category. In 1967 the U n i v e r s i t y of Saskatchewan Hospi ta l Systems Study Group produced a f o u r - l e v e l c l a s s i f i c a t i o n system for i d e n t i f y i n g pat ient nurs ing needs. The i r ana lys i s of nurs ing a c t i v i t y studies resul ted i n the development of a t o o l that qu i ck ly and simply c l a s s i f i e d pat ients in to four categories of nurs ing care inc lud ing 28 minimal, average, above average, and intense . This re su l tant c l a s s i f i c a t i o n system was tested for r e l i a b i l i t y 29 and v a l i d i t y i n 1968. I t was shown to be a s a t i s f ac tory method of c l a s s i f y i n g pat ients i n a. short per iod of t ime. Since t h i s c l a s s i f i c a t i o n t o o l was used i n the present study, a general summary of i t s elements i s presented. 30 Information was taken from the study by Sjoberg and B i c k n e l l . This pat ient c l a s s i f i c a t i o n system contains s ix primary nurs ing need categories inc lud ing personal care, feeding, 28 B. A . Holmund, Nursing Study - Phase I - Univer s i ty  H o s p i t a l , Hosp i ta l Systems Study Group, Univer s i ty of Saskatchewan, Saskatoon, Saskatchewan, September, 1967. 29 K. Sjoberg and P . B i c k n e l l , Pat ient C l a s s i f i c a t i o n  Study, Hosp i ta l Systems Study Group, Univer s i ty of Sask-atchewan, Saskatoon, Saskatchewan, September, 1968. 30 Ib id 25 observation, a c t i v i t y , f eca l incontinence, and pre-operative care . The determiners i n d i c a t i n g the category to which the pat ients belong y i e l d a combination of h i s i d e n t i f i e d needs. Minimal care determiners include i n -dependent personal care, such as r equ i r ing only basin or tub, independent i n feeding, observation every four hours or l e s s , and unre s t r i c t ed a c t i v i t y . Average care determin-ers include bathing with ass i s tance, p a r t i a l help i n feed-i n g , observation every two to four hours, and r e s t r i c t e d phys i ca l a c t i v i t y such as 'up with ass istance* or on 'bed res t with bathroom p r i v i l e d g e s * . Above average and intense determiners include complete bathing by the nurse, fed by the nurse, or nothing by mouth, intravenous therapy, tube feeding, constant or hourly observation, p o s i t i o n i n g by the nurse i n bed or cha i r , f e c a l incontinence, and preoperative preparat ion . One basic assumption includes psychosocial support on a continuouscbasis . I f psychosocia l or pat ient teaching needs are primary, they would be included i n the observat ional determiner. I t i s the combination of these needs that place the pat ient into one of the four categories for nurs ing care . In 1970 r e l i a b i l i t y and v a l i d i t y t e s t ing of a f ive l e v e l c l a s s i f i c a t i o n t o o l , developed at Vancouver General 31 H o s p i t a l , Vancouver, B r i t i s h Columbia, was undertaken. 31 P h y l l i s G iovanet t i , et a l , The R e l i a b i l i t y and  V a l i d i t y Test ing of a Subjective Pat ient C l a s s i f i c a t i o n  System. The Vancouver General H o s p i t a l , Vancouver, B r i t i s h Columbia, June, 1970. 26 The f i ve l e v e l c l a s s i f i c a t i o n , subjective i n nature, was not found to be s t a t i s t i c a l l y r e l i a b l e or v a l i d . I t was f e l t that a f i v e - l e v e l t o o l would be more sens i t ive i n the i d e n t i f i c a t i o n of the pat ients * nurs ing care needs. Although the r e l i a b i l i t y and v a l i d i t y was not s t a t i s t i c a l l y s i g n i f i c a n t , the t o o l was found to be useful as a guide for s t a f f i n g . 32 P r i c e ' s study on s t a f f ing c l a s s i f i e d pat ients into one of three categories - independent, p a r t i a l l y independent, and dependent. This c l a s s i f i c a t i o n was based on the a c t i v i t i e s of d a i l y l i v i n g . In t h i s study the researchers eventual ly disregarded c l a s s i f i c a t i o n of the p a t i e n t s ' nurs ing needs, and appeared to r e l y more on the i n t u i t i o n of the nurse. I I I . MEASUREMENTS OF PATIENT CARE WORKLOAD 33 The program developed by CASH for s t a f f u t i l i z -a t ion and contro l suggested an inter im s t a f f ing guide. This included i d e n t i f i c a t i o n of the t o t a l hours ava i l ab le for g i v i n g d i r e c t care to the pat ients i n each category. The researchers i d e n t i f i e d basic care time and spec ia l care 32 Elmina P r i c e , S ta f f ing for Pat ient Care. Springer Publ i sh ing Company, I n c . , New York, 1970. 33 Nursing Servicet S ta f f U t i l i z a t i o n and Control  Program Or ienta t ion Report. May.. 1964. Commission f o r Administrat ive Services i n Hosp i ta l s , CASH. 27 time i n the a c t i v i t y studies conducted. The t o t a l hours ava i l ab le from nursing personnel were d iv ided mathemati-c a l l y by the pat ient care requirements. The i r ana lys i s ind ica ted that the pa t ient s , o v e r a l l , received 45 per cent care time on days, 37 per cent nurs ing care time on eveen-ings , and 18 per cent nursing care time on n ight s . Using t h i s as a base l i n e , determination of approximate s t a f f requirements could be made at the s t a r t of each s h i f t based on the number of pat ients and t h e i r estimated needs for nurs ing care . The program also suggested a more even d i s t r i b u t i o n of care throughout the 24 hour day, rather than the oeak periods o f a c t i v i t y i d e n t i f i e d i n t h e i r time s tud ies . 35 The research group at Oxford Regional H o s p i t a l , using a c t i v i t y sampling and continuous pat ient observation, es tabl i shed the amount of time spent i n g i v i n g nursing care to each category of p a t i e n t . The r a t i o between the three l e v e l s of care over a 24 hour per iod was found to be 1 t 2 t 5 • An o v e r a l l index of workload could be es tabl i shed by mul t ip ly ing the number of pat ients i n each category by the r a t i o for that care group plus summation 34 Nursing Servicet S ta f f U t i l i z a t i o n and Control  Program Or ienta t ion Report, May, 1964, Commission fo r Administrat ive Services i n Hosp i t a l s , CASH. 35 Measurement of Nursing Care, no. 9 i Operat ional Research U n i t , Oxford Regional Hospi ta l Board, Headington, Oxford, 1967 . 28 36 of the t o t a l s . The d i r e c t care index associated with the c l a s s i f i -ca t ion system at the John Hopkins Hospi ta l gave a measure of d a i l y nurse hours of d i r e c t care . The average time per pat ient category inc luded , s e l f care - one-half hour; p a r t i a l care - one hour; and complete care - one and one-half hours 37 of d i r e c t nursing care per 24 hour day. More s p e c i f i c numerical ra t ings were assigned to each care category i n the development of the workload index at the Univer s i ty H o s p i t a l , Saskatoon, Saskatchewan. Because t h i s was the t o o l chosen for modi f icat ion i n the present study, an indepth review of i t s elements are presented. At the Univer s i ty Hospi ta l the workload index i s based on the amount of d i r e c t nurs ing care each category of pat ient receives on each s h i f t . I t i s further based on how the nurs ing personnel spend t h e i r time on each s h i f t inc lud ing d i r e c t pat ient care, 38 personal time, and other functions not re l a ted to pat ient care . 36 Measurement of Nursing Care, no. 9. Operational Research U n i t , Oxford Regional Hosp i ta l Board, Headington, Oxford, 1967, 37 Ruth Preston, "Add Meaning to Your Hosp i ta l Census," Nursing Outlook, v o l , 1, no, 7i ( Ju ly , 1962), pp 466 - WTol 38 P. B i c k n e l l , S ta f f ing by Pat ient Care Workload. Hosp i ta l Systems Study Group, Univer s i ty of Saskatchewan, Saskatoon, Saskatchewan, December, 1970. 29 The development of a numerical weighting factor resulted during Phase II of the nursing study, when the s t a t i s t i c i a n recognized a rel a t i o n s h i p between the amount of care that the patients i n each of the four categories 39 received on each s h i f t . On the day s h i f t , the average care patient received twice as much d i r e c t nursing care time as the minimal care patient, the above average care patient received s i x times as much care as the minimal care patient, and the intense care patient received twelve times as much d i r e c t nursing care time as the minimal care patient On the evening s h i f t , again r e l a t i n g each care category to the minimal care patient, the average care patient received twice as much d i r e c t nursing care, the above average care patient received seven times as much care, and the intense care patient received fourteen times as much d i r e c t nursing care time. Again, r e l a t i n g each category of patient to the amount of d i r e c t nursing care time received by the minimal care patient, on the night s h i f t the average care 39 K. Sjoberg and P. B i c k n e l l , Nursing Study -Phase II-t A P i l o t Study to Implement and Evaluate the  Unit Assignment System. Hospital Systems Study Group. University of Saskatchewan, Saskatoon, Saskatchewan December, 1969. 40 P. B i c k n e l l , S t a f f i n g by Patient Care Workload. Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, December, 1970. 41 I b i d . 30 pat ient received twice as much d i r e c t care, the above average received seven times as much d i r e c t care, and the intense care pat ient received twenty-five times as much 42 d i r e c t nurs ing care time. I l l u s t r a t i o n S h i f t Minimal Average Above Average Intense D 1 2 6 12 E 1 2 7 14 N 1 2 7 25 The s t a t i s t i c i a n a lso i d e n t i f i e d a r a t i o between the average amount of care received by a l l pat ients between the day s h i f t the evening s h i f t , and the night s h i f t . This 43 r a t i o was 4 t 2 t 1. Index weighting factors were a r r i v e d at by m u l t i -p l y i n g the r a t i o found on each s h i f t with the corresponding 44 re l a t ionsh ip s of d i r e c t nurs ing care on the same s h i f t . 42 P . B i c k n e l l , S ta f f ing by Pat ient Care Workload. Hosp i ta l Systems Study Group, Univer s i ty of Saskatchewan, Saskatoon, Saskatchewan, December, 1970. 43 I b i d . 44 I b i d . 3 1 I l l u s t r a t i o n S h i f t Minimal Average Above Average Intense 4 x = D 4 8 2 4 4 8 2 x = E 2 4 1 4 2 8 1 x = N 1 2 7 25 To achieve the workload index f o r any given s h i f t the number of patients i n each category i s multiplied by the weighting fa c t o r f o r that patient category on that p a r t i c u l a r s h i f t . The summation of these multiples gives 45 the workload index. Calculation of the Workload Index Example: census = 40 Patient C l a s s i f i c a t i o n i minimal = 5 average = 25 above average = 5 intense = 5 Calculation f o r the Day Shift i £ i 7J I i iT average above average intense Workload Index 5 x 4 * C 2 0 25 x 8 = 2 0 0 5 x 2 4 = 1 2 0 5 x 4 8 = 2 4 0 = 5 8 0 45 P. B i c k n e l l , S t a f f i n g by Patient Care Workload. Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, December, 1 9 7 0 . 32 In order to convert the workload index into minutes of d i r e c t care time required by each pa t i ent , the basic u n i t of care was establ i shed as the amount of care time that the minimal care pat ient received during the night s h i f t . Time studies ana lys i s during Phase II of the study 46 revealed that t h i s measurement was equal to f ive minutes. To convert the weighting factors to minutes o f d i r e c t nurs ing care time, the t o t a l workload index i s m u l t i p l i e d 47 by 5» To ind ica te the average minutes of d i r e c t nurs ing care time for each pa t ient , on each s h i f t , m u l t i p l i c a t i o n of the weighting factors by 5t would give the t o t a l minutes 48 consumed per p a t i e n t . I l l u s t r a t i o n S h i f t Minimal Average Above Average Intense D 20 40 120 240 E 10 20 70 140 N 5 10 35 125 46 P. B i c k n e l l , S ta f f ing by Pat ient Care Workload. Hosp i ta l Systems Study Group, Univer s i ty of Saskatchewan, Saskatoon, Saskatchewan, December, 1970. 47 I b i d . 48 I b i d . 33 Work Sampling studies i d e n t i f i e d the amount of time nurs ing personnel a c t u a l l y spent i n prov id ing d i r e c t nurs ing care . The a c t i v i t y ana lys i s noted a l l functions of the nursing personnel inc lud ing d i r e c t pat ient care, i n d i r e c t pat ient care, other funct ions , and personal t ime. I t was found that , on the average, nurs ing personnel spent 42 per cent of t h e i r time, during the day tour of duty, g i v i n g d i r e c t care to pa t i en t s . By i d e n t i f y i n g t h i s fac tor the workload index could be converted to indicate the number of required nurs ing s t a f f at the beginning of each s h i f t . Conversion of Workload Index to Required S ta f f ExampleJ Index = 200 uni t s One u n i t = 5 minutes of care 50 Minutes of d i r e c t nurs ing care needed: Converted to hourst Hours of d i r e c t care provided per nurse per 8 hour s h i f t « Tota l nurs ing s t a f f needed to meet a l l care requirements fo r the 8 hour s h i f tJ 200 x 5 = 1000 minutes 1000 16.67 hours 42 x 8 _ 3.36 hours/nurse 100 5 1 16.6, 3.3< ~ 5 nurses 49 P. B i c k n e l l , S ta f f ing by Pat ient Care Workload, Hosp i ta l Systems Study Group, Univer s i ty of Saskatchewan, Saskatoon, Saskatchewan, December, 1969. 50 I b i d . 51 •Nurse' represents any nursing s t a f f who provides d i r e c t care to the pa t i en t s . 34 This method of c a l c u l a t i n g s t a f f requirements has been used since A p r i l , 1970, at University Hospital, Saskatoon, Saskatchewan, i n a l l nursing departments with the exception of p e d i a t r i c s and psychiatry. The necessity for further research on the workload index was summed up by the Director of Inservice Education at University Hospital. She had worked cl o s e l y with the research group throughout the f i v e year study, and assisted with the 52 writing of the Phase III report. "As a r e s u l t of the research at Univer-s i t y Hospital over the past f i v e years, many tools have been made available to us. Many s t a f f members now recognize the need f o r research i n nursing. This, i n i t s e l f , i s reason to be o p t i m i s t i c . The opportunity to test and experiment with the workload index has convinced us that there are solutions to s t a f f i n g problems i n nursing, and that eventually we w i l l s t a f f to meet the patients* needs, and be equipped to provide patients with care that i s personalized." 53 52 K. Sjoberg, E. Heieren, and P. B i c k n e l l , Nursing  Study - Phase IIIt Implementation and Evaluation of Unit  Assignment i n a Multi-Ward Setting, Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, August, 1971. 53 Eleanor Heieren, Nursing Service Research Reportt  Workload Index, prepared f o r the Hospital Systems Study Group Third Annual I n s t i t u t e , University of Saskatchewan, Saskatoon, Saskatchewan, September 29, 1971* 35 Summary of the Review of the L i t e ra ture The review of the l i t e r a t u r e has revealed the many approaches that have been taken i n order to study s t a f f i n g of the nursing service department and to provide safe care to pa t i en t s . C l a s s i f i c a t i o n of the pat ients according to t h e i r needs for nurs ing care has been given much a t tent ion over the past two decades. In the past few years , researchers have attempted to develop methods for numerical ly i d e n t i f y i n g the pat ient care load, and the number of s t a f f required to meet the needs of the p a t i e n t . Use of these object ive too l s , combined with the nurse ' s profes s iona l judgement have indicated good r e s u l t s . The wr i ter be l ieves that i f standardized methods of i d e n t i f y i n g estimated quant i ta t ive care needs to provide safe pa t ient care can be es tab l i shed , nurs ing research can concentrate on the measurement of q u a l i t a t i v e nursing care . CHAPTER III METHOD I . OVERVIEW A descr ip t ive and explanatory approach was under-taken to evaluate the a d a p t a b i l i t y of the workload index s t a f f i n g t o o l . P r i o r to each data c o l l e c t i o n per iod the inves t iga tor c l a s s i f i e d pat ients into one of four categories according to t h e i r needs for nurs ing care . Two types of nurs ing a c t i v i t y studies were used to obtain the desired .1 informat ion. One focused on the d i r e c t care received by pat ients i n each category of care . The second focused on how nurs ing s t a f f spend t h e i r time during each eight hour s h i f t . These two s tudies , the Inroom A c t i v i t y Study and the Ind i rec t Care Work Sampling Study, were run concurrent ly , beginning on October 3 , 1 9 7 2 and concluding on November 13» 1 9 7 2 . P r i o r to t h i s , o r i en ta t ion sessions were held for a l l nurs ing s t a f f invo lved . The observations for both studies were continuous for each eight hour s h i f t observed. The researcher was present during a l l observation periods 1 How to Study Nursing A c t i v i t i e s , United States Department of Health, Education, and Welfare, Publ ic Health Service , D i v i s i o n of Nursing, Washington, D. C. 2 0 2 0 1 , 1964. 36 37 and. d id the actual observations for a l l but three of the 2 s h i f t s . I I . SAMPLE The study was conducted i n one extended care h o s p i t a l with a pat ient populat ion of 63. The eight hour s h i f t s observed were selected at random. The sample, for the observation of d i r e c t pat ient care, included 10 pat ients from each of the nurs ing care categories on each s h i f t . This re su l ted i n 60 e ight hour observations. Pat ients with pr ivate duty nurses were not included i n the study. Four pat ients were observed simultaneously on eacheight hour s h i f t . The s e l e c t i o n of the pat ients thus depended, to a large degree, on the proximity of the pat ients to each other . The sample, for the observation of i n d i r e c t pat ient care, included nurs ing s t a f f personnel on duty at the time of data c o l l e c t i o n . There were 14 eight hour observations of nursing s t a f f i n d i r e c t care a c t i v i t i e s . Pr ivate duty nurses were not included i n the study. To ensure r e l i a b i l i t y the f i r s t three eight hour observations were di scarded. I t was f e l t that the s t a f f were comfortable with the presence of the researcher a f ter the f i r s t three eight hour s h i f t s . 2 The researcher acknowledges, with gra t i tude , the assistance of tv/o second year nursing graduate students -Jo Ann Albers and Diane Brennan; 38 I I I . PATIENT CLASSIFICATION The c l a s s i f i c a t i o n t o o l , developed by researchers 3 at the University of Saskatchewan, was used to categorize the patients according to t h e i r needs f o r nursing care. This was done p r i o r to each eight hour observation period. This t o o l has been used throughout University Hospital, Saskatoon, Saskatchewan, on a l l wards except p e d i a t r i c s and psychiatry, by a l l head nurses, assistant head nurses, and the majority of registered nurses since 1969* I t has also been used i n several other hospitals including Calgary F o o t h i l l s Hospital, Calgary, Alberta, Lethbridge Municipal Hospital, Lethbridge, Alberta, Rosetown Union Hospital, Rosetown, Saskatchewan, and several other hospitals i n Canada. I t has shown consistency, s t a b i l i t y , 4 and r e p e a t a b i l i t y . A study done to test the tool's v a l i d i t y was conducted i n 1968, at University Hospital, Saskatoon, 3 Blaine Holmund, Nursing Study - Phase I - University Hospital, Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, September, 1967. 4 Personal communication and work with Mrs. K. Sjoberg, Project Leader, Nursing Research, Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, 1969.- 1971* 39 5 Saskatchewan. I t has face v a l i d i t y i n that i t s components contain nursing care needs of patients. The review of the l i t e r a t u r e on other c l a s s i f i c a t i o n systems indicated that the t o o l has content v a l i d i t y . In the study the tool was compared with the c l a s s i f i c a t i o n system developed by 6 MacDonell and Murray and the subjective judgement of the Head Nurse on the ward. S t a t i s t i c a l analysis indicated s i g n i f i c a n t concurrent v a l i d i t y . IV. THE INROOM ACTIVITY STUDY DATA COLLECTION This study measured the amount of service provided to each category of patient, and determined who provided t h i s service f o r each category of patient. Patients i n each of the two categories, Average and Above Average, were observed during the day, evening, and night s h i f t s . This required 7 day observations, 6 evening observations, a.nd f i v e night observations. During these observations, the researcher recorded the following: (1) the category of s t a f f member who entered the room, (2) the time of entry and e x i t , (3) whether the a c t i v i t y was 5 K. Sjoberg and P. B i c k n e l l , Patient C l a s s i f i c a t i o n  Study, Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, September, 1 9 6 8 , 6 J . A. K. MacDonell and G. B. Murray, "An Index of Care," Medical Services Journal. Canada, v o l . XXI, no. 8 , (September 8 , 1965), pp W - 517. 40 associated with the general room, or was directed toward 7 the patient, and (4) a narrative description of the a c t i v i t y . The following i s a summary of the task codes used i n the Inroom A c t i v i t y Study: 01 Dependent Functions of Nursing - included a l l therapeutic and diagnostic functions performed by nursing as a r e s u l t of a doctor's written order, 02 Medications - tasks associated with the preparation and administration of medications i n the patient area. 0 3 Independent Functions of Nursing - included a l l personal hygiene, feeding, etc? 04 Communication - patient i n s t r u c t i o n 0 5 Communication - general conversation with the patient. 0 6 Communication - between s t a f f members about the patient being observed,,' 07 Doctor's Rounds - included nursing s t a f f accompanying the doctor. 08 Nursing Rounds - included checking and i n q u i r i n g into the status of the patient by the nursing s t a f f . 0 9 Recording and Charting - included a l l paperwork and charting completed at the patient's bedside. 7 K. Sjoberg, Manual f o r Nurse Observers. Hospital Systems Study Group, University of Saskatchewan, Saskatoon, Saskatchewan, 1968, Unpublished material. 4 l 10 Porter ing - t r ans f e r r ing the pat ient to and. from other sect ions of the h o s p i t a l or to another room on the same ward, 1 1 Dietary Services - included serving and removing t rays , f i l l i n g water jugs, (This does not include actua l feeding of the pat ient) 12 Room Housekeeping and Maintenance 13 Looking for People and Things 14 Supplies and Equipment - included preparat ion and c leaning of suppl ie s , 15 Communication - not with or about the pa t ient being observed, V, THE INDIRECT CARE ACTIVITY STUDY DATA COLLECTION These observations determined the percentage of s t a f f time spent on each type of a c t i v i t y on the ward. A work sampling technique was used. This study was c a r r i e d out during each eight hour s h i f t and included 5 day observat i 5 evening observations, and 4 night observations. A random s e l e c t i o n of the s h i f t s was made to se lec t s h i f t s on week days that were representative of the usual busyness of the u n i t . Random s e l e c t i o n also allowed fo r days i n which the s t a f f i n g was ne i ther inadequate nor overabundant fo r the given workload. The researcher remained for the f u l l s h i f t and made one observation every f i f t e e n minutes on each s t a f f member working on the u n i t f o r that s h i f t . The researcher recorded 42 8 t h e i r l o c a t i o n and a c t i v i t y . The f o l l o w i n g codes were used i n a n a l y s i s of the data* 01 D i r e c t P a t i e n t Care - any d i r e c t contact with the p a t i e n t , i n c l u d e d c o n v e r s a t i o n . (DIR) 02 Paper Work P a t i e n t Oriented - i n c l u d e d a l l reading or w r i t i n g a c t i v i t i e s a s s o c i a t e d with the care of p a r t i c u l a r p a t i e n t s . (PPT) 03 Paper Work S t a f f and Supply Oriented - i n c l u d e d a l l paper work which was not p a t i e n t o r i e n t e d . (PSS) 04 Medications - a l l a c t i v i t i e s a s s o c i a t e d w i t h medications except a d m i n i s t r a t i o n to the p a t i e n t (DIR) and c h a r t i n g (PPT). 05 Supplies and T r a v e l - a l l a c t i v i t i e s a s s o c i a t e d with the handling of non-medical s u p p l i e s and a l l types of t r a v e l . (SUP) 06 P e r s o n a l , Non-Productive - i n c l u d e d a l l a c t i v i t i e s which were not r e l a t e d to the a c t u a l performance of the person's job such as coffee and meal times. (PERj 07 Communication wi t h Nursing S t a f f - included a l l non-personal communication among ward s t a f f members. (CNU) 08 Communication with Other Health Team Members -in c l u d e d a l l non-personal communication with the other members o f the h e a l t h team? e;g. doctors, p h y s i o t h e r a p i s t s , occupational t h e r a p i s t s . (CHT) 8 K. Sjoberg, Manual f o r N u r 3 e Observers. H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, 1968, Unpublished m a t e r i a l . 4 3 09 Communication with Other Hospi ta l S ta f f - included a l l non-personal communication with other personnel such as housekeeping, laundry, e t c . (COH) 10 Communication with V i s i t o r s - included a l l conver-sa t ion with the pat ients r e l a t i v e s and f r i e n d s . (CVO) Each code has been given an abbreviat ion to be used i n the ana lys i s of data when presenting tables or f i g u r e s . CHAPTER IV ANALYSIS OF THE DATA I . ANALYSIS OF THE INROOM ACTIVITY STUDY Table 1 represents the sample s ize during the inroom observations. The extended care hosp i t a l populat ion consisted of , p r i m a r i l y , pat ients i n the average care and above average care categor ies . There were no pat ients i n the minimal care category, and approximately two pat ients per day i n the intense care category. Pat ients moved into the intense care category from the above care category when they received t h e i r weekly tub bath or shower. The study focused only on the two major categories present . Table 1 Number of Pat ients Observed Sh i f t Average Above Average D 10 10 E 10 10 N 10 10 Amount of Di rec t Care Provided The f igures i n Table 2 represent the average minutes of care provided to each category of pat ient on each s h i f t i n the extended care u n i t . 44 4 5 Table 2 Average Minutes of Di rec t Nursing Care per Pat ient Category per S h i f t S h i f t Average Above Average D 2 2 . 3 5 3 . 9 E I7i9 3 1 . 3 N 9 . 7 1 2 . 3 By examining the above f igures , a r e l a t i o n s h i p between the average amount of d i r e c t nurs ing care time each category of pat ient received on each s h i f t can be i d e n t i f i e d . On the day s h i f t above average care pat ients received approximately twice as much d i r e c t nursing care time as the average care pa t i en t s . On the evening s h i f t above average care pat ients received approximately twice as much care as the average care pa t i ent s . During the night s h i f t both categories of pat ients rece ived , on the average, the same amount of care . Table 3 i l l u s t r a t e s these r e l a t i o n s h i p s . Table 3 Relat ionship Between Amount of Care Received per Pat ient Category per Sh i f t Sh i f t Average Above Average D 1 2 E 1 2 N 1 1 46 The f igures i n Table 4 represent the average amount of care that a l l pat ients receive on each s h i f t i n the extended care h o s p i t a l . Table 4 Average Minutes of D i rec t Nursing Care -per Pat ient per Sh i f t Sh i f t Minutes of Care D 76.2 E 49.2 N 22.0 The a c t i v i t y study shows that , on the average, pat ients received three times more d i r e c t nurs ing care on the day s h i f t than on the night s h i f t , and twice as much care on the evening s h i f t as on the night s h i f t . Thus, the r a t i o between the amount of nurs ing care time on the day, evening, and night s h i f t s was found to be 3 » 2 t 1. By m u l t i p l y i n g the day s h i f t r e l a t ionsh ips through by 3» and the evening s h i f t r e l a t ionsh ip s through by 2, the r a t i o s discussed above r e f l e c t not only the r e l a t i o n s h i p between s h i f t s for each category, but a l so the re l a t ionsh ip s between s h i f t s for each category. Table 5 shows these r e l a t i o n s h i p s • Table 5 Ratios of D i rec t Nursing Care Time Received ^ ^ - ^ C a t e g o r y Sh i f t ^ ^ ^ - ^ Average Above Average D 3 6 E 2 4 N 1 1 47 I t should be emphasized that these f i g u r e s represent the amount of care the p a t i e n t s r e c e i v e , and these are to be used as an estimate of the care p a t i e n t s a c t u a l l y r e q u i r e . The p o s s i b i l i t y of the d i f f e r e n c e between the two cannot be determined without extensive q u a l i t a t i v e s t u d i e s . The r a t i o s shown i n Table 5 can be used as weight f a c t o r s f o r the corresponding c a t e g o r i e s on each s h i f t to a r r i v e a t an index of p a t i e n t care load on the ward f o r any s h i f t . For example, i f the ward census i s made up of 30 average care p a t i e n t s , and 32 above average care p a t i e n t s , the workload index on the day s h i f t would be c a l c u l a t e d by m u l t i p l y i n g the number of p a t i e n t s i n each category by the weight f a c t o r f o r t h a t category, and summation of the r e s u l t s . Thus, the workload index f o r days would bei (30 x 3) + 02 + 6) = 282, The same would be done f o r the evening and n i g h t s h i f t s , which would have workload i n d i c e s of 188 and 62, r e s p e c t i v e l y . The workload index f i g u r e s mean very l i t t l e by themselves, but i f they were viewed comparatively over a p e r i o d of time they would become very i n f o r m a t i v e . For example, i f the census remained the same but the number of p a t i e n t s i n the above average care category increased, the workload would i n c r e a s e . This demonstrates that census can be very misleading i f i t i s used as the sole b a s i s f o r judging workload. D i s c u s s i o n The data presented answers the f i r s t three questions 48 posed f o l l o w i n g the problem statement, (see pages 4 and 5 ) Question (1.) There i s a d i f f e r e n c e between the average amount of d i r e c t n u r s i n g care time t h a t each category of p a t i e n t r e c e i v e s on days and the average amount o f time each category of p a t i e n t r e c e i v e s on eve-n i n g s . However, there i s no s u b s t a n t i a l s i f f e r e n c e between the average amount of d i r e c t n u r s i n g care time each category of p a t i e n t r e c e i v e s on the n i g h t s h i f t . Question (2) There i s a d i r e c t r a t i o between the average amount of d i r e c t n u r s i n g care time a l l p a t i e n t s r e c e i v e on days, the average amount o f time a l l p a t i e n t s r e c e i v e on evenings, and the average amount o f time a l l p a t i e n t s r e c e i v e on n i g h t s . Question Q ) Weighting f a c t o r s can be e s t a b l i s h e d from the r e l a t i o n s h i p of the average amount o f d i r e c t n u r s i n g care time r e c e i v e d by each category of p a t i e n t on each s h i f t , and the r a t i o between the average amount of d i r e c t care a l l p a t i e n t s receive on each s h i f t . These weighting f a c t o r s d i f f e r from those i d e n t i f i e d i h the o r i g -1 i n a l development of the workload index s t a f f i n g t o o l . O v e r a l l , a n a l y s i s of the data c o l l e c t e d i n the Inroom A c t i v i t y Study i n d i c a t e s the n e c e s s i t y o f modifying the e x i s t i n g workload index s t a f f i n g t o o l i f i t i s to be of any value to the extended care s e t t i n g . 1 P. B i c k n e l l , S t a f f i n g by P a t i e n t Care Workload. H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, December, 1 9 7 0 . 4£ Other Findings i n the Inroom A c t i v i t y Study A d d i t i o n a l ana lys i s of data from the Inroom A c t i v i t y Study gives information regarding the type of nurs ing functions i n the extended care f a c i l i t y and the l e v e l of s t a f f who perform these funct ions . This inform-a t ion i s presented to stimulate ideas regarding change i n the p r o v i s i o n of care to pat ients i n extended care u n i t s . The Type of Funct ions . Figure 2 shows the type of functions performed fo r each category of pat ient on each s h i f t i n the extended care u n i t . The f igure demonstrates what the average d i r e c t nurs ing care times are comprised of i n terras of three broad groups of funct ions . Group A - Dependent Functions of Nursing Group B - Independent Functions of Nursing Group C - Miscellaneous The dependent functions of nurs ing (Group A) are functions which are d i r e c t l y re la ted to the medical ly i n i t i a t e d therapies . This group includes the fo l lowing task codes which have been prev ious ly described* (see page 40) 01 Dependent functions of nurs ing 02 Medications 07 Doctor*s rounds The independent functions of nurs ing (Group B) include a l l functioms which are performed by the nursing s t a f f without a s p e c i f i c doctor*s order . This includes the fo l lowing task codesi 03 Independent functions of nurs ing 04 Communication - pat ient i n s t r u c t i o n 05 Communication - general conversation with the pat ient 06 Communication - between s t a f f about pat ient 08 Nursing rounds 09 Recording and chart ing 10 I Por ter ing The Miscellaneous group (Group)C) includes the remainder of the task codes. 11 Dietary services 12 Room housekeeping and maintenance 13 Looking for equipment 14 Supplies and equipment 15 Communication - not with or about the pat ient As can be seen i n Figure 2, on a l l s h i f t s , for each category of pa t ient , the major components of care deal with the independent functions of nurs ing . The d e f i n i t i o n of an extended care u n i t ind ica tes that t h i s ahould be the case since i t i s p r i m a r i l y an i n s t i t u t i o n e x i s t i n g to provide s k i l l e d nursing care. The dependent functions of nursing are p r i m a r i l y concerned with the g i v i n g of medications and accompanying the phys ic ian on rounds• The miscellaneous functions are p r i m a r i l y concerned with t i d y i n g the p a t i e n t ' s bedside area . The supportive services provided by the housekeeping department keep t h i s funct ion at a minimum for nurs ing s t a f f . <S1 Average D i r e c t Nursing Care Time by P a t i e n t Category and Type o f Function 54 52 50 48 46 44 42 40 - 6^ c 3o £ 32 g 30 u 2 8 55 26 ft 24 to ?2 +> 20 18 16 14 12 2 10 5 08 4 06 04 02 00 Days Average Above Average Evenings Average Above <& Average Nights Average Above Average Legend i Figure 2 Independent n u r s i n g f u n c t i o n s Dependent n u r s i n g f u n c t i o n s Miscellaneous 52 L e v e l s of S t a f f who Provide D i r e c t Nursing Care. Figure 3 demonstrates the average minutes of d i r e c t n u r s i n g care time per p a t i e n t provided by each l e v e l of n u r s i n g s t a f f i n the extended care u n i t . There are only two l e v e l s of n u r s i n g s t a f f i n the extended care h o s p i t a l s t u d i e s ; these are the r e g i s t e r e d nurse (R.N.) and the n u r s i n g aide (N.A.). The f i g u r e demonstrates t h a t the n u r s i n g aide provides the m a j o r i t y of d i r e c t care to a l l p a t i e n t s i n each category on each s h i f t . This i s understandable when one r e a l i z e s t h a t the r a t i o of p r o f e s s i o n a l s t a f f to a u x i l l i a r y s t a f f i s 1 t 5« The r e g i s t e r e d nurse's d i r e c t contact with the p a t i e n t i n v o l v e s , p r i m a r i l y , the g i v i n g of medications, assessment of problems brought to her a t t e n t i o n by the n u r s i n g a i d e , and s u p e r v i s i o n of the n u r s i n g a i d e . D i s c u s s i o n Further a n a l y s i s of the data gathered during the Inroom A c t i v i t y Study provided more inf o r m a t i o n regarding the n u r s i n g care of p a t i e n t s i n the extended care u n i t . I t was not the purpose of t h i s study to analyze a l l aspects of the care given to these p a t i e n t s . However, the i n v e s t i g a t o r b e l i e v e s t h a t i t i s b e n e f i c i a l to present t h i s i n f o r m a t i o n to emphasize the need f o r encouraging f u r t h e r research of n u r s i n g care i n extended care u n i t s . 53 Average Di rec t Nursing Care Time by Pat ient Category and Level of S ta f f 54 52 50 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 08 06 04 02 00 N.A. o r : N.A. R.N., N.A N.A. R .N. N .A . R .N. N.A. R .N. Days Average Above Average Evenings Average Above Average Nights Average Above Average Figure 3 54 I I . ANALYSIS OF THE INDIRECT CARE STUDY Table 6 shows the number of s t a f f observed per s h i f t during the Ind i rec t Care A c t i v i t y Study. Table 6 Number of Staf f Observed Date S h i f t Head Nurse Registered Nurse Nursing Aide Oct . 4, 1972 E 0 1 6 | Oct . 6, 1972 N 0 1 2 Oct . 9, 1972 D 0 2 io ! Oct . 11, 1972 D 1 2 10 Oct . 13, 1972 E 0 1 6 ! Oct . 17, 1972 N 0 1 2 Oct . 18, 1972 N 0 1 2 Oct . 19, 1972 E 0 2 5 Oct . 21, 1972 N 0 1 2 Nov. 2, 1972 E 0 1 6 Nov. 3, 1972 D 1 2 9 Nov. 7, 1972 E 0 2 6 Nov. 9, 1972 D 1 2 8 Nov. 13, 1972 D 0 2 9 With observations recorded on these s t a f f members every f i f t e e n minutes, the number of observations shown i n Table 7 were obtaine. 55 Table 7 To ta l Observations Recorded Sh i f t Head Nurse Registered Nurse Nursing Aide D Qll 3 0 3 1 3 2 0 E 0 2 2 3 9 1 3 N 0 184 4 0 7 Table 8 shows the percentage of s t a f f time spent on each a c t i v i t y during the day, evening, and night s h i f t s . (The abbreviat ions for the task codes have been i d e n t i f i e d on pages 42 and 43.) Table 8 Percent of S ta f f Time Spent on Each A c t i v i t y Per Sh i f t Days H.N. R .N. N.A. Evenings R.N. N.A. DIR 13.9* 31.00 61.90 DIR 31.90 59.60 [VIED - 8.9 - MED 19.3 0.1 PPT 6.4 17.8 0.8 PPT 13.9 1.3 PSS ii6.1 0.7 0.2 PSS 0.4 0.5 CNU 27.7 17.8 6.4 CNU 9.1 6.6 CHT 22.3 5.3 0.1 CHT 3.1 -COH _ 0.1 COH 0.5 -CVO 4.3 4^6 0.3 CVO 5.8 0.4 SUP 1.1 5.6 15.5 SUP 4.5 17.3 PER 8.5 8.3 14.7 PER 11.7 14'; 2 Tota l 100.3^ 100.00 100.00 Tota l 100.20 100.08c Nights R .N. N .A . DIR 16.80 48.80 MED 32.1 0.7 PPT 20.7 6.6 PSS 2.2 CNU 10.3 12.7 CHT _ COH CVO 0.5 mm SUP 7.1 18.4 PER 10.3 12.7; T o t a l 100.00 99.9# 56 The amount of d i r e c t care that the reg i s tered nurse i s able to provide i s the same on both the day and evening s h i f t s . However, on nights her d i r e c t involvement with the pa t ient drops by 16 per cent. This may be explained i n part by the amount of time the reg i s tered nurse spends i n the preparat ion of medications, and i n updating the Kardex. The reg i s tered nurse spends approximately twice as much time on nights communicating with other nursing personnel when compared to the amount of time spent on t h i s a c t i v i t y on days and evenings. The amount of time the nursing aide i s able to spend i n prov id ing d i r e c t pat ient care i s high on a l l s h i f t s . ( daysi 62 per cent; e v e n i n g s « 60 per centj and nightsi 49 per cent) The Work Sampling Study was conducted p r i m a r i l y to determine the percentage of nurs ing s t a f f time spent on a c t i v i t i e s other than d i r e c t pat ient care . Averaging out t h i s percentage inc lud ing only the reg i s tered nurse and the nursing aide, the fo l lowing percentage on i n d i r e c t care a c t i v i t i e s i s i d e n t i f i e d a s » days, 54 per centt evenings, 54 per cent; and nights , 67 per cent . Thus, the values used for the percentage of time nursing s t a f f spend g i v i n g d i r e c t pat ient care are 46 per cent for both days and evenings, and 33 per cent for the night s h i f t . The f i n a l question posed, fo l lowing the problem statement, can now be answered. Nursing personnel i n the acute care center were able to spend 42 per cent of t h e i r 57 2 time i n g i v i n g d i r e c t pa t ient care . I t was only es tabl i shed 3 for the day s h i f t . Nursing personnel i n the extended care se t t ing were able to provide 46 per cent on both days and evenings, and 33 per cent on n ight s . Since the o r i g i n a l study provides information for the day s h i f t , i t can be stated that nursing personnel i n the extended care un i t are able to spend a greater per-centage of t h e i r time i n provid ing d i r e c t pa t ient care on the day s h i f t . This di f ference may be further i l l u s t r a t e d by comparing the s t a f f i n g of both uni t s on days. In the acute care un i t one 50 bed medical ward was s taf fed, on the average, by 12 nursing personnel . In the extended care u n i t used i n t h i s study, the s t a f f i n g was, on the average, 12 nursing personnel fo r 63 pat ients on the day s h i f t . I I I . STAFFING GUID3 USING THE WORKLOAD INDEX Data ana lys i s of both a c t i v i t y studies have revealed 2 P. B i c k n e l l , S ta f f ing by Pat ient Care Workload. Hosp i ta l Systems Study Group, Univer s i ty of Saskatchewan, Saskatoon, Saskatchewan, December, 1970, p . 10. 3 Personal communication with Mrs. Peggy B i c k n e l l , Systems Analyst , Hosp i ta l Systems Study Group, Univer s i ty of Saskatchewan, Saskatoon, Saskatchewan, December, 1972. 4 Marion Jackson, Operational Budget - Department  of Medical Nursing, Univer s i ty H o s p i t a l , Saskatoon, Sask-atchewan, January, 1971. 58 the modif icat ions i n the workload index s t a f f i n g t o o l necessary fo r i t s a p p l i c a t i o n i n the extended care u n i t . I f the index of d i r e c t care workload i s to be re la ted to the number of nursing s t a f f required to meet the needs of the pat ients i n the extended care u n i t i t requires one f i n a l s tep. To make the conversion from workload index to required s t a f f i t i s necessary to know the number of hours of d i r e c t nurs ing care that the index represents . F i r s t , r e fer to the weighting factors presented on page 46, A l l f igures are expressed as mul t ip les of the amount of care the average care pat ient receives on n i g h t s . The a c t i v i t y studies ind ica ted that t h i s represents ten minutes of d i r e c t nurs ing care . Thus, i f the ca lcula ted workload index for any s h i f t i s m u l t i p l i e d by 10/60, the r e s u l t i s the number of hours of d i r e c t nurs ing care required on that u n i t . The Ind i rec t Care Study indicates that the nurse i s able to spend only a por t ion of her eight hour day i n provid ing d i r e c t pat ient care . On the day and evening s h i f t each s t a f f member contributes just 46 per cent of 8 hours (3*68 hours) towards the t o t a l d i r e c t nursing care requirements of the u n i t . On the night s h i f t the nursing s t a f f member contributes 33 per cent of 8 hours (2,60 hours) towards the t o t a l d i r e c t nursing care requirements of the u n i t . An estimate of the number of s t a f f needed to provide the t o t a l d i r e c t and i n d i r e c t requirements of care 59 i n the u n i t can be ca lcula ted by d i v i d i n g the t o t a l d i r e c t care time required on the u n i t by the amount of d i r e c t care provided by each nursing s t a f f member. The der iva t ion of the method of conversion of the workload index to required nursing s t a f f i s presented i n Table 9. In Table 9« M - represents the average number of minutes of d i r e c t nurs ing care received by an average care pat ient on the night s h i f t , ( e . g . M= 10 minutes) P - i s the percentage of nursing s t a f f time spent on d i r e c t nursing care per s h i f t , ( e . g . P = 460 = .46) Index - i s the workload index for one s h i f t , ( e . g . Index = 300) Table 9 Conversion of Workload Index to Required S ta f f Der iva t ion of Conversion Method Example Minutes of d i r e c t nurs ing care required on the ward: INDEX x M Hours of ."direct nurs ing care required INDEX x M on the ward: 60 Hours of d i r e c t nurs ing care provided per nurse per 8 hour s h i f t : P X 8 HOURS Tota l nurs ing s t a f f needed to meet a l l INDEX x;:M care requirements 60 for the 8 hour s h i f t : P x 8 300 x 10 = 3000 minutes 300 x 10 = 5 0 . 0 hours 60 .46 x 8 = 3.68 hours/ j nurse j 50 hours r eq 'd _ 13.7 3*68 hours/nurse nurses 1 t f Summary The c a l c u l a t i o n of the number of s t a f f required to meet the estimated nursing care needs of the pat ients can be determined by use of the workload index s t a f f i n g t o o l . I f a f l e x i b l e s t a f f ing p o l i c y l i k e t h i s were adopted the v a r i a b i l i t y i n workload could be i d e n t i f i e d and s t a f f i n g could be adjusted accord ing ly . This would tend to promote consistency i n s t a f f ing which i s c lo se ly matched to the pa t i en t s ' estimated needs for nurs ing care . . CHAPTER V SUMMARY, CONCLUSIONS, RESEARCH IMPLICATIONS AND RECOMMENDATIONS I . SUMMARY This d e s c r i p t i v e study was designed to evaluate what m o d i f i c a t i o n s of an e x i s t i n g workload index s t a f f i n g t o o l were necessary to provide f o r i t s p r a c t i c a l a p p l i c a t i o n i n an extended care s e t t i n g . Two types of a c t i v i t y s t u d i e s were conducted i n one extended care h o s p i t a l i n Vancouver, B r i t i s h Columbia, Canada. The f i r s t was an inroom a c t i v i t y study conducted to determine the average amount of nur s i n g care time p a t i e n t s , i n one of two n u r s i n g care c a t e g o r i e s , r e c e i v e d on each s h i f t . P a t i e n t s were assigned to ca t e g o r i e s 1 by the use of an e x i s t i n g p a t i e n t c l a s s i f i c a t i o n t o o l . The second study was an i n d i r e c t care work sampling study used to define how n u r s i n g personnel spend t h e i r time during t h e i r e i g h t hour s h i f t . Observations were made on each n u r s i n g s t a f f member every f i f t e e n minutes throughout each s h i f t . For the Inroom Study the t o t a l sample c o n s i s t e d 1 K. Sjoberg and P. B i c k n e l l , P a t i e n t C l a s s i f i c a t i o n  Study. H o s p i t a l Systems Study Group, U n i v e r s i t y o f Saskatchewan, Saskatoon, Saskatchewan, September, 1968. 61 62 of 10 patients i n each of the two categories on each s h i f t . This resulted i n 60 eight hour observations. The sample f o r the Indirect Care Study included 58 nursing s t a f f members on days y i e l d i n g 1,717 observations, 36 nursing s t a f f members on evenings y i e l d i n g 1,136 observations, and 12 nursing s t a f f members on nights y i e l d i n g 591 observations. Data f o r the Inroom Study was collected by continuous eight hour observations of the nursing care given to each category of patient on each s h i f t . The researcher recorded the a c t i v i t y , the length of time i t took to perform the a c t i v i t y , and the l e v e l of s t a f f who performed the a c t i v i t y . Data f o r the Indirect Care Work Sampling Study was collected by observing a l l s t a f f members on duty, every f i f t e e n minutes throughout the eight hour s h i f t . This was done on f i v e day s h i f t s , f i v e evening s h i f t s , and four night s h i f t s . For both studies the days and the s h i f t s to be ob-served were selected at random to ensure an unbiased selection of days of the week and obtain a cross section of s h i f t s and days of the week. The re s u l t s indicated that modification of the workload index was necessary i f i t was to be of p r a c t i c a l value i n the extended care s e t t i n g . On the average, patients i n both categories received fewer minutes of di r e c t nursing care time than those figures presented by 2 the o r i g i n a l workload index s t a f f i n g t o o l . The weighting f a c t o r s e s t a b l i s h e d f o r the extended care u n i t d i f f e r e d 3 markedly from those i n the o r i g i n a l t o o l . Furthermore, the n u r s i n g personnel appeared to be able to spend more time i n g i v i n g d i r e c t p a t i e n t care i n the extended care s e t t i n g . I I . CONCLUSIONS The r e s u l t s of the Inroom A c t i v i t y Study i n the extended care s e t t i n g have demonstrated the s i g n i f i c a n t d i f f e r e n c e s i n the amount and type of d i r e c t n u r s i n g care provided i n t h i s type of u n i t , compared with more acute general wards. The average minutes of d i r e c t n u r s i n g time per p a t i e n t category observed dur i n g the extended care I n -room Study may be used to determine new weight f a c t o r s f o r the workload index. The I n d i r e c t Care Study showed th a t n u r s i n g s t a f f spend a g r e a t e r percentage of t h e i r time g i v i n g d i r e c t p a t i e n t care i n the extended care u n i t than the 42 per 2 P. B i c k n e l l , S t a f f i n g by P a t i e n t Care Workload. H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, December, 1970. 3 I b i d . 64 cent being used i n the conversion of the workload index to r e q u i r e d number of s t a f f . A more accurate f i g u r e would be 46 per cent or 3 « 6 8 hours of d i r e c t n u r s i n g care on the day and evening s h i f t s , and 33 per cent or 2 . 6 hours of d i r e c t n u r s i n g care time on the n i g h t s h i f t . Any d i r e c t comparison between the two i n s t i t u t i o n s r e g arding the workload index would be hazardous f o r s e v e r a l reasons. Each i n s t i t u t i o n has i t s own s p e c i a l nature of n u r s i n g care requirements o f p a t i e n t s . The h o s p i t a l s are i n d i f f e r e n t provinces i n Canada, and i n a l l l i k l i h o o d have d i f f e r i n g amounts of money f o r the n u r s i n g departments o p e r a t i o n a l budgets. Furthermore, the r a t i o of p r o f e s s i o n a l s t a f f to a u x i l l i a r y s t a f f i s v a s t l y d i f f e r e n t . The acute 4 care has a r a t i o of 1 i 1 while the extended care has a 5 r a t i o of 1 i 5 * The workload index g i v e s estimates of the number of n u r s i n g s t a f f r e q u i r e d each s h i f t but does not i n d i c a t e the l e v e l of s t a f f best s u i t e d to meet the needs of the p a t i e n t s . I t was observed during the a c t i v i t y s t u d i e s , i n the extended care s e t t i n g , t h a t n u r s i n g aides assume more 4 Marion Jackson, Operational Budget - Department  of Medical Nursing, U n i v e r s i t y H o s p i t a l , Saskatoon, Saskatchewan, January, 1 9 7 1 • 5 Personal communication w i t h Mrs. L i l l i a n McLean, D i r e c t o r of Nursing, Louis B r i e r Home and H o s p i t a l , Vancouver, B r i t i s h Columbia, November, 1 9 7 2 . 65 r e s p o n s i b i l i t y i n the a c t u a l p r o v i s i o n o f d i r e c t p a t i e n t care than the r e g i s t e r e d nurses, p a r t i c u l a r l y i n per-forming f u n c t i o n s c l a s s i f i e d as independent n u r s i n g f u n c t i o n s . I t seems u n l i k e l y , to the i n v e s t i g a t o r , t h a t one r e g i s t e r e d nurse can capably monitor the p s y c h o l o g i c a l and p h y s i o l o g i c a l behaviors of approximately 32 p a t i e n t s p l u s supervise the a c t i v i t i e s of 5 or 6 n u r s i n g a i d e s . These r e s p o n s i b i l i t i e s are f u r t h e r l i m i t e d by the amount of time r e g i s t e r e d nurses spend i n the p r e p a r a t i o n and a d m i n i s t r a t i o n o f medications, and the amount of time spent i n r e c o r d i n g i n the Kardex and p a t i e n t s * c h a r t s . The a c t i v i t y s t u d i e s i n d i c a t e d t h a t there tends to be a steady pace of a c t i v i t y d i r e c t e d a t p a t i e n t care throughout the 24 hour day w i t h no peak per i o d s of busy-ness. This i s p a r t i c u l a r i l y true of the day and evening s h i f t s . While the tempo slows down on the n i g h t s h i f t f o r the p a t i e n t s , the n u r s i n g personnel continue to work s t e a d i l y throughout t h i s s h i f t . Nursing aides p a r t i c u l a r i l y appear to have a steady f l o w of d i r e c t n u r s i n g care a c t i v i -t i e s . Jflany of the i n d i r e c t care s e r v i c e s are s u p p l i e d by the housekeeping, k i t c h e n , and laundry s t a f f s a l l o w i n g the nu r s i n g aides to concentrate on d i r e c t p a t i e n t care. The po r t a b l e supply c a r t used by the n u r s i n g aides i s p a r t i c -u l a r i l y impressive as i t saves much time spent * i n f l i g h t * o b t a i n i n g equipment necessary f o r p a t i e n t care. The r e g i s t e r e d nurses are unable to spend as much time i n d i r e c t contact with the p a t i e n t because of med-66 i c a t i o n d u t i e s , paperwork, and frequent i n t e r r u p t i o n s by incoming telephone c a l l s . I t would appear t h a t the e l i m i n a t i o n of the Kardex, some i n v e s t i g a t i o n as to the n e c e s s i t y of numerous medications given to the p a t i e n t s , and the placement of a ward c l e r k to answer telephone c a l l s and take messages would a l l o w the r e g i s t e r e d nurse to per-form the f u n c t i o n she i s modt capable of - t h a t of g i v i n g p a t i e n t care. Even i f the above recommendations were considered f u r t h e r study should be conducted to determine what the p r e f e r r e d r a t i o of p r o f e s s i o n a l to a u x i l l i a r y s t a f f should be to best meet the needs of the p a t i e n t . Figure 4 represents the c a l c u l a t i o n of the workload index, and the e s t i m a t i o n of r e q u i r e d number of s t a f f f o r the days observed d u r i n g October, 1972. The present s t a f f -i n g i n c l u d e s , on the average, 12 n u r s i n g personnel on days, 7 n u r s i n g personnel on evenings, and 3 n u r s i n g personnel 6 on n i g h t s . The c a l c u l a t i o n s i n Figure 4 estimate an increase of 1 s t a f f member on days, 2 s t a f f members on evenings and 1 s t a f f member on n i g h t s i f the p a t i e n t s are to r e c e i v e the estimated number of minutes of care estab-l i s h e d i n t h i s study. Figure 5 represents a graph of the workload index c a l c u l a t i o n s f o r the days observed during October, 1972. 6 Personal communication w i t h Mrs. L i l l i a n McLean, D i r e c t o r of Nursing, Louis B r i e r Home and H o s p i t a l , Vancouver, B r i t i s h Columbia, November, 1972. 67 C a l c u l a t i o n of Workload Index and E s t i m a t i o n of Required S t a f f Numbers f o r October, 1972 Categories Above Load Inc lex S t a f f Required Date Average Average Census D E ! N D N 1 2 3 4 < 32 31 63 282 188 ! 63 13 9 4 J 6 7 30 33 63 288 192 : 63 13 9 4 8 9 10 i 11 12 13 14 i 15 16 17 18 19 20 21 22 23 ! 24 25 26 27 28 29 30 31 32 28 32 28 37 30 32 28 32 35 29 35 34 37 28 31 35 31 35 25 33 31 35 31 27 34 27 29 25 35 63 63 P 63 62 63 63 63 63 62 63 62 63 62 63 282 ' 294 282 294 251 288 282 294 282 267 287 267 2?6 : 251 294 188 196 188 196 174 192 188 196 188 178 194 178 184 174 196 ; 63 ! 63 63 62 P 63 63 63 62 63 i 62 P 62 63 13 13 13 13 11 13 13 13 13 12 13 12 13 11 13 9 9 9 9 8 9 9 9 9 8 9 8 8 8 9 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Figure 4 68 Graphical Representation of Workload Index Ca lcu la t ion for October, 1972 INDEX 30O •280 260 -240 £ 2 0 200 180 160 140 120 100 80 60 40, 20 0. Date _Days i n consecutive order Days not i n consecutive order One Unit = 10 minutes J v / / \ / • / N > \ > 1 \ \ \ / < \ / 1 \ -»-. / \ / / S / V m ' r > r -« •s / - \ \ \ / / \ t. m a 1 ; 7 c \ 1 k 1 1 5 1 7 i 9 2 1 2-\ 2 5 2J 7 c 9 3) D N Figure 5 6 9 I I I . RESEARCH IMPLICATIONS This study was a modified r e p l i c a t i o n of a study 7 conducted i n an acute care center. I t would be of value to r e p l i c a t e the study again i n another extended care s e t t i n g i n the c i t y of Vancouver, B r i t i s h Columbia. More meaningful knowledge might be obtained by r e p l i c a t i n g the study i n an extended care u n i t attached to an acute care h o s p i t a l , and running a c t i v i t y s t u d i e s c o n c u r r e n t l y i n both u n i t s of comparable s i z e . The workload index and s t a f f i n g guide as described are only rough estimates a t best. Refinement o f the t o o l might be achieved by more exact measures of the determiners comprising the c l a s s i f i c a t i o n system described i n the 8 review o f the l i t e r a t u r e . I f weight f a c t o r s could be e s t a b l i s h e d f o r each component of the c l a s s i f i c a t i o n system i t might r e s u l t i n a s t a f f i n g t o o l t h a t would be a p p l i c a b l e i n any i n s t i t u t i o n p r o v i d i n g n u r s i n g care s e r v i c e s . I t i s of prime importance to recognize t h a t the 7 P. B i c k n e l l , S t a f f i n g by P a t i e n t Care Workload. H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, December, 1 9 7 0 . 8 K. Sjoberg and P. B i c k n e l l , P a t i e n t C l a s s i f i c a t i o n  Study, H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, September, 1 9 6 8 . f i g u r e s presented i n t h i s study represent an estimate of the care p a t i e n t s r e c e i v e and not the care p a t i e n t s r e q u i r e . However, i f s t a n d a r d i z a t i o n i n the amount of care given i s achieved n u r s i n g researchers can concentrate on the question of what care the p a t i e n t a c t u a l l y r e q u i r e s . IV. RECOMMENDATIONS The f o l l o w i n g recommendations are made f o r f u r t h e r i n v e s t i g a t i o n ! 1. R e p l i c a t i o n o f t h i s study i n other extended care u n i t s i n B r i t i s h Columbia i n order to i d e n t i f y i n c o n s i s t e n c i e s i n the amount of nur s i n g care time p a t i e n t s r e c e i v e or to s u b s t a n t i a t e the f i n d i n g s of the present study. 2. A c t i v i t y s t u d i e s should be c a r r i e d out to determine the average amount of nu r s i n g care time i n v o l v e d i n each of the determiners or components o u t l i n e d i n the p a t i e n t c l a s s i f i c a t i o n system used i n t h i s study. 3» A c t i v i t y s t u d i e s conducted c o n c u r r e n t l y i n acute care and extended care u n i t s of comparable s i z e and wit h comparable s t a f f i n g . 4.# A study conducted to assess the q u a l i t y of care p a t i e n t s r e c e i v e i n the extended care u n i t used i n t h i s study. BIBLIOGRAPHY 71 BIBLIOGRAPHY A. BOOKS Abdellah, Paye and Eugene Levine. E f f e c t of Nurse S t a f f i n g  on S a t i s f a c t i o n w i t h Nursing Care. Chicago. I l l i n o i s i American H o s p i t a l A s s o c i a t i o n , H o s p i t a l Monograph, S e r i e s no. 4, 1958. Abdellah, Faye G., et a l . Patient-Centered Approaches to  Nursing. The MacMillan Company, New York, I960. Abdellah, Faye G. and Eugene Levine. B e t t e r P a t i e n t Care  Through Nursing Research. The MacMillan Company, New York, 1965. Barnes, R. M. Work Sampling. John Wiley and Sons, London, 1964. How to Study Nursing A c t i v i t i e s . United S t a t e s Department of Health, Education, and Welfare, P u b l i c Health S e r v i c e , D i v i s i o n of Nursing, Washington, D. C. 20201, 1964. P a e t z n i c k , Margeurite. A Guide f o r S t a f f i n g a H o s p i t a l Nursing S e r v i c e . P u b l i c Health Papers. World Health Organization, 1966. P r i c e , Elmina M. S t a f f i n g f o r P a t i e n t Care. Springer P u b l i s h i n g Company, I n c . , New York, 1970. B. JOURNALS Ayde l o t t e , Myrtle K. "The Use of P a t i e n t Welfare as a C r i t e r i o n Measure," Nursing Research, v o l . 11, (Spr i n g , 1962), p. 10. Connor, Robert J . , et a l . " E f f e c t i v e Use of H o s p i t a l Resources 1 A Research Report," H o s p i t a l s JAHA, v o l . 35. no. 5, (May, 1 9 6 1 ) , pp 30 - 39. Flanagan, E i l e e n C. and Irene M. Herdan. "A P r e l i m i n a r y Study and A n a l y s i s o f Nursing Requirements i n Ne u r o l o g i c a l and Neurosurgical Nursing," Canadian Nurje, v o l . 51» no. 11, (November, 1955)» pp 855 -862. 73 G i f f i n , Margaret. "Your S t a f f i n g S i t u a t i o n i s D i f f e r e n t , " American J o u r n a l of Nursing, v o l . 52, no. 11, (November, 1952), pp 1348 - 1351. Hardin, C l a r a A. "Using the Studies of Nursing Functions," American J o u r n a l of Nursing, v o l . 57, no. 5» (May, 1957), pp 622 - 623. Levine, Eugene. "Nurse S t a f f i n g i n H o s p i t a l s , " American  J o u r n a l of Nursing, v o l . 61, no. 9, (September, T961), pp 65 - 68. MacDonell, J . A. K. and G. B. Murray. "An Index of Care," Medical S e r v i c e s J o u r n a l , Canada, v o l . XXI, no. 8, (September 8, 1965), pp 499 - 51?> Preston, Ruth. "Add Meaning to Your H o s p i t a l Census," Nursing Outlook, v o l . 10, no. 7. ( J u l y , 1962), pp 466 - 470. Sjoberg K. B., E. L. Heieren, and M. R. Jackson. "Unit Assignment1 A Patient-Centered System," Nursing  C l i n i c s of North America, v o l . 6, no. 2, (June, 1971). pp 333 - 342. "Statement on Nursing S t a f f Requirements f o r I n - P a t i e n t Health Care S e r v i c e s , " prepared by the Committee on Nursing S e r v i c e s , American Nurses' A s s o c i a t i o n , American J o u r n a l of Nursing, v o l . 67, no. 5, (May, 1967), pp 1029 - 1030. S t r e e t , Margaret. " S t a f f i n g Problems i n Nursing S e r v i c e , " Canadian Nurse, v o l . 6 l , no. 2, (February, 1965), PP 91 - 93. C. MANUALS Sjoberg, K. Manual f o r Nurse Observers.Hospital Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, 1968, Unpublished m a t e r i a l . D. PAPERS Heieren, Eleanor L. Nursing Service Research Report - Workload Index, prepared f o r the T h i r d Annual H o s p i t a l Systems Study Group I n s t i t u t e , U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, September 29, 1971. 7 4 E. PERSONAL COMMUNICATIONS Personal communication and work with Mrs. K. B. Sjoberg, P r o j e c t Leader, Nursing Research, H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, 1969 - 1971. Personal Communications with Mrs. L i l l i a n McLean, D i r e c t o r of Nursing, Louis B r i e r Home and H o s p i t a l , Vancouver, B r i t i s h Columbia, 1971 - 1972. Personal communication with Mrs. Peggy B i c k n e l l , Systems An a l y s t , H o s p i t a l Systems Study Group, U n i v e r s i t y o f Saskatchewan, Saskatoon, Saskatchewan, December, 1972. F. RESEARCH REPORTS B i c k n e l l , Peggy. S t a f f i n g by P a t i e n t Care Workload. H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, December, 1 9 7 0 . Canadian Nurses' A s s o c i a t i o n . H i s t o r i c a l Overview of ... Approaches to S t a f f i n g the H o s p i t a l Nursing~Service  Department. Canadian Nurses* A s s o c i a t i o n , 5 0 The Driveway, Ottawa 4 , 1 9 6 6 . Committee on Studies of the N a t i o n a l League o f Nursing Education, "A Study of the Nursing Service i n F i f t y Selected H o s p i t a l s , " Reprinted from The  H o s p i t a l Survey f o r New York, v o l . I l l , Chapter 5 , New York, The United H o s p i t a l Fund of New York, 1 9 3 7 . F l a g l e , C. D., et a l . Optimal Organization and F a c i l i t y f o r a Nursing U n i t . Operations Research D i v i s i o n , The John Hopkins' H o s p i t a l , Baltimore, 1959. G i o v a n e t t i , P h y l l i s , et a l . The R e l i a b i l i t y and V a l i d i t y  T e s t i n g of a Sub j e c t i v e P a t i e n t C l a s s i f i c a t i o " n  System. The Vancouver General H o s p i t a l , Vancouver, B r i t i s h Columbia, June, 1 9 7 0 . Holmund, B l a i n e A. Nursing Study - Phase I - U n i v e r s i t y H o s p i t a l . H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, September, 1 9 6 7 . Measurement of Nursing Care, no. 9 , Operational Research U n i t , Oxford Regional H o s p i t a l Board, Old Road, Headington, Oxford, 1 9 6 7 . 75 CASH. (Commission f o r A d m i n i s t r a t i v e -Services i n H o s p i t a l s ) , Nursing S e r v i c e t S t a f f U t i l i z a t i o n and Con t r o l  Program O r i e n t a t i o n Report. May, 1964. Sjoberg, K. and P. B i c k n e l l . P a t i e n t C l a s s i f i c a t i o n Study. H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, September, 1968. Sjoberg, K. and P. B i c k n e l l . Nursing Study - Phase l i t A  P i l o t Study to Implement and Evaluate the U n i t  Assignment System. H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, December, 1969. Sjoberg, K. and P. B i c k n e l l . The Development of a Research  Tool to Evaluate the Standard of P a t i e n t Care. H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, A p r i l , 19711 Unpublished, Sjoberg, K. and E. Heieren and P. B i c k n e l l , Nursing Study  Phase H i t Implementation and E v a l u a t i o n of U n i t Assignment i n a Multi-Ward S e t t i n g . H o s p i t a l Systems Study Group, U n i v e r s i t y of Saskatchewan, Saskatoon, Saskatchewan, August, 1971* G. REPORTS - ANNUAL, ADMINISTRATIVE Jackson, Marion R. Annual Report - Medical Nursing Depart- ment. Submitted to the Nursing A d m i n i s t r a t o r , U n i v e r s i t y H o s p i t a l , Saskatoon, Saskatchewan, December, 1970. Jackson, Marion R. Operational Budget - Department o f Medical Nursing. U n i v e r s i t y H o s p i t a l , Saskatoon, Saskatchewan, January, 1971. APPENDIX A PATIENT CLASSIFICATION TOOL 76 PATIENT CLASSIFICATION FORM X X X COMPLETE BATH X X X X X X X X X X X X X X X X X X BASIN OR TUB C ASSISTANCE X X X BASIN OR TUB X X X X X FED OR NPO X X X PARTIAL HELP CONSTANT - qlh X 02 - 4h X X X X X X X X X X X X X X X X X X X X X X X Q4h or less X X X X X X X X IN BED OR CHAIR WI POSITION & SUPPORT X X X X X X X X X X X X UP WITH ASST. OR BED REST BRP X X X X UP AND ABOUT X X X X X X X X X X X INCONTINENCE PRE-OP t-» ro >-» h-» »-» (-» t-» l-» l-» t-» h-» t-» ro (-» ro H» ro ro > MINIMAL (-» »-» ro ro ro ro ro ro 1—ft »-» ro ro ro VoO ro ro ro o o 03 AVERAGE o o o o o V J J ro VJO v_o o ro ro o o o »-» i-» i - * o AB. AV. * INTENS ro ro ro ro ro ro ro ro V J J ro ro ro ro ro ro ro ro ro CATEGORY ro II •o =**! rO II i 77 ' COMMENTS GUIDELINE FOR INTERPRETING CATEGORIES 78 T . O T A L S CATEGORY A B C DOES THE A.B.C. TOTAL YIELD THIS COMBINATION? No 0 v IS »C» GREATER THAN OR EQUAL TO »B" or IS "C" GREATER THAN "A" ? No V Yes MINIMAL CARE IS "A" GREATER THAN OR EQUAL TO »C" or IS "B" GREATER THAN "C" ? 3 1 1 2 TTo No 1 1 j 1 3 0 1 1 4 0 Yes AVERAGE CARE Yes ABOVE AVERAGE CARE ARE THERE k OR MORE NEEDS LISTED IN THE "C» COLUMN ? 0 | 0 | 6 0 0 | 5 0 1 | 4 Yes > INTENSE CARE In-Service Education, University Hosp., Saskatoon. APPENDIX B DIRECT OBSERVATION OF PATIENT DATA FORM 79 DATA COLLECTION - D IRECT OBSERVATION OF P A T I E N T CARE  o D A T E : Qrfc. \Qv \Cnaj ROOM: 3|g S H I F T : Ibou^S P T . BED NUMBER: PATIENT CATEGORY: 3 00 STAFF NUMBER ENTRY TIME BED Mins 1^ ^ >fecs. TASK DESCRIPTION OF ACTIVITIES R . r t . 3 5 00 •+ 3 O S » i A . 3 <V.^uVSo ^ 5 p r e p o i < • p " t . Pa-r "+rpra'VrwvvV to «pejrv. o.r«.o_S oft 3 o U btu ' frnc.VeG. ^ V-i&eA . h e a d la.rvsp> o.ppU'<»A. . ^ ^ / v O P r s a - W a A . \ i r» ii>:\<\So o o vo:ai'»o \ & \u N.A. |0'-%<a '»o LL \3b m a A c * * ^ h^A^ eJ.eaw\<nej VxiA^Cele. a r e a H . A . \o 3 \v.vv. oo o o .3 M. A. a. V o 3 OLSS \'<,WV\C^  A-V^er fV .A. c_-o <wJ e t o A - v a ^ 0^-rve.rcLA M. A . \0 t> A . \o 10 s i -ft \ o 3 tJ. A . \ © |>'Sft'. 10 V o N . A . 0 ? -rt. A . 9 p \ 0 O.OO cKec\<<'/\c^ paAie.yv4'S r^^cl t -Vi 'a^ VO J : v \ : \ o 1 5 5. O^iulAO^ pa_/Vic*H A§ miVVc N A 1 t> awv+'.oo i ? o CAe.Q^iv \ a^ ooi i 5^>r««»in4 C*\ r o e *w _ C o m m o A Q -M . A . V O <^\\I'.A<^ p#^'ti»yv+ <iriftVc V\e.a_lHL, "V&CLcti^n^ •> o ^ J • "»> ^ i w./^ o . *\d <v(VsA«-v'^r^ p^^ p T \1r ^^-A1? r a l v \ . N . 3L s v O - i "VaVWi«^ t> U . A . a.\fi«i>A p « k s c ^ a w k i r o A u g . ' 7 2 . APPENDIX C WORK SAMPLING DATA COLLECTION FORM 81 D A T A C O L L E C T I O N - WORK S A M P L I N G DATE: OcV. \\^ \Cfl1> SHIFT: 3>OL^S, TIME STAFF NUMBER LOCATION TASK DESCRIPTION OF ACTIVITY AND COMMENTS S •A.A. S N.A. \ \ pV. room V N.A. pV. roam \ ro\Vl<\ft^  up Vi©.acL c£ paA-ifcnA*«» NOPA. N.ft. -i 1 vU.U Vt) p"V. cat>tr\ \ N. ft; 9' p. *J. \ N.A. (H. cat+rs. »J. A . pr- roovvt I N.A. r. \\OLVV 5" •* ^US- u. pOUwVirtf^ <fv\P,<41'<»a.-Won *» N* ft • P-V. fot.m \ N . A . s i Pt - Vfl6f« \ \ U.ft. s N.A. <5 M • A . 3L ts-\ -1 <^ tla.ll N.A. ft a-Aug.'72. 

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