Measuring Nurse Workload in Ambulatory Care

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College of Nursing Faculty Papers & Presentations Jefferson College of Nursing

September 2005

Measuring nurse workload in ambulatory care

Beth Ann Swan PhD, CRNP Thomas Jefferson University

Karen F. Griffin MSN, RN, CNAA South Texas Veterans Healthcare System

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Recommended Citation Swan, Beth Ann PhD, CRNP and Griffin, Karen F. MSN, RN, CNAA, "Measuring nurse workload in ambulatory care" (2005). College of Nursing Faculty Papers & Presentations. Paper 6. https://jdc.jefferson.edu/nursfp/6

This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in College of Nursing Faculty Papers & Presentations by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: [email protected]. Beth Ann Swan Perspectives in Ambulatory Care Karen F. Griffin

Measuring Nursing Workload in Ambulatory Care

nursing time required to care for patients. However, Executive Summary time is not the only factor to consider when measur- ᮣ Nurses and adequate nurse staffing are critical to ing nursing workload, a prerequisite for developing the delivery of safe, cost-effective, and quality ambulatory care nurse staffing models. For this rea- patient care in every health care setting. son, when nurses, managers, and administrators ask ᮣ This has been proven time and again through var- about the method for determining the levels and num- ious research studies and recognized by various bers of nursing staff appropriate for delivering quality accrediting bodies such as JCAHO. care in the ambulatory setting, there is no magic solu- ᮣ However, the information available on required or tion. Many variables must be considered, and mea- optimal ambulatory care nurse staffing is limited sured, when designing optimal ambulatory nurse and varies across ambulatory care settings. ᮣ staffing models. This is the first of two articles which An overview of instruments for measuring nurs- will provide an overview of definitions and instru- ing workload in ambulatory care, a critical prerequisite when identifying best nurse staffing ments for measuring nursing workload in ambulatory models for diverse ambulatory care settings, is care. In the second article (to be published in an provided. upcoming issue of Nursing Economic$), the use of these instruments for developing ambulatory nurse staffing models and their link with providing quality VER THE PAST 30 YEARS, patient care will be discussed. there has been rapid Historical Overview development of measure- Oment systems for health Patient classification systems originated for uti- services resource allocation in lization review purposes to analyze physician prac- the United States, not always tice patterns and resource consumption of hospital- matched by using the same defin- ized patients (Arbitman, 1986). Selected patient clas- ition of concepts, not consistently sification systems are listed in Table 1. For nursing, based on any assessment of relia- patient classification and workload measurement bility or validity and/or thorough developed to quantify and qualify the variable Beth Ann Swan understanding of the phenome- nature of the demand for nursing care. Nursing non being measured. An example workload measurement systems grew out of a neces- is the development of nursing workload measurement sity to forecast the number of nurses required for systems for ambulatory care. Although substantial dif- care in hospitals on a daily basis. Systems typically ferences exist among the measurement approaches, at include one or more instruments for measuring the a minimum they all seek to estimate the total hours of time required for direct and indirect nursing care, selected ongoing infrastructure functions of the nursing organization, and the personal activities of the nurse (Edwardson & Giovannetti, 1994). Several BETH ANN SWAN, PhD, CRNP, is an Associate Professor, Thomas Jefferson University, Jefferson College of Health Professions, comprehensive reviews of the literature relevant to Department of Nursing, Philadelphia, PA. acute care nursing workload measurement systems have been completed (Edwardson & Giovannetti, KAREN F. GRIFFIN, MSN, RN, CNAA, is an Associate Chief 1994). Terms used in nursing workload measure- Nursing Service, South Texas Veterans Healthcare System, Kerrville, TX. ment include workload measurement system, nursing workload, patient classification systems, patient ACKNOWLEDGMENT: The authors acknowledge the contribu- classification instruments, activity classification sys- tions of the Expert Panel of the Ambulatory Care Nurse Staffing: tems, and timed activity classification systems (see an Annotated Bibliography publication. Portions of this article are Table 2). Review of nursing workload measurement reprinted from Ambulatory Care Nurse Staffing: An Annotated Bibliography (2005) by permission of the publisher, the American and comparability of instruments in the ambulatory Academy of Ambulatory Care Nursing. care setting has received limited attention in the literature over the past 25 years. NOTE: This column is written by members of the American Academy of Ambulatory Care Nursing and edited by ELIZABETH Literature Search DICKEY, MPH, RN, FNP. For more information about the organization, contact: AAACN, East Holly Avenue, Box 56, Pitman, NJ A literature review was conducted using 08071-0056; (856)256-2300; (800)AMB-NURS; FAX (856)589- PubMed, MEDLINE, CINAHL, Cochrane Database of 7463; E-mail: [email protected]; Web Site: http://www.aaacn.org Systematic Reviews, Database, and HealthStar data-

NURSING ECONOMIC$/September-October 2005/Vol. 23/No. 5 253 Table 1. Table 2. Selected Patient Classification Systems Definition of Nursing Workload Measurement Terms Name of Classification Description Term Definition

Diagnosis Related Developed as a tool for utiliza- Workload “A method for quantifying Groups (DRGs) tion review to retrospectively Measurement nursing activity for staffing Fetter et al. (1979) analyze practice patterns and System purposes.” resource consumption patterns Edwardson & Giovannetti by case type. (1994, p. 96)

Disease Staging Designed as a tool to evaluate Nursing Workload “The amount and difficulty of Gonnella et al. quality patient care by grouping work required by nurses in a (1976) patients in accordance with sim- given situation.” ilar disease-specific severity. Hastings (1987, p. 52)

Severity of Illness Used to explain physician prac- Patient “Is the full program for identi- Index tice patterns by examining the Classification fying the number and type of Horn & Sharkey severity level of patients treated, Systems staff needed to meet the care (1983) developed specifically for inpa- requirements of clients. A sys- tient analysis. tem includes the time the instrument is completed, the Medical Illness Developed to diagnosis inde- process by which data are han- Severity Grouping pendent severity groupings dled, and the mathematics System (MEDIS- designed to facilitate measure- involved in calculating the GRPS) ment of the effectiveness of hos- number of hours of care and Brewster et al. pital and physician services by types of staff per classification (1984) controlling for initial severity. category.” Verran (1986a, p. 247) Patient Developed to define patient Management types, or products, treated by Patient “Is a tool to identify nursing Categories (PMCs) hospitals and to identify the rel- Classification care requirements of patients Young (1984) ative costs of producing those Instruments in a specific setting…reliable, products. valid, generalizable, and clini- cally useful.” Ambulatory Patient Designed to classify ambulatory Verran (1986a, p. 247) Related Groups patients in groups homoge- Fetter et al. (1984) neous in terms of patterns of Activity “Taxonomy of nursing role service required for care, believe Classification characteristics that can be used that grouping patients in this Systems to analyze and compare roles way would facilitate compara- in a given setting, or across tive analysis of practice patterns settings, according to qualita- across different providers – tive differences in types of based on DRG concept activities and focus of role.” Hastings (1987, p. 59)

Timed Activity “A special type of analysis in Classifications which specific activities of pro- bases. The search was limited to articles from 1980 Systems cedures are analyzed in terms to date. Primary search terms used were ambulatory of time requirements.” care, ambulatory care facilities, personnel staffing Hastings (1987, p. 59) and scheduling, nursing staff, staffing patterns, staffing models, and patient intensity. Secondary search terms used in combination with primary search terms were clinics, outpatient service, pain research-based literature; and focused on the scope clinics, nurse-managed centers, professional prac- and dimensions of ambulatory care nursing practice, tice, primary health care, physician practices, ambu- ambulatory care nursing workload, nursing intensity latory surgery, telenursing, telehealth, call centers, and patient classification, and ambulatory care nurse urgent care centers, and oncology clinics. References staffing. from retrieved articles were also searched. Articles Nursing Workload Measurement in Ambulatory Care selected for review were published between 1980 to the present; ranged from descriptive in nature to When the authors began their literature search,

254 NURSING ECONOMIC$/September-October 2005/Vol. 23/No. 5 there was an assumption that little published infor- Table 3. mation existed on nursing workload measurement Ambulatory Care Practice Settings Identified in and ambulatory care nurse staffing compared to the the Reviewed Literature body of evidence on hospital nurse staffing. The authors were surprised to find over 100 articles. A • Ambulatory care clinics complete annotated bibliography is available • Multi-specialty group practice through the American Academy of Ambulatory Care • Hospital-based ambulatory care Nursing (AAACN) at www.aaacn.org. In addition, • Ambulatory oncology clinic readers are referred to AAACN’s standards for pro- • Ambulatory oncology research centers fessional performance on staffing that state, “An ade- • Oncology outpatient treatment centers quate number of ambulatory care nurses are available to meet the patient care needs for the practice • Ambulatory surgery setting and maintain a safe and caring work environ- • Endoscopy center ment” (AAACN, 2004a, p. 3). AAACN’s telehealth • Free-standing ambulatory surgery center standards of professional performance for staffing • Orthopedic ambulatory surgery state, “An adequate number of competent telehealth • Dermatology outpatient clinic nursing staff is available to meet the patient care needs for the telehealth practice setting. Staffing • Family planning clinics models address the complexity of the telehealth • Family practice medical office encounter care needs while maintaining a safe and • Internal medicine clinic caring work environment” (AAACN, 2004b, p. 4). In • Medical outpatient clinic addition, the 2005-2006 Standards for Ambulatory • OB/GYN outpatient clinic Care from the Joint Commission on Accreditation of • Ophthalmology outpatient clinic Healthcare Organizations include standard HR.1.10, “The organization provides an adequate number and • Pediatric outpatient clinic mix of staff and licensed independent practitioners • Surgical outpatient clinic that are consistent with the organization’s staffing • Urology outpatient clinic plan…and to meet the care, treatment, and service • Indian Health Service needs of the patients” (p. HR-9). • Nurse-managed centers In the ambulatory care setting, nursing workload is influenced by patient characteristics (patient clas- • Outpatient burn care sification systems), nursing role characteristics • Outpatient university student health center (activity classification systems – dimensions, taxon- • Primary care to the homeless omy), and the number of patients requiring care. In • Urgent care centers 1981, Verran completed the first published research • Veterans Affairs primary care on activity categories in the domain of ambulatory care nursing. Over a decade passed before Haas and colleagues (1995a, b, c) published their research on the staff nurse role in ambulatory care. While the domains were being defined, research related to While the majority of articles are descriptive patient classification in ambulatory care and nursing summaries or single case studies, they offer concrete workload, as well as ambulatory care nurse staffing models and tools for ambulatory care nurse staffing. was also beginning. Some of this early work on More research-based publications were identified patient classification was adapted from inpatient than originally expected. Unlike the hospital nurse classification systems; while later work clearly built staffing literature, there were over 25 ambulatory on Verran’s Ambulatory Care Client Classification care settings identified where registered nurses Instrument (ACCCI) (1986a & b). deliver patient care (see Table 3). In addition, 28 During the time of this early work, payers were still tools were identified as being used in a variety of reimbursing health care delivery retrospectively, DRGs ambulatory care settings. These tools, listed in Table did not come into play until the mid-1980s, and man- 4, describe various components necessary for devel- aged care had not yet begun to dominate the health care oping staffing models: nurse activity classification, marketplace. For this reason, some of the early 1980s patient classification, and nursing workload. Some studies were included for historical reference purposes. of the instruments listed were used to test staffing For example, Camp’s 1981 article about an all RN staff models for ambulatory care and some were adapted for ambulatory surgery may not be useful for staffing an from the acute care setting. Despite the growing field ambulatory surgery unit in 2005, but certainly adds of telehealth nursing practice, there were no search- valuable information to the current debate on all RN able research-based articles on telehealth nurse staffs for telehealth nursing and call centers. staffing.

NURSING ECONOMIC$/September-October 2005/Vol. 23/No. 5 255 Table 4. Summary of Tools for Ambulatory Nurse Workload Measure Author & Year Tool Type Purpose Verran (1981) Taxonomy of Nurse Activity Identified the six domains of ambulatory care Ambulatory Classification nursing and described functions of nurses in Nursing Practice ambulatory care.

Henninger & Dailey Tool name not Nursing Workload Described a nursing workload measurement sys- (1983) provided Measurement tem, using the concept of relative value units System (RVUs) in the outpatient department of a regional cancer center; workload could be quantified with- out reducing it to a series of task-oriented skills that did not accurately reflect actual practice.

Schneeweiss et al. Diagnosis Clusters Patient Developed to facilitate comparison of ambulatory (1983) Classification practice patterns across differing providers; 92 clusters were formed representing 86% of all diagnoses.

Fetter et al. (1984) Ambulatory Patient Designed to classify all ambulatory care patients Patient Related Classification into 14 major ambulatory categories (MACS); sub- Groups (APGs) divisions under each category resulted in 154 APGs (based on DRG concept).

Genovich-Richards Tool name not Patient Described method for analyzing nursing staff pat- & Tracy (1984) provided Classification terns in general internal medicine practices based on total visit time regressed on tasks performed to estimate time for each activity: check-in, exam room, check-out.

Hoffman & Ambulatory Patient Patient Developed an instrument to assist in controlling Wakefield (1986) Classification Classification costs in the ambulatory setting. System Instrument

Verran (1986a) Ambulatory Care Patient Measured nursing care complexity in ambulatory Clinic Classification Classification care; comprises 44 nursing activities weighted for Instrument (ACCCI) Instrument complexity factors and grouped into six responsibility areas.

Verran (1986a) Ambulatory Care Patient Measured concepts of Knowledge of Client, Organizational Classification Standardized Treatment, Workload Variability, and Analysis Scale Instrument Analysis of Intervention Strategies; 20-item visual (ACOAS) analog scale.

Verran & Reid (1987) Nursing Model Testing Complexity of nursing care in ambulatory setting; Technology Model model tested using ACCCI and ACOAS. (NTM)

Parrinello (1987) Nursing Patient Patient Adapted inpatient patient classification instru- Classification Classification ment, 35-items, and piloted test in ambulatory System (NPCS) Instrument surgery center.

Horn et al. (1988) Ambulatory Patient Adapted from the Severity of Illness Index, a Severity Index Classification generic measure of patient severity designed to (ASI) Instrument assess the total burden of illness a patient pre- sents to the hospital.

Parinello et al. (1988) Ambulatory Care Patient Adapted and tested Verran’s instrument; adapted Clinic Classification Classification instrument composed of 34-items and patient vis- Instrument (ACCCI) Instrument its were categorized 1 through 4 based on nursing (Verran) intensity scores; tested in pediatrics, OB/GYN, medicine, outpatient surgery.

256 NURSING ECONOMIC$/September-October 2005/Vol. 23/No. 5 Table 4. (continued) Summary of Tools for Ambulatory Nurse Workload Measure Author & Year Tool Type Purpose Smith & Elesha- Student Health Patient Developed 26-item patient classification Adams (1989) Services Patient Classification instrument for use in student health service. Classification Instrument System

Hastings & Muir- Ambulatory Care Patient Adapted and tested Verran’s instrument; adapted Nash (1989) Clinic Classification Classification instrument composed of 61 nursing activities Instrument (ACCCI) Instrument grouped into nine responsibility areas. (Verran)

Johnson (1989) Allocation, Patient Adapted inpatient patient classification instru- Resource Classification ment for use in large multi-specialty ambulatory Identification, and Instrument care setting Costing (ARIC)

Miller & Folse (1989) Taxonomy of Patient Adapted Verran’s taxonomy using a time and motion Ambulatory Classification methodology to develop new patient classification Nursing Practice Instrument instrument for adult ambulatory surgery clinic. (Verran)

Prescott (1991) Patient Intensity Patient Developed to measure nursing intensity needed for Nursing Index Classification by patients in inpatient settings (general medical- (PINI) Instrument surgical, specialty, and intensive care); includes four dimensions of care including severity of illness, patient dependency, complexity of nursing care, and time.

Prescott (1991) Patient Intensity Patient Adapted from PINI to measure nursing intensity for Nursing: Classification for use in ambulatory care; includes 4 dimensions Ambulatory Care Instrument of care including severity of illness, patient psy- (PINAC) chosocial needs, complexity of nursing care, and time.

Schade & Austin Ambulatory Care Patient Adapted and tested Verran’s ACCCI instrument; (1992) Patient Classification adapted instrument composed of 44 activity cate- Classification Tool Instrument gories and both time and complexity weights (ACPCT) were established.

Porter (1995a & b) Ambulatory Nursing Activity Adapted from Verran’s taxonomy to develop a Oncology Nursing Classification patient classification instrument for ambulatory Checklist oncology clinics.

Haas & Hackbarth Dimensions of Nursing Activity Defined core dimensions of the current and future (1995a & b) Current Staff Classification role of ambulatory care staff nurses in four types Nurse Role of ambulatory care settings (university hospital outpatient, community hospital outpatient, physician group practices, and health maintenance organizations).

Davis (1996) Tool name not Nursing Workload Adapted from Henninger & Dailey’s work using provided Measurement RVUs in an outpatient ophthalmology clinic. System

Kusler-Jensen (1996) Patient Patient Adapted from an inpatient patient classification Classification Classification and developed a patient classification instrument System for Instrument for preoperative and postoperative care delivered Freestanding in a freestanding ambulatory surgery center. Ambulatory Surgery Centers

NURSING ECONOMIC$/September-October 2005/Vol. 23/No. 5 257 Table 4. (continued) Summary of Tools for Ambulatory Nurse Workload Measure Author & Year Tool Type Purpose American Society of Resource 9 Patient Staffing Model Developed staffing model for same-day surgery Peri Anesthesia Classification unit based on patient acuity, census, and physical Nurses (1997) facility.

Farrell et al. (1998) Care Tracker Patient Developed to describe nursing encounters by Classification type, intervention, staff, time, and cost. Instrument

Reeves (2002) Staffing formula Staffing Model Described staffing benchmarks by job category guided by industry based on support staff per physician FTE and standard bench- staffing expenses as a percent of revenue with marks adjustments made for midlevel providers, physician productivity, satellite locations, practice styles, staff expertise and experience, work performed by others outside the practice, and staff salaries.

Indian Health RRM Ambulatory Staffing Model Developed to estimate the requirements for nurs- Service (2004) Nursing Staffing es that provide comprehensive health care and Module education to the individual and family in the ambulatory care setting.

Cusack et al. Ambulatory Patient Developed to quantify nursing care in an outpa- (2004a & b) Intensity System Classification tient cancer center and used in conjunction with a Instrument computerized appointment system.

Components for Developing Ambulatory Care Nurse dictability, and required knowledge involved in Staffing Models delivering a nursing service or activity (Verran, Common components of patient classification 1986a). There is quantification scheme variability instruments, adapted from acute care tools, include among the tools listed, some include both time and indicators of care, instrument format, and quantifi- complexity/intensity and some include one or the cation scheme (Verran, 1986a). Indicators of care are other. Finally, to be useful, a patient classification descriptor’s of clients needs for nursing services and instrument (and system) must be both reliable and are applicable in all ambulatory care areas. There are valid (Giovannetti, 1979; Medvec, 1994). three tools or taxonomies of ambulatory care staff Challenges in Measuring Nursing Workload in nurses’ activities listed in Table 4 that may serve as Ambulatory Care indicators of care when designing a staffing model (Haas & Hackbarth, 1995a; Porter, 1995a & b; Verran, Some of the tools identified in the literature 1981). Instruments are usually formatted in one of were adapted from the acute care setting. Differences two ways: prototype evaluation design or factor eval- exist in nursing interactions and care structures uation design. Prototype evaluation design includes between acute and ambulatory care, making it diffi- broad descriptions and characteristics of the typical cult to apply the same tools for measuring nursing patient in each category versus factor evaluation workload and thus designing ambulatory care nurse design that delineates specific elements of care for staffing models. These include the episode of care, which the patient is rated independently (Verran, treatment period, requirement for nursing, workload 1986a). Both types of formats are represented in capacity, control of timing, and organizational posi- Table 4. There are two types of quantification tion of nursing (Hastings, 1987). Ambulatory care schemes used to classify clients and the use of both nurses provide care in person at well over 25 differ- is helpful and recommended. First, assesses nursing ent settings, as well as remotely via telephone, the time expended for a category or in an activity (time Internet, and other e-technologies. They may have a required to deliver categories of care). Second, one-time only, brief encounter with a patient or care assesses complexity or intensity of nursing care for a patient over many years. It is often difficult to delivered. The terms complexity and intensity refer differentiate the role and work of ambulatory care to the degree of routineness, standardization, pre- nurses from other health care providers, leading to

258 NURSING ECONOMIC$/September-October 2005/Vol. 23/No. 5 unclear and variable requirements for nursing care. • Competency level of staff and educational needs. There are minimal limits on workload capacity and The practice environment and professional com- frequent scheduling modifications due to patient plexity of the role (including staff mix) must be flow, making ambulatory nursing workload often taken into consideration, along with direct and indi- less predictable because it is controlled by patient rect care activities. Ambulatory care nurses and and contextual factors. Also, the organizational lead- administrators should understand the strengths and ership position for ambulatory nursing care may not limitations of each tool but should also take advan- be occupied by a nurse (Hastings, 1987). tage of the information each provides.$

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ADDITIONAL READINGS Detwiler, C., & Clark, M.J. (1995). Acuity classification in the urgent care setting. Journal of Nursing Administration, 25(2), 53-61. Haas, S.A., Gold, C.R., & Androwich, I. (1997). Identifying issues in nursing workload. AAACN Viewpoint, 19(2), 8-9. Hackbarth, D.P., Haas, S.A., Kavanagh, J.A., & Vlasses, F. (1995). Dimensions of the staff nurse role in ambulatory care. Part I: Methodology and analysis of data on current staff nurse practice. Nursing Economic$, 13(2), 89-98. Jones, A., Cusack, G., & Chisholm, L. (2004). Patient intensity in an ambulatory oncology research center: A step forward for the field of ambulatory care–Part II. Nursing Economic$, 22(3), 120-123, 107. Parrinello, K.M. (1990). Measuring and monitoring nursing intensity. Medical Group Management Journal, 37(2), 32-35. Parrinello, K.M., & Witzel, P.A. (1990). Analysis of ambulatory nursing practice. Nursing Economic$, 8(5), 322-328. Prescott, P.A., Ryan, J.W., Soeken, K.L., Castorr, A.H., Thompson, K.O., & Phillips, C.Y. (1991). The patient intensity for nursing index: A validity assessment. Research in Nursing & Health, 14, 213-221. Prescott, P.A., & Soeken, K.L. (1996). Measuring nursing intensity in ambulatory care. Part I: Approaches to and uses of patient classification systems. Nursing Economic$, 14(1), 14-21, 33. Prescott, P.A., & Soeken, K.L. (1996). Measuring nursing intensity in ambulatory care. Part II: Developing and testing PINAC. Nursing Economic$, 14(2), 86-91, 116.

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