Thomas Jefferson University Jefferson Digital Commons 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 Follow this and additional works at: https://jdc.jefferson.edu/nursfp Part of the Nursing Commons Let us know how access to this document benefits ouy 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 pre- requisite 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, nurs- ing 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 lit- erature 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 organiza- tion, 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-