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Nursing activities and factors influential to nurse staffing decision-making

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DOI: 10.5430/jha.v4n4p24

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www.sciedu.ca/jha Journal of Hospital Administration 2015, Vol. 4, No. 4

ORIGINAL ARTICLE

Nursing activities and factors influential to nurse

staffing decision-making
∗1
Judith Young1 , Mikyoung Lee , Laura Prouty Sands2 , Sara McComb3
1
Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana, United States
2
Department of Human Development, College of Liberal Arts and Human Sciences, Virginia Tech Center for Gerontology,
Blacksburg, Virginia, United States
3
School of Industrial Engineering, Purdue University, West Lafayette, Indiana, United States

Received: April 10, 2015 Accepted: April 24, 2015 Online Published: May 7, 2015
DOI: 10.5430/jha.v4n4p24 URL: http://dx.doi.org/10.5430/jha.v4n4p24

A BSTRACT
Objective: There is limited published research supporting the effectiveness of nursing workload measurement to comprehensively
measure nursing workload and to formulate nurse resource need. Predictive accuracy is impaired due to variation in direct and
indirect care-related activities across measurement instruments. This study aimed to (1) identify common nursing activities
considered by nurse managers for staffing decision-making, (2) systematically review such nursing activities in relation to
existing nursing workload instruments and Nursing Intervention Classification taxonomy, and (3) describe challenges perceived
by managers in staffing decision-making.
Methods: A survey was developed from an inclusive review of 20 nursing workload instruments collectively measuring 502
nursing activities. Nurse managers in 13 medical-surgical and two intensive care units at a Midwest healthcare organization
identified nursing activities considered daily for staffing decision-making.
Results: Twenty-one activities were commonly considered by at least 90 percent of managers (n = 13) for daily staffing decision-
making, although none of the instruments reviewed included all 21 activities.
Conclusions: Lack of a standardized framework for nursing workload measurement might have led to nurse managers’ different
perceptions about appropriate determinants of these measurements. A standardized approach for measuring nursing workload
would facilitate benchmarking for estimating nurse resource need. Further research is needed to design a systematic infrastructure
that ensures staffing to meet patient care need. A process is also needed to alleviate the challenges in staffing decision-making
that nurse managers face, such as fluctuations in census and patient acuity, nurse competency-based patient assignments, and
limited information resources for staffing estimation.

Key Words: Nursing workload, Staffing, Decision-making, Nursing intervention classification

1. I NTRODUCTION ber of registered nurses (RNs) is likely the best strategy to

facilitate high care quality; however, with escalating health-
Nurse staffing is a priority issue for nurse managers to ensure care costs, nurses have been the target of cost-cutting strate-
patient safety, nurse satisfaction, and productivity. Research gies.[5] Therefore, having optimal nurse staffing is highly
is mounting that supports a significant association between challenging.
nurse staffing and patient outcomes.[1–4] Increasing the num-
∗ Correspondence: Mikyoung Lee; Email: [email protected]; Address: 1111 Middle Drive, Indianapolis, Indiana, United States.

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A variety of nursing workload measurement (NWM) instru- used in a psychiatric setting[26] and two in outpatient set-
ments have been developed, refined, and utilized to guide tings.[27, 28] Few instruments in the studies had been designed
staffing decision-making. The existing NWM instruments based on a theoretical framework; three (15%) of the 20
can be grossly categorized into three approaches: patient instruments were based upon, respectively, Benner’s Novice-
classification system (PCS); nursing workload (NW); and Expert, the NIC, and Nursing Outcome Classification;[12]
nursing intensity (NI). The PCS, known as the prototype Horta’s Basic Needs Theory;[13] and the Nursing Process
approach, involves a subjective assessment for determining Model.[26]
the patient care category most representative of the patient
In total, 1,438 nursing activities from 20 instruments were
care needs based upon the average timeframes and skill mix
extracted and sorted according to the NIC. The NIC is a
required.[6, 7] The NW is the summative task approach, using
comprehensive standardized classification of nursing care
a comprehensive list of tasks or care indicators with numer-
interventions that addresses physiological to psychosocial
ical sums of average time for and frequency of performing
patient care need, illness treatment, and health prevention
each task determining nursing skills required and resource
and promotion in comprehensive dimensions.[29] The NIC
needs for the next shift or day.[8] The NI approach links
includes nursing care provided within and across healthcare
direct and indirect care activities performed to specific time
settings as well as interventions conducted by nursing care
standards, healthcare provider educational preparedness, ex-
providers at different levels. In addition to direct nursing
perience and skill level, and patient acuity categories. The
care, it includes indirect nursing activities such as chart doc-
sum of time requirements according to skill mix provides
umentation, interdisciplinary collaboration, and communica-
estimations for resource need.[8, 9]
tion needs to incorporate within staffing calculations.[29] It
The estimations of nurse staffing needs vary significantly by is useful for clinical documentation, communication about
setting and even across units within a setting, depending upon care across settings, integration of data across systems and
the types/approaches of NWM instruments used. The predic- settings, competency evaluation, and productivity measure-
tive accuracy of staffing estimations has often been cited as a ment.[29]
challenge due to the limited use of objective tools to estimate
The NIC has a taxonomy structure in four levels; at the top
staffing and the tools’ limited comprehensiveness in fully re-
level, there are seven domains including Physiological Basic,
flecting the nursing workload required for addressing patient
Physiological Complex, Behavioral, Safety, Family, Health
care needs. Multiple factors, including physical, emotional,
System, and Community. At the 2nd level, 30 classes are
and cognitive patient care needs, drive nursing activities and
specified across the domains, for example, Crisis Manage-
impact nursing workload.[10] Therefore, it is very important
ment and Risk Management under the domain of Safety.
to gather and comprehensively review nursing activities that
At the 3rd level, there are 542 nursing interventions; each
have been included in existing NWM instruments with nurse
nursing intervention lists a set of specific nursing activities,
managers in order to find strategies that comprehensively
which constitute the 4th level. Briefly, 1,438 nursing activ-
reflect nursing work as well as more accurately predict nurse
ities are grouped to 542 interventions in 30 classes within
staffing needs.
seven domains in the 5th edition of NIC. An intervention is
This study aimed to (1) identify common nursing activities defined as any treatment based upon clinical judgment and
considered by nurse managers for staffing decision-making knowledge that a nurse performs to enhance patient/client
in one large health organization, (2) systematically review outcomes.[29] In the NIC, each intervention is composed of a
such nursing activities in relation to existing NWM tools and label, a definition, and a set of activities that a nurse performs
the Nursing Intervention Classification (NIC), and (3) de- to carry out the intervention.
scribe challenges perceived by managers in staffing decision-
Referring to the definitions of and nursing activities related
making.
to each nursing intervention in the NIC, the 1,438 nursing
activities were mapped and sorted. Utilizing a second re-
2. M ETHODS viewer, duplicated or redundant activities were excluded. As
2.1 Survey development a result, 502 nursing activities were incorporated into the sur-
Twenty workload instruments were reviewed, including three vey along with a frequency rating scale (daily, occasionally,
patient classification, ten nursing workload, and seven nurs- or not at all) to identify nursing activities that nurse man-
ing intensity instruments, and were reflected within the sur- agers predominantly consider to determine nurse staffing
vey to achieve a comprehensive representation of nursing needs. The greatest number of nursing activities (n = 179)
workload (see Table 1). Seventeen of the instruments had was related to 65 interventions and linked to the eight classes
been used in an acute care setting,[5, 9, 11–25] followed by one
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of the NIC domain Physiologic Complex, which include linked to 26 interventions related to its six classes: Behavior
Electrolyte and Acid-Base Management, Drug Management, Therapy, Cognitive Therapy, Communication Enhancement,
Neurologic Management, Perioperative Care, Respiratory Coping Assistance, Patient Education, and Psychological
Management, Skin/Wound Management, Thermoregulation, Comfort Promotion. The sixth NIC domain was Family Care,
and Tissue Perfusion Management. The next greatest number and 25 nursing activities were matched with 18 interventions
of nursing activities was related to the NIC domain Health under three classes: Childbearing Care, Childrearing Care,
Systems, including 103 nursing activities linked to 23 inter- and Lifespan Care.
ventions in three classes including Health System Mediation,
The survey was comprised of: (1) seven questions about
Health System Management, and Information Management.
unit characteristics related to nursing staffing, (2) questions
A third NIC domain, Physiologic Basic, included six classes:
asking which of 502 nursing activities the respondents rou-
Activity & Exercise Management, Elimination Management,
tinely used to estimate nurse staffing need, and (3) 13 open-
Immobility Management, Nutrition Support, Physical Com-
ended questions regarding challenges related to the staffing
fort Promotion, and Self-Care Facilitation. Mapped to these
decision-making process. Unit characteristics included unit
six classes were 101 nursing activities that were part of 41
type, census, bed capacity, average nursing hours per patient
interventions. Under the fourth NIC domain, Safety, 47 nurs-
day, skill mix (the proportion of RN to non-RN staff for each
ing activities were linked to 18 interventions in two classes,
shift), average length of stay, and the frequency of nursing
Crisis Management and Risk Management. The fifth NIC
staffing decision-making.
domain was Behavioral Care, and 47 nursing activities were

Table 1. Nursing workload measurement instruments included within survey development

Authors Names of Instruments (codes)
1 Crouch & Williams, 2006[11] Jones Dependency Tool (PCS - 1)
2 Malloch et al., 1999[12] Third-generation PCS (3PCS) (PCS - 2)
3 Perroca & Ek, 2007[13] Perroca (PCS - 3)
[26]
4 Davidhizar et al., 1998 Psychiatric PCS (NW - 1)
5 Kwok et al., 2005[14] Simplified Therapeutic Intervention Scoring System (TISS-28) (NW - 2)
6 Miranda et al., 1997[15] Nine Equivalents of Nursing Manpower Use Score (NEMS) (NW - 3)
7 Miranda et al., 2003[16] Nursing Activities Score (NAS) (NW - 4)
[5]
8 Mullinax & Lawley, 2002 Neonatal Acuity Score (NW - 5)
9 Pyykko et al., 2004[17] Intensive Care Nursing Scoring System (ICNSS) (NW - 6)
10 Sawatzky-Dickson & Bodnaryk, 2009[18] Winnipeg Assessment of Neonatal Nursing Needs Tool (WANNNT) (NW - 7)
11 Scribante et al., 1996[19] Critscore (NW - 8)
[20]
12 Walthier et al., 2004 Modified Nursing Care Recording System (NCR11) (NW - 9)
13 Yamase, 2003[21] Comprehensive Nursing Intervention Score (CNIS) (NW - 10)
14 De Jong et al., 2009[9] Not Available (NI - 1)
15 Duclos-Miller, 1996[22] Labor, Delivery, Recovery, Postpartum Model (LDRP) (NI - 2)
16 Hlusko & Nichols, 1996[23] Not Available (NI - 3)
[24]
17 Hoi et al., 2010 Workload Intensity Measurement System (WIMS) (NI - 4)
18 Karr & Fisher, 1997[27] Not Available (NI - 5)
19 Moore & Hastings, 2006[28] Not Available (NI - 6)
20 Chou et al., 2007[25] Chinese Nursing Interventions in ICU (CNI-ICU) (NI - 7)

2.2 Survey procedure teen of the managers completed the survey, for a response
The study was approved by the Institutional Review Boards rate of 47%.
of the healthcare organization and two universities. Nurse
managers were informed about the study at an all-campus 2.3 Data analyses
management meeting. The survey was sent via SurveyMon- Descriptive analyses were conducted to identify common
key to 32 managers at one large Midwest healthcare system nursing activities considered by nurse managers across units
over a three-week period. Any identifiable information was for estimating nurse staffing. The narrative responses to
protected by encrypting the information in the data site. Fif- the questions about perceived challenges to staffing decision-
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making were characterized by the following themes: resource 3.3 Challenges in the nurse staffing decision-making
availability, nurse competency consideration, nurse satisfac- process
tion, and patient outcomes. 3.3.1 Resource availability
Staffing calculations were completed at four-, eight-, or
twelve-hour intervals or as needed. In two thirds of the units
3. R ESULTS
(67%), including the two ICUs and eight MSUs, staffing
3.1 Unit characteristics needs were calculated every four hours or more frequently
as needed due to fluctuation in census, the dynamic nature
Fifteen managers representing medical-surgical units (MSU,
of nursing workload, and patient acuities. The remaining
n = 13) and intensive care units (ICU, n = 2) completed the
managers (n = 5) reviewed staffing needs shift by shift.
survey. The average unit occupancy was 77 percent (ranging
from 43% - 90%). Length of patient stay ranged from two The use of existing NWM instruments was limited. The
days in ICUs to 10 days in MSUs. The average nursing managers of two MSUs utilized an in-house PCS tool, cate-
hours per patient day (NHPPD) ranged from 23.5 hours for gorizing patient care needs according to levels one through
patients in ICUs to 3.2 hours for the medical-surgical patient three. The remainder (86%), comprised of two ICUs and 11
population. Nurse-to-patient ratios ranged from 1:1 (ICU) to MSUs, followed a census-driven staffing policy that included
1:7 (MSU night shift). a unit staffing grid with predetermined nurse-to-patient ra-
tios and staffing mix. For example, the ICUs had different
nurse-to-patient ratios for different types of patients: 2:1 for
3.2 Nursing activities to estimate nurse staffing needs a patient donor of organs at end of life; 1:1 for a patient
In total, 502 nursing activities were mapped to 200 nurs- within 6 - 8 hours of the postoperative period; and 1:2 for
ing interventions under 26 classes and six domains of NIC. patients of lower acuity, but still meeting critical care criteria
The number of nursing activities for each domain ranged requiring frequent monitoring of vital signs and assessment
from 25 (Family) to 189 (Physiologic Complex). Out of (e.g., every two hours). The nurse-to-patient ratios on the
502 nursing activities only 21 (4%) were commonly con- MSUs were reported as 1:5 on the day and evening shifts
sidered by at least 90% (n = 13) of the nurse managers for and 1:6 or 1:7 on the night shifts.
daily staffing decision-making (see Table 2). Although more Seven managers stated that no feature of the electronic
than one nursing activity comprised each of the NIC nurs- health record (EHR) could automatically or directly facilitate
ing interventions, only one nursing activity per intervention staffing decision-making. However, the managers indicated
was commonly considered when nurse managers estimated that staffing needs and nurse-to-patient assignments were
nurse staffing. For example, although two nursing activities made by reviewing patient acuity status, which was deter-
comprised Nausea Management of NIC, only one of them, mined from particular patient information in the EHR (e.g.,
“Symptom management of nausea”, was commonly consid- isolation, history, physical data, medications, fall risk, and
ered by nurse managers when estimating nurse staffing. As social/family issues).
another example, 57 nursing activities comprised the NIC in-
tervention, “Medication Administration: Intravenous (IV)”; 3.3.2 Nurse competency consideration
however, “Monitoring IV medication” was the only nursing The two ICU nurse managers and eight MSU nurse managers
activity considered by at least than 90% of nurse managers considered nurse competency level for staffing. In particular,
when estimating staffing needs (see Table 2). In addition to nurse competency level was considered when assigning float-
direct nursing activities, at least 90% of nursing managers ing nurses from a resource pool. In this case, the charge nurse
considered four indirect care activities that were contained would verify nurse competency level prior to completing the
within one NIC class, Information Management (see Table patient assignments. Specifically, ICU managers considered
2). Thirteen of the 502 nursing activities were not considered nurses’ competency levels regarding procedures scheduled
at all for staffing decision-making by 90% of nurse managers at the bedside or outside the unit. For example, a nurse not
(see Table 3). ICU managers reported they have also con- certified in advanced cardiovascular life support would not
sidered some nursing activities that were not listed in the be assigned to a patient who would be travelling during the
survey, including heavy lifting, adoption, loss of an infant be- shift. Managers of MSUs generally scheduled an appropriate
reavement, and application of an epidural patch. MSU nurse mix of experienced and novice nurses for each shift, and
managers reported involvement of child protection service one MSU manager mentioned that a newly graduated nurse
and suspected drug or child abuse were additional nursing would have fewer patients than experienced nurses. Overall,
activities considered with staffing. the managers tried to equalize nursing workload within indi-
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vidual nursing assignments by avoiding disproportionately physician demands, patient care needs, and the fluctuating
assigning patients with greater care needs to the same nurse. census. One MSU nurse manager reported that staff believed
the unit was understaffed and nurse satisfaction was lower
3.3.3 Nurse satisfaction
due to the lack of nursing assistant support, which led to
One ICU manager stated that nurses were probably satisfied
nurses feeling overwhelmed occasionally or on a daily basis.
with the current staffing processes, NHPPD, and nurse-to-
One manager reported, “We staff for patients in the unit only,
patient ratios because she made an effort to ensure that as-
not for what if situations.” Similarly, most managers reported
signments were fair and equitable with the workload evenly
that they were guided by the pre-determined staffing grid and
dispersed. However, she was concerned that staff morale
patient census only.
might be low and nurses might feel frustrated because of

Table 2. Nursing activities considered daily by at least 90% of managers

NIC Nursing Activities of the Survey
Number of
Domain Classes Nursing Activities Considered by at Least 90%
Interventions (Level III) Nursing Instruments†
(Level I) (Level II) of Managers
Activities*
Physical Nausea Management 2 Symp tom management of Nausea PCS - 1
Physiological:
Comfort Vomiting Management 3 Symptom management of vomiting PCS - 1
Basic
Promotion Pain Management 14 Pain management with IV analgesic infusions NW - 10
Respiratory
Respiratory Monitoring 8 Pulse Oximetry monitoring NW - 8
Physiological: Management
Complex Drug Medication Administration:
57 Monitoring of IV Medication NW - 4
Management Intravenous
Decision Making support 7 Support for decision making NW - 1
Coping
Coping Enhancement 20 Identify stressors NW - 1
Assistance
Behavioral Emotional Support 2 Provide reassurance NW - 1
Patient Teaching: Individual 7 Giving information NI - 4
Education Teaching Disease Process 13 Discharge teaching NI - 8
Pressure Ulcer Prevention 5 Skin risk PCS - 3
Risk Fall Prevention 1 Fall risk NW - 10
Safety
Management Risk Identification Control behaviors that might cause physical harm,
5 PCS - 2
precipitate injury or falls
Family Presence
1 Personal/family dynamics NW - 7
Facilitation
Family Integrity Promotion 3 More than usual amount of family support PCS - 2
Family Life Span Care
Family Involvement
8 Involve family in care PCS - 2
Promotion
Family Support 9 Face to face contact time NW - 1
Chart documentation of clinical assessment, care
Documentation 16 NI - 4
planning & evaluation, update patient care plan
Information Case Management 27 Nursing diagnosis NW - 1
Health System
Management Shift Report 1 Handover report NI - 4
Health Care Information
7 Giving information NI - 4
Exchange
*
= the number of nursing activities associated with each NIC intervention; † = types of instruments from which the nursing activity was extracted

3.3.4 Patient outcomes impacted due to heavy workload and high patient-to-nurse
One of the ICU managers stated, “Patient teaching is affected ratios, which resulted in insufficient time to provide patient
if a nurse cannot remain in the room more than 10 to 15 min- discharge education or social interaction as needed. Some of
utes.” Both ICU managers remarked that, although the care the MSU managers also expressed their concern that delays
in their units was of good quality, some care such as edu- in the discharge process could occur due to heavy workload,
cation couldn’t be done as needed due to time constraints. although it had not happened often, which might impact
The MSU managers reported that patient outcomes might be patient satisfaction.

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Table 3. Nursing activities not considered daily by at least 90% of managers

NIC Nursing Activities of the Survey
Number of
Domain Classes Nursing Activities Not Considered by at Least
Interventions (Level III) Nursing Instruments†
(Level I) (Level II) 90% 0f Managers
Activities*
Neurologic Tube Care: Ventriculoscopy/ External ventricular drain requiring frequent
1 NW - 7
Management Lumbar drain adjustments
Drug Medication Administration;
57 Cassette Change NI - 6
Management Intravenous
Physiological: Respiratory Mechanical Ventilation
13 Jet Ventilation NW - 5
Complex Management Management: Invasive
Tissue Circulatory Care: Mechanical 4 Mechanically assisted circulation NW - 10
Perfusion Assist Device 4 Intra-aortic balloon assist NI - 8
Management Shock Management: Cardiac 6 Post-operative cardiac surgery for the first 24 hours NW - 8; NW - 3
11 Teaching endometrial biopsy NI - 6
Patient
Behavioral Teaching Procedure/treatment 11 Colposcopy NI - 6
Education
11 IUD insertion NI - 6
43 Insert intra cerebral pressure device NW - 10
Health
Health Examination Assistance 43 Cystography NW - 10
System
Systems 43 PAP test routine Gynecological test NI - 6
Management
Supply Management 14 Management of a burn bed NW - 10
*
= the number of possible nursing activities associated with each NIC intervention; † = the types of instruments from which the nursing activity was extracted

4. D ISCUSSION considered. These findings suggest that different determi-

This study confirmed that staffing decision-making repre- nants of nursing workload across units are relevant to the
sented a central activity for nursing managers since the ma- dominant patient populations in each unit. Furthermore, the
jority reviewed and adjusted staffing every four hours or findings also illustrate that there were diverse nursing work-
more frequently as needed. Measuring nursing workload is load measurements used across units, resulting in limited
an international concern of healthcare providers and a variety benchmarking and limited evidence to support staffing needs.
of NWM instruments has been available to guide staffing The lack of a standardized framework for NWM, even within
decision-making. This study initially reviewed 20 NWM in- this one organization, might have led nurse managers to dif-
struments that had presented the contents of the instruments ferent opinions about appropriate determinants of nursing
in published articles, although there could be more diverse workload measurements.
NWM instruments in existence. The fact that 502 unique No one instrument contained all of the 21 nursing activities
nursing activities were identified from a total of 1,438 nurs- identified by at least 90% of nurse managers. This finding
ing activities extracted from these 20 instruments suggests may explain why there have been doubts about the reliabil-
that nursing workload has been very differently measured ity of workload measurement approaches in their present
by different instruments. Furthermore, the extent to which form and why the available NWM tools remain underutilized.
nursing work is comprehensively measured by each of the At this study site only two managers used a PCS tool; the
instruments is in question, and comparing their nursing work- majority of managers used a census-driven staffing policy,
load effects on patient or system outcomes would be difficult which included a unit staffing grid with predetermined nurse-
due to the great differences in the workload measurements. to-patient ratios and staffing mix. This static approach is
Surprisingly, out of the 502 nursing activities only 21 were limited for addressing fluctuations in census, the dynamic
reported to be commonly considered by at least 90% of nature of nursing workload, and patient acuities. Inconsis-
the participating nurse managers for daily staffing decision- tent dimensions and the lack of a standardized approach for
making; 17 direct nursing activities and four indirect care measuring nurse workload compound the challenges for man-
activities were included in this set of 21 activities. When agers to account for multiple factors that influence workload
the cut-off for common consideration was set at 80%, 34 complexity.[6] Accuracy for determining nursing resource
nursing activities were identified, and the number of nurs- need is essential to support high quality nursing care and
ing activities commonly considered by more than 50% of patient safety in a cost-effective manner. We believe that the
managers increased to 50. Notably, the great majority of the use of an instrument whose framework is scientific, compre-
502 nursing activities within the survey were not commonly hensive, and holistic is an immediate need to standardize the
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approach for measuring nursing workload. be limited; however, the survey did embrace the diverse units
within the setting. Furthermore, only half of the nurse man-
In the 502 nursing activities extracted in our review, the NIC
agers actually completed the survey, and feedback suggested
was used as the framework to organize the similarities and
this was at least partly because it was lengthy and required
differences in aspects of the nursing activities. The NIC
up to two hours for completion. This may have affected the
provides consistent dimensions as represented in its taxon-
quantity and quality of the data. Finally, the survey instru-
omy, and it provides a standardized approach for measuring
ment may not have included all factors related to nursing
nursing workload with time estimates and type of personnel
staffing decision-making; however, the study provided a good
to perform each of the 542 nursing interventions.[29] For
opportunity to review the capacities of existing NWM instru-
example, Nausea Management is appropriate for RNs with
ments as well as the reality of the workload measurement
basic education to perform and requires 16 - 30 minutes. Pain
process with nurse managers.
Management also needs to be provided by RNs with basic
education but takes more than one hour to perform. The
NIC also lists the interventions appropriate for delegation 5. C ONCLUSIONS
to a nursing assistant or to an RN with post-basic education. There has been no comprehensive and systematic approach
It was good to find that most of the managers in this study to measure nurse workload. Varied dimensions, the lack of
considered nurse competency level and patient acuity with a standardized approach for measuring nursing workload,
assignment decisions. In the future, it would be meaning- and the opportunity for subjectivity in judgments have com-
ful to review the nurse managers’ complex nursing staffing pounded the challenge for managers to accurately estimate
decision process, including nurse-to-patient assignment ra- nurse resource predictions. A standardized approach for mea-
tios, delegation, nurse competency judgements according to suring nursing workload would address an immediate need to
the nursing workload measures, along with the set of time assist nurse staffing decision-making. The NIC System could
estimates and type of personnel determined by the NIC. provide a framework for the development of a standardized
approach to determine nurse workload; its taxonomy would
Although nurses were reported to be satisfied with the current organize the nursing workload measurements in a compre-
staffing processes, the managers were concerned that staff hensive approach, and the labels of nursing interventions and
nurses had low morale and frustration due to the fluctuating activities would help to represent and measure nursing work
census and lack of nursing assistant support to meet care in a standardized manner. The review of existing NWM tools
needs on a daily basis. A system or resource to address these or the development of a tool with the NIC is recommended
problems is needed for nurse managers. In the survey, nurse to determine comprehensive nursing workload measures ap-
managers indicated that no feature of the EHR could auto- propriate for particular types of units or patient populations.
matically or directly facilitate staffing decision-making, and Although the NWM tools would be specific to the dominant
they utilized the EHR to a minimal extent. Using available patient populations of each unit, the tools based on the NIC
information technology to facilitate prompt and accurate es- would facilitate benchmarking of staffing impacts across set-
timations for nurse resource needs would provide a more tings or patient populations because standardized terms are
efficient approach. Standardized terminologies such as those used. The NWM tool integrated with hospital information
used by the NIC could be built into such healthcare technol- systems is highly recommended to assist nurse administra-
ogy. tors to efficiently optimize nurse staffing as well as to ensure
patient safety, quality care, and nurse satisfaction.
Limitations
The survey was administered in one healthcare setting, and C ONFLICTS OF I NTEREST D ISCLOSURE
therefore the representativeness of the study findings might The authors declare no conflict of interest.

R EFERENCES 14621688.
[1] Aiken L, Clark S, Sloane D. Hospital nurse staffing and patient mor- [3] Kane R, Shamliyan T, Mueller C, et al. The association of regis-
tality, nurse burnout, and job dissatisfaction. Journal of the American tered nurse staffing levels and patient outcomes: Systematic re-
Medical Association. 2002; 288(16): 1987-1993. PMid: 12387650. view and meta-analysis. Medical Care. 2007; 45(12): 1195-1204.
http://dx.doi.org/10.1001/jama.288.16.1987 PMid: 18007170. http://dx.doi.org/10.1097/MLR.0b013e3
[2] Aiken L, Clarke S, Silber J, et al. Hospital nurse staffing, educa- 181468ca3
tion, and patient mortality. LDI Issue Brief. 2003; 9(2): 1-4. PMid: [4] Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and

30 ISSN 1927-6990 E-ISSN 1927-7008

 www.sciedu.ca/jha Journal of Hospital Administration 2015, Vol. 4, No. 4

the quality of care in hospitals. New England Journal of Medicine. [17] Pyykko A, Ala-Kokko T, Laurila J, et al. Validation of the new in-
2002; 346(22): 1715-1722. PMid: 12037152. http://dx.doi.org tensive care nursing score system (ICNSS). Intensive Care Medicine.
/10.1056/NEJMsa012247 2004; 30: 254-259. PMid:14714105. http://dx.doi.org/10.10
[5] Mullinax C, Lawley M. Assigning patients to nurses in neonatal inten- 07/s00134-003-2040-4
sive care. Journal of the Operational Research Society. 2002; 53: 25- [18] Sawatzky-Dickson D, Bodnaryk K. Validation of a tool to measure
35. http://dx.doi.org/10.1057/palgrave/jors/2601265 neonatal nursing workload. Journal of Nursing Management. 2009;
[6] De Groot, H. Patient classification system evaluation part 1: Essential 17: 84-91. PMid: 19166526. http://dx.doi.org/10.1111/j.1
system elements. Journal of Nursing Administration. 1989a; 19(6): 365-2834.2008.00877.x
30-35. PMid: 2723792. http://dx.doi.org/10.1097/0000511 [19] Scribante J, Muller M, Lipman J. Development and validation of
0-198906010-00010 a critical care patient classification system. American Journal of
[7] De Groot H. Patient classification system evaluation part 2: System Critical Care. 1996; 5(4): 282-288. PMid: 8811151.
selection and evaluation. Journal Nursing Administration. 1989b; [20] Walther S, Jonasson U, Karlsson S, et al. Multicentre study of valid-
19(7): 24-30. PMid: 2760676. ity and interrater reliability of the modified Nursing Care Recording
[8] Brady A, Byrne G, Horan P, et al. Measuring the workload of System (NCR11) for assessment of workload in the ICU. Acta Anaes-
community nurses in Ireland: A review of the workload measure- thesiologica Scandinavica. 2004; 48: 690-696. PMid: 15196100.
ment systems. Journal of Nursing Management. 2007; 15: 481-489. http://dx.doi.org/10.1111/j.0001-5172.2004.00397.x
PMid: 17576246. http://dx.doi.org/10.1111/j.1365-2834. [21] Yamase H. Development of a comprehensive scoring system to mea-
2007.00663.x sure multifaceted nursing workloads in ICU. Nursing and Health
[9] De Jong A, Leeman J, Middelkoop E. Development of a nursing Sciences. 2003; 5: 299-308. http://dx.doi.org/10.1046/j.1
workload measurement instrument in burn care. Burns-Oxford. 2009; 442-2018.2003.00165.x
35: 942-948. PMid: 19577371. http://dx.doi.org/10.1016/j
[22] Duclos-Miller P. Workload measurement tracking system. Nursing
.burns.2009.04.005
Management. 1996; 27(9): 39-41. http://dx.doi.org/10.1097
[10] Carayon P, Alvarado C. Workload and patient safety among critical /00006247-199609000-00017
care nurses. Critical Care Nursing Clinics of North America. 2007;
[23] Hlusko D, Nichols B. Can you depend on your patient classification
19: 121-129. PMid: 17512468. http://dx.doi.org/10.1016/j
system? The Journal of Nursing Administration. 1996; 26(4): 39-44.
.ccell.2007.02.001
PMid: 8774471. http://dx.doi.org/10.1097/00005110-199
[11] Crouch R, Williams S. Patient dependency in the emergency depart-
604000-00012
ment (ED): Reliability and validity of the Jones Dependency Tool. Ac-
[24] Hoi S, Ismail N, Ong L, et al. Determining nurse staffing needs: The
cident and Emergency Nursing. 2006; 14: 219-229. PMid: 16904323.
workload intensity measurement system. Journal of Nursing Man-
http://dx.doi.org/10.1016/j.aaen.2006.06.005
agement. 2010; 18: 44-53. http://dx.doi.org/10.1111/j.136
[12] Malloch K, Neeld A, McMurry C, et al. Patient classification systems,
5-2834.2009.01045.x
Part 2: The third generation. The Journal of Nursing Administration.
1999; 29(9): 33-42. PMid: 10491667. http://dx.doi.org/10. [25] Chou S, Wu L, Chang I, et al. The Chinese nursing interventions
1097/00005110-199909000-00008 instrument. Journal of Nursing Scholarship. 2007; 39(2): 198-199.
PMid:17535322. http://dx.doi.org/10.1111/j.1547-5069.
[13] Perroca M, Ek A. Assessing patient’s care requirements: A compari-
2007.00167.x
son of instruments. Scandinavian Journal of Caring Science. 2007;
21: 390-396. PMid: 17727552. http://dx.doi.org/10.1111/j [26] Davidhizar R, Mallow G, Bechtel G, et al. A patient classifica-
.1471-6712.2007.00484.x tion system for the chronic psychiatric patient. Australian and New
[14] Kwok Y, Wing W. The reliability and validity of the therapeu- Zealand Journal of Mental Health Nursing. 1998; 7: 126-133. PMid:
tic activity index. Journal of critical care. 2005; 20(3): 257-263. 10095462.
PMid: 16253795. http://dx.doi.org/10.1016/j.jcrc.2005 [27] Karr J, Fisher RA. Patient classification system for ambulatory care.
.06.004 Nursing Management. 1997; 28(7): 27-28. PMid: 9335835.
[15] Miranda D, Moreno R, Iapichino G. Nine equivalents of nursing [28] Moore M, Hastings C. The evolution of an ambulatory nursing in-
manpower use score (NEMS). Intensive Care Medicine. 1997; 23: tensity system. The Journal of Nursing Administration. 2006; 36(5):
760-765. http://dx.doi.org/10.1007/s001340050406 241-248. PMid: 16705305. http://dx.doi.org/10.1097/000
[16] Miranda D, Nap R, de Rijk A, et al. Nursing activities score. Criti- 05110-200605000-00017
cal Care Medicine. 2003; 31(2): 374-382. PMid: 12576939. http: [29] Bulechek G, Butcher H, Dochterman J. Nursing Interventions Classi-
//dx.doi.org/10.1097/01.CCM.0000045567.78801.CC fication (NIC). (5th ed.) St Louis, MO: Mosby Elsevier; 2008.

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