Workload, Skill, Outcomes

Nosokinetics

Nursing Workload, Skill mix and Outcomes Research

Christine Duffield

Nurses are significant players in the provision of health care services and their actions and skill-mix affect patient outcome and length of stay. Professor Christine Duffield, Prof of Nursing Studies at the Centre for Health Services Management at the University of Technology, Sydney is leading a group conducting an innovative three-year research project to determine the impact of workload and skill mix on outcomes. and Outcomes Study. This is the first large scale work of its kind in Australia with unique methodological challenges combining retrospective and prospective data collection. Here Prof Christine Duffield outlines the research methodology and reports progress to date.

Nursing Workload, Skill mix and Outcomes Research

In 2003 NSW Health funded the Centre for Health Services Management at the University of Technology, Sydney to conduct an innovative three-year research project, the Nursing Workload, Skill mix and Outcomes Study. The study will extend the current knowledge of factors that explain variations in nursing costs, nursing workload and client, nurse, and system outcomes of care. The focus of this study is the unit level. The results will complement overseas evidence that nurse staffing is closely linked to patient outcomes and system effectiveness. It is anticipated that findings will be used to develop effective mechanisms and policies for planning, monitoring, and estimating the provision of nursing services that are most likely to reduce patient adverse outcomes.

The specific aims of the research are to:

1. Collect empirical evidence on the impact of increased in-patient acuity and reduced length of hospital stay (LOS) on nurses’ workload by retrospective data collection from NSW Health & Hospital Information Systems;

2. Establish the relationship between nursing skill mix and models of nursing care on patient outcomes, case-mix adjusted by prospective data collection in a random sample of hospitals across NSW.

Significance of the study:

This is the first large scale work of its kind in Australia with unique methodological challenges combining retrospective and prospective data collection. It is anticipated that the findings will provide policy makers with insight into the characteristics of patients that influence nursing service utilisation, workload and quality patient outcomes with a particular focus on unit-level activity. This study will also help to identify policy or administrative initiatives that could maximise nursing productivity and client outcomes. Nurse managers will be provided with information to guide them in selecting and managing nursing resources to ensure the best quality of care at the least cost. Organisations will learn about the structures and processes that influence the workload and ability of nurses to provide care at the appropriate level to help retain and recruit nurses to the workforce.

Some questions which may be addressed include:

Factors which might impact on retention including:
workload variables:
- Effects of casualisation
- Perceptions of quality of care
- Working hours, absenteeism
- Job satisfaction
Has nursing workload changed?
- What factors impact on nurses’ workload?
- Are nurses undertaking activities others could do?
Is there a relationship between skill mix and patient outcomes? Findings could relate to:
- Mix of registered nurses, enrolled nurses and assistants in nursing
- Years of experience
- Qualifications
- Unit characteristics
- Patient admissions/transfers
- Nurse physician relationships

Data Being Collected:

Unit / Hospital Characteristics

A. Predominant Care Delivery Model
B. Revised Nurse Work Index Scale
C. Nurse Demographic And Work Environment

These three instruments comprise the nurse survey, which will be administered once to each nurse in the sampled units (approx. 20 minutes)

D. The Daily Unit Staffing Form:
Completed daily by the UTS data collector or the Nurse Unit Manager

E. The Hospital And Unit Profile
Completed once by the UTS Data Collector with assistance from the NUM

Patient Characteristics and Outcomes

F Patient Data Form
Completed per patient by the UTS Data Collector using medical records

G. Health Records Data
Completed per patient from the NSW HIE

Nursing Workload

H. PRN Workload Measurement
Completed daily by the UTS Data Collector

I. The Environmental Complexity Measure
Completed once each shift by each nurse in the sampled units (approx. 1-2 minutes)

Progress to date

The first round of prospective data collection has been completed at 19 randomly selected hospitals in what are now eight Area Health Services (12 of previous 17 AHS). In these hospitals 80 acute medical-surgical wards were been randomly selected and data collected on each ward for a seven-day period. In addition data will be collected on up to 50% of the first sample, again randomly selected. Data collection is complete on 17 of these units. The inter-rater reliability overall is 87.10%. Thus far:

1976 nurses have been surveyed and 2100 nurses are expected to participate by the completion of the study with an average response rate of 72% thus far,
5610 Environmental Complexity Forms have been completed and 6400 are expected,
4580 patient files have been accessed and it is expected that this will increase to 5050,
Information has been collected on 17650 patient days and this is likely to increase to 20250 patient days.

The Nursing Workload, Skillmix and Outcomes Study is due for completion in 2006. For more information and updates, www.chsm.uts.au or contact Professor Christine Duffield on Christine.Duffield@uts.edu.au

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