Nursing summary and experienced workload

computer methods and programs in biomedicine ELSEVIER

ComputerMethodsand Programsin Biomedicine43 ( 1994} 177-- 183

Nursing summary and experienced workload A.C. Delacr6taz*, P.

Frutiger

Unit£ de Recherche M£dico-Economique, H~pital de Morges, Chemin du Cr~t 2, CH 1110 Morges, Switzerland

Abstract

Nursing summary and experienced workload form a new approach to patient documentation. The data used for this documentation are provided by nurses without being subjected to a formal nomenclature. It is important to highlight patient complexity, nursing difficulty and to evaluate workload. The emphasis on these concepts provides data which allow qualitative and quantitative assessment of the patient's entire stay. After a discussion of the philosophical and economic aspects that are the basis of the methodology, this paper focuses on the design and the development of a nursing database. Key words: Nursing; Workload; Complexity; Documentation; Costs

1. Introduction

The nursing process is a problem-oriented record in order to establish nursing diagnoses and to deduce corresponding actions [1,2]. This paper proposes a new complementary approach called nursing synthesis. This synthesis consists of two parts. (1) The summary which attempts to respond to the following background question: 'after having taken care of a particular patient, what was more or less difficult than expected from a nursing point of view?'. The primary goal of this question is to highlight major nursing difficulties and everything which is not directly implicit to the medical diagnoses. (2) The workload assessment represents real experienced, not predetermined, workload.

* Corresponding author.

The objectives of the nursing synthesis are:

(1) To emphasize apparent inadequacy between complexity of nursing task (summary) and nursing costs (workload and direct costs from the ward unit) by means of a bottom-up analysis of particular patient records; this facility will provide original alternatives for nursing education and training and therefore will change nursing practice. (2) To enable the optimization of patient care, taking into account budget limitations, the social-economic and environmental situation of the patient. The nursing documentation would be a counterpart to the medical synthesis which also consists of a summary and a workload assessment [3]. Justification of human resources utilization are vital in the struggle of medico-economic decision making.

0169-2607/94/$07.00 © 1994 Elsevier Science Ireland Ltd. All rights reserved. SSDI 0169-2607(93)1487-Z

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(3) To ensure compatibility with international standards, such as Nursing Minimum Data Sets [4], Nursing Related Groups (NRGs) [5], Nursing classifications [6,7], in order to link the expressions of the summary to those items and to compare local practice with commonly accepted protocols of nursing. (4) To measure indirectly the quality of nursing care by critical self-audit. Indeed, systematic reviewing of records, with apparent high complexity and low cost as well as apparent low complexity and high cost, induces updating of protocols. The purpose of the nursing synthesis proposed here is not to provide an indicator of time consumption and allocation of nursing staff to ward units like PPN [8,9].

2. Philosophical issues After several years of experience with nursing workload assessment at Assistance PubliqueH6pitaux de Paris [10], we have concluded that nurses should explain the experienced workload intensity by a summary text. Nursing notes and processes do not supply an overview of the most relevant difficulties even if data are detailed. The action of writing down a synthesis is a new specific task. The North American Nursing Diagnosis Association (NANDA) has already formulated the definitive terms for diagnosis taxonomy and the subsequent possible actions for nursing treatment [6]. One of the primary goals of nursing language standardization is to enable data for reimbursement. In our view the nursing process, formulated simply in terms of nomenclature, cannot provide usable data to document concrete nursing activities and their outcomes. Qualitatively, data processing only functions on the level of fixed terms and concepts without considering their links. All local and personal language is eliminated, thus impoverishing part of the data. In order to enter the required information, the user must adhere to a predetermined terminology which results in rigidity.

Quantitatively, Predetermined Diagnosis + Subsequent Actions 4: real nursing workload [11]. The nursing documentation should be considered in a different manner, thus favouring a bottom-up approach in order to maintain flexibility and to preserve data for future use. It is our aim to calculate the complexity of nursing tasks directly from the summary text. This is the reason why a scoring algorithm of text elements has to be created comparable with the physicians' Normalized Complexity Index [12]. Moreover, the severity of the medical diagnosis is not systematically correlated to the main nursing difficulties. By the same token, the nursing care can be difficult for patients whose diagnosis and therapy are not complex. It is essential to focus on the notion of complexity. The patient, his/her environment, and the hospital form a complex system because of the great number of interactive variables, in which evolution can be extremely rapid and unpredictable. A complex system is at the same time more and less than the sum of its parts. This is why it should be understood and then accepted as a crucial element that the whole should be seen, that a particular situation should be seen as a totality rather than a fractured one [13]. The concept of complexity is not only related to a physical and psychological state but also to the social and family environment. Nursing is frequently subtle and intricate, considering factors related to the patient her/himself and to her/his environment. The concept of nursing complexity is exemplified by the different specialties required to provide quality care. Considering the mechanisms which govern drafting and reading text, it seems that a pragmatic framework of nursing activity could be useful (1) in order to attribute expressions to semantic categories (e.g. technical problem of nursing, reaction of the patient, difficulties encountered on discharge) and (2) to represent expressions with their concepts (e.g. physical disability, family or neighbourhood induced problem, management difficulty). Such a pragmatic schema is today under development. It can be distinguished from the medical framework [14] particularly by the fact

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that the different problems of a patient are treated by nurses in a global way and that transmission between nursing shifts imply concurrent responsibility. Both measurement of complexity and assessment of workload contain objective as well as subjective elements. Working stress should be assessed as objectively as possible; but it is evident that subjectivity plays an important part in this domain. Description and workload assessment may be different from one nurse to another due to the degree of personal experience; but this difference also corresponds to the difference of cost and therefore gives a realistic view of the utilization of human resources. If NRGs as a corrolary to DRGs [15] have to represent iso-resource consumption, the grouping algorithm must deal with the difficulty of the task due to medical, nursing, psychological and social problems of the patient. NRGs could then better evaluate personnel workload which represents 60-70% of ihospital ward expenditure. 3. Material and methods 3.1. S u m m a r y

Morges General Hospital contains 223 acute care beds. Five main disciplines are represented: surgery, medicine, gynecology, obstetrics and paediatrics. In 1991, 8021 patients were treated with a mean LOS of 7.44 days. One hundred and

#

Subject

Expression

Main concepts

1

patient

night disorientation psy

2

patient

anxiety

3

patient

walking difficulties phy

4 patient etc.

Parkinson's disease cpp

cpp

179

eighty nurses are employed. Each year approximately one hundred and fifty students nurses undertake training for varying periods. Each patient's stay is documented by means of medical and nursing syntheses. These are written down at the end of each stay on a ward. In order to process pertinent nursing information, only expressions which contain a relevant description of nursing difficulties or a significant fact are captured. The following input schema (Fig. 1) has been designed in order to verify if the internal database structure contains the essential elements for calculation of nursing complexity and not predetermined interrogations. After introduction of the subject (e.g. patient, family) and the expression, the computer prompts for default values of the corresponding main concepts which have been previously recorded for this expression at least once. With the ENTER key the user accepts a concept (bold), with the T A B key the user skips (italics) and at the end the user can even enter a new concept as being valuable in the context of this patient. At any time, these noun phrases can be linked to one or several other phrases (e.g. 'and', 'due to', 'is cause of' (ca)). The algorithm establishes automatically the bidirectional correspondent links. Four dictionary index files have been built up and currently contain the following numbers of items: (i) Subjects (n = 5), (ii) Expressions (n = 700), (iii)

New concept

Link to #

I I I I

I I

#

ca

3

psy cpp

Fig. 1. Summaryinput structure.

#

#

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Main concepts (n = 6) and (iv) Links (n = 5). These index files have an open architecture, thus allowing references to nursing classifications and nomenclatures used as referentials [16]. In order to minimize data handling, a speech recognition interface is being introduced. The length of the expressions has to be adapted to facilitate their automatic recognition. It is the reason why a new thesaurus is being built up. To date it contains 2000 terms. In order to calculate a complexity index directly from the text of the summary and for research issues, the following procedure has been set up. First, a regional working group of experts in nursing was asked to define precisely the different parameters which determine the level of nursing complexity. Second, on the basis of the outcomes of the working group, a ranking number has been attributed to each term of the thesaurus. The calculation of patient's complexity and nursing difficulty is therefore enabled directly from the text of the summary. The patient's overall complexity index can be summed up by means of this score.

3.2. Validation of the complexity index The complexity index is validated taking into account the globality of the text rather than the validation of each term separately [17]. A group of nurses are asked to criticize and, after the required readjustements, to accept the ordinal classing of different summaries considering the complexity and the difficulty of care, as in Table 1.

3.3. Workload The workload is not an inherent property but emerges from the interaction between the requirements of a task, the circumstances under which it is performed and the skills, behaviors and perceptions of the operator [18]; thus our conception of workload is human centered rather than task centered. Experienced workload sticks to reality, while suppositions about theoretically needed nursing effort based on patients' problems are analogous to the complexity score. In order to assess workload, we use a method which has similarities to

Table 1 The complexity index. Patient, female, 71 years old, LOS: 18 d.

Patient female, 72 years old, LOS: 6 d.

Surgery: Eventration cure Ineffective patient continuous analgesia Hyperalgia Non controlled high bloodpressure Nausea and vomiting Low intestinal transit time

Surgery: Eventration cure Postoperative vomiting

Complexity index: 1328

Complexity index: 665

that used by the National Aeronotics and Space Administration (NASA) to assess pilots' mental workload [18]. We determine a task load index by means of a Visual Analogue Scale (VAS), which is a bar at least 10 cm long without any subdivisions (Fig. 2). Marks on the left end represent minimum workload, on the right end the highest degree of workload, considering all the patients of the ward throughout the year; it is not indeed the highest degree of imagineable workload. The intermediate values between minimum and maximum can be interpreted as an exponential function y = f ( x 2) because the second half of the workload bar intuitively implies much more burden than the first half. To date, we distinguish between three different workloads: (1) basic, (2) technical, (3) relational and educational nursing [10]. As the sum never represents the total of its elements in a holistic form, nurses indicate on the back of the sheet the global effort on a bar of slightly different length. This analogue scale allows weighting of workload within patients' stays on a ward better than the sum of standard time values of elementary nursing actions. The results of imputing nursing wages to patients' stays using a digressive factor for length of stay (working knowledge through acquaintance with patient's specific problems) are more easily interpretable and acceptable. Writing down nursing summary before experienced workload is important. It is only when the

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A.C. Delacr~taz, P. Frutiger / Comput. Methods Programs Biomed. 43 (1994) 177~183

Nursing effort

basic

I. . . . . . . . . . . . . . . .

technical

I. . . . . . . . . . . . . . . . . . . . .

relational

I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X .............................................................

X ........................................................

I

I X ...... I

& educational

global I............................................................X...........................I

Fig. 2. Visual Analogue Scale (VAS) for nursing workload assessment.

entire file has been skimmed through and the summary composed that the workload can be scored comparing all patients on the ward throughout the year. 4. R e s u l t s ,

perspectives

and emerging

issues

A nursing nomenclature originating from current local professional language is built up as a referential to other classifications. These French language expressions are simultaneously translated into English and German in order to propose, in time, a multilingual nursing thesaurus. Collaboration with other nursing research centers in Europe is ongoing [4,5,7,10]. An implementation of the entire system in France is currently being examined. Imputing nursing personnel costs to patient's stays is made available to and undergoes critical analysis by our nursing staff. Complexity scores are calculated using a pragmatic schema and the consensually determined weights of contextually selected concepts. The balance between separately calculated nursing difficulty and nursing costs reveals apparent inadequacies and incites nurses to review these records in order to optimize the nursing process. Summary and workload influence each other. To some extent, the summary explains the different workload assessments; but as difficulty scores are calculated directly from text using complex algorithms and therefore cannot be ma-

nipulated, differences between patients' problems and experienced workload are still evident. The simple fact of drafting summaries changes the nursing process. Within months, a positive impact on nursing behaviour can be observed. The quality of the decision making process is enhanced, actions become more preventive; information exchange, general motivation and positive thinking are favoured. We relate here some reflections of our nursing staff: 'Quantifying observations makes us aware of the real dimensions of problems and burdens. Exchanging experiences concerning some specific problems during elaboration of the dictionaries is rewarding. Searching together for new solutions to unforseen problems gives us new insights and improves our work.' Even if the medical and nursing syntheses provide a more global and a more exhaustive view of the patient, the collected information could be more complete. Other professional teams should also participate in documentation: e.g. social workers, physiotherapists and dieticians. On-line accessibility of patient records, including administrative, economic, medical, nursing and paramedical data will be made available for clinical as well as for managerial retrieval and statistical analysis. Measurement of quality in health care is of course a permanent concern [19]. 5. C o n c l u s i o n

The nursing synthesis, being composed of a

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Table 2 Complementarity of medical and nursing synthesis. Patient, male, 50 ears old, LOS: 25 d. Medical synthesis

Nursing synthesis

Summary Digestive malignancy

Summary 1 Parenteral diet fog 17 days 2 Well tolerated realimentation 3 Penrose drainage's discharge 4 High fever with (link) 3 (#) 5 Diagnosis clearly announced 6 Insufficient mastery of English

Carcinoma of stomach Gastrectomy Splenectomy

Medical complexity index: 320/3690

Nursing context index." 945/2500

Workload Investigation: 40 Therapy: 80

Workload Basic: 30 Technical: 80 Relat./educ.: 70

summary comprising (1) difficulty score, and (2) experienced workload assessments, allows bottom-up analysis. It clearly reflects the realities of the situation and does so in the most reliable manner. The new principle of interactive attribution of contextually bound concepts is innovative. In our view, the entire method will allow substantial savings due to optimization of care and preventive actions. The content of this documentation also supplies new and often unexpected research hypotheses. Compatibility by means of multilingual referentials with international Nursing Data Sets and Classifications ensures the possibility of comparing data between institutions and of monitoring issues concerning commonly accepted protocols.

Acknowledgments The authors would like to express their gratitude to Ms. C. Thouverez, general head nurse,

and to the nurses of Morges hospital who are all actively involved in this very new nursing dynamic.

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