Participants
To classify patients according to their nursing needs and calculate nursing intensity, three nursing units at a single tertiary general hospital in J Province, South Korea, were selected as the study units. The comprehensive nursing care unit is a unit equipped with necessary features, such as appropriate nursing personnel and enhancing the nursing work environment by providing necessary care services to patients without a family caregiver or a privately employed one. The number of patients per nurse in the comprehensive nursing care unit is lower than that in the general units [14]. Given that the comprehensive nursing care unit system in South Korea is expanding and revolutionizing nursing work and the nurse staffing system, it was included in this study.
According to nursing needs, patient classification and nursing time in each unit were investigated over 10 days between September 1 and 30, 2018, excluding weekends. Night shift nurses in charge of the three nursing units performed patient classification of all patients admitted to their units using the Korean Patient Classification System on Nursing Needs for Intensive Care Units (KPCSNI), a tool developed by Ko and Park [13]. The total number of patients who were subjected to classification comprised 473, 278, and 143 patient-days in the internal medicine, surgical, and comprehensive nursing care units, respectively. The three nursing units (internal medicine, surgical, and comprehensive) of a tertiary general hospital were selected for this study. At the time of the investigation, 20, 28, and 22 nurses belonged to the internal medicine, surgical, and comprehensive wards, respectively. (Table 1).
Table 1
The participants during data collection period
|
Internal medicine unit
|
Surgical unit
|
Comprehensive unit
|
Number of nurses
|
20
|
28
|
22
|
Person-day for 10 days (nurses)
|
87
|
125
|
77
|
Patient-day for 10 days (patient)
|
473
|
278
|
143
|
The nursing time of all nurses in the nursing units who performed patient classification were investigated on that same day in the relevant nursing unit. Nurses who worked day, evening, or night shifts were instructed to complete a self-report questionnaire immediately after the end of their working, thereby minimizing recall errors. The number of nurses who participated in the survey of nursing time comprised 87, 125, and 77 person-days in the internal medicine, surgical, and comprehensive nursing care units, respectively, totaling 289 person-days.
Definitions of terms
1. Patient classification
The patient classification system is a method of classifying patients according to the amount and complexity of nursing care provided to them over a certain period [15]. Here, it refers to classifying patients admitted to the units into groups 1 to 4 using the KPCSNI. As the patient classification group number increases from 1 to 4, the total score for each item increases, indicating that patients’ nursing needs are higher.
2. Nursing intensity
Nursing intensity refers to direct and non-direct nursing activities related to patients; it includes patients’ dependency, severity of the disease, complexity of nursing care, and time required for nursing as factors directly affecting such nursing activities [16]. To calculate nursing intensity, patient classification scores were calculated using a tool that was modified and supplemented based on the one developed by Ko and Park [13]. This tool comprises 50 direct nursing activities covering eight domains (symptom management infection control, nutrition and medication, personal hygiene and secretion, activity, sleep and rest, guidance in nursing/emotional support, nursing activity planning, and coordination), and 11 indirect activities. Based on the calculated patient classification scores, the weighting coefficient per nursing unit, that is nursing intensity, was calculated following a method used by Fagerström et al. [9].
3. Personal time
Personal time excludes direct and non-direct nursing activity times during working time and includes meal and rest times.
4. Non-direct nursing time
Non-direct nursing activities include managing the necessary items and environment for nursing and maintaining the operation of nursing units except for direct nursing care for patients [17]. Non-direct nursing time refers to the sum of the nursing time required for handover, making rounds, work delay, recording, patient-related calls and deliveries, administrative affairs, cognitive workload, education/supervision, research, and so on, as measured using the patient classification tool developed by Ko and Park [13].
5. Direct nursing time
Direct nursing time refers to nursing time [17] for providing direct nursing care to patients, as well as preparing and organizing nursing care. Here, it refers to total working time after subtracting personal and indirect nursing times.
Measurement
1. Patient classification and calculation of nursing intensity for nursing units based on nursing needs
Patient classification based on nursing needs was conducted using the KPCSNI. This tool is a factor-type classification tool and includes scores for the clinical features of patients in addition to scores for nursing needs when calculating patient classification scores. It consists of 8 domains and 18 sub-domains covering 50 nursing activities. After the tool was reviewed by the researchers, its content validity was tested in consultation with six nursing professors. The average daily value of the calculated patient classification scores for each date was calculated. As a result, a patient classification score of 1–30 points was classified as Group 1, a score of 31–60 points was classified as Group 2, a score of 61–90 points was classified as Group 3, and a score of 91 points or more was classified as Group 4 based on the results of the study by Ko and Park [13].
Nursing intensity was measured following the calculation method presented in a study by Fagerström et al. [9]. After setting the patient classification score in Group 1 as the reference value of “1,” the patient classification scores in groups 2–4 were each divided by the patient classification score in Group 1 to calculate nursing intensity weighting coefficients for the groups. Nursing intensity scores for nursing units were calculated by multiplying the weighting coefficient for each group by the number of patients in each group and then summing up the values. Fagerström et al. [9] propounded the “Professional Assessment of Optimal Nursing Care Intensity Level” (PAONCIL), a new method that goes beyond the traditional time study methodology. It calculates nursing intensity based on patient classification results and assesses nursing intensity for nursing units by reflecting statistical estimations and expert opinions. Fagerström et al. [9] suggested this method as an alternative to the classical time studies, stating that it could establish optimal nursing intensity levels for individual units.
2. Calculating nursing time
Nursing time was measured using a questionnaire developed by this study’s researchers with reference to non-direct nursing activities in a tool developed by Ko and Park [13]. This questionnaire comprises 28 items, including total working, break, and non-direct nursing times of the day. Total working time was calculated based on the time at which nurses logged into work and left for the day, while the break time was calculated by summing up the meal and rest times. Non-direct nursing time was calculated by summing the time for each subdomain of the three domains (nursing activity planning and coordination, non-direct activity, and break time). Direct nursing time was calculated by subtracting the non-direct nursing time including leisure time from the total working time (Formula 1). The validity of the direct nursing calculation method was reviewed by six nursing professors and one expert.
$$\text{F}\text{o}\text{r}\text{m}\text{u}\text{l}\text{a} 1: {\sum }_{\text{i}=1}^{\text{n}}\text{}\text{D}\text{N}{\text{T}}_{\text{i}}={\sum }_{\text{i}=1}^{\text{n}}\text{}\text{T}\text{W}{\text{T}}_{\text{i}}-{\sum }_{\text{i}=1}^{\text{n}}\text{}\text{N}\text{D}\text{N}{\text{T}}_{\text{i}}$$
DNT = Direct nursing time
TWT = Total working time
NDNT = Non-direct nursing time
n = Number of nurses in a nursing unit
3. Calculating direct nursing time per inpatient by patient classification groups
To calculate direct nursing time by patient classification groups, direct nursing time per nursing intensity point was calculated (Formula 2). This value was then multiplied by the weighting coefficient for each patient classification group to calculate direct nursing time per inpatient by patient classification groups (Formula 3).
$$\text{F}\text{o}\text{r}\text{m}\text{u}\text{l}\text{a} 2: \text{D}\text{N}\text{T}\text{p}\text{N}\text{I}= \frac{{\sum }_{\text{i}=1}^{\text{n}}\text{}{\text{D}\text{N}\text{T}}_{\text{i}}}{{\sum }_{\text{i}=1}^{\text{m}}\text{}\text{N} {\text{I}}_{\text{i}}}$$
DNTpNI: Direct nursing time per nursing intensity weighting coefficient
DNT: Direct nursing time
NI: Nursing intensity weighting coefficient
n: Total number of nurses in a nursing unit
m: Total number of inpatients in a nursing unit
$$\text{F}\text{o}\text{r}\text{m}\text{u}\text{l}\text{a} 3: \text{D}\text{N}\text{T}\text{p}\text{P}={\text{W}\text{C}}_{\text{i}}\times \text{D}\text{N}\text{T}\text{p}\text{N}\text{I}$$
DNTpP: Direct nursing time per patient
WC: Weighting coefficients
DNTpNI: Direct nursing time per nursing intensity weighting coefficients
i: Patient classification group
3. Calculating the optimal number of nurses
The optimal number of nurses in the internal medicine, surgical, and comprehensive nursing care units was estimated by applying the calculated nursing time results to formulas 4-6. After non-direct nursing time was calculated using the ratio (20%) of non-direct nursing time to the total nursing working time—calculated with the nursing time analysis results—the total nursing time was calculated (Formula 5). The optimal number of nurses was calculated by adding 40% to the value obtained by dividing the total nursing work time by the mean daily work hours (Formula 6).
The total number of annual holidays in the current clinical reality is estimated to be about 134 days, considering weekly holidays: 52 weeks × 2 (Saturday and Sunday) based on an average of 20 working days per month, plus 15 legal holidays (excluding Sundays), 15 basic annual holidays, and additional annual holidays according to the nurses’ professional positions. Although 1.4 can be assigned as an additive value due to the number of holidays by rounding off 1.37 [(134+365)/365], a constant of 1.6 was used in this study following previous studies [18, 19].
$$\text{F}\text{o}\text{r}\text{m}\text{u}\text{l}\text{a} 4: \text{T}\text{D}\text{N}\text{T}=\left({\text{m}}_{1}\times \text{D}\text{N}\text{T}\text{p}\text{P}{\text{t}}_{1}\right)+\left( {\text{m}}_{2 }\times \text{D}\text{N}\text{T}\text{p}\text{P}{\text{t}}_{2 }\right)+\left({\text{m}}_{4}\times \text{D}\text{N}\text{T}\text{p}\text{P}{\text{t}}_{3}\right)+ \left({\text{m}}_{4}\times \text{D}\text{N}\text{T}\text{p}\text{P}{\text{t}}_{4}\right)$$
\(\text{F}\text{o}\text{r}\text{m}\text{u}\text{l}\text{a} 5:\text{T}\text{N}\text{W} = \text{T}\text{D}\text{N}\text{T} + \text{T}\text{N}\text{D}\text{N}\text{T} =\text{T}\text{D}\text{N}\text{T} +\text{T}\text{D}\text{N}\text{T}\times \frac{20}{80}\) \(\text{F}\text{o}\text{r}\text{m}\text{u}\text{l}\text{a} 6:\text{O}\text{N}\text{N} = \frac{\text{T}\text{N}\text{W}}{8} \times 1.6\)
TDNT: Total direct nursing time
DNTpP1: Direct nursing time per patient for Group 1
DNTpP2: Direct nursing time per patient for Group 2
DNTpP3: Direct nursing time per patient for Group 3
DNTpP4: Direct nursing time per patient for Group 4
m1: Number of patients in Group 1; m2: Number of patients in Group 2; m3: Number of patients in Group 3; m4: Number of patients in Group 4
TNDNT: Total non-direct nursing time
ONN: Optimal number of nurses
TNW: Total nursing workload of the nursing unit
8 = Working time per day
1.6 = Additive value due to the number of holidays