Cherrie Lowe

At the stroke of midnight, all is quiet in the ward. Only three out of six beds are occupied.

A service manager might be wondering why the ward’s charge nurse manager keeps complaining about understaffing.

But roll back the clock and you will see some of those ’empty’ beds had up to three patients through them during the day as patients were discharged, transferred, admitted, or died. So while the midnight census shows just three patients, five other patients had been nursed on the ward that day, making an average bed utilisation of 6.67 patients for those six beds.

Cherrie Lowe, founder of TrendCare and a doctoral candidate, says using the wrong data can underestimate nursing work and a midnight census “doesn’t recognise at all the nursing workload”.

Higher workloads

Nurses are experiencing higher workloads than ever before due to four main reasons, says Lowe. These are increased patient throughput, decreasing length of stay, increasing patient acuity, and an inadequate supply of skilled nurses.

It is not a new trend but has accelerated in the past decade, with her data indicating the average length of stay in a standard surgical ward dropped from nine days to four days between 2002 and 2013.

She points out this hasn’t lessened the nursing workload – just squeezed the clinical and administration time required into a shorter timeframe. The patient acuity is constantly high, whereas in the old regime, says Lowe, by the end of their stay, patients were self-mobilising and “helping with the flowers”. The result is that acuity calculations show that the average nursing hours per patient day (HPPD) required for a surgical ward has gone up from 4.1 HPPD in 2002 to 4.7 HPPD in 2013.

Lowe acknowledges there is “chaos” in some wards due to increasing demands on nursing staff, and it is very stressful for ward leaders having to “put out bushfires” every day.

To convert chaos into order, she believes the best thing a nurse ward leader can do is take time out and gather data to put a case for a solution. She says the problem is nursing not being correctly staffed, though the answer may not always be to employ more nurses.

First, ward leaders need to convince service managers – particularly those who aren’t nurses themselves – that there is a problem with the ward’s staff resources, and for that, Lowe says, hard data is needed (such as HPPD, patient turnover and length of stay) to make the nursing workload visible. “If you don’t have data, emotions don’t cut it.”

In addition, emotive arguments can see nursing leadership losing control of this nursing issue to non-nursing leaders. Lowe says one of her “greatest heartbreaks” on first coming to New Zealand was discovering the loss of nursing leadership and finding herself talking to nursing service managers who weren’t nurses and didn’t understand nursing.

“You might just think that I’m here trying to sell my show,” acknowledges Lowe. “But if you don’t measure acuity, then you have nothing to work with.”

She points to Australia’s adoption of nurse-to-patient ratios, which she claims has proven to be a “blunt instrument” by not allowing for the wide variation in patient acuity that can be faced on a ward.

She argues that collecting accurate acuity data and accurately representing nursing costs is one of the best strategies for ensuring adequate funding of nursing services. Models of care need to be looked at because nursing not being correctly staffed doesn’t always mean nursing is understaffed, as sometimes what is needed is a skill mix change and re-engineering the roster to ensure the right staff at the right time are doing the right work.

At the conference, she presented a table with a guideline of recommended skill mix between registered nurse (RN), enrolled nurse (EN), and healthcare assistant (HCA) per shift. This ranged from 100 per cent RN patient care for intensive care units down to RN (15 per cent)/EN (30 per cent)/HCA (55 per cent) in the night shift at residential aged care hospitals. Other suggested skill mixes include 60/20/20 for general medical wards during the day shift, stepping up to 75/25/0 in the night shift. And 70/20/10 for a general surgery ward day shift, moving to 75/25/0 overnight.

Lowe’s presentation concluded with analysis from the latest TrendCare acuity data benchmarking that showed the range and mean of nursing HPPD measured for 106 patient types cared for across nearly 50 hospitals in Australia, Singapore, and New Zealand during 2012–2013*. Drawn from 3.3 million patient days and 9.9 million nursing shifts, the nursing acuity measures are shown for day oncology to high dependency mental health adolescent patients and a huge range in between.

“These results clearly show increasing patient acuity and support the urgent need for nursing services globally to collect, analyse, and use nursing data proactively if a strong viable nursing service is to be maintained with adequate funding,” says Lowe.

As nursing is the largest labour force, nursing services are often targeted when cost savings are required.

Without data backing the hours and skill mix required to deliver quality clinical services, Lowe believes that nursing hours may be reduced inappropriately – increasing nursing workloads to an unsafe level – or conversely, resulting in overstaffing of some areas and wasting nursing hours needed in another area.

“As the patient’s level of dependence on nursing hours increases and the patient throughput increases, the nursing workload continues to grow. If this growth is not accurately monitored and resourced, patient safety will be adversely affected and nurses’ job satisfaction will decrease, contributing to high staff turnover.”

Staying within your safe staffing ‘buffer’ in CCDM

  • CCDM’s Mix and match system uses patient acuity data to determine nursing hours required including a “realistic allowance for non-clinically available time”.*
  • The total predicted nursing hours required for a specific shift includes a 12.5 per cent buffer above the calculated nursing hours required.
  • About four per cent of this buffer is to allow for tea breaks (up to 40 minutes per FTE).
  • The remaining 8.5 per cent is an allowance or ‘buffer’ for unpredicted extra work required during the shift.
  • If the gap between the hours required and the hours available is over the 8.5 per cent mark, then there is no buffer. At this point, nurses’ breaks start being shortened or dropped, contributing to nurse fatigue and an increasing risk of clinical errors.
  • If the variance between hours required and hours available is more than 12.5 per cent, then the shift “flips into a critical zone”.
  • The ideal is for the hours required to match the hours available or not to go over the 8.5 per cent variance threshold.

* From ‘Acuity in Action’ presentation to Nurse Managers Conference in Christchurch 6 November by Rebecca Oakes of the joint NZNO/DHB initiative, the Safe Staffing Health Workplace (SSHW) Unit.

The unit’s care capacity demand management (CCDM) system uses nurse-entered TrendCare patient acuity data to determine nursing and HCA hours required.

2012–2013 nursing hours per patient day (HPPD) benchmarking findings*

  • Surgical patients majority range between 3.02 to 6.12 HPPD
  • Medical patients majority range between 3.4 to 5.94 HPPD
  • Orthopaedic majority range between 3.46 to 5.81 HPPD
  • Mental Health (acute adult) majority range between 2.1 to 6.9 HPPD
  • Intensive Care majority range between 11.42 to 17.75 HPPD

*Using anonymised TrendCare patient acuity data entered by nurses in hospitals in Australia,
New Zealand and Singapore. TrendCare is used by 16 of the 20 district health boards and is the basis of the CCDM system (see other sidebar).


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