CASELOAD AND WORKFORCE PLANNING
Using a complex audit tool to measure workload, staffing and quality in district nursing Esther Kirby, Keith Hurst
Esther Kirby is Deputy Director of Nursing, Quality and Patient Experience, Cumbria Partnership NHS Foundation Trust; Keith Hurst is Independent Analyst, Nottinghamshire Email: [email protected]
T
he NHS in Cumbria is faced with one of the most challenging demographic and geographic environments in the UK (NHS Cumbria, 2013). This is due to an ageing population, leading to a shift in health needs, with more people accessing a range of community services that support domiciliary care for patients with long-term conditions. Cumbria, which is the second largest county in England, has a population of approximately 500 000 that is largely rural and has the second-lowest population density among English counties. Further challenges include sustaining nursing services, given the age profile of the nursing workforce, with a large number of impending retirements and difficulties in recruitment and retention. There is also a lack of a modern career framework and little knowledge and understanding around caseloads and staffing levels and the significance of this in planning services for the future. An audit was commissioned following concerns around nurse staffing levels in community hospitals raised by staff, patients and the board of directors. This led to audits in the three main areas of nursing provision within the trust (community hospitals, community nursing and mental health).
© 2014 MA Healthcare Ltd
Caseload and workforce planning This is the third in a series of articles aimed at presenting some of the evidence-based solutions for workload and caseload management currently being used to inform workforce and service planning in British district nursing practice. The main aim of the audit was to understand the current workload, the acuity and dependency of patients being cared for in the community by district nursing teams by using an evidence-based tool. The tool used was the Safer Nursing Care Tool (SNCT), and the results will be used to inform future commissioning intentions as Cumbria’s out-of-hospital strategy takes shape.
Context The numbers and complexity of patients being treated by district nursing teams has increased in the last 5 years,
British Journal of Community Nursing May 2014 Vol 19, No 5
with progressively larger amounts of acute care being delivered outside hospitals and earlier in the patient’s care pathway. Despite this, the numbers of district nurses holding the specialist practitioner qualification had fallen from 12 500 to 7500 in 2013 (Queen’s Nursing Institute (QNI), 2013). Many higher education institutions have ceased to provide the course due to the lack of places being commissioned (QNI, 2013). This, together with the lack of evidence to inform district nurse workforce structures and lack of national standards (e.g. full-time equivalent (FTE) staff-to-patient ratios) has led to a national workstream (action area 5 of the Chief Nursing Officer’s Compassion in Practice (Department of Health,
ABSTRACT
This major community, workload, staffing and quality study is thought to be the most comprehensive community staffing project in England. It involved over 400 staff from 46 teams in 6 localities and is unique because it ties community staffing activity to workload and quality. Scotland was used to benchmark since the same evidence-based Safer Nursing Care Tool methodology developed by the second-named author was used (apart from quality) and took into account population and geographical similarities. The data collection method tested quality standards, acuity, dependency and nursing interventions by looking at caseloads, staff activity and service quality and funded, actual, temporary and recommended staffing. Key findings showed that 4 out of 6 localities had a heavy workload index that stretched staffing numbers and time spent with patients. The acuity and dependency of patients leaned heavily towards the most dependent and acute categories requiring more face-to-face care. Some areas across the localities had high levels of temporary staff, which affected quality and increased cost. Skill and competency shortages meant that a small number of staff had to travel significantly across the county to deliver complex care to some patients.
KEY WORDS
w Community, dependency w Workload w Service quality w Workforce planning
219
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on October 13, 2015. For personal use only. No other uses without permission. . All rights rese
CASELOAD AND WORKFORCE PLANNING
Methodology The audit was fully funded by Cumbria Partnership NHS Foundation Trust as one of three studies to establish a benchmark across community hospitals, community nursing and mental health nursing services. Training in data collection, to ensure consistency, and the data collection itself was overseen by a project coordinator who reported to the Deputy Director of Nursing to report progress against the project key milestones. As this was only the second study of its kind in the UK, the only comparison that can be made is with the audit undertaken in Scotland. Further similar audits are planned across England; this will allow benchmarking using a more comprehensive database. This would be useful not only for provider organisations, but also to provide an evidence base for planning and decision-making by education providers and commissioners. The work, which is a snapshot, commenced in April 2013 and 394 community staff kept a diary for up to 7 days, recording how they spent their time and with what type of patient, then completing a service quality questionnaire. Data were collected for each team over a whole month, which was a major piece of work, and included: w Completing 2292 patient-dependency/acuity assessments w Analysis of 1284 ‘diary days’ and recording 16 735 nursing interventions throughout a 24-hour day over a full Monday-to-Sunday working week w Testing 10 148 service quality standards comprising the quality audit w Collecting each teams funded, actual and temporary staffing levels The uptake of data collection was consistently high, with 394 out of 400 completing all four areas of the audit.
220
Data accuracy The main threat to workload-based staffing methods is inaccurate patient dependency/acuity assessment and activity recording inconsistencies by community practitioners. All 46 teams from the 6 localities were involved in the audit, with all the nurses involved in the audit attending an intense training day delivered by the second-named author to ensure that the data collection was accurate, consistent and ultimately reproducible. The strength of this method lies in the data collection accuracy and consistency check, which render impossible the falsification of data collected due to inbuilt ‘traps’ that would permit detection of aberrant data items, thereby allowing the data to be discounted. The training included the importance of avoiding errors in interpretation and data collection; the need to cooperate and ensure fairness; and mutual respect between colleagues collecting data and staff providing clinical care. Data sharing policies and the need for confidentiality were also covered. The checking of the measurement issue was even more important because the community staff (i.e. data collectors) acted as ‘judge and jury’ as it is was impossible to have independent observers in the community setting due to the number of teams involved and also inappropriate given that the setting was in patients’ homes.
Ethical considerations Although this study did not require ethical approval from a recognised body, consideration was given to the use of this tool, particularly the reliability of the tool and reproducibility of data, as this exercise would be repeated to build a database. Considerations included the validity of the tool to ensure the measurements were accurate and that the outcomes were what were intended.
Findings
1. Caseload Each registered nurse (RN) and health-care assistant (HCA) assessed the patients visited each day for up to 7 days and placed patients into four categories ranging from low (1) to high dependency (4). Dependency is a standard measure indicating a patient’s reliance on the district/community nurse to meet his/her needs. Higherdependency patients need more direct care; for example, patients in dependency level 4 require around eight times more face-to-face nursing care than those in dependency level 1 (see Table 1). There are several interesting and useful findings from this table. On average, around 11 patients were visited daily by each nurse. If each patient receives one intervention at each visit, taking about 30 minutes, then the 8-hour working day shift (even before travel and office work is counted) is easily filled. There was clear evidence to suggest that some nurses worked 12-hour shifts to maintain this level of care. While this demonstrates a dedication to patients, it is not conducive to good work–life balance and is a phenomenon heavily criticised by the Keogh review (Keogh, 2013).
© 2014 MA Healthcare Ltd
2012), redefining the role of the district nurse and the numbers required to keep pace with the demand. Community nurses were enthusiastic about being involved in this audit as it was the first real opportunity for the organisation to gain an in-depth understanding of current staffing levels and workload through an evidencebased approach rather than a historic understanding. This comprehensive audit captured data regarding staffing levels, workload and quality and was the first to be undertaken in England. It used the results from an audit in Scotland as comparators in geography, population size and density and workforce numbers. Scotland was used to benchmark since the same evidence-based Safer Nursing Care Tool methodology developed by the second-named author was used (apart from quality) and took into account population and geographical similarities (Scottish Government, 2013). Unfortunately it was not possible to benchmark against the quality element of the audit as the Scotland audit opted to measure nursing interventions instead. On the evidence of the audit, the key elements that influence nurse staffing levels are patient dependency, nursing activity, staff mix and workload.
British Journal of Community Nursing May 2014 Vol 19, No 5
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on October 13, 2015. For personal use only. No other uses without permission. . All rights rese
CASELOAD AND WORKFORCE PLANNING
The dependency and acuity of patients shown in Table 1 and Table 2 lean heavily towards the most dependent and acute categories. However, comparisons between in-patients and community patients require caution, as few general acute hospital wards approach this dependency/acuity level. This is valuable information as there is a general perception that the majority of acutely ill patients are nursed in hospitals and that patients cared for by community nurses are less unwell. There is a reliance on community nurses to provide nursing care in primary care services and the independent nursing home sector that adds significant pressures and costs to the service. By using the workload index to calculate daily visits, patient mix and the attention patients receive for the first time gave a picture of nurses’ workloads. Index ‘1’ indicates that the workload is equitable (i.e. practitioner has a fair caseload); less than 1 indicates that the worker is under-occupied; greater than 1 shows that the nurse is over-stretched. The two main findings were that RNs treat and care for more dependent and acute patients than their HCA colleagues, which is an appropriate use of resources, and that two of the six localities warranted further monitoring, since two-thirds of the patients fell into the highest dependency/acuity category.
Activity comparisons The activity data collected by Scottish and English community staff permits comparisons as the basic four levels (dependency 1 to dependency 4) are the same. Apart from cities (e.g. Glasgow versus Carlisle), Scotland and Cumbria’s socio-economic environments are reasonably comparable (e.g. Highland versus Fells) (Scottish Government, 2013). The main finding from this comparison is that the workload index in Scotland is lower than in Cumbria, largely because the Cumbria teams deliver more interventions to patients in the higher dependency/acuity categories.
© 2014 MA Healthcare Ltd
2. Staff activity: time spent on direct patient care/workload index Data collected using daily diary sheets by Cumbria community staff regarding their time spent was organised into four categories: w Direct nursing, face-to-face, care, e.g. redressing a wound w Indirect care and patient-related activity that is one step removed from the patient, e.g. writing nursing notes w Associated work e.g. routine clerical work w Travelling time w Unproductive periods. Main staff activities are shown in Table 3 since full activity tables are dense and the main message can be lost. It would appear from the data that community nurses in Cumbria are overall less patient-time-centred than their Scottish counterparts, with the range in Cumbria being greater
British Journal of Community Nursing May 2014 Vol 19, No 5
Table 1. Overall Cumbria dependency/acuity and caseload (patient-based) Diary days
No. of patients visited per day 11.3
1284
Direct care per visit (minutes) Case mix by staff grade
Dep. 1
Dep. 2
Dep. 3
Dep. 4
Workload index
11%
27%
33%
29%
1.11
16.7
20.2
25.3
34.9
Patients
Dep. 1
Dep. 2
Dep. 3
Dep. 4
Cumbria RNs
11
8%
26%
36%
30%
Cumbria HCAs
12.5
21%
30%
25%
24%
Dep. 1 = independent; Dep. 2 = low–medium dependency; Dep. 3 = medium–high dependency; Dep. 4 = dependent
Table 2. Comparison of dependency/acuity and caseload between regions (intervention-based) Area
Interventions
Dep. 1
Dep. 2
Dep. 3
Dep. 4
Workload index
Scotland
886 501
26%
28%
29%
17%
1.08
Cumbria
16 735
15%
22%
33%
30%
1.11
Dep. 1 = independent; Dep. 2 = low–medium dependency; Dep. 3 = medium–high dependency; Dep. 4 = dependent
Table 3. Distribution of activity across all staff between regions Code
Scotland
Cumbria
Observations
866 501
16 735
Direct care
39%
35%
Indirect care
11%
22%
Associated
35%
23%
Travel
13%
19%
Unproductive
Using a complex audit tool to measure workload, staffing and quality in district nursing Esther Kirby, Keith Hurst
Esther Kirby is Deputy Director of Nursing, Quality and Patient Experience, Cumbria Partnership NHS Foundation Trust; Keith Hurst is Independent Analyst, Nottinghamshire Email: [email protected]
T
he NHS in Cumbria is faced with one of the most challenging demographic and geographic environments in the UK (NHS Cumbria, 2013). This is due to an ageing population, leading to a shift in health needs, with more people accessing a range of community services that support domiciliary care for patients with long-term conditions. Cumbria, which is the second largest county in England, has a population of approximately 500 000 that is largely rural and has the second-lowest population density among English counties. Further challenges include sustaining nursing services, given the age profile of the nursing workforce, with a large number of impending retirements and difficulties in recruitment and retention. There is also a lack of a modern career framework and little knowledge and understanding around caseloads and staffing levels and the significance of this in planning services for the future. An audit was commissioned following concerns around nurse staffing levels in community hospitals raised by staff, patients and the board of directors. This led to audits in the three main areas of nursing provision within the trust (community hospitals, community nursing and mental health).
© 2014 MA Healthcare Ltd
Caseload and workforce planning This is the third in a series of articles aimed at presenting some of the evidence-based solutions for workload and caseload management currently being used to inform workforce and service planning in British district nursing practice. The main aim of the audit was to understand the current workload, the acuity and dependency of patients being cared for in the community by district nursing teams by using an evidence-based tool. The tool used was the Safer Nursing Care Tool (SNCT), and the results will be used to inform future commissioning intentions as Cumbria’s out-of-hospital strategy takes shape.
Context The numbers and complexity of patients being treated by district nursing teams has increased in the last 5 years,
British Journal of Community Nursing May 2014 Vol 19, No 5
with progressively larger amounts of acute care being delivered outside hospitals and earlier in the patient’s care pathway. Despite this, the numbers of district nurses holding the specialist practitioner qualification had fallen from 12 500 to 7500 in 2013 (Queen’s Nursing Institute (QNI), 2013). Many higher education institutions have ceased to provide the course due to the lack of places being commissioned (QNI, 2013). This, together with the lack of evidence to inform district nurse workforce structures and lack of national standards (e.g. full-time equivalent (FTE) staff-to-patient ratios) has led to a national workstream (action area 5 of the Chief Nursing Officer’s Compassion in Practice (Department of Health,
ABSTRACT
This major community, workload, staffing and quality study is thought to be the most comprehensive community staffing project in England. It involved over 400 staff from 46 teams in 6 localities and is unique because it ties community staffing activity to workload and quality. Scotland was used to benchmark since the same evidence-based Safer Nursing Care Tool methodology developed by the second-named author was used (apart from quality) and took into account population and geographical similarities. The data collection method tested quality standards, acuity, dependency and nursing interventions by looking at caseloads, staff activity and service quality and funded, actual, temporary and recommended staffing. Key findings showed that 4 out of 6 localities had a heavy workload index that stretched staffing numbers and time spent with patients. The acuity and dependency of patients leaned heavily towards the most dependent and acute categories requiring more face-to-face care. Some areas across the localities had high levels of temporary staff, which affected quality and increased cost. Skill and competency shortages meant that a small number of staff had to travel significantly across the county to deliver complex care to some patients.
KEY WORDS
w Community, dependency w Workload w Service quality w Workforce planning
219
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on October 13, 2015. For personal use only. No other uses without permission. . All rights rese
CASELOAD AND WORKFORCE PLANNING
Methodology The audit was fully funded by Cumbria Partnership NHS Foundation Trust as one of three studies to establish a benchmark across community hospitals, community nursing and mental health nursing services. Training in data collection, to ensure consistency, and the data collection itself was overseen by a project coordinator who reported to the Deputy Director of Nursing to report progress against the project key milestones. As this was only the second study of its kind in the UK, the only comparison that can be made is with the audit undertaken in Scotland. Further similar audits are planned across England; this will allow benchmarking using a more comprehensive database. This would be useful not only for provider organisations, but also to provide an evidence base for planning and decision-making by education providers and commissioners. The work, which is a snapshot, commenced in April 2013 and 394 community staff kept a diary for up to 7 days, recording how they spent their time and with what type of patient, then completing a service quality questionnaire. Data were collected for each team over a whole month, which was a major piece of work, and included: w Completing 2292 patient-dependency/acuity assessments w Analysis of 1284 ‘diary days’ and recording 16 735 nursing interventions throughout a 24-hour day over a full Monday-to-Sunday working week w Testing 10 148 service quality standards comprising the quality audit w Collecting each teams funded, actual and temporary staffing levels The uptake of data collection was consistently high, with 394 out of 400 completing all four areas of the audit.
220
Data accuracy The main threat to workload-based staffing methods is inaccurate patient dependency/acuity assessment and activity recording inconsistencies by community practitioners. All 46 teams from the 6 localities were involved in the audit, with all the nurses involved in the audit attending an intense training day delivered by the second-named author to ensure that the data collection was accurate, consistent and ultimately reproducible. The strength of this method lies in the data collection accuracy and consistency check, which render impossible the falsification of data collected due to inbuilt ‘traps’ that would permit detection of aberrant data items, thereby allowing the data to be discounted. The training included the importance of avoiding errors in interpretation and data collection; the need to cooperate and ensure fairness; and mutual respect between colleagues collecting data and staff providing clinical care. Data sharing policies and the need for confidentiality were also covered. The checking of the measurement issue was even more important because the community staff (i.e. data collectors) acted as ‘judge and jury’ as it is was impossible to have independent observers in the community setting due to the number of teams involved and also inappropriate given that the setting was in patients’ homes.
Ethical considerations Although this study did not require ethical approval from a recognised body, consideration was given to the use of this tool, particularly the reliability of the tool and reproducibility of data, as this exercise would be repeated to build a database. Considerations included the validity of the tool to ensure the measurements were accurate and that the outcomes were what were intended.
Findings
1. Caseload Each registered nurse (RN) and health-care assistant (HCA) assessed the patients visited each day for up to 7 days and placed patients into four categories ranging from low (1) to high dependency (4). Dependency is a standard measure indicating a patient’s reliance on the district/community nurse to meet his/her needs. Higherdependency patients need more direct care; for example, patients in dependency level 4 require around eight times more face-to-face nursing care than those in dependency level 1 (see Table 1). There are several interesting and useful findings from this table. On average, around 11 patients were visited daily by each nurse. If each patient receives one intervention at each visit, taking about 30 minutes, then the 8-hour working day shift (even before travel and office work is counted) is easily filled. There was clear evidence to suggest that some nurses worked 12-hour shifts to maintain this level of care. While this demonstrates a dedication to patients, it is not conducive to good work–life balance and is a phenomenon heavily criticised by the Keogh review (Keogh, 2013).
© 2014 MA Healthcare Ltd
2012), redefining the role of the district nurse and the numbers required to keep pace with the demand. Community nurses were enthusiastic about being involved in this audit as it was the first real opportunity for the organisation to gain an in-depth understanding of current staffing levels and workload through an evidencebased approach rather than a historic understanding. This comprehensive audit captured data regarding staffing levels, workload and quality and was the first to be undertaken in England. It used the results from an audit in Scotland as comparators in geography, population size and density and workforce numbers. Scotland was used to benchmark since the same evidence-based Safer Nursing Care Tool methodology developed by the second-named author was used (apart from quality) and took into account population and geographical similarities (Scottish Government, 2013). Unfortunately it was not possible to benchmark against the quality element of the audit as the Scotland audit opted to measure nursing interventions instead. On the evidence of the audit, the key elements that influence nurse staffing levels are patient dependency, nursing activity, staff mix and workload.
British Journal of Community Nursing May 2014 Vol 19, No 5
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on October 13, 2015. For personal use only. No other uses without permission. . All rights rese
CASELOAD AND WORKFORCE PLANNING
The dependency and acuity of patients shown in Table 1 and Table 2 lean heavily towards the most dependent and acute categories. However, comparisons between in-patients and community patients require caution, as few general acute hospital wards approach this dependency/acuity level. This is valuable information as there is a general perception that the majority of acutely ill patients are nursed in hospitals and that patients cared for by community nurses are less unwell. There is a reliance on community nurses to provide nursing care in primary care services and the independent nursing home sector that adds significant pressures and costs to the service. By using the workload index to calculate daily visits, patient mix and the attention patients receive for the first time gave a picture of nurses’ workloads. Index ‘1’ indicates that the workload is equitable (i.e. practitioner has a fair caseload); less than 1 indicates that the worker is under-occupied; greater than 1 shows that the nurse is over-stretched. The two main findings were that RNs treat and care for more dependent and acute patients than their HCA colleagues, which is an appropriate use of resources, and that two of the six localities warranted further monitoring, since two-thirds of the patients fell into the highest dependency/acuity category.
Activity comparisons The activity data collected by Scottish and English community staff permits comparisons as the basic four levels (dependency 1 to dependency 4) are the same. Apart from cities (e.g. Glasgow versus Carlisle), Scotland and Cumbria’s socio-economic environments are reasonably comparable (e.g. Highland versus Fells) (Scottish Government, 2013). The main finding from this comparison is that the workload index in Scotland is lower than in Cumbria, largely because the Cumbria teams deliver more interventions to patients in the higher dependency/acuity categories.
© 2014 MA Healthcare Ltd
2. Staff activity: time spent on direct patient care/workload index Data collected using daily diary sheets by Cumbria community staff regarding their time spent was organised into four categories: w Direct nursing, face-to-face, care, e.g. redressing a wound w Indirect care and patient-related activity that is one step removed from the patient, e.g. writing nursing notes w Associated work e.g. routine clerical work w Travelling time w Unproductive periods. Main staff activities are shown in Table 3 since full activity tables are dense and the main message can be lost. It would appear from the data that community nurses in Cumbria are overall less patient-time-centred than their Scottish counterparts, with the range in Cumbria being greater
British Journal of Community Nursing May 2014 Vol 19, No 5
Table 1. Overall Cumbria dependency/acuity and caseload (patient-based) Diary days
No. of patients visited per day 11.3
1284
Direct care per visit (minutes) Case mix by staff grade
Dep. 1
Dep. 2
Dep. 3
Dep. 4
Workload index
11%
27%
33%
29%
1.11
16.7
20.2
25.3
34.9
Patients
Dep. 1
Dep. 2
Dep. 3
Dep. 4
Cumbria RNs
11
8%
26%
36%
30%
Cumbria HCAs
12.5
21%
30%
25%
24%
Dep. 1 = independent; Dep. 2 = low–medium dependency; Dep. 3 = medium–high dependency; Dep. 4 = dependent
Table 2. Comparison of dependency/acuity and caseload between regions (intervention-based) Area
Interventions
Dep. 1
Dep. 2
Dep. 3
Dep. 4
Workload index
Scotland
886 501
26%
28%
29%
17%
1.08
Cumbria
16 735
15%
22%
33%
30%
1.11
Dep. 1 = independent; Dep. 2 = low–medium dependency; Dep. 3 = medium–high dependency; Dep. 4 = dependent
Table 3. Distribution of activity across all staff between regions Code
Scotland
Cumbria
Observations
866 501
16 735
Direct care
39%
35%
Indirect care
11%
22%
Associated
35%
23%
Travel
13%
19%
Unproductive
