Measurement of Nursing Workload and Nurse Practitioners Contribution in Critical Care : A Resource-Based Relative Value Scale Approach

Transcription

1 Measurement of Nursing Workload and Nurse Practitioners Contribution in Critical Care : 1 Jinhyun Kim, 2 KyungSook Kim, 3 CheongSuk Yoo, 4 KyoungA Lee 1, First Author College of Nursing, Seoul National University, jinhyun@snu.ac.kr *2,Corresponding Author Department of Nursing, Namseoul University, kgs4321@hanmail.net 3 Seoul National University Hospital, csy@snuh.org 4 College of Nursing, Seoul National University, tj720221@snu.ac.kr Abstract The aim of this study is to classify the advanced nursing practices of Critical Care Nurse Practitioners (CCNPs) and then to measure the nursing workload and contribution of CCNPs in critical care. Twenty practices were classified as advanced nursing practices of CCNPs. The workload for the practices of CCNPs was measured with the resource-based relative value scale (RBRVS) and nursing time. The workload for the maintenance and management of CRRT was the highest among the 20 advanced nursing practices. recruitment maneuver had the lowest workload. The differences in the workload scores for the advanced nursing practices of CCNPs were more than 70 fold. The recognition of the contribution by CCNPs was investigated with the 13 item Performance Indicator developed by Kleinpell. Both nurses and CCNPs considered the contribution by CCNPs as great. The high level of awareness on contribution was indicated by staff education, patient education, improved medical management, and adherence to best-practice guidelines. The CCNP system is an effective way to improve the quality of care in intensive care units. For an active CCNP system, it is necessary to create a social reward system and to pass legislation that allows CCNPs to perform a variety of practices beyond current ones. Keywords: Critical care nurse practitioner, Advanced nursing practice, RBRVS, Critical Care 1. Introduction In the 21st century, the use of medicine is changing from an inpatient to an outpatient system through high technology medicine. These trends have led to the increased hospitalization of patients with severe illnesses [1]. Based on changes in the healthcare environment, the certificate of critical care nurse practitioner was included in advanced nurse practitioner programs in South Korea from Intensive care units (ICUs) are the place where the most severe sick patients with various health problems are hospitalized. Critical care is becoming more important, and the quality of intensive care is influenced by the care provider s specialty. Thus, professional knowledge and skills are needed to provide complex nursing care, and the role of critical care nurses is one of the most anticipated ones in ICUs[2]. In the case of South Korea, there were 519 critical care nurses as of 2013, and on average, 95 critical care nurses were added every year from 12 advanced nurse practitioner education programs[3]. Yet, because of a lack of a social reward system, the demand for critical care nurse practitioners was low in terms of hospital management. The advanced nurse practitioner system is a system that improves patient care and provides new practical knowledge and skills to registered general nurses applied to nursing practices. This system complements the role of nurses and establishes nursing care plans. As a result, effective nursing care shortens the length of stay and increases the hospital bed turnover rate through improved nursing care quality and cost savings[4]. In addition, the role of the advanced nurse practitioner has developed and diversified globally because of a reduction in the working hours of junior doctors and a shortage in medical manpower[5]. In previous studies, the efficacy and outcomes of the roles of critical care nurses have been demonstrated in the USA. Pirret (2008) reported that critical care nurse practitioners in nursing care had an influence on decreasing the re-admission rates of ICU patients after discharge[6]. Sidani et al. (2007) compared patients who received nursing care from acute care nurse practitioners (ACNPs) to patients who did not receive nursing care from the ACNPs. When comparing those two groups, the intervention group receiving nursing care from the ACNPs reported higher satisfaction, functional status, symptom relief, and sense of well-being than that of the control group[7]. As a result, International Journal of Engineering and Industries (IJEI) Volume 5, Number 1, March

2 professional critical care nurse practitioners contributed to many aspects of healthcare system including reducing national healthcare costs, the satisfaction of patients and quality of life, and increasing the job satisfaction of doctors and registered general nurses. However, the roles of critical care nurse practitioners have not been identified and not analyzed specifically. In addition, there are not enough studies showing the outcomes of their practical roles in South Korea s healthcare system. Therefore, the aims of this study were (1) to classify the advanced nursing practices of critical care nurse practitioners, (2) to measure the nursing workload of critical care nurse practitioners, and (3) to investigate the contributions of critical care nurse practitioners. With these aims, the results of this study could be used as basic data to evaluate the outcomes of various activities carried out by advanced nurse practitioners in healthcare. 2. Methods 2.1. Study design This study was a descriptive exploratory study to classify advanced nursing practices and to investigate nursing workload and role perceptions as to the contributions of critical care nurse practitioners at a tertiary hospital in South Korea Measurement After the ICU nursing experts and research team selected nursing practices of critical care nurse practitioners (CCNPs), the nursing workload and contribution of CCNPs were investigated Classification of advanced nursing practices of CCNPs After selecting ICU nursing practices through a literature review, the practices were divided into the practices of general ICU nurses and CCNPs and services for doctors by a panel of ICU nursing experts. The panel and research team defined each practice and described the procedures Nursing workload To measure nursing workload, the resource-based relative value scale (RBRVS) was used. The RBRVS was actually applied to calculate the National Health Insurance (NHI) fee in South Korea. It included four dimensions: Working time, physical efforts, mental efforts, and stress. Working time was measured by direct observation, and the remaining three domains were measured with the magnitude estimation method using ventilator care as a standard nursing practice through self-administered questionnaires. Magnitude estimation is a sensitive and accurate technique producing ratio level scales that offer advantages over ordinal level scales frequently used in relative value scale research in nursing Recognition of contribution by critical care nurse practitioners We used the 13 item Performance Indicator developed by Kleinpell in 2005[8]. This instrument has 13 indicators: length of stay, health care costs, readmission rates, adherence to best-practice guidelines, improved medical management, complications, resource utilization, continuity of care, patient access to care, patient satisfaction, patient education, education of patients' families, and staff education. This instrument used a 5-point Likert scale to measure the perception on the contribution of the advanced nurse practitioners role. Cronbach's alpha was Data collection Data collection proceeded after getting prior approval (No ) from the Institutional Review Board of Seoul National University College of Nursing. Before the survey, informed consent was given by the participants, and they were notified that they could withdraw from the study at any time. Access 9

3 to the data was strictly limited to the researchers. This study was done between July and August 2013 using questionnaires, and the questionnaires were delivered to and collected from critical care nurse practitioners in person. Incomplete and non-response questionnaires were excluded in this study. A total of 98 subjects was recruited for the data analysis. The working time of nurses was measured during the daytime (7 am to 4 pm) except for weekends by 5 CCNPs who are experts in critical care nursing activities and skills. Each CCNP measured the working time over 2 days. The working time of each practice was measured by dividing the preparation time, practice time and retrospective time by units of seconds from direct one on one observations. Taking into consideration overtime work, the working time in the evening or at night was partially measured based on the researchers judgment. Before measuring the working time, researchers explained the purpose of the study, measurement criteria and methods, and provided education on the protocols for the 20 advanced nursing practices of CCNPs. Advanced nursing practices that did not occur during the measurement period were analyzed using experience time Data analysis These results were analyzed with descriptive statistics including mean, standard deviation, range of the scores, and t-test. 3. Results 3.1. Advanced nursing practices of critical care nurse practitioners in ICUs Twenty practices were classified as advanced nursing practices of CCNPs by the ICU nursing experts and research team. The advanced nursing practices are ventilator care, assessment of neurological system-cranial nerve examination, assessment of delirium, assessment of respiratory system, application and decision making for oxygen therapy in ICU patients, chest physiotherapy-high frequency chest wall oscillator, decision making and application of aerosol therapy, inhaled NO therapy, recruitment maneuver, application of the NIV (noninvasive ventilation), management of home ventilator assisted patients, education on home ventilator assisted patients, management of mechanical ventilator weaning, artificial airway management-maintenance, extubation, management of patients with ECMO, management of patients with IABP, start of CRRT, maintenance and management of CRRT, and nursing care for chest tube removal (Table 1) Resource-based relative value scale, time and workload There were 98 respondents who completed the survey of which 46 were nurses and 52 critical care nurse practitioners (CCNPs). The average age of the nurses was 27.5 years (27.5 ± 3.75) and that of the CCNPs was 35.7 years (35.8±2.81). The calculated scores of the resource-based relative value scale (RBRVS) for the 20 advanced nursing practices ranged from 88.7 to with an average of points. The RBRVS score for decision making and application of aerosol therapy was the lowest and that for management of patients with ECMO had the highest score. Performing the maintenance and management of CRRT had the longest time taking 21 minutes 56 seconds. It took only 46 seconds to perform the recruitment maneuver. The workload score, which included the RBRVS and nursing time, for the maintenance and management of CRRT was the highest among the 20 advanced nursing practices at 4, Additionally, the workload scores for education on home ventilator assisted patients and application of the NIV (noninvasive ventilation) were also high at over 2,500 points. These practices need high level skills and time in their performance. On the other hand, recruitment maneuver, decision making and application of aerosol therapy and extubation had lower workload scores in practices. The differences in workload scores among the advanced nursing practices of CCNPs were more than 70 fold. 10

4 Table 1. Resource-based relative value scale and time of advanced nursing practices of CCNPs Advanced nursing practices Resource-based relative value scale Mental Technical Stress Mean effort Time RVS*T Ventilator care :45 1,245.0 Assessment of neurological system-cranial nerve examination : Assessment of delirium : Assessment of respiratory system : Application and decision making for oxygen therapy in ICU patients : Chest physiotherapy-high frequency chest wall oscillator : Decision making and application of aerosol therapy : Inhaled NO therapy :07 1,677.7 Recruitment maneuver : Application of the NIV (noninvasive ventilation) :14 2,705.5 Management of home ventilator assisted patients : Education on home ventilator assisted patients :43 2,780.5 Management of mechanical ventilator weaning :51 2,384.1 Artificial airway management- maintenance : Extubation : Management of patients with ECMO :09 1,022.1 Management of patients with IABP : Start of CRRT :56 1,536.4 Maintenance and management of CRRT :56 4,572.9 Nursing care for chest tube removal : N(%) / Mean :34 1, Recognition of the contribution by CCNPs role The average of the 13 performance outcomes using a 5-point Likert scale to measure the recognition of the contribution of advanced nurse practitioners role was 3.35 (±0.95) for nurses and 3.21(±0.86) for CCNPs. There was no significant difference in the recognition of the contribution of advanced nurse practitioners role between nurses and CCNPs statistically according to the analyzed results from the 13 outcome indicators. Both nurses and CCNPs considered CCNPs contribution to be great. The highest level of awareness on contribution was staff education with an average of 3.87 (±1.04) for nurses and 3.65 (±0.86) for CCNPs. They also recognized that CCNPs contributed to patient education, improved medical management and adherence to best-practice guidelines. On the other hand, both nurses and CCNPs recognized that the contribution towards reducing the readmission rate, length of stay and healthcare cost was slightly lower. 11

5 Table 2. Contribution of CCNPs recognized by nurses and CCNPs Outcome indicators Length of stay Healthcare costs Readmission rates Adherence to best-practice guidelines Improved medical management Complication Resource utilization Continuity of care Patient access to care Patient satisfaction Patient education Education of patients' families Staff education Nurse (n=46) Mean(SD) CCNP (n=52) t-value 2.83(1.04) 3.09(0.86) (1.04) 2.89(0.85) (1.05) 2.93(0.94).770* 3.42(0.94) 3.59(0.78) (0.95) 3.63(0.85) (1.05) 3.26(0.95) (1.03) 3.13(0.96) (1.01) 3.28(0.95) (1.01) 3.33(1.01) (0.95) 3.40(0.96) (1.00) 3.65(0.99) (0.96) 3.50(1.13) (0.97)) 3.87(1.04) Mean(SD) 3.21(0.86) 3.35(0.95) 4. Conclusion In 2003, an advanced nurse practitioner system was introduced to South Korea, and the activities of advanced nurse practitioners began. Intensive care units are the place where patients in critical condition stay in the hospital. A clear classification of advanced nursing practices is necessary to expand the advanced nurse practitioner system in ICUs. However, the practices of critical care nurse practitioners are not compensated for separately, and their reimbursement is usually included in physician fees or intensive care unit patient fees. In addition, the activities of advanced nurse practitioners are restricted in performing certain procedures. Invasive care nursing practices such as needle thoracentesis, lumbar punctures, and pulmonary artery catheter insertion are not allowed. In addition, many activities are done collaboratively by nurses, CCNPs and doctors. Therefore, readjustments need to made to the role of CCNPs. The unclear defined roles and inconsistent expectations of advanced nurse practitioners can result in role conflict and role overload and cause barriers to advanced nursing practices[9]. In South Korea, to improve the current advanced nurse practitioner system, nurses must prove the effectiveness and benefits of advanced nursing practices to the public health system. We classified 20 advanced nursing practices of CCNPs, calculated the workload of each of the 20 practices, and surveyed the recognition of CCNPs role. Affecting patients outcomes was identified as an advantage of CCNPs practices. Most nurses and CCNPs recognized the role of the CCNP as having contributed a lot. Especially, CCNPs were perceived to contribute to staff education, patient education, improved medical management, and adherence to best-practice guidelines. According to recent research, doctors and nurses have recognized the necessity of the CCNP system[10]. All of them recognized that the activities of CCNPs would be required, and they were expected to perform nursing practices, education, counseling, research, etc.[11]. In this study, only the advanced clinical activities of CCNPs were classified into 20 practices except for research, counseling 12

6 and general nursing activities. The practices of CCNPs included the assessment of the neurological system and cranial nerve examination, assessment of delirium and respiratory system, application and decision making for oxygen therapy in ICU patients, chest physical therapy, high frequency chest wall oscillator, decision making and application of aerosol therapy, inhaled NO therapy, recruitment maneuver, application of the NIV (noninvasive ventilation), management of home ventilator assisted patients, education on home ventilator assisted patients, management of mechanical ventilator weaning, artificial airway management-maintenance, extubation, management of patients with ECMO, management of patients with IABP, start of CRRT, maintenance and management of CRRT, nursing care for chest tube removal, and ventilator care. From an educational point of view, the role of CCNPs has become to be viewed as contributing the most. But recognition of contribution towards decreasing the length of stay, reducing the healthcare costs, and reducing the readmission rates was relatively small. However, in Wheeler (2000) s study, the length of hospital stay for patients who were cared for by CCNPs were for a short duration, and there were few complications[12]. Therefore, medical expenses have been reduced. Although critical care nurse practitioners (CCNPs) contribute by providing high quality care and decreasing medical costs [13], the contribution of advanced nursing practices of CCNPs is unclear, and they have been treated unfairly. Thus, the contributions of advanced nurse practitioners in reducing medical costs must also be recognized financially[5]. Through this study, the recognition of CCNPs contributions was confirmed both in nurses and CCNPs. It suggests that CCNPs improve the outcomes and care of patients and their families in the critical care area. In addition, we believe the CCNP system is an effective way to improve the quality of care in the intensive care unit. The advanced nurse practitioner system is an effective way to overcome the problem of insufficient medical manpower and reduce medical costs. Additionally, this system creates a positive impact on patient care and the national healthcare system[14]. For an active CCNP system, it is necessary to prove the effectiveness of advanced nurse practitioners[15]. Therefore, further research on advanced nurse practitioners practices should be extended to other advanced nursing practices, and it is necessary to evaluate the economic value of advanced nursing practices in the national health insurance system. Through this effort, a social demand for advanced nurse practitioners could be promoted. In addition, it is imperative to enact legislation that allows CCNPs to perform a variety of practices in order to further develop the advanced nurse practitioner system in South Korea. 5. Acknowledgement This study was supported by a National Research Foundation of Korea (NRF) grant funded by the Korea government (NRF ). 6. References [1] Korea Health Industry Development Institute, A study on projected manpower and development of management system, [2] Sole, M., Klein, G., and Moseley, M., Introduction to Critical Nursing(4th ed), Elsevier Saunders(st. Louis), [3] Korean Accreditation Board of Nursing, [4] Nuccio, S. A, Costa-Lieberthal K. M, Gunta K. E., Mackus, M, L., Riesch, S. K., Schmanski, K. M., and Westen, B. A., A Survey of 636 staff nurses: Perceptions and factors influencing the CNS role, Clinical Nurses Specialist, vol. 7, no. 3, pp , [5] Williamson, S., Twelvetree, T., Thompson, J., and Beaver, K., An ethnographic study exploring the role of ward-based Advanced Nurse Practitioners in an acute medical setting, Journal of Advanced Nursing, vol.68, no.7, pp , [6] Pirret, A. M., The role and effectiveness of a nurse practitioner led critical care outreach service, Intensive and Critical Care Nursing, vol. 24, no. 6, pp , [7] Sidani, S., Doran, D., Porter H., LeFort, S., O'Brienn-Pallas L. L., Zahn, C., and Sarkissian,S., Outcomes of nurse practitioners in acute care: An exploration, Internet Journal of Advanced Nursing Practice, vol. 8, no. 1, pp.15,

7 [8] Kleinpell, R. M., Acute care nurse practitioner practice: results of a 5-year longitudinal study, American Journal of Critical care, vol. 14, no. 3, pp , 2005 [9] Graiffin, M. and Melby, V. Developing an advanced nurse practitioner service in emergency care; attitudes of nurses and doctors, Journal of Advanced Nursing, vol.56, no.3, pp , 2006 [10] Cho, M. S., Cho, Y. A., Kwon, I. G., Seo, M J., and Baek, H. J., Importance, satisfaction and contribution of advanced practice nurses' role recognized by health care professionals, Journal of Korean Academy of Nursing Administration, vol. 17, no. 2, pp , 2011 [11] Sung, Y. H., Yi Y. H., Kwon, I. K., and Cho, Y. A., The roles of critical care advanced practice nurse, Journal of Korean Academy Nursing, vol. 36, no. 8, pp , 2006 [12] Wheeler, E. C., The CNS s impact on process and outcome of patients with total knee replacement, Clinical Nurses Specialist, vol. 14, no. 4, pp , 2000 [13] O Brien, J. M. How nurse practitioners obtained provider status: lessons for pharmacists, Journal of Health System Pharmacy, vol.60, no.22, pp , 2003 [14] Clarke, P., and Aiken, L. H. Failure to rescue, American Journal of Nursing, vol.103, no.1, pp.42-47, [15] Litaker, D., Mion, L., Planavsky, L., Kippes, C., Mehta, N., and Frolkis, J. Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients perception of care, Journal of Interprofessional Care, vol.17, no.3, pp ,