Applied Nursing Research 28 (2015) 132–136
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Nurses' roles in direct nursing care delivery in China Hui Jiang, PhD, RN a,⁎,1, Hongxia Li, PhDc b,1,2, Lili Ma, MSN, RN a, Yan Gu, BSN, RN a a b
Nursing Department of Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China, 200120 School of Public Health, Fudan University, Shanghai, China, 200032
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Article history: Received 15 March 2014 Revised 7 September 2014 Accepted 11 September 2014 Keywords: China Direct nursing care Nursing workload measurement Nurses' roles
a b s t r a c t Aim: To study the nurses' roles in direct nursing care delivery in the neurology ward in China. Background: As patients' demands for healthcare have increased, the quality of the nursing service has become a focus of attention. Nurses play an important role in the delivery of care and can affect the quality of patient care. Methods: This was a non-participation, observational, time-task/activity study. All nursing care providers were observed during two shifts (16 hours) as constituents of the workload to explain the nurses' roles. Results: An astonishingly low percentage (25.6%) of the total patient care workload was conducted by registered nurses. The rest of the care was provided by nursing students (10.5%), health care assistants (21%), and a substantial portion by the patients' relatives (43.7%). Conclusions: Nurses' roles in direct nursing care delivery are inadequate in China. Nurse staffing and allocation must meet the increasing demand from clients to secure the highest quality and safety of healthcare. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Nurses are important front-line members of the healthcare workforce, and their contribution is recognized as essential to meet the development goals and delivery of safe and effective care (Buchan & Aiken, 2008; Esparza, Zoller, White, & Highfield, 2012). At a time of cost containment, efficiency, safety, and quality are very important considerations for the healthcare sector. These concerns, coupled with the increased demands for services and global nurse shortages, underscore the significance of nurses' roles in care delivery. Establishing appropriate nurse staffing and allocation procedures are helpful. 2. Background 2.1. The development of nursing care in China China is a developing country with approximately one-fifth of the world's population. China has a booming economy with rapid industriAuthor contributions: JIANG Hui was responsible for all aspects of the research study, including conceptualization of the design, drafting, and revision of the manuscript. LI Hongxia assisted with the design, drafting and revisions of the manuscript. GU Yan and MA Lili assisted for the data collection and analysis. Conflict of interest: The authors declare that there were no conflicts of interest with respect to this publication. Source of Funding: And this project was funded by the Shanghai health and family planning commission (Grant-in-Aid No.20134061) and the Shanghai Science and Technology Committee (Grant-in-Aid No. 14401932100). ⁎ Corresponding author at: Shanghai East hospital, Tongji University School of Medicine, No. 150, Jimo Road, Pudong New Area, Shanghai, 200120, China. Tel.: + 86 15316773595; fax: + 86 21 58798999. E-mail addresses: [email protected] (J. Hui), [email protected] (H. Li), [email protected] (L. Ma), [email protected] (Y. Gu). 1 Contributed equally to this work. 2 Tel.: +86 18964323305; fax: +86 21 58798999. http://dx.doi.org/10.1016/j.apnr.2014.09.003 0897-1897/© 2014 Elsevier Inc. All rights reserved.
alization and urbanization for the last three decades. Similarly, the nursing workforce in China experienced a significant increase in number from 0.47 million nurses in 1980 to 2.18 million in 2011 (Gao, Chan, & Cheng, 2011). In 2004, the nursing education system completed its academic structure by the introduction of the doctorate degree in nursing. This development catapulted nursing in China from vocational education to higher education, and now nursing includes five different educational programs (diploma, associate, bachelor's, master's, and doctorate; Gui, While, Chen, Barriball, & Gu, 2011). In addition to this academic maturity, nursing regulations and licensing evolved. The Registration Ordinance for nurses in China was enacted in 1994, which states that nurses are required to pass the national examination for registration and to re-register every 5 years. This regulation was enacted to guarantee the knowledge and skills of active nurses (Liu, Kunaiktikul, Senaratana, Tonmukayakul, & Eriksen, 2007). In addition, Chinese nurses are given academic titles, which divide them into five levels (junior nurse, senior nurse, nurse-in-charge, assistant chief senior nurse, and chief senior nurse). These titles are in accordance with their educational background, ability in nursing service, and experience with nursing practice (Hui, Wenqin, & Yan, 2013; Yun, Shen, & Jiang, 2010). In 2011, nursing was formally elevated to a first-level discipline in China, which ended the history of subordination to clinical medicine and provided new opportunities and challenges for nursing to develop rapidly (Wang et al., 2013).
2.2. Nurse staffing, skill mix, and nurses' roles in China Internationally, nurse staffing models can be classified as the nurseto-patient ratio, nurse-to-bed ratio, or nursing hours per patient day (NHPPD) work load measurement staffing models (Hoi, Ismail, Ong, & Kang, 2010; Spetz, 2004). In 1979, the Chinese government established
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guidelines for hospital nurse staffing that required the ward nurse-tobed ratio to be at least 0.4:1 (Wong, 2010). In 2011, the 1:8 nurse-topatient staffing models for the general ward were recommended by the Ministry of Health of the People's Republic of China (MHC) to better satisfy the nurse staffing levels (MHC, 2011–2015). Until recently, both the nurse-to-bed ratio and the nurse-to-patient ratio staffing models were accepted and used in China. Unfortunately, the 1:8 nurse-topatient ratio staffing level can only be met for the day shift, and the actual clinical nurse staffing is still at low levels in China in comparison with the 1:5 mandatory nurse-to-patient staffing models in California (USA) and 1:4 in Victoria (Australia) for the same general surgical/medical wards (Chapman et al., 2009; Gerdtz & Nelson, 2007). Except the widespread reason of cost containment, the severe nurse staffing shortage in China may be caused by the inequities and imperfections of the Chinese healthcare system and may also be caused by the Chinese nurse migration to the developed countries (Yun et al., 2010). In China, nursing skill mix consists of nurses, nursing students, and health care assistants. This is different when compared to the registered nurse, enrolled nurse/health care assistant, or registered nurse/licensed practical nurse/unlicensed assistant personnel mix in other countries, such as the USA, UK, Australia, Canada, and Singapore (Ayre, Gerdtz, Parker, & Nelson, 2007; Gerdtz & Nelson, 2007; Hui et al., 2013; McHugh, Kelly, Sloane, & Aiken, 2011). The registered nurse typically carries out skilled, professional tasks for the patients (nursing assessment, medication administration, and patient education), and their roles are mainly treatment-oriented and implementation of physician's orders. In addition, nursing students mainly assist with the fundamental basic nursing procedures, such as oral care, IV catheter care, urine catheter care, or vital sign monitoring. Health care assistants and relatives mainly take care of patients' activities of daily living (ADL), such as feeding, elimination, and hygiene. Similar to western countries, the health care assistants are employed to perform the non-professional simple nursing tasks in support of registered nurses as a means of reducing nurse staffing costs (Buchan & Dal Poz, 2002; Crossan & Ferguson, 2005).
2.3. Nursing care delivery model in China Nursing care delivery can be classified into four groups (total patient care, functional nursing, team nursing, and primary nursing; Esparza et al., 2012). In China, the nursing model utilizes team nursing as the main nursing care delivery model. All of the patient care providers in the wards are divided into several small groups guided by a registered nurse as the team leader; in addition to the registered nurse, there are nursing students and health care assistants to take care of the patients for an entire shift. The other nursing model occasionally used is the functional nursing model. In this model, which is task-oriented, a specific action is assigned to each individual nurse, for example, checking a physician's orders in the computer or preparing IV drips for the patients. In China, the inpatient nursing care standard is guided by the National Patient Classification System, which was begun in 1956 in China and belonged to the prototype patient classification. The decision of the patient classification of nursing care level is based on the combination of the patients' acuity and self-care ability. The patients' acuity is usually assessed by the physician, and the self-care ability is assessed by the charge nurse using the Barthel scale. Physicians are required to prescribe and order the nursing care level after all the admission assessment is completed. All patients are assigned a nursing care level by the doctor, and it is changed over the course of a patient's hospitalization. The classification system grades patient care needs into four levels: special-level (one-to-one care); level 1 (close monitoring of patients every 30–60 min and assisting with basic care); level 2 (partial self-care and monitoring the patient every 2–4 h); and level 3 (total selfcare and monitoring the patient twice per day) (Kalisch & Liu, 2009; Yuan, Peng, & Jiang, 2012).
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2.4. The future challenge for nurse staffing and skill mix in China Nurses play an important role in health care delivery and can affect the quality of patient care (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Currently, the majority of nurses in China are employed fulltime and are expected to provide client-centered and holistic patient care (Wong, 2010). The increasing demand for healthcare has pushed major healthcare reforms in China. These reforms strive to enhance the accessibility, affordability, and availability of care to the entire Chinese population. The reforms place special emphasis on the role nurses play in order to attract wider attention from the whole society (Chen, 2009). These reforms have adopted the many descriptive roles currently defined by The International Council of Nurses (ICN). The ICN defines nursing as autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well, and in all settings. Thus, nursing encompasses the promotion of health, prevention of illness, and care of the ill, disabled, and dying. Other important roles of nursing include advocacy, promotion of a safe environment, research, and participation in shaping health care policy, as well as patient and health system management, and education (ICN, 2010). However, the role as caregiver remains the core of nursing and requires nurses to deliver care holistically. These international role expectations have been influenced in China by the culture of Confucianism and filial responsibilities (Chen, 2001). Family members and relatives play an important role in patient care and provide considerable help at the bedside, rendering direct, non-professional nursing care, which may separate nurses' roles in China from other countries. Thus, it is important for Chinese nursing administrators to understand the Chinese nurses' involvement in patient care and what role nurses play in the direct nursing care delivery. The importance of nurse staffing and skill mix in the care quality prompted us to look at this issue in the neurology ward in one of the major tertiary hospitals in Shanghai, China. 2.5. Study design 2.5.1. Aims The aims of this study were to observe and record the direct nursing care workload and nurses' roles in direct nursing care delivery in a neurology ward of a general tertiary hospital in China. Describing the current nursing care delivery status and proper staff allocation will help improve nursing care quality, safety, and patient satisfaction. 3. Method The study used the method of a non-participation, observational, time-task/activity workload measurement design. Direct nursing care was defined based on direct clinical nursing care observations and a literature review. The research team selected 102 items covering 13 dimensions. These items were used to measure the workload. These tasks included nursing assessment (six items), vital signs and discomfort monitoring (14 items), patient education (11 items), medication administration (eight items), specimen collection (eight items), patient resuscitation (seven items), patient hygiene (nine items), nutrition (four items), elimination (four items), turning and movement (five items), escorting for examination (two items), nursing procedures (21 items), and assisting rehabilitation exercises (three items).The time invested in direct nursing care was calculated by the observers, who stayed by the patient's bedside to calculate nursing time. The time measured was from the start of the direct nursing care task to the end of the same task. 3.1. Setting and participants The study was conducted in a tertiary general hospital in Shanghai. A convenient sampling method was used. The neurology ward has 60 beds and allocates 21 nurses (total 24 nurses according to the 0.4:1
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nurse-to-patient ratio [three nurses were on maternity leave]) along with six final year nursing students and five health care assistants. Sixty-nine consecutive new admissions within 4 consecutive weeks in the neurology ward were recruited as participants. In total, the nursing workload of 530 hospitalized days of all participants was measured. The study duration included patient admission, and inpatient and discharge days. 3.2. Data collection A study data collection sheet was prepared and included patients' demographics, nursing care level, and date of the observation. Items of direct nursing care, and nursing time charting space were also included. The Barthel scale was used to assess patient performance in activities of daily living (ADL). The Barthel scale uses 10 variables and 100 scores describing ADL and mobility. A higher score is associated with a greater likelihood of independence. Eighteen nurses were recruited and trained as observers for the standard procedure of nursing workload measurement. The training was provided by the researcher and lasted for 1 h, which included the study purpose, measurement items, measurement method, and charting method. The nursing workload was measured from 06:00 to 22:00, and the observer was scheduled for two shifts (morning shift, 0600–1400; and afternoon shift, 14:00–22:00). The observers were requested to stay in the patient's room, which is usually shared by three patients. After measurement, the observers were requested to chart the time on the form immediately. One observer was assigned to be the coordinator for each shift and was responsible for the quality of the workload measurement. The workload included all of the patient's nursing care needs during hospitalization, which was done by registered nurses, nursing students, health care assistants, as well as the patients' relatives. The study was conducted in July 2013 over 4 weeks. A stopwatch was used, and seconds were used as the unit for work time measurement, then converted to hours by the researcher. If several staff delivered care at the same time, then the entire time for the procedure was the unit time for each time multiplied by the number of staff. 3.3. Ethical considerations The study was permitted by Shanghai health and family planning commission and also approved by the institutional review board of the hospital. Participants were fully informed about the purpose of the study. An informed written consent was obtained from every participant. Patients were told that they could withdraw from the study and withdrawal would not have any impact on their care. 3.4. Statistical analysis Statistical analyses were performed using SPSS (version 17.0 software package for Windows; SPSS, Inc., Chicago, IL, USA). The results were entered into the software package by the researcher and were double-checked by another research member. Descriptive statistics were used for data analysis. 3.5. Findings The demographics of the participants were as follows: age range, 26–91 years (average, 67.7 ± 12.3 years); 37 males and 32 females; admission diagnosis included cerebral infarction (n = 56), cerebral hemorrhage (n = 3), epilepsy (n = 2), and other diagnoses (n = 6). Nursing care level 1 patients were measured for 56 days, level 2 patients were measured for 474 days, and no special-level and level 3 patients were measured within the research period. The average assessment score for ADL based on the Barthel scale was 61.1 ± 34.1. The average length of hospital stay of the study ward was 14.2 days, the average mortality rate was 1.5%, and the readmission rates within
1 day, 2 weeks, and 1 month were 0.3%, 5.7%, and 9.2%, respectively. Approximately two-thirds of patients had relatives or privately-hired caregivers during the day time. Hospital regulations permitted relatives or caregivers of level 1 patients to stay in the hospital overnight, but relatives or caregivers of level 2 patients were not permitted to stay after 21:00. All 21 nurses who were observed on the neurology ward were females and ranged in age between 21 to 40 years (average, 27.2 ± 4.8 years). The work experience of the neurology ward nurses ranged from 1 to 20 years (average, 6.5 ± 5.5 years). Greater than one-half of the nurses (11 [52.4%]) were not married. The highest level of education achieved by the majority of the participants was an associate degree (14 [66.6%]), followed by a baccalaureate degree (4 [19.1%]), and a diploma (3 [14.3%]). The nurse-to-patient ratios during the study period for the day and evening shifts were 1:8.6 ± 4.1 and 1:27.3 ± 5.1, respectively. 3.6. Description of direct nursing care delivery The results of the nursing workload for the 13 dimensions in direct nursing care are listed in Table 1. The top five workloads for the patients on the inpatient neurology ward were elimination, followed by nutrition, nursing procedures, hygiene, and medication treatments. 3.7. Description of the nursing workload from different providers Fig. 1 shows that only a small portion of total direct nursing care (25.6%) was conducted by registered nurses. The remainder of care was provided by non-licensed nursing providers, as follows: 10.5% by nursing students; 21% by health care assistants; and 43.7% by the patients' relatives. The average nursing hours per patient from 06:00 to 22:00 was 1.3 h. 4. Discussion The nursing workforce is one of the most important human resources and constitutes the largest segment of employees in the healthcare industry, both in China and other countries (Buchan & Aiken, 2008; Hui et al., 2013). The quality of nursing care delivery is closely related to the nurse staffing level and skill mix (McGlynn, Griffin, Donahue, & Fitzpatrick, 2012). Many US states have recognized factors related to the quality of nursing care delivery and enacted laws to provide guidance to nurse staffing. For example, California AB 394 stated that the level of nurse staffing should be based on the severity of illness, the need for specialized equipment and technology, the complexity of care, and the patients' ability to provide self-care (Chapman et al., 2009). In China, however, because the Chinese tradition emphasizes family responsibility, patients want their relatives to provide their care (Hui et al., 2013) and given the severe nursing staff shortage, the
Table 1 Description of the nursing workload of the 13 dimensions from 06:00 to 22:00 (n = 530). Dimension
Nursing workload (hours, %)
Ranks
Elimination Nutrition Nursing procedures Patient hygiene Medication administration Escorting for examination Turning and movement Vital signs and discomfort monitoring Assisting rehabilitation exercises Patient education Nursing assessment Specimen collection Patient resuscitation Total hours Average hours
149.8 (22.11) 140.3 (20.71) 118.2 (17.45) 64.4 (9.51) 53.9 (7.96) 44.0 (6.50) 37.3 (5.51) 26.5 (3.90) 16.8 (2.48) 12.2 (1.79) 4.8 (0.71) 4.7 (0.70) 4.6 (0.67) 677.5 1.3
1 2 3 4 5 6 7 8 9 10 11 12 13
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the patient's condition deteriorates. Therefore, critical consideration of the nurse staffing and nurse skill mix needs to be a top priority by the healthcare sectors and nursing administrators in China. Nurses' roles in direct nursing care need to be properly amended and followed to ensure a sufficient number of nurses to be available to take care of the patients for effective surveillance and to improve the safety and quality of nursing care. 4.1. Implications for practice, policy, and future research
Fig. 1. Percentage of direct nursing workload by four different providers.
relatives of patients are involved to a large extent in bedside nursing care (43.7%), although the relatives of patients are excluded in the skill mix nursing workforce; this fact was confirmed by the findings of our research. In the current study, with 60 beds occupied most of the time by the neurology patients, only 21 nurses (including the head nurse and charge nurse) are available for the three daily shifts. Nurses only have time to focus on the medical treatment and nursing skill procedures, thus leaving a large portion of the healthcare to be carried out by the non-licensed nursing providers (nursing students, health care assistants or patients' relatives). These reasons can explain the findings (Table 1) that nurses are not doing more than 1.3 hours of care from 06:00 to 22:00 per day per patient in the neurology ward. The findings from Fig. 1 showed that there is a quantitative difference in the way in which the different nursing providers carry out different nursing activities. The alarming fact in our study that should alert the nurse managers to consider was that the nurses' role in direct nursing care delivery accounted for only 25.6% of the total work load and 64.7% of the direct nursing care in the ward, such as nutrition, hygiene, and elimination, was done by the patients' relatives and health care assistants. The findings from the Fig. 2 also showed that except the tasks of patient resuscitation, nursing assessment, medication administration and patient education, the unlicensed nursing students, health care assistants or even patients' relatives involved in a large amount of hospital healthcare tasks, which may affect the hospital nursing care quality and cause potential risks of patient safety. As the registered nurses provide around-the-clock surveillance system in any hospital and serve as the monitors for the early detection and prompt intervention when
Nurse staffing levels and skill mix are recognized as central elements of cost, and are now considered the primary determination of quality (Buchan & Dal Poz, 2002; Duffield, Roche, Diers, Catling-Paull, & Blay, 2010). As China continues its industrialization process and the size of the family shrinks, family support of sick relatives will dwindle. In addition, relying heavily on the family to provide a significant portion of nursing care ultimately affects the quality of care provided to patients in Chinese hospitals. Thus, reliance on relatives to cover the shortage of nurses is not going to be possible in the future in China. The cost containment pressures underscore the need to better understand how nursing resources can be optimally configured. The meaningful implication for clinical management is that nursing managers should be aware of the importance of nurse staffing and skill mix, and proper number of nursing staff based on patients' acuity, self-care ability, amount of treatment, patients' admissions, discharge number, assessment, and amount of education should be recommended. Nursing managers should also balance the quality, safety, budget, and efficiency and set up the proper skill mix of the nursing workforce in order to ensure that nurses have enough time to complete the professional nursing work and at the same time guide and supervise the nursing care assistants effectively and slowly decrease the involvement of the relatives in hospital nursing care, relieve the caring duties of the relatives, and maintain the safety and quality of hospital nursing care. Future areas of research are recommended to focus on the skill mix related to patient outcomes in China. 4.2. Limitations The study was conducted in the neurology ward of one tertiary general hospital in the highly developed and densely populated city of Shanghai, which may limit the applicability of the study findings to other wards, other hospitals, and other locations in China (or internationally). A significantly larger sample size is recommended to better understand the nurses' roles in direct nursing care.
Fig. 2. Proportions of the four nursing care providers in the 13 dimensions.
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Reference
5. Conclusions In light of the global nursing shortage and local pressures within international health services, questions of appropriate nurse staffing levels and skill mix are becoming increasingly important. Both factors are directly related to nursing quality and patient safety, thereby affecting the in-depth development of the nursing service. In China, the nursing workforce size is inadequate, and nurses' roles in direct nursing care are also inadequate. Relatives in China continue to play significant roles as caregivers for patients who are hospitalized; however, such deeply rooted concepts are now changing. Thus, it is very important to improve the supply of nurses and set the proper proposals for the skill mix to find an ideal solution for the families and the hospitals. Acknowledgments The authors are grateful to all participants for their involvement of the study. The authors would also like to thank the Shanghai health and family planning commission and the Shanghai Science and Technology Committee for the funding support for this project. The views expressed in this paper are those of the authors. Appendix. Nursing task checklist for direct nursing care workload measurement
Dimensions
Items
Nursing assessment
Nursing admission assessment, inpatient assessment, muscle strength assessment, discharge assessment, activity of daily living assessment, and Glasgow Coma score assessment Intermittent IV therapy check, patient consciousness monitoring, pupil monitoring, taking TPR, taking BP, reaction to medication, side effect monitoring, lab result monitoring, clinical signs monitoring, nutrition, activity, psychology fitness, muscle strength, and SpO2 monitoring Admission education, medication education, nutrition education, examination education, treatment education, discharge education, emotional support, communication with patients' families, exercise instruction, clinical pathway education, and instructing the patient or family Oral medication, intravenous injection, intramuscular injection, subcutaneous injection, blood infusion, intradermal injection, IV infusion, and changing IV medication Taking blood, urine, stool, sputum and wound samples, and measuring the intake and output Monitoring EKG, CVP, using simple breathing bag, CPR resuscitation, defibrillation, ventilator monitoring, and assisting doctors with resuscitation efforts Morning and evening oral care, personal hygiene, and assisting in routine perineal care Supply food for patient, assist drinking, feed patient, and clean patient's hands before meal Assist patients to use bedpan or walk to toilet, give enemas, and disinfect the urinal or bedpan Change patient position, assist patients to turn over and mobilize, assist transfer of the patients or move in and out of bed Escort patient for examination in other departments
Vital signs and discomfort monitoring
Patient education
Medication administration Specimen collection Patient resuscitation Patient hygiene Nutrition Elimination Turning and movement Escorting for examination Nursing procedures
Rehabilitation exercises
IV catheter insertion, prepare IV drip, remove IV plug, use warm or cold pad, physical cooling, using physical restraint, catheter care, dumping drainage, care of dead body, Foley's catheter insertion, washing the bladder, nasogastric tube insertion, bowel clearance, blind enema, oxygen therapy, aerosol inhalation, bedside blood glucose monitoring, suction, care of patients with tracheotomies or endotracheal tubes, tube feeding, and wound care Speech therapy, rehabilitation exercise, and rehabilitation massage
Notes: Some items need to be done directly by the RN and the others were allowed to be done with the supervision by the nurse of the non-licensed nursing providers.
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Nurses' roles in direct nursing care delivery in China Hui Jiang, PhD, RN a,⁎,1, Hongxia Li, PhDc b,1,2, Lili Ma, MSN, RN a, Yan Gu, BSN, RN a a b
Nursing Department of Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China, 200120 School of Public Health, Fudan University, Shanghai, China, 200032
a r t i c l e
i n f o
Article history: Received 15 March 2014 Revised 7 September 2014 Accepted 11 September 2014 Keywords: China Direct nursing care Nursing workload measurement Nurses' roles
a b s t r a c t Aim: To study the nurses' roles in direct nursing care delivery in the neurology ward in China. Background: As patients' demands for healthcare have increased, the quality of the nursing service has become a focus of attention. Nurses play an important role in the delivery of care and can affect the quality of patient care. Methods: This was a non-participation, observational, time-task/activity study. All nursing care providers were observed during two shifts (16 hours) as constituents of the workload to explain the nurses' roles. Results: An astonishingly low percentage (25.6%) of the total patient care workload was conducted by registered nurses. The rest of the care was provided by nursing students (10.5%), health care assistants (21%), and a substantial portion by the patients' relatives (43.7%). Conclusions: Nurses' roles in direct nursing care delivery are inadequate in China. Nurse staffing and allocation must meet the increasing demand from clients to secure the highest quality and safety of healthcare. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Nurses are important front-line members of the healthcare workforce, and their contribution is recognized as essential to meet the development goals and delivery of safe and effective care (Buchan & Aiken, 2008; Esparza, Zoller, White, & Highfield, 2012). At a time of cost containment, efficiency, safety, and quality are very important considerations for the healthcare sector. These concerns, coupled with the increased demands for services and global nurse shortages, underscore the significance of nurses' roles in care delivery. Establishing appropriate nurse staffing and allocation procedures are helpful. 2. Background 2.1. The development of nursing care in China China is a developing country with approximately one-fifth of the world's population. China has a booming economy with rapid industriAuthor contributions: JIANG Hui was responsible for all aspects of the research study, including conceptualization of the design, drafting, and revision of the manuscript. LI Hongxia assisted with the design, drafting and revisions of the manuscript. GU Yan and MA Lili assisted for the data collection and analysis. Conflict of interest: The authors declare that there were no conflicts of interest with respect to this publication. Source of Funding: And this project was funded by the Shanghai health and family planning commission (Grant-in-Aid No.20134061) and the Shanghai Science and Technology Committee (Grant-in-Aid No. 14401932100). ⁎ Corresponding author at: Shanghai East hospital, Tongji University School of Medicine, No. 150, Jimo Road, Pudong New Area, Shanghai, 200120, China. Tel.: + 86 15316773595; fax: + 86 21 58798999. E-mail addresses: [email protected] (J. Hui), [email protected] (H. Li), [email protected] (L. Ma), [email protected] (Y. Gu). 1 Contributed equally to this work. 2 Tel.: +86 18964323305; fax: +86 21 58798999. http://dx.doi.org/10.1016/j.apnr.2014.09.003 0897-1897/© 2014 Elsevier Inc. All rights reserved.
alization and urbanization for the last three decades. Similarly, the nursing workforce in China experienced a significant increase in number from 0.47 million nurses in 1980 to 2.18 million in 2011 (Gao, Chan, & Cheng, 2011). In 2004, the nursing education system completed its academic structure by the introduction of the doctorate degree in nursing. This development catapulted nursing in China from vocational education to higher education, and now nursing includes five different educational programs (diploma, associate, bachelor's, master's, and doctorate; Gui, While, Chen, Barriball, & Gu, 2011). In addition to this academic maturity, nursing regulations and licensing evolved. The Registration Ordinance for nurses in China was enacted in 1994, which states that nurses are required to pass the national examination for registration and to re-register every 5 years. This regulation was enacted to guarantee the knowledge and skills of active nurses (Liu, Kunaiktikul, Senaratana, Tonmukayakul, & Eriksen, 2007). In addition, Chinese nurses are given academic titles, which divide them into five levels (junior nurse, senior nurse, nurse-in-charge, assistant chief senior nurse, and chief senior nurse). These titles are in accordance with their educational background, ability in nursing service, and experience with nursing practice (Hui, Wenqin, & Yan, 2013; Yun, Shen, & Jiang, 2010). In 2011, nursing was formally elevated to a first-level discipline in China, which ended the history of subordination to clinical medicine and provided new opportunities and challenges for nursing to develop rapidly (Wang et al., 2013).
2.2. Nurse staffing, skill mix, and nurses' roles in China Internationally, nurse staffing models can be classified as the nurseto-patient ratio, nurse-to-bed ratio, or nursing hours per patient day (NHPPD) work load measurement staffing models (Hoi, Ismail, Ong, & Kang, 2010; Spetz, 2004). In 1979, the Chinese government established
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guidelines for hospital nurse staffing that required the ward nurse-tobed ratio to be at least 0.4:1 (Wong, 2010). In 2011, the 1:8 nurse-topatient staffing models for the general ward were recommended by the Ministry of Health of the People's Republic of China (MHC) to better satisfy the nurse staffing levels (MHC, 2011–2015). Until recently, both the nurse-to-bed ratio and the nurse-to-patient ratio staffing models were accepted and used in China. Unfortunately, the 1:8 nurse-topatient ratio staffing level can only be met for the day shift, and the actual clinical nurse staffing is still at low levels in China in comparison with the 1:5 mandatory nurse-to-patient staffing models in California (USA) and 1:4 in Victoria (Australia) for the same general surgical/medical wards (Chapman et al., 2009; Gerdtz & Nelson, 2007). Except the widespread reason of cost containment, the severe nurse staffing shortage in China may be caused by the inequities and imperfections of the Chinese healthcare system and may also be caused by the Chinese nurse migration to the developed countries (Yun et al., 2010). In China, nursing skill mix consists of nurses, nursing students, and health care assistants. This is different when compared to the registered nurse, enrolled nurse/health care assistant, or registered nurse/licensed practical nurse/unlicensed assistant personnel mix in other countries, such as the USA, UK, Australia, Canada, and Singapore (Ayre, Gerdtz, Parker, & Nelson, 2007; Gerdtz & Nelson, 2007; Hui et al., 2013; McHugh, Kelly, Sloane, & Aiken, 2011). The registered nurse typically carries out skilled, professional tasks for the patients (nursing assessment, medication administration, and patient education), and their roles are mainly treatment-oriented and implementation of physician's orders. In addition, nursing students mainly assist with the fundamental basic nursing procedures, such as oral care, IV catheter care, urine catheter care, or vital sign monitoring. Health care assistants and relatives mainly take care of patients' activities of daily living (ADL), such as feeding, elimination, and hygiene. Similar to western countries, the health care assistants are employed to perform the non-professional simple nursing tasks in support of registered nurses as a means of reducing nurse staffing costs (Buchan & Dal Poz, 2002; Crossan & Ferguson, 2005).
2.3. Nursing care delivery model in China Nursing care delivery can be classified into four groups (total patient care, functional nursing, team nursing, and primary nursing; Esparza et al., 2012). In China, the nursing model utilizes team nursing as the main nursing care delivery model. All of the patient care providers in the wards are divided into several small groups guided by a registered nurse as the team leader; in addition to the registered nurse, there are nursing students and health care assistants to take care of the patients for an entire shift. The other nursing model occasionally used is the functional nursing model. In this model, which is task-oriented, a specific action is assigned to each individual nurse, for example, checking a physician's orders in the computer or preparing IV drips for the patients. In China, the inpatient nursing care standard is guided by the National Patient Classification System, which was begun in 1956 in China and belonged to the prototype patient classification. The decision of the patient classification of nursing care level is based on the combination of the patients' acuity and self-care ability. The patients' acuity is usually assessed by the physician, and the self-care ability is assessed by the charge nurse using the Barthel scale. Physicians are required to prescribe and order the nursing care level after all the admission assessment is completed. All patients are assigned a nursing care level by the doctor, and it is changed over the course of a patient's hospitalization. The classification system grades patient care needs into four levels: special-level (one-to-one care); level 1 (close monitoring of patients every 30–60 min and assisting with basic care); level 2 (partial self-care and monitoring the patient every 2–4 h); and level 3 (total selfcare and monitoring the patient twice per day) (Kalisch & Liu, 2009; Yuan, Peng, & Jiang, 2012).
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2.4. The future challenge for nurse staffing and skill mix in China Nurses play an important role in health care delivery and can affect the quality of patient care (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Currently, the majority of nurses in China are employed fulltime and are expected to provide client-centered and holistic patient care (Wong, 2010). The increasing demand for healthcare has pushed major healthcare reforms in China. These reforms strive to enhance the accessibility, affordability, and availability of care to the entire Chinese population. The reforms place special emphasis on the role nurses play in order to attract wider attention from the whole society (Chen, 2009). These reforms have adopted the many descriptive roles currently defined by The International Council of Nurses (ICN). The ICN defines nursing as autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well, and in all settings. Thus, nursing encompasses the promotion of health, prevention of illness, and care of the ill, disabled, and dying. Other important roles of nursing include advocacy, promotion of a safe environment, research, and participation in shaping health care policy, as well as patient and health system management, and education (ICN, 2010). However, the role as caregiver remains the core of nursing and requires nurses to deliver care holistically. These international role expectations have been influenced in China by the culture of Confucianism and filial responsibilities (Chen, 2001). Family members and relatives play an important role in patient care and provide considerable help at the bedside, rendering direct, non-professional nursing care, which may separate nurses' roles in China from other countries. Thus, it is important for Chinese nursing administrators to understand the Chinese nurses' involvement in patient care and what role nurses play in the direct nursing care delivery. The importance of nurse staffing and skill mix in the care quality prompted us to look at this issue in the neurology ward in one of the major tertiary hospitals in Shanghai, China. 2.5. Study design 2.5.1. Aims The aims of this study were to observe and record the direct nursing care workload and nurses' roles in direct nursing care delivery in a neurology ward of a general tertiary hospital in China. Describing the current nursing care delivery status and proper staff allocation will help improve nursing care quality, safety, and patient satisfaction. 3. Method The study used the method of a non-participation, observational, time-task/activity workload measurement design. Direct nursing care was defined based on direct clinical nursing care observations and a literature review. The research team selected 102 items covering 13 dimensions. These items were used to measure the workload. These tasks included nursing assessment (six items), vital signs and discomfort monitoring (14 items), patient education (11 items), medication administration (eight items), specimen collection (eight items), patient resuscitation (seven items), patient hygiene (nine items), nutrition (four items), elimination (four items), turning and movement (five items), escorting for examination (two items), nursing procedures (21 items), and assisting rehabilitation exercises (three items).The time invested in direct nursing care was calculated by the observers, who stayed by the patient's bedside to calculate nursing time. The time measured was from the start of the direct nursing care task to the end of the same task. 3.1. Setting and participants The study was conducted in a tertiary general hospital in Shanghai. A convenient sampling method was used. The neurology ward has 60 beds and allocates 21 nurses (total 24 nurses according to the 0.4:1
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nurse-to-patient ratio [three nurses were on maternity leave]) along with six final year nursing students and five health care assistants. Sixty-nine consecutive new admissions within 4 consecutive weeks in the neurology ward were recruited as participants. In total, the nursing workload of 530 hospitalized days of all participants was measured. The study duration included patient admission, and inpatient and discharge days. 3.2. Data collection A study data collection sheet was prepared and included patients' demographics, nursing care level, and date of the observation. Items of direct nursing care, and nursing time charting space were also included. The Barthel scale was used to assess patient performance in activities of daily living (ADL). The Barthel scale uses 10 variables and 100 scores describing ADL and mobility. A higher score is associated with a greater likelihood of independence. Eighteen nurses were recruited and trained as observers for the standard procedure of nursing workload measurement. The training was provided by the researcher and lasted for 1 h, which included the study purpose, measurement items, measurement method, and charting method. The nursing workload was measured from 06:00 to 22:00, and the observer was scheduled for two shifts (morning shift, 0600–1400; and afternoon shift, 14:00–22:00). The observers were requested to stay in the patient's room, which is usually shared by three patients. After measurement, the observers were requested to chart the time on the form immediately. One observer was assigned to be the coordinator for each shift and was responsible for the quality of the workload measurement. The workload included all of the patient's nursing care needs during hospitalization, which was done by registered nurses, nursing students, health care assistants, as well as the patients' relatives. The study was conducted in July 2013 over 4 weeks. A stopwatch was used, and seconds were used as the unit for work time measurement, then converted to hours by the researcher. If several staff delivered care at the same time, then the entire time for the procedure was the unit time for each time multiplied by the number of staff. 3.3. Ethical considerations The study was permitted by Shanghai health and family planning commission and also approved by the institutional review board of the hospital. Participants were fully informed about the purpose of the study. An informed written consent was obtained from every participant. Patients were told that they could withdraw from the study and withdrawal would not have any impact on their care. 3.4. Statistical analysis Statistical analyses were performed using SPSS (version 17.0 software package for Windows; SPSS, Inc., Chicago, IL, USA). The results were entered into the software package by the researcher and were double-checked by another research member. Descriptive statistics were used for data analysis. 3.5. Findings The demographics of the participants were as follows: age range, 26–91 years (average, 67.7 ± 12.3 years); 37 males and 32 females; admission diagnosis included cerebral infarction (n = 56), cerebral hemorrhage (n = 3), epilepsy (n = 2), and other diagnoses (n = 6). Nursing care level 1 patients were measured for 56 days, level 2 patients were measured for 474 days, and no special-level and level 3 patients were measured within the research period. The average assessment score for ADL based on the Barthel scale was 61.1 ± 34.1. The average length of hospital stay of the study ward was 14.2 days, the average mortality rate was 1.5%, and the readmission rates within
1 day, 2 weeks, and 1 month were 0.3%, 5.7%, and 9.2%, respectively. Approximately two-thirds of patients had relatives or privately-hired caregivers during the day time. Hospital regulations permitted relatives or caregivers of level 1 patients to stay in the hospital overnight, but relatives or caregivers of level 2 patients were not permitted to stay after 21:00. All 21 nurses who were observed on the neurology ward were females and ranged in age between 21 to 40 years (average, 27.2 ± 4.8 years). The work experience of the neurology ward nurses ranged from 1 to 20 years (average, 6.5 ± 5.5 years). Greater than one-half of the nurses (11 [52.4%]) were not married. The highest level of education achieved by the majority of the participants was an associate degree (14 [66.6%]), followed by a baccalaureate degree (4 [19.1%]), and a diploma (3 [14.3%]). The nurse-to-patient ratios during the study period for the day and evening shifts were 1:8.6 ± 4.1 and 1:27.3 ± 5.1, respectively. 3.6. Description of direct nursing care delivery The results of the nursing workload for the 13 dimensions in direct nursing care are listed in Table 1. The top five workloads for the patients on the inpatient neurology ward were elimination, followed by nutrition, nursing procedures, hygiene, and medication treatments. 3.7. Description of the nursing workload from different providers Fig. 1 shows that only a small portion of total direct nursing care (25.6%) was conducted by registered nurses. The remainder of care was provided by non-licensed nursing providers, as follows: 10.5% by nursing students; 21% by health care assistants; and 43.7% by the patients' relatives. The average nursing hours per patient from 06:00 to 22:00 was 1.3 h. 4. Discussion The nursing workforce is one of the most important human resources and constitutes the largest segment of employees in the healthcare industry, both in China and other countries (Buchan & Aiken, 2008; Hui et al., 2013). The quality of nursing care delivery is closely related to the nurse staffing level and skill mix (McGlynn, Griffin, Donahue, & Fitzpatrick, 2012). Many US states have recognized factors related to the quality of nursing care delivery and enacted laws to provide guidance to nurse staffing. For example, California AB 394 stated that the level of nurse staffing should be based on the severity of illness, the need for specialized equipment and technology, the complexity of care, and the patients' ability to provide self-care (Chapman et al., 2009). In China, however, because the Chinese tradition emphasizes family responsibility, patients want their relatives to provide their care (Hui et al., 2013) and given the severe nursing staff shortage, the
Table 1 Description of the nursing workload of the 13 dimensions from 06:00 to 22:00 (n = 530). Dimension
Nursing workload (hours, %)
Ranks
Elimination Nutrition Nursing procedures Patient hygiene Medication administration Escorting for examination Turning and movement Vital signs and discomfort monitoring Assisting rehabilitation exercises Patient education Nursing assessment Specimen collection Patient resuscitation Total hours Average hours
149.8 (22.11) 140.3 (20.71) 118.2 (17.45) 64.4 (9.51) 53.9 (7.96) 44.0 (6.50) 37.3 (5.51) 26.5 (3.90) 16.8 (2.48) 12.2 (1.79) 4.8 (0.71) 4.7 (0.70) 4.6 (0.67) 677.5 1.3
1 2 3 4 5 6 7 8 9 10 11 12 13
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the patient's condition deteriorates. Therefore, critical consideration of the nurse staffing and nurse skill mix needs to be a top priority by the healthcare sectors and nursing administrators in China. Nurses' roles in direct nursing care need to be properly amended and followed to ensure a sufficient number of nurses to be available to take care of the patients for effective surveillance and to improve the safety and quality of nursing care. 4.1. Implications for practice, policy, and future research
Fig. 1. Percentage of direct nursing workload by four different providers.
relatives of patients are involved to a large extent in bedside nursing care (43.7%), although the relatives of patients are excluded in the skill mix nursing workforce; this fact was confirmed by the findings of our research. In the current study, with 60 beds occupied most of the time by the neurology patients, only 21 nurses (including the head nurse and charge nurse) are available for the three daily shifts. Nurses only have time to focus on the medical treatment and nursing skill procedures, thus leaving a large portion of the healthcare to be carried out by the non-licensed nursing providers (nursing students, health care assistants or patients' relatives). These reasons can explain the findings (Table 1) that nurses are not doing more than 1.3 hours of care from 06:00 to 22:00 per day per patient in the neurology ward. The findings from Fig. 1 showed that there is a quantitative difference in the way in which the different nursing providers carry out different nursing activities. The alarming fact in our study that should alert the nurse managers to consider was that the nurses' role in direct nursing care delivery accounted for only 25.6% of the total work load and 64.7% of the direct nursing care in the ward, such as nutrition, hygiene, and elimination, was done by the patients' relatives and health care assistants. The findings from the Fig. 2 also showed that except the tasks of patient resuscitation, nursing assessment, medication administration and patient education, the unlicensed nursing students, health care assistants or even patients' relatives involved in a large amount of hospital healthcare tasks, which may affect the hospital nursing care quality and cause potential risks of patient safety. As the registered nurses provide around-the-clock surveillance system in any hospital and serve as the monitors for the early detection and prompt intervention when
Nurse staffing levels and skill mix are recognized as central elements of cost, and are now considered the primary determination of quality (Buchan & Dal Poz, 2002; Duffield, Roche, Diers, Catling-Paull, & Blay, 2010). As China continues its industrialization process and the size of the family shrinks, family support of sick relatives will dwindle. In addition, relying heavily on the family to provide a significant portion of nursing care ultimately affects the quality of care provided to patients in Chinese hospitals. Thus, reliance on relatives to cover the shortage of nurses is not going to be possible in the future in China. The cost containment pressures underscore the need to better understand how nursing resources can be optimally configured. The meaningful implication for clinical management is that nursing managers should be aware of the importance of nurse staffing and skill mix, and proper number of nursing staff based on patients' acuity, self-care ability, amount of treatment, patients' admissions, discharge number, assessment, and amount of education should be recommended. Nursing managers should also balance the quality, safety, budget, and efficiency and set up the proper skill mix of the nursing workforce in order to ensure that nurses have enough time to complete the professional nursing work and at the same time guide and supervise the nursing care assistants effectively and slowly decrease the involvement of the relatives in hospital nursing care, relieve the caring duties of the relatives, and maintain the safety and quality of hospital nursing care. Future areas of research are recommended to focus on the skill mix related to patient outcomes in China. 4.2. Limitations The study was conducted in the neurology ward of one tertiary general hospital in the highly developed and densely populated city of Shanghai, which may limit the applicability of the study findings to other wards, other hospitals, and other locations in China (or internationally). A significantly larger sample size is recommended to better understand the nurses' roles in direct nursing care.
Fig. 2. Proportions of the four nursing care providers in the 13 dimensions.
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Reference
5. Conclusions In light of the global nursing shortage and local pressures within international health services, questions of appropriate nurse staffing levels and skill mix are becoming increasingly important. Both factors are directly related to nursing quality and patient safety, thereby affecting the in-depth development of the nursing service. In China, the nursing workforce size is inadequate, and nurses' roles in direct nursing care are also inadequate. Relatives in China continue to play significant roles as caregivers for patients who are hospitalized; however, such deeply rooted concepts are now changing. Thus, it is very important to improve the supply of nurses and set the proper proposals for the skill mix to find an ideal solution for the families and the hospitals. Acknowledgments The authors are grateful to all participants for their involvement of the study. The authors would also like to thank the Shanghai health and family planning commission and the Shanghai Science and Technology Committee for the funding support for this project. The views expressed in this paper are those of the authors. Appendix. Nursing task checklist for direct nursing care workload measurement
Dimensions
Items
Nursing assessment
Nursing admission assessment, inpatient assessment, muscle strength assessment, discharge assessment, activity of daily living assessment, and Glasgow Coma score assessment Intermittent IV therapy check, patient consciousness monitoring, pupil monitoring, taking TPR, taking BP, reaction to medication, side effect monitoring, lab result monitoring, clinical signs monitoring, nutrition, activity, psychology fitness, muscle strength, and SpO2 monitoring Admission education, medication education, nutrition education, examination education, treatment education, discharge education, emotional support, communication with patients' families, exercise instruction, clinical pathway education, and instructing the patient or family Oral medication, intravenous injection, intramuscular injection, subcutaneous injection, blood infusion, intradermal injection, IV infusion, and changing IV medication Taking blood, urine, stool, sputum and wound samples, and measuring the intake and output Monitoring EKG, CVP, using simple breathing bag, CPR resuscitation, defibrillation, ventilator monitoring, and assisting doctors with resuscitation efforts Morning and evening oral care, personal hygiene, and assisting in routine perineal care Supply food for patient, assist drinking, feed patient, and clean patient's hands before meal Assist patients to use bedpan or walk to toilet, give enemas, and disinfect the urinal or bedpan Change patient position, assist patients to turn over and mobilize, assist transfer of the patients or move in and out of bed Escort patient for examination in other departments
Vital signs and discomfort monitoring
Patient education
Medication administration Specimen collection Patient resuscitation Patient hygiene Nutrition Elimination Turning and movement Escorting for examination Nursing procedures
Rehabilitation exercises
IV catheter insertion, prepare IV drip, remove IV plug, use warm or cold pad, physical cooling, using physical restraint, catheter care, dumping drainage, care of dead body, Foley's catheter insertion, washing the bladder, nasogastric tube insertion, bowel clearance, blind enema, oxygen therapy, aerosol inhalation, bedside blood glucose monitoring, suction, care of patients with tracheotomies or endotracheal tubes, tube feeding, and wound care Speech therapy, rehabilitation exercise, and rehabilitation massage
Notes: Some items need to be done directly by the RN and the others were allowed to be done with the supervision by the nurse of the non-licensed nursing providers.
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