Nursing Intensity in Home Health Care

Abstract

Background: As people get older, their health needs become more chronic and complex. In that the burden on health and long-term care systems and services will increase alongside the aging population, well-functioning municipal health care systems will be needed. Also, because of the shift from hospital and long-term settings to home health care, nurse leaders need systematic information about patients’ care needs for staff resources. To guarantee person-centered and safe care, the correct allocation of staff resources and acceptable nursing workload levels are essential. Consequently, reliable instruments for measuring nursing intensity are needed.

Aims: The overarching aim of the thesis was to identify currently used patient classification systems (PCSs) developed and tested in HHC, with a special emphasis on validity, reliability and staff allocation, and to test the validity and reliability of the modified Oulu Patient Classification (OPCq) instrument. This also included describing nurses’ work experiences with and perceptions on the modified OPCq instrument’s usability when using it to classify nursing intensity (NI) in an HHC setting.

Theoretical framework: The RAFAELA® system is based on a holistic view of patients and incorporates a nursing perspective with a caring and person-centered approach. In RAFAELA®, a balance is sought between each patient’s individual care needs and nursing resources. Developed from a humanitarian point of view, the OPCq instrument is used to measure a patient’s physical, social and spiritual/existential needs.

Design, materials and methodology: The study was a part of a municipal research and development program in home health care and realized during 2012-2014 in collaboration with the University of South-Eastern Norway. The modified OPCq instrument was tested in two home health care units. To provide an overview and broader knowledge of the existing patient classification systems used in home health care, a scoping review was conducted.

Paper I was a scoping review and included searches of the Cinahl, Medline, Embase and SweMed electronic databases, resulting in 1247 records being identified; an additional 56 records were identified through searches of the Google and Google Scholar databases and hand searches of key journals. After the removal of duplicates, 1040 records were screened (title and abstract), resulting in 55 records that were re-screened, with 39 being excluded. The remaining 16 full-text articles were assessed for eligibility, and three were excluded with reasons. Consequently, thirteen papers were included in the final review. In Paper II, a descriptive design was used and the study included a questionnaire comprised of a total of 13 questions with set answers and the possibility to comment on eight of the questions; ten questions had a five-point Likert scale. Descriptive analyses and simplified content analyses occurred. Participants, comprised of registered nurses, practical nurses and assistants, answered the questionnaire in spring 2013 and spring 2104. In Paper III, a reliability study, the interrater reliability of the modified OPCq instrument was tested using a new multiple parallel classification method for data collection. The guidelines for Reporting Reliability and Agreement Studies were followed when reporting the study. There were 2010 parallel classifications (335 x 6 sub-areas) conducted during the period November 2013 to February 2014, involving 53 patients. Participants were registered nurses, practical nurses, assistants and nursing students. In Paper IV a qualitative design was used, including focus group interviews to collect data. Four focus group interviews were conducted, two in April 2013 and two in May 2013. A total of 24 registered nurses and practical nurses were invited to participate in the study.

Results: In Paper I, 13 patient classification systems used in home health care were reviewed. All were found to measure patients’ needs and/or nursing requirements. Five instruments were or had been tested for validity, five tested for reliability, and one validity and reliability tested and evaluated. How accurately the systems were described varied, with some very well described and others not. Specific information on staff allocation was missing from most of the systems.

In Paper II, participants evaluated the OPCq instrument’s sub-areas 1-6 (M=2.98-3.11, MD=3, SD 0.77-0.96). About 80% of the participants evaluated sub-area 1 (planning and co-ordination of nursing care), sub-area 2 (breathing, blood circulation and symptoms of disease) and sub-area 4 (personal hygiene and secretion) as being very well/well or pretty well described in the instrument. The nursing intensity levels A-D described in the instrument’s sub-areas were also assessed (M=2.70-2.90, MD 3, ST= 0.88-0.97). Here the highest scores were given for sub-area 1 (planning and co-ordination of nursing care), sub-area 2 (breathing, blood circulation and symptoms of disease) and sub-area 6 (Teaching, guidance in care and follow up care, emotional support).

In Paper III, consensus in percent in relation to the parallel classification of the OPCq instrument’s sub-areas 1-6 was undertaken and seen to be 64.78%-77.61%. Cohens’ kappa showed an interrater reliability of 0.49-0.69. Sub-area 4 (Personal hygiene and secretion) showed the highest consensus and sub-area 6 (Teaching, guidance in care and follow up care, emotional support) showed the weakest consensus.

In Paper IV, three themes emerged from the focus group interviews: (a) Classifying the modified Oulu patient classification correctly; (b) Technological problems hinder the use of the instrument; (c) Classifying nursing intensity when time pressure dominates. The nurse participants expressed some uncertainty about the various levels in the OPCq instrument and where or how to classify some tasks or duties. There were also some technical problems with the registering of OPCq measurements. A lack of time during the work day was a significant stress factor when classifying.

Conclusion: While various patient classification systems used in home health care were seen in the scoping review, few were validity and/or reliability tested or evaluated. How well and accurately the patient classification systems were described in the reviewed papers varied, and information about the allocation of staff was lacking.

The OPCq instrument was considered to fulfill the requirements for validity and reliability. However, the OPCq manual should be improved to better suit a home health care setting, specifically sub-areas 1-6 and nursing intensity levels A-D and keywords. The OPCq instrument was considered useful in classifying nursing intensity in home health care, although there was uncertainty about where or how to classify non-patient factors.