Background:
The workload of oncology nurses is associated with the quality and safety of nursing care. The increasing number of cancer patients, a relatively aged patient population, the technological and complex nature of treatment, the respective complexity of care demands all combined can translate into a high workload for oncology nurses. Without appropriate staffing management, high workload has shown to be associated with poor outcomes for patients and nurses. The ability to maintain appropriate nurse staffing levels (i.e., the number of nurses, their education and experience) is crucial to the optimization of care provision in terms of quality, safety and efficiency, but remains a challenge for nursing managers and administrators. Considering the negative effects that a high workload can have, the overall aim of this thesis was to describe nurse workload and patient safety in inpatient oncology units. To achieve this aim, this thesis describes the current state of a) patient safety with regards to adverse events (AEs), b) the estimated workload with a typically used measurement tool (Project Research in Nursing, PRN), the estimated acuity of hospitalized cancer patients (Oncology Acuity Tool for French-speaking Switzerland, OAT-FS) as well as the estimation of workload with a simple Professional Judgement approach, c) the perceived workload (NASA- Task Load Index, NASA-TLX) of oncology nurses in inpatient units in French speaking Switzerland.
Method:
This descriptive study was conducted in two university hospitals (1550-1900 hospital beds) and one urban tertiary hospital (570 hospital beds) in Switzerland. One hematological unit (unit 4), one unit with solid-tumor cancer patients (unit 3), and two mixed units (units 1 and 2) (hematological and solid-tumor) were included in the study. The units varied in size ranging from 9 to 23 beds. They covered all types of cancer malignancies and severity levels. Our sample included records from adult patients who were diagnosed with cancer and hospitalized (>24 hours) in one of the participating oncology units. Registered nurses with a diploma or bachelor’s degree were recruited. Data was collected during January 22nd to June 27th, 2018. Firstly, to collect data on adverse events, we used an adapted version of the Global Trigger Tool. We conducted a retrospective record review of patients discharged from oncology units. Secondly, we collected patient care demands scores through three methods (i.e. PRN, OAT-FS, Professional Judgement). The OAT-FS scores were measured at the end of each shift by nurses in order to score prospectively for the next shift, the acuity of the patients they were caring for. PRN scores were retrieved from the hospital database. The nurses at the end of their shift evaluated prospectively the Professional Judgement (acuity) score of patients they had cared for. Thirdly, workload was measured with the French version of the NASA-TLX. The perceived workload was measured retrospectively at the end of every shift by each nurse participating in the study. Descriptive statistics were used as appropriate.
Results:
From the sample of 224 reviewed records, we identified 661 triggers and 169 AEs in 94 patients (42%). Pain related to care was the most frequent AE (n = 29), followed by constipation (n = 17). AEs rates were 75.4 per 100 admissions and 106.6 per 1000 patient days. Most of the identified AEs (78%) caused temporary harm to the patient and required clinical
intervention. Among AEs during hospitalization (n = 125), 76 (61%) were considered not preventable, 28 (22%) preventable, and 21 (17%) undetermined.
We found differences between units in mean care demand scores, with large variations and ranges. The highest variability between patients and between nurses was observed in PRN scores (ICC1 = .45 for both). The shift explained 31% of the PRN score variance. The OAT-FS score variance was explained to a similar extent by the patient (ICC = .39) and the nurses (ICC
= .38) but less by the shift (ICC = .11). Finally, Professional Judgement score variance was explained mostly by the patient (ICC = .33), rather than nurses’ (ICC = .20) or the shift scores (ICC = .06).
Overall perceived workload measures revealed a mean score of 54.3 (SD=16.6) out of 100. We observed that mental demand (how many mental activities were required: thinking, deciding, calculating, remembering, looking, searching, etc.) was the major component of overall workload for oncology nurses with a mean score of 71.7 (SD=21.1). Conversely, frustration (how insecure, discouraged, irritated, stressed and annoyed versus secure, gratified, content, relaxed and complacent did you feel during the task?) had the lowest scores amongst all items, with a mean score of 39.6 (SD=27.1).
Discussion:
About half of the hospitalized oncology patients suffered from at least one AE related to care during their hospitalization. Pain, constipation, and nosocomial infections were the most frequent AEs. It is, therefore, essential to identify AEs to guide future clinical practice initiatives to ensure patient safety.
Nursing workload, particularly in the discussion on patient safety, is an important issue. Our analysis questioned the validity and reliability of the existing tools measuring the patient care demands. Indeed, we observed that the patients and the nurses explained 45% of the PRN score variance, while shifts explained less but still 31% of the score variance. Theoretically, we would expect the patient to explain more variance of the PRN score (e.g. 50% or 60%), and nurses not at all or to a small amount (e.g. 5% or 10% of the PRN scores). We would expect some of the PRN scores to be explained by the shift, because the night shifts are different from the day shifts, but to a smaller extend than the observed 31%. As with PRN scores, ICCs showed high variability between individual patients and nurses in OAT-FS scores. However, OAT-FS score variance were less explained by the shift. Interestingly, the simplest approach (i.e., Professional Judgement) seemed to be most closely mapped to the expectation and therefore to be more robust, at least based on our analysis.
The perceived workload was shown to be comparable to other inpatient units, with high complexity. Nevertheless, if we look at the different dimensions of the NASA-TLX, we can identify areas where nurses would probably need more support, i.e. for mental and physical activities.
Conclusion:
For the first time in Switzerland we provide a comprehensive depiction of the current state of adverse events and workload issues in inpatient oncology units. According to our results, none of the applied assessment tools of workload measures were shown to provide a reliable representation of patient care demands, whereas a relatively high number of AEs was observed and a perceived workload that shows need for improvement, particularly regarding mental demands. To conclude, patient safety and measures to estimate its remains a significant issue for inpatient oncology units in Switzerland.