SURVEY NEONATAL NURSING WORKLOAD-CAN IT BE MEASURED ?

continuing pres^sure an tertiary hospitals 10 riduee expenses has inwttably meant a dmand to reduce nursing stcff. This fm ittns^ed the need to ensure timst<^n$ {dlocatUm istqwoprkKe* A m tkid fo cckvil0e s w i^ i ra4ds hm d m a m ’emnt af n m m ta lm H d o a d is e x p io r e d ,


INTRODUCTION
In a political and socio-economic climate where ethical dilemmas of just distribution of scarce resources are constantly present as in South Africa, it is appropriate to assess how resources designated for care of the newborn are used.Salaries for nursing personnel constitute a considerable percentage of the costs involved and while there are demands to re d u c e s ta f f n u m b e rs, it m u st be acknowledged that adequate staffing levels are a pre-requisite for an acceptable standard of neonatal care.
The measurement of nursing workload or development of indicators of nursing intensity for ill new borns is problem atical.The dependency scales which are used for adult patients are obviously of limited value in a situation where all patients are always 100% dependent.There are few tools for measuring neonatal nursing workload in the literature, and the nature o f neonatal practice in a developing country could mean that such tools might need to be modified in the light of local conditions.
A preliminary exploration of possible ways of measuring nursing workload was undertaken in Groote Schuur Maternity Centre in the n ew b o rn c a re u n it (M C N ) in O ctober/N ovem ber 1993.This nursery operates primarily as a tertiary referral hospit^ for the Peninsula M aternal and Neonatal Service (PMNS).This is largely State funded and caters for approximately 80% of all births in the region.Roughly half of the annual 34 000 deliveries in the PMNS take place in the community in the Midwife Obstetric Units (MOU).These mothers and babies are not considered to be risk for maternal or neonatal problems and both mother and baby are discharged home within six to eight hours of delivery.The remainder are booked to deliver at one of the secondary level hospitals in the region or if indicated, at the tertiary level referral Maternity Centre at Groote Schuur Hospital.
TTie policy regarding all well newborns in the PMNS is that as far as possible babies are not separated from their mothers.This means that newborns are not routinely admitted to a nursery and accompany their mothers directly from the labour ward to the postnatal ward.This also applies to well babies who are delivered by caesarean section or forceps.
Only ill babies, low birth weight babies or babies requiring careful observation or frequent investigations are admitted to this nursery.MCN has an open visiting policy for the immediate family and siblings of all infants admitted.Mothers are encouraged to give as much care as they possibly can to their babies.
The majority of infants admitted here are preterm (approximately 90%).However the absence of alternative community hospitals means that these babies have to remain in this hospital until fit for discharge home when they weigh around 2000g.In many other countries these infants would be transferred back to an institution nearer their homes as soon as their condition permitted.
The newborn care unit has an official total of 60 beds.This is divided into the following areas: Intensive C are Unit (ICU) (12 incubators) Infants here typically present with following problem s -low birth weight (<1 OOOg), re sp ira to ry d istre ss req u irin g assisted ventilation or levels of inspired oxygen above 35% or sophisticated monitoring.

N ursery No. 2 (12 incubators)
The population of this nursery has very uniform characteristics.As a rule they are all preterm , older than 48 hours and weigh between 1 000 and 1 500gm.All are in incubators and are almost exclusively tube fed 12 X 24 hours.

N urseries 3 & 4 (20 cots and incubators)
The population of this nursery is also relatively uniform.Babies weigh between 1 500 and 1 800gm., they are either tube fed, bottle fed or a combination of both.A baby who becomes ill or otherwise gives cause for concern is moved into another area of MCN.Mothers have free access to their babies and are encouraged to spend as much time as possible with their infants, breast feeding and helping with care.
N ursery 5 (10-12 cots) This area is primarily for babies awaiting discharge and who require routine baby care.
N ursery 6 (Observation Nursery) (usually about 4 incubators and 4 cots) The nursing workload in this area is strikingly varied.Infants admitted here weigh more than 1500g, are ill or unstable or require careful observation and frequent investigations.The length of stay in this area varies fi^om a couple of hours to several weeks.
In addition there are 3 cubicles with space for one cot or incubator for isolation purposes when indicated.

LITERATURE SURVEY
"Ideally, a system of woridoad measurement should be suitable to the local situation and simultaneously facilitate comparability across wards/units, specialities, hospitals, districts and regions.At present such a system does not ex ist... " (Arthur and James, 1 ^4 :5 6 2 ) Much of the available literature describes methods of determining appropriate stafTmg levels and developing formulae to achieve this.Most of this is not applicable to neonates.
A report o f the British A ssociation for Perinatal Medicine in association with the Neonatal Nurses Association on categories of babies requiring neonatal care (1992:868-9) describes four categories o f infants.The criteria however, relate more specifically only to seriously ill babies.
The second phase of the work done in the Liverpool Maternity Hospital and reported by Williams, Whelan, Weindling and Cooke (1993:534-8) describes 3 classes of infants in th e ir q u e s t to d e te rm in e th e n u rsin g requirem ents of sick infants.O nce the patients have been appro{»iately categorised and w eighted a w orkload index can be calculated.M ethods of determining the demand for nursing care are discussed with great clarity in the taxonomy of Arthur and James (1994;558-565).The approach used in this study w ould be classed as using a "bottom-up" management approach.The strengths of this method can be its relative objectivity and simplicity in implementation b ut th is m ust be balan ced a g a in st the task-orientated approach and the fact that to implement a proper study is expensive.
A very useful conceptual framework was provided by the Patient Intensity for Nursing Index (PINI) as described by Prescott et al in 1991.This describes the four major constructs upon which nursing workload essentially depends.There are as follows:--severity of the illness -intensity of the patient needs for nursing care -the complexity of the nursing process, tasks and procedures -time spent caring for a specific patient It is interesting to relate each construct to the nursing workload in MCN.

Severity of Illness
This is essentially a medical construct, based on a medical diagnosis, and whilst it usually follows that the sicker the infant the greater the demand for nursing care, there are obvious exceptions.For example, the newborn with a cleft lip and palate may not be ill at aU, but could need a gieat deal of nursing time and e x p e r tis e to g et fe e d in g te c h n iq u e s established.Sim ilarly the nursing effort expended to get a preterm infant suckling on the breast or to reassure and support an anxious parent need bear no relation to the "sickness" of the infant.

Intensity of Nefeds for Nursing C are
This in v o lv es the use o f som e sort of mechanism which uses patient characteristics to predict nursing requirem ents.Some systems for classification or categorisation of infants with a view to estimating nursing workload have recently been described in the literature.The one which appeared to be most relevant to local neonatal practice was that which originated in work commissioned by the Northern Regional Health Authority in the UK in 1982.The dependency scale which evolved, known as the Northern Neonatal Network (NNN) scale, (see Table 1) has been used to estimate staffing needs on the basis that infants can be categorised to give an indication of nursing care required.(NNN, Northern Regional Health Authority 1993:539).

Complexity of Tasks
This is a particularly important aspect of measurement of nursing work for hospital adm inistrato rs since the level o f sta ff employed to provide the skills directly relates to employment costs.This is also a notoriously difficult aspect to measure particularly in the neonatal field.The simplest "task", eg.changing a napkin can, w hen p erfo rm ed by an o b serv an t and well-inform ed nurse, yield much valued inform ation -renal and gastro-intestinal function, neurological status etc.Similarly, not all tasks are visible -how does one measure decision making?Newborn care is a very dynamic process and nurses are often required to initiate treatment procedures before medical staff are available for consultation.A recent and com prehensive analysis of nursing activities in the Mersey Regional Neonatal Intensive Care Unit is described by Williams et al (1993).

Time Taken to Execute Tasks
Subjecting an individual at work to scrutiny by an observer with a stop watch is not a popular exercise.
• The w orker can feel threatened and uncomfortable; conversely the Hawthorne 3. Babies whose whole fluid intake was provided intravenously in the prevbus 24 hours.
4. Babies with a stoma or a pleural, peritoneal, or urethral drain in situ.
7. Babies currently receiving some intravenous fluid.
8. Babies at least partially tube fed in the past 24 hours.9. Babies wrfio have had a fit or apnoec attack (>20 sec) in the previous 24 hours.effect can be observed and work output can improve in quality and quantity.
• There are difficulties in nursing in deciding where a specific task begins and ends -it is not necessarily a discrete entity., • N u rses o ften perform a sin g le task concurrently with others.Nursery nurses have been seen to be bottle feeding a baby, answering the telephone and copying laboratory results into the infants folder simultaneously. •

Task Analysis
A small convenience sample of experienced neonatally trained nurses was selected by virtue of the fact that they were on duty and in charge of Observation nursery on the day of observation.They were observed for periods ranging from four to six hours and activities were sampled at 5 minute intervals and then analysed to determine what percentage of time was spent in each dimension of care.Ethical considerations were addressed as described below.

Intensity of Needs for Nursing
The study was primarily a descriptive survey using nonparticipative observation to record the time spent on nursing interventions.

Ethical Considerations
The observer introduced herself on each occasion to the nurses involved and explained the purpose of the exercise.Nurses were inform«i that there would be no record of names and that the focus was on the duration of care given each infant and not the manner in which it was given.The nurse was given the opportunity to refuse to participate in this exercise. Sampling: A convenience sample from all categories of infants was randomly selected.The selection was influenced by factors such as the position of the incubator in the nursery -the observer wished to have a good vantage point but to be as unobtrusive as possible. Timing: This was continuous for each infant during the period of observation (2,5 -4 hours).All nursing interventions were timed using the same nurses' watch with a second hand -this was done by a single observer.Care was timed with no regard to the level of nurse giving the care.

Data collection:
This included a brief perinatal history, age, weight, and any significant information, the time of commencement and completion of each nursing intervention as well as an abbreviated description of the intervention eg.nappy changing, observations, helping with x-rays etc.

Analysis of Data:
The total time devoted to each infant was divided by the duration of the observation fHjriod to obtain an hourly rate.From this an average hourly rate was calculated for each category of infant.These rates were compared with those determined in the NNN study.

ASSUMPTIONS;
• Certam activities in a neonatal unit take up 100% of the nurse's time during a specific period eg.admission of a baby to the ICU.Since this occurs only once in an average stay of 5-6 weeks this was not included in the observation period.
• Direct nursing care in a neonatal unit does not differ significantly between day and night.

I.Intensity of Needs:
In addition to the difficulties generally associated with the timing of nursing tasks further problems arose in MCN.The "task" is often executed in a fragmented manner and by a multiplicity of nurses.One nurse will put the feeding tubes on top of the incubators, another will put out the bottles containing the feed; one will add the prescribed medication to the feed, another will acmally administer the tube feed.The fiill recording of the feed in the notes might be done by consulting yet another nurse who bathed and changed the baby half an hour before feeding time.
This factory assembly line approach to care is worrying.It has evolved over a period of time marked by a steady erosion of staff numbers without a reduction in the number of infants requiring care.In terms of efficiency and economy of effort it can only be classed as a superb performance; however, for a variety of reasons this system of delivery of neonatal nursing care has inherent potential dangers.For the nurse it could mean a reduction in job satisfaction and consequent "bum out"; for the infant, increased risk of cross-infection and lack of holistic care (see Table 3).A similar process was followed for Categories "C" & "D" infants in Nurseries 2 to 5. "C" category infants have an average hourly rate of 6.5 minutes, with early morning (07h(X)-10h00) rate significantly higher than afternoon and evening rales -8.9 : 4 minutes per hour.This could be anticipated since the in fan ts are bathed and w eighed in the mornings.
"D" category infants demand essentially the same amount of direct nursing care as "C" category, but in our practice there is a considerable amount of nursing time spent on indirect care and education such as Uaising with social workers and ensuring parents can cope with the infant on discharge.

N ursery 6 (O bservation Nursery)
A ttem p ts to m easure d irect care were abandoned.The nursing workload was certainly heavier here than in other areas but siiKe the purpose o f the timing was primarily to verify the NNN scale of category of infant, it seemed that more value could be derived from an analysis of total workload.(See Table 2) F a c to rs c o n trib u tin g to th e increased w orkload in this area: 1.The infants do not usually stay long in this area.This means that two of the most tim e-consum ing nursing activitiesnamely admission and discharge occur far more frequendy here.A rough and not always complete record is kept of arrivals and departures by the nurses them selv es to fa c ilita te telep h o n e e n q u irie s c o n c e rn in g in fa n ts whereabouts.On some occasions there were as many as 24 adm issions or discharges within 24 hours recorded.
An attempt to measure how much nursing time was devoted to these activities was made by asking the trained neonatal nurses who had considerable experience in th is area to com p lete a sim ple questionnaire .The nurses were asked to ring w hat they considered was the average time (nursing time) spent on several different types of admissions and discharges.The times most consistently ringed were as follows:  The increased workload of the registered nurse (RN) particularly in ICU is made possible by using carefully selected enrolled nursing assistants (ENAs) to support and help the RN.This appears to be working extremely well in an atmosphere of mutual trust and respect.
Subjective accounts o f w hat constituted excessive nursing workload were given by several RNs.The main factor mentioned related to instability of the infant's condition; others m entioned w ere quality o f help available (neonatal experience was rated much more important than level of nurse).Quantity of staff was also important, but inexperienced "pairs of hands" were judged to be of little value in a crisis.
L im itations of the study -the exploratory nature which examined many aspects of care caused the scale of investigation to be small.The convenience sample makes findings not able to be generalised.

Conclusion and Recom m endations
This study underlined the difficulties of measuring nursing workload in a neonatal settin g .H ow ever, it w ould seem that classification of infants into two main groups i.e. high dependency care and low dependency care using the modified NNN scale is a better means of allocating members of nursing staff to babies than the conventional formula of nurses per cot."It is babies, not cots, that generate work" (NNN 1993:543) It should not be difficult or expensive to extend the activity sampling time period to 24 hours and expand the scope of the task analysis to include aU levels of staff if the self-reporting method of William et al (1993: 535) was utilised.This would involve each nurse marking off on a prepared work card the time she spends on each activity.Since at any given time each nurse is caring for a single distinct group o f infants (O b serv atio n nursery excluded) and the local hourly rate of direct care is known, it should be possible to calculate the rest from the work sheet.
Alternatively, all non-direct care can be based on cot occupancy, with only direct care being calculated by dependency classification d e sc rib e d by R hys H earn (G o ld sto n e 1980:238).Both of these methods merit a little more examination concerning their validity as a measurement of neonatal nursing workload in a tertiary level hospital in a developing country.
A perfect m eans o f m easurem ent w ill probably elude even the most dedicated researcher, but it is essential that in a situation with shrinking economic resources and clear demands for accountability that some means is devised to justify the pleas for more nurses.Pleas are made to hospital authorities by those responsible for the care of small vulnerable infants and who know the tragic consequences of too many sick babies and too few nurses.

A C K N O W L E D G E M E N T S
Thanks to Mrs M Venneulen and Professor A F Malan of Groote Schuur Maternity Centre for their encouragement and to all my Nursing c o lle a g u e s w ho so p a tie n tly and good humouiedly endured the scrutiny.Thanks also to Mrs A van der W alt, Deputy Director: Nursing, Groote Schuur Hospital for permission to publish.
10. Babies currently weighing between 1 OOOgm and 1 750 gm.Each baby is to be categorised by the first (that is the towest numbered) defining condition.IPPV: intermittent positive pressure ventilation; IMV: intermittent mandatory ventilation; CPAP: constant positive airway pressure.Reference: (1993;68:539-543.) percentage of time spent on administration Is because one nurse Is generally responsible tor ttiis as it relates to the entire MCN Low percentage ot time spent on support is a favourable consequence of the ■Carl system" of centralised stoddng and re-ordering o( consumable stores at GSH High percentage of time spent on personal can be attrfcuted to the four hour continuous observation period often Indudng a meal and or tea breaic and is thus not an accurate reflection H lai«n over a 12 hour shift.

TABLE 3 ; TIMES SPENT IN CARE GIVING CATEGORY "A" (Intensive Care) Infant Observation Period in Mins. Total time spent in mlns.
A verag e rate p e r h