/ntemmr (.nre ,\‘urrq (1991) 7, 189-190 0 Lon~rnan Group L’K Lrd 1991

EDITORIAL

Managing classification for individualised care

Any good nurse recognises that each patient is a unique individual who requires care designed to meet individual needs for nursing. But for management purposes in matching needs and resources patients must be considered in groups.

When the early work studies of nursing were

done in the late 1950s and 1960s many of the nurses who were aware of them (and many were not) found the reports worrying. The studies were done by non-nurses and were focused very much on the tasks performed by nurses. Could such task-oriented systems of analysis really reflect nursing? Many clinical nurses and nurse administrators thought they could not, and

chose to ignore them, and staff continued to be allocated to wards and units according to custom and other criteria which were not always

rational. In the 1970s there was a desirable trend

towards recognising that some characteristics of patients affected the nursing workload whatever the routine physical activities required. For

example, Khys Hearn and Potts (1977) identified factors such as obesity, confusion, unusual emotional dependence, and communication

difficulties which \cer-e subsequently used to weight the scores for nursing activities required. Since zhe was not a nurse she also involved nurses in deciding what activities were necessar! for a b,tseline level of care.

Since, then increasing pressure on available resour( es for health care has ensured the development of a number of different classifi- cation systems: and clinical nurses can no longer ignore the need liar ‘hard data’ to support ar<gumrnts for resources. Many critical care nurses have recognised that their patients are more ill, older, are transferred earlier and have more ,md more complex interventions than previously, while staff numbers and skill levels remain the same or decrease. Yet the systems designed to identify such discrepancies in other

areas do not fit critical care situations. It is encouraging that clinical nurse managers are working with their staff to design and 11se more suitable workload measurement systems (See

pages 2 14 and 222). Birdsall (19911, in a useful review and discuss-

ion of patient classification. suggests seven ques- tions which must be addressed before assuming

that a nursing classification svstem is effective, as follows:

_ What indirect and non-nursing tinle is built into the system?

- How does the system handle lime for patient and family teaching and emotional suppol‘t’

_ Were time-motion stlldies completed to chech the time value assigned to yome oft he specialised tasks?

_ Were reliability and I alic!it\ stutlies ever

done?

- How was the system adapted 10 the mdi\itl- ual hospital and critical (‘arc ullil and I)\

whon1?

_ lfused f’or slaffing, is the workload realistic . and are productivity measure9 r\aluated?

_ Was the system designed IO cti.lrge tot nursing ser1 ic es?

(Hirdsall. 1 iI!) 1 11. 143)

She also points out that patient (Iassih(ation can be based on nursing, medic~al. or patients needs and illustrates how scores from dif’f’errnt measures can be compared and c 0ml)inetl to

produce overall nursing intenstix scc,res. fat individuals or fi)r the unit.

The use of data available from different kinds of classification systems is particulzrtp important in the Llnited States of America where the diagnosis related group (DKG) into which each patient is classified defines the level of third party reimbursement the hospital receives -- irrespecti\,e of the actual cost of 1 hr patient’s

I X!!

190 INTENSIVE CARE NURSING

hospital stay. With this system nurses quickly realised that the levels of nursing intensity required vary considerably across different DRGs and within single DRGs. Nurses had to take steps to try to ensure that nursing is more adequately included in costing.

With the increased emphasis in the United Kingdom on costing the treatment of patients with particular conditions, in order to allow completion of service provider contracts, the same situation is likely to arise. There are still many people in influential places who fail to recognise that professional nursing is more than the visible physical tasks of providing food, personal hygiene and elimination services, and prescribed medical treatment. The importance or even existence of patient education, anxiety reduction, information-giving, emotional support and other such nursing contributions to patients’ welfare and even survival are often not recognised. Nurses have to find ways to make them more visible so that they are included in resource calculation.

‘The ideal patient classification system of the future will reveal the individual patient’s true nursing costs. Until it is developed, interpreta- tion rests with the astute manager who can use the data to plan and predict future directions’ (Birdsall 1991, ~152-153.)

Now more than ever it is essential, for the sake of patients and staff, to have nurses in critical care who are familiar with both current clinical realities and the use of management data sys- tems, and can hold their own in a multidiscipli- nary and cash-limited service and compete successfully for the resources necessary to pro- vide the care each individual patient needs.

References

Birdsall C 1991 Patient classification. In: Birdsall C (ed) Management issues in critical care. Mosby, St Louis, Ch9 pp 131-154.

Rhys Hearn C, Potts D 1977 The effect of patients’ individual characteristics upon ‘activity times’ for items of nursing rare. International Journal of Nursing Studies 15: 23-30.