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Workload measurement in a community care program.

NURSING WORKLOAD measurement has been used to determine staffing requirements and skill mix on a specific acute care hospital unit. There are various types of workload measurement that use task measurement, direct or indirect time measurement, patient dependency, or intensity of care required when determining appropriate skill mix required or nurse-to-client ratio. Many workload tools were developed and tested in an acute care setting and are not directly transferable to a community care (home care) program. A workload measurement tool developed by the community care program at WestView Health Centre (Stony Plain, Alberta, Canada) sought to address the unique challenges of determining workload while caring for clients in their own homes.

The delivery of services in the community is a expanding area of health care due to the rapid shift from institutional to community care. However, limited attention has been given to accurately predict or measure nursing resource utilization (O'Brien-Pallas et al., 2001). As well, links between complex client demands, the organization of nursing work, and nurse resource utilization have not been widely examined (Mitchell & Shortell, 1997). Little is known about how managers make decisions regarding staffing, continuity of care provider, and caseload influence of nursing utilization (O'Brien-Pallas et al., 2001).

There is no common definition of nursing workload found in the literature but it is important that any definition be large enough in scope to encompass all aspects of nursing work (Morris, MacNeela, Scott, Treacy, & Hyde, 2007). Nursing work includes both the work that nurses carry out on behalf of a client and non-patient work that is often related to the organization or setting in which the nurse works (Morris et al., 2007). Care coordination in community is a resource-intensive component of client care that is often difficult to quantify but affects clinical outcomes of patients (Cloonan & Shuster, 1990).

The ideal workload measurement tool would be a valid and reliable process/model/system that measures nursing work by including the many factors that influence nursing workload and affect client outcomes (Canadian Nurses Association, 2003). In addition, it should include nurses who are providing the care and ability to interpret workload data based on their actual experience (Canadian Nurses Association, 2003).

The measurement of nursing workload grew out of the need to forecast the number and mix of professionals needed on a daily basis in hospitals (Swan & Griffin, 2005). In community care the need to predict staffing is not required as there is not the same urgency. Instead, there is a need to balance a case mix; provide for the ability to respond to urgent, unpredictable client needs; and consider geographical distances traveled. The ability to prevent overload on individual staff members may have the added benefit of contributing to staff retention and satisfaction by ensuring equity. Ellenbecker, Neal-Boylan, and Samia (2006) noted that if job satisfaction among community health nurses is to be achieved, then the stress and workload demands on nurses must be addressed while facilitating autonomy of practice and supporting clinical decision making.

Neal-Boylan (2006) identified three stages that community care nurses progress as they become proficient in the delivery of home based care.

* Stage 1. Nurses have initial feelings of being overwhelmed when confronted with the logistical and clinical aspects of patient care. Progression towards stage 2 is seen over time as confidence develops and experience grows.

* Stage 2. Nurses typically feel more confidence in applying clinical knowledge, but the logistical aspects of care remain difficult and support from managers and other nurses is important.

* Stage 3. Nurses perceive themselves as autonomous in both the clinical and logistical aspects of providing home-based care.

The ability to manage workload within any setting would be in part determined by the stage that each nurse has progressed through and can be reflected in a subjective audit tool. Following implementation of a case weight system with community, Ferrant (2004) found the following benefits were realized:

* Novice clinicians can gradually acquire case management skills.

* Patient care was improved by matching patients with the clinician's skill level.

* By assuring that each nurses' caseload is fair and equitable, the system has contributed to lower levels of nurse burnout, promoting retention.

* The system provides a measurement tool that helps track costs per episode of care and overall cost savings by assuring correct staff are working in the various situations.


WestView Health Centre is a rural facility located in Stony Plain, Alberta, Canada. The health centre provides health care to approximately 75,000 residents in the surrounding community (Statistics Canada, 2006). Considered an integrated primary health care site within the larger Capital Health region, services available include community care, hospital-based acute care, public health, emergency care, maternity care, integrated rehabilitation, mental health, and continuing care. The area covered by the Stony Plain Community Care office extends from the western edge of the city of Edmonton and is approximately 52 km long. Within the area served, approximately 50% of the population lives in a city or town setting (Statistics Canada, 2006).

Community care service delivery in the Stony Plain area has changed over the years from its inception. In the beginning, the program provided housekeeping services, foot and nail care, personal care, and some health monitoring targeted at the elderly living in their own homes. As the program evolved and acute care hospital pressures became greater, the program began changing. The downsizing of beds in hospitals in the mid '90s led to larger numbers of individuals being discharged sooner to their own homes and requiring more short-term acute health care. In addition, more people with end-of-life diagnoses who required complex care began to choose to die at home rather than in facility. Both of these trends led to greater numbers of individuals being admitted to the community care program.

While the Community Care program has experienced many changes since regionalization of health care, the underlying philosophy to maintain individuals as long as possible in their own homes by enhancing their self-care abilities and providing support both emotionally and physically has not changed. The primary focus of the program now is to provide health services to individuals and access to a social worker if there is financial or housing assistance required. The health services are provided in a number of ways such as traditional home visits, drop-in healthy aging clinics, an ambulatory care clinic, in-home personal care and respite, access to facility respite, health monitoring and education, and an adult day program.

Using the concept of single point of access for ongoing community care, the program currently has a caseload of 650 clients. These clients are managed by 9.46 FTE of registered nurses (RN) and 3.74 FTE of licensed practical nurses (LPN). The program also offers an ambulatory care clinic that delivers care for individuals and has an average of 650 visits per month. The visiting nurses carry a mixed caseload that includes individuals requiring ongoing health care monitoring and/or regular personal care, acute short-term interventions (wound care, teaching), and palliative end-of-life care. An assessment team is responsible for functional assessments using a standardized assessment tool that allows for determining care levels required and allocates resources according to assessed needs. The Community Care program divides service delivery into five program categories: long term (admission greater than 3 months), case management (primary care need is personal care assistance, intermittent health monitoring, education), palliative (possible death within 3 months), short term (admission less than 3 months), and community care clinic (ambulatory care, short-term or regular intermittent interventions).

The Community Care program has experienced an increased number of clients it provides service to and an increased acuity. The program has grown by 26% since 2001 and needed a way to objectively measure caseload requirements between individual nurses. Based on a local standard of 50 clients for 1.0 FTE, the program manager determined the number of clients for each staff member. However, due to the mixed caseload and distance traveled to client homes, it was necessary to objectively quantify how much care each client required. A method of determining the most appropriate case manager for each client was also required. Clients who have unstable health conditions requiring frequent and complex intervention may be more effectively managed by a RN. Those clients whose care needs are stable and predictable may be more effectively managed by a LPN. The need to develop a standardized audit tool to help quantify workload, determine the most appropriate case manager, and incorporate the unique challenges associated with home-based care was identified. The tool could also be used to ensure that each nurse would have a mix of all care needs within her/his caseload, helping to equalize work among the team members.

Workload Assessment Tool

The tool developed was based on an understanding of what it means to be a community care nurse and the bundle of services available to the client. It collects basic demographic information and includes diagnosis, which program category the client falls into, and whether a baseline assessment of functional ability has been completed or is required. In addition, the Regina Risk Inventory Tool (RRIT), the standardized Mini-Mental Status Evaluation, and an assessment of homebound status are requested. Each client is assessed using the following categories to determine an intervention weighting:

* Identified nursing need.

* Frequency (yearly, quarterly, monthly).

* Length of the home visit (<30 minutes, >30 minutes, >60 minutes).

* How far the client resides from the home office (one way).

* Coordination time required each month (<1 hour/ month, 1 to 4 hours/month, 4 to 8 hours/month, > 8 hours/month).

* Client stability (stable, variable, unstable).

* Client and/or caregiver's coping skill (0 to 1 hour/ month, 1 to 2 hours/month, 2 to 3 hours/month, > 3 hours/month).


Each criterion is weighted by assigning a number to the categories with the lowest score being applied to the category requiring the least intervention. The total scores are then added and a weighting is arrived at indicating the amount of intervention received by the client. For example, an individual who required a quarterly visit (score of 2), of <30 minutes (score of 2), is stable (score of 1), <15 kin from home office (score of 2), with <1 hour coordination time/month (score of 2) and <1 hour of coping intervention (score of 1) would receive a total intervention score of 10 and would be considered to be in the low intervention group. Intervention group rankings were divided into low (score 8 to 13), moderate (score 14 to 21) and high (score >22) (see Figure 1).


Each nurse within the program was provided time to assess each client in their current caseload using the assessment tool developed. The manager then met with each nurse to review the audit tools. Each nurse received a summary of the audit outcomes for her/his clients and the total results were used to balance caseload mix between nurses. During the audit process, it became possible to analyze each nurse's current case mix to determine if the work required could be completed within that staff members' work week. The use of the tool allowed comparison between individual staff members to ensure equality of case mix among staff. It also identified which clients would be best managed by a LPN and which clients required a RN.


The implementation of this tool facilitated improved understanding of work requirements associated with each client on caseload. Previous to the implementation, the only information available was shared caseload numbers. Once an intervention weighting was assigned to each client, the process of determining caseload distribution and staffing requirements became more transparent for all staff. This process contributed to a better understanding in the staff about workload-related issues and most appropriate case mix for each professional. For this process to achieve the maximum potential, it would be necessary to complete this audit on a regular basis to ensure equity of caseload remains among providers. The benefits documented by Ferrant (2004) have not been formally evaluated within this setting.


There are some limitations to the use of this tool. Since each staff member completes the audit tool on her/his own clients, there is the possibility of subjective bias. It is not possible to ensure inter-rater reliability is the same for all nurses. This tool has also not been tested in any other community care programs. It is also important to ensure that the staff feels comfortable the tool will not be used as a performance appraisal document. If there is the possibility of negative repercussions based on their own workload assessment, the likelihood of obtaining accurate results is less likely to occur. In addition the tool is work intensive and is often hard to fit into a usual workday. To be the most beneficial, the tool should be used regularly over the year to identify trends within the program. To date this has been difficult to achieve.

Implications for Future Research

Community care workload measurement is an area that has not received a great deal of attention from nursing researchers. It would be beneficial to develop a workload measurement tool that helps to balance case mix for care providers, determine guidelines for the amount of intervention that is reasonable for a staff to provide, and balance total work required among all available care providers in a specific office location. Further testing of this tool would be beneficial to determine validity and reliability.


The implementation of this tool within the Community Care program has provided valuable information to the staff and manager about program needs, client mix, and methods to quantify the information for program planning purposes. The continued use of this tool will lead to refinement of case mix and professional utilization, and may show benefits in the future for novice nurse growth, staff retention, and satisfaction.$


Canadian Nurses Association. (2003). Measuring nurses' workload. Nursing Now: Issues and trends in Canadian nursing, 15, 1-4.

Cloonan, P.A., & Shuster, G. (1990). Care coordination: A resource-intensive component of home health nursing practice. Public Health Nursing, 7(4), 204-208.

Ellenbecker, C., Neal-Boylan, L., & Samia, L. (2006). What home healthcare nurses are saying about their jobs. Home Healthcare Nurse, 24(5), 315-324.

Ferrant, A. (2004). An acuity-based case weight system for equitable clinician case loads. Home Healthcare Nurse, 22(12), 815-819.

Mitchell, P.H., & Shortell, S. (1997). Adverse outcomes and variation in organization of care delivery. Medical Care, 35(11 Suppl.), 19-32.

Morris, R., MacNeela, P., Scott, A., Treacy, P., & Hyde, A. (2007). Reconsidering the conceptualization of nursing workload: Literature review. Journal of Advanced Nursing, 57(5), 463-471.

Neal-Boylan, L. (2006). Job satisfaction: An analysis of the differences between hospital and home healthcare nurse. Home Healthcare Nurse, 24(8), 505-512.

O'Brien-Pallas, L., Doran, D., Murray, M., Cockerill, R., Sidani, S., Laurie-Shaw, B., et al. (2001). Evaluation of a client care delivery model, part 1: Variability in nursing utilization in community home nursing. Nursing Economic$, 19(6), 267-276.

Statistics Canada. (2006).2006 community profiles. Retrieved January 16, 2008, from data/profiles/community/Index.cfm?Lang=E

Swarm, B., & Griffin, K. (2005). Measuring nursing workload in ambulatory care. Nursing Economic$, 23(5), 253-260.

LINDA CAWTHORN, MN(c), RN, is Project Coordinator for Implementation of Medication Reconciliation, Capital Health, Stony Plain, Alberta, Canada.

LISA RYBAK, BScN, RN, is Community Care Manager, WestView Health Centre, Stony Plain, Alberta, Canada.
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Title Annotation:$uccess $tories
Author:Cawthorn, Linda; Rybak, Lisa
Publication:Nursing Economics
Geographic Code:1CANA
Date:Jan 1, 2008
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