In Papers II-IV included in this thesis, the Oulu Patient Classification (OPCq) instrument was tested in an HHC setting. The OPCq is part of the RAFAELA® Nursing Intensity and Staffing system. The RAFAELA® system was developed in the mid-1990s for hospital settings at the Vaasa Central Hospital in Finland (Fagerström, 1999; Fagerström & Rainio, 1999) and is the most commonly used, validity and reliability tested PCS. It has been used for more than 20 years in hospital settings throughout the Nordic countries (Andersen et al., 2014; Fagerström, 1999; Frilund, 2013; Pusa, 2007; Rauhala, 2008).
The OPCq instrument was developed at the Oulu University Hospital during 1991-1993 and is based on the Hospital Systems Study Group (HSSG) instrument. It was modified and implemented at Vaasa Central Hospital in 1995 (Fagerström, 1999; Fagerström &
Rainio, 1999). The RAFAELA® system’s name is derived from the original research team’s surnames: Rainio, Fagerström and Rauhala (Fagerström, 2000; Fagerström et al., 2014;
Rainio & Ohinmaa, 2005). The RAFAELA® system is based on a holistic view of the human being from a caring and nursing science perspective and includes complex caring components (Fagerström, 2000, 2009), person-centered perspectives on each individual’s care needs and a clear focus on nursing staff’s work situation (Fagerström, 2017).
The RAFAELA® system includes three parts:
1. Daily registration of patients’ care needs using the OPCq instrument.
2. Daily registration of actual nurse staffing resources.
3. Periodical determination of optimal NI level using the PAONCIL instrument.
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Daily registration of patients’ care needs using the OPCq instrument
The OPCq instrument is used in the daily registration of patients’ care needs. The first version was developed for use in hospital and specialist healthcare settings. Newer versions have been developed for outpatient units and emergency services (POLIHOIq), mental health services (PPC), operating and recovery rooms and day-surgery (PERIHOIq), and radiation therapy (SÄDESHOIq) (FCG). While a specific version for use in HHC has not yet been developed, as part of this actual research study the OPCq instrument was modified to better suit an HHC setting.
In the OPCq instrument, nursing care and care needs are organized into the following six sub-areas: 1. Planning and co-ordination of nursing care; 2. Breathing, blood circulation and symptoms of disease; 3. Nutrition and medication; 4. Personal hygiene and secretion;
5. Activity, sleep and rest; 6. Teaching, guidance in care and follow-up care, emotional support. The NI can range between 1 to 4 points in each area. Points for each sub-area are added up and can range between 6 to 24 points per patient. Using the OPCq instrument, nurses measure the six sub-areas at regular intervals. A=1 point and indicates a patient who manages more or less on his/her own; B=2 points and indicates a patient who is sometimes in need of care, in partial need of help; C=3 points and indicates a patient in repeat need of help, complex situation; D=4 points and indicates a patient in constant need of help, completely helpless, very complex situation (Fagerström & Rainio, 1999).
Based on a total score, patients are classified into five groups. Category 1: 6-8 raw points (minimal need for care); Category II: 9-12 raw points (average need for care); Category III: 13-15 raw points (more than average need for care); Category IV: 16-19 raw points (maximum need for care); Category V: 20-24 raw points (intensive care required) (Fagerström, 2009; Rauhala & Fagerström, 2004).
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Daily registration of actual nurse staffing resources
A unit manager registers which nurses have worked with which patients on a unit in a resource register each day. The OPCq score is divided by the number of nurses on the unit, yielding daily NI per nurse, which describes the productivity of nursing care on the unit (Fagerström & Rainio, 1999; Fagerström et al., 2000b).
Periodical determination of optimal NI level using the PAONCIL instrument
The Professional Assessment of Optimal Nursing Care Intensity Level (PAONCIL) method (Fagerström & Rainio, 1999; Fagerström, Rainio, Rauhala, & Nojonen, 2000a; Rauhala &
Fagerström, 2004) is based on patients’ actual care needs and staff’s work situation and trust between staff and nurse leaders (Fagerström, 2017). The optimal NI level is when a nurse working on a unit can manage the standard of good nursing care determined for that unit without compromises. The optimal level is determined periodically for each unit during a period of at least 3-4 weeks. After each shift, each nurse records on a form a numerical/scale estimate of the extent to which he/she had the time to meet patients’
care needs. The scale ranges from -3 to +3, with zero considered optimal and indicating that the number of nurses is in balance. The level of nursing care intensity is: 3 = very high, 2 = high, 1 = fairly high, 0 = optimal level, -1 = fairly low, -2 = low and -3 = very low.
Each nurse makes an overall assessment of nursing resources, that is whether nursing resources have been sufficient in relation to patients’ needs that day. By using the NI score per nurse as an independent variable and the PAONCIL score as the dependent variable (the same day), the results can be analyzed using linear regression analysis.
The implementation process of the RAFAELA® system
The Association of Finnish Local and Regional Authorities owns the RAFAELA® system, and all training and license systems are managed by the Finnish Consulting Group Ltd (FCG) (Finnish Consulting Group, 2017).
The FCG is responsible for introducing the RAFAELA® system and for training nurses in classification. All nurses on the units using the system are presupposed to have taken part
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in an introductory educational program. After a test period of 2-3 months, which includes daily classification of NI using the OPCq instrument, parallel classifications occur with about 100-150 patient cases for about 2 months. After the parallel classifications reach at least 70% agreement, the calculation of optimal NI-level with PAONCIL assessment can start (Figure 1). In the papers included in this thesis, the research was limited to the implementation of the first, second and third phases of the system.
Figure 1: Implementation process of the RAFAELA® system, Frilund and Fagerström, 2009, (reprinted with permission from the authors).
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