**6. Topics for further research**

We believe that there is scope for further investigation of the points below to enable the al‐ gorithms constructed for this study to reflect reality more accurately.

#### **6.1. On nursing intensity**

Given that it is based on subjective observation, the concept of nursing intensity is lack‐ ing in objectivity. Evaluation of patient nursing intensity was carried out on the ward studied by highly experienced nurses. Fixed evaluation standards exist on certain wards and confidence is high with respect to the replicability of judgments on those wards, but it is clear that these standards differ from one ward to the next. In order to make clear what factors enter into evaluations relating to nursing intensity, it is necessary to secure methods of evaluation of patient condition that use phenomena observable by anyone, with objective indicators such as 'how many drains have been inserted.' We believe it is necessary to investigate objective indicators to replace nursing intensity, or to attempt to effectively quantify nursing intensity.

#### **6.2. On the collection of patient condition information**

Since there is a time-lag between actual patient condition and the collection of patient condition information, there may be some margin of error in estimated care times. The patient condition information used in this study was based on information gathered at about 10:00 a.m. during the day shift. Information on patients who underwent surgery or other invasive procedures during the day shift and whose nursing intensity changed was incrementally updated and adjusted appropriately. The reason for carrying out the evalu‐ ation at 10:00 a.m. was simply that this was a convenient time from the point of view of the running of the ward, and in spite of the fact that patients' conditions were actually changing hour by hour, care time was only estimated for one shift at a time. In the present study, we regarded this as a limitation about which nothing could be done, but we believe that it will be necessary to carry out further investigations in the future, as de‐ velopments in IT systems within institutions make it possible to accumulate information concerning changes in patient condition in real time.

#### **6.3. On the statistical values for numbers of patients on the ward**

There is a need to calculate averages and variances for changes in number of patients on the ward over a relatively long period. For this study, averages and standard deviations for numbers of patients on the ward were calculated using data from a short-term time study and cannot be used as population means with any confidence. But when long-term changes in numbers of patients on the ward are used, it has to be borne in mind that numbers of pa‐ tients on the ward fluctuate markedly during holiday periods such as New Year and the summer O-bon Festival, on weekends, and at times when conferences attended by large numbers of doctors are held.

#### **6.4. Handling skewed values**

As mentioned in 3.3.2, data relating to anomalous tasks deviated from normal distribution and was therefore excluded from the present analysis. However, it is a fact that nurses may carry out duties on the ward in the morning and undertake anomalous tasks such as attend‐ ing meetings in the afternoon. Such anomalous tasks occur in a certain proportion through‐ out the year and a special distribution, different from those of ordinary tasks, must be assumed for them. We believe that we need to improve the accuracy of our simulation by actively seeking to include data concerning unusual phenomena as variables.

#### **6.5. Seasonality**

2) We constructed simulation algorithms combining the results under 1) with information accumulated over an extended period on the length of hospitalization and patient condition

We believe that there is scope for further investigation of the points below to enable the al‐

Given that it is based on subjective observation, the concept of nursing intensity is lack‐ ing in objectivity. Evaluation of patient nursing intensity was carried out on the ward studied by highly experienced nurses. Fixed evaluation standards exist on certain wards and confidence is high with respect to the replicability of judgments on those wards, but it is clear that these standards differ from one ward to the next. In order to make clear what factors enter into evaluations relating to nursing intensity, it is necessary to secure methods of evaluation of patient condition that use phenomena observable by anyone, with objective indicators such as 'how many drains have been inserted.' We believe it is necessary to investigate objective indicators to replace nursing intensity, or to attempt to

Since there is a time-lag between actual patient condition and the collection of patient condition information, there may be some margin of error in estimated care times. The patient condition information used in this study was based on information gathered at about 10:00 a.m. during the day shift. Information on patients who underwent surgery or other invasive procedures during the day shift and whose nursing intensity changed was incrementally updated and adjusted appropriately. The reason for carrying out the evalu‐ ation at 10:00 a.m. was simply that this was a convenient time from the point of view of the running of the ward, and in spite of the fact that patients' conditions were actually changing hour by hour, care time was only estimated for one shift at a time. In the present study, we regarded this as a limitation about which nothing could be done, but we believe that it will be necessary to carry out further investigations in the future, as de‐ velopments in IT systems within institutions make it possible to accumulate information

There is a need to calculate averages and variances for changes in number of patients on the ward over a relatively long period. For this study, averages and standard deviations for numbers of patients on the ward were calculated using data from a short-term time study

gorithms constructed for this study to reflect reality more accurately.

(nursing intensity).

240 Advances in Discrete Time Systems

**6. Topics for further research**

effectively quantify nursing intensity.

**6.2. On the collection of patient condition information**

concerning changes in patient condition in real time.

**6.3. On the statistical values for numbers of patients on the ward**

**6.1. On nursing intensity**

In this study, as we explained under 'Method,' only simulations of day-shifts on weekdays were carried out and we were unable to accommodate the special systems in force on week‐ ends and at the holiday times mentioned above. Under these special systems, the numbers of nurses on duty and of patients on the ward fluctuate considerably. Because this greatly affects task times, we believe that there is room here for future investigation.

#### **6.6. On the roles and level of experience of nurses**

We have not incorporated into our simulation the difference in function of nurses such as team leaders, who head and support a team rather than taking responsibility for patients, or nurses that have responsibility for a small number of patients and carry out management tasks along‐ side these duties, as is very often the case with ward supervisors. We assumed for the purpose of the present simulation that all nurses were nurses whose actual work involved being re‐ sponsible for patients, but in fact there are nurses who perform their roles in different ways. In addition, each year there are new recruits who need constant guidance from experienced nurses. They may, after some months, be able to cope with basic tasks, but they still have limi‐ tations, such as not being able to take responsibility for patients whose condition is severe. Fur‐ ther investigation of a methodology that will reflect this state of affairs is needed.

#### **6.7. Comparison with the real world**

It is not possible at this stage, but an evaluation that compared simulation results with reali‐ ty would be the most reliable form of evaluation. In recent years, computer systems such as ordering systems, distribution systems, and electronic patient charts have been actively adopted as hospital information systems, and even more widespread use of IT→it can be ex‐ pected in the future. We believe that if it becomes possible to collect task time data without committing large amounts of effort and funding, as required for time studies at present, this is an approach that must be investigated.

that this has great significance for the improvement of nursing care. We are entering an era when patients are expected to draw sharp distinctions among hospitals. As a result, more and more hospitals are increasing the number of their private rooms, where pa‐ tients can spend their hospital stay in privacy, and are giving thought to the appearance of the hospital's interior and the richness of its amenities. But we believe that what is more important to patients than the physical elements of the institution is that they should be able to receive care that they are satisfied with in an atmosphere based on a re‐ lationship of trust with the medical personnel. Sickness is a special condition, and pa‐ tients need warm-hearted support at all times. The nurses, who spend more time in contact with the patient than any other medical personnel, have a particularly large role

Investigation of a Methodology for the Quantitative Estimation of Nursing Tasks on the Basis of Time Study Data

http://dx.doi.org/10.5772/51014

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In the present study we analyzed only the day shift, but we believe that by constructing a virtual ward environment that takes other shifts into account and carrying out simulations, it would be possible to show the relationship between task time and nurses' fatigue. It has been pointed out that symptoms of fatigue among nurses are greatest after the evening shift and that where the night shift is concerned there is considerable fatigue before the shift be‐ gins. There is concern that the physical and mental fatigue of nurses on the night shift has a negative effect on their work. Attempts have long been made to reduce the burden on nurses and to establish an efficient nursing system. One notable example was the introduc‐ tion of the two-shift system, but no reference has been made to investigation of specific as‐ pects of this working system, such as how its merits and demerits are related to the characteristics of the ward. It is important to re-investigate nurses' work systems, including

In this study we chose pattern of nursing intensity as the clinical path and, having fixed pa‐ tient severity as a definite condition, it was possible to make a preliminary calculation of ac‐ tual nursing task times. In recent years, much has been made of efficiency of treatment, and an increasing number of institutions have introduced the clinical path as a specific method‐ ology. Among city hospitals and privately run general hospitals, there are institutions and wards that have almost completely adopted clinical paths, and that have been successful in the management of planned admission with almost no variance. We believe that in hospital institutions like this, it will be possible to effectively apply patterns of change in nursing in‐ tensity to items such as preliminary calculations of nursing personnel costs, which have a

We feel that a combination of the experimental results derived from virtual environments as described in this study and other information will be helpful in the management of nursing

to play, and are at the forefront of ensuring customer satisfaction.

*7.2.4. Link between patterns of change in nursing intensity and clinical path*

*7.2.3. Level of fatigue*

conditions such as these.

great influence on hospital management.

tasks suited to various goals.
