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The purpose of our research was to develop a evidenced-based methodology that could be applied to define how clinical services were staffed to deliver care of the highest quality and built around clients’ needs. Development of the Client Care Needs Assessment Tool (CCNA) appropriate for inpatient mental health was the cornerstone of this methodology.
Commitment to evidence based care requires evidence based decision making. Staffing decisions are critical to achieving quality care. The aim of skill-mix review endeavors is to optimize efficiency and effectiveness (http://www.who.int/management/determining_skill_mix.pdf), that is have the right care by the right provider for the client at the right time. Health care environments across the globe are facing considerable fiscal challenges along with increasing patient acuity and complexity, and a changing healthcare workforce. Matching client need with the appropriate healthcare provider is imperative for providing high quality, safe and cost-effective care.
Previous work in this area has focused on RN/RPN skill mix in general hospitals and medical settings (Blastorah et. al, 2010; Kohr et al, 2012). Frameworks to guide this work include the College of Nurses of Ontario 3 factor framework (Client, Nurse, Environment) (CNO, 2012), Staff Mix Decision Making Framework developed by the Canadian Nurses Association (CNA, 2010), and the Synergy Model developed by the American Association of Critical Care Nurses to determine nursing staffing (Hardin & Kaplow,2005). Applicability of the current approaches and particularly the client care needs assessment tool to mental health is limited. Very little work has been done in this area specific to mental health and an inter-professional team context.
Methods:
The CCNA tool is based on the domains of the Synergy Model (Hardin & Kaplow, 2005) and was developed in two phases: Phase one: guided by a literature review and interprofessional panel development of indicators (Client Care Needs Assessment) for the Synergy Model domains using a modified Delphi approach and an initial pilot of the CCNA on two inpatient mental health and additction units; and phase 2 where the indicators were refined and revised version of the Client Care Needs Assessment was piloted on additional inpatient mental health units.
The final CCNA tool has 13 yes/no questions and 31 indicators grouped under 8 Synergy Model Domains of stability, complexity, vulnerability, resiliency, participation in decision-making, participation in care, resource availability.
Along with the indicators, the process of tool implementation has also evolved over the two phases. The average time required for completion now stands at 13 mins / patient as compared to 45/60 minutes in Phase I. This can be further reduced as staff gain familiarity with the tool. Other outcomes include standard language & framework to define client need across domains in an inter-professional context; defining and measuring constructs, such as impulsivity, across mental health settings; and fostering interdisciplinary knowledge. Consistent with what has been reported by others, there is significant value in the process of assessing clients through the CCNA tool with respect to understanding and strengthening team functioning. While this was not measured objectively in our work, it could easily be quantified in subsequent application. A limitation of our work was the focus on inpatient settings in one hospital. We are now exploring opportunities for testing in outpatient settings and across other organizations.
Conclusion:
Although, further testing of the psychometric properties is needed, the CCNA tool is a promising tool to assess clients in a mental health and addictions setting in a holistic manner. Explicating the needs will allow teams to better align their staff skill mix with the needs of the client population. The CCNA tool can also lead to bette insights into the core competencies needed with the interprofessional team as well as facilitate decision making with respect to staff complements within the interprofessional team. The CCNA tool can be used by itself or as part of a broader initiative on workforce transformation.