Objective: Nursing intensity in ambulatory care is a difficult construct to explain and measure, yet it is a critical workforce issue from a cost and quality perspective. The objective of the study is to define the construct of ambulatory care nursing intensity and to delineate the dimensions that are encompassed within the construct. Gaining consensus from ambulatory care nurse experts is the first step.
Design: A modified Delphi technique was used that included: selection of a panel of experts, mailing of questionnaires, analysis and summarization of responses, and successive rounds of data collection. The Institutional Review Board for Protection of Human Subjects approved the study design and instruments.
Population, Sample, Setting, Years: The population for the study was nurse managers working in a variety of ambulatory care settings nationwide who were members of the American Academy of Ambulatory Care Nursing (AAACN) in 1998. The sampling frame was the membership directory of AAACN. Conceptual Framework and Variables: Perrow's Model of Organizational Analysis (1967, 1972) was used as the conceptual framework. The literature review suggested that nursing intensity encompasses both client needs for care and nurses actions in response to those needs. Four major variables or categories were posited to define nursing intensity: complexity of patient need, complexity of nursing services, capabilities nurses bring to an encounter and the context of care. The term "category" was used instead of dimension to avoid suggesting to participants that the posited categories had already been deemed dimensions prior to this study.
Methods: The researchers developed a questionnaire. The 53-item tool had two sections. The first was designed to gain consensus on the four posited categories. The second section was designed to gain consensus on the unique "features" of each category. Participants could rank each item on a Likert scale from 0 meaning "not relevant" to 4 indicating "very relevant." Categories and features could be added, modified or deleted. Demographic data were also collected. Questionnaires were mailed to a random sample of 211 potential participants. The achieved sample on round one was 80 with 76 usable questionnaires for a response rate of 36%, No follow up of non-respondents was done. In round two, modified questionnaires were sent to all participants with their previous response to each item and the mean response from all respondents to each item. The response rate for round two was 63%.
Findings: Ambulatory nurse manager participants were female, masters prepared, with a mean age of 48.7, over 20 years in nursing and 12.5 years experience in ambulatory care. A method of focused analysis was used to set the criterion for consensus by ranking each item by mean and standard deviation (SD). For example, items were retained if they were deemed to be both extremely relevant (mean above 3.8) and demonstrated high consensus (SD below 0.6). Other items were discarded if the mean showed low relevance (below 1.99) and high consensus (SD below 0.6). Analysis of data led to retention of the four categories, addition of four features and modification of three features. Complexity of patient need and complexity of nursing services were ranked as extremely relevant. Capability the nurse brings to the encounter was ranked as very relevant and the context of care as moderately relevant. The items representing features were similarly analyzed. These items provide rich information about the content of each category.
Conclusions: Nurse experts working in a variety of ambulatory settings achieved consensus in defining the dimensions of nursing intensity using a Delphi design. The four posited categories were confirmed as major dimensions of nursing intensity in ambulatory care. Features of each dimension were delineated. The study was limited by the small sample size and the wide variety of settings and patient populations represented in the study.
Implications: The extreme relevance of the dimensions of patient need and complexity of nursing services needs to be confirmed with larger samples and a variety of patient populations. Replication should occur with specific ambulatory care patient populations who may have more homogenous needs, for example oncology patients or heart failure patients. In addition, replication should be done separately in primary care patient populations where levels of need and complexity of care are extremely variable. Once consensus of the dimensions of ambulatory care nursing intensity is further validated, measurement tools can be devised to aid in planning, staffing, defining staffing ratios, analyzing performance outcomes and determining the cost of care.
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