GRASP Workload Nursing Measurement System at end of life

Abstract

The purpose of this quality improvement initiative was to analyze how nurses record their workload in the GRASP Workload Measurement System and document the end-of-life nursing care provided to imminently dying patients. The analysis was done in conformity with the Comfort Measures Order Set in our hospital. Nursing documentation was examined (n = 4 patient records) covering 15 oncology nursing shifts. Nurses are expected to complete the GRASP tool after each shift for all the patients in their care. It is presumed that nurses’ workload data will be reported accurately and reliably, as well as interrelate with their nursing documentation. Workload audits are conducted routinely to ensure accuracy. Interrater Reliability Monitoring was used to analyze the degree of agreement between the ratings performed on the audit of the completed GRASP tool and the nursing documentation on end-of-life care delivered. The GRASP compliance rate was 66.6% and GRASP-documentation accuracy rate was 60–70%. These observations were below the established target of 90%. The results provide insight regarding any gaps between documentation and GRASP at end of life.

INTRODUCTION AND BACKGROUND

GRASP methodology was designed in 1980 at Grace Hospital in the United States (Hadley et al., 2005). By 1987, many hospitals in United States, Canada, and the United Kingdom adopted this methodology as an automated tool for work measurement (Hadley et al., 2005). GRASP Workload Measurement System (WMS) is defined as a software standard system that measures, collects, and analyzes nursing workload by measuring each nursing task (Qureshi et al., 2019). Nursing workload is defined as direct and indirect patient nursing care, as well as professional development activities in a workplace, that are quantified in time (Alghamdi, 2016). Hospital management and senior leadership and the Ministry of Health and Long-Term Care, in Ontario, have a great interest in GRASP WMS to appraise the cost of healthcare delivery (Registered Nurses Association [RNAO], 2005).

Identifying accurate nursing workload data assists an organization to understand the nursing work, make decisions on patient’s cost during a hospital stay, assess nurse/patient ratios, and document the time it takes a nurse to perform a particular care task or activity. As well, it helps to determine the needed workforce and financial resources required to meet patients’ needs (Ferguson-Paré, & Bandurchin, 2010; Mittman et al., 2008; Qureshi et al., 2019; RNAO, 2005; Sunnybrook Health Science Centre [SHSC], 2015). The GRASP tool influences internal decision making and determines the economic value and budget impact on new treatments and procedures, research, and quality and risk management initiatives (Mittman et al., 2008; Qureshi et al., 2019). Misreported data results in inadequate funding that subsequently affects the quantity and quality of healthcare services (Hunter & Murray, 2019). GRASP WMS benefits the healthcare system and government by creating a common standard for measurement of nursing workload, thus assisting decision makers in assessing and determining the scope and costs of nursing patient and non-patient care, analyzing the nursing workforce resources, and performing an economic evaluation to define hospital funding formula (Mittman et al., 2008; SHSC, 2015).

In our organization, current policy states that nurses are accountable for completing GRASP as part of their job description (SHSC, 2015). The GRASP tool is to be completed for each assigned patient prior to the completion of a nurse’s shift. It is expected that workload data will be reported accurately and reliably as part of the daily nursing duties.

To ensure the unit’s ongoing adherence to the GRASP completion practice, weekly audits of 10% of the units’ census are conducted on a rotating basis by either the nursing educator/advance practice nurse or the unit point-of-care nurse. Through the identification of inaccurate interpretation and/or selection of the workload indicators, we can identify the need for additional training and education of the nursing staff. Furthermore, these audits ensure the GRASP tool indicators represent the nursing care skills on the unit. It is considered best practice to have each unit’s valid workload instrument reviewed every 18 months to ensure ongoing reliability and validity. This practice sets the time to review and adjust any items on the instrument to better reflect changes in the care provided by the nurses to the patients on the unit. The standard compliance target goal is set at 90%. However, our organizational average compliance and accuracy remains at 53.13%.

Knowing that quality end-of-life (EOL) care is an integral part of healthcare, our organization developed a corporate wide initiative called, Quality Living and Dying. This initiative aims to ensure dying patients and their families receive the highest quality of care, which is well described by Stilos et al., (2016). The initiative includes a standardized approach to EOL care and an order set which also outlines the nursing assessment and management of common EOL symptoms. The order set was built using Freeman’s (2013) framework, "CARES".

Currently, the GRASP tool does not have a designated section for EOL care needs. The GRASP tool indicator consists of various categories that nurses are expected to navigate through and capture all the items that apply to each of their patients. The categories include: Assessment, Skin & Wound Care, Pain, Diagnostic Procedures, Planning/Counselling/Teaching, Nutrition, Elimination, Hygiene, Activity/Mobility, Respiratory, Chemotherapy (for the oncology units), Medications/Fluids, Patient Safety Management, Treatments/Procedures, Patient Transportation, Monitoring and Evaluation, and Consultation/Collaboration.

PURPOSE

The purpose of this quality improvement audit initiative was twofold: to examine oncology nurses’ completion and accuracy of the GRASP tool as it pertains to the organization’s workload standard practice at EOL, and to understand and evaluate oncology nursing workload compliance and accuracy of the postmortem care provided. Nurses’ awareness of the value of capturing their workload has been noted to be suboptimal. We were optimistic that the audit would identify areas in need of improvement and assist us in increasing the accuracy in recording of the data.

METHOD

A quantitative approach was used in this quality improvement initiative. The records of oncology patients who were on the CMOS were examined through the lens of GRASP WMS and nursing documentation. The nursing documentation in each patient’s healthcare record was examined (n = 4), which covered 15 shifts. GRASP compliance was measured and Interrater Reliability Monitoring (IRM) was used to audit the documentation and GRASP accuracy. IRM determines the degree of agreement between the ratings performed on the audit for the completed GRASP tool and the nursing care documentation in the patient record for the same patient. IRM was completed by EC (one of the authors), who is a nurse experienced in completing this task. Each workload data entry was compared to what was documented in the patient’s care record for that shift. Analysis of the 15 shifts focused on EOL nursing interventions to identify whether they were both GRASPed and documented (for example, Pain Assessment In-depth, Dying Patient – Comfort Care Assessment Patient/Family, and Post Mortem care). Additionally, the EOL documentation and the GRASP audit were divided in two parts, before and after death.

RESULTS

The results showed that the oncology nurses did not meet the organization’s expected target rate of 90%. Of the 15 shifts analyzed, GRASP and nursing documentation was completed 10 times giving a compliance rate of 66.6%. Completion accuracy for the 10 shifts (as it is seen through the IRM) for those EOL care patients was 60–70%. It is important to note that GRASP and documentation are independent of each other, but are equally important for different reasons.

The selected, documented and GRASP items must be reflective of the care or interventions provided to the patient. Throughout the 10 shifts, 34 nursing interventions were documented in the chart, but not GRASPed, and 30 nursing interventions were GRASPed but not documented in the chart. Furthermore, the audit revealed that EOL care nursing interventions and postmortem care are documented in charts only 42–45% of the time, while GRASP audit showed that GRASP was completed for those interventions 27–29% (see Figure 1).

Figure 1.

Further scrutiny of the nursing interventions highlighted the following common interventions: assessment and management of pain, shortness of breath, agitation, and spiritual distress. The use of the Continuous Ambulatory Analgesic Delivery pump including the set-up, management, and removal were also acknowledged. In addition, items that are not limited to EOL were identified such as suctioning; repositioning; oral care; and subcutaneous port insertion, maintenance, and removal.

The analysis of the four charts of deceased patients revealed the postmortem activity and additional nursing interventions completed (see Figure 2). Patients were screened for organ and tissue donation and given general postmortem care while emotional support was provided for the family during this period. Of particular relevance was the observation that nurses only captured the postmortem care in 42% of the nursing documentation, and 29% in the GRASP tool, despite it being a compulsory nursing task at EOL.

Figure 2.

DISCUSSION

GRASP compliance and accuracy was 66.6% in our audit review. Although the rate was higher than the current hospital average of 53.13%, it is still considered low. Having two concurrent tasks to complete at the end of a shift can be daunting for an oncology nurse after an already busy clinical day. Eliminating the duplication of work and transitioning to one mandated standardized tool that integrates nursing documentation and nursing workload could likely resolve this issue (Michaelson et al., 2017). Oncology nurses have noted that “time constraint was seen as a challenge” when faced with competing priorities (Michaelson et al., 2017, p. 387). In addition, conducting a qualitative component to this work will help get to the ‘root of this issue’. It may be that nurses do not fully appreciate the value of completing GRASP and how that impacts their current workload and future prospective staffing. This barrier has been noted previously, “that in-depth understanding of GRASP resulted in staff adherence to complete the tool and staff engagement” (Michaelson et al., 2017, p. 386).

Routinely, oncology nurses are reminded that if the government does not receive reliable and accurate information from the hospital regarding the costs of the healthcare services provided, the result is inadequate funding in the future. Consequently, this will affect the quantity and quality of healthcare services (Hunter & Murray, 2019). For that reason, nurses need to advocate for their profession, highlighting its true contribution to the publicly funded healthcare system. Their adherence to WMS and recording the accurate number of hours worked will quantify nursing work and will provide valuable workload information (Ministry of Health and Long-Term Care [MOHLTC], 2008/2009). This will help to ensure staffing and the provision of safe and high-quality nursing care; increase productivity, nurses’ satisfaction, and empowerment; and decrease turnover and work stress (Alghamdi, 2016).

A notable limitation in this work was the difficulty in deciphering whether some of the non-completion of GRASP was due to an agency nurse or a Nursing Resource Team staff member caring for the patient on a shift. Both are required to complete their nursing workload using a designated login and password. If they are unfamiliar with the GRASP tool, assistance can be sought from another nursing colleague.

NEXT STEPS

The results of this quality improvement initiative will be disseminated to nursing managers, leaders, nursing council, and nursing staff on the units where these patients resided. An overview about GRASP software and workload measures expectations will be reviewed with oncology nursing staff. Reviving strategies such as huddles, staff meetings, and one-to-one discussions on the unit will also be implemented to help engage nursing staff in improving compliance and accuracy (Michaelson et al., 2017).

Once the patient dies, the nurses’ role is one of the postmortem care. The postmortem nursing care is standardized across our organization. It includes preparing the patient for viewing by the family, supportive care of the family during the viewing, ensuring proper identification of the patient prior to transport to the morgue or funeral home, and gathering the patient’s belongings for disposition. However, our audit shows that the postmortem care was not entirely captured in the EOL phase of a patient’s journey. This gap could be easily remedied through highlighting the protocol for EOL care and the expectation of the nurses’ role in that care. Nurses must recognize that this aspect of the patient’s care is just as significant and must be captured routinely, as it is a specified dedicated time.

Sustaining quality EOL care can be difficult. Through sharing the results of this audit with oncology nurses we aim to influence their accuracy and comprehensiveness in completing the GRASP tool and their documentation practice regarding the EOL care they provide. Having this information allows a nurse to reflect upon their practice, feel a positive sense of accomplishment, and see an opportunity to enhance the performance of a team (Michaelson et al., 2017). A vital change that could improve EOL nursing documentation is to align EOL interventions within the GRASP application, where possible. Our team is planning a subsequent audit later in the year to reevaluate those system changes, and how they may influence EOL care documentation and workload in GRASP.

CONCLUSION

Completing GRASP is part of a nurse’s responsibility in our organization. Enhancing oncology nurses’ awareness about the relevance and importance of completing GRASP is paramount in the current environment of healthcare funding cuts. GRASP at all levels represents the nursing profession and demonstrates the quantity of nursing work and the contribution they make to the healthcare of oncology patients.