northwick park care needs assessment: adaptation for inpatient neurological rehabilitation settings

Northwick Park Care Needs Assessment: adaptation for inpatient

neurological rehabilitation settings

Heather Williams, Ruth Harris & Lynne Turner-Stokes

Accepted for publication 7 March 2007

Correspondence to Heather Williams:

e-mail: [email protected]

Heather Williams MSc RN

Research Fellow

Regional Rehabilitation Unit, North West

London Hospitals NHS Trust, Harrow,

Middlesex, UK

Ruth Harris BSc MSc PhD RN

Senior Researcher

Faculty of Health and Social Care Sciences,

Kingston University and St George’s,

University of London, London, UK

Lynne Turner-Stokes DM FRCP

Director of Regional Rehabilitation Unit

Northwick Park Hospital, Harrow,

Middlesex; Herbert Dunhill Chair of

Rehabilitation, Department of Palliative

Care, Policy and Rehabilitation, Kings

College London, London, UK

WILLIAMS H., HARRIS R. & TURNER-STOKES L. (2007)WILLIAMS H., HARRIS R. & TURNER-STOKES L. (2007) Northwick Park Care

Needs Assessment: adaptation for inpatient neurological rehabilitation settings.

Journal of Advanced Nursing 59(6), 612–622

doi: 10.1111/j.1365-2648.2007.04344.x

AbstractTitle. Northwick Park Care Needs Assessment: adaptation for inpatient neurolo-

gical rehabilitation settings

Aim. This paper is a report of a study to establish which timings and assumptions of

the Northwick Park Dependency Scale and Care Needs Assessment are appropriate

to the inpatient rehabilitation setting and which, if any, require adjustment.

Background. Cost-effective provision of nursing care relies on being able to adjust

staffing levels in accordance with patient dependency. The Northwick Park

Dependency Scale and Care Needs Assessment enables direct assessment of nursing

care needs in community settings.

Method. An observational study was conducted in 2004 to record the time taken to

complete direct nursing care interventions in a rehabilitation ward and to compare

these times with simultaneously recorded time-estimates provided by the Care

Needs Assessment. A total of 1168 nursing interactions were timed for 50 care

episodes.

Results. There was considerable variation in the time taken for each nursing

intervention, depending on overall patient dependency and the number of nurses

required. Although there was good correlation between observed care times and

those estimated by the Care Needs Assessment, observation confirmed that most

interventions took substantially less time than the estimates. There was also a very

different pattern of care in hospital compared with the community, with shorter,

more frequent interactions as nurses distribute their time between different patients,

and activities other than direct patient care.

Conclusion. The Northwick Park Care Needs Assessment tool already has wide-

spread application in other countries and its continued use for estimating commu-

nity care needs remains relevant. The tool, once fully developed, will have the

potential to contribute to international rehabilitation nursing workforce planning

and research.

Keywords: activity analysis, dependency, instrument development, neurological

nursing, Northwick Park Care Needs Assessment, nursing care hours, rehabilitation

RESEARCH METHODOLOGYJAN

612 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

Introduction

Cost-effective provision of nursing care in any ward setting

relies on being able to adjust staffing levels in accordance

with patients’ need for nursing care (nursing dependency).

Accurate measurement or assessment of patients’ need for

nursing care provides a challenge for all areas of nursing,

because of fluidity in workload and patient throughput in

any given time-frame. This measurement process is mainly

dependent on using a robust tool that is easy and quick to use

and can be applied in a systematic way to identify changes in

patient need and staffing requirements. This study is part of a

larger programme of work to develop a tool to assess patient

care needs and estimate nursing staff numbers and skill mix

in an inpatient neurological rehabilitation setting.

Since the early 1980s, an increasing number of tools has

been developed to measure nursing dependency, mostly

designed for acute (Stevens & Goucher 1985, MacNaughton

1995, Harrison 2004) or elderly care settings (MacGuire &

Newberry 1984, Lohrmann et al. 2003), and thus not suitable

for use in rehabilitation settings, where patients’ require-

ments for nursing care and time are often very different.

Nolan et al. (1997) identified five key components of

rehabilitation nursing: (1) maintaining the physical well

being of clients; (2) providing specialist care in particular

areas such as continence and skin care; (3) reinforcing/

carrying out the instructions of therapists; (4) providing a

supportive environment for rehabilitation and (5) being a

24-hour presence. A more recent review of the literature

corroborated Nolan et al.’s findings and broadened the

nursing role to include assessment, co-ordination and com-

munication, therapy integration and continuation, technical

and physical care, emotional support and facilitating family

involvement (Long et al. 2002).

Nurses working in a rehabilitation environment are

pivotal in prompting, encouraging and supporting patients

to practise new strategies and skills learnt in therapy

sessions which are intended to assist them regain or

maintain independence following life-changing events (Hill

& Johnson 1999, Long et al. 2002). Nurses working in

rehabilitation aim to transfer skills back to patients, often

by using a ‘stand back’ approach that allows individuals to

develop planning, sequencing and implementation skills but

which, in turn, may require more nursing time than simply

doing the care activity for them. The number of nurses, and

the nursing skills required to meet patient need, will vary

depending on the needs of the client group. These needs are

influenced by many factors including a patient’s stage of

recovery, level of disability, emotional recovery and social

circumstances (Burton & Gibbon 2005).

Patients with recently acquired physical disability, espe-

cially following neurological insult or injury, are often

severely disabled and require two or more nurses to handle

and position them. Some may require considerable amounts

of time for care interventions, such as correct positioning to

control spasticity, or for meaningful communication. Most

existing measures of dependency for self-care activities, such

as FIMTM or the Barthel, do not account for these additional

staffing requirements. Grace Reynolds Application and Study

of PETO (GRASP) (Meyer 1978) is a generic workload tool

designed to estimate nurse staffing levels. It suggests that a

minimum of 6 minutes should be allocated to a nursing

activity and increased depending on the level of help required.

However, it would require specific adaptation for the

rehabilitation setting to incorporate the additional require-

ments mentioned above. Other tools developed for use in a

rehabilitation setting focus on specific neurological problems,

such as head injury (Mayer et al. 1989), physical disability

(Stride 1988, Stride & Andrews 1989) and stroke (Gross

et al. 2001), rather than on generic neurological rehabilit-

ation needs.

The Northwick Park Dependency Score (NPDS) (Turner-

Stokes et al. 1998) is one of the few tools specifically designed

to measure nursing dependency in a neurological rehabilit-

ation setting. The NPDS is a simple ordinal scale, which

consists of 12 items reflecting personal care activities called

‘Basic Care Needs’ (BCN): mobility, transfers, bladder

management, bowel management, grooming, showering,

dressing, eating/drinking/enteral feeding, skin pressure relief,

safety awareness, communication and behavioural manage-

ment, and seven items reflecting ‘Special Nursing Needs’

(SNN), which might require intervention from a Registered

Nurse (RN): tracheostomy management, wound care, more

than twice nightly interventions psychological support,

isolation, intercurrent medical/surgical problems and one-

to-one special nursing. The NPDS has been shown to be

reliable in the United Kingdom (UK) (Turner-Stokes et al.

1998) and Sweden (Svensson et al. 2005) and is comparable

with the Barthel index in assessing care needs (Post et al.

2002, Hatfield et al. 2003). In each item, the ordinal levels

reflect the number of nurses required and the approximate

time required to complete each activity. The range of scores

for each item within the BCN section can be 0 to 3 (i.e. 0, 1, 2

or 3), 0 to 4 or 0 to 5 reflecting the level and complexity of

care required. The total score for this section is obtained by

adding together the scores from all 12 items, giving a

composite score from 0 to 65. The SNN section has

dichotomous variables, a score of five indicating the activity

occurs and a score of nought indicating that the activity is not

required. The total score for the SNN section is 0–35. The

JAN: RESEARCH METHODOLOGY Northwick Park Care Needs Assessment

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 613

overall NPDS score is achieved by summing the total scores

of both the BCN and SNN sections (range 0–100) and scores

can then be used to assign patients to one of three dependency

categories:

• Low dependency (NPDS score <10) – mainly independent

in self-care.

• Medium dependency (NPDS 10–25) – requires one person

for most care activities.

• High dependency (NPDS >25) – requires help from two

people for most care activities.

The assignment of a dependency category assists nurses to

(a) identify the number of patients in each category on a daily

basis, (b) assess the nursing workload and (c) schedule new

admissions.

The NPDS can also be used to provide an assessment of

patient care needs in the community setting – the Northwick

Park Care Needs Assessment (NPCNA) (Turner-Stokes et al.

1999a) (Figure 1). Five specific questions relating to the

community setting are attached to the NPDS tool forming a

third section: Care Needs Assessment (CNA). A validated set

of assumptions, which includes the number of people

required to complete the activity and the number of times

per day the activity is performed, and timings (Turner-Stokes

et al. 1999a) are applied to each item in the NPDS (including

the five CNA items) through a computerized algorithm.

These times are then summed to provide a direct estimate of

the total care hours required by that individual in the

community setting for both basic (personal) care and skilled

(technical) nursing needs. The final timings include a travel

time allowance. Timings are capped at an upper and lower

limit to cater for the fact that some care activities are

completed simultaneously. In addition, these capped timings

reflect the minimum and maximum lengths of time for a

community visit. A suggested care package for discharge is

also produced. The NPDS and NPCNA are routinely used in

clinical practice at our study site and in many rehabilitation

units in the UK (Turner-Stokes et al. 1999b) and abroad (Post

et al. 2002, Griffiths & Sironi 2005, Svensson et al. 2005).

Although an individual’s care needs may be very similar

whether they are in hospital or in the community, there are

several differences between hospital and community settings

which may affect precise estimation of staffing hours required

to support those needs. For example, in the community,

nursing and care staff generally care for one patient at a time

and need to travel between them whereas, in a ward setting, a

team of nurses is present at all times, and a single nurse can

often supervise two or more patients simultaneously if they

only need prompting or incidental help for certain elements

Northwick Park Care Needs Assessment (NPCNA) A generic assessment of care hours in the community

Northwick Park Dependency Score (NPDS)Simple ordinal scale

Designed for use in hospital rehabilitationsettings

(a) the number of carers required and(b) time taken to complete the task

19 items, scored at 4–6 levels reflecting:

Divided into two sub-sections

12 items (Score range: 0–65) Section 1: Basic Care Needs

Section 2: Special Nursing Needs7 items (Score range: 0–35)

+

Total NPDS score (Range 0–100)

Serial records show changingdependency

Score > 25: High dependency

Score 10–25: Medium dependency

Score 0–9: Low dependencyMain NPDS categories

Largely self-caring, incidental help only

Requires two carers for most tasks

Requires one carer for most care tasks

Translate into changing care needs in thecommunity

NPCNA computerized outputs include:

Estimate of total care hours required per weekTime-table of care needs – indicating tasks for which help is required and timing of care needsthroughout the day and nightCare package required to meet the care needsApproximate weekly cost of care package

··

··

Scores entered into a computerized programmeApplies algorithm based on a validated set ofassumptions and timings

+Data from Sections 1 and 2 of the NPDS

Section 3: 5 additional questions relating toneeds for care in the community

Figure 1 Relationship between the North-

wick Park Dependency Score (NPDS) and

Northwick Park Care Needs Assessment

(NPCNA).

H. Williams et al.


of care. We realized the necessity of investigating how ward

staffing levels were estimated, including the suitability of

using or adapting the NPDS/NPCNA for this purpose.

In earlier work, we used the NPCNA to provide an

estimate of the total care-hour requirements for the caseload

in an inpatient rehabilitation unit and compared this with the

nursing staff hours provided (Williams et al. 2007). Over a

6-month period, the NPCNA estimated care-hours were

consistently higher, with a suggested average nursing shortfall

of 6 hours a day, which seems feasible, given that nurses

often feel overstretched. However, the NPCNA appeared to

grossly underestimate SNN, in terms of nursing hours, while

over-estimating time for BCN. Therefore, whilst the NPDS

could continue to be used to assess dependency, a different

algorithm was required to calculate nursing staff hours in

order to determine staffing levels required to meet patients’

care needs in the inpatient setting.

The study

The data we report in this paper are taken from a larger

study, the aim of which was to develop a method for

calculating the nursing staff numbers required in an inpatient

neurological rehabilitation unit, based on an assessment of

dependency needs. The NPCNA was identified as a tool

suitable for adaptation for use in inpatient neurological

rehabilitation settings. In this paper, we have used the terms

‘nurse’ and ‘nursing’ to denote individuals and activities

relating to care of patients on an inpatient, neurological

rehabilitation unit; the terms can, therefore, refer either to

Registered Nurses or other nursing staff and nursing activity.

Aim

The aim of the part of the study we report here was to

establish which timings and assumptions of the NPCNA were

appropriate to inpatient rehabilitation settings and which, if

any, required adjustment.

There were five objectives for this part of the study:

• To compare observed direct care times with the time-

estimates provided by the NPCNA.

• To identify direct care activities performed that are not

items in the NPDS, and establish how long these activities

take to complete.

• To compare total direct care time between dependency

groups.

• To establish the frequency of care interventions.

• To identify nursing workload patterns in relation to

interventions completed by registered and non-registered

nursing staff.

Design

We used a non-participant continuous observation design in

one care setting to record the time spans nurses were involved

in direct nursing care. The data were collected in 2004.

Participants

We conducted the study in a 26-bedded, postacute regional

rehabilitation unit in north-west London, UK. The unit

provides inpatient neuro-rehabilitation therapy to adults with

complex disabilities. We expected there would be a wide

range of times for each aspect of direct nursing care, varying

with patients’ levels of ability, and therefore selected a patient

sample which spanned a range of dependency needs.

We used purposive sampling to include 15 care episodes in

each of the low and high dependency groups, and 20 care

episodes in the medium dependency group (based on the NPDS

as described above), thus observing and timing a total of 50

episodes. We defined a care episode as all direct care provided

for an individual patient during an 18-hour period 06:00–

00:00), split over two observational sessions, 06:00–15:00 and

15:00–00:00 (normally on consecutive days). The period from

00:00 to 06:00 was not included as night-time interventions are

not assigned care time in the NPCNA, and therefore compar-

isons between observed times and NPCNA times could not be

made. However, we recognize the necessity of establishing the

time required for night-time intervention in future work.

A total of 28 patients was involved in the study. No patient

was observed for more than two care episodes and where two

care episodes were observed, the time interval between

observations was at least 4 weeks, by which time there had

rarely been substantial change in the individual’s needs for

care. The number of participants observed during a session

varied between one and four (in eight sessions one patient

was observed, in 11 sessions two, in 14 sessions three and in

seven sessions four). Therefore, the 50 care episode observa-

tions were completed during 40 observational sessions.

Data collection

Observation

All 40 observational sessions during a 4-month period in

2004 were carried out by HW. Where possible the early

(06:00–15:00) and late (15:00–00:00) sessions were carried

out on consecutive days for the same patient group to mini-

mize changes in care needs that might have affected nursing

care intervention. Nine hours may not always be a suitable

timeframe for this type of investigation, but in the study

setting patients are involved in an active rehabilitation



https://www.researchgate.net/publication/6223500_Can_the_Northwick_Park_Care_Needs_Assessment_be_used_to_estimate_nursing_staff_requirements_in_an_in-patient_setting?el=1_x_8&enrichId=rgreq-231b8ebf-f609-44cd-a640-bcb488d9e282&enrichSource=Y292ZXJQYWdlOzYxOTQxMjc7QVM6MTAyNDgyMzg2NjIwNDMzQDE0MDE0NDUxMTUwNzA=

programme and therefore have scheduled therapy sessions.

We were aware of participants’ therapy timetables and could

plan breaks knowing that no nurse–patient interaction would

be occurring.

At the start of an observation period, participants were

selected based on their dependency care needs (as indicated

by the NPDS) and their proximity to one another on the

ward. The researcher sat in a suitable place during each

session to ensure that she was not causing an obstruction to

patients or staff, but could observe and time all direct nursing

care activity for participants identified at the start of the

session. If participants moved outside of the bay/side room,

she moved as well to continue the observation. All direct

nursing care activities were observed and timed (in seconds,

using a stop watch) to define the range of time taken for each

care activity in the NPDS. Direct nursing care was identified

as ‘any nursing intervention that was patient centred and

occurred in the presence of the patient and/or family’ (Flynn

et al. 1999). The data from this activity analysis was to be

used to inform an algorithm for translation of the NPDS into

care hours for use in the hospital setting. Therefore, the

nursing care interventions observed were categorized under

headings corresponding to items in the NPDS described

earlier. This was quite difficult at times because of the multi-

tasking nature of the nursing workload. Any observed nurse–

patient interactions that were not items in the NPDS were

timed and data collected under ‘other’ activity; the precise

activity was also recorded.

Interactions and interventions

Allocation of timing under the headings of the different care

activities proved to be complex because:

• several different care activities were often undertaken

simultaneously, with the same nurse frequently assisting

one patient whilst instructing another;

• the care routine for a given patient was often divided into

several visits as the nurse was called away halfway through

an activity, or left the patient to give them a rest before

embarking on the next stage;

• some care activities required more than one carer for all or

part of the time.

In order to describe these accurately, the terms ‘interven-

tion’ and ‘interaction’ were applied:

• An ‘intervention’ is a care activity that corresponds to a

certain heading on the NPDS, such as ‘eating’ or ‘dressing’.

• An ‘interaction’ refers to the total continuous time during

which at least one nurse was involved in direct nursing care.

An interaction could include just one intervention or

several interventions. So, for example, a nurse may be

observed to come and give the patient their breakfast (two

interventions: eating and drinking) and may then help them

to clean their teeth (part of a third intervention ‘washing and

grooming’).

The beginning and end of a direct care interaction/

intervention was clearly defined at the outset:

• The beginning of an interaction/intervention occurred as

soon as the nurse entered the bay/room (or approached the

patient in the corridor/toilet) and indicated either verbally

or with gestures to a patient that an intervention was going

to occur.

• The end of an intervention occurred when the nurse was

observed to have changed activity (as above, where he/she

changes from giving the patient breakfast to helping them

to clean their teeth).

• The end of an interaction was the point at which the nurse

either moved away from the patient or stopped including

the patient in the care activity. For example, the nurse might

continue to tidy the bed area, but without discussion with

the patient. The point at which the nurse appeared no longer

to include the patient, timing stopped. However, if the nurse

continued to talk to the patient, either in a social manner, or

about the intervention or care needs, then this was included

in the timed intervention as direct patient care.

Data collected

The following data were collected:

• intervention(s) performed;

• number of nurses involved;

• length of time each nurse was involved;

• grade of staff;

• time of day, and

• patient’s nursing dependency score/category (using the

NPDS).

To establish the total nursing time required to complete an

intervention, all the recorded times for each member of

nursing staff involved in the specific intervention were

summed. For example, during one care activity, three nurses

were present during some part of the intervention. Nurses 1

and 2 stayed for the duration of the interaction lasting

5 minutes (300 seconds) but nurse 3 left after 2.5 minutes

(150 seconds), so the total nursing time required was 750 sec-

onds or 12.5 minutes (2 · 300 seconds þ 150 seconds).

Personal care activities (grooming, bathing and dressing)

were sometimes difficult to differentiate for timing purposes,

as it would have been inappropriate to actually observe these

care needs being performed. Where appropriate, nursing staff

would provide cues, such as ‘let’s clean your teeth’ or ‘all we

need to do now is get you dressed’, but when this level of

detail was not available, the complete interaction was timed

and recorded as ‘personal care’.

H. Williams et al.


Organization of data

The range of observed care times was plotted alongside the

ordinal descriptors in the NPDS (in an Excel worksheet) prior

to comparison with the algorithm timings used in the NPCNA.

Reliability

The researcher acted as the only data collector and, therefore,

assessing inter-observer reliability was not possible. How-

ever, the clearly defined criteria to identify when an inter-

vention started and stopped, as discussed earlier, give some

assurance of the robustness of data collection. All observa-

tions were timed using a stopwatch and recorded in seconds

to increase accuracy.

Ethical considerations

Approval for the study was obtained from the local health

service ethics committee and consent was obtained from

nursing staff and patients at the start of each observation

session. Patients and staff were informed that we were timing

nursing care and that all data collected would remain

confidential and be stored in compliance with the data

protection act. Patient privacy and dignity was respected and

no intrusion behind bed curtains or into washing areas

occurred as part of the research. The quality of care per se

was not observed, but as the data collector held a nursing

qualification, she was duty-bound to report any irregularities.

Similarly, she would have had a duty of care to patients if any

emergency or unusual incident occurred when no unit nurse

was in the area. However, no such incidents occurred.

Data analysis

Timings were observed in seconds and then converted to

minutes (rounded to the nearest quarter) to facilitate

interpretation. The data were collated on a spreadsheet

(Microsoft Excel) and transferred to SPSS version 14Æ0 (SPSS

Inc., Chicago, IL, USA) for statistical analysis. Data distri-

bution fell outside the accepted limits of normality (Shapiro

Wilk 0Æ857 P < 0Æ001), and so non-parametric statistical

tests were applied. Descriptive statistics are given in medians

and inter-quartile ranges. Spearman correlations and Wilcox-

on tests were applied to examine the relationship between the

observed timings and the NPCNA estimations.

Results

In all, 28 participants were involved in the study. Their mean

age was 45 years (SDSD 13, range 19–67); 27 had an acquired

brain injury and one person (4%) had multiple sclerosis. The

brain injuries were caused by a stroke in 20 cases (71%) and by

traumatic brain injury in seven (25%). Six patients were female

and 22 male. The variation in dependency scores which we

aimed for was achieved. Scores spanned the category range in

the low and medium dependency groups [0–9, median 2, inter-

quartile range (IQR) 0–4, and 10–25, median 16Æ5, IQR 12Æ5–

20Æ5 respectively] and scores ranging from 26 to 73 (median 49,

IQR 37–60) was represented in the high dependency group.

Across the 50 care episodes, a total of 1168 interactions

was timed: 641 during the early session (06:00–15:00) and

527 during the late session (15:00–00:00). These included a

total of 1486 direct care interventions, ranging from just

2 seconds for a routine check, to 54 minutes for bathing a

heavily dependent patient.

Comparison of observed care hours and NPCNA hours

Overall there was a strong correlation between the observed

care hours for any given patient during an 18-hour care episode

and those estimated by the NPCNA (Spearman rho ¼ 0Æ86

P < 0Æ001). However, the NPCNA time estimations (median

330 minutes, IQR 142Æ5–427Æ5) are significantly higher than

the observed care hours (median 103 minutes, IQR 39–210)

(Wilcoxon z ¼ �6Æ04, P < 0Æ001).

Table 1 shows a breakdown comparison of the time

estimations by dependency group across three different time

periods (morning, afternoon and evening), in comparison

with the NPCNA estimates of care hours for that period.

With the exception of the afternoon and evening sessions in

the heavily dependent group of patients, timed observations

were universally lower.

Table 2 shows a comparison between the observed times

(for each care activity in the NPDS) and the NPCNA

estimation. In most instances the NPCNA timing was nearly

twice the maximum observed timing for the item, although

there were one or two exceptions, such as faecal incontinence

and hoisting.

Direct care activity observed but item not in the NPCNA

algorithm

Table 3 shows observed timings for SNN activities that are

not specified in the NPCNA, and additional observed acti-

vities that are not included in the NPDS/NPCNA. These

include timings for activities such as tracheostomy manage-

ment, wound care, routine checks, recording vital signs,

splint application and assisting therapy staff.

Frequency of care interaction/interventions

The total nursing time taken to provide direct care for an

individual patient throughout the 18-hour care episode varied

with dependency, as we expected. In the low dependency



group, the median care time was 22 minutes (IQR 11–52);

for the medium dependency group, it was 106Æ5 minutes

(IQR 68Æ5–135Æ5), and for the high dependency group

293 minutes (IQR 258–389 minutes). These differences were

highly significant between groups (Kruskal–Wallis 33Æ8,

P < 0Æ001), and were statistically significantly different

between the low and medium groups (Mann–Whitney

U ¼ 26, P < 0Æ001) and between the medium and high de-

pendency groups (Mann–Whitney U ¼ 30, P < 0Æ001).

The NPCNA estimated care times were significantly

greater than the observed care times in all three dependency

groups (Wilcoxon signed rank tests z ¼ �2Æ95, P ¼ 0Æ003 in

the low dependency group, z ¼ �3Æ92, P < 0Æ001 in the

medium dependency group and z ¼ �3Æ41, P ¼ 0Æ001 in the

high dependency group).

The number of interactions during each of these care

episodes also varied somewhat between the dependency

groups, but was quite high, confirming, as suspected, that

nurses frequently ‘pop in and out’ between patients in a

hospital setting, as they divide their time across the ward

caseload, and between direct patient care and other activities.

The median number of interactions whilst providing care to a

single patient over an 18-hour period was 14 (IQR 11–17) for

the low dependency group, 28 (IQR 21–31) for medium

dependency and 30 (IQR 22–23) for high dependency.

Although there were significantly fewer interactions in the

low dependency group (Mann–Whitney U ¼ 38, P ¼ 0Æ001),

there was no significant difference between the medium

and high dependency groups (Mann–Whitney U ¼ 126Æ5,

P ¼ 0Æ44), indicating that the medium dependency group

requires intervention as often as the high dependency group,

although the nursing time for each interaction is lower,

because typically it involves only one person, as opposed to

two or even three.

Interactions consisting of more than one intervention

occurred 167 (14%) times. Interactions involving one inter-

vention took a median of 1 minute (IQR 0Æ5–3), while those

involving two or three interventions took a mean of 8 min-

utes (IQR 4–17), and those involving four or more interven-

tions took a median of 27Æ5 minutes (IQR 15Æ75–52).

Nursing workload patterns

Of the 1311 interventions requiring the assistance of one

person, 520 (40%) were completed by a RN. It is unclear

whether this was essential in all cases. All tracheostomy

care needs and most medication administrations were

completed by a RN, although at times a non-RN (with

competency in medication administration) applied topical

medication.

Twelve per cent (175/1486) of interactions required two or

more members of nursing staff to complete the interventions.

At least one RN was present at 118 (67%) interventions

requiring two or more members of staff. The interventions

requiring two or more nurses were predominantly BCN items

and were required for patients with high nursing dependency

needs. On four occasions, two or more nurses were required

to administer medication to patients in the low and medium

nursing dependency categories.

Discussion

Study limitations

There are several limitations to this investigation. First, we

conducted it in one setting, which may not be representative

of all rehabilitation units. Secondly, an observational tech-

nique conducted in this way can be criticised for only

measuring what is seen and not necessarily what ideally

Table 1 Comparison of observed care hours and predicted care hours using Northwick Park Care Needs Assessment (NPCNA)

Time periods

Direct care hours (in minutes)

Low dependency care needs Medium dependency care needs High dependency care needs

Observed care

times, median

(IQR)

Predicted

NPCNA time,

median (IQR)

Observed care

times, median

(IQR)

Predicted

NPCNA time,

median (IQR)

Observed care

times,

median (IQR)

Predicted

NPCNA time,

median (IQR)

07Æ30–12Æ00 10 (4–38) 45 (30–60) 51 (37–73) 150 (120–150) 129 (91–151) 270 (210–300)

Wilcoxon Z–2Æ6 P ¼ 0Æ008 Z–3Æ8 P < 0Æ001 Z–3Æ4 P ¼ 0Æ001

12Æ00–18Æ00 2 (1–8) 30 (0–30) 15 (4–26) 75 (60–90) 92 (54–145) 90 (90–120)

Wilcoxon Z–1Æ9 P < 0Æ055 Z–3Æ9 P < 0Æ001 Z–0Æ6 P ¼ 0Æ55

18Æ00–00Æ00 2 (1–8) 30 (0–30) 15 (5–27) 76 (61–92) 93 (55–148) 92 (92–122)

Wilcoxon Z–1Æ9 P ¼ 0Æ055 Z–3Æ9 P < 0Æ001 Z–0Æ6 P ¼ 0Æ55

IQR, inter-quartile range.

H. Williams et al.


should happen. Thirdly, only direct nursing care was inclu-

ded. We acknowledge that direct nursing care only represents

part of nursing and, therefore, additional work is being

undertaken to establish the percentage of time this represents

prior to estimating nursing workload using a dependency

tool. Incorporation of non-direct care will be essential if the

tool is to be used to estimate nursing staff numbers to carry

out work effectively. In addition, our investigation was

unable to answer questions relating to the optimal skill mix in

relation to the frequency of reassessment of care needs by

Table 2 Observed and NPCNA ¼ Northwick Park Care Needs Assessment (NPCNA) intervention times for Basic Care Needs

Basic care need

Level of assistance

(based on ordinal score of NPDS) n

Median

time

(minutes)

Inter-quartile

range

(minutes)

Range

(minutes)

NPCNA

(minutes)

Mobility In ward (needs help from 1) 17 1 0Æ75–1Æ75 0Æ25–4 0

To another department (help from 1) 1 25Æ75 – 25Æ75

Transfers Assistance, needs help from 1 63 2Æ25 1Æ25–3Æ5 0Æ25–8Æ75 15

Assistance, needs help from 2 3 4Æ25 3Æ5–5Æ00 3Æ5–5 15

Hoist, needs help from 2 or more 28 6 4Æ75–10Æ75 2–15 15

Toileting bladder Set up (i.e. leaving urinal in

reach/positioning of commode)

12 0Æ5 0Æ5–0Æ75 0Æ25–1Æ25 15

Catheter/conveen 21 1Æ75 1–2 0Æ25–5 15

Assistance, needs help from 1 86 2Æ5 1Æ25–3Æ75 0Æ25–9Æ25 15–30

Assistance, needs help from 2 or more 8 4 2–15 0Æ5–45 15

Incontinence, needs help from 2 or more 5 22 10Æ5–23Æ5 9Æ5–24Æ5 30

Toileting bowels Set up (e.g. giving suppositories/enema) 0 – – – 15

Assistance, needs help from 1 8 2 1–4 0Æ75–7 15–30

Assistance, needs help from 2 2 12Æ75 8Æ5–17 8Æ5–17 15–30

Incontinence, needs help from 2 or more 9 15Æ5 13–23Æ75 12Æ25–31 30

Grooming Set up (e.g. laying things out, filling bowl

with water)

2 1 1–1 1 15

Assistance, needs help from 1 15 3 1Æ25–8 0Æ25–16Æ5 30–60

Assistance, needs help from 2 or more 8 5 4Æ25–6 4–9Æ5 30–60

Bathing/showering Set up (e.g. running bath, soaping flannel) 7 2Æ5 0Æ5–4 0Æ25–5Æ75 15

Excludes transfers Assistance, needs help from 1 21 13 8Æ25–21 3–42Æ25 30–60

Assistance, needs help from 2 or more 3 17Æ5 6–18Æ25 6–18Æ25 30–60

Dressing Set up (e.g. laying out clothes) 2 5Æ75 5Æ5–6 5Æ5–6 15

Excludes transfers Incidental help with shoes 7 1Æ75 0Æ5–4Æ5 0Æ25–6 15

Assistance, needs help from 1 26 10 3–14 1Æ5–25 30–60

Assistance, needs help from 2 or more 11 4Æ25 3Æ75–8Æ25 2Æ25–10Æ5 30–60

Combined personal Assistance, needs help from 1 13 25 16–45 3Æ25–53Æ25 0

Care (excludes transfers) Assistance, needs help from 2 8 27Æ5 20–42 17Æ75–54

Eating Serving – no set up 33 0Æ25 0Æ25–0Æ5 0Æ25–1 0

Set up (opening packets etc.) 101 1Æ25 0Æ5–2Æ25 0Æ25–7Æ5 15

Assistance needs help from 1 6 16 13–24 13–34Æ25 30–60

Drinking Set up (pouring/thickening drink) 37 0Æ75 0Æ5–1 0Æ25–4Æ5 15

Assistance, needs help from 1 16 1Æ5 0Æ5–2 0Æ25–15Æ25 30–60

Enteral feeding Set up feed 20 1Æ5 0Æ5–4 0Æ25–8Æ75 0

Bolus feed 9 2Æ25 1–2Æ75 0Æ75–3 15

Flush tube, needs help from 1 48 2Æ25 1–3 1–8Æ5 15

Flush tube, needs help from 2 or more 11 1Æ5 1–2Æ5 0Æ5–4Æ25 15

Positioning Needs prompting 1 1Æ75 – 1Æ75 0

Assistance, needs help from 1 19 1Æ5 1–2Æ5 0Æ25–9Æ5 15

Assistance, needs help from 2 34 5 3–8 1Æ5–25Æ25 15

Safety awareness Needs supervision from 1 11 4 2Æ5–5Æ75 1–11 0

Communication Able to communicate 229 0Æ75 0Æ5–1 0Æ25–22 0

Some communication needs help 63 0Æ75 0Æ25–1Æ5 0Æ25–16

Uses communication aid 32 0Æ5 0Æ5–2Æ25 0Æ25–4Æ5No effective communication 11 1 0Æ25–2 0Æ25–5

NPDS, Northwick Park Dependency Score.



RNs, the evaluation of patient outcomes, or the completeness

of care provided.

Notwithstanding these limitations, our study has examined

an area of nursing practice which has received little attention

in the literature to date.

Discussion of results

The timed observational data from this study confirm that the

care activities performed in this in-patient environment were

not dissimilar to those completed in the community. How-

ever, the time taken to complete them was much less than in

the community. This comes as no surprise, as the NPCNA

makes some allowance for travel time of carers to get to the

patient, which is not applicable in the inpatient setting. There

was substantial variation in the time required to complete

different nursing interventions for different dependency needs

dependent, to a large extent, on whether patients required

one or more members of staff to help. It showed, as we

expected, that the pattern of care provision in an inpatient

setting differs considerably from that in the community,

generally with much shorter and more frequent interactions

than in the community setting where, traditionally, the

majority of an individual’s care needs are met in one to three

visits during the day, perhaps for an hour or more on each

occasion. This shorter pattern of interaction may allow

nurses to encourage patients (particularly in the lower

dependency group) to undertake an activity for themselves

and then to call back in a short while to check on progress

and/or deliver further prompts, thus helping them to achieve

independence. High dependency care needs required a longer

time, with many interactions requiring two or more staff

members to complete them. Therefore, all timings and

frequencies will need adapting in the developing tool.

Earlier work suggested that the NPCNA algorithm under-

represented the care hours required for items within the

Special Nursing Needs section, particularly those requiring a

RN. From our study, two items (tracheostomy management

and wound care) now have time allowances established.

Therapeutic splint application/removal and 24-hour postural

management were not included in the NPCNA as they are

unlikely to be performed in a patient’s own home (although

they would be performed in long-term care homes), but are

particularly pertinent to the inpatient setting. This study has

provided additional information on the time required to

complete these activities.

Although the grade of staff involved in any intervention was

recorded, no conclusions could be reached regarding the

desired skill mix from these data alone. Although a RN may

have been present to undertake the activity, it is not clear to

Table 3 Observed and Northwick Park Care Needs Assessment (NPCNA) nursing intervention times for Special Nursing Needs and additional

inpatient nursing need

Special nursing

needs

Level of assistance

(based on dichotomous scores of NPDS) n

Median time

(minutes)

Inter-quartile

range

(minutes)

Range

(minutes)

NPCNA

(minutes)

Tracheostomy Tracheostomy care, needs help from 1 28 3Æ25 1–5 0Æ75–8 0

Tracheostomy care, needs help from 2 4 5 3–9 2Æ5–10Æ25

Dressing change, needs help from 1 8 4Æ25 2–5 0Æ5–8

Dressing change, needs help from 2 4 5Æ5 2–12Æ75 1Æ75–14Æ5Wound Care Simple wound management from 1 14 4 1Æ5–12 1–37Æ75 0

Medication Oral medication (not controlled drugs) 111 3 2–4Æ5 0Æ5–21Æ5 15

Controlled drugs (excludes preparation) 4 2 1–4Æ5 1Æ5–5

Intravenous injection (excludes preparation) 1 2Æ75 – 2Æ75

Subcutaneous injection 6 1 0Æ5–2Æ5 0Æ25–2Æ75

Medication via gastrostomy 41 6Æ5 3–9Æ25 1–17

Assisting other HPs* Total 11 5 1Æ75–14 0Æ75–30 0

Routine checks Total 55 0Æ25 0Æ25–0Æ5 0Æ25–1Æ75 0

Vital signs Total 57 1Æ5 1–2 0Æ25–7Æ75 0

Collecting specimens Total 3 3Æ75 1Æ25–9Æ5 1Æ25–9Æ5 0

Splint application Splint application, needs help from 1 25 1 0Æ5–2 0Æ25–8Æ75 0

Splint application, need help from 2 6 2 1Æ5–3Æ5 1Æ5–3Æ5Other Clinical support 21 2Æ5 1–4Æ5 0Æ25–12Æ5 0

Incidental support (passing things) 10 1 0Æ5–1Æ5 0Æ5–5

General support (leisure pursuits) 10 7 2–10Æ75 0Æ5–16

NPDS, Northwick Park Dependency Score.

HPs, health professionals.

H. Williams et al.


what extent qualified nursing input was needed or what impact

this had on patient care. However, RNs always completed

tracheostomy management and most medication administra-

tion, reflecting the complexity of these interventions and

compliance with hospital protocols of care. Further work is

required to identify which care activities can reasonably be

completed by non-registered staff in the hospital setting, and

those that must be, or would be better, completed by a RN.

Very few other researchers have attempted to perform

detailed analysis of care activities in a neurological rehabil-

itation setting. Neatherlin and Prater (2003) conducted a

study in a spinal cord injury unit and found differences in the

time spent in specific nursing interventions per shift. However

they took a different approach in the analyses by calculating

the collective nursing time per shift, whereas we have studied

a small sample of patients over the course of any one shift.

The two datasets are therefore not comparable. Our findings,

therefore, make an important contribution to the evidence-

base in this specialty. The strong correlation between the

observed care hours and those estimated by the NPCNA

provides some evidence of criterion-related validity of the

tool to measure dependency. Furthermore, the significant

differences in observed care hours between each dependency

level also support the utility of the NPCNA in predicting the

amount of nursing care required by patients.

Conclusion

This investigation of the accuracy of the NPCNA for use in

an inpatient setting demonstrates that there is a need to

develop an alternative algorithm for this purpose. Our

findings have provided valuable insight into the time spent

by nurses in giving direct care, with potential time allocations

and frequency of intervention for use in the development of

an algorithm to derive nursing care hours from the NPDS in

an inpatient setting. This will, in the future, form the basis for

estimating nursing staff requirements in relation to case mix

in a neurological rehabilitation inpatient service.

In this investigation, we have identified the nursing time

required to complete direct nursing interventions, but other

aspects of nursing care could not be assessed because of

methodological limitations. Therefore, as part of our contin-

ued programme of work, we are including investigations into

the proportion of time direct care represents and what other

activities nurses are involved in; this should assist in ensuring

that the final estimation of nursing time incorporates all

aspects of the nursing role.

The NPCNA tool already has widespread application in

other countries and its continued use for estimating commu-

nity care needs remains relevant. We anticipate that the tool

we are developing, to which this research has contributed, will

also be relevant and generalizable to other healthcare systems

and countries and there will be a need to test the reliability and

validity in these settings. The tool, once fully developed, will

have the potential to contribute to international rehabilitation

nursing workforce planning and research.

Acknowledgements

We would like to thank all the patients and staff who took

part in the observational study. In addition the authors would

like to thank Professor Derick Wade who kindly provided

advice in the preparation of this paper. The Dunhill Medical

Trust gave financial support for this study and the Luff

Foundation provided support in the preparation of the

manuscript.

Author contributions

HW, RH and LTS were responsible for the study conception

and design and the drafting of the manuscript. HW per-

formed the data collection. HW, RH and LTS performed data

analysis. LTS obtained funding. HW provided administrative

support. RH and LTS made critical revisions to the paper.

HW, RH and LTS provided statistical expertise. RH and LTS

supervised the study.

What is already known about this topic

• Dependency tools can be used to measure nursing care

needs for individual patients and total unit workloads.

• Estimating nursing care hours is complex because of the

multi-tasking aspect of nursing care.

• Nursing activities can be categorized into direct nursing

care, indirect nursing care, unit related and personal

time.

What this paper adds

• Care patterns in hospital were very different from those

in the community, with shorter, more frequent inter-

actions as nurses distributed their time between differ-

ent patients and activities other than direct patient care.

• There was considerable variation in the time taken for

each nursing intervention, depending on overall patient

dependency and the number of nurses required.

• The preliminary timings for nursing interventions in a

rehabilitation setting can be used to develop an algo-

rithm for estimating nurse staffing levels in inpatient

rehabilitation settings.



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