Introduction

Workforce planning is an essential component of guaranteeing that the hospitals organisational objectives are met by ensuring that ‘the right number of people, with the right skills, in the right place at the right time’ are present to deliver them1. This is against the current pressure of cost containment, reform and sustainability of current levels of health and social care services.2

The literature suggests that a multifaceted approach, including staff ratio allocation, time and motion study or work sampling methods, should be used by health and social care professionals to determine current staff and activity levels.3, 4, 5 To date, there is a reported ‘lack of basic and accurate information necessary to inform comprehensive workforce modelling supply’6, 7 and as, a report commissioned by the Scottish Executive8 highlighted, there is a need for ‘real time workforce data that is consistent, evidenced, relevant and meaningful’.

In dietetics, there is limited published evidence related to workforce measurement, staffing levels and activity3, 6, 7, 9, 10, and to date, there is no spinal cord injury (SCI) centre (SCIC) specific information available reporting dietetic workforce activity.

The specialised SCIC not only provides care following SCI, which usually lasts many months but also provides life-long care for patients living with SCI whose medical needs differ significantly from those of the general population. For people with no sensation below the level of injury, the body learns to function in different ways, conditions such as pressure ulcers can go undiagnosed, and complications which would not be serious for another patient can become life-threatening. The SCICs therefore aim to provide an extensive range of medical and allied health services, and not only those which are obviously related to paralysis. Indeed, previous literature reported staffing issues including nursing, and allied health professionals was an issue in the UK, Australia and Italian SCICs.11

The present study aimed to: (1) review current clinical workforce allocation and compare it with recommended previous literature and professional standards6, 12, 13; (2) document dietetic time spent in direct patient care and activities that contribute to patient care; (3) report nutritional practice and management in the United Kingdom and Republic of Ireland SCI centres.

Materials and Methods

A cross-sectional investigation of dietician practices was undertaken using a self-reported measurement tool. A questionnaire was developed by the Principal Investigator (SW) based on clinical expertise and previous literature6, 7and was modified further by a team of multi-disciplinary professional working in SCICs.

The questionnaire consisted of three parts. The first was designed to capture baseline demographic data and workforce characteristics of SCICs. A spokesman for each SCIC was asked to provide the number of available SCI beds and the number of whole-time-equivalent (WTE) levels of clinical staff (Supplementary Appendix 1, 2 and 3). The second part focused on the dietitian’s practice, staff grade and nutrition-screening practice and; the third part focused on a ‘time and motion’ study of dietitians. A tool was devised using an Excel spreadsheet (Microsoft Corp, Redmond, WA, USA) to capture this information. The timeframe for the working data started at 0730 hours and ended at 1900 hours. The time period was divided into 15 min slots. To save time and make it easier to record and process in the analysis stage, a series of codes were devised to reflect different work tasks that were recorded locally (Supplementary Appendix). Before the launch of the study, all local investigators attended a meeting and received training on how to complete the questionnaire (Supplementary Appendix: Supplementary Information).

The tool was piloted within the dietetic department of the Principal Investigator’s institution over a 1-week period, aiming to determine whether information collected would reflect current work practices and to highlight any reporting issues that may arise. The tool was then discussed with other collaborators via email and a consensus was agreed on as to which activity codes would constitute direct and indirect care. It was agreed that each centre’s dietitians would be required to complete the tool for 1 week.

Survey administration

The survey was sent to all dietitians working in the United Kingdom and Republic of Ireland SCICs (Republic of Ireland: n=1 centre and the United Kingdom: n=11 centres) between April 2014 and June 2014. Participants were reassured that all findings would be treated anonymously and in confidence to encourage respondents to answer honestly. Completed questionnaires were anonymised prior to analysis. Two reminders were sent (one at 4 weeks and one 8 weeks after the initial survey distribution).

The data collected were received either via email or post. The results from the questionnaires were processed in an Excel spreadsheet to provide descriptive information on the centres that participated. Data from the work sampling tools were transferred into Excel spreadsheet for analysis. Descriptive statistics were used to identify the proportion of the working day spent on each activity.

Ethics

Formal ethical opinion to conduct the study was not required as this was considered to be a clinical audit not involving active patient participation14. The questionnaires were approved by the local clinical audit departments at the participating SCICs for phrasing and grammar of the questions.

Statistical analysis

Descriptive statistics were used to calculate the response frequency. Data are reported as mean (s.d.) or median (range).

The workforce data were compared between SCICs and previous published figures6.Dietitian time spent on patient care and other related activities were compared between SCICs and by staff grade. For numeric data on an ordinal level, the Mann–Whitney test was used. The data was analysed using Minitab version 15 (Minitab Ltd, Coventry, UK) and significance was accepted if P<0.05.

Results

Medical and dietetic staff from 12 SCICs were approached (11 in the United Kingdom and 1 in the Republic of Ireland), 8 (66.7%) respondents (7 in the UK and 1 in the Republic of Ireland) completed and returned the questionnaire (Tables 1 and 2). The centres represented 390 of 531 (73.4%) UK and Ireland SCI beds (1 SCIC in the Republic of Ireland (n=36) and 7 SCICs in the United Kingdom (n=354); Table 2).

Table 1 Workforce distribution in UK & Ireland SCI centres
Table 2 Nutrition practice and management in UK & Eire SCI centres

For the 390 allocated beds, the mean numbers of beds per WTE staff (s.d.) were as follows: consultants: 20.3 (5.5); nurses: 1.1 (0.5); dietitians: 99.5 (51.2); physiotherapists: 5.4 (1.4); occupational therapists: 8.6 (2.9). The number of beds–staff ratio in SCICs were summarised in Table 2, when compared with the previously reported figures6 using Mann–Whitney test. There were no statistical significant changes in different staff groups (Table 3).

Table 3 Human resources allocation in participating SCICs

Numbers in WTE and grade of dietitians are summarised in Tables 2 and 3. The number of dietetic staff in SCICs ranged from 34 to 160 beds to a WTE dietitian.

Nutrition practice in SCICs

All SCICs reported that they used a nutritional screening tool. Six of eight SCICs (75%) used a validated nutrition screening tool (n=3: Malnutrition Universal Screening Tool15; n=3: Spinal Nutrition Screening Tool16 and the remainder (n=2) used a local un-validated tool). Six of eight (75%) SCICs reported they aim to complete nutritional screening within 24 h of admission and two of eight SCICs (25%) aim to complete nutritional screening within 48 h. The number of patients under dietitian care ranged from 30.4 to 82% of the allocated SCIC’s beds. None of the SCICs provided dietetic cover during the weekend and five of eight SCICs dietitians in SCICs wore a uniform.

Work sampling tool results

There were a total of 32 work sampling questionnaires (from 8 SCICs) completed and returned for analysis.

The median time reported in direct face-to-face contact with patients was reported to be 12.2% of the working day (Table 4). Assessing patients was the second highest activity recorded for direct care. The median time spent was 6.7% of the day. Monitoring patients was the third highest activity reported, contributing 5.9% of time, followed by liaison with health professionals (4.0%). In total, direct patient activities contributed to 39.1% of the working day in total.

Table 4 Proportion of the working day (%) spent in direct and indirect patient activity by staff grade

In total, 60.9% of the working day was spent on indirect activities. Most of the time (11.9%) was spent on patient’s administration such as writing reports or letters for patients. Other tasks such as e-mail, work prioritization or planning for meetings contribute to general administration, which take up to 11.2% of the working day. Clinical audit takes up to 6.6% and clinical supervision and team meetings are reported at almost 3–4%.

Discussion

The present study found that each WTE consultant covers18 SCI beds, and they now need to cover three more patients when compared with previous published figures (15 SCI beds)6, although this was a non-significant increase (P=0.153). Nursing and other allied health workforces were stable and in line with national recommendations12 (Table 1).

At the present time, no formal recommendation has been set by the specialist commissioners13 for optimal staffing level for dietitians. The present audit found that the provision of dietitians did not significantly improve in the last 5 years (Table 1). The number of staff in different SCICs still varied considerably (34 to 160 beds per WTE dietitian). This is comparable to the findings reported in other clinical specialties such as paediatrics,7 critical care,9 and thermal injury.10

Only three of eight (37.5%) SCICs meet the recommended dietitian to bed ratio 1:60 set by the SCI dietitians group of the British Dietetic Association (BDA)6. In addition, dietitians in five of eight (62.5%) SCICs still report covering >100 patients per WTE. A study by Windle9 found that the allocation for dietitians in the adult intensive care unit was also under resourced. Indeed, low staffing level issues were also highlighted in recent international SCICs survey.11 The variation in staff levels could be due to each SCIC having its own unique needs and challenges and therefore comparisons do have limitations (especially over a small sample of centres). However the impact remains; recent literature suggests malnutrition, including both under- and over-nutrition (obesity) is common in patients with SCI and it is associated with poorer clinical outcomes and increased healthcare costs17. Recently, health commissioners’ recognised the unique and important role of dietitians and support the inclusion of dietitians in the core multidisciplinary team for SCI care.13 However, the inconsistencies and inadequacies in dietetic provision suggest malnutrition will continue to go under-recognised and under-treated.

The median time spent in direct face-to-face contact was 12.2% (range: 5.1–22.7%) of the working day. This is comparable with other studies in medicine and nursing reporting that less than one-fifth of the working day is spent via direct face-to-face contact.18, 19

In the present study, the amount of all direct patient contact totalled to 39.1% of the dietitians’ time. Health professional liaison, multidisciplinary team meetings and education were included in direct activity (4.9%). Indeed, spinal dietitians are required to communicate with other professionals and carers to formulate and deliver nutritional care plans for patients. Therefore we would count these activities as direct patient contact, however, communication-related activities were classified as indirect contact in previous research.19 Consensus was agreed prior to data collection by all participants.

This study reported that 39.1% of working time is spent on direct patient’s activity. If we take account of patient’s administration, such as writing clinical letters as direct patient activity, the adjusted total direct patient activity will be 49.1%. This is still low when compared with literature reporting paediatric dietitian (58.9% on direct patient’s activity)7 and the BDA that 75% of dietetic time is spent in actual direct patient contact19. Therefore, the BDA recommendation (75%) may not accurately reflect the proportion of time dietitians spend on indirect patient contact, nor indeed any other professionals. Further research on what constitutes direct activity is required to ensure that different studies are comparable and classify work in the same manner. The present study found that dietitians with a senior grade spend less time in direct patient contact when compared with those of a junior grade (Table 4). This may be a result of inexperience in the junior grades (who may take longer to complete a nutrition assessment) and senior staff spending more time in additional roles such as involvement in discharge planning of complex patients.

There were a number of limitations in previous literature reporting provision of human resources and nutrition practice in the UK and Ireland SCICs. These include a lack of activity-based data to support the recommendations.6 The previous study primarily focused on staffing levels in SCICs but, it failed to take into account the complexity of care, the amount of indirect care, telephone contacts and clinical outcomes, which in this study account for 60.9% of the working day. This is the first study to report activity in dietetic staff working in the UK and Ireland’s SCICs.

Previous recommendations from SCIC dietitians suggested dietetic staffing level of 1.0 WTE dietitian to cover 60 SCI beds6, although this figure may limit dietitians to attend multi-disciplinary team meetings and undertake research. Of note, the BDA does recommend that an extra 20% of staff time should be added when calculating for adequate levels of staff. The present study found that up to 12.4% of time was needed to cover absence (continue professional development, training and study leave—Table 4). After taking into account the required absence, the recommended staffing level would be 50 beds per 1 WTE dietitian, making the current provision seem even more inadequate.

Another important variance in staffing levels identified by the current study was the seniority of the dietitians. Only five of eight SCIC dietitians were funded at the recommended level of seniority, with one centre recruiting a newly qualified dietitian. As SCICs are specialist areas, it is inappropriate to expect a novice practitioner to have sole responsibility for the complex caseloads within SCIC, and may have effects that potentially compromise care.

Finally, in the present study, while six of eight SCICs reported using a validated nutritional screening tool, the nutrition-screening practices in SCIC are still below the recommendations set by National20 and International21 best practice guideline that all patients should be nutritionally screened on admission to hospital by a validated nutrition screening tool.

Limitations

Thirty-two days ‘work-sampling’ sheets were returned, with 10 of these originating from dietitians working in teaching hospitals. There are recognised limitations when using work sampling tools and time and motion studies, including the ‘Hawthorne effect’22 and overestimation of time spent completing an activity23, these problems are more apparent in continuous observation rather than self-reporting and therefore biases are likely to be limited in this study. The healthcare environment also presents issues around patient confidentiality or infection control that can limit the undertaking of time and motion studies, therefore only a small number of published studies are available and low data return rates for this important aspect of care.

In addition, problems in collecting workforce data include ‘definitional inconsistency’, in that there is no consistent approach for capturing activity data that can subsequently be compared with previous studies. There are problems in describing what constitutes direct or indirect patient care and problems in making comparison between centres and professional groups.4 A consensus approach was utilized to mitigate these factors within this study.

Conclusion

This study has updated the workforce data and reported on dietitian’s time and activity spent in SCICs in the UK and Ireland. The data sample can be considered to be indicative of activities undertaken by dietitians and may assist managers in their future workforce planning.

The study highlights staffing levels varied across the SCICs audited and some are below the professional recommendation6. Further research is warranted to assess whether optimised dietetic resources could prevent nutrition-related complications and a strategy to plan how to deliver services to achieve optimised clinical outcomes for patients with increasing limited resources; consistency in measurement of activity (and outcomes) would facilitate comparisons between studies and over time24.

Data Archiving

There were no data to deposit.