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Feature
May 2014 | Volume 21 | Number 2 NURSING MANAGEMENT
Art & science | staff allocation
Correspondence
lisbeth.fagerstrom@hbv.no
Lisbeth Fagerstrm is a professor
of nursing science at Buskerud
and Vestfold University College
faculty of health sciences,
Kongsberg, Norway
Kjersti Lnning is a nurse
manager
Marit Helen Andersen is a
researcher
Both at Oslo University Hospital,
Norway
Date of submission
February 18 2014
Date of acceptance
March 31 2014
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
nm.rcnpublishing.com
The RAFAELA system: a workforce
planning tool for nurse staffing
and human resource management
Lisbeth Fagerstrm and colleagues describe a method
pioneered in Finnish hospitals that aims to uphold
staffing levels in accordance with patients care needs
Abstract
The RAFAELA system was developed in Finland
during the 1990s to help with the systematic and
daily measurement of nursing intensity (NI) and
allocation of nursing staff. The system has now been
rolled out across almost all hospitals in Finland,
and implementation has started elsewhere in
Europe and Asia. This article describes the system,
which aims to uphold staffing levels in accordance
with patients care needs, and its structure,
which consists of three parts: the Oulu Patient
Classification instrument; registration of available
nursing resources; and the Professional Assessment
of Optimal Nursing Care Intensity Level method, as
an alternative to classical time studies. The article
also highlights the benefits of using a systematic
measurement of NI.
Keywords
Nursing intensity, staffing, care needs, leadership,
nursing resources, management, human resource
management
ECONOMIC PRESSURE on the European healthcare
sector has increased in recent years, and changing
age profiles and a surge in the number of older
people will continue to affect healthcare systems
perhaps more than we can imagine (Butler and
Volkov 2010). Throughout Europe, politicians call
for more cost-effective healthcare service systems
(Finnbakk et al 2012), but at the same time laws are
passed that ensure people have the right to high
quality care and treatment. Additionally, there is
increasing emphasis on evidence-based care, patient
safety and person-centred care.
International research shows a clear
association between nursing staff resources and
nursing-sensitive quality indicators, patient safety
issues, mortality rates, work environments and job
satisfaction (Aiken et al 2002, Rafferty et al 2007,
Needleman et al 2011). Nursing resources are
often the largest budgetary expenditure in
healthcare systems, so it is necessary to ask
whether nursing staff are allocated accurately in
accordance with patients care needs or whether
resources are wasted due to traditional allocation
planning methods.
The Royal College of Nursing (RCN) guidance
on safe nurse staffing levels in the UK (RCN 2010)
states that the issue of what constitutes the optimal
number and mix of nurses required to deliver good
quality care as cost effectively as possible has
become a perennial question.
Interest in developing instruments and systems
for measuring nurse staffing levels began in the US
in the 1940s and 1950s (Alward 1983, Fagerstrm
1999). The primary objective of such initiatives has
been to achieve suitable staffing levels to enable
nurses to meet the constant variation of patients
care needs (Giovannetti 1979). In the 1960s, time
study methods were taken from industry and
applied to hospitals, and this approach became
the primary method for calculating nursing
resources (Procter and Hunt 1994).
There are many instruments and systems in
hospitals or primary healthcare environments that
are used to measure nursing intensity (NI), nursing
31 NURSING MANAGEMENT May 2014 | Volume 21 | Number 2
workload, patient dependency levels, nurse staffing
and nurse-patient ratios (RCN 2010).
Most, however, have significant flaws: they have
not been scientifically tested; they can be time
consuming; the software programs do not support use
of the information gathered; managers fail to use the
data collected; and it is difficult to compare systems
(Fagerstrm 1999, Rauhala 2008, RCN 2010). Further,
while nurse-patient ratios are easy for politicians and
the public to understand, and hopefully guarantee
a minimum ratio, managers are the ones who must
realise such guarantees in everyday care.
Peoples unique and individual characteristics, such
as gender, age, state of health and contextual factors,
affect their care needs and consequently affect nurses
workload and NI. The workload of nurses can be
measured by patient classification systems, based
on the measurement of NI. However, it is important
to make the distinction between patient-related
and ward-related workload. NI measures only the
patient-related, direct and indirect, workload of
nurses and does not include their ward-related
work (Morris et al 2007).
Various factors influence the need for nursing
resources, and a resource allocation system in which
nursing staff are merely divided evenly between
patients is not sufficient (Rauhala and Fagerstrm
2007); there must be a balance between nursing
resources, NI level and patients actual needs.
The RAFAELA system
The RAFAELA system was developed for hospital
settings in Finland in the late 1990s (Fagerstrm
1999, Pusa 2007, Rauhala 2008); its name is derived
from the surnames of the original research group
members. The validity of the RAFAELA systems
measurement tools, and its feasibility for use in
human resource management in nursing, have been
assessed in four doctoral dissertations (Fagerstrm
1999, Pusa 2007, Rauhala 2008, Frilund 2013).
Nurse managers can use this tool to balance
patients care needs and nursing resources, to
indicate optimal nurse staffing levels. The core idea
is to ensure that the workload per nurse, expressed
in NI points, is at the optimal NI level, thereby
assuring the quality of nursing, patient outcomes
and working conditions for staff and the effective
use of resources (Fagerstrm 1999).
The theoretical framework of the system is
based on two perspectives: the nursing science
perspective, which encompasses a holistic view
of people, the importance of human needs and the
complexity of nursing (Fagerstrm 1999, 2009); and
the human resource management perspective, which
emphasises the importance of a top-down approach,
a belief in staff competence, and the importance of
a strategic and engaged leadership (Rauhala 2008,
Fagerstrm 2009). Nurses perspectives are crucial
in assessing what nursing resources are needed for
high quality care.
Structure and implementation
The RAFAELA system consists of the following
components:
Instruments for measuring NI in different
contexts daily registration of patients using
the Oulu Patient Classification qualisan (OPCq)
instrument, a generic instrument for all hospital
specialties; the Pitkniemi Patient Classification
qualisan (PPCq) for mental health care; the
Poliklinikka Hoitoisuus qualisan (POLIHOIq)
for outpatient departments and emergency
rooms; the Perioperatiivinen Hoitoisuus qualisan
(PERIHOIq) for operating and recovery rooms, and
for day surgery; and the Sdehoito Hoitoisuus
qualisan (SDEHOIq) for radiation therapy.
Staff resources: daily registration of actual
nursing staff resources (in numbers of nurses).
Determination of optimal NI level using the
PAONCIL instrument over a period of between
four and six weeks.
Financial information, sent in by organisations
annually for calculating costs and
benchmarking purposes.
The OPCq instrument, used to measure daily
NI inpatient settings, consists of six needs and
the nursing activities connected to the following
nursing domains:
Planning and co-ordination of nursing care.
Breathing, blood circulation and symptoms
of disease.
Nutrition and medication.
Personal hygiene and secretion.
Activity, sleep and rest.
Teaching, guidance in care and follow-up care,
and emotional support (Fagerstrm 1999).
Nursing intensities can vary for each domain
between 1 and 4, and the points are added up to
give a range of between 6 and 24 NI points per
patient. The total sum of NI points for a unit is
calculated by adding all NI points. Thereafter, the
total unit NI is divided by the total number of nurses
caring for patients in the unit during that calendar
day. For example, given a total unit NI of 240 points
and ten nurses in the unit, the actual workload per
nurse is 24 NI points.
The validity and reliability of the OPCq
instrument has been tested by different methods
and from various angles (Fagerstrm et al 2000a,
Rauhala 2008, Frilund and Fagerstrm 2009).
32 May 2014 | Volume 21 | Number 2 NURSING MANAGEMENT
Art & science | staff allocation
The validation process started with an assessment
of patients perceived care needs compared to the
content of the OPCq manual (Fagerstrm et al 1998).
Using expert nurse panels, the content validity was
then tested with good results in hospital (Fagerstrm
2000) and primary healthcare settings (Frilund
and Fagerstrm 2009). Thereafter the construct
validity of the OPCq instrument was established in
two Finnish hospitals (Fagerstrm et al 2000a).
Most recently the construct validity was found to
be at the same good level as in a comparable study
at Oslo University Hospital (Andersen et al 2014).
Reliability testing of the OPCq instrument by parallel
classifications at each unit where the instrument
is in daily use should occur annually (Frilund and
Fagerstrm 2009). The implementation process of
the RAFAELA system is shown in Figure 1.
After testing the reliability of the OPCq
classifications, the PAONCIL instrument is
applied. This is an alternative to classic-time studies
(Fagerstrm et al 2000b) and can be described as
nurses professional assessment of the sufficiency
of resources in relation to the actual NI of patients
during a shift (Fagerstrm and Rainio 1999). The
content validity of the PAONCIL instrument, including
its manual, was evaluated in a mixed-method design
study at the beginning of 2000 in two hospitals
(Fagerstrm et al 2002).
Optimal NI is the intensity that every trained
professional nurse working in a unit can manage
without compromising the standard of care
determined for the unit. The level of optimal NI
that is obtained after the PAONCIL study can vary
within 15% either side of the optimal point to create
a good reference area for the unit (Figure 2). The
workload per nurse should fall in this optimal area,
for example 70% of the time.
Using the PAONCIL instrument, an optimal
NI level is determined for each unit on the basis
of nurses professional assessments over at
least three weeks. Every nurse makes an overall
assessment at the end of each shift or before leaving
the department, which determines whether the
nursing resources have been enough in relation to
patients needs and NI. He or she does so on a scale
from -3 to +3, on which a score of 0 is considered
optimal and indicates that the number of nurses is
balanced with patients needs and NI, and that staff
have had the opportunity to provide good care.
The optimal staffing level of a unit can be
established through linear regression analysis of the
results of the OPCq points per nurse and PAONCIL
scores (Rauhala and Fagerstrm 2004). When using
the PAONCIL instrument, we recommend that the
study should be repeated every second or third year,
or after organisational or extensive staff changes.
The PAONCIL instrument includes 12 additional
questions aimed at revealing non-patient factors that
can affect nurses workload during a shift. These
include aspects of organisation and planning of
work, managerial roles, staff situations, meetings,
training events or other absences, students and
co-operation with doctors. By analysing these,
nurse managers can determine which might be
stressing nursing staff or easing the overall work
situation (Rauhala and Fagerstrm 2007).
Figure 2 Nursing intensity per nurse in July 2011 in relation to the
good reference area of a Finnish surgical unit
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Figure 1 The process to implement the RAFAELA system
Introducing the RAFAELA system
OPC classification, two to three months
Reliability testing through parallel classification
(Modified from Frilund and Fagerstrm 2009)
PAONCIL assessments, at least three to four weeks
The optimal OPC points per care giver and unit
Over optimum
Optimum
Under optimum
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33 NURSING MANAGEMENT May 2014 | Volume 21 | Number 2
The credibility and usefulness of the RAFAELA
system was tested in 14 Finnish hospitals between
2000 and 2002 with good results (Fagerstrm
and Rauhala 2003). After this initial testing, the
Association of Finnish Local and Regional Authorities
took ownership of the system, while the Finnish
Consulting Group Ltd is charged with overseeing the
license system, quality assurance and staff education
(Fagerstrm and Rauhala 2003, 2007). More than 90%
of Finnish hospitals have implemented this system,
and the process has been underway in Iceland since
2010, Norway since 2011, and the Netherlands,
Sweden and Vietnam since last year.
Benefits
The RAFAELA system is a tool that can be integrated
into an organisations management and patient
administrative systems. The system uses data on
patients care needs and nurses workload, and
provides an effective platform for the management
of nursing resources, operatively and strategically.
It enables efficient allocation of nursing resources
over time in accordance with patients real care
needs; it also has a positive effect on nurses clinical
practice and therefore influences patient outcomes.
Once the system is integrated into a unit with
nurses classifying every patient each calendar day
and performing daily registration of available nursing
resources the system provides information in
four main domains: patients need for individual care,
nurses workload, nursing staff costs, and productivity
of nursing staff (Fagerstrm and Rauhala 2007).
With the system it is possible to:
Improve person-centred care for patients, by
starting with the care needs of each individual.
Improve workforce planning and decrease
staff costs, for example through effective
allocation of available resources and reducing
the need for deputy, or assistant, nurses, acute
replacements or permanent reserves. The system
also provides information for budget planning
and cost calculation.
Improve quality and manage risks better, by
taking patients individual care needs, not just
their number and diagnoses, into account.
Optimal workload per nurse reduces the
incidences of mistakes and adverse events
and so improves safety.
Increase nurses job satisfaction and decrease
the amount of sick leave taken, by allocating
resources optimally to create a better balanced
and more equally distributed workload.
Enhance patient documentation, by having daily
and systematic classifications based on nurses
experiences and the nursing documentation
recorded in each patients record. Better
documentation gives a more reliable
classification of NI.
The RAFAELA system provides different kinds
of information, in the form of reports that can be
used for various purposes by staff nurses, nurse
managers at various levels and politicians. Below
are examples of how nurse managers can use
the information derived from the system when
developing person-centred care and in evidence-
based human resource management.
Figure 3 shows an example of a RAFAELA system
report of patients need for care and the associated
NI, measured using OPCq. The report shows the
average NI points for two patient groups, those
with cerebral infarction (Diagnosis Related Group
(DRG) 14) and those with rhythmic cardiac disease
(DRG 139) during one year. Figure 3 shows that
patients with cerebral infarction require on average
a higher NI than those with rhythmic cardiac
disease. The data were measured using the OPCq
instrument, which measures domains not commonly
calculated by other instruments including planning
and co-ordination of care, teaching, guidance in care,
follow-up care, emotional support and relatives
need for support and guidance.
The inclusion of the first domain in the OPCq
instrument has proved to be a wise decision;
traditionally, planning and co-ordination of care have
been categorised as indirect care but are deemed
prerequisites for efficient care pathways under this
system. For example, the average age of patients
with rhythmic cardiac disease is lower than that of
patients with cerebral infarction, and these patients
can usually take care of their hygiene once discharged
Figure 3 An example of a RAFAELA system report of patients need for care and
nursing intensity, measured using Oulu Patient Classification qualisan

Patients with cerebral infarction

Patients with rhythmic cardiac disease
Planning Symptoms Nutrition and Hygiene Activity Support

medication
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34 May 2014 | Volume 21 | Number 2 NURSING MANAGEMENT
Art & science | staff allocation
from the hospital. Cerebral infarction, however, often
leads to aphasia or decreased physical functioning, so
patients and their relatives need guidance in self-care
and follow-up care before discharge.
The OPCq instrument has been regarded as rather
broad with six needs domains (Fagerstrm 1999);
however, when the classification of each patients
needs and NI requirements occurs daily, a sensitive
picture of patients constantly changing acuity is
revealed. The value and importance of person-
centred health information, mentoring, trust and
support cannot be overestimated, and the structure
of the OPCq reminds nurses of the most central
dimensions in nursing.
A head nurse can also refer to RAFAELA system
reports during discussions about aspects of care
quality such as the use of working time and the
prioritisation of nursing activities. At the Oslo
University Hospital, head nurses hold monthly
meetings with their staff and on the clinical level with
the management team to discuss patients NI profiles.
Figure 2 shows a RAFAELA system report that
encompasses the main characteristics of the system;
that is, nurses workload compared to a units optimal
NI level. When the system is used every day, a units
head nurse can plan and allocate staff proactively on
the basis of the data collected the previous day or
over the most recent period, and adjust staffing so
that an optimal workload is achieved.
The data in Figure 2 was measured using the
PAONCIL instrument. On this unit, nurses workload
was at an optimal level 58% of the time (18 days),
while for 23% of the time (seven days) patients
NI requirements were higher than staff resources.
Nurses also experienced six lighter days (19% of
the time) with low workload. Such reports can be
generated monthly or from several years worth of
data and can show how the average workload per
nurse has increased, decreased or remained the same
during a five-year period, for example, or seasonally.
Senior managers can compare the workload per nurse
between units, clinics or even hospitals.
After three years of using the RAFAELA system
at the Oslo University Hospital, it has been found
that the reports generated are particularly useful
when discussing allocation of nurses or planning
staff resources. It can help establish, for example,
whether the reorganisation of a units activities is
likely to result in a more stable workload per nurse,
in line with the optimal NI level.
The RAFAELA system reports are easy to
comprehend, and patients and their relatives can
also use them to understand the care provided on a
unit. Would patients, for example, elect to be cared
for on a unit in which nurses are working more than
optimally most of the time? Would patients choose
this unit or hospital?
These questions are pertinent to countries in
which patients have the right to choose where
they receive care.
Figure 4 is an example of a RAFAELA system
benchmarking report that shows in percentages the
number of days over the optimal NI level (red areas),
at the optimal NI level (green), and under the optimal
NI level (yellow). The information is displayed as
a traffic-light rating system, where one bar can
represent a single unit, clinic or division, hospital,
region or country.
The example in Figure 4 is a benchmarking report
from Finland and shows the workload situation of
nurses at one 16-unit hospital in 2011. Such reports
give nurse executives, nursing directors or nursing
staff co-ordinators an overview of staff workload,
and the data can be used easily to compile other
kinds of reports about job satisfaction, sick leave,
adverse events or nurse-patient ratios.
According to nurse managers experiences
in Oslo, combinations of different reports give
a comprehensive and rich overview of nurses
work situations, and can highlight problems in a
new way so that innovative solutions can be found,
for example to improve patient outcomes or nurses
work situations by allocating more staff.
Where the RAFAELA system is in use in Finland,
data on areas such as staff costs, staff structure
and the organisational model of nursing are
collected from units (Fagerstrm and Rauhala 2007)
for an annual national comparative report, covering
more than 1,000 care providers. These comparative
data are combined with NI data and compiled in a
benchmarking report that is delivered to RAFAELA
system users once a year.
The report delineates, for example, the mean
annual level of patients NI, available human
resources, actual skill mix, NI per nurse, and
staff costs per organisation and specialist field,
among other variables.
Discussion
Leaders and nurse managers can use RAFAELA
system reports with other reports regarding patients
and organisational characteristics when considering
nursing resources in daily staff planning and in more
strategic planning. At Helsinki University Hospital, the
RAFAELA system is used to allocate working hours,
network with different units, plan patient flows and
define costs per length of stay (Aschan et al 2009).
It also provides evidence for difficult decisions,
for example about decreasing or increasing unit
resources or cutting staff costs. The reorganisation
NURSING MANAGEMENT May 2014 | Volume 21 | Number 2 35
of units or hospitals is common and usually
involves reallocation of nursing resources, so it
is an advantage during such processes to have
the data produced by the RAFAELA system.
The system is also used for productivity
analyses, cost calculations and pricing hospital
services (Rainio 1996, Pusa 2007). If nurse managers
are to improve their evidence-based human resource
management, they need reliable and easy-to-use
systems that are not too time consuming, yet yield
practical and reliable data.
Implementation of the RAFAELA system should
be supported by organisational leaders; if it is not,
nurses may not be motivated to classify each patient
every day (Rainio and Ohinmaa 2005) as the process
requires commitment. Experiences from Finland,
Iceland, Norway and other countries indicate that
nurses need to know that their managers support
the system and use the data. This is a central
motivating factor for staff nurses to continue
with daily classifications.
A standardised RAFAELA reporting system
for different management levels is recommended,
so that, for example, weekly and monthly reports
can be discussed on units and at clinic level,
while annual reports can be addressed to senior
management. The RAFAELA system provides reliable
information about NI and the need for nursing
resources, and is a feasible tool for knowledge
management; in other words, that decision making
is based on valid data (Aschan et al 2009).
The RAFAELA system is based on research and
is usually considered by nurses and managers as
easy to use, while remaining complex in terms of
all the possible uses of the data. Project leaders in
Oslo found the implementation process to be more
time consuming than expected (Andersen et al
2014). A longer implementation process can improve
learning among nurses and leaders on different
levels, however, in that the question What is good
nursing care? is discussed continuously.
The research results from Oslo show that the
RAFAELA system is reliable (Andersen et al 2014),
but continuous quality assurance and training in use
of the system are necessary for staff nurses and new
leaders. Research from Finland, meanwhile, shows
that a usually part-time co-ordinator is needed to
manage the system in the long term (Fagerstrm and
Rauhala 2003). Co-ordinators can take responsibility
for quality assurance in relation to the use of the
system, availability of and accessibility to reliable
data, arrangement of annual reliability tests,
organising training sessions or internal seminars for
nurses and leaders, and ensuring that the benefits
of the RAFAELA system database are realised.
Co-ordinator positions have been established in
many Finnish hospitals to support nurses with
making daily and reliable classifications, to take
responsibility for training new staff in using the
system, and to arrange seminars and workshops
to maintain staff motivation.
A systematic review and meta-analysis of staffing
levels and patient outcomes by Kane et al (2007)
found an association between high nurse-patient
ratios and low hospital-related mortality and fewer
adverse patient events. The authors note that the
strength of the association between nurse staffing
and patient outcomes can be affected by the
method used to calculate staff resources. Patients
care needs and NI, not nurse-patient ratios, are the
foundations of the RAFAELA system.
According to Lang et al (2004), the literature
offers minimal support for specific minimum
nurse-patient ratios for units in acute care hospitals,
and shows that the use of minimum nurse-patient
ratios alone seems to be inadequate in ensuring
good quality care. Lang et al (2004) recommend
that patient acuity, nursing skill mix and nurse
competence are among the variables that should be
considered when delineating staffing requirements.
One weakness of the RAFAELA system is that
the nurse competence variable that can be included
in the PAONCIL instrument has not been used to
its full potential, and this should be considered in
further development of the system.
There are many uses for the data produced by the
RAFAELA system; it can be used to determine cost
calculations per hospital day and length of stay,
for example (Rainio 1996). A multicentre study using
the RAFAELA system suggested that, if NI per nurse
Figure 4 Sample comparative database from RAFAELA for a 16-unit hospital
in Finland in 2011

Over optimum

Optimum

Under optimum
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May 2014 | Volume 21 | Number 2 NURSING MANAGEMENT 36
Art & science | staff allocation
Conflict of interest
None declared
Online archive
For related information, visit
our online archive and search
using the keywords
Aiken LH, Clarke SP, Sloane DM (2002)
Hospital nurse staffing and patient mortality,
nurse burnout, and job dissatisfaction.
Journal of the American Medical Association.
288, 16, 1987-1993.
Alward R (1983) Patient classification systems:
the ideal vs reality. Journal of Nursing
Administration. 13, 14-19.
Andersen MH, Lnning K, Fagerstrm L (2014)
Testing reliability and validity of the Oulu
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is above the optimal level, sick leave lasting more
than three days increases (Rauhala et al 2007),
which suggests that the optimal NI level has
a positive effect on nurses health.
Conclusion
The successful implementation and use of the system
depend to a great extent on nurse managers interest
and competence in using the different reports
and data. After 15 years of systematic use of the
RAFAELA system in Finland, and based on experiences
elsewhere, the authors believe that nurses, managers
and organisations can benefit from the data the
system produces (Rainio 1996, Rainio and Ohinmaa
2005, Pusa 2007, Aschan et al 2009).
The most important factor is nurses commitment
to the system and their daily and reliable classification
of patients needs and NI. Nurse staffing, quantitatively
in terms of people and qualitatively in terms of
competence, is an important issue for healthcare
research. It should be analysed in relation to work
conditions, organisational structure and leadership
support, and an overview of nurses work situation
should be undertaken so that patient outcomes can
be improved (Aiken et al 2002).
Data from the RAFAELA system can be related
easily to data from patient safety systems. A new
research project has started in Finland, the aim of
which is to show the association between patients
needs, NI and mistakes in nursing. Preliminary
analyses indicate that more mistakes occur when
workload per nurse, as measured in NI points, is
above the optimal NI level. Nonetheless, further
analyses of more comprehensive data are needed.