A Qualitative Study of Manager Experiences Using the RAFAELA System


Objective: The objective was to explore manager experiences using the RAFAELA system. Background: The RAFAELA system was developed in Finland during the 1990s to create a work situation where patients’ care needs were balanced with personnel resources. The system is used in almost all hospitals in Finland and is implemented in several European countries. However, the system has never been evaluated outside Finland. This study, focusing on the managers’ perspective, represents the second report from a larger Norwegian evaluation project of the RAFAELA system. Methods: An explorative qualitative design was chosen. Data were collected by individual in-depth interviews at a university hospital in Norway during 2012-2013. A total of 10 informants in various management positions were interviewed. The tape-recorded interviews were transcribed verbatim, and the transcripts were analysed using Kvale’s method for content analysis. Results: Four main themes emerged from the qualitative data: making the invisible visible; a common language; a system for prospective planning; and a resource-demanding tool. Conclusions: The study indicated that the RAFAELA system provided useful information about the patients’ care needs and nursing activities. Also the system provided a common reference frame for discussing nursing, staffing and allocation. Although the managers considered the RAFAELA to be time consuming in the implementation phase, they considered the system to be an important tool.

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Hustad, N. , Hellesø, R. and Andersen, M. (2015) A Qualitative Study of Manager Experiences Using the RAFAELA System. Open Journal of Nursing, 5, 1024-1032. doi: 10.4236/ojn.2015.511109.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Adams, A. and Bond, S. (2003) Staffing in Acute Hospital Wards: Part 1. The Relationship between Number of Nurses and Ward Organizational Environment. Journal of Nursing Management, 11, 287-292.
[2] Lucero, R.J., Lake, E.T. and Aiken, L.H. (2009) Variations in Nursing Care Quality across Hospitals. Journal of Advanced Nursing, 65, 2299-2310.
[3] McGillis Hall, L., Wodchis, W.P., Ma, X. and Johnson, S. (2013) Changes in Patient Health Outcomes from Admission to Discharge in Acute Care. Journal of Nursing Care Quality, 28, 8-16.
[4] Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S. and Wilt, T.J. (2007) The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care, 45, 1195-1204.
[5] Purcell, S.R., Kutash, M. and Cobb, S. (2011) The Relationship between Nurses’ Stress and Nurse Staffing Factors in a Hospital Setting. Journal of Nursing Management, 19, 714-720.
[6] Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L. and Neff, D.F. (2011) Effect of Nurse Staffing and Nurse Education On Patients’ Death in Hospital with Different Nurse Work Environments. Medical Care, 49, 1047-1053.
[7] Aiken, L., Sloane, D.S., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M.D., Moreno-Casbas, M.T., Rafferty, A.M., Schwendimann, R., Scott, A.P., Tishelman, C., Theo van Achterberg, T. and Sermeus, W. (2014) Nurse Staffing and Education and Hospital Morality in Nine European Countries: A Retrospective Observational Study. The Lancet, 383, 1824-1830.
[8] Pastastavrou, E., Andreou, P. and Efstathiou, G. (2014) Rationing of Nursing Care and Nurse-Patient Outcomes: A Systematic Review of Quantitative Studies. The International Journal of Health Planning and Management, 29, 3-25.
[9] Fasoli, D.R. and Haddock, K.S. (2010) Results of an Integrative Review of Patient Classification Systems (Chap. 11). Annual Review of Nursing Research, 28, 295-316.
[10] Perroca, M.G. and Ek, A-C. (2007) Utilization of Patient Classification System in Swedish Hospitals and Degree of Satisfaction among Nursing Staff. Journal of Nursing Management, 15, 472-480.
[11] Report No. 47 to the Parliament 2009. The Coordination Reform 2008-2009.
[12] South-Eastern Norway Regional Health Authority (2012) Annual Report.
[13] Fagerström, L., Rainio, A.-K., Rauhala, A. and Nojonen, K. (2000) Validation of a New Method for Patient Classification, the Oulu Patient Classification. Journal of Advanced Nursing, 31, 481-490.
[14] Fagerström, L., Rainio, A.-K., Rauhala, A. and Nojonen, K. (2000) Professional Assessment of Optimal Nursing Care Intensity Level—A New Method for Resource Allocation as an Alternative to Classical Time Studies. Scandinavian Journal of Caring Sciences, 14, 97-104.
[15] Rauhala, A. and Fagerström, L. (2004) Determining Optimal Nursing Intensity: The RAFAELA Method. Journal of Advanced in Nursing, 45, 351-359.
[16] Andersen, M.H., Lønning, K. and Fagerström, L. (2014) Testing Reliability and Validity of the Oulu Patient Classification Instrument—The First Step in Evaluating the RAFAELA System in Norway. Open Journal of Nursing, 4, 303-311.
[17] Fagerström, L., Lønning, K. and Andersen, M.H. (2014) The RAFAELA System: A Workforce Planning Tool for Nurse Staffing and Human Resource Management. Nursing Management, 21, 30-36.
[18] Fagerström, L. and Rauhala, A. (2007) Benchmarking in Nursing Care by the RAFAELA Patient Classification System. Journal of Nursing Management, 15, 683-692.
[19] Polit, C.F. and Beck, C.T. (2004) Nursing Research: Principles and Methods. 7th Edition, Lippincott Williams & Wilkins, Philadelphia.
[20] Patton, M.Q. (2002) Qualitative Research & Evaluation Methods. 3rd Edition, SAGE Publications, Thousand Oaks.
[21] Kvale, S. (2007) Det kvalitative forskningsintervju. Gyldendal Norsk forlag AS.
[22] Allen, D. (2007) What Do Nurses Do at Work? Profession Building and Doing Nursing. International Council of Nurses, 54, 41-48.
[23] Canzan, F., Heilemann, M.V., Saiani, L., Mortari, L. and Ambrosi, E. (2014) Visible and Invisible Caring in Nursing from the Perspectives of Patients and Nurses in the Gerontological Context. Scandinavian Journal of Caring Sciences, 28, 732-740.
[24] Hendrich, A., Chow, M., Skierczynski, B.A. and Lu, Z. (2008) A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time? The Permanente Journal, 12, 25-34.
[25] Cornell, P., Riordan, M., Townsend-Gervis, M. and Mobley, R. (2011) Barriers to Critical Thinking Workflow Interruptions and Task Switching among Nurses. The Journal of Nursing Administration, 41, 407-414.
[26] Harper, K. and McCully, C. (2007) Acuity System Dialog and Patient Classification System Essentials. Nursing Administration Quarterly, 31, 284-299.
[27] Whelchel, C., Berg, L., Brown, A., Hurd, D., Koepping, D. and Stroud, S. (2013) What’s the Impact of Quality Bundles at the Bedside? Nursing, 43, 18-21.
[28] Morris, R., MacNeela, P., Scott, A., Treacy, P. and Hyde, A. (2007) Reconsidering the Conceptualization of Nursing Workload: Literature Review. Journal of Advance Nursing, 57, 463-471.
[29] Brown, D.S., Donaldson, N., Burnes Bolton, L. and Aydin, C.E. (2010) Nursing-Sensitive Benchmarks for Hospital to Gauge High-Reliability Performance. Journal of Health Quality, 32, 9-17.
[30] Myny, D., Van Gouberger, D., Gobert, M., Vanderwee, K., Van Hecke, A. and Defloor, T. (2011) Non-Direct Patient Care Factors Influencing Nursing Workload: A Review of the Literature. Journal of Advanced Nursing, 67, 2109-2129.
[31] Harper, K. and McCully, C. (2007) Acuity Systems Dialogue and Patient Classification System Essentials. Nursing Administration Quarterly, 31, 284-299.
[32] Baernholdt, M., Cox, K. and Scully, K. (2010) Using Clinical Data to Capture Nurse Workload. Implications for Staffing and Safety. CIN: Computers, Informatics, Nursing, 28, 229-234.

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