'Nursing Manpower' for Neonatal Surgical Intensive Care Unit Seema Sachdeva, Raman Kalia, Prema Menon Abstract : Nurses are one of the major components of manpower in the field of healthcare. The skills and knowledge of nursing personnel may be directed towards health promotion, crisis intervention, maintenance, rehabilitation/restoration or palliation in care of critically ill patients. The complexities of medical and surgical interventions undertaken in hospitals require an ever bigger and more sophisticated clinical workforce. The nursing service department strives to increase the number of well trained nurses to provide quality care to patients. The present study was conducted to explore the nursing manpower required for Neonatal Surgical Intensive Care Unit (NSICU), PGIMER, Chandigarh during the period of 2008-09. The study population comprised of the total number of nursing activities performed during study period. Based upon 'work measurement' concepts, all nursing care activities were observed for their average time and their frequency. Total calculated time (frequency x average time) was utilized to determine the number of nurses required for unit. The results of the study revealed that thirty four nurses were required for 24 hrs in NSICU, PGIMER Chandigarh for an average census of twenty three patients. The study recommends the nurse administrators to adopt such more sophisticated work measurement methodologies to determine the nursing workforce to deliver the quality care to newborns.
Key words : Nurse manpower, frequency of nursing care activities
Correspondence at : Dr. Raman Kalia, Principal Swift Institutes of Nursing, Village Ghaggar Sarai Rajpura, Distt. Patiala
Introduction Nursing is a profession in terms of specialized knowledge, usage of scientific methods, subsequent enlargement of knowledge, social value, practical ethics and ser vice to public. 1-2 Nursing personnel comprises of almost half of all employees in health care set up.3 Nurses have significant contribution in the recovery of patients and sufficient number of nurses are required to maintain acceptable standard of care.4 Due to
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advancement in health care technology, there has been expansion of nursing services, specialization and diversification of traditional role of nurses. In this changed role, accountability and quality of nursing services are expected more than ever.5 Therefore it is a sensitive issue to re-examine nurse patient ratio to provide safe, economical and quality care to patients. 6 Research conducted on issue of nurse patient ratio has concluded that higher nurse to patient ratio affects quality of treatment, high stress level and mental exhaustion among nurses, leads to increase in mistakes, accidents and ultimately increase in malpractice suits.7 A survey conducted in Pennsylvania, which included the report from 168 hospitals, showed that with the increase in nurse patient ratio from 1:4 to 1:6 neonatal mortality rate increased to 7% and an elevation from 4 to 8 patients per nurse resulted in 14% increase in mortality rate8. In January 2004, US first staffing ratio law, mandated a minimum nurse to patient ratio of 1:2 in intensive care units, 1:3 in pediatric care unit: 1:4 in oncology and 1:6 in general wards and internal medicine units. 4 Review of literature revealed a number of flexible nurse staffing models for the calculation of nursing staff for a unit are based on patient census, admissions per shift to provide ideal number of registered nurses. A patient service associate (PSA) model to staff the unit included the average time and frequency of task per shift to calculate the nursing hours per patient which is an impor tant indicator for nurse manager to
monitor or to assign nurse per patient ratio.9 However universally acceptable nurse staffing standard cannot be fixed due to variety of factors like demographic str ucture, technology, personnel quality, organizational and managerial competence. Mandating nurse staffing standard will aver t substantial worsening of quality of care associated with high nurse patient ratio.10 The policy makers needs to make decisions on nurse staffing ratio in terms of nursing productivity, nursing quality, clinical and economical factors.11 There is paucity of data related to nursing manpower requirement for neonatal units in Indian scenario. Moreover there is absence of any specific policy or guidelines available to decide nurse to patient ratio in Neonatal Surgical Intensive Care Unit at APC, PGIMER, Chandigarh. Thus the present study was undertaken to explore the adequate nurse to patient ratio to promote safe and quality care patient. Objectives To determine the nursing manpower requirement for Neonatal Surgical Intensive Care Unit, Advance Pediatric Centre, PGIMER, Chandigarh, 2008-09. Materials and methods An explorator y study design was employed to calculate the number of nurses required, in Neonatal Surgical Intensive Care Unit (NSICU), Advance Pediatric Center, PGIMER, Chandigarh, in the month of August 2008. The Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh
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was conceived in 1960 as a centre of excellence in an endeavour to develop patterns of best clinical services and teaching in postgraduate medical education. The centre was mandated to provide high quality patient care, attain self- sufficiency in postgraduate medical education and to meet the country's need for highly qualified medical teachers in all medical and surgical disciplines. PGIMER Chandigarh is one of the ter tiary care hospitals of India to provide medical, paramedical, educational services and to promote research. Advance Pediatrics Centre was attached to PGIMER, Chandigarh in 1996 as an exclusive child care centre to provide all diagnostic, curative and rehabilitative and follow up services to pediatric population. Neonatal Surgical Intensive Care Unit (NSICU) is situated at sixth floor, B block of Advance Paediatric Centre. Newborns with congenital malformation which require surgical interventions are admitted in this unit. NSICU has three units for patients care i.e. Intensive care unit, recovery unit and private unit. Intensive care unit has been designed to treat the neonates who are critical ill, hence require close observation and constant monitoring while recovery unit and private unit have been set for neonates who are clinically stable and recovering from illness. Target population and sample for the present study was all nursing care activities, carried out in NSICU during study period. Concepts of present study were derived from work measurement for manpower planning. 12 Based upon these concepts, the study was
conducted into three phases: planning phase (for development of tool), actual work measurement phase (for data collection) and measurable output phase (for calculation of nurses manpower). The tool was designed in 'planning phase' and it comprised of 'Nursing care activities sheet'. This sheet was further divided in two parts: average time record sheet to record the time of each nursing activity and frequency sheet to observe the frequency of each nursing activity. Tool was validated from experts in the field of paediatric surgery and nursing. Pilot study was conducted in similar settings on 21st and 22nd July 2008, to observe the feasibility and practicability of tool. During pilot study five routine nursing care activities were selected as sample size to observe their time and frequency in all units of NSICU (ICU, Recovery unit and Private unit). The tool for data collection was found feasible during pilot study. In second phase of the study i.e. 'actual work measurement phase' data collection was done. Data was collected in the month of August 2008. Verbal consent was taken from study subjects and they were made clear that study was not an evaluation of individual performance. Activities were divided into direct and indirect patient's care activities. The direct patient care activities were concerned to individual patient, admitted in ward like: providing hygiene care, monitoring vitals, nutritional care, therapeutic care, assisting physician, attending rounds, taking and handing over and census related activities etc whereas indirect patient care activities performed by nurses were common to all
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patients and not related to individual patient care eg. supervision, maintaining cleanliness, taking and handing over the charge of resuscitators, communication, taking break, etc. Three observations of time were done to determine average time for each nursing activity by using a stop watch. Time observations were done separately for ventilated and non ventilated patients in all unit of NSICU except private unit as there was no patient on ventilator support in this unit. Frequency of nursing activities was derived from observations and records. Total time for each nursing care activity was calculated for all subunits of NSICU by using the following formulae. Total time = Total frequency X Average time for nursing care activity Total time for nursing activities per day was calculated by adding the time for all individual nursing activities carried out in all subunits of NSICU.
Total time/day (NSICU) = Time/day (ICU) + Time/day (Recovery) + Time/day (Pvt. Unit) A statistical formula developed by Mitchell and Gesick9 was used to calculate the number of nurses per day from total time to provide nursing care. Number of nurses required/ day = Total time/day required for providing patient care for 24 hrs + 8.33% allowance period* Nursing work shift hrs *The allowance time period (8.33%) was taken to calculate the task which could not be measured directly like communication, travel time, sitting for a while for personal fatigue, etc. Results A census was maintained on daily basis of NSICU during study period (1-8-08 to 31-8-08). An average census per day for NSICU was 23 patients (for all units). A daily maintained census was described using following figure.
Figure 1: Census of NSICU from 1-8-08 to 31-8-08 Nursing and Midwifery Research Journal, Vol-6, No. 2, April 2010
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A seprate census sheet was maintained for all units of NSICU on daily
basis during study period. An average census has been described by using following table (Table -1)
Table 1 : Average census for all units of NSICU (1-8-08 to 31-8-08) S.No
Units of NSICU
Average number of patients Total Census Ventilated patients Non ventilated patients (1-8-08 to 31-8-08)
1
ICU
3
3
6
2
Recovery unit
2
14
16
3
Private unit
--
1
1
A total of 701 patients were observed during study period and ninety five nursing activities were observed for their average time and frequency. Table (2) depicts the average time for direct patient care activities for ventilated and non ventilated patients and time for indirect patient care activities in all units of NSICU. The results (table 2) revealed that there is difference in average time of nursing activities for ventilated patient (V) and non ventilated (NV) patients. The activities required the maximum time period were; Assisiting the physician in patient care activities ( assisting in insertion of chest tube drainage, assist in dressing, assist in catheteraization , putting central line ) followed by time period required for admission and discharge or death related activities.On the other hand, certain activities which required the minimum time period were; monitoring weight, monitoring vital signs, taking and handing over the charge and change of nursing record charts.
Direct patient care activities like assisting physician in patient care activities required more time for ventilated patients (166.49 min) than non ventilated patients (77.04 min) in ICU.Whereas for recovery unit of NSICU, the time required was more in case of non ventilated patients (206.23 min) than ventilated patients(186 min) for the same activity. Certain activities like therapeutic care (82.45), taking and handing over the charge (5 min), providing body hygiene (31.5 min) required more time for patients on ventilator support for both units of NSICU. However, there was variation of time required for certain nursing activities among all three unit of NSICU, e.g. time required to provide nutritional care to non ventilated patients is more in recovery unit (32.08 min) than ICU and private unit (21.56 min and 9.33 min respectively).Time for indirect care activities, which were common for ventilated and non ventilated patients was consuming more time in ICU (187 min) than recovery unit (156 min) and private unit (141 min).
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Table 2 : Average time for nursing activities in ICU, Recovery and Private Unit Nursing care activities
Direct care activities Routine hygiene care Monitoring vital signs Oxygen administration Nebulization Suctioning Nutritional care Ventilator related care Therapeutic care Checking weight Assisting physician in patient care activities Attending rounds Care of ostomies Phototherapy care Canulation Change of daily nursing care charts Documentation Taking and handing over charge of patient Admission related activities Discharge activities Care of dead patient Indirect care activities
Average time (min: sec) ICU Recovery Private V NV V NV NV 31.50 30.36 5.47 5.33 --2.35 --2.31 14.15 16.25 20.00 21.56 52.64 --82.45 57.27 3.45 3.33 166.49 77.04 10.00 10.00 ----10.05 10.05 13.00 11.00 5.05 6.11 8.00 8.00 5.00 3.45 54.00 49.05 --25.1 45.00 --187.00
30.35 23.46 18.33 5.47 5.30 5.30 --2.35 2.35 --2.24 3.10 12.45 15.30 6.34 19.00 32.08 3.22 31.28 ----91.00 51.14 31.14 1.25 1.16 1.20 186 206.23 46.39 12.00 10.00 10.00 5.00 3.46 --8.05 5.44 --13.35 11.28 12.45 6.12 5.33 3.54 6.12 5.33 3.16 5.00 3.46 2.00 64.30 55.22 29.28 --- 12.44 22.5 31.00 ----156.00 141.00
V= patients on Ventilator support, NV= Non Ventilated patients Frequency of nursing activities had a list of direct patient care as well as indirect Frequency of nursing activities was patient care activities. The direct care activities taken by researcher from prescribed were related to individual patient admitted in frequency ordered by unit doctor on patient's ward while indirect patient care activities were treatment char t and from records and common to all patients admitted in ward observation. Table 3 depicts the frequency during study period. Indirect care activities of nursing activities. The frequency sheet include supervision of workers, taking and Nursing and Midwifery Research Journal, Vol-6, No. 2, April 2010
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handing over the charge of ward articles and equipments, taking break etc. Frequency of indirect care activities were occurring once in each shift except sending and receiving the ar ticles from CSSD which was taking place only once in a day. As shown in table 3, the most frequent occurring activities were; monitoring vital signs followed by
ventilated related care (monitoring ventilator parameters), care of neonates on phototherapy, nutritional care, suctioning and care of ostomies. While the less frequent occurring activities in a day were for e.g. providing routine hygiene care, recording weight, attending rounds and change of nursing care charts i.e. once in a day.
Table 3 : Frequency of nursing activities in subunits of NSICU Nursing care activities
Average frequency per day
Direct care activities
ICU V
Recovery V NV
NV
Routine hygiene care
Once
Once
Once
Monitoring vital signs
One hourly
One hourly
One hourly Two hourly
Nebulization
---
Three hourly
---
Once
Private NV Once Three hourly
Three hourly Three hourly
Suctioning
Three hourly Three hourly Three hourly Three hourly Three hourly
Nutritional care
Three hourly Three hourly Three hourly Three hourly Three hourly
Ventilator related care
One hourly
Therapeutic care
In each shift In each shift In each shift In each shift In each shift
-----
Checking weight
once
Assisting the physician in patient care activities
In each shift In each shift In each shift In each shift In each shift
Attending rounds
Once
once Once
One hourly --once Once
once Once
---once Once
Care of ostomies
Three hourly Three hourly Three hourly Three hourly Three hourly
Phototherapy care
Two hourly
Two hourly
Two hourly Two hourly
Two hourly
Change of daily nursing care charts
Once
Once
Once
Once
Documentation
In each shift In each shift In each shift In each shift In each shift
Taking and handing over charge of patient
In each shift In each shift In each shift In each shift In each shift
Care of intravenous site
In each shift In each shift In each shift In each shift In each shift
Care of drainage
Once
Once
Indirect care activities Sending and receiving the articles from CSSD Taking and handing over the charge of ward articles and equipments Supervision and maintaining cleanliness of the unit Break
Once
Once
once
once
Once a day Once in each shift Once in each shift Once in each shift
V= patients on Ventilator support, NV= Non Ventilated patients
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Total time for nursing activities in subunits of NSICU
August 2008 by multiplying time and frequency of each nursing activities carried out in 24 hrs in NSICU (table 4) and later mean of total time/ day (1/8/2008-31/8/2008) was calculated for all units of NSICU as shown in table 5.
Total time per day was calculated by multiplying time and frequency of nursing activities in all sub-units of NSICU. This time was calculated on daily basis from 1st to 31st Table 4: Average total time per day for nursing activities in subunits of NSICU (1/8/2008-31/8/2008) Nursing care activities
Direct care activities Routine hygiene care Monitoring vital signs Oxygen administration Nebulization Suctioning Nutritional care Ventilator related care Therapeutic care Checking weight Assisting the physician in patient care activities Attending rounds Care of ostomies Phototherapy care Canulation Change of daily nursing care charts Documentation
Taking and handing over charge of patient Admission related activities Discharge activities Care of dead patient Indirect care activities
Average total time per day (min: sec) ICU Recovery Private V
NV
121.16 525.12 ----226.4 102.40 549.50 358.57 8.40 332.45 30.00 ---20.13 36.00 15.15 24.00 15.00 28.00 ---0.30
57.20 255.84 22.94 23.10 325.00 172.48 -271.40 7.41 45.34 20.00 ---8.05 26.12 18.33 24.00 10.35 10.00 4.03 ---
187.00
V 43.00 191.40 ----166.00 47.00 349.12 194.37 2.45 45.56 20.00 10.00 6.12 20.00 12.12 12.20 10.00 4.30 --0.38 156.00
NV 220.00 720.00 55.44 35.36 465.45 102.00 --689.00 16.24 58.15 30.00 25.14 10.34 64.14 58.44 54.32 30.46 110.00 10.00 ---
NV 15.00 40.40 0.32 3.06 3.12 3.22 ---10.00 1.20 12.15 10.00 -----3.12 13.00 10.48 6.00 8.46 5.00 ---
141.00
V= patients on Ventilator support, NV= Non Ventilated patients
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Table 5: Average total time (per day) in different units of NSICU Units of NSICU
Nursing care activities for ventilated and non ventilated patients
Total time (in hrs) Mean ± SD
Average census / day
Total time/ patient/day (In hours)
ICU
Direct patient care activities
V
32±18
3
11.00
NV
31±16
3
10.33
Indirect activities Recovery unit
Direct patient care activities
9.00 V
23±16
2
11.5
NV
86±18
14
6.14
1
6.00
Indirect activities Private Unit
Direct patient care activities
8.00 NV
Indirect activities
6±2 5.00
V= patients on Ventilator support, NV= Non Ventilated patients
The average total time per day for each unit was computed by adding total time for each nursing care activities for both ventilated and nonventilated patients. The average time per day for nursing care activities in ICU for ventilated patients was 32±18 hours and for non ventilated patients 31± 16 hrs while for indirect care nursing activities total time per day was 9 hrs. For recovery unit, total time /day for ventilated patients was 23±16 hours , for non ventilated patients 86± 18 hrs and for indirect care nursing activities it was 8 hrs.. For private unit total time per day was 6± 2 hrs for direct care activities and 5 hrs for indirect care activities. According to the census during study period , an average of 11 hrs /
day were required for each ventilated patient and around 10.33 hrs per day to each non ventilated patient in ICU. For recovery unit, an average of 11.5 hrs /day was required for each ventilated patient and 6.14 hrs per day for each non ventilated patient. On the other hand, in private unit the least amount of time i.e. 6 hrs/ day were required for each patient. Number of nurses for NSICU A statistical formula9 was employed to calculate the number of nurses required per day in NSICU from total calculated time. Number of nurses = Total time/day required for providing patient care for 24 hrs + 8.33% allowance 8 hrs work shift
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The number of nurses required to work in all subunits of NSICU were calculated by using above mentioned formula, on daily
basis during the study period (1/8/08-31/8/08) as shown in figure 2.
Figure 2: Number of nurses required per day for NSICU (1-8-08 TO 31-8-08)
Table 6 : Number of nurses for different units of NSICU Units of NSICU
Average number of nurses
Average Census/ day
ICU
9
6
Recovery unit
16
16
Private unit
1
1
The number of nurses required to work in different units of NSICU was calculated from the average of nurses required for thirty one days(1-8-08 to 31-8-08). The results as
shown in table 6 revealed that the mean number of nurses required for ICU was 9 nurses/ day for an average 6 patients/day. In recovery unit 16 nurses/ day were required to
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provide care to average of 16 patients/ day whereas for Private Unit one nurse is required for 24 hrs for an average of 1 patient/ day. A total of 26 nurses were required per day (Range = 24-33 ) for an average of 23 patients/ day. Finally 30 % nurses were added for leave reserve among total working nurses for 24 hrs in NSICU. By adding 30% nursing staff for leave reserve 12, it was found that 34 nurses were required per day to provide care to the patients admitted in NSICU during the period of august 2008. Discussion The importance of manpower planning in the nursing profession is being recognized increasingly at both national and international levels. Adequate number of nurses is required to promote safe and quality care and to ensure patient safety 1. Literature review suggests sufficient studies have not been conducted in India to calculate the number of nurses required to staff a unit. There is no standard protocol or work measurement model in India to ascertain nurse patient ratio in specialized units of hospital.2 In present study, all nursing activities, carried out in unit, were included to calculate nurse manpower for Neonatal Surgical Intensive Care unit while a study conducted in the university hospitals of Netherlands has used a nine equivalents manpower score (NEMS) for observation of nursing activities to determine nurses required for neonatal unit.14 In present study, the time of nursing activities was measured to calculate the
nursing manpower. A similar strategy was followed in a study conducted in North Carolina hospitals to determine the amount of time allocated to direct care nursing activities for chronically ill and demented patients.13 The findings of this study resulted (as shown in table 6) that 9 nurses were required for 24 hrs to provide patient care to 6 patients per day in ICU. For recover y unit 16 nurses were required for 24 hrs, for an average of 16 patients per day and in private unit a single nurse was sufficient to take care of an average of one patient per day. Which means more number of nurses were required to work in recovery unit than ICU and private unit primarily because of more number of patients per day and hence more nursing interventions. A study on 'Patient associate model' conducted by NEELY suggested that more number of nurses are required for Intensive Care Units according to its workload than nurses required for step down Units and Intermediate Care Unit based upon the number of medical, surgical and nursing interventions 15 . It was analyzed that mean number of nurses/ day to work in NSICU were calculated to be 26 for an average of 23 patients per day. By adding 30% nurses for leave reserve 12 the number of nurses required for NSICU was 34 nurses for 24 hrs. The calculated nurse to patient ratio for NSICU in each shift was 1:2.5. In further calculation N: P ratio for ICU was 1:2, for recovery unit N: P ratio in each shift was 1:4 and in private unit N: P/ shif t was0.5:1.It is clear from the figures that though more number of nurses were required to work in recovery unit but the N:P ratio was
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high in ICU than recovery unit because of more complex and frqeuent nursing interventions in ICU. These findings are close to the recommendations given by the California Board of Health Services for nurse patient ratio of 1:2 for ICU, and 1:4-1:5 for Step Down units so as to reduce nurses work load and to provide quality patient care.16, 17 The evidence suppor ted the probable relationship between the nursing workload and number of nurses required for the unit. Based upon present study findings, it is recommended that a similar study can be conducted on large samples with increased duration to generalize the study findings. The concepts of present study can be used for developing quality standards for measurement of nursing care activities. References 1
2
3
4
5
Reid NG. The effective training of nurses: manpower implications. International Journal of Nursing Studies 1985; 22:89-98. Hurst K. Relationships between patient dependency, nursing workload and quality. International Journal of Nursing Studies 2005;42:75-84. Kumar TD. Nurses need to improve patient care. The nursing journal of India 2007; 4:34-36. Aiken L, Clarke SP. Nurse reports in hospital care in five countries about Health affairs. International journal of nursing studies 2007; 44:165-167. Buchan J. The global nursing shortages. British medical journal 2005; 324: 751-752.
6
7
8
9
10
11
12
13
14
15
16
17
Safe staffing saves life. International council of nurses 2006.Available from URL: http:/ /www.safestaffingsaveslives.org.html dated 4.4.4008. Arthur T, James N. Determining nurse staffing levels: a critical Review of the literature. Journal of Advanced Nursing1994; 19:558-565. Alabama. Safe staffing for pediatric patients. Available from URL : findarticles.com/ p/articles/mi_qa4090/2004.html dated 12.4.2008. Carrie AK, Robertson S, Behner KG. A flexible staffing model for patient service associates. Journal of Nursing administration 1997 ;27,1:48-54 Twigg D, Duffield CA review of staffing workload measure. International Journal of Nursing Studies 1996;46:132-140 Unruh L. Nurse staffing- patient, nurse and financial outcome. American Journal of Nursing 2008; 108: 62-70. Nursing resource planning: approach and emphasis. A report of panel discussion of TNAI biennial conference. Nursing Journal of INDIA 1993; LXXXXV,3: 65-67 Pardee G et al. Classifying the patients to predict staff requirement. American Journal of Nursing 1968;68: 517-520 Scott C. Setting safe Nurse Staffing levels: an exploration of the issues. Royal College of Nursing 2003;14-19 Smith PJ, Drake IR. Manpower requirement planning in administration. 6th edition. Jaypee publication1988; 54-87 No author. RN-to-Patient Ratios. Available at www.calnurse.org/finalrat/ ratiobox.html: 2003 dated 24.5.2008 Cardona P, Tappen MR, Terill M, Acosta M, Euseba IM. Nursing staff allocation in long term care: A work sampling study. Journal of Nursing Administration 1997; 27:28-36
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