ESTIMATION OF NURSING STAFF

REQUIRMENTS

S.MOHAN

Patient classification system( PCS) ,which quantifies the quality of the nursing care, is essential to staffing nursing units of hospitals and nursing homes. In selecting or implementing a PCS , a representative committee of nurse manager can include a representative of hospital administration, which would decrease skepticism about the PCS.

The primary aim of PCS is to be able to respond to constant variation in the care needs of patients.

Patient Classification Systems

Differentiate intensity of care among definite classes

Measure and quantify care to develop a management engineering standard.

Match nursing resources to patient care requirement . Relate to time and effort spent on the associated

activity.

Be economical and convenient to repot and use

Characteristics

Be mutually exclusive , continuing new item under more than one unit.

Be open to audit. Be understood by those who plan , schedule

and control the work. Be individually standardized as to the

procedure needed for accomplishment. Separate requirement for registered nurse

from those of other staff

CONT…

The system will establish a unit of measure for nursing, that is , time , which will be used to determine numbers and kinds of staff needed.

Program costing and formulation of the nursing budget.

Tracking changes in patients care needs. It helps the nurse managers the ability to moderate and control delivery of nursing service

Purposes

Determining the values of the productivity equations

Determine the quality: once a standards time element has been established, staffing is adjusted to meet the aggregate times. A nurse manager can elect to staff below the standard time to reduce costs.

CONT…

The first component of a PCS is a method for grouping patients categories .Johnson indicates two methods of categorizing patients. Using categorizing method each patient is rated on independent elements of care, each element is scored , scores are summarized and the patient is placed in a category based on the total numerical value obtained.

Components:

Johnson describe prototype evaluation with four basic category for a typical patient requiring one –on- one care. Each category addresses activities of daily living , general health, teaching and emotional support, treatment and medications. Data are collected on average time spent on direct and indirect care.

CONT…

The second component of a PCS is a set of guidelines describing the way in which patients will be classified, the frequency of the classification, and the method of reporting data..

CONT…

The third component of a PCS is the average amount of the time required for care of a patient in each category. A method for calculating required nursing care hours is the fourth and final component of a PCS .

CONT…

Area of care Category I Category II Category III Category IV

Eating Feeds self Needs some help in preparing

Cannot feed self but is able to chew and swallowing

Cannot feed self any may have difficulty swallowing

Grooming Almost entirely self sufficient

Need some help in bathing, oral hygiene …

Unable to do much for self

Completely dependent

Excretion Up and to bathroom alone

Needs some help in getting up to bathroom /urinal

In bed, needs bedpan / urinal placed;

Completely dependent

Comfort Self sufficient Needs some help with adjusting position/ bed..

Cannot turn without help, get drink, adjust position of extremities …

Completely dependent

.

General health

Good Mild symptoms

Acute symptoms

Critically ill

Treatment Simple – supervised, simple dressing…

Any Treatment more than once per shift, foley catheter care, I&O….

Any treatment more than twice /shift…

Any elaborate/ delicate procedure requiring two nurses, vital signs more often than every two hours..

Health education and teaching

Routine follow up teaching

Initial teaching of care of ostomies; new diabetics; patients with mild adverse reactions to their illness…

More intensive items; teaching of apprehensive/ mildly resistive patients….

Teaching of resistive patients,

CONT…

The following are the hours of nursing care needed for each level patient per shift:

Calculating Staffing Needs

Category I Category II Category III Category IV

NCHPPD for Day shift

2.3 2.9 3.4 4.6

NCHPPD for P.M (Evening) shift

2.0 2.3 2.8 3.4

NCHPPD for night shift

0.5 1.0 2.0 2.8

1.Projecting Staffing NeedsSome steps to be taken in projecting staffing needs

include: Identify the components of nursing care and nursing

service. Define the standards of patient care to be maintained. Estimate the average number of nursing hours needed

for the required hours. Determine the proportion of nursing hours to be

provided by registered nurses and other nursing service personnel

Determine polices regarding these positions and for rotation of personnel

A guide to staffing nursing services

2.Computing number of nurses required on a Yearly Basis Find the total number of general nursing hours needed

in one year. Average patient census X average nursing hours per patient for 24 hours X days in week X weeks in year.

Find the number of general nursing hours needed in one

year which should be given by registered nurses and the number which should be given by ancillary nursing personnel.

Number of general nursing hours per year X percent to be given by registered nurses.

Number of general nursing hours per year X percent to be given be ancillary nursing personnel.

,

Computing number of nurses assigned on weekly basis

Find the total number of general nursing hours needed in one week. Average patient censes X average nursing hours per patient in 24 hours X days in week.

Find the number of general nursing hours needed in the week which should be given by registered nurses and the number which could be given by ancillary nursing personnel.

Number of general nursing hours per week X percent to be given by registered nurses.

Number of general nursing hours per week X percent to be given by ancillary nurses.

.

To determine the number of nursing staff for staffing a hospital involves establishing the number of work days available for service per nurse per year.

Example : Analysis of how the days are used; Days in the year 365 Days off 1 day/week 52 Casual leave 12 Privilege leave 30 1 Saturday /month 12 Public Holidays 18 Sick Leave 8 Total non-working days 132 Total working days /nurse/year 233 So 1 nurse = 233 working days /year Example, 20 nurse means 20X233= 4660 hours 4660/365= 12.8 (13).

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Requirement for staffing are based on whatever standard unit of measurement for productivity is used in a given unit. A formula for calculating nursing care hours per patient day (NCH/PPD) is reviewed.

NCH/PPD = Nursing hours worked in 24 hours

………………………………………. Patient Census

 

Work load measurement tools

There are 3 factors: quality, quantity, and utilization of personnel.

Quality and Quantity: This factor depends on the appropriate

education or training provided to the nursing personnel for the kind of service they are being prepared for i.e., professional, skilled, routine or ancillary.

Utilization of personnel: Nursing personnel must be assigned work in such a way that her/his knowledge and skills learnt are based used for the purpose she was educated or trained.

Important Factors of staffing

Acutely Ill : Where the life saving is the priority or bed ridden condition which might require 8-10 hours / patient /day ie., direct nursing care in 24 hours or nurse patient ratio may have to be 1:1, 2:1,3:1…

Moderately Ill: here 3.5 HPD are required in 24 hours or nurse patient ration of 1:3 in teaching hospitals and 1:5 non-teaching hospitals.

Mildly Ill: this required 1-2 HPD and for such patients 1:6 or 1:10.

Fluctuation of workload: workload is not constant. Number of medical staff: In PHC , 30,000 to 50,000

population getting care from 3 to 4 medical staff but only 1 PHN gives care for all… like in hospital the ratio is vary from medical and nursing staff.

Other factors affecting staffing

Modified work week: This using 10 and 12 hour shifts and other methods are common place. A nurse administrator should be sure work schedules are fulfilling the staffing philosophy and policies, particularly with regard to efficiency. Also , such schedules should not be imposed on the nursing staff but should show a mutual benefits to employer, employees and the client served.

Modified approaches to nurse staffing and scheduling

One modification of the worksheet is four 10 hour shifts per week in organized time increments. One problem with this model is time overlaps of 6 hours per 24 –hour day. The overlap can be used for patient –centered conference, nursing care assessment and planning and staff development. It can be done by hour or by a block of 3-4 hours. Starting and ending time for the 10 hours shifts can be modified to provide minimal overlaps, the 4- hour gap being staffed by part-time or tempory workers

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A second scheduling modification is the 12 hour shift, on which nurses work even shifts , on which nurses work seven shift in 2 weeks: three on , four off: four on, three off . they work a total 84 hours and are paid of overtime. Twelve hour shifts and flexible staffing have been reported to have improved care and saved money because nurses can better manage their home and personal lives.

Cont…

The weekend alternatives : another variation of flexible scheduling is the weekend alternative. Nurses work two 12 hour shifts and are paid for 40 hours plus benefits. They can use the weekdays for continued education or other personal needs. The weekend scheduled has several variations. Nurses working Monday through Friday have all weekends off.

Other modified approaches : team rotation is a method of cyclic staffing in which a nursing team is scheduled as a unit .It would be used if the team nursing modality were a team practice.

Premium day weekend: nursing staffing is a scheduling pattern that gives the nurse an extra day off duty, called a premium day, when he/she volunteers to work one additional weekend worked beyond those required by nurse staffing policy. This technique does not add directly to hospital costs.

Premium vacation night: staffing follows the same principle as does premium day weekend staffing. An example would be the policy of giving extra 5 working days of vacation to every nurse who works a permanent night shifts for a specific period of time , say 3, 4, or 6 months.

A flexible role: this programme has enabled the hospitals to better meet the staffing needs of units whenever workload increases. Since establishment of the resources acuity nurse position, nurses position, nurse’s morale has improved because they know short-term helps is more readily available and will be more equitably distributed among units.

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Cross training: It can improve flexible scheduling. Nurses can be prepared through cross-training to function effectively in more than one area of expertise. To prevent errors and incidence job satisfaction during cross training nurses assigned to units and in pools require complete orientation and ongoing staff development.

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Hanson defines a management information system as “an array components designed to transform a collective set of data into knowledge that is directly useful and applicable in the process of directing and controlling resources and their application to the achievement of specific objectives”.

Scheduling with Nursing Management Information Systems

State the management objective clearly. Identify the actions required to meet the objective. Identify the responsible position in the

organization. Identify the information required to meet the

objective. Determine the data required to produce the

needed information. Determine the system’s requirement for

processing the data. Develop a flowchart.

The following process for establishing any MIS:

Productivity is commonly defined as output divided by input. Hanson translates this definition into following:

Required staff hours…………………………… ×100Provided staff hours

Example  380 hours …………. X 100 = 95% productivity 400 hours  Productivity can be increased by decreasing the provided staff

hours holding the required staff hours constant or increasing them.

Productivity

HPPD is determined by the formula   Staff hours………………… Patient days  For example, 52000………… 2883 Answer = 18 HPPD

hoursper patient day (HPPD)

Budget utilization Provided HPPD X 100 = budget utilization Budgeted HPPD     Example 18.03 % so, answer is 112.7% Budget

………utilization. 16  

Budgeted HPPD ……………………. X100 , this is known as Required HPPD

Budget adequacy   16/18.03= 88.74% budget adequacy.

Budget adequacy

Staffing in educational setting As per INC Staffing norms to the Nursing Institution is B.Sc. (N) and M.Sc. (N) Annual intake of 60 students in B.Sc.(N) and 25 students for

M.Sc.(N) programme Professor-cum-Principal 1 Professor-cum-Vice Principal 1 Reader / Associate Professor 5 Lecturer 8 Tutor / Clinical Instructor 19 --------------- Total 34   One in each specialty and the entire M.Sc (N) qualified

teaching faculty will participate in all collegiate programmes.   Teacher Student Ratio = 1: 10 for M.Sc. (N) Programme.

STAFFING PATTERN  

Ministerial Administrative Officer 1 Office Superintendent 1 PA to Principal 1 Accountant/Cashier 1  

Other Staff (Minimum requirements)

• Upper Division Clerk 2 • Lower Division Clerk 2 • Store Keeper 1 Maintenance of stores 1 Classroom attendants 2 Sanitary staff As per

the physical space Security Staff As per

the requirement Peons/Office attendants 4

• • Library Librarian 2 Library Attendants As per the

requirement

• Hostel Wardens 2 Cooks, Bearers, As per the

requirement Sanitary Staff Ayas /Peons As per the

requirement Security Staff As per the

requirement Gardeners & Dhobi Depends on

structural facilities (desirable)  

,

BASIC B.SC. NURSING Teaching Faculty

Admission Capacity

Annual Intake 25-50 51-100

Professor-cum-Principal

1 1

Professor-cum-Vice Principal

1 1

Reader/Associate Professor

1 2

Lecturer 5 10

Tutor/Clinical Instructor

14 28

Total 22 42

Teacher Student Ratio= 1:10

BASIC B.SC. NURSING Teaching Faculty

Staff nurse Staff ( each shift ) Department sister/assistant nursing superintendent

Medical ward 1:3 1:25 1 for 3-4 wards

Surgical ward 1:3 1:25 1for 3-4 weeks

Orthopedic ward 1:3 1:25 1 for 3-4 weeks

Pediatric ward 1:3 1:25 1 for 3-4 weeks

Gynecology 1:3 1:25 1for 3-4 weeks

Maternity ward 1:3 1:25 1 for 3-4 weeks

Intensive care unit 1:1 (24 hours ) 1

Coronary care unit 1:1( 24hours ) 1

Nephrology 1:1 (24hours ) 1 1 department sister/ assistant nursing ,superintendent for 3-4 units clubbed together

Special wards –eye ,ENT,etc

1:1 (24hours ) 1

Operation theatre 3 for 24 hours per table

1 1 departmental sister/assistant nursing superintendent for 4-5 operating rooms

Causality and emergency unit

2-3 staff nurses depending on the number of beds

1 1 departmental sister/ assistant nursing, superintendent for emergency , causality etc.

Staffing in hospital setting

Nurse Staffing Measure Definition

Nurse to patient ratio Number of patients cared for by one nurse typically specified by job category (RN, Licensed Vocational or Practical Nurse-LVN or LPN); this varies by shift and nursing unit; some researchers use this term to mean nurse hours per inpatient day

Total nursing staff or hours per patient day All staff or all hours of care including RN, LVN, aides counted per patient day (a patient day is the number of days any one patient stays in the hospital, i.e., one patient staying 10 days would be 10 patient days)

RN or LVN FTEs per patient day RN or LVN full time equivalents per patient day (an FTE is 2080 hours per year and can be composed of multiple part-time or one full-time individual)

Nursing skill (or staff) mix The proportion or percentage of hours of care provided by one category of caregiver divided by the total hours of care (A 60% RN skill mix indicates that RNs provide 60% of the total hours of care)

Nurse Staffing, Models of Care Delivery, and Interventions

Nursing Care Delivery Models Definition

Patient Focused Care A model popularized in the 1990s that used RNs as care managers and unlicensed assistive personnel (UAP) in expanded roles such as drawing blood, performing EKGs, and performing certain assessment activities

Primary or Total Nursing Care A model that generally uses an all-RN staff to provide all direct care and allows the RN to care for the same patient throughout the patient's stay; UAPs are not used and unlicensed staff do not provide patient care

Team or Functional Nursing Care A model using the RN as a team leader and LVNs/UAPs to perform activities such as bathing, feeding, and other duties common to nurse aides and orderlies; it can also divide the work by function such as "medication nurse" or "treatment nurse"

Magnet Hospital Environment/Shared governance

Characterized as "good places for nurses to work" and includes a high degree of RN autonomy, MD-RN collaboration, and RN control of practice; allows for shared decisionmaking by RNs and managers Jean Ann Seago, Ph.D., RN

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Norms are standards that guide, control, and regulate individuals and communities. For planning nursing manpower we have to follow some norms. The nursing norms are recommended by various committees, such as; the Nursing Man Power Committee, the High-power Committee, Dr. Bajaj Committee, and the staff inspection committee, TNAI and INC. The norms has been recommended taking into account the workload projected in the wards and the other areas of the hospital. 

 NORMS OF STAFFING( S I U- staff inspection unit)

All the above committees and the staff inspection unit recommended the norms for optimum nurse-patient ratio. Such as 1:3 for Non Teaching Hospital and 1:5 for the Teaching Hospital. The Staff Inspection Unit (S.I.U.) is the unit which has recommended the nursing norms in the year 1991-92. As per this S.I.U. norm the present nurse-patient ratio is based and practiced in all central government hospitals. 

The norms for providing staff nurses and nursing sisters in Government hospital is given in annexure to this report. The norm has been recommended taking into account the workload projected in the wards and the other areas of the hospital.

The posts of nursing sisters and staff nurses have been clubbed together for calculating the staff entitlement for performing nursing care work which the staff nurse will continue to perform even after she is promoted to the existing scale of nursing sister.

Out of the entitlement worked out on the basis of the norms, 30%posts may be sanctioned as nursing sister. This would further improve the existing ratio of 1 nursing sister to 3.6. staff nurses fixed by the government in settlement with the Delhi nurse union in may 1990.

Recommendations of S.I.U:

The assistant nursing superintendent are recommended in the ratio of 1 ANS to every 4.5 nursing sisters. The ANS will perform the duty presently performed by nursing sisters and perform duty in shift also.

The posts of Deputy Nursing Superintendent may continue at the level of 1 DNS per every 7.5 ANS

There will be a post of Nursing Superintendent for every hospital having 250 or beds.

There will be a post of 1 Chief Nursing Officer for every hospital having 500 or more beds.

It is recommended that 45% posts added for the area of 365 days working including 10% leave reserve (maternity leave, earned leave, and days off as nurses are entitled for 8 days off per month and 3 National Holidays per year when doing 3 shift duties).

Most of the hospital today is following the S.I.U.norms. In this the post of the Nursing Sisters and the Staff Nurses has been clubbed together and the work of the ward sister is remained same as staff nurse even after promotion. The Assistant Nursing Superintendent and the Deputy Nursing Superintendent have to do the duty of one category below of their rank.

1. General Ward2. Special Ward - ( pediatrics, burns, neuro surgery, cardio thoracic, neuro medicine, nursing home, spinal injury, emergency wards attached to casuality)

1:61:4

 

3.      Nursery 1:2 

4.      I.C.U. 1:1(Nothing mentioned about the shifts)

5.      Labour Room 1:l per table

6.      O.T. Major - 1 :2 per table

Minor - 1:l per table

The Nurse-patient Ratio as per the S.I.U. Norms 

7.      Casualty- a. Casualty main attendance up to 100 patients per day thereafter b.for every additional attendance of 35 patientsc.       gynae/ obstetric attendance d.      thereafter every additional attendance of 15 patients.

 3 staff nurses for 24 hours, 1:1per

shift. 

1:35 

·3 staff nurses for 24 hours, 1:1/ shift 

1:15

8.  Injection room OPD Attendance upto 100 patients per day 1 staff nurse120-220 patients: 2 staff nurses221-320 patients: 3 staff nurses321-420 patients: 4 staff nurses

9.   OPDNAME OF THE DEPARTMENT·        Blood bank·        Paediatric·        Immunization·        Eye·        ENT·        Pre anaesthetic·        Cardio lab·        Bronchoscopy lab·        Vaccination anti rabbis·        Family planning·        Medical·        Dental·        Central sample collection centre·        Orthopaedic·        Gyne·        Xray·        Skin·        V D centre·        Chemotherapy·        Neurology·        Microbiology·        Psychiatry·        Burns 

  

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Estimation of direct cost and resource allocation in intensive care: correlation with Omega system.

Abstract OBJECTIVE: An instrument able to estimate the direct costs

of stays in Intensive Care Units (ICUs) simply would be very useful for resource allocation inside a hospital, through a global budget system. The aim of this study was to propose such a tool.

DESIGN: Since 1991, a region-wide common data base has collected standard data of intensive care such as the Omega Score, Simplified Acute Physiologic Score, length of stay, length of ventilation, main diagnosis and procedures. The Omega Score, developed in France in 1986 and proved to be related to the workload, was recorded on each patient of the study.

researches

SETTING: Eighteen ICUs of Assistance Publique-Hôpitaux de Paris (AP-HP) and suburbs.

PATIENTS: 1) Hundred twenty-one randomly selected ICU patients; 2) 12,000 consecutive ICU stays collected in the common data base in 1993.

MEASUREMENTS: 1) On the sample of 121 patients, medical expenditure and nursing time associated with interventions were measured through a prospective study. The correlation between Omega points and direct costs was calculated, and regression equations were applied to the 12,000 stays of the data base, leading to estimated costs. 2) From the analytic accounting of AP-HP, the mean direct cost per stay and per unit was calculated, and compared with the mean associated Omega score from the data base. In both methods a comparison of actual and estimated costs was made.

RESULTS: The Omega Score is strongly correlated to total direct costs, medical direct costs and nursing requirements. This correlation is observed both in the random sample of 121 stays and on the data base' stays. The discrepancy of estimated costs through Omega Score and actual costs may result from drugs, blood product underestimation and therapeutic procedures not involved in the Omega Score.

CONCLUSIONS: The Omega system appears to be a simple and relevant indicator with which to estimate the direct costs of each stay, and then to organise nursing requirements and resource allocation.

Centre for Health Economics, University of York, UK. Abstract The large industry which has grown up around the estimation of

nursing requirements for a ward or for a hospital takes little account of variations in nursing skill; meanwhile nursing researchers tend to concentrate on the appropriate organisation of the nursing process to deliver best quality care. This paper, drawing on a Department of Health funded study, analyses the relation between skill mix of a group of nurses and the quality of care provided. Detailed data was collected on 15 wards at 7 sites on both the quality and outcome of care delivered by nurses of different grades, which allowed for analysis at several levels from a specific nurse-patient interaction to the shift sessions. The analysis shows a strong grade effect at the lowest level which is 'diluted' at each succeeding level of aggregation; there is also a strong ward effect at each of the lower levels of aggregation. The conclusion is simple; you pay for quality care.

The impact of nursing grade on the quality and outcome of nursing care.

Berger AM, Hobbs BB. College of Nursing, University of Nebraska

Medical Center, Omaha, USA. aberger@unmc.edu Abstract Shift work generally is defined as work hours that

are scheduled outside of daylight. Shift work disrupts the synchronous relationship between the body's internal clock and the environment. The disruption often results in problems such as sleep disturbances, increased accidents and injuries, and social isolation. Physiologic effects include changes in rhythms of core temperature, various hormonal levels, immune functioning, and activity-rest cycles. Adaptation to shift work is promoted by reentrainment of the internally regulated functions and adjustment of activity-rest and social patterns

Impact of shift work on the health and safety of nurses and patients.

. Nurses working various shifts can improve shift-work tolerance when they understand and adopt counter measures to reduce the feelings of jet lag. By learning how to adjust internal rhythms to the same phase as working time, nurses can improve daytime sleep and family functioning and reduce sleepiness and work-related errors. Modifying external factors such as the direction of the rotation pattern, the number of consecutive night shifts worked, and food and beverage intake patterns can help to reduce the negative health effects of shift work. Nurses can adopt counter measures such as power napping, eliminating overtime on 12-hour shifts, and completing challenging tasks before 4 am to reduce patient care errors.

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Unruh L. Department of Health Professions, University of Central

Florida, Orlando, FL, USA. lunruh@mail.ucf.edu Comment in: Am J Nurs. 2008 Apr;108(4):13. Abstract Because there's no scientific evidence to support

specific nurse-patient ratios, and in order to assess the impact of hospital nurse staffing levels on given patient, nurse, and financial outcomes, the author conducted a literature review. The evidence shows that adequate staffing and balanced workloads are central to achieving good outcomes, and the author offers recommendations for ensuring appropriate nurse staffing and for further research.

Nurse staffing and patient, nurse, and financial outcomes.

Aydin CE, Bolton LB, Donaldson N, Brown DS, Buffum M, Elashoff JD, Sandhu M.

Nursing Research and Development, Room 2021, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, USA. aydin@cshs.org

Abstract PURPOSE: To explicate a replicable methodology for

designing and analyzing a large ongoing reliable and valid quality database to examine nurse staffing and patient care outcomes in acute care hospitals.

DESIGN: Prospective nurse staffing, process of care, and patient outcomes data based on the American Nurses Association's (ANA) nursing quality indicators collected from a voluntary convenience sample at acute care hospitals in California with rolling-site accrual.

Creating and analyzing a statewide nursing quality measurement database.

METHODS: The ongoing CalNOC database development and repository project, the largest statewide effort of its kind in the United States (US), currently includes data on hospital nurse staffing, patient days, patient falls, pressure ulcer and restraint prevalence, registered nurse (RN) education, and patients' perceptions of satisfaction with care.

FINDINGS: As of May 2003, the CalNOC database contained staffing data from 842 units in 134 acute care hospitals over 20 quarters from April 1998 to March 2003. The repository also included clinical outcome information on 34,262 reported patient falls, pressure ulcer prevalence data on 41,982 patient observations, and service outcome data on patient satisfaction from 26,461 patients. Participating hospitals receive quarterly reports allowing them to benchmark their own performance against other participating hospitals. CalNOC methods have been adapted and replicated by both the Military Nursing Outcomes Database and VA Nursing Outcomes Database projects, and CalNOC nursing-sensitive measures have been endorsed by the National Quality Forum.

CONCLUSIONS: This working model for collecting reliable and valid data was derived from multiple hospitals across California. The data are the basis for studies to contribute to the development of evidence-based public policy, and for ongoing study of the effects of nurse staffing on clinical and service outcomes.

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