Manu Sharma, Sunita Sharma, Rana S. Singh


Abstract : Nursing workforce forms the backbone of any healthcare organization. Quality and number of these frontline care providers has direct impact on the outcome of patients. Keeping it in mind an exploratory study was conducted to determine the nursing manpower requirement for the Cardio-thoracic vascular surgery (CTVS) ICU, Step-down ICU and ward at PGIMER, Chandigarh. In the present study measurement of patient dependency, nursing activity along with professional judgments was used for determining the workload which led to the determination of the nursing manpower. Modified Jones dependency tool was used according the clinical situation. Measurement of nursing hours required for the patient in each dependency level was determined. The algorithm given by K. Hurst was followed for calculation of the nursing manpower of each unit of CTVS. The results revealed the nurse patient ratio required for CTVS ICU was 1:1.5, for CTVS step down ICU 1:3 and for the ward 1:6. Total 34 nurses were required for the three units of CTVS which were having 34 beds. It was recommended for the nursing administrators to utilize these findings to plan nursing manpower for cardiac units. Sophisticated work measurement methodologies to determine the nursing workforce to deliver the quality care to newborns.

Key words :Manpower, Patient dependency, Workload and nurse to patient ratio.

Correspondence at :Manu Sharma, Lecturer Kular College of Nursing Kishangarh Near Khanna, Distt. Ludhiana

Introduction:Health human resources play a critical role in the improvement of quality of life. Nurses are the linchpin of the hospital care delivery. These frontline caregivers represent a critical and costly resource. Maximizing the efficiency and effectiveness of nurses is essential to the integrity of hospital function and the promotion of safe patient care.1 Today nurse to patient ratio is becoming an issue of discussion among the nurse administrator even in the developing countries like India which are facing the nursing manpower shor tage. Nurse to patient ratio sets the maximum number of patients that may be assigned to a nurse during one shift. When the nurse to patient ratio is high it means that one nurse has a relatively more number of patients to care for, and when the nurse to patient ratio is low it means conversely that one nurse has responsibility for a relatively less number of patients.2 A high nurse to patient ratio has far reaching repercussions. This can affect the working efficiency of the overburdened nursing staff which leads to compromised nursing care affecting the patient’s outcome. Among factors affecting the quality of nursing care, staffing levels are believed to be the most basic component with a direct bearing on patient care. Understaffing not only impedes provision of the planned care, but also may introduce human error that jeopardizes patient safety.3 If we look at the impact of the improper allocation of the nursing staff in the various patient care areas, then there arises the need to determine the accurate requirement of the nursing manpower for the patient care units to prevent the negative patient outcomes. In many of developed countries like USA and Australia there are set legislation which guides the nursing manpower for the various patient care units.4 However, universally applicable nurse-staffing standards cannot be fixed due to a variety of factors such as patient case mix, demographic structure, economic situation, staff availability, personnel quality,organizational settings, managerial competence, technology, culture, etc.5 So, there arises a need to determine the nursing manpower requirement for all specialized units. During the review of literature many manpower planning method were found. These methods are broadly categorized into bottom-up and top – down approaches. Some of these methods include Telford, Northern, Cheltenham, Leicestershire, Rhys- Hearn methods, GRASP method and Dependency-acuity -quality method.Dependency-acuity -quality (DAQ) method given by K.Hurst is most commonly used method. It is focused on workload assessment of the unit along with finding the acuity. Workload index (WLI) is defined as figure indicating the nursing work required to meet patients’ needs in a given situation. For calculating the WLI algorithm proposed by K.Hurst can be used. Dividing the WLI by the ward’s number of occupied bed is known as the acuity. Acuity is best interpreted as the equivalent number of dependency 0 patient in the ward in each occupied bed6. In DAQ method proposed by K.Hurst, three independent but closely related data sets are to be measured. The first, a measure of patient dependency, a simple indicator signifying the patient’s reliance on nurses to meet his or her needs should be assessed. Nursing activities, using non-par ticipant observation to be collected alongside these patient dependency data. Within each 10-min cycle, specially trained observers needs to be located for recording the activities of all ward staff. Alongside the nursing activity analysis is to be done. Patient dependency, nursing activity and quality data are to be entered into DAQ algorithms-step-by-step calculations for determining an appropriate nursing team size6. This method overcomes many of the limitations met during the use of other methods of manpower measurement. Measurement of patient dependency, nursing activity along with professional judgments has been used in this study for determining the workload which has led to the determination of the nursing manpower Cardio thoracic and vascular surgery unit is a specialized unit. The patients admitted in these units have specific pre- operative and post-operative health care needs. Adequate number of nurses plays an impor tant role on the recovery of the patients. In the present set up there is no set criteria followed for determining the nursing manpower requirement for the specific unit. Determination of nurse to patient ratio for a specific unit is a very difficult question especially for the specific patient unit. So, an attempt is made to answer this question.

Objective:To find out the nursing manpower requirement for Cardio-thoracic vascular surgery Intensive care unit, Step-down intensive care unit and ward

Methodology:An exploratory design was adopted for determining the manpower. The method adopted for the calculation of nursing manpower in present study was dependency- acuity- quality method given by K.Hurst for determining the nursing workforce requirement of the unit. The study was conducted in the in patient units of Cardio Thoracic and Vascular Surgery (CTVS) depar tment of Nehru Hospital, PGIMER, Chandigarh. PGIMER is a tertiary level hospital which caters to the healthcare needs of the patients coming mostly from north region of India. Units of CTVS taken under study included Cardio Thoracic and Vascular Surgery Intensive Care Unit, Cardio Thoracic and Vascular Surgery Step-down Intensive Care Unit and Cardio Thoracic and Vascular Surgery Ward. These units were having a bed capacity of 34 for which the nursing manpower was calculated.The cardiac surgeries mainly performed include Coronary artery bypass grafting, Mitral valve replacement or repair, aor tic valve replacement, Intra cardiac repair for congenital heart diseases, palliative surgeries like BT shunting and other closed heart surgeries as well as chest surgeries. Patients are admitted pre-operatively in the ward .Then patient is shifted to the operation theatre for surgery and after surgery the patient is kept in the ICU for 48 to 72 hours. After stabilizing patient’s condition he/she is shifted to the CTVS Step down ICU and kept there for next two to three days i.e. for 72-96 hrs after the surgery. After complete stabilization of the condition of the patient he/she is shifted to the ward.The methodology of present study was divided into three phases. The first phase was the planning phase, which emphasized on development of pre-requisites required for study which included development of the tools along with data collection sheets. Modified Jones dependency tool was used for categorizing the patients into different dependency levels according to their nursing needs. All patients were categorized into four dependency categories. Category 0 patient were fully independent, Cat 1 patient belonged to moderate dependency level, cat 2 were highly dependent whereas patient falling in category 3 were fully dependent.Data collections sheets and Task classification system was developed by taking the guidance from the experts from nursing faculty and Cardiac surgeons for recording the daily load of patients in each unit along with the daily census. Another sheet named Nursing Activity Sampling Sheet was developed for recording the time required for performing the activities. In this sheet three readings of time required for performing each nursing activity were recorded.The second phase of the study focused on the execution which includes the data collection. To obtain representative dependency data, all patients in study area over 1 month were assessed for their dependency level. Total of 970 patients were assessed. Patient’s load for each unit was determined by per forming the daily assessment of all the admitted patients of the units. Average time required for performing each nursing care activity was determined by performing the activity thrice. Nursing care activities were categorized into two main categories as direct and indirect and these were divided into six sub categories i.e. routine care activities, medicine administration, monitoring, other interventions, documentation and rounds.Based on the information gathered during the execution phase final nursing care sheet for 24hrs of nursing care was prepared for one patient of each category of dependence. The sheet included the list of all nursing care activities performed along with the frequency in 24hrs coupled with time required for performing that activity once. This sheet was given to 14 exper ts for their professional judgment. The experts included were CTVS consultants, nursing faculty members, senior residents and staff nurses of the CTVS units. The sheet was used for determining the time spent by the nurse in 24 hrs for caring one patient belonging to different dependency levels.In the third phase i.e. the interpretation phase analysis of the data was done to get the final results. Algorithm proposed by K.Hurst was used for the calculation of workload index and acuity and finally the nursing manpower requirement for the unit was determined.

Results:The algorithm purposed by K.Hurst for calculation of nursing manpower requirement was used for calculating nursing manpower requirement the CTVS unit. The algorithm has 10 steps:-

Step1:- The patient dependency data along with census of each unit of was analyzed. It led to the determination of the patient load for each unit of CTVS. Table 1 presents census of each unit along with the number of patients in each category with respect to their dependency level. This has led to the calculation of patient load. Patient load defines the daily number patient present in the units with respect to the dependency levels. Total of 970 patients assessed in a month i.e. average daily 31 patients in the all units of CTVS. In CTVS ICU total of 91 patients were assessed and about half of the patient belonged to category 2 (45%) and there was no patient in the category 0. IN CTVS Step- down ICU total of 149 patient assessed and 60% patient belonged to the category 1 whereas in the ward total of 730 patients assessed and out of this 660 were of category

  1. Average patient load was 3, 5 and 24 in CTVS ICU, CTVS Stepdown and CTVS Ward respectively.
  2. Table 1: Patient load of the CTVS units                                                              N= 970
of patient’s as per their dependency level Total Patients ( 31 days) Average Patient load per Day Total Patients Total Patients ( 31 days) Average Average per Day Total Patients Total Patients ( 31 days) Average Average per Day
Total patients 91 3 149 5 730 24
Cat 3 Patients 29 1
Cat 2 Patients 45 1.5 9 .3
Cat 1 Patients 17 0.5 89 2.9 70 3
Cat 0 Patients 51 1.7 660 21

Categories                         CTVS ICU                  CTVS Step-down ICU                CTVS Ward

Step 2:- Total time spent on nursing care of each patient under each dependency level per day was determined. It was found that patient belonging to fully dependent category i.e. category 3 requires 752 minutes of nursing care, category 2 patient requires 586 minutes, category 1 needs 382 minutes and category 0 patient needs 148 minutes of nursing care in a day. (Fig 1.)

Figure 1: Total nursing care time required per patient of each dependency level in 24 hrs

Total nursing time spent for caring a patient in 24 hrs was further divided into two main categories direct nursing care and indirect nursing care activities. Further more these categories were subdivided into six more sub categories as discussed earlier in methodology. It was found that in the fully dependent patient routine care activities

Fig. 1.2 Nursing time required for various nursing care activities with respect to the dependency category of the patient consume the maximum nursing time. In the patient belonging to category 2 and 1 routine care activities needs more of the nursing time as compare to other activities. In the patients belonging to 0 category monitoring activities takes away the largest proportion of nursing care time. Fig 2 shows the comparison of the time consumed on each category of nursing care activities with respect to the dependency level of the patient.

Step 3:- In this step time differentials was conver ted into ratios. It was done by dividing time required for dependency category 0 (reference value) with each level of dependency. Time differential ratios value for category 0 was considered as one. For category 1 it was 2.58 (382 divided with 148), similarly for category 2 value after dividing time required for caring one patient of category 2 with reference value was 3.96 and then for category three it was 5.08 (Table-2)

Table 2 : Time differential ratios of each dependency category patient

Dependency Category                     0                          1                     2                  3

Time differential Ratios                      1                          2.58               3.96            5.08

Step 4:- In this step workload index of each unit of CTVS was determined. It was

Table 3 : Workload index for CTVS Units calculated by multiplying the ratios by average daily number of patients in each dependency

Dependency Category 0 1 2 3 Total

Time differential Ratios (a) Average no. of Patient / day (b) Workload Index (a x b)


















– 3.00


CTVS Stepdown ICU          
Time differential Ratios (a) 1.0 2.58 3.96
Average no. of Patient / day (b) 1.7 2.90 0.30 4.90
Workload Index (a x b) 1.7 7.48 1.19 10.37
CTVS Ward          
Time differential Ratios (a) 1 2.58
Average no. of Patient / day (b) 21 3.00 24.00
Workload Index (a x b) 21 7.74 28.74

category as shown in table-3 to obtain the workload index (WLI). The value of WLI came out be highest for the ward which was 28.74 followed by CTVS ICU i.e. 12.31. Minimum workload index was for CTVS Stepdown ICU i.e. 10.37.

Step 5:- In this step calculation of Bed acuity was undertaken. In other words in CTVS ICU, the WLI (workload index) is equal to the nursing work needed to care for 12.31 patients of dependency 0 patients. Dividing WLI by the occupancy (12.31/3 = 4.10) gives the bed acuity. value of acuity was highest for the CTVS ICU (4.1).

Fig 3 shows the comparison of the WLI, acuity and bed occupancy of these units. The value of WLI came out be highest for the ward ( 28.74) whereas the value of acuity was highest for the CTVS ICU ( 4.1). The value of bed acuity was lowest in CTVS ward (1.2)

Fig 3. Comparison of the values of workload index, bed occupancy and the acuity in all the three units of CTVS

Step 6:- In this step total nursing time required for caring all the patients in the unit was calculated. The nursing time required for care of a dependency 0 patient, as we discussed above, is 148 minutes per day (Fig.2). Hence total nursing care time for all patients in the CTVS ICU is:- 12.31 (WLI) x 148 minutes = 1822 minutes per day. Nursing care time spent on patient care in CTVS stepdown ICU was 1573 minutes and for CTVS ward it was 4254 minutes.The above calculated time is influenced the type of the patient present in the unit and their number. But there are certain activities which are not influenced by the patient type and all such activities are enlisted under miscellaneous activities

Step 7:- In this step time spent on other miscellaneous activities was determination. The list of miscellaneous activities along with average time required for performing each activity once was referred while calculating nursing manpower requirement. These activities include intubations, extubations, transfers, setting of the resuscitation trolley, patients’ transfer in and out, admissions, discharges, managing class four workers, immediate postoperative care etc. Time spent on these activities per day is shown in table 4. Total 127.44 minutes were spent on miscellaneous activities in CTVS ICU, 28 minutes in CTVS stepdown ICU and 228.22 minutes in CTVS ward.

Table 4 : Nursing time spent on miscellaneous activities/day in CTVS Units Unit Total nursing care time spent on Miscellaneous activities ( in minutes)

CTVS ICU                                                                127.44

CTVS Stepdown ICU                                                     28.00

CTVS Ward                                                            228.22

Step 8:- Total nursing care time required for each unit per day was calculated by the summation of time spent on patient care and miscellaneous activities of the unit i.e. [time spent patient care with respect to dependency level x census] + [time spent on Miscellaneous Activities]

Total nursing time spent in CTVS ICU

=1822+127.44=1949.44 minutes  =32.49 hours.

Total nursing time spent in CTVS stepdown ICU = 1573 +28= 1601mins =26.68 hours= 27 hours.

Total nursing time required for the CTVS ward = 4254+228= 4482 minutes.= 75 hours.

Step 9:- This step includes calculation of the number of Full Time Equivalent (FTE) or a nurse required for the unit in a day. Each FTE works for 40 hours a week which is around 5.7 hrs per day. So the FTE required for the unit per day is calculated by dividing the total nursing care hours with hours spent by one FTE per day, which comes out to be 6 nurses per day for CTVS ICU (32.49/5.7), 5 nurses per day for CTVS stepdown ICU (26.88/5.7) and 13 per day for CTVS ward (75/5.7).

Step 10:- This step includes the calculation of total nursing manpower or FTEs required for the unit by adding 30% of the manpower as leave reserve required per day into the per day manpower requirement.Total FTEs or nurses required = Number of FTEs per day + 30% of FTEs Required per day. For the three bedded CTVS ICU the total number of nurses or the FTEs required were 8(6 + 1.7 = 7.7), for six bedded CTVS Stepdown ICU is was 7 (5+1.5) and for 25 bedded CTVS ward it was 17 (13+4). Hence total 32 nurses are required for CTVS units.Considering the value of acuity which was highest for the ICU indicating the more load per bed pointing on the need of lowering the nurse to patient ratio. According to results of the nurse to patient ratio for the CTVS ICU required is 1:1.5, for CTVS Step-down ICU is 1:3 and for the ward is 1:6. This ratio was determined by considering the average daily occupancy of the unit with the total manpower requirement for the unit.

Discussion: Determination of nursing manpower for any patient care unit is becoming an emerging issue, which is the focus of concern for the nurse managers. There is no perfect method which can ensure a perfect match between the demand and supply of nursing staff. It is clear that many of the existing methods of establishing staffing levels can be met with serious objections. It has been suggested that it will be beneficial to use the information which is available on a routine daily basis.7 There is a need to identify the best suitable method for answering this question among the various methods identified by the nursing experts.Patient’s dependency along with measurement of activities was used to determine the nursing workload which in turn led to the determination of the nursing requirement of the unit. This method is also known as dependency- acuity-quality method given by K.Hurst. This method takes into consideration the type of patients present in the unit and considers the needs of these patients. Assessment of the dependency level of the patients constitutes an important step in this process or method. Modified Jones Dependency tool was used to determine the dependency levels of the patient admitted in the unit. In many studies many other dependency assessment tools were used to determine the level of patient’s dependence on the nurse. K.Hurst has given the tool based on the ADLs for assessment of patient dependence. There are many other Dependency tools available in the literature like TISS, TOSS, NEMS and many others depending on type of patients6. Daily nursing hours required for the care were determined for the patient belonging to each dependency level. Results have shown that patient in the dependency category 3 required 752mins in 24 hours of nursing care which is around 13 hrs per day whereas the patient in the category 0 required 148mins of nursing time which is 2.5 hrs daily. Nearly similar results are observed in another study using WISN (Work load indicators of staffing needs) method i.e. Dependent patient needs around 15 hrs of nursing care whereas a fully independent patient requires 2.14 hrs daily8. Dependent patient requires maximum time for providing the routine care whereas in case of fully independent patient maximum time is consumed on monitoring activities.In the present study, workload index as well as acuity values are determined for all the three units under study. Acuity presents the bed load value whereas the workload is the ward index. It is possible that the ward with high workload index can have low acuity value.6 If we look at the results of present study CTVS ICU has workload index of 12.31 which is lower than the ward value which is 28.74 but on the other hand the acuity value of the CTVS ICU is 4.10 which is higher than that of the ward which is 1.2. Higher the value of workload index (WLI) more is the manpower required for the unit. We find that, the value of WLI is highest in the ward and it is least in the CTVS Step- down ICU which is 10.37. So, the nursing manpower requirement came out to be highest for the ward which is calculated as, 17 and that required in the CTVS Step-down ICU was 7.It is concluded that the patient’s dependence on the nurse was found to be the more helpful indicator of staffing requirement than a fixed ratio of staff to bed. Taking into consideration the needs of the patients the nursing manpower requirement for the unit was calculated. The results of the study have shown that total required nursing manpower for the three units of CTVS is 32 where as presently only 24 nurses are deployed for providing the patient care.Hence it is recommended that sufficient nursing manpower should be deployed in the unit for its effective functioning. Fur ther more dependency assessment per shift can be performed for determining the workload per shift. This will help to determine the nurse to patient ratio more accurately.


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