An exploratory study on “nursing manpower” requirement for coronary care unit of PGIMER, CHANDIGARH

http://doi.org/10.33698/NRF0103  Deepi, Sunita Sharma, Yash Paul Sharma

 

Abstract : In the present era nurse patient ratio has become a concern to the providers of the health services. As the era of advanced technology has led to increased complexity of the patient’s status, so more number of competent nurses are required to care for these patients. Thus calculating the adequate nurse patient ratio is mandatory to provide comprehensive and safe health care to the patients, especially the critical ill patients of the intensive units. An exploratory study was conducted to determine the nursing manpower for Coronary Care Unit. Data was collected by recording time and frequency of all the direct and indirect nursing activities. Direct nursing activities included were independently performed, activities assisted to the doctor and other activities needed to meet the health needs of different dependency level patients admitted in the month of August 2008. Indirect activities included were unit related nursing activities. A statistical formula has applied to convert the total calculated time for nursing activities into number of required nurses. Findings revealed that total number of required nurses to care for the cardiac patients in ten bedded Coronary Care Unit of PGIMER, Chandigarh required was 23. Recommendations of study is that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

Key words :Nursing Manpower, Competencies, Coronary Care Unit.

Correspondence at :Deepi C/o National Institute of Nursing Education PGIMER, Chandigarh

Introduction:Today’s health care system and nursing workforce issues are facing limited resources and increasing demands on their services1. The demand for competent and responsible nurses in giving care to patients has also been increased.2 Nurses, the largest group of health care providers, are experiencing significant changes in their work according to the changing health needs of the society. Their workload has been increased and the number of nurses per patient is diminished, which puts the patient’s safety at risk.3 In 1999 California became the first state in union to impose mandatory nurse patient ratio. It had given 1: 2 ratio for intensive care patients.4 According to Indian Nursing Council every hospital should have adequate number of staff nurses to provide better health services to the patients.5 Research has proved the advantages of adequate nurse patient. Their findings revealed that adequate nurse patient ratio ensures safe and quality patient care6, provides clear standards for nursing7, saves money, improves patient care and allocates fairer nursing workloads. It also allows nurses to regain confidence and control over their working conditions.8 Many research findings showed that poor nurse patient ratio leads to poor quality of nursing care, staff stress, poor patient care & misuse of the budget9. Poor ratio of nurse manpower pose a potential threat to continuity & safety of patients and increases nursing workload.10 Statistics show that over the past decade the number of nurses has been increased by 23%, and in-patients has been increased by 25% i.e. a few more nurses are caring for many more patients. So to keep number of nurses pace with number of patients11 and to facilitate the best nursing care to individual patient, we need to calculate the adequate nurse manpower.12 Consumer classification systems (e.g. age groups) in 1970’s, the introduction of nursing care related to diagnostic groups in 1980s & technology and research increased markedly in 1990’s, was a move towardsgreater consumer involvement. It contributed to the development of more sensitive patient’s classification system (PCS’s) to calculate nursing workload on a shift basis in a practical way, which was essential to find adequate nurse manpower.13 Thus in this the average number of nursing hours per month can be used to find out the required number of full time equivalent employees. The total hours for full time equivalent employee consist of both productive and non productive work. The productive nursing work includes direct nursing care and non productive nursing work includes break, holidays, and leaves. 14 Later on advanced technology database was used to find required nursing manpower13 Most of the time nursing pattern is determined by the predetermined standards, which may include hours per patient per day like in medical units, visits per month like in home health agencies or minutes per case like in operation theatre. But the patient census, number of patient visits or cases per day does not remain constant forever. So staffing ratio should be adjusted according to the decreased or increased number of patients. The standard formula for calculating nursing care hours per patient per day is equal to nursing hours worked in 24 hours divided by patient census.15 There are two methods to calculate required nursing manpower fall under two methods i.e. Top-down’ methods and ‘Bottom up’ methods. ‘Top-down’ methods relate number of nurses to cost or measures of activity such as beds, visits, attendances etc. Trent formula regression analysis and ‘Bottom-up’ methods are on the basis of patient’s dependency levels, professional judgment of nurses. e.g. Aberdeen formula, Telford system, Rhys Hearn method.16 staffing pattern also depends on the objectives of the hospital, services provided by it, type of patient served, number of beds, amount of suppor tive services available etc. Indian Nursing Council has laid down some specific staffing patterns in different wards of the hospital to ensure efficient functioning of the hospital and patient satisfaction. For example for intensive care unit of the Government hospital the staffing ratio should be 1:0.8.17 It has been observed that, there is lack of specific standards regarding the “required nurse manpower” in Coronary Care Unit of PGIMER, Chandigarh and according to the continuous increasing complexity in the health needs of cardiac patients as well as the technological advancement; nurses need to be more competent in providing care. Therefore the proposed study is undertaken with the objective to find the nursing manpower requirement in Coronary Care Unit of PGIMER, Chandigarh.

Methodology:The exploratory study was conducted in multispeciality hospital of North India i.e. PGIMER, Chandigarh. It has bed capacity of 1600. Coronary Care Unit of PGIMER, Chandigarh was chosen for study. It is situated at the 3rd floor in C block of Nehru Hospital of PGIMER, Chandigarh. It is ten bedded unit. There is separate cabin for each patient and total ten cabins are there in Coronary Care Unit for 10 patients. There is nursing station for nurses facing the cabins of patients. The patients admitted are mostly with medical conditions like myocardial infarction, sick sinus syndrome, hypertension etc. Pre and post procedural cardiac patients from catheterization laboratory and Cardiac OT after cardiac catheterization are also admitted. Target population consisted of sum total of all the nursing activities performed in the Coronary Care Unit, including the frequency of all nursing activities and the patients admitted in Coronary Care Unit in the month of June to August 08. Sampling technique was purposive. Sample size was each nursing care activity according to its frequency and patient according to dependency level.After reviewing literature, the researcher prepared patient dependency tool, a list of nursing activities, a Performa to record observation of time and frequency for nursing activities and patient’s census record sheet. Patients’ classification tool to categorize the patients admitted in Coronary Care Unit according to the dependency level with respective scores i.e. low dependent patients (1-8), partially dependent patient (9-16) and fully dependent patient (17-24)). The reliability of tool was checked by inter rated method and calculated by spearman rank correlation. The calculated rs was 0.91 which shows, tool was reliable. The nursing care activities list prepared after one week unit activities observation by researcher (included list of all the possible unit activities according to the patients’ needs under each category of the patients). An observation Per forma of nursing care activities prepared to record the time taken for performing each nursing activity three times by researcher (consisted of nursing procedures and columns for recording the time for three times for each category of the patients). The patient’s census record sheet was prepared to maintain the daily record of number of patients in each category of dependency level.Five nursing experts were given tools for validation. Modifications were made as per expert’s suggestions and guidance of guide and co-guide. Pilot study was undertaken in July 2008 and result showed that it was feasible to conduct the study. Data was collected in the month of August 2008. Patients were classified daily based by using patients’ classification tool. This helped the researcher to know the total number of fully dependent, partial dependent, low dependent patients in one day and at the end of 30 days the census of total number of patients in each category of dependency.Nursing care activities divided into: Direct nursing care activities (Independently performed, Assistance to doctor and others) and Indirect nursing care activities (Unit related). For nursing care activities, time is noted by performing the each nursing activity activities in each shift and then calculated for the 24 hours.Frequency related to non routine nursing activities, the total number of times each nursing activity performed in 30 days was recorded and then average was taken to find the frequency of each activity in one day.Average time and average frequency were calculated for each nursing activity for each dependency category patients and unit activities. Then average time and average frequency were multiplied for each nursing activity of ward and patients to calculate the total time for all nursing activities for all three categories patients and unit activities. A statistical formula was applied to convert the total calculated time for nursing activities into number of required nurses i.e. Total nursing manpower = man hours taken for performing direct+ indirect nursing care activities +break divided by 8hrs which was multiplied by 30% leave reserve.

Results:Table: 1 shows that the most of the patients in CCU during 30 days were either fully dependent (114) or partially dependent (116) and only 46 patients were of low dependency level.

Table-1: Number of patients of each dependency level in 30 days in CCU thrice by researcher herself. Then the average   of three readings was taken. Frequency of routine and unit activities noted by observing the number of time activities performed in each shift, five patients of each dependency category were observed for frequency of

Dependency level of patients            Fully dependent                               114

Partially dependent                          116

Low dependent                                 46

Figure 1 shows the average frequency of nursing Care activities for one fully dependent, one partially dependent and one low dependent patient in 24 hours. All nursing Care activities on x-axis comprised of sub activities like medication includes oral medication, intravenous bolus, and intravenous infusions, subcutaneous, topical. It is clear from the figure that for fully dependent patient, frequency of administering medication was maximum followed by frequency of recording intake output, taking vital signs, removal of invasive lines, monitoring blood glucose level, insertion of invasive lines, bedding and frequency of taking samples was minimum. For partially dependent patient frequency of administering medication was higher followed by frequency of taking vital signs, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and frequency of taking samples was low. For low dependent patient frequency of taking vital signs was higher followed by frequency of recording intake output, administering medication, monitoring blood glucose level, bedding, removal of invasive lines, insertion of invasive lines and frequency of taking samples was low. Figure 2 shows the average frequency of direct and indirect nursing care activities in Coronary Care Unit of PGIMER, Chandigarh in 24 hours. It is clear from the figure that direct care nursing activities were having more frequency (93.84%) than the frequency of Figure 1: Frequency of nursing care activities as per dependency level of patient in 24 hours indirect care nursing activities (6.17%). Thus direct care activities were performed more than the indirect nursing care activities.Figure 3 shows the average time taken in minutes to perform the nursing activities for one fully dependent, partially dependent and low dependent patient in 24 hours. It is clear from the figure that for fully dependent patient, time of administering medication was maximum followed by time taken in removal of invasive lines, taking vital signs, recording intake output, inser tion of invasive lines, bedding, monitoring blood glucose level and time for taking samples was minimum. For par tially dependent patient time of administering medication was maximum followed by time taken in taking vital signs, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and time for taking samples was minimum. For low dependent patient time of taking vital signs was maximum followed by time taken in administering medication, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and time for taking samples was minimum.Figure- 3: Average time taken to perform nursing activities for one fully dependent, par tially dependent and low dependent patient in 24 hours.Table- 2 depicts the Average time taken to perform nursing care activities for number of patient in each dependency level in 24 hrs. It was observed that on an average in a day fully dependent patient required 22.48 nursing care hours where as par tially dependent patient required 8.00 nursing care

Figure- 3: Average time taken to perform nursing activities for one fully dependent, partially dependent and low dependent patient in 24 hours.hours and low dependency patient required only 3.55 nursing care hours. Hence two third (66 %) nursing man hours were needed to care for fully dependent patient followed by 24 % nursing man hours were needed to care for partially dependent patient and the only10 % nursing man hours were required for low dependent patients.

Table – 2 Time required to perform nursing care activities in 24 hours

 

Dependency level of patient	Total number of patients in each dependency level in 30 days in CCU	Average time taken to perform nursing care activities for one patient in 24 hours	Total time taken to perform nursing care activities for all the patient in 24 hrs
Fully dependent	114	22.48	2562.72 (66%)
Partially dependent	116	8.00	928.00 (24%)
Low dependent	46	3.55	163.30 (10%)

Table 3 shows the average time taken in hours to perform the direct, indirect nursing care activities and for break. It is clear from the table that the maximum time 94% was taken to perform direct nursing care activities and least time was taken by the break time (0. 52%) in ten bedded Coronary Care Unit of PGIMER Chandigarh

Table 3: Nursing man hours required to perform the different nursing care activities in 24 hrs in 10 bedded CCU.

 

Nursing care Activities	Average nursing man hours taken in hours in 24 hrs in 10 bedded CCU
Direct care	136.33 (94.54%)
•   Independently performed	•  121.74 (89.29%)
•   Assistance to doctor	•  8.42 ( 6.17%)
•   Others	•  6.17 ( 4.52%)
Indirect care	7.12 ( 4.94%)
Break	0.75 ( 0.52%)
Total Time	144.2

Hence total nursing man hours required for direct (assistance to doctor + independently done), indirect nursing care activities and for break in Coronary Care Unit were144.2 man hours in 24hours. If one nurse provides 8 hours care then the number of nurses required to care in a day = 18 By keeping 30% reserve (according to INC)5 the number of nurses required = 23 nurses.

Discussion:The present study was conducted in CCU of PGIMER Chandigarh by considering the patient’s dependency level for care on nurses. Patients were classified into three categories of dependency i.e. fully dependent patients, par tially dependent and low dependent patients. Meyer G and James C calculated the nursing manpower on the basis of dependency level of the patients i.e. high dependency level, medium dependency level and low dependency level and found a successful method to calculate the number of nurses for unit.19 Donnelly P used four dependency categories of patient according to the time needed to spent on the nursing care to calculate the required nurses for a children’s unit.22 A study by Brien G used the intuitive method of patient dependency to classify the patients for calculation of required nurses for the unit.23 Present study was also used same methodology by considering the patient’s dependency level for care on nurses.Findings revealed that the fully dependent patients required maximum time i.e. 66% of the total time followed by the patients in category of partially dependent i.e. 24% of the total time and least time was required for the patients in category of low dependent patients i.e. 10% of total time. Thus more nursing time was required for fully dependent patients. This study also showed that if there are more dependent patients in the unit, the more is the workload and thus keeping in the mind the needs of the unit the number of staff required also increases.18 The Indian Nursing Council (2004) recommended “the nurse patient ratio in intensive coronary care unit should be 1:1.5 Present study results showed the total number of required nurses in ten bedded Coronary Care Unit of PGIMER were 23 which makes the nurse patient ratio 1: 2 for ten patients by keeping the 8 nurses reserve for offs & holidays. It is recommended that in intensive coronary unit the minimum number of nurses in day time should be one nurse per two beds and one nurse per three beds in night time.19 In one of the study Reid calculated nursing hours per patient by dividing the number of nursing hours available by the number of patients to calculate the required nursing manpower. In present study researcher also calculated the nursing hours needed for each dependency category patient. 20 Fagerstrom used a PAONCIL methodology to find out required staff level in hospital which is based on nursing staff’s professional conception of when the state of the ward is such that it is possible to provide good care to the patients. She   emphasized the importance professional estimates in assessing the need for staff. 21 In United States and other developed countries use of database software is practiced to calculate required number of nursing manpower in various units of the hospital. This helps the nursing supervisor to calculate the daily requirement of number of nursing personnel in a particular ward.Thus study concluded that in Coronary Care Unit of PGIMER, Chandigarh, the nurses were performing more, direct nursing care activities than indirect nursing care activities and the fully dependent patient required more nursing care hours. Most of the nursing time was consumed in providing patient care as compared to ward related activities. In this unit one nurse is required to nurse two patients during day & three patients during night time.Recommendations of study are that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

References

1. Unruh Employement conditions at the bedside. A cause of and solution to the RN shortage. Journal of Nursing Administration 2005;35(1):11-13.
2. Tzeng Nurse’s self-assessment of their nursing competencies, Job demands and job performance in the Taiwan hospital system. International Journal of Nursing Studies 2004; 41:487-496.
3. Akkadechanunt, Thitinut S, The relationship between nurse staffing and patient Journal of Nursing Administration 2008;35(9):478.

4. Lang T, Margret H, Olson V, Romano P, Richard K. Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient,       nurse   employee, and hospital Journal of nursing Administration 2004;34(7/8):326

5.Indian Nursing Guide for school of nursing in India 2002. Indian Nursing Council New Delhi 2002.

6.Khan Factors affecting quality assurance in nursing. Nursing Journal of India1999;Lxxxx.8: 173.s

7.Spetz Public policy & nurse staffing: what approach is best? Journal of Nursing Administration 2005;35(1):14-16.

8. Welton M, Unruh L, Halloran Nurse Staffing, nursing Intensity, staff mix, and direct nursing care costs across Massachusetts Hospitals. Journal Of Nursing Administration 2006;(36)9:416-424.

9. Welton M, Unruh L, Halloran Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals. Journal of Nursing Administration 2006;(36)9:416-424.

10.Dunton N, Gajewski B, Taunton R, Moore Nurse staffing and patient falls on acute care hospital units. Nursing Outlook 2004;52:53-59.

11. Tiffany B, Nutall P, Armstrong M, Clark J, Boylan Lies, damn lies and nursing statistics. Nursing Times 1984;(22):32.

12.Hogston R. Evaluating quality nursing care through peer review and reflection; the findings of a qualitative study. International Journal of Nursing Study 1995;(32)2 :162-172.

13’Brien G. The intuitive method of patient dependency, occasional Nursing Times 1996; 8(82):57-61.

14.Ellis J. Hartley L. Celic. Managing and coordinating nursing care. 4th edition. Lippincott Williams and Wilkins publication 2005;78-79.

15.Marquis L, Huston J. leadership roles and management in nursing theory and 5th edition, Lippincott Williams and Wilkins Publications 2006;222-223.

16.Rushworth, Tacket, Bottoms Up? News Nursing Times 1984: 16-18.

17.Kumari S, Singh C. Staffing pattern in the nursing department of selected Nursing Times. July 2008; 9 (4): 41-43, 63.

18.Meyer G, James Matching staff to patient dependency. Nursing Times 1990; 86(40): 40-42.

19.Scott Setting safe nurse staffing levels, an exploration of the issue. A report by research fellow. Royal College of Nursing 2003.

20.Eid G, Melaugh Nurse hours per patient : a method for monitoring and explaning staffing levels. International Journal of Nursing Studies 1987; 24:1-14.

21.Fagerstrom L, Rainio Professional adjustment of optimal nursing care intensity level: a new method of assessing resources for nursing care. Journal of clinical nursing 1999; 8:369-379.

22.Donnelly Staffing a children’s unit. Nursing Times September 1986; 35-36.

23.O’Brien The intuitive method of patient dependency, occasional paper. Nursing Times 1996; 8(82):57-61.

24.An exploratory study on “nursing manpower” requirement for coronary care unit of PGIMER, Chandigarh

Deepi, Sunita Sharma, Yash Paul Sharmard.

Thus study concluded that in Coronary Care Unit of PGIMER, Chandigarh, the nurses were performing more, direct nursing care activities than indirect nursing care activities and the fully dependent patient required more nursing care hours. Most of the nursing time was consumed in providing patient care as compared to ward related activities. In this unit one nurse is required to nurse two patients during day & three patients during night time.

Recommendations of study are that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

References

1. Unruh Employement conditions at the bedside. A cause of and solution to the RN shortage. Journal of Nursing Administration 2005;35(1):11-13.
2. Tzeng Nurse’s self-assessment of their nursing competencies, Job demands and job performance in the Taiwan hospital system. International Journal of Nursing Studies 2004; 41:487-496.
3. Akkadechanunt, Thitinut S, The relationship between nurse staffing and patient Journal of Nursing Administration 2008;35(9):478.

4. Lang T, Margret H, Olson V, Romano P, Richard K. Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse         employee, and hospital Journal of nursing Administration 2004;34(7/8):3265.

5.  Indian Nursing Guide for school of nursing in India 2002. Indian Nursing Council New Delhi 2002.

6.Khan Factors affecting quality assurance in nursing. Nursing Journal of India1999;Lxxxx.8: 173.s

7.Spetz Public policy & nurse staffing: what approach is best? Journal of Nursing Administration 2005;35(1):14-16.

8. Welton M, Unruh L, Halloran Nurse Staffing, nursing Intensity, staff mix, and direct nursing care costs across Massachusetts Hospitals. Journal Of Nursing Administration 2006;(36)9:416-424.

9.Welton M, Unruh L, Halloran Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals. Journal of Nursing Administration 2006;(36)9:416-424.

10.Dunton N, Gajewski B, Taunton R, Moore

11.Nurse staffing and patient falls on acute care hospital units. Nursing Outlook 2004;52:53-59.

12. Tiffany B, Nutall P, Armstrong M, Clark J, Boylan Lies, damn lies and nursing statistics. Nursing Times 1984;(22):32.

13.Hogston R. Evaluating quality nursing care through peer review and reflection; the findings of a qualitative study. International Journal of Nursing Study 1995;(32)2 :162-172.

14.Brien G. The intuitive method of patient dependency, occasional Nursing Times 1996; 8(82):57-61.

15.Ellis J. Hartley L. Celic. Managing and coordinating nursing care. 4th edition. Lippincott Williams and Wilkins publication 2005;78-79.

16.Marquis L, Huston J. leadership roles and management in nursing theory and 5th edition, Lippincott Williams and Wilkins Publications 2006;222-223.

17. Rushworth, Tacket, Bottoms Up? News Nursing Times 1984: 16-18.

18.Kumari S, Singh C. Staffing pattern in the nursing department of selected Nursing Times. July 2008; 9 (4): 41-43, 63.

19. Meyer G, James Matching staff to patient dependency. Nursing Times 1990; 86(40): 40-42.

20.Scott Setting safe nurse staffing levels, an exploration of the issue. A report by research fellow. Royal College of Nursing 2003.

21.Eid G, Melaugh Nurse hours per patient : a method for monitoring and explaning staffing levels. International Journal of Nursing Studies 1987; 24:1-14.

22.Fagerstrom L, Rainio Professional adjustment of optimal nursing care intensity level: a new method of assessing resources for nursing care. Journal of clinical nursing 1999; 8:369-379.

23.Donnelly Staffing a children’s unit. Nursing Times September 1986; 35-36.

24.O’Brien The intuitive method of patient dependency, occasional paper. Nursing Times 1996; 8(82):57-61.

 

 

 

 

 

 

 

 

 

 

 

 

 

An exploratory study on “nursing manpower” requirement for coronary care unit of PGIMER, Chandigarh

Deepi, Sunita Sharma, Yash Paul Sharma

 

Abstract : In the present era nurse patient ratio has become a concern to the providers of the health services. As the era of advanced technology has led to increased complexity of the patient’s status, so more number of competent nurses are required to care for these patients. Thus calculating the adequate nurse patient ratio is mandatory to provide comprehensive and safe health care to the patients, especially the critical ill patients of the intensive units. An exploratory study was conducted to determine the nursing manpower for Coronary Care Unit. Data was collected by recording time and frequency of all the direct and indirect nursing activities. Direct nursing activities included were independently performed, activities assisted to the doctor and other activities needed to meet the health needs of different dependency level patients admitted in the month of August 2008. Indirect activities included were unit related nursing activities. A statistical formula has applied to convert the total calculated time for nursing activities into number of required nurses. Findings revealed that total number of required nurses to care for the cardiac patients in ten bedded Coronary Care Unit of PGIMER, Chandigarh required was 23. Recommendations of study is that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

 

 

 

Key words :

Nursing Manpower, Competencies, Coronary Care Unit.

 

 

 

 

Correspondence at :

Deepi

C/o National Institute of Nursing Education PGIMER, Chandigarh

Introduction

Today’s health care system and nursing workforce issues are facing limited resources and increasing demands on their services1. The demand for competent and responsible nurses in giving care to patients has also been increased.2 Nurses, the largest group of health care providers, are experiencing significant changes in their work according to the changing health needs of the society. Their workload has been increased and the number

 

 

 

 

 

 

 

of nurses per patient is diminished, which puts the patient’s safety at risk.3 In 1999 California became the first state in union to impose mandatory nurse patient ratio. It had given 1: 2 ratio for intensive care patients.4 According to Indian Nursing Council every hospital should have adequate number of staff nurses to provide better health services to the patients.5 Research has proved the advantages of adequate nurse patient. Their findings revealed that adequate nurse patient ratio ensures safe and quality patient care6, provides clear standards for nursing7, saves money, improves patient care and allocates fairer nursing workloads. It also allows nurses to regain confidence and control over their working conditions.8

Many research findings showed that poor nurse patient ratio leads to poor quality of nursing care, staff stress, poor patient care & misuse of the budget9. Poor ratio of nurse manpower pose a potential threat to continuity & safety of patients and increases nursing workload.10 Statistics show that over the past decade the number of nurses has been increased by 23%, and in-patients has been increased by 25% i.e. a few more nurses are caring for many more patients. So to keep number of nurses pace with number of patients11 and to facilitate the best nursing care to individual patient, we need to calculate the adequate nurse manpower.12

Consumer classification systems (e.g. age groups) in 1970’s, the introduction of nursing care related to diagnostic groups in 1980s & technology and research increased markedly in 1990’s, was a move towards

greater consumer involvement. It contributed to the development of more sensitive patient’s classification system (PCS’s) to calculate nursing workload on a shift basis in a practical way, which was essential to find adequate nurse manpower.13 Thus in this the average number of nursing hours per month can be used to find out the required number of full time equivalent employees. The total hours for full time equivalent employee consist of both productive and non productive work. The productive nursing work includes direct nursing care and non productive nursing work includes break, holidays, and leaves. 14 Later on advanced technology database was used to find required nursing manpower13

Most of the time nursing pattern is determined by the predetermined standards, which may include hours per patient per day like in medical units, visits per month like in home health agencies or minutes per case like in operation theatre. But the patient census, number of patient visits or cases per day does not remain constant forever. So staffing ratio should be adjusted according to the decreased or increased number of patients. The standard formula for calculating nursing care hours per patient per day is equal to nursing hours worked in 24 hours divided by patient census.15

There are two methods to calculate required nursing manpower fall under two methods i.e. Top-down’ methods and ‘Bottom up’ methods. ‘Top-down’ methods relate number of nurses to cost or measures of activity such as beds, visits, attendances etc. Trent formula regression analysis and ‘Bottom-

 

 

 

 

 

 

 

up’ methods are on the basis of patient’s dependency levels, professional judgment of nurses. e.g. Aberdeen formula, Telford system, Rhys Hearn method.16 staffing pattern also depends on the objectives of the hospital, services provided by it, type of patient served, number of beds, amount of suppor tive services available etc. Indian Nursing Council has laid down some specific staffing patterns in different wards of the hospital to ensure efficient functioning of the hospital and patient satisfaction. For example for intensive care unit of the Government hospital the staffing ratio should be 1:0.8.17

It has been observed that, there is lack of specific standards regarding the “required nurse manpower” in Coronary Care Unit of PGIMER, Chandigarh and according to the continuous increasing complexity in the health needs of cardiac patients as well as the technological advancement; nurses need to be more competent in providing care. Therefore the proposed study is undertaken with the objective to find the nursing manpower requirement in Coronary Care Unit of PGIMER, Chandigarh.

Methodology

The exploratory study was conducted in multispeciality hospital of North India i.e. PGIMER, Chandigarh. It has bed capacity of 1600. Coronary Care Unit of PGIMER, Chandigarh was chosen for study. It is situated at the 3rd floor in C block of Nehru Hospital of PGIMER, Chandigarh. It is ten bedded unit. There is separate cabin for each patient and total ten cabins are there in

Coronary Care Unit for 10 patients. There is nursing station for nurses facing the cabins of patients. The patients admitted are mostly with medical conditions like myocardial infarction, sick sinus syndrome, hypertension etc. Pre and post procedural cardiac patients from catheterization laboratory and Cardiac OT after cardiac catheterization are also admitted. Target population consisted of sum total of all the nursing activities performed in the Coronary Care Unit, including the frequency of all nursing activities and the patients admitted in Coronary Care Unit in the month of June to August 08. Sampling technique was purposive. Sample size was each nursing care activity according to its frequency and patient according to dependency level.

After reviewing literature, the researcher prepared patient dependency tool, a list of nursing activities, a Performa to record observation of time and frequency for nursing activities and patient’s census record sheet. Patients’ classification tool to categorize the patients admitted in Coronary Care Unit according to the dependency level with respective scores i.e. low dependent patients (1-8), partially dependent patient (9-16) and fully dependent patient (17-24)). The reliability of tool was checked by inter rated method and calculated by spearman rank correlation. The calculated rs was 0.91 which shows, tool was reliable. The nursing care activities list prepared after one week unit activities observation by researcher (included list of all the possible unit activities according to the patients’ needs under each category of the

 

 

 

 

 

 

 

patients). An observation Per forma of nursing care activities prepared to record the time taken for performing each nursing activity three times by researcher (consisted of nursing procedures and columns for recording the time for three times for each category of the patients). The patient’s census record sheet was prepared to maintain the daily record of number of patients in each category of dependency level.

Five nursing experts were given tools for validation. Modifications were made as per expert’s suggestions and guidance of guide and co-guide. Pilot study was undertaken in July 2008 and result showed that it was feasible to conduct the study. Data was collected in the month of August 2008. Patients were classified daily based by using patients’ classification tool. This helped the researcher to know the total number of fully dependent, partial dependent, low dependent patients in one day and at the end of 30 days the census of total number of patients in each category of dependency.

Nursing care activities divided into: Direct nursing care activities (Independently performed, Assistance to doctor and others) and Indirect nursing care activities (Unit related). For nursing care activities, time is noted by performing the each nursing activity

activities in each shift and then calculated for the 24 hours.

Frequency related to non routine nursing activities, the total number of times each nursing activity performed in 30 days was recorded and then average was taken to find the frequency of each activity in one day.

Average time and average frequency were calculated for each nursing activity for each dependency category patients and unit activities. Then average time and average frequency were multiplied for each nursing activity of ward and patients to calculate the total time for all nursing activities for all three categories patients and unit activities. A statistical formula was applied to convert the total calculated time for nursing activities into number of required nurses i.e. Total nursing manpower = man hours taken for performing direct+ indirect nursing care activities +break divided by 8hrs which was multiplied by 30% leave reserve.

Results

Table: 1 shows that the most of the patients in CCU during 30 days were either fully dependent (114) or partially dependent (116) and only 46 patients were of low dependency level.

Table-1: Number of patients of each dependency level in 30 days in CCU

 

thrice by researcher herself. Then the average                                                                            

 

of three readings was taken. Frequency of routine and unit activities noted by observing the number of time activities performed in each shift, five patients of each dependency category were observed for frequency of

Dependency level of patients                n

Fully dependent                               114

Partially dependent                          116

Low dependent                                 46

 

 

 

 

 

 

 

 

Figure 1 shows the average frequency of nursing Care activities for one fully dependent, one partially dependent and one low dependent patient in 24 hours. All nursing Care activities on x-axis comprised of sub activities like medication includes oral medication, intravenous bolus, and intravenous infusions, subcutaneous, topical. It is clear from the figure that for fully dependent patient, frequency of administering medication was maximum followed by frequency of recording intake output, taking vital signs, removal of invasive lines, monitoring blood glucose level, insertion of invasive lines, bedding and frequency of taking samples was minimum. For partially dependent patient frequency of administering medication was higher followed by

frequency of taking vital signs, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and frequency of taking samples was low. For low dependent patient frequency of taking vital signs was higher followed by frequency of recording intake output, administering medication, monitoring blood glucose level, bedding, removal of invasive lines, insertion of invasive lines and frequency of taking samples was low.

Figure 2 shows the average frequency of direct and indirect nursing care activities in Coronary Care Unit of PGIMER, Chandigarh in 24 hours. It is clear from the figure that direct care nursing activities were having more frequency (93.84%) than the frequency of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: Frequency of nursing care activities as per dependency level of patient in 24 hours

 

 

 

 

 

 

 

 

indirect care nursing activities (6.17%). Thus direct care activities were performed more than the indirect nursing care activities.

Figure 3 shows the average time taken in minutes to perform the nursing activities for one fully dependent, partially dependent and low dependent patient in 24 hours. It is clear from the figure that for fully dependent patient, time of administering medication was maximum followed by time taken in removal of invasive lines, taking vital signs, recording intake output, inser tion of invasive lines, bedding, monitoring blood glucose level and time for taking samples was minimum. For par tially dependent patient time of administering medication was maximum followed by time taken in taking vital signs, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and time for

taking samples was minimum. For low dependent patient time of taking vital signs was maximum followed by time taken in administering medication, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and time for taking samples was minimum.

Figure- 3: Average time taken to perform nursing activities for one fully dependent, par tially dependent and low dependent patient in 24 hours.

Table- 2 depicts the Average time taken to perform nursing care activities for number of patient in each dependency level in 24 hrs. It was observed that on an average in a day fully dependent patient required 22.48 nursing care hours where as par tially dependent patient required 8.00 nursing care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure- 3: Average time taken to perform nursing activities for one fully dependent, partially dependent and low dependent patient in 24 hours.

 

hours and low dependency patient required only 3.55 nursing care hours. Hence two third (66 %) nursing man hours were needed to care for fully dependent patient followed

by 24 % nursing man hours were needed to care for partially dependent patient and the only10 % nursing man hours were required for low dependent patients.

 

Table – 2 Time required to perform nursing care activities in 24 hours

 

Dependency level of patient	Total number of patients in each dependency level in 30 days in CCU	Average time taken to perform nursing care activities for one patient in 24 hours	Total time taken to perform nursing care activities for all the patient in 24 hrs
Fully dependent	114	22.48	2562.72 (66%)
Partially dependent	116	8.00	928.00 (24%)
Low dependent	46	3.55	163.30 (10%)

 

 

 

 

 

 

 

Table 3 shows the average time taken in hours to perform the direct, indirect nursing care activities and for break. It is clear from the table that the maximum time 94%

was taken to perform direct nursing care activities and least time was taken by the break time (0. 52%) in ten bedded Coronary Care Unit of PGIMER Chandigarh

 

Table 3: Nursing man hours required to perform the different nursing care activities in 24 hrs in 10 bedded CCU.

 

Nursing care Activities	Average nursing man hours taken in hours in 24 hrs in 10 bedded CCU
Direct care	136.33 (94.54%)
•   Independently performed	•  121.74 (89.29%)
•   Assistance to doctor	•  8.42 ( 6.17%)
•   Others	•  6.17 ( 4.52%)
Indirect care	7.12 ( 4.94%)
Break	0.75 ( 0.52%)
Total Time	144.2

 

Hence total nursing man hours required for direct (assistance to doctor + independently done), indirect nursing care activities and for break in Coronary Care Unit were144.2 man hours in 24hours. If one nurse provides 8 hours care then the number of nurses required to care in a day = 18 By keeping 30% reserve (according to INC)5 the number of nurses required = 23 nurses.

Discussion

The present study was conducted in CCU of PGIMER Chandigarh by considering the patient’s dependency level for care on nurses. Patients were classified into three categories of dependency i.e. fully dependent patients, par tially dependent and low dependent patients. Meyer G and James C calculated the nursing manpower on the

basis of dependency level of the patients i.e. high dependency level, medium dependency level and low dependency level and found a successful method to calculate the number of nurses for unit.19 Donnelly P used four dependency categories of patient according to the time needed to spent on the nursing care to calculate the required nurses for a children’s unit.22 A study by Brien G used the intuitive method of patient dependency to classify the patients for calculation of required nurses for the unit.23 Present study was also used same methodology by considering the patient’s dependency level for care on nurses.

Findings revealed that the fully dependent patients required maximum time i.e. 66% of the total time followed by the patients in category of partially dependent i.e. 24% of

 

 

 

 

 

 

 

the total time and least time was required for the patients in category of low dependent patients i.e. 10% of total time. Thus more nursing time was required for fully dependent patients. This study also showed that if there are more dependent patients in the unit, the more is the workload and thus keeping in the mind the needs of the unit the number of staff required also increases.18

The Indian Nursing Council (2004) recommended “the nurse patient ratio in intensive coronary care unit should be 1:1.5 Present study results showed the total number of required nurses in ten bedded Coronary Care Unit of PGIMER were 23 which makes the nurse patient ratio 1: 2 for ten patients by keeping the 8 nurses reserve for offs & holidays. It is recommended that in intensive coronary unit the minimum number of nurses in day time should be one nurse per two beds and one nurse per three beds in night time.19

In one of the study Reid calculated nursing hours per patient by dividing the number of nursing hours available by the number of patients to calculate the required nursing manpower. In present study researcher also calculated the nursing hours needed for each dependency category patient. 20

Fagerstrom used a PAONCIL methodology to find out required staff level in hospital which is based on nursing staff’s professional conception of when the state of the ward is such that it is possible to provide good care to the patients. She emphasized the importance professional estimates in

assessing the need for staff. 21

In United States and other developed countries use of database software is practiced to calculate required number of nursing manpower in various units of the hospital. This helps the nursing supervisor to calculate the daily requirement of number of nursing personnel in a particular ward.

Thus study concluded that in Coronary Care Unit of PGIMER, Chandigarh, the nurses were performing more, direct nursing care activities than indirect nursing care activities and the fully dependent patient required more nursing care hours. Most of the nursing time was consumed in providing patient care as compared to ward related activities. In this unit one nurse is required to nurse two patients during day & three patients during night time.

Recommendations of study are that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

References

1. Unruh Employement conditions at the bedside. A cause of and solution to the RN shortage. Journal of Nursing Administration 2005;35(1):11-13.
2. Tzeng Nurse’s self-assessment of their nursing competencies, Job demands and job performance in the Taiwan hospital system. International Journal of Nursing Studies 2004; 41:487-496.
3. Akkadechanunt, Thitinut S, The relationship between nurse staffing and patient Journal of Nursing Administration 2008;35(9):478.

 

 

 

 

 

 

 

4. Lang T, Margret H, Olson V, Romano P, Richard K. Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital Journal of nursing Administration 2004;34(7/8):326
5. Indian Nursing Guide for school of nursing in India 2002. Indian Nursing Council New Delhi 2002.
6. Khan Factors affecting quality assurance in nursing. Nursing Journal of India1999;Lxxxx.8: 173.s
7. Spetz Public policy & nurse staffing: what approach is best? Journal of Nursing Administration 2005;35(1):14-16.
8. Welton M, Unruh L, Halloran Nurse Staffing, nursing Intensity, staff mix, and direct nursing care costs across Massachusetts Hospitals. Journal Of Nursing Administration 2006;(36)9:416-424.
9. Welton M, Unruh L, Halloran Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals. Journal of Nursing Administration 2006;(36)9:416-424.
10. Dunton N, Gajewski B, Taunton R, Moore
11. Nurse staffing and patient falls on acute care hospital units. Nursing Outlook 2004;52:53-59.
12. Tiffany B, Nutall P, Armstrong M, Clark J, Boylan Lies, damn lies and nursing statistics. Nursing Times 1984;(22):32.
13. Hogston R. Evaluating quality nursing care through peer review and reflection; the findings of a qualitative study. International Journal of Nursing Study 1995;(32)2 :162-172.
14. ‘Brien G. The intuitive method of patient dependency, occasional Nursing Times 1996; 8(82):57-61.
15. Ellis J. Hartley L. Celic. Managing and coordinating nursing care. 4th edition. Lippincott Williams and Wilkins publication 2005;78-79.
16. Marquis L, Huston J. leadership roles and management in nursing theory and 5th edition, Lippincott Williams and Wilkins Publications 2006;222-223.
17. Rushworth, Tacket, Bottoms Up? News Nursing Times 1984: 16-18.
18. Kumari S, Singh C. Staffing pattern in the nursing department of selected Nursing Times. July 2008; 9 (4): 41-43, 63.
19. Meyer G, James Matching staff to patient dependency. Nursing Times 1990; 86(40): 40-42.
20. Scott Setting safe nurse staffing levels, an exploration of the issue. A report by research fellow. Royal College of Nursing 2003.
21. Eid G, Melaugh Nurse hours per patient : a method for monitoring and explaning staffing levels. International Journal of Nursing Studies 1987; 24:1-14.
22. Fagerstrom L, Rainio Professional adjustment of optimal nursing care intensity level: a new method of assessing resources for nursing care. Journal of clinical nursing 1999; 8:369-379.
23. Donnelly Staffing a children’s unit. Nursing Times September 1986; 35-36.
24. O’Brien The intuitive method of patient dependency, occasional paper. Nursing Times 1996; 8(82):57-61.

 

 

 

 

 

An exploratory study on “nursing manpower” requirement for coronary care unit of PGIMER, Chandigarh

Deepi, Sunita Sharma, Yash Paul Sharma

 

Abstract : In the present era nurse patient ratio has become a concern to the providers of the health services. As the era of advanced technology has led to increased complexity of the patient’s status, so more number of competent nurses are required to care for these patients. Thus calculating the adequate nurse patient ratio is mandatory to provide comprehensive and safe health care to the patients, especially the critical ill patients of the intensive units. An exploratory study was conducted to determine the nursing manpower for Coronary Care Unit. Data was collected by recording time and frequency of all the direct and indirect nursing activities. Direct nursing activities included were independently performed, activities assisted to the doctor and other activities needed to meet the health needs of different dependency level patients admitted in the month of August 2008. Indirect activities included were unit related nursing activities. A statistical formula has applied to convert the total calculated time for nursing activities into number of required nurses. Findings revealed that total number of required nurses to care for the cardiac patients in ten bedded Coronary Care Unit of PGIMER, Chandigarh required was 23. Recommendations of study is that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

 

 

 

Key words :

Nursing Manpower, Competencies, Coronary Care Unit.

 

 

 

 

Correspondence at :

Deepi

C/o National Institute of Nursing Education PGIMER, Chandigarh

Introduction

Today’s health care system and nursing workforce issues are facing limited resources and increasing demands on their services1. The demand for competent and responsible nurses in giving care to patients has also been increased.2 Nurses, the largest group of health care providers, are experiencing significant changes in their work according to the changing health needs of the society. Their workload has been increased and the number

 

 

 

 

 

 

 

of nurses per patient is diminished, which puts the patient’s safety at risk.3 In 1999 California became the first state in union to impose mandatory nurse patient ratio. It had given 1: 2 ratio for intensive care patients.4 According to Indian Nursing Council every hospital should have adequate number of staff nurses to provide better health services to the patients.5 Research has proved the advantages of adequate nurse patient. Their findings revealed that adequate nurse patient ratio ensures safe and quality patient care6, provides clear standards for nursing7, saves money, improves patient care and allocates fairer nursing workloads. It also allows nurses to regain confidence and control over their working conditions.8

Many research findings showed that poor nurse patient ratio leads to poor quality of nursing care, staff stress, poor patient care & misuse of the budget9. Poor ratio of nurse manpower pose a potential threat to continuity & safety of patients and increases nursing workload.10 Statistics show that over the past decade the number of nurses has been increased by 23%, and in-patients has been increased by 25% i.e. a few more nurses are caring for many more patients. So to keep number of nurses pace with number of patients11 and to facilitate the best nursing care to individual patient, we need to calculate the adequate nurse manpower.12

Consumer classification systems (e.g. age groups) in 1970’s, the introduction of nursing care related to diagnostic groups in 1980s & technology and research increased markedly in 1990’s, was a move towards

greater consumer involvement. It contributed to the development of more sensitive patient’s classification system (PCS’s) to calculate nursing workload on a shift basis in a practical way, which was essential to find adequate nurse manpower.13 Thus in this the average number of nursing hours per month can be used to find out the required number of full time equivalent employees. The total hours for full time equivalent employee consist of both productive and non productive work. The productive nursing work includes direct nursing care and non productive nursing work includes break, holidays, and leaves. 14 Later on advanced technology database was used to find required nursing manpower13

Most of the time nursing pattern is determined by the predetermined standards, which may include hours per patient per day like in medical units, visits per month like in home health agencies or minutes per case like in operation theatre. But the patient census, number of patient visits or cases per day does not remain constant forever. So staffing ratio should be adjusted according to the decreased or increased number of patients. The standard formula for calculating nursing care hours per patient per day is equal to nursing hours worked in 24 hours divided by patient census.15

There are two methods to calculate required nursing manpower fall under two methods i.e. Top-down’ methods and ‘Bottom up’ methods. ‘Top-down’ methods relate number of nurses to cost or measures of activity such as beds, visits, attendances etc. Trent formula regression analysis and ‘Bottom-

 

 

 

 

 

 

 

up’ methods are on the basis of patient’s dependency levels, professional judgment of nurses. e.g. Aberdeen formula, Telford system, Rhys Hearn method.16 staffing pattern also depends on the objectives of the hospital, services provided by it, type of patient served, number of beds, amount of suppor tive services available etc. Indian Nursing Council has laid down some specific staffing patterns in different wards of the hospital to ensure efficient functioning of the hospital and patient satisfaction. For example for intensive care unit of the Government hospital the staffing ratio should be 1:0.8.17

It has been observed that, there is lack of specific standards regarding the “required nurse manpower” in Coronary Care Unit of PGIMER, Chandigarh and according to the continuous increasing complexity in the health needs of cardiac patients as well as the technological advancement; nurses need to be more competent in providing care. Therefore the proposed study is undertaken with the objective to find the nursing manpower requirement in Coronary Care Unit of PGIMER, Chandigarh.

Methodology

The exploratory study was conducted in multispeciality hospital of North India i.e. PGIMER, Chandigarh. It has bed capacity of 1600. Coronary Care Unit of PGIMER, Chandigarh was chosen for study. It is situated at the 3rd floor in C block of Nehru Hospital of PGIMER, Chandigarh. It is ten bedded unit. There is separate cabin for each patient and total ten cabins are there in

Coronary Care Unit for 10 patients. There is nursing station for nurses facing the cabins of patients. The patients admitted are mostly with medical conditions like myocardial infarction, sick sinus syndrome, hypertension etc. Pre and post procedural cardiac patients from catheterization laboratory and Cardiac OT after cardiac catheterization are also admitted. Target population consisted of sum total of all the nursing activities performed in the Coronary Care Unit, including the frequency of all nursing activities and the patients admitted in Coronary Care Unit in the month of June to August 08. Sampling technique was purposive. Sample size was each nursing care activity according to its frequency and patient according to dependency level.

After reviewing literature, the researcher prepared patient dependency tool, a list of nursing activities, a Performa to record observation of time and frequency for nursing activities and patient’s census record sheet. Patients’ classification tool to categorize the patients admitted in Coronary Care Unit according to the dependency level with respective scores i.e. low dependent patients (1-8), partially dependent patient (9-16) and fully dependent patient (17-24)). The reliability of tool was checked by inter rated method and calculated by spearman rank correlation. The calculated rs was 0.91 which shows, tool was reliable. The nursing care activities list prepared after one week unit activities observation by researcher (included list of all the possible unit activities according to the patients’ needs under each category of the

 

 

 

 

 

 

 

patients). An observation Per forma of nursing care activities prepared to record the time taken for performing each nursing activity three times by researcher (consisted of nursing procedures and columns for recording the time for three times for each category of the patients). The patient’s census record sheet was prepared to maintain the daily record of number of patients in each category of dependency level.

Five nursing experts were given tools for validation. Modifications were made as per expert’s suggestions and guidance of guide and co-guide. Pilot study was undertaken in July 2008 and result showed that it was feasible to conduct the study. Data was collected in the month of August 2008. Patients were classified daily based by using patients’ classification tool. This helped the researcher to know the total number of fully dependent, partial dependent, low dependent patients in one day and at the end of 30 days the census of total number of patients in each category of dependency.

Nursing care activities divided into: Direct nursing care activities (Independently performed, Assistance to doctor and others) and Indirect nursing care activities (Unit related). For nursing care activities, time is noted by performing the each nursing activity

activities in each shift and then calculated for the 24 hours.

Frequency related to non routine nursing activities, the total number of times each nursing activity performed in 30 days was recorded and then average was taken to find the frequency of each activity in one day.

Average time and average frequency were calculated for each nursing activity for each dependency category patients and unit activities. Then average time and average frequency were multiplied for each nursing activity of ward and patients to calculate the total time for all nursing activities for all three categories patients and unit activities. A statistical formula was applied to convert the total calculated time for nursing activities into number of required nurses i.e. Total nursing manpower = man hours taken for performing direct+ indirect nursing care activities +break divided by 8hrs which was multiplied by 30% leave reserve.

Results

Table: 1 shows that the most of the patients in CCU during 30 days were either fully dependent (114) or partially dependent (116) and only 46 patients were of low dependency level.

Table-1: Number of patients of each dependency level in 30 days in CCU

 

thrice by researcher herself. Then the average                                                                            

 

of three readings was taken. Frequency of routine and unit activities noted by observing the number of time activities performed in each shift, five patients of each dependency category were observed for frequency of

Dependency level of patients                n

Fully dependent                               114

Partially dependent                          116

Low dependent                                 46

 

 

 

 

 

 

 

 

Figure 1 shows the average frequency of nursing Care activities for one fully dependent, one partially dependent and one low dependent patient in 24 hours. All nursing Care activities on x-axis comprised of sub activities like medication includes oral medication, intravenous bolus, and intravenous infusions, subcutaneous, topical. It is clear from the figure that for fully dependent patient, frequency of administering medication was maximum followed by frequency of recording intake output, taking vital signs, removal of invasive lines, monitoring blood glucose level, insertion of invasive lines, bedding and frequency of taking samples was minimum. For partially dependent patient frequency of administering medication was higher followed by

frequency of taking vital signs, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and frequency of taking samples was low. For low dependent patient frequency of taking vital signs was higher followed by frequency of recording intake output, administering medication, monitoring blood glucose level, bedding, removal of invasive lines, insertion of invasive lines and frequency of taking samples was low.

Figure 2 shows the average frequency of direct and indirect nursing care activities in Coronary Care Unit of PGIMER, Chandigarh in 24 hours. It is clear from the figure that direct care nursing activities were having more frequency (93.84%) than the frequency of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: Frequency of nursing care activities as per dependency level of patient in 24 hours

 

 

 

 

 

 

 

 

indirect care nursing activities (6.17%). Thus direct care activities were performed more than the indirect nursing care activities.

Figure 3 shows the average time taken in minutes to perform the nursing activities for one fully dependent, partially dependent and low dependent patient in 24 hours. It is clear from the figure that for fully dependent patient, time of administering medication was maximum followed by time taken in removal of invasive lines, taking vital signs, recording intake output, inser tion of invasive lines, bedding, monitoring blood glucose level and time for taking samples was minimum. For par tially dependent patient time of administering medication was maximum followed by time taken in taking vital signs, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and time for

taking samples was minimum. For low dependent patient time of taking vital signs was maximum followed by time taken in administering medication, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and time for taking samples was minimum.

Figure- 3: Average time taken to perform nursing activities for one fully dependent, par tially dependent and low dependent patient in 24 hours.

Table- 2 depicts the Average time taken to perform nursing care activities for number of patient in each dependency level in 24 hrs. It was observed that on an average in a day fully dependent patient required 22.48 nursing care hours where as par tially dependent patient required 8.00 nursing care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure- 3: Average time taken to perform nursing activities for one fully dependent, partially dependent and low dependent patient in 24 hours.

 

hours and low dependency patient required only 3.55 nursing care hours. Hence two third (66 %) nursing man hours were needed to care for fully dependent patient followed

by 24 % nursing man hours were needed to care for partially dependent patient and the only10 % nursing man hours were required for low dependent patients.

 

Table – 2 Time required to perform nursing care activities in 24 hours

 

Dependency level of patient	Total number of patients in each dependency level in 30 days in CCU	Average time taken to perform nursing care activities for one patient in 24 hours	Total time taken to perform nursing care activities for all the patient in 24 hrs
Fully dependent	114	22.48	2562.72 (66%)
Partially dependent	116	8.00	928.00 (24%)
Low dependent	46	3.55	163.30 (10%)

 

 

 

 

 

 

 

Table 3 shows the average time taken in hours to perform the direct, indirect nursing care activities and for break. It is clear from the table that the maximum time 94%

was taken to perform direct nursing care activities and least time was taken by the break time (0. 52%) in ten bedded Coronary Care Unit of PGIMER Chandigarh

 

Table 3: Nursing man hours required to perform the different nursing care activities in 24 hrs in 10 bedded CCU.

 

Nursing care Activities	Average nursing man hours taken in hours in 24 hrs in 10 bedded CCU
Direct care	136.33 (94.54%)
•   Independently performed	•  121.74 (89.29%)
•   Assistance to doctor	•  8.42 ( 6.17%)
•   Others	•  6.17 ( 4.52%)
Indirect care	7.12 ( 4.94%)
Break	0.75 ( 0.52%)
Total Time	144.2

 

Hence total nursing man hours required for direct (assistance to doctor + independently done), indirect nursing care activities and for break in Coronary Care Unit were144.2 man hours in 24hours. If one nurse provides 8 hours care then the number of nurses required to care in a day = 18 By keeping 30% reserve (according to INC)5 the number of nurses required = 23 nurses.

Discussion

The present study was conducted in CCU of PGIMER Chandigarh by considering the patient’s dependency level for care on nurses. Patients were classified into three categories of dependency i.e. fully dependent patients, par tially dependent and low dependent patients. Meyer G and James C calculated the nursing manpower on the

basis of dependency level of the patients i.e. high dependency level, medium dependency level and low dependency level and found a successful method to calculate the number of nurses for unit.19 Donnelly P used four dependency categories of patient according to the time needed to spent on the nursing care to calculate the required nurses for a children’s unit.22 A study by Brien G used the intuitive method of patient dependency to classify the patients for calculation of required nurses for the unit.23 Present study was also used same methodology by considering the patient’s dependency level for care on nurses.

Findings revealed that the fully dependent patients required maximum time i.e. 66% of the total time followed by the patients in category of partially dependent i.e. 24% of

 

 

 

 

 

 

 

the total time and least time was required for the patients in category of low dependent patients i.e. 10% of total time. Thus more nursing time was required for fully dependent patients. This study also showed that if there are more dependent patients in the unit, the more is the workload and thus keeping in the mind the needs of the unit the number of staff required also increases.18

The Indian Nursing Council (2004) recommended “the nurse patient ratio in intensive coronary care unit should be 1:1.5 Present study results showed the total number of required nurses in ten bedded Coronary Care Unit of PGIMER were 23 which makes the nurse patient ratio 1: 2 for ten patients by keeping the 8 nurses reserve for offs & holidays. It is recommended that in intensive coronary unit the minimum number of nurses in day time should be one nurse per two beds and one nurse per three beds in night time.19

In one of the study Reid calculated nursing hours per patient by dividing the number of nursing hours available by the number of patients to calculate the required nursing manpower. In present study researcher also calculated the nursing hours needed for each dependency category patient. 20

Fagerstrom used a PAONCIL methodology to find out required staff level in hospital which is based on nursing staff’s professional conception of when the state of the ward is such that it is possible to provide good care to the patients. She emphasized the importance professional estimates in

assessing the need for staff. 21

In United States and other developed countries use of database software is practiced to calculate required number of nursing manpower in various units of the hospital. This helps the nursing supervisor to calculate the daily requirement of number of nursing personnel in a particular ward.

Thus study concluded that in Coronary Care Unit of PGIMER, Chandigarh, the nurses were performing more, direct nursing care activities than indirect nursing care activities and the fully dependent patient required more nursing care hours. Most of the nursing time was consumed in providing patient care as compared to ward related activities. In this unit one nurse is required to nurse two patients during day & three patients during night time.

Recommendations of study are that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

References

1. Unruh Employement conditions at the bedside. A cause of and solution to the RN shortage. Journal of Nursing Administration 2005;35(1):11-13.
2. Tzeng Nurse’s self-assessment of their nursing competencies, Job demands and job performance in the Taiwan hospital system. International Journal of Nursing Studies 2004; 41:487-496.
3. Akkadechanunt, Thitinut S, The relationship between nurse staffing and patient Journal of Nursing Administration 2008;35(9):478.

 

 

 

 

 

 

 

4. Lang T, Margret H, Olson V, Romano P, Richard K. Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital Journal of nursing Administration 2004;34(7/8):326
5. Indian Nursing Guide for school of nursing in India 2002. Indian Nursing Council New Delhi 2002.
6. Khan Factors affecting quality assurance in nursing. Nursing Journal of India1999;Lxxxx.8: 173.s
7. Spetz Public policy & nurse staffing: what approach is best? Journal of Nursing Administration 2005;35(1):14-16.
8. Welton M, Unruh L, Halloran Nurse Staffing, nursing Intensity, staff mix, and direct nursing care costs across Massachusetts Hospitals. Journal Of Nursing Administration 2006;(36)9:416-424.
9. Welton M, Unruh L, Halloran Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals. Journal of Nursing Administration 2006;(36)9:416-424.
10. Dunton N, Gajewski B, Taunton R, Moore
11. Nurse staffing and patient falls on acute care hospital units. Nursing Outlook 2004;52:53-59.
12. Tiffany B, Nutall P, Armstrong M, Clark J, Boylan Lies, damn lies and nursing statistics. Nursing Times 1984;(22):32.
13. Hogston R. Evaluating quality nursing care through peer review and reflection; the findings of a qualitative study. International Journal of Nursing Study 1995;(32)2 :162-172.
14. ‘Brien G. The intuitive method of patient dependency, occasional Nursing Times 1996; 8(82):57-61.
15. Ellis J. Hartley L. Celic. Managing and coordinating nursing care. 4th edition. Lippincott Williams and Wilkins publication 2005;78-79.
16. Marquis L, Huston J. leadership roles and management in nursing theory and 5th edition, Lippincott Williams and Wilkins Publications 2006;222-223.
17. Rushworth, Tacket, Bottoms Up? News Nursing Times 1984: 16-18.
18. Kumari S, Singh C. Staffing pattern in the nursing department of selected Nursing Times. July 2008; 9 (4): 41-43, 63.
19. Meyer G, James Matching staff to patient dependency. Nursing Times 1990; 86(40): 40-42.
20. Scott Setting safe nurse staffing levels, an exploration of the issue. A report by research fellow. Royal College of Nursing 2003.
21. Eid G, Melaugh Nurse hours per patient : a method for monitoring and explaning staffing levels. International Journal of Nursing Studies 1987; 24:1-14.
22. Fagerstrom L, Rainio Professional adjustment of optimal nursing care intensity level: a new method of assessing resources for nursing care. Journal of clinical nursing 1999; 8:369-379.
23. Donnelly Staffing a children’s unit. Nursing Times September 1986; 35-36.
24. O’Brien The intuitive method of patient dependency, occasional paper. Nursing Times 1996; 8(82):57-61.

 

 

 

 

 

 

 

 

 

 

An exploratory study on “nursing manpower” requirement for coronary care unit of PGIMER, Chandigarh

Deepi, Sunita Sharma, Yash Paul Sharma

 

Abstract : In the present era nurse patient ratio has become a concern to the providers of the health services. As the era of advanced technology has led to increased complexity of the patient’s status, so more number of competent nurses are required to care for these patients. Thus calculating the adequate nurse patient ratio is mandatory to provide comprehensive and safe health care to the patients, especially the critical ill patients of the intensive units. An exploratory study was conducted to determine the nursing manpower for Coronary Care Unit. Data was collected by recording time and frequency of all the direct and indirect nursing activities. Direct nursing activities included were independently performed, activities assisted to the doctor and other activities needed to meet the health needs of different dependency level patients admitted in the month of August 2008. Indirect activities included were unit related nursing activities. A statistical formula has applied to convert the total calculated time for nursing activities into number of required nurses. Findings revealed that total number of required nurses to care for the cardiac patients in ten bedded Coronary Care Unit of PGIMER, Chandigarh required was 23. Recommendations of study is that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

 

 

 

Key words :

Nursing Manpower, Competencies, Coronary Care Unit.

 

 

 

 

Correspondence at :

Deepi

C/o National Institute of Nursing Education PGIMER, Chandigarh

Introduction

Today’s health care system and nursing workforce issues are facing limited resources and increasing demands on their services1. The demand for competent and responsible nurses in giving care to patients has also been increased.2 Nurses, the largest group of health care providers, are experiencing significant changes in their work according to the changing health needs of the society. Their workload has been increased and the number

 

 

 

 

 

 

 

of nurses per patient is diminished, which puts the patient’s safety at risk.3 In 1999 California became the first state in union to impose mandatory nurse patient ratio. It had given 1: 2 ratio for intensive care patients.4 According to Indian Nursing Council every hospital should have adequate number of staff nurses to provide better health services to the patients.5 Research has proved the advantages of adequate nurse patient. Their findings revealed that adequate nurse patient ratio ensures safe and quality patient care6, provides clear standards for nursing7, saves money, improves patient care and allocates fairer nursing workloads. It also allows nurses to regain confidence and control over their working conditions.8

Many research findings showed that poor nurse patient ratio leads to poor quality of nursing care, staff stress, poor patient care & misuse of the budget9. Poor ratio of nurse manpower pose a potential threat to continuity & safety of patients and increases nursing workload.10 Statistics show that over the past decade the number of nurses has been increased by 23%, and in-patients has been increased by 25% i.e. a few more nurses are caring for many more patients. So to keep number of nurses pace with number of patients11 and to facilitate the best nursing care to individual patient, we need to calculate the adequate nurse manpower.12

Consumer classification systems (e.g. age groups) in 1970’s, the introduction of nursing care related to diagnostic groups in 1980s & technology and research increased markedly in 1990’s, was a move towards

greater consumer involvement. It contributed to the development of more sensitive patient’s classification system (PCS’s) to calculate nursing workload on a shift basis in a practical way, which was essential to find adequate nurse manpower.13 Thus in this the average number of nursing hours per month can be used to find out the required number of full time equivalent employees. The total hours for full time equivalent employee consist of both productive and non productive work. The productive nursing work includes direct nursing care and non productive nursing work includes break, holidays, and leaves. 14 Later on advanced technology database was used to find required nursing manpower13

Most of the time nursing pattern is determined by the predetermined standards, which may include hours per patient per day like in medical units, visits per month like in home health agencies or minutes per case like in operation theatre. But the patient census, number of patient visits or cases per day does not remain constant forever. So staffing ratio should be adjusted according to the decreased or increased number of patients. The standard formula for calculating nursing care hours per patient per day is equal to nursing hours worked in 24 hours divided by patient census.15

There are two methods to calculate required nursing manpower fall under two methods i.e. Top-down’ methods and ‘Bottom up’ methods. ‘Top-down’ methods relate number of nurses to cost or measures of activity such as beds, visits, attendances etc. Trent formula regression analysis and ‘Bottom-

 

 

 

 

 

 

 

up’ methods are on the basis of patient’s dependency levels, professional judgment of nurses. e.g. Aberdeen formula, Telford system, Rhys Hearn method.16 staffing pattern also depends on the objectives of the hospital, services provided by it, type of patient served, number of beds, amount of suppor tive services available etc. Indian Nursing Council has laid down some specific staffing patterns in different wards of the hospital to ensure efficient functioning of the hospital and patient satisfaction. For example for intensive care unit of the Government hospital the staffing ratio should be 1:0.8.17

It has been observed that, there is lack of specific standards regarding the “required nurse manpower” in Coronary Care Unit of PGIMER, Chandigarh and according to the continuous increasing complexity in the health needs of cardiac patients as well as the technological advancement; nurses need to be more competent in providing care. Therefore the proposed study is undertaken with the objective to find the nursing manpower requirement in Coronary Care Unit of PGIMER, Chandigarh.

Methodology

The exploratory study was conducted in multispeciality hospital of North India i.e. PGIMER, Chandigarh. It has bed capacity of 1600. Coronary Care Unit of PGIMER, Chandigarh was chosen for study. It is situated at the 3rd floor in C block of Nehru Hospital of PGIMER, Chandigarh. It is ten bedded unit. There is separate cabin for each patient and total ten cabins are there in

Coronary Care Unit for 10 patients. There is nursing station for nurses facing the cabins of patients. The patients admitted are mostly with medical conditions like myocardial infarction, sick sinus syndrome, hypertension etc. Pre and post procedural cardiac patients from catheterization laboratory and Cardiac OT after cardiac catheterization are also admitted. Target population consisted of sum total of all the nursing activities performed in the Coronary Care Unit, including the frequency of all nursing activities and the patients admitted in Coronary Care Unit in the month of June to August 08. Sampling technique was purposive. Sample size was each nursing care activity according to its frequency and patient according to dependency level.

After reviewing literature, the researcher prepared patient dependency tool, a list of nursing activities, a Performa to record observation of time and frequency for nursing activities and patient’s census record sheet. Patients’ classification tool to categorize the patients admitted in Coronary Care Unit according to the dependency level with respective scores i.e. low dependent patients (1-8), partially dependent patient (9-16) and fully dependent patient (17-24)). The reliability of tool was checked by inter rated method and calculated by spearman rank correlation. The calculated rs was 0.91 which shows, tool was reliable. The nursing care activities list prepared after one week unit activities observation by researcher (included list of all the possible unit activities according to the patients’ needs under each category of the

 

 

 

 

 

 

 

patients). An observation Per forma of nursing care activities prepared to record the time taken for performing each nursing activity three times by researcher (consisted of nursing procedures and columns for recording the time for three times for each category of the patients). The patient’s census record sheet was prepared to maintain the daily record of number of patients in each category of dependency level.

Five nursing experts were given tools for validation. Modifications were made as per expert’s suggestions and guidance of guide and co-guide. Pilot study was undertaken in July 2008 and result showed that it was feasible to conduct the study. Data was collected in the month of August 2008. Patients were classified daily based by using patients’ classification tool. This helped the researcher to know the total number of fully dependent, partial dependent, low dependent patients in one day and at the end of 30 days the census of total number of patients in each category of dependency.

Nursing care activities divided into: Direct nursing care activities (Independently performed, Assistance to doctor and others) and Indirect nursing care activities (Unit related). For nursing care activities, time is noted by performing the each nursing activity

activities in each shift and then calculated for the 24 hours.

Frequency related to non routine nursing activities, the total number of times each nursing activity performed in 30 days was recorded and then average was taken to find the frequency of each activity in one day.

Average time and average frequency were calculated for each nursing activity for each dependency category patients and unit activities. Then average time and average frequency were multiplied for each nursing activity of ward and patients to calculate the total time for all nursing activities for all three categories patients and unit activities. A statistical formula was applied to convert the total calculated time for nursing activities into number of required nurses i.e. Total nursing manpower = man hours taken for performing direct+ indirect nursing care activities +break divided by 8hrs which was multiplied by 30% leave reserve.

Results

Table: 1 shows that the most of the patients in CCU during 30 days were either fully dependent (114) or partially dependent (116) and only 46 patients were of low dependency level.

Table-1: Number of patients of each dependency level in 30 days in CCU

 

thrice by researcher herself. Then the average                                                                            

 

of three readings was taken. Frequency of routine and unit activities noted by observing the number of time activities performed in each shift, five patients of each dependency category were observed for frequency of

Dependency level of patients                n

Fully dependent                               114

Partially dependent                          116

Low dependent                                 46

 

 

 

 

 

 

 

 

Figure 1 shows the average frequency of nursing Care activities for one fully dependent, one partially dependent and one low dependent patient in 24 hours. All nursing Care activities on x-axis comprised of sub activities like medication includes oral medication, intravenous bolus, and intravenous infusions, subcutaneous, topical. It is clear from the figure that for fully dependent patient, frequency of administering medication was maximum followed by frequency of recording intake output, taking vital signs, removal of invasive lines, monitoring blood glucose level, insertion of invasive lines, bedding and frequency of taking samples was minimum. For partially dependent patient frequency of administering medication was higher followed by

frequency of taking vital signs, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and frequency of taking samples was low. For low dependent patient frequency of taking vital signs was higher followed by frequency of recording intake output, administering medication, monitoring blood glucose level, bedding, removal of invasive lines, insertion of invasive lines and frequency of taking samples was low.

Figure 2 shows the average frequency of direct and indirect nursing care activities in Coronary Care Unit of PGIMER, Chandigarh in 24 hours. It is clear from the figure that direct care nursing activities were having more frequency (93.84%) than the frequency of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: Frequency of nursing care activities as per dependency level of patient in 24 hours

 

 

 

 

 

 

 

 

indirect care nursing activities (6.17%). Thus direct care activities were performed more than the indirect nursing care activities.

Figure 3 shows the average time taken in minutes to perform the nursing activities for one fully dependent, partially dependent and low dependent patient in 24 hours. It is clear from the figure that for fully dependent patient, time of administering medication was maximum followed by time taken in removal of invasive lines, taking vital signs, recording intake output, inser tion of invasive lines, bedding, monitoring blood glucose level and time for taking samples was minimum. For par tially dependent patient time of administering medication was maximum followed by time taken in taking vital signs, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and time for

taking samples was minimum. For low dependent patient time of taking vital signs was maximum followed by time taken in administering medication, recording intake output, monitoring blood glucose level, bedding, insertion of invasive lines, removal of invasive lines and time for taking samples was minimum.

Figure- 3: Average time taken to perform nursing activities for one fully dependent, par tially dependent and low dependent patient in 24 hours.

Table- 2 depicts the Average time taken to perform nursing care activities for number of patient in each dependency level in 24 hrs. It was observed that on an average in a day fully dependent patient required 22.48 nursing care hours where as par tially dependent patient required 8.00 nursing care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure- 3: Average time taken to perform nursing activities for one fully dependent, partially dependent and low dependent patient in 24 hours.

 

hours and low dependency patient required only 3.55 nursing care hours. Hence two third (66 %) nursing man hours were needed to care for fully dependent patient followed

by 24 % nursing man hours were needed to care for partially dependent patient and the only10 % nursing man hours were required for low dependent patients.

 

Table – 2 Time required to perform nursing care activities in 24 hours

 

Dependency level of patient	Total number of patients in each dependency level in 30 days in CCU	Average time taken to perform nursing care activities for one patient in 24 hours	Total time taken to perform nursing care activities for all the patient in 24 hrs
Fully dependent	114	22.48	2562.72 (66%)
Partially dependent	116	8.00	928.00 (24%)
Low dependent	46	3.55	163.30 (10%)

 

 

 

 

 

 

 

Table 3 shows the average time taken in hours to perform the direct, indirect nursing care activities and for break. It is clear from the table that the maximum time 94%

was taken to perform direct nursing care activities and least time was taken by the break time (0. 52%) in ten bedded Coronary Care Unit of PGIMER Chandigarh

 

Table 3: Nursing man hours required to perform the different nursing care activities in 24 hrs in 10 bedded CCU.

 

Nursing care Activities	Average nursing man hours taken in hours in 24 hrs in 10 bedded CCU
Direct care	136.33 (94.54%)
•   Independently performed	•  121.74 (89.29%)
•   Assistance to doctor	•  8.42 ( 6.17%)
•   Others	•  6.17 ( 4.52%)
Indirect care	7.12 ( 4.94%)
Break	0.75 ( 0.52%)
Total Time	144.2

 

Hence total nursing man hours required for direct (assistance to doctor + independently done), indirect nursing care activities and for break in Coronary Care Unit were144.2 man hours in 24hours. If one nurse provides 8 hours care then the number of nurses required to care in a day = 18 By keeping 30% reserve (according to INC)5 the number of nurses required = 23 nurses.

Discussion

The present study was conducted in CCU of PGIMER Chandigarh by considering the patient’s dependency level for care on nurses. Patients were classified into three categories of dependency i.e. fully dependent patients, par tially dependent and low dependent patients. Meyer G and James C calculated the nursing manpower on the

basis of dependency level of the patients i.e. high dependency level, medium dependency level and low dependency level and found a successful method to calculate the number of nurses for unit.19 Donnelly P used four dependency categories of patient according to the time needed to spent on the nursing care to calculate the required nurses for a children’s unit.22 A study by Brien G used the intuitive method of patient dependency to classify the patients for calculation of required nurses for the unit.23 Present study was also used same methodology by considering the patient’s dependency level for care on nurses.

Findings revealed that the fully dependent patients required maximum time i.e. 66% of the total time followed by the patients in category of partially dependent i.e. 24% of

 

 

 

 

 

 

 

the total time and least time was required for the patients in category of low dependent patients i.e. 10% of total time. Thus more nursing time was required for fully dependent patients. This study also showed that if there are more dependent patients in the unit, the more is the workload and thus keeping in the mind the needs of the unit the number of staff required also increases.18

The Indian Nursing Council (2004) recommended “the nurse patient ratio in intensive coronary care unit should be 1:1.5 Present study results showed the total number of required nurses in ten bedded Coronary Care Unit of PGIMER were 23 which makes the nurse patient ratio 1: 2 for ten patients by keeping the 8 nurses reserve for offs & holidays. It is recommended that in intensive coronary unit the minimum number of nurses in day time should be one nurse per two beds and one nurse per three beds in night time.19

In one of the study Reid calculated nursing hours per patient by dividing the number of nursing hours available by the number of patients to calculate the required nursing manpower. In present study researcher also calculated the nursing hours needed for each dependency category patient. 20

Fagerstrom used a PAONCIL methodology to find out required staff level in hospital which is based on nursing staff’s professional conception of when the state of the ward is such that it is possible to provide good care to the patients. She emphasized the importance professional estimates in

assessing the need for staff. 21

In United States and other developed countries use of database software is practiced to calculate required number of nursing manpower in various units of the hospital. This helps the nursing supervisor to calculate the daily requirement of number of nursing personnel in a particular ward.

Thus study concluded that in Coronary Care Unit of PGIMER, Chandigarh, the nurses were performing more, direct nursing care activities than indirect nursing care activities and the fully dependent patient required more nursing care hours. Most of the nursing time was consumed in providing patient care as compared to ward related activities. In this unit one nurse is required to nurse two patients during day & three patients during night time.

Recommendations of study are that study can be replicated in Coronary Care Unit with more number of beds and in different settings like in surgical wards, in dialysis unit etc.

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