http://doi.org/10.33698/NRF0244Harpreet kaur, Bindu k, Prabhjot Saini

Abstract: Intensive care unit (ICU) is a specially designed and equipped facility staffed by skilled personnel to provide comprehensive and continuous care to critically ill patients. Shortage of nursing manpower in ICU may affect the workload of existing staff and poses a potential threat to the continuity and safety of patients. Objective: To explore the nursing manpower requirement for caring critically ill patients in Medical ICU (MICU). Methodology: Total 509 patients over the period of 30 days were studied by total enumerative sampling technique for 17 bedded Medical Intensive Care Unit (MICU) in a tertiary care hospital, Ludhiana. The dependencies of subjects were categorized as per Modied Jones dependency tool (1990) along with nursing time spent in each category. K Hurst algorithm was followed for determining nurse-patient ratio. Results: Findings revealed that total mean average time of nursing care (Direct, Indirect & Miscellaneous) was 5040.6 min (84.01 hr) per day. Total workload index was 22.70 and Full time equivalent was calculated to be 13.12. Therefore the total nursing manpower requirement was calculated to be 17.06 for 17 bedded MICU. The nurse – patient ratio was calculated to be 1:1. Therefore it is recommended for the nursing administrators to utilize these ndings to plan nursing manpower for medical ICU’s for effective functioning.

Keywords: Manpower requirement, Nurse- Patient ratio, Medical ICU

Correspondence at

Harpreet kaur Lecturer,

Silver Oaks College Of Nursing Abhipur, Distt Mohali, Punjab

Introduction

Human resources in health care are central to its functioning. They play a crucial role in determining the health status of the population as they contribute to different skills and undertake various tasks in the Health system.1 Nurses focus on the care of individuals, families and communities so that they can attain optimal health and quality of life. Nurses develop a plan of care and work collaboratively with the physicians and the therapists, along with the other team members, that focus on treating illness and help in improving the quality of life.2

Shortage affects the workload of existing staff and poses a potential threat to the continuity and safety of the patient. Inpatients in hospitals with lower nurses to patient ratio are more likely to die or suffer with complications than patients in hospital with higher nurse to patient ratio. An increase of one hour worked by registered nurse per patient day was associated with 8.9% decrease in odds of pneumonia. Similarly a 10% increase in registered nurse proportion was associated with 9.5% decrease in the cases of pneumonia. This can be maintained by appropriate nursing manpower.3-5

Nursing manpower calculation or nurse stafng has become important at all level from national and regional structures to ward levels. Forecasting the demand of nurses is a complex and difcult problem. The scheduling of appropriate number of nurses is critical to the provision of the high quality care, especially in the intensive care unit where patients are fully dependent upon nurses for care. As the number of patients’ increases the number of nurses required for the care also increases. 6-8 The various methods used for calculating nurse to patient ratio includes top down basis, bottom up methods, Patient dependency classication systems and Patient dependency scoring system. Several authors emphasized on the aspects of needs of the a patients, the different activities carried out to meet the needs of the patients and the time spent to meet the needs of the patients, time consumed in carrying out various procedures, etc.9-12

Patient dependency is categorized into various categories like category 0, 1, 2, & 3. Hence is described by Modied Jones dependency tool. Level 0 indicate that patient is independent and can carry the activities as its own, Category 1 indicated patient is moderately dependent, Category 2 indicates patient is highly dependent and in Category 3 patient is totally dependent cannot carry out the activities as it on. The basic factors involved in estimating nurses requirements for an inpatient unit, given stipulated patient nurse ratio are bed occupancy, bed capacity and percentage share of patients in each unit according to patient classication system.12,13

Nurses are the one who provide 24 x 7 care in the hospitals. The nursing activities and time record sheet consisted of lists of all patients with different dependency categories. Nursing care activities can be grouped into three main types that include direct, indirect and miscellaneous activities. Direct care activities include Physical care, Maintenance of airway, Medication administration, monitoring the patient, feeding, etc. Indirect activities include giving hand over the patient Report writing Indenting medication, etc. Miscellaneous activities include admission, transfers, setting of the resuscitation trolley, etc.

Determination of nurse to patient ratio is a very difcult question especially for the specic patients unit. Safe, effective and ethical nurse stafng requires sufcient number and appropriate use of competent nurses available to care for patients. Hence nurse patient ratio is needed to promote safe and quality care to the patient. The major concern should be how the nurse stafng ratios will affect the care the patients receive. So an attempt is made to answer this question.

Objective: To explore nursing manpower requirement for Medical Intensive Care Unit (MICU).

Materials and Methods

An exploratory research design was adopted for determining manpower. The method adopted for the calculation of nursing manpower in present study was given by K. Hurst for determining the nursing workforce requirement of the unit. The study was conducted in the medical intensive care unit of DMC, Ludhiana, Punjab. MICU is a specialized care unit where critically ill patients are treated. It is 17 bedded intensive care unit. The multidisciplinary staff is highly collaborative and supportive, working together to achieve the best patient outcomes. The study was approved by Institution Ethics C o m m i t t e e , D M C , L u d h i a n a . T h e methodology of present study was divided into three phases. The rst phase was the planning phase, which emphasized on development of pre-requisites required for study which included development of the tools along with data collection sheets. Modied Jones dependency tool was used for categorizing the patients into different dependency levels according to their nursing needs. All patients were categorized into four dependency categories. Category 0 patient were fully independent, Cat 1 patient belonged to moderate dependency level, cat 2 were highly dependent whereas patient falling in category 3 were fully dependent. Data collections sheets for recording daily census was developed by taking the guidance from the experts from nursing faculty for recording the daily load of patients in unit along with the daily census. Another sheet named Nursing Activity Sampling Sheet was developed for recording the time required for performing the activities. In this sheet three readings of time required for performing each nursing activity were recorded. The second phase of the study focused on the execution which includes the data collection. To obtain representative dependency data, all patients in study area over 1 month were assessed daily for their dependency level. Total of 509 patients were assessed. Patient’s load for each unit was determined by per forming the daily assessment of all the admitted patients of the units. Average time required for performing each nursing care activity was determined by performing the activity thrice. Nursing care activities were categorized into three main categories as direct and indirect and miscellaneous activities. Based on the information gathered during the execution phase nal nursing care sheet for 24 hrs of nursing care was prepared for one patient of each category of dependence. The sheet included the list of all nursing care activities performed along with the frequency in 24hrs coupled with time required for performing that activity once. This sheet was given to experts for their professional judgment. The sheet was used for determining the time spent by the nurse in 24 hrs for caring one patient belonging to different dependency levels. In the third phase i.e. the interpretation phase analysis of the data was done to get the nal results. Algorithm proposed by K.Hurst was used for the calculation of workload index and acuity and nally the nursing manpower requirement for the unit was determined.

Results

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

The patient dependency data along with census of each unit was analyzed. It led to the determination of the patient load for each unit of MICU. Census of each unit along with the number of patients in each category with respect to their dependency level. This has led to the calculation of patient load. Patient load denes the daily number patient present in the units with respect to the dependency levels. Total 509 patients assessed in a month i.e. average daily 17 patients. In MICU total 509 patients were assessed and about Majority of the patient belonged to category 1 (61.5%) and there was less patient in the category 0 (3.1%). Average patient load in category 3, 2, 1 & 0 was 2.73, 3.27, 10.43 and 00.53 respectively. The overall patient load/day in MICU is 16.97.

Figure 1 illustrates the total time spent on nursing care of each patient under each dependency per day. It was found that nurses spent more time for patient belonging to category 3 (totally dependent patients), i.e. 253.008 min of nursing care. Category 2 (highly dependent patients) required 249.469 mins, category 1 (moderately dependent patients) required 191.196 min and category 0 (independent patients) patients needed 157.00 min of nursing care in a day.

 

Table 1: Average patient load/day in MICU

*Dependency category Total patients (30 days) n (%) Average patient load/day
Category-3 082 (16.1) 02.73
Category-2 098 (19.3) 03.27
Category-1 313 (61.5) 10.43
Category-0 016 (3.1) 00.53
Overall 509 16.97

*Based on Modied Jones dependency tool

Figure-1: Average amount of time (min) given to each dependency category Table 2: Nursing care spent for various nursing care activities for category per day

 

Categories Time spent on Nursing care activities in minutes
Monitoring Medicine Administration Routine Care Intervention Documentation Rounds
Category-0 86.67 85.01 287.44 26.5 223.32 72.1
Category-1 333.43 117.37 467.90 182.35 405.69 156.42
Category-2 623.27 316.42 445.64 376.33 501.25 133.88
Category-3 382.23 154.85 221.98 271.14 287.76 84.77

 

Table 2 depict most of the time spent on nursing care per day. For category 3 patients nursing time spent was 382.23 mins for Monitoring folllowed by Medicine administration (154.85 min), Routine care (221.14 min), Intervention (271.14 min), Documentation (287.76 min) and Rounds (84.77 mins). For category 2 nursing time spent on Monitoring was 623.27 mins. Time spent on other nursing care activities were: Medicine administration (316.42 mins) followed by Routine care (445.65 mins), for Interventions (376.24 min), for Documentation (501.25 min) and 133.88 mins was spent on Rounds. For category 1 Nursing care spent on Monitoring was 333.43 mins. 117.37 mins for Medicine administration followed by 467.90 mins for Routine care, 182.35 mins for Intervention, 405.69 mins for Documentation and 156.42 mins was spent on Rounds. For category 0 Nursing care activities spent was 86.67 mins on Monitoring, 85.01 mins for Medicine administration followed by Routine care 287.44 min, Intervention 26.5 mins, Documentation 223.32 mins and last for the Round 72.1 mins was spent on nursing care activities per day.

To find out nursing manpower requirement for MICU

Table 2 shows the Time Differential Ratio (TDR) of nursing care in MICU. In this step the time spent on nursing care was converted into ratios. It was calculated by dividing the time of category 0 (reference value) with each dependency categories. TDR for Cat 0 was found to be 1, for Cat 1 it was 1.21 similarly for Cat 2 it was 1.58 and for Cat 3 it was 1.61.

Table 3 depicts the workload index for each category patients in MICU. It was calculated by multiplying the time differential ratio by average daily number of patients in each dependency category. Workload Index (WLI) is the nursing work needed to meet patient’s needs in a given situation i-e in MICU for 16.97 patients. The workload was found to be 22.7. While considering the category wise workload index, it was found that WLI was highest for category 1 patients i.e. 12.62, followed by category 2 (5.16), category 3 (4.39) and minimum workload index was observed for category 0 patients (00.53).

Table 2: Time differential ratio (TDR) of nursing care in MICU

Category Average time spent (min) Time Differential Ratios
Category-3 253.01 min 1.61
Category-2 249.47 min 1.58
Category-1 191.20 min 1.21
Category-0 157.00 min 1.00

Table 3 : Workload index in MICU

 

Categories

Time Differential Ratios

(a)

Average No. of patients per

day (b)

Work Load Index (a× b)
Category-3 1.61 02.73 04.39
Category-2 1.58 03.27 05.16
Category-1 1.21 10.43 12.62
Category-0 1.00 00.53 00.53
Total 16.97 22.70

Table 4 shows mean bed acuity in MICU. Dividing Work load index by occupancy give the bed acuity. Bed acuity is the equivalent number of dependency 0 patient in MICU in each occupied bed. The mean bed acuity in MICU was found to be 1.337.

Table 5 shows the total nursing care time required for caring all patients in the unit. It was calculated by multiplying the workload index by the average nursing care time spent on patient care in MICU, and it was found to be 4827.6 minute. It shows that nurse spent 4827.6 minutes to care all patients in MICU per day, through direct and indirect nursing activities.

Table 6 shows the time spent on other miscellaneous activities. These are certain activities which are not inuenced by the patient type and all such activities are enlisted under miscellaneous activities. These include admission of patient, setting of resuscitation trolley, transfer patient, accompany patient for CT scan, discharge and others. It shows that nurses spent 213 min on miscellaneous activities for all the patient per day.

Table 7 revels the total nursing care time spent in MICU per day. This was calculated by adding the total time spent on patient direct and indirect care along with miscellaneous activities of the unit. It came out to be 84.01 hrs.

Table 8 shows Full Time Equivalent in MICU. Full Time Equivalent (FTE) is the number of nurses required in a day. Total FTEs or nurses required = Number of FTEs per day + 30% of FTEs Required per day It was calculated by dividing the total nursing care hours spent with working hours per day. Each nurse works for 6.4 hrs per day in MICU. Average shifts for 12 hrs, 17 day shifts for 6 hours and 6 off duties per month. So the FTE required for MICU per day was calculated which came out to be 13.12 per day.

Table 9 shows the manpower requirement in MICU. This is done by adding 30% of manpower as leave reserve required per day with full time equivalent. So for 17 bedded  MICU, the nursing manpower required per day was 17.06. That shows a total of 17 nurses are required for 17 bedded MICU. Hence nurse patient ratio MICU is 1:1.

Ta ble 4: Mean bed acuity in MICU

Work load index (a) Average patient load/day (b) Mean bed acuity (a ÷ b)
22.70 16.97 1.337

 Table 5 : Nursing care time for all patients per day in MICU

Workload index (a) Nursing time (b) Nursing care time for all patient per day (a × b)
22.70 212.67 4827.6 min

 

Table 6 : Nursing care time spent on Miscellaneous activity in MICU

Activity Total time spent (min)
Miscellaneous activities 213

 

 Table 7 : Total nursing time per day in MICU

Nursing care time spent on activities

(min)

Total nursing time per Day
Direct & Indirect Miscellaneous 5040.6 min OR

84.01hrs

4827.6 213

 

Table 8 : Full time equivalent in MICU

Total nursing time per

day (hrs) (a)

Working hours

per day (hrs) (b)

(Full Time Equivalents) (FTE)

(a / b)

84.01 6.4 13.12

 

Table 9 : Nursing manpower requirement in MICU

Full time equivalents

(a)

30% leave reserve

(b)

Nursing manpower requirement

(a + b)

13.12 3.94 17.06

 Discussion: There is a growing evidence that low nurse stafng jeopardizes the quality of patient care. There is lack of sufcient evidence to determine the optimum nursing manpower requirement. Nurse patient ratio is considered a global issue and a major challenge in nursing and health care organization. The appropriate nurse patient is very much important to maintain acceptable standard of care, to decrease the mortality rate and to meet the challenging need of the patient in medical intensive care unit. The present study was conducted at DMC & Hospital to nd out exact nursing manpower required for medical intensive care unit which is equipped with advanced technology like ventilator, monitors, computer for recording data and analyzing, infusion and syringe pump etc. Patient’s dependency along with measurement of activities was used to determine the nursing workload which in turn led to determination of nursing requirement of the unit. This method was given by K Hurst. Assessment of dependency level of patient contributes as important step in this process. Modied Jones dependency tool was used to determine the dependency levels of patient admitted in the medical intensive care unit. This tool was used to classify patients into 4 categories as (Cat-0) independent, between independent and dependent (Cat-1) dependent (Cat-2) and fully dependent is (Cat-3). Daily nursing hours spent for the patients belonging to each dependency category were determined.12,13

For this total nursing activities were observed. These activities are grouped into three heading as direct care, indirect care and miscellaneous activities. Time required for each activity was calculated by carrying out each activity thrice by the researcher and the time was recorded w Results have shown that the bed occupancy in MICU was almost 100% during the study period. There are 17 beds in MICU and the average patient load/day was 16.97with the help of electronic stop watch and the average time was taken.

Similar results were observed by Rajinder Kaur, in the study on nursing manpower requirement for patients of neurosurgical units, where they found 101% bed occupancy in neuro surgery intensive care unit.14

Daily nursing hours required for the care were determined for the patient belonging to each dependency level. Results have shown a total of 63 nursing activities were observed, and these were grouped under direct, indirect and miscellaneous activities. Results have shown that patients in dependency cat 3 required 253.01 mins in 24 hrs of direct and indirect care which is around 4.2 hrs per day where as patients in cat 0 required 157 min which is 2.6 hours daily.

Nearly similar results were observed in another study conducted by Manu Sharma on nursing manpower requirement for cardio thoracic vascular surgery ICU, step down ICU and ward. The results showed that dependency category 3 required 13 hours of nursing care whereas cat. 0 required 2.5 hours daily. Dependent patients require maximum time is consumed on monitoring of activities.15

In the present study Workload index (22.7) and acuity (1.337) values were determined for MICU. Workload index is the nursing work  needed to care for 22.7 patients of cat 0 patients and the acuity presents workload. With this the result of the study have shown that total required nursing manpower is 17.06 for 17 bedded MICU that shown a 1:1 nurse patient ratio. Similar study conducted by Manu Sharma shows the results as 8 nursing manpower required for 3 bedded CTVS ICU.15

It is concluded that the patient’s dependence on the nurse was found to be the more helpful indicator of stafng requirement than a xed ratio of staff to bed. Taking into consideration the needs of the patients the nursing manpower requirement for the unit was calculated

REFERNCES

  1. Gill R. Nursing shortage in India with special reference to international migration of nurses theme & debate social medicine. [Internet]. Reena; 1 March 2013 [Cited on 14 February 2016].2011. 6(1). Available from https://www.researchgate.net./25929232.
  2. Nursing [Internet] [Cited on 19 February 2016 at 19:59]. Available from: http://www.en. Wikipedia.org/wiki/Nursing.
  3. Mitchell GJ. Nursing shortage or nursing famine: looking beyond numbers. Nurs Sci Quart [Internet]. 2003 [Cited on 22 February 2016]; 16: 219-24.Available from http://nsq.sagepub.com/content/16/3/219.
  4. Norman J, Grifths Outcomes of variation in hospital nurse stafng in English hospitals. Int J Nurs Stud [Internet]. 2007;44: 165-6. [Cited on 12 February 2016] Available from journalofnursingstudies.com.
  1. Cho SH, Ketean The effects of nurse stafng on adverse events, morbidity, mortality and medical costs. Nur Res [internet]. 2003; 52: 71-9 [Cited on 3 March, 2016]. Available from http://www.ncbi.nlm.nih.gov/pubmed/12 657982.
  2. Lewis KK. Nurse – to – Patient Ratio: Research and reality [Internet].[Cited on 5 February 2016]; Available from http://masshealthbrandeis.edu/publication/pdf /25Mar05/Issuebrief.pdf.
  1. Rowland JG. Nurse-to-Patient Ratio study [Internet]. [Cited on 6 Ferburary 2016]; Available from http://www.ct.gov/ohca/lib/ohca/publicati ons/npreport pdf.
  2. Aiken LH, Smith HL, Lake Lower Medicare, mortality among a set of hospitals known for good nursing care. Med Care, 1994, Aug; 32 (8): 771-87
  3. Care [Internet]. 1994 [Cited on 6 February 2016]; 32: 771-87. Available from http://www.jstor.org/stable/3766652.
  4. Blegen ME, Vaughn A multi-site study of nurse stafng and patient occurrences. Nurse Econ [Internet]. 1998;16:196-203 [Cited on 7 February 2016]. Available from http://www.aornjournal.org/article/S0001 -2092 (08)00107-5/references.
  1. Blegen ME, Goode CJ, Reed L. Nurse Stafng and patient outcomes. Nurs Res [Internet]. 1998;47:43-50 [Cited on 8 March 2016]. Available fromhttp://www.protectmasspatients.org/ docs/BlegenNurseStafngAndPatientOut pdf
  2. Adomat R, Hewison A. Assessing Patient category/dependence for determining the nurse/patient ratio in ICU and HDU: A review of approaches. J NursManag [Internet]. 2004;12; 299-308 [Cited on 7 March 2016]. Available from http://www.ncbi.nlm.nih.gov/pubmed/15
  3. Scott C. Setting safe Nurse Stafng levels: an exploration of the issues [Internet].London: Cherill Scott; February 2003 [Cited on 4 March 2016]; Available from http://www.rcn.org. uk/ data/ assets/ pdf le/ 0008/ 78551/ 001934
  4. Kaur R, Vati J, Chhabra R, Exploratory study on nursing manpower requirement for patients of Neuro-surgical unit nursing, Nursing & Midwifery Research Journal 2010; 6 (2): 58-70
  5. Sharma M, Sharma S, Singh R, An exploratory study on nursing manpower requirement for Cardio-thoracic vascular surgery intensive care unit, step down intensive care unit and ward. Nursing and Midwifery Research Journal 2010; 6 (2): 47-58