A Study on "Nursing Manpower Requirement in Neo-Natal Intensive Care Unit": PGIMER, Chandigarh

A Study on "Nursing Manpower Requirement in Neo-Natal Intensive Care Unit": PGIMER, Chandigarh Amanvir Kaur, Sukhwinder Kaur, Raman Kalia, Praveen Kumar Abstract : The lack of unequivocal decision on the nurse patient ratio at the global level raises the issue to measure the required nurse patient ratio at all levels. Adequate nurse staffing levels are a fundamental prerequisite for satisfactory neonatal care. Staffing level in the specific setting like neonatal intensive care units should give due consideration to critical factors like number of neonates, level of intensity of neonate needs and organizational support. The present research work was undertaken to analyze the nursing manpower required for a NICU. The Study was conducted during the month of August 2008 in the Neonatal Intensive Care Unit of Nehru Hospital, PGIMER, Chandigarh. Data was collected while making observation for record of time of each nursing care activity which was performed on neonates (ventilated and non-ventilated). A total of 600 observations were made to record the time of each nursing care activity in a period of one month on a total of 132 ventilation and 285 non-ventilation neonatal days. Frequency of each nursing care activity was taken from observation and records maintained by nursing personnels of all neonates on daily basis. Then the total time per day was calculated on daily basis for all neonates. The required nursing manpower was calculated on daily basis and total number of nurses required per day was finalized. Based on the findings of the present study it is concluded that one nurse can provide nursing care to maximum two ventilated neonates and one nurse can provide nursing care to three non-ventilated neonates in the present neonatal intensive care unit setup in hospital like PGIMER. Chandigarh. Hence it is recommended that these findings can be used as baseline data for making decision on nurse neonate ratio in NICU. Key words : Nursing care activities, nursing manpower, ventilated and non-ventilated neonates. Correspondence at : Amanvir Kaur Assistant Nursing Superintendent Govt. Medical College and Hospital Sector-32, Chandigarh Introduction Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Adequate nurse staffing levels are a fundamental prerequisite for satisfactory neonatal care. The appropriate nurse neonate ratio is very impor tant to maintain acceptable standard of care to 1

decrease the mortality rate and to meet the changing health need of the neonates. International Council of Nurses defined the safe staffing as the appropriate number and skill mix of nursing personnel on duty at any one time, which is critical to patient outcome. 1 Staffing level in the specific setting like neonatal intensive care units should give due consideration to critical factors like the number of neonates and level of intensity of neonatal needs. "To determine the Nurse-to-Patient ratio is a global issue". Nurse-to-patient ratio means the maximum number of patients that may be assigned to a nurse during one shift. It is difficult to generalize the adequate and appropriate nurse to patient ratio, because of various factors like characteristics of the patients, nurses and work environment; ratio that's sufficient for one unit might not be sufficient for another unit and lack of scientific evidences. 2 Nurse patient ratio is a major challenge for nursing and health organizations like International Council of Nurses, Indian Nursing Council and World Health Organization. In 2006 WHO also submitted a report on the current crisis in the global health workforce and ambitious proposals to tackle it over the next ten years. 3 National Health Policy of India 2002 also emphasizes on the need for an improvement in the ratio of nurses/bed. In India present nurse population ratio is 1:1250 and total number of nurses registered with state nursing council is 9 lakh. 4 There are various studies on effect of nurse staffing on patient, nurse employee and hospital outcomes. It is concluded that adequate Nurse Staffing and organizational support for nursing is key to improve the quality of patient care, to diminish nurse job dissatisfaction and burnout and high nurseto-patient ratio affects the quality of treatment, leading to increase in incidents and length of 5,6,7,8 hospitalization. Risk-adjusted mor tality did not differ across neonatal units. However, survival in neonatal care for very low birth weight or preterm infants was related to proportion of nurses with neonatal qualifications per shift. A few studies have attempted to empirically test the relationship between staffing and neonatal outcomes, but they provide us with inconclusive evidence. 9 In the light of the complexity of the issue of nurse-to-patient ratio, there is ongoing discussions worldwide, on the enactment of standardized nurse-to-patient ratio. Most of the studies show that Nurse Patient Ratio is clearly a global issue. But no studies primarily empirically examined a specific nurse staffing policy. 7 There are various methods and models for calculation of Nursing Manpower. Mitchell and Gesick developed a patient service associate model to staff the unit which is used very commonly in literature. This model included the average amount of time for a task and frequency of task per shift to calculate the total time required. The time standard for each patient was multiplied with total time 2

required. An allowance of 8.33% was added to account for personal fatigue, communication, travel time and some other activities which could not be captured by time standards. 8 The nurse administrator needs to make the policy to make decisions on nurse staffing in terms of nursing productivity, nursing quality, clinical and economical factors. The few evidences points toward some linkage between the quality and nursing, but without fur ther analysis data standardization and wider data availability, it would be premature to move forward in recommending specific staffing solutions as a means to address the quality of care issues. The experts need to gather more data on nurse patient ratio issue to make some decision at the top level. Patient acuity, skill mix, nurse competence, technological suppor t, architecture and geography of the environment should be considered while calculating nursing manpower for a particular unit. Some studies show that staffing formula needs to be based on nursing and the patient activity data drawn only from effective and efficient wards so that workforce planners reduced the risk of perpetuating the poor practice. In India there are very few studies that had addressed the issue of nursing manpower measurement for all units of the hospital. So it is felt that implementing any standards before understanding the scenario of staffing in neonatal units will be highly unrealistic. The purpose of the present study is to find out the Nurse to patient ratio for a neonatal intensive care unit as per needs of the Neonates as there is no such study done in Neonatal Intensive Care Unit at PGIMER, Chandigarh. The adequate nurse to patient ratio is needed to promote safe and quality care to the neonates. There is also a need for integration of nursing staffing data into health care statistics on a local level. This study may help the nurse administrator to make the decision for allocation of nurses for neonatal intensive care unit. Objective To find out the total "Nursing Manpower required in Neo-Natal Intensive Care Unit" of PGIMER,Chandigarh. Materials and Methods The study is conducted in Neo-Natal Intensive Care Unit (NICU) in Nehru Hospital, PGIMER, at Chandigarh. This is autonomous Institute under the Ministry of Health and Family Welfare. This institute was established in 1962 with the efforts of the Chief Minister of Punjab, Shri Partap Singh Kairon. NICU is situated at third floor of the Nehru Hospital near the labor room adjacent to Neo-Natal Nursery and Maternity Ward. NICU has a capacity of sixteen incubators and ten ventilators. There is one divider which divides the unit in two parts. On the left side of the divider, the unit has a capacity of seven incubators and most of the time infants on ventilators are kept on that side. On the right side of the divider, the unit has a capacity of nine incubators. Both units are equipped with central oxygen and suction facilities. The unit is equipped with advanced technology i.e. ventilators with high frequency ventilation facility, incubators, pulse oximeter, central oxygen and suction supply, infusion pump, syringe pumps and cardiac monitors. There is a separate room facility for mothers for 3

breast feeding and extraction of breast milk. The unit has the facility of ultrasound and laboratory services attached to NICU. Hand washing facility is available in both the areas and at the entrance of restricted area. Data collection for Nursing Manpower requirement in NICU is collected in the month of August 2008.Target population was all nursing care activities per formed on neonates in NICU in the month of August 2008. Purposive sampling is adopted to obser ve the nursing care activities on ventilated and non-ventilated neonates in NICU. Tools for data collection i.e. time observation Performa, frequency observation & census record performa was used to collect the data. Time observation and frequency observation performa is prepared by observation of nursing care activities performed on neonates of NICU. List of all nursing care activities is prepared and categorized in to two main categories i.e. direct care and indirect nursing care activities. Direct nursing care activities are further divided into Patient Care Basic and Patient care complex activities. Patient Care Basic includes all the nursing activities which are related to comfor t and wellbeing, maintenance of health and prevention of infection, regardless of the patient's health status e.g. routine hygiene care, Comfort of the neonate, nutrition, elimination care and hand Washing etc. Patient care complex includes nursing care activities related to patient's specific needs and health status e.g. admission related activities, recording of general obser vation, nebulisation, suctioning, oxygen therapy, assisting the physician for various procedures, ventilator related care, transfer related activities and care of dead neonate etc. Indirect care activities are the common activities that are related to ward work e.g. daily cleanliness of incubator, requisition of CSSD material (Linen and articles), health teaching / communication with attendants, making census and patient list etc. The activities related to supervision, infection control and quality control are not included in the study. Frequency observation performa also prepared which includes the list of nursing care activities. Validity of research tools was established by seeking the opinion of guide, co-guide and experts from nursing and neonatology regarding the content and language validity of the tools. After obtaining the permission for the study data was collected through non participatory observation. The census of neonates admitted in NICU was obtained daily. Non par ticipatory observation for time record of each nursing care activity was done. Time record observations fixed to one unit, first the activities were observed on ventilated neonates and then on the non-ventilated neonates. Observation for time record was started when the event was performed and time observation done first for the routine activities and then moving on the procedures which were performed rarely. Time record observations were done for three times for each activity to get the accuracy and the average time taken from three observations. Frequency of each nursing care activity taken from observation and record maintained (Daily NICU nursing care plan Performa) by nurses for each neonate and maintained daily for 24 hrs. Frequency record 4

was analyzed on daily basis for all neonates admitted in the unit and calculated differently for ventilated and non-ventilated neonates in NICU. The obser va-tions for time and frequency were distributed between 8 AM to 8 PM and night hours from 8 PM to 8 AM.Three night duties from 8pm to 8 AM to obser ve the activities which were performed during night hours were also undertaken. The total 600 observations were spread over a period of one month to record the time and frequency for various nursing care activities. Total time to perform each nursing care activity was calculated from average of three obser vations of each nursing care activity multiplied with frequency of each activity per 24hrs for each neonate of NICU. Total time per neonate per day was calculated on daily basis from total time of all neonates. Total Requirement of Nursing Manpower for NICU was calculated with a flexible staffing model for patient service associates given by Mitchell and Gesick: Total Number of Nurses=Total time in hours per day for nursing care activities of the NICU+8.33% allowance/work shift hours. 8.33% allowance period has been given to calculate the task which cannot be measured e.g. travel time, sitting for a while for personal fatigue etc. 8 The 50% nurses are added for offs and leave reserve as recommended by Guha K Dipak et al for requirement of neonatal nurses. 10 Analysis of data was carried out manually and with the help of Microsoft Excel. Results Census: Census of Neonatal intensive care unit was maintained daily. Out of 70 admitted neonates, 34 were new admissions, 02 discharges, 22 death, 11 transfer to other area and 01 left against medical advice during the month of August 2008. Average census of neonates was 13 during the study period (Fig.-1) and it ranged from 11 to 16 neonates. Figure 1: Daily census of neonates during the study period. 5

Table 1: Distribution of time to perform each nursing care activity on ventilated and non-ventilated neonates S. No. Nursing care activities Time taken for nursing care activities ( min: sec) of neonates Ventilated Non-ventilated I Direct care 25.03 23.20 A Basic care activities 2. Comfort of the neonate 09.05 08.03 3. Nutrition 07.10 28.09 4. Elimination care 03.58 02.33 5. Hand Washing 02.00 02.00 B. Patient care complex 1. Admission related activities 98.20 43.20 2. Handing & taking over of Infant & Resuscitation trolley 03.42 02.26 3. Recording of general observation 00.33 00.33 4. Preparation of list of medicine and articles 03.05 02.25 5. Maintenance of temperature 04.51 01.53 6. Vital sign monitoring 05.05 06.00 7. Medication 64.20 35.09 8. Checking weight 06.00 02.43 9. Abdominal girth 01.06 01.20 10. Nebulisation 07.00 00.00 11. Suctioning 06.33 04.10 12. Oxygen Therapy 20.00 03.30 13. Care of Intravenous site 00.37 00.26 14. Care of drains 04.13 00.00 15. Phototherapy care 08.03 08.06 16. Urine Specific gravity 01.43 01.50 17. Urine Sampling 02.20 02.16 18. Stomach wash 03.30 00.00 19. Rectal Wash 03.58 00.00 20. Assisting the physician for various procedures 387.31 238.02 21. Ventilator related care 59.08 00.00 22. Assisting the mother for various procedures 00.00 23.00 23. Rounds and discussion 23.20 08.20 24. Documentation of nursing care 11.35 08.22 25. Transfer related activities 16.00 58.50 26. Discharge procedure 00.00 45.00 27. Discharge/LAMA of Ventilated Neonate 45.00 00.00 28. Care of dead neonate 49.20 00.00 * II Indirect care activities: - 210.26 minutes 6

Time to perform each nursing care activity: Table 1 depicts the time to perform each nursing care activity (direct and indirect) on ventilated and non-ventilated neonates which was observed for three times through non participatory observation. Average time is taken from three observation made for each activity. It depicts the maximum time to per form nursing care activities related to assisting the physician in neonatal care activities which includes intravenous canulation, sampling, lumber-puncture, surfactant administration, insertion of chest tube, insertion of abdominal drain, umbilical catheterization, preparation of TPN and blood exchange etc i.e. 387.31 minutes followed by admission related activities i.e. 98.20 minutes. The activities which takes more time for neonates are medication, ventilator related care, care of dead neonates and discharge of neonates. Minimum time taking activities are recording of general observation and care of intravenous site. Table is also showing that time for performing nursing care activities on ventilated neonate is different than nonventilated neonate as admission related activity for ventilated neonates takes 98.20 minutes where as 43.20 minutes for nonventilated neonates etc. Indirect care activities are the common activities of the unit performed by nurses per day which takes 210.26 minutes. Total time calculation for NICU per day: Figure 2 describes the total time (in hours) to perform nursing care activities of NICU per day which include the direct and indirect nursing care activities of the unit. Total Figure 2: Total time to perform nursing care activities per day in NICU during the month of August 2008. 7

mean time to perform all nursing care activities of NICU was 129.75 ±10.41hours with range from 113.26 to 161.06 hours per day during the study period. Total time to perform direct nursing care activities: Total time to perform direct nursing care activities in NICU per day on all ventilated and non-ventilated neonates in the month of August 2008 was calculated. Total time is calculated from Time of each nursing care activity multiplied by Frequency of each nursing care activity. Figure 3 depicts the daily workload of NICU separately for direct care activities on ventilated and non-ventilated neonates in the month of August 2008. Figure 3 also showing that total time to perform direct nursing care activities on nonventilated neonates was found more than ventilated neonates because of number of ventilated neonates according to census were less than non-ventilated neonates. Ventilated neonates required a mean time 46.08 hours to perform direct nursing care activities per day for an average four ventilated neonates. As well as non- ventilated neonates required a mean time 65.50 hours to perform direct nursing care activities per day for an average nine non-ventilated neonates. Total time per neonate per day to perform the direct nursing care activities was calculated as average of total time of all neonates. Table 2 depicts that one ventilated neonate requires 11.5 hours of direct nursing care out of 24 hours. It means that one nurse can provide nursing care to maximum two ventilated neonates. On the other hand one non-ventilated neonate requires 7.27 hours of direct nursing care out of 24 hours. It means that one nurse can provide nursing care to maximum three non-ventilated neonates. Figure 3: Distribution of total time to perform nursing care activities (in hours) on ventilated and non-ventilated neonates per day of NICU. 8

Table 2 : Distribution of total time per neonate per day to perform the direct nursing care activities Category of Neonates Total time per neonate/ day (Hours) Ventilated neonates 11.5 Non-Ventilated neonates 7.27 Total Number of nurses required per 24hrs on daily basis in the month of August 2008: Figure 4 presents the total number of nurses required per day according to daily workload of the NICU during the study period. The average number of nurses required per day was 17±1.4 and ranges between 15-21 nurses per day. Calculation of nursing manpower required according to present census of NICU was calculated with the formula given by Mitchell and Gesick: Total Number of Nurses=Total time in hours per day for nursing care activities of the NICU+8.33% allowance/work shift hours. 8.33% allowance period has been given to calculate the task which cannot be measured e.g. travel time, sitting for a while for personal fatigue etc.8 The 50% nurses are added for offs and leave reserve as recommended by Guha K Dipak et al for requirement of neonatal nurses.11 It is found that total time was required for NICU is 140.54 hours for an average 13 neonates i.e. 04 ventilated and 09 non-ventilated. Total 27 numbers of nurses was required for NICU for the present number of neonates. (Table -3) Figure 4 : Total number of nurses required per day according to daily workload of the NICU in the month of August 2008. 9

Table 3 : Distribution of number of nurses required for NICU according to census during the study period: Nursing care activities Census Total time Total time Total No.of Nurses to perform required to required /day Nursing perform all (including 50% care nursing care extra for offs and activities activities of leave reserve) NICU/ 24 hrs (Hours) Direct care activities on Ventilated neonates 04 46.08 140.54 27 Direct care activities on Non-ventilated neonates 09 65.50 Indirect care activities of NICU+8.33% 13 28.96 Requirement of Nurses per day for ventilated and non-ventilated neonates in NICU according to bed strength is calculated on the basis of nursing hour per neonate per day. The unit has the capacity of 16 incubators with 10 ventilators. The total time required to perform nursing care for 16 neonates in NICU is 191.5 hours including direct, indirect and 8.33%time given to calculate the task which cannot be measured. Then by adding 50% nurses for offs and leave reserve the total number of nurses required for NICU is 36. (Table-4) Table 4 : Distribution of total Requirement of Nursing Manpower for NICU according to bed strength: Nursing care Bed strength Total time Total time Total No. of Nurses required/ activities to perform required to 24Hours Nursing perform without 50% offs Total care nursing care 50% leave and leave activities activities of reserve reserve (Hours) NICU / 24 hrs (Hours) Direct care activities on Ventilated neonates 10 115 191.5 24 12 36 Direct care activities on Non-ventilated neonates 06 43.62 Indirect care activities of NICU+8.33% 16 32.88 10

Discussion Nurse patient ratio issue is considered a global issue and a major challenge in front of nursing and health organizations. In India there is a lack of research on the issue of nurse patient ratio in different settings like wards, ICUs and special units of the hospital. Adequate nurse staffing levels are a fundamental prerequisite for satisfactory neonatal care. Staffing level in the specific setting like neonatal intensive care units should give due consideration to critical factors like number of neonates and level of intensity of neonate needs and organizational support. The appropriate nurse neonate ratio is very impor tant to maintain acceptable standards of care, to decrease the mortality rate and to meet the changing health need of the neonates. The present study was conducted at Nehru Hospital, PGIMER, Chandigarh to find out the Nursing Manpower required for Neo-Natal Intensive Care Unit (NICU). The NICU is equipped with advanced technology like ventilators with facility of high frequency ventilation, incubators, monitors, computers for data recording and analyzing, infusion and syringe pumps, ultrasound and laboratory services are the same that the facility in the present study setting had with their western counterpar ts. The nurse neonate ratio calculated in the current study was found to be approximates when compared to those found in the studies done in the developed countries. The methodology used to find out the nursing manpower required is in terms of activity analyzing and nursing hour per day. A total time to perform nursing care activities was calculated for ventilated and non-ventilated neonates and then the total workload is measured for the whole unit. Nursing care activities were categorized into two main category i.e. direct care and indirect nursing care activities. The additional 8.33% hour were added for the nursing care activities which cannot be measured. The activities related to supervision, infection control and quality control are not included in the study. Similar study done by William S and A Whelan in neonatal intensive care unit on ventilated, and non-ventilated neonates to measure the workload of the unit and categorized the nursing care activities into eight groups.i.e. direct, indirect, education, administration, suppor t, telephone, personal and domestic and others. 11 In the present study, it was found that the ventilated neonates required a mean time 46.08 hours to perform direct nursing care activities per day for an average four ventilated neonates. Non- ventilated neonates required a mean time 65.50 hours to perform direct nursing care activities per day for an average nine non-ventilated neonates. Total neonates of NICU required a total time 140.54 hours for nursing care per day. Over a 24 hour period the mean time accorded 11.5 and 7.27 nursing hour to each ventilated and each nonventilated neonate respectively. It means nurses spent 47.9 % time for direct nursing care activities on ventilated neonates, 30% on non-ventilated neonate and 28% for indirect nursing care activities of the unit. A similar study on neonates by William S et al at NICU 11

Liverpool Maternity Hospital U.K revealed that a ventilated neonate took up 48% of a nurse's shift in their time in direct care contact. The mean time accorded to each ventilated neonate was 10.5 nursing hours and each non-ventilated neonate with special care requires 6.5 hours per day. 11 In the present study, total number of nurses required was calculated on daily basis and ranging between15-21 during the study period. The total number of nurses required for NICU calculated and required number is 27 nurses per day on an average for 13 neonates by adding the 50%nurses for offs and leave reserve. It means that one nurse is able to provide nursing care to maximum two ventilated neonates and one nurse is able to provide nursing care to maximum three non- ventilated neonates of NICU of PGIMER, Chandigarh. This ratio is approximates to the ratios given by other studies. Similar results are found in the study done at Mersey neonatal intensive care unit, Liverpool at UK by S William and Cooke that one nurse was able to look after two ventilated infants during one shift and three to four for special care infants. 11 The Neonatal Intensive Care Unit of PGIMER, Chandigarh having capacity for 16 incubators with a facility of 10 ventilators. So the nursing manpower for ten ventilated and six non-ventilated neonates is calculated and 50 % nurses are added for day offs and leave reserve as per guidelines given by Guha K Dipak, Swarnarekha Bhat and SR Philomin for Neonatology nursing manpower. 10 Indian Nursing Council has given recommendation for nurse to patient ratio of intensive care units is 1:1, pediatric unit 1:2 but ratio is not specified for neonatal intensive care unit. 12 British association of peri-natal medicine (BAPM) given 1:1 for NICU, 1:2 for high dependency care and 1:4 for neonates requiring special care. 13 One time utilization study of nurses in ICU carried out by National Institute of Health and Family Welfare, the number of patients that could be conveniently looked after by one nurse was 2.4 patients in morning shift. 3.2 patients in evening and 5.5 patients during night shift. 14 It is concluded that, total 36 numbers of nurses required for Neonatal Intensive Care Unit of PGIMER, Chandigarh excluding the requirement of supervisory, infection control and quality control nurses. But the present strength of Neo-natal Intensive Care Unit of PGIMER, Chandigarh is 30 nurses. It is recommended that findings can be used as baseline data for the decision on the issue of nurse neonate ratio in NICUs. Similar studies can be done in other hospitals to reach some conclusions about the standard nurse neonate ratio in developing countries. References 1. International Council of Nurses.Available at http://en.wikipedia.org/ wiki/nursing: 2008 on dated12.1.08. 2. Vincent Lombardi, Nurse staffing and patient, Nurse and financial Outcome. Available at http://gorefest.blogspot.com:2008 on dated 24.2.08. 3. Rosen koetter Marlene M, Deena A Nardi. White paper on Global Nursing and Health. Nursing Outlook 2005; 54:113-114. 4. Knight Karla A. Working Condition Critical 12

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