Estimation procedure for inpatient units

The basic factors involved in estimating nurse requirement for an inpatient unit, given stipulated patient nurse ratios, are : bed capacity, bed occupancy rate and the percentage share of patients in each unit according to an accepted patient classication system (e.g. high/medium/low dependency). Nurse requirement is also determined by the intended quality of nursing care in terms of the time nurses spend on each patient in the high/medium/low dependency category. When a 3-shift system is in operation, nursing needs in then on-critical care units for the afternoon and night shifts are usually less because of reduced activity. In this context, we may dene a relevant concept namely, workload factor (WF). For the purposes of this paper, WF is dened as the multiplier by which the afternoon and night shift nursing time is deated relative to that required forth e morning shift. For example, WF(A) 0.9 implies that average nursing time required per patient in the after -noon shift is 90% of that required In the morning shift , and WF (N) 0.8 for night shift means that average nursing time required per patient in the night shift is 80% of that required in the morning shift. For a 12-hour 2-shift system one may assume that the workload in the second shift will be 80% of that in the morning shift. Estimation of nurse requirement for the critical care in patient units is similar to that of noncritical care in patient units, except that, within a specic type of critical care inpatient unit ,all patients get intensive nursing care during the shifts .One or more nursing supervisors may be assigned for each inpatient care unit depending on its size.

Estimation procedure for other units It is difcult to set precise norms for allocation of nurses in outpatient clinics. Depending on the nature of clinics, expected number of outpatients ,and number of consultants to be assigned, one or more nurses may be allocated to a clinic. Nurse requirement for operating theatres (OTs) depends on the number of OTs functional in each shift and the required team size per OT. Allocation for delivery suites, A&E unit and

renal dialysis unit depend on the facilities available, expected number of patients and required team size needed per shift.

Illustration The estimation procedure is illustrated below for a multispeciality hospital (Hospital A) with 300 beds. The required data are extracted from the hospitals service statistics/ annual reports .The beds in non-critical care in patient units are classied into high dependency, medium dependency and low dependency .In the absence of mandated patientnurse ratios, reasonable norms are xed for the respective care level based on activity sampling and discussion with nursing leaders. Outpatient Units run for 250 days/year in the morning shift.A nurse works 220 days/year after deducting annual leave (28days) government holidays(13) and weekends (104). The shifts are assumed to be 8-hourly. The common parameters are represented as under:

Nurse requirement in inpatient units Table1 below details department-specic input parameters, norms, related formulae as well as the estimated output gures for a non-critical care inpatient ward with 64 beds having 80% bed occupancy and a critical care inpatient unit (viz. SCBU) with 21 bed shaving 70% bed occupancy. The beds in the non-critical ward are distribute in the ratio 20:30:50 among high, medium and low dependency category. Assumed patientnurse ratios are 5,6 and7 respectively for high, medium and low dependency category of beds .The assumed patientnurse ratio for the critical care units is 1.5.However,this ratio can be higher in developing countries such as Oman depending on the admission policy and practice as well as the countrys economic situation. The WF for the non- critical ward are assumed to be 0.9 for the afternoon shift and 0.8 for the night shift.

Nurse requirement in out- patient department

Nurse requirement for OPD clinic is estimated based on expected patient attendance and the required number of doctors. This sums upto a total of 30 nurses. Let NP denote the number of nurses required (excluding super-visory nurses) for physical allocation in OPD and NP*

denote the actual requirement of nurses (excluding supervisory nurses) for OPD after providing leave coverage.

Actual requirement of nurses NP*

= Required physical allocation (N ) * Total OPD working days in a year(W)

Total working days/nurse/year ( D )

= 30 * 250 / 220 = 34

Hospital A assigns two OPD supervisors .

Input parameter

Notation Formula

Typical Typical non critical care critical care in patient unit (SCBU)

Inputs Number of inpatient care beds Average bed occupancy Number of working days/nurse/year Patient classification High dependency beds share Medium dependency beds share SH SM 20% 30% 100% 0 B O D 64 80% 220 21 70% 220

Low dependency beds share

SL

50%

Norms High dependency patients/nurse NH 5 1.5

Medium dependency patients/nurse

NM

Low dependency patients/nurse

NL

Workload factor afternoon

LA

0.9

Workload factor night

LN

0.8

Outputs

Requirement for the morning shift Number per shift for high dependency RH (B*O*SH)/NH 2.0 9.8

Number per shift for medium dependency

RM

(B*O*SM)/NM 2.5

60

Number per shift for low dependency

RL

(B*O*SL)/NL

3.6

60

Overall requirement per shift

RO

RH+RM+RL

8.22

9.8

Requirement for the afternoon and night shift

Number per shift in the afternoon shift

RA

RO*LA

7.4

9.8

Number per shift in the night shift Total requirement for a day Total nurse days required in a year Total equivalent nurse requirement Supervisory nurse requirement Overall nurse requirement for the unit

RN RD ND EN SN TN

RO* LN RO+RA+RN RD* 365 ND/D

6.6 22.2 8103 37 2

9.8 29.4 10731 49 1 50

EN+SN

39

Nurse requirement in operating theatres

Four OTs are scheduled in the morning and one OT in the afternoon on all weekdays [(4+1)5] and ve OT shifts/week for emergency operations. Hence, the number of planned OT shifts per week OW 30.Nurses per OT per shift 4 (Circulating Nurse, Scrub Nurse, Control Room Nurse and Recovery Room Nurse one each).

OT Nurse Requirement =

Planned OT shifts per week (OW) *Number of weeks per year * Nurses per OT per shift Total working days/nurse/year (D)

= 30 * 5*4 /220 = 28

Nurse requirement in accident and emergency unit and delivery suites

These units are manned round the clock .Shift-wise allocation of nurses depends on the number of patients managed , complications expected, interventions required and expected times spent per patient. Let nurses required per shift in A&E = ES = 4, and the number of shifts per day = 3. One nursing supervisor is allocated for supervision. Nurse requirement for delivery suite can be estimated similarly

A&E nurse requirement N E =

Nurses/shift * Number of shifts in a day *Number of days in a year Total working days/nurse/year (D)

= 4 * 3 * 365 / 220 = 20

One nursing supervisor is allocated for supervision of the OTs.

Nurse requirement in renal dialysis unit

Nurse requirement for a dialysis unit depends on the number of dialysis shifts. One nurse is allocated per dialysis station per shift. Let RS denote the number of renal dialysis stations .Let rS denote the number of sessions/station/week , and NR denote nurse requirement. A dialysis station functions two shifts per day for 6 days (2* 6 =12sessions) per week and there are eight such stations .Hence,

For the hospital including nurse managers and with all allowances provided. Then NH=NA*+NM .In Hospital A, there are eight nurse managers. This includes one Nursing Ofcer , one Assistant Nursing Ofcer and six Ward Nurses. Then NH the overall nurse requirement for the hospital NH= 385+8= 393. The consolidation of nurse requirements for Hospital A is presented in Table 2.

Renal dialysis nurse requirement NR =

Number of sessions/station/week *Number of stations * Number of weeks in a year * Nurse/station Total working days/nurse/year (D)

= 12 * 8 * 52* 1/ 220 = 23

One nursing supervisor is allocated for supervision. Nurse requirement for shift supervision A nursing supervisor is assigned per shift for overall coordination. Hence, ve shift supervisors are needed. Consolidation of nurse requirement estimates Let NA denote the overall nurse requirement for the hospital (except nurse managers)for all functions and departments combined. Then NA is the summation of nurse requirement of all the units in the hospital. This can be mathematically represented as NA=ENi+ ESi where Ni denotes the nurse requirement for uniti and Si represents the nursing supervisor requirement for unit i wherei varies from 1 tok to cover all units where nurses are allocated. Total requirement of (EN I =) 340 Staff Nurses and (E Si = ) 22 Nursing Supervisors. Then NA= 340+22=362.It is necessary to provide a margin for ensuring that maternity ,sickness and deputation leave not considered earlier, do not substantially affect actual nurse availability for deployment .Let P1 and P2 respectively denote maternity-cum-sick leave allowance factor and study leave factor (expressed in proportions). Assume P1= P2=3%. Let NA* denote the overall nurse requirement (except nurse managers) including allowances for maternity/sickness/study leave. Then Let NM denote the number of nurse managers required and NH denote the overall nurse requirement for the hospital including nurse managers and with all allowances provided. Then NH= NA*+NM. In Hospital A, there are eight nurse managers. This includes one Nursing Ofcer, one Assistant Nursing Ofcer and six Ward Nurses. Then NH the overall nurse requirement for the hospital NH= 385+8=393. The consolidation of nurse requirements for Hospital A is presented in Table 2.

User-friendly computer model It is evident from the discussion above that nurse requirement planning in a multispeciality hospitals complex and time-consuming. A computer-assisted nurse requirement-planning model helps in systematizing and accelerating this estimation process. The computer model proposed here generates nurse requirement estimates for a specied set of input parameters through a user-friendly graphical user interface (GUI)-based computer application software (developed in JAVA). The inputs required are grouped into two categories: (1) hospital- specic and (2) standards-related. Hospital- specic inputs are : total working days per year, work

days per nurse per year, work hours per day, number of beds in each ward(non-critical and critical care in patient units),expected bed occupancy, patient mix in terms of high/medium/low dependency ,number of dialysis stations ,number of OPD clinics and the number of OT shifts per week, etc. Standards-related inputs are: patients per nurse norms for high, medium and low dependency non-critical care inpatient units ,patients per nurse norms for critical care in patient units, allocation of nurses per OT per shift ,allocation of nurses for each clinic, allocation of nurses for A&E and delivery suite per shift, WF in the afternoon and night shifts, number of supervisory nurses and nurse administrators needed. Some of these inputs are standards stipulated by law, while others are based on professional judgement. The computer user interface is in the form of a computer screen with required input and output elds suitably identied and arranged in different panels as shown inFigure2.Some hospital-specic input elds and standards-related input elds are grouped in the top panel. Details of the OPD clinics and allocation of nursing personnel in these clinics and in nursing administration are

Nurse requirement consolidation for Hospital A

Unit in Hospital A

Nurse managers(NM)

Staff nurse requirement (Ni)

Nursing supervisor requirement (Si)

Medical ward Surgical ward

37 37

2 2

Burns unit

Paediatric ward

37

Obstetrics and gynaecology ward

30

SCBU

49

Intensivecareunit(ICU)

16

Critical care in patient unit (CCU)

19

VIP/privateward

Renaldialysis

23

Operatingtheatres

28

Deliverysuite

20

Accident and emergency unit (A&E)

20

OPD

34

Shift and OPD supervision

Nursing administration 8

Maternity and sick leave coverage

11

Educational leave coverage

12

Overall nursing

383

22

Figure 2 Nurse requirement planning graphical user interface.Table2