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Standard workload‑based estimation
of nursing manpower requirement
in the ICU of a tertiary care teaching
hospital: A time and motion study
Website:
www.jehp.net Ritu Rani, Suresh K. Sharma1, Manoj K. Gupta
DOI:
10.4103/jehp.jehp_972_22
Abstract:
BACKGROUND: The safety of patients remain at risk due to a higher workload and lower
nurse‑to‑patient ratio. However, in India, most hospitals still adhere to long‑known nurse staffing
norms set by their statutory or accreditation bodies. Therefore, the present study was undertaken
to recommend a standard workload‑based estimation of nursing manpower requirement in the ICU
of a tertiary care teaching hospital.
MATERIALS AND METHODS: It was a descriptive, observational, time and motion study was
conducted in the medicine ICU of a tertiary care teaching hospital. Data collection was done by using
demographic and clinical profile sheet of patients, NPDS‑H dependency assessment scale, time and
activities record sheet, and WHO WISN tool. The nurses’ activities were observed by nonparticipatory and
non‑concealment technique. Data analysis was done using descriptive statistics and the WHO WISN tool.
RESULTS: The bed occupancy rate and the average length of stay in the medicine ICU were 93.23%
and 7.18 days respectively. Distribution of dependency level of the medical ICU patients was very
high (41.67%), low‑high (33.33%), and medium‑high (25.0%) dependency level. Considering available
resources and workload in tertiary care hospitals in India, the study recommended a nurse‑to‑patient
ratio of 1:1.2 in each shift for the medicine ICU of a tertiary care hospital.
CONCLUSION: The study suggested minimum nurse-to-patient ratio in medical ICU should be
1:1.2 with provision of power to ICU incharge nurse to allocate nurses according to the workload in
different shifts. Also, nurse staffing norms in hospitals need to be estimated or selected with serious
consideration of health care demands when employing nurse staffing norms.
Keywords:
Nursing manpower, nurse‑to‑patient ratio, time and motion study, workload

Introduction half of the current shortage.[3] It was reported

that raising the nurse‑to‑patient ratio from

I n today’s world, human resources are

recognized as a strategic factor of an
organization. Human resource development
1:4 to 1:6 increased patient mortality by 7%,
while increasing the ratio to 1:8 increased
the mortality rate to 14%. The enactment of
College of Nursing, AIIMS,
contributes to the development of countries standardized nurse staffing norms continues
Rishikesh, Uttarakhand,
and organizations, and health organizations to stir debate throughout the world, as
India, 1College of
Nursing, AIIMS, Jodhpur, are primarily responsible for promoting health care institutes with varying resources
Rajasthan, India and maintaining the health status of the struggle to recruit nurses with adequate
community.[1,2] However, there is a global nurse‑to‑patient ratios.[4] Further extending
Address for shortage of health workers, particularly the fact that enforced nurse‑to‑patient ratios
correspondence: nurses and midwives, who account for over did not benefit the outcomes intended.[5] As
Prof. Suresh K. Sharma,
College of Nursing, AIIMS, these laws and regulations give rise to external
This is an open access journal, and articles are
Jodhpur, Rajasthan, India. distributed under the terms of the Creative Commons
E‑mail: sk.aiims17@gmail. Attribution‑NonCommercial‑ShareAlike 4.0 License, which How to cite this article: Rani R, Sharma SK,
com allows others to remix, tweak, and build upon the work Gupta MK. Standard workload-based estimation of
non‑commercially, as long as appropriate credit is given and nursing manpower requirement in the ICU of a tertiary
Received: 07‑07‑2021 care teaching hospital: A time and motion study. J Edu
the new creations are licensed under the identical terms.
Accepted: 23‑08‑2022 Health Promot 2023;12:61.
Published: 28-02-2023 For reprints contact: [email protected]

© 2023 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow 1
 Rani, et al.: Standard workload‑based estimation of nurses in the ICU

restrictions, individual organizations retain substantial Study participants and sampling

flexibility in their staffing strategies. Therefore, some The samples were patients admitted and activities
organizations, such as the American Nurses Association performed by the nurses working during the study
and the American Organization of Nurse Executives period in the ICU of AIIMS, Rishikesh. This study
support evidence‑based nurse‑to‑patient ratios. [6] In was conducted in June 2021. Patients were selected
India, however, most hospitals adhere to long‑established by consecutive sampling technique followed by work
nurse‑to‑patient ratio or nurse staffing norms stated by sampling of activities performed by nurses working in
the statutory or accreditation bodies, including the Staff the selected ICU of a tertiary care hospital. Inclusion
Inspection Unit (SIU), Indian Nursing Council (INC), criteria were nurses working as nursing officers and
Medical Council of India (MCI), and National Accreditation willing to participate in the study; Also, the activities
Board for Hospitals and Health Care Providers (NABH). performed by the nurses working in ICU during the
study period and patients who were admitted in the
As there is no invariable strategy to estimate staffing ICU during the study period. The exclusion criteria were
numbers, the concept of an ideal level of nurse staff patients who were less than 18 years of age and all the
planning is a bit controversial. As a general rule, staffing activities performed on them.
requirements are calculated using facility‑based ratios or
staffing standards. However, these methodologies not Data collection tool and technique
only have significant flaws but also fail to take into account The researcher employed a nonparticipatory and
vast geographic differences in health care demand and non‑concealment observation technique to collect data.
providers.[7] As a result, nurse staffing levels should rely on The researcher acted solely as a nonparticipant observer
a mix of patient health care needs (acuity and dependency throughout the study. The following tools were used to
level), patient throughput, nursing competency, and collect data for the study.
ancillary staff availability.[5] The patient dependence
scale is a relatively precise scale for categorizing patients Demographic and clinical profile sheet of patients
based on the amount and complexity of their nursing It is a self‑structured close‑ended questionnaire. It
care demands in order to determine the ideal staffing consists of items related to the socio‑demographic and
levels to address these needs.[8,9] Health managers, if they clinical profiles of the patients. It includes age, gender,
have to regulate their valuable manpower resources well, clinical diagnosis, any surgery, date of admission, and
require a better and more consistent way to make staffing date of surgery.
decisions. The World Health Organization’s (WHO)
Workload Indicators of Staffing Need (WISN) is one Northwick Park dependency assessment
such method, which utilizes nurses’ workload to estimate scale‑Hospital (NPDS‑H)
nursing manpower requirement in hospitals.[7] It is a standardized tool available in the public domain.
This tool was developed in Northwick Park hospital,
The optimal nurse‑to‑patient ratio must be identified Great Britain, published in 1999, and modification was
in order to aid in the time distribution of nursing care done in 2004. Permission to use the tool for the study
activities, which will not only minimize nurses’ workload was obtained from the author of the NPDS‑H tool.[12]
but also improve patient safety and satisfaction. [10]
Furthermore, in today’s world, the complexity of treatment Description of the NPDS‑H tool: It provides an assessment
and technological advancements have increased.[11] In of patient care needs. It is an ordinal scale incorporating
addition, studies are very limited to address the question activities of daily living, safety awareness, behavioral
of nursing manpower measurement for all clinical management, and communication. NPDS‑H is an
departments of the hospital. In India, no study has been extension of the original NPDS. NPDS‑H includes the
undertaken in the previous ten years to determine the basic care needs section, which consists of 12 basic care
nurse‑to‑patient ratio based on the available workload needs/psychological needs ordinal questions, scoring
and dependency level in the ICU. As a result, the current 0–65, and the in‑patient nursing care needs section,
study is being conducted to estimate nursing manpower which contains 8 dichotomous and 8 ordinal questions,
requirements based on patient dependency levels and scoring 0–35. The total score of the tool is 0–100. Higher
standard workload in selected hospital units. scores are indicative of increased dependence on
assistance for all care needs. This tool has to be filled
Materials and Methods by the nurse or the carer who knows the patient’s care
needs well.
Study design and setting
A descriptive observational time and motion study was Validity and reliability of the tool: It is shown to be a valid
conducted among nurses of a tertiary care teaching and reliable tool. The Interrater reliability (rho) of the
hospital in Uttarakhand, India. NPDS tool is 0.80.[13]
2 Journal of Education and Health Promotion | Volume 12 | February 2023
 Rani, et al.: Standard workload‑based estimation of nurses in the ICU

Daily nursing care activities and frequency record activities and the frequency of the activities were recorded
sheet on the ‘Daily Nursing Care Activities and Frequency
It is a self‑structured worksheet. It was prepared to Record Sheet’ by the researcher. Total nursing care activities
record all major nursing care activities performed by the performed for each dependency level patient were summed
nurses working in the medicine ICU. up for standard workload estimation using the WHO WISN
tool. At the end of data collection, all the participants were
Time record sheet of nursing care activities thanked for their participation in the study.
It is a self‑structured worksheet. It was prepared to
record the time to complete each selected nursing activity Ethical consideration
performed by the nurses. This study is the part of the research project for which
ethical approval was obtained from the institutional
Workload indicator of staffing need (WISN) WHO ethics committee under the IEC reference letter number—
tool AIIMS/IEC/19/915, Reg. No. 246/IEC/Ph.D./2019.
It is a standardized tool available in the public domain, Prior to the commencement of the study, permission
prepared by Peter Shipp, published by WHO in 1998, and was also obtained from the Senior Nursing Officers of
revised in 2008.[14] The permission to use this tool for the each ward for the overall investigation. The participant
present study was taken from the copyrighted authors of information sheet was provided to all participants and
the WISN tool. It is a human resource management tool. written informed consent was taken after a complete
The WISN method is based on a health care worker’s explanation of the study. The participants were informed
workload, with activity (time) standards applied for that the participation was voluntary. Confidentiality of
each workload component. This method determines how information and anonymity of the participants were also
many health workers of a particular type are required to assured throughout the study.
cope with the workload of a given health facility; assesses
the workload pressure of the health care workers in that Data analysis
facility. It provides two types of results—differences and The data were entered in a Microsoft Excel sheet, cleaned,
ratios. The difference between the actual and calculated and checked for missed variables. Further data were
number of health care workers shows the level of staff labeled and categorized. The data analysis was done
shortage or surplus for the particular staff category and using Microsoft Excel 2016. Descriptive statistics were
health facility type for which WISN has been developed. used to express the patients’ dependency level and
nursing care activities in frequency and percentages,
Data collection and the WHO WISN tool was used to estimate nursing
Daily patients’ census of the selected ward was obtained. manpower requirements.
After providing a participant information sheet, informed
consent from patients/their legal guardians was also Results
obtained. Demographic data of all the patients who met the
inclusion criteria were collected using the “demographic The bed occupancy rate and the average length of
and clinical profile sheet of patients” for a period of 30 days. stay (ALS) in the medicine ICU were 93.23% and 7.18 days,
The daily dependency level of the patients’ was assessed respectively as shown in Table 1. It was noted that most of
using “The Northwick Park Dependency Assessment the patients had very high (41.67%), low‑high (33.33%),
Hospital Scale (NPDH‑S)” for a period of 30 days. After and medium‑high (25.0%) dependency levels of the
categorizing the patients’ dependency level, every day,
a cubicle of the ward was selected for the observation Table 1: Bed occupancy rate in the Medicine ICU
of the nurses’ activities for a total of 9 days (3 days for Variables No. of days (in 30 days)
New admissions 179
each morning, evening, and night shifts) and time was
Transfer in 18
recorded. The time was recorded by the researcher through
Transfer out 34
nonparticipatory and non‑concealment observation
Discharges 151
methods. For the morning, evening, and night shifts,
On LAMA/Abscond 33
observations were made from 8 am to 2 pm, 2 pm to 8 pm, Total beds 1170
and 8 pm to 8 am, respectively. At least three observations Vacant beds 85
and the average time of the three observations were Total occupied beds 1085
considered as the standard time needed to perform that *LAMA ‑ Leave Against Medical Advice
activity for each dependency level patient. After recording Bed Occupancy Rate (BOR ) =
No. of inpatient days in a given month
× 100
No. of available bed days in that month
the time of the activities, the frequency of the activities
=611×00 / 840=72.73%
was logged for the next 15 days (5 days for each morning, Average Length of Stay (ALS)=Total inpatients days/no. of discharges
evening, and night shifts) for all patients in the ward. These =1085/151=7.18

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 Rani, et al.: Standard workload‑based estimation of nurses in the ICU

patients as demonstrated in Table 2. It was observed that dependency patients were 0.64 as shown in Table 4.
out of all nursing care activities, the maximum performed (0.54) followed by writing notes (0.37). The number of
activities were taking vitals and giving IV medication in nurses required for giving IV medications (0.54) was
all three shifts as illustrated in Table 3. It was observed higher than for writing notes (0.37). Overall, nurses
that the maximum number of nurses were required required for medium‑high dependency patients were
for giving IV medications (0.20) followed by writing 1.72 as displayed in Table 5. It was reported that the
notes (0.17). Overall, nurses required for low‑high maximum number of nurses were required for giving
IV medications (0.58) followed by writing notes (0.4).
Table 2: Patients’ categorization based on their Overall, nurses required for very high dependency
dependency level as admitted to the medicine ICU patients was 1.94 illustrated in Table 6. The basic nursing
Dependency level Dependency score Frequency (%) staff requirement for admission and discharge of all
Low‑high 26‑30 4 (33.33) dependency level patients was found to be 4.7 as shown
Medium‑high 31‑45 3 (25.0) in Table 7. The category allowance standard (CAS),
Very high > 46 5 (41.67) which encompasses all support activities, observed that
Total 12 (100) most time was spent updating census and medication

Table 3: Frequency of nursing care activities performed by nurses working in the ICU in various shifts
Activities Morning shift f (%) Evening shift f (%) Night shift f (%) Total (M+E+N) f (%)
Discussion with doctors 9 (45.0) 4 (20.0) 7 (35.0) 20 (100)
Vitals 73 (24.58) 76 (25.59) 148 (49.83) 297 (100)
Bedding 10 (52.63) 05 (26.31) 04 (21.05) 19 (100)
Dressing 0 (0.0) 0 (0.0) 1 (100.0) 1 (100)
Oral medication 1 (33.33) 1 (33.33) 1 (33.33) 3 (100)
IV medication 34 (31.77) 31 (28.97) 42 (39.25) 107 (100)
Hand & take over 34 (31.69) 32 (32.65) 32 (32.65) 98 (100)
IV cannulation 0 (0.0) 1 (100.0) 0 (0.0) 1 (100)
IV cannula removal 0 (0.0) 1 (100.0) 0 (0.0) 1 (100)
RBS 14 (27.45) 10 (19.61) 27 (52.94) 51 (100)
Foleys catheterization 1 (50.0) 1 (50.0) 0 (0.0) 2 (100)
Foleys removal 1 (50.0) 1 (50.0) 0 (0.0) 2 (100)
IO monitoring 19 (32.76) 11 (18.96) 28 (48.27) 58 (100)
Blood sampling 10 (33.33) 13 (43.33) 07 (23.33) 30 (100)
COVID sample 2 (50.0) 1 (25.0) 1 (25.0) 4 (100)
Sent for billing 1 (16.67) 3 (50.0) 2 (33.33) 6 (100)
Urine Sample 3 (60.0) 2 (40.0) 0 (0.0) 5 (100)
Sent for ECG/X ray 6 (33.33) 3 (16.67) 9 (50.0) 18 (100)
S/C injection 4 (22.22) 3 (16.67) 11 (61.11) 18 (100)
CPT 5 (22.72) 4 (18.18) 13 (59.09) 22 (100)
ABG sampling 2 (50.0) 1 (25.0) 1 (25.0) 4 (100)
Oxygen application 2 (50.0) 1 (25.0) 1 (25.0) 4 (100)
Nebulization 8 (34.78) 2 (8.69) 13 (56.52) 23 (100)
IM injection 1 (100.0) 0 (0.0) 0 (0.0) 1 (100)
NG aspiration 1 (100.0) 0 (0.0) 0 (0.0) 1 (100)
Blood transfusion 0 (0.0) 0 (0.0) 1 (100.0) 1 (100)
Infusion 1 (25.0) 2 (50.0) 1 (25.0) 4 (100)
Report collection 1 (50.0) 1 (50.0) 0 (0.0) 2 (100)
Suctioning 6 (18.75) 10 (31.25) 16 (50.0) 32 (100)
RT Feed 16 (38.09) 10 (23.81) 16 (38.9) 42 (100)
Bladder irrigation 0 (0.0) 1 (100.0) 0 (0.0) 1 (100)
Notes writing 34 (34.69) 32 (32.65) 32 (32.65) 98 (100)
Patient positioning 37 (30.08) 36 (29.27) 50 (40.65) 123 (100)
Foleys care 17 (100.0) 0 (0.0) 0 (0.0) 17 (100)
Oral care 17 (100.0) 0 (0.0) 0 (0.0) 17 (100)
Changing clothes 17 (100.0) 0 (0.0) 0 (0.0) 17 (100)
Tracheostomy care 17 (100.0) 0 (0.0) 0 (0.0) 17 (100)
Total 404 (34.62) 299 (25.62) 464 (39.76) 1167 (100)
*IV ‑ Intravenous, ABG ‑ Arterial Blood Gas, RBS ‑ Random Blood Sugar, RT ‑ Ryle’s Tube, IO ‑ Intake Output, S/C ‑ Subcutaneous, I/M ‑ Intramuscular,
CPT ‑ Chest Physiotherapy, OT ‑ Operation Theatre, ECG ‑ Electrocardiography, COVID ‑ Coronavirus Disease, M ‑ Morning, E ‑ Evening, N ‑ Night

4 Journal of Education and Health Promotion | Volume 12 | February 2023

 Rani, et al.: Standard workload‑based estimation of nurses in the ICU

Table 4: Nurses requirement for low‑high dependency level patients based on standard workload in the
medicine ICU
Nursing activity Activity standard Frequency AWT Total workload 9/3=3 Basic staff requirement
Low high dependency (M+E+N) (unit time) Frequency/3×365 Total workload/Standard workload
Vitals 1.32 36 103680 4380 0.055763889
Bedding 2.4 5 103680 608.3333333 0.01408179
IV medication 10.82 16 103680 1946.666667 0.203153292
Hand over 1.4 18 103680 2190 0.029571759
RBS 3.03 5 103680 608.3333333 0.01777826
Assist in Foleys catheterization 9.43 2 103680 243.3333333 0.02213188
Foleys removal 3.04 2 103680 243.3333333 0.007134774
IO monitoring 2.03 10 103680 1216.666667 0.023821695
Blood sample 8.2 2 103680 243.3333333 0.019245113
S/C injection 3.24 2 103680 243.3333333 0.007604167
Nebulization 3.14 7 103680 851.6666667 0.025793146
Positioning 2.23 9 103680 1095 0.023551794
Writing notes 12.22 12 103680 1460 0.172079475
Doctors rounds 3.5 4 103680 486.6666667 0.016428755
Total 66.0 0.638139789
*IV ‑ Intravenous, RBS ‑ Random Blood Sugar, RT ‑ Ryle’s Tube, IO ‑ Intake Output, S/C ‑ Subcutaneous, AWT ‑ Available Working Time

Table 5: Nurses requirement for medium‑high dependency level patients based on standard workload in the
medicine ICU ward
Nursing activity Activity Frequency AWT Standard Workload Total Workload 9/3=3 Basic staff requirement
Medium‑high standard 103680/AS Frequency/3×365 Total workload/
dependency (M+E + N) (unit time) Standard workload
Vitals 1.63 60 103680 63607.36196 7300 0.11476659
Bedding 2.4 3 103680 43200 365 0.008449074
IV medication 22.05 21 103680 4702.040816 2555 0.543381076
Hand over 2.99 18 103680 34675.58528 2190 0.063156829
RBS 3.03 10 103680 34217.82178 1216.6667 0.03555652
IO Monitoring 2.03 11 103680 51073.89163 1338.3333 0.026203864
Blood Sample 6.36 6 103680 16301.88679 730 0.044780093
COVID Sample 2.9 1 103680 35751.72414 121.66667 0.003403099
Sent for billing 3.4 2 103680 30494.11765 243.33333 0.007979681
Urine sample 2.97 1 103680 34909.09091 121.66667 0.003485243
Sent for ECG/Consultation 3.68 9 103680 28173.91304 1095 0.038865741
S/C injection 3.24 1 103680 32000 121.66667 0.003802083
ABG 4.06 1 103680 25536.94581 121.66667 0.004764339
Nebulization 3.14 2 103680 33019.10828 243.33333 0.00736947
Suctioning 5.56 10 103680 18647.48201 1216.6667 0.065245628
RT feed 12.8 21 103680 8100 2555 0.315432099
Patient positioning 2.23 22 103680 46493.27354 2676.6667 0.057571052
Writing notes 17.44 18 103680 5944.954128 2190 0.36837963
Doctors rounds 3.5 03 103680 29622.85714 365 0.012321566
Total 105.41 1.724913677
*IV ‑ Intravenous, ABG ‑ Arterial Blood Gas, RBS ‑ Random Blood Sugar, RT ‑ Ryle’s Tube, IO ‑ Intake Output, S/C ‑ Subcutaneous, AWT ‑ Available Working Time

refilling followed by updating and maintaining the are medical leaves; and 38 are earned and casual leaves.
registers. In total, the CAS was 43.51% as depicted in Therefore, it was observed that in the medicine ICU, the
Table 8. The Individual Allowance Standard (IAS) was total working days available in a year were 216. In one
calculated to be 144 hours in a year as shown in Table 9. day, the average number of working hours was 8 hours.
A total of 1728 working hours were available each year.
Tables 4–6 show that the highest number of nurses were
required for medium‑high dependency (1.7), followed Using the WHO WISN method, nurses’ staff calculations
by very high dependency (1.9) level of the patients. In were conducted and the required nurse‑to‑patient ratio
a year, there are 365 possible working days. Of these, 5 was found to be 1:1.2 based on the workload available
are gazetted and restricted holidays; 96 are days off; 10 in the medicine ICU.
Journal of Education and Health Promotion | Volume 12 | February 2023 5
 Rani, et al.: Standard workload‑based estimation of nurses in the ICU

Table 6: Nurses requirement for very high dependency level patients based on standard workload in the
medicine ICU
Nursing activity Activity Frequency AWT Standard Total workload 26/3 Basic staff requirement
Standard workload
Very high dependency (unit time) 103680/AS Frequency/8.67×365 Total workload/
(M+E+N) Standard workload
Vitals 1.63 189 103680 63607.36196 7956.747405 0.125091611
Bedding 3.04 9 103680 34105.26316 378.8927336 0.011109509
IV medication 24.3 59 103680 4266.666667 2483.852364 0.582152898
Hand & Take over 3.76 52 103680 27574.46809 2189.158016 0.079390761
IV cannulation 3.25 1 103680 31901.53846 42.09919262 0.00131966
Foleys care 4.3 11 103680 24111.62791 463.0911188 0.019206132
Removal of IV cannula 1.53 1 103680 67764.70588 42.09919262 0.000621255
RBS 3.03 30 103680 34217.82178 1262.975779 0.036909882
IO monitoring 2.03 37 103680 51073.89163 1557.670127 0.030498364
Blood sample 6.36 16 103680 16301.88679 673.5870819 0.041319578
Writing notes 18.8 52 103680 5514.893617 2189.158016 0.396953807
COVID sample 3.08 2 103680 33662.33766 84.19838524 0.002501264
Sent for billing 3.4 4 103680 30494.11765 168.3967705 0.005522271
Urine sample 2.97 2 103680 34909.09091 84.19838524 0.002411933
Sent for ECG/X ray consultation 3.7 5 103680 28021.62162 210.4959631 0.007511912
S/C injection 3.24 15 103680 32000 631.4878893 0.019733997
ABG 4.06 3 103680 25536.94581 126.2975779 0.004945681
Nebulization 3.14 11 103680 33019.10828 463.0911188 0.014024943
IM injection 2.75 1 103680 37701.81818 42.09919262 0.001116636
Suctioning 3.55 64 103680 29205.6338 2694.348328 0.092254404
RT feed 12.1 73 103680 8568.595041 3073.241061 0.358663357
Patient positioning 2.23 87 103680 46493.27354 3662.629758 0.078777627
Oral care 4.99 11 103680 20777.55511 463.0911188 0.022288047
Doctors rounds 3.5 5 103680 29622.85714 210.4959631 0.007105863
Total 124.74 1.94143139
*IV ‑ Intravenous, ABG ‑ Arterial Blood Gas, RBS ‑ Random Blood Sugar, RT ‑ Ryle’s Tube, IO ‑ Intake Output, S/C ‑ Subcutaneous, I/M ‑ Intramuscular,
COVID ‑ Coronavirus Disease, ECG ‑ Electrocardiography, AWT ‑ Available Working Time

Table 7: Nurses requirement for all dependency level patients based on standard workload in the medicine ICU
Nursing Activity Activity Frequency AWT Standard Workload Total Workload Basic Staff Requirement
Standard 103680/AS Frequency/30×365 Total Workload/Standard
(unit time) workload
Admission of the patient 10 156 103680 10368 2201.7 0.212355324
Discharge of the patient 10 143 103680 10368 1837.166667 0.177195859
Total 4.694036041
AWT ‑ Available Working Time

Calculation of Staff requirements, based on WISN AWT = [365 – (5 + 96 + 10 + 38)] × 8

In this formula: AWT = 216 days/year × 8 = 1728 hours/year
Available working time in a year = 1728 hours
AWT is the total available working time: • Low‑high level = 0.638 nurses
• A is the number of possible working days in a • Medium‑high level = 1.725 nurses
year = 365 days • Very high level = 1.941 nurses
• B is the number of days off for gazetted and restricted
holidays in a year = 3 + 2 = 5 days Total staff needed for health care
• C is the number of days off in a year = 8 × 12 = 96 days activities = 0.638 + 1.725 + 1.941 + 0.389 = 4.694 or 5
• D is the number of days off due to medical leave in nurses.
a year = 10 days
• E is the number of days off due to earned leave and Calculation of individual allowance factor (IAF)
casual leave = 30 + 8 = 38 days IAF = Annual total IAS/AWT = 144/1728 = 0.08
• F is the average number of working hours in one day.
= 6 + 6 + 12 = 24/3 = 8 hours IAF = 0.08
6 Journal of Education and Health Promotion | Volume 12 | February 2023
 Rani, et al.: Standard workload‑based estimation of nurses in the ICU

Table 8: Setting Category Allowance Standards

Workload components (Support activities) CAS (Actual working time) CAS % (Percentage working time)
Housekeeping management 6 min per day 1.25% = [(6/60)/8] × 100
Arranging articles in wards 12 min per day 2.5% = [(12/60)/8] × 100
Writing in line register 6 min per day 1.25% = [(6/60)/8] × 100
Assignment register writing 10 min per day 2.08% = [(10/60)/8] × 100
Sending/Update census 30 min per day 6.25% = [(30/60)/8] × 100
Medication register update 20 min per day 4.17% = [(20/60)/8] × 100
Medicine arrangement/Medication refill 30 min per day 6.25% = [(30/60)/8] × 100
CSSD sending 15 min per day 3.12% = [(15/60)/8] × 100
Dressing trolley arrange 15 min per day 3.12% = [(15/60)/8] × 100
Consumption check 10 min per day 2.08% = [(10/60)/8] × 100
Material 5 min per day 1.04% = [(5/60)/8] × 100
Bed side lockers 5 min per day 1.04% = [(5/60)/8] × 100
Fridge check 15 min per day 3.12% = [(15/60)/8] × 100
Crash cart 15 min per day 3.12% = [(15/60)/8] × 100
Board update 5 min per day 1.04% = [(5/60)/8] × 100
Laundry/Blanket counting 10 min per day 2.08% = [(10/60)/8] × 100
Total CAS% 43.51%

Table 9: Setting Individual Allowance Standard

Staff category: Nursing officers in medicine ICU of a tertiary care teaching hospital
Workload group Workload components No. of staff IAS (actual working Annual IAS (for all staff
performing the work time per person) performing activity)
Additional activities of Supervision of students 1 5 h/year 90 h
certain nursing officer Workshops/CNE 1 3 days/year 54 h
Total IAS in a year 144 h

Total staff requirement = Staff required for health done during COVID‑19 crisis, there is a possibility that
service activities × Total CAS percentage + Total IAF the lower bed occupancy rate was due to the COVID‑19
in a year pandemic. It was explained that after the lockdown
onset, there was a decline in the daily occupancy rate of
= 5 × 1.77 + 0.08 = 9.93 or 10 nurses beds reserved for COVID‑19 cases at a tertiary hospital,
demonstrating that this measure leads to a sustainable
• Average no. of admitted patients/beds in a month = 12 reduction in bed occupancy rates to prevent health
• Required nurse‑to‑patient ratio in medical services from collapsing and overloading.[17]
ICU = 12/10 = 1:1.2
The ALS refers to the number of days each admitted
Discussion patient stayed in the hospital.[15] Length of hospital
stay (LOS) is another important indicator of the use
The World Health Report 2014 estimates that 20%–40% of medical services that is used to assess the efficiency
of all resources allocated to the health sector are wasted. of hospital management, patient quality of care, and
To reduce resource waste, it is imperative to increase functional evaluation.[18] In our study, the LOS was
efficiency in using available resources, and the first step reported as 7.2 days in the ICU. In previous studies, the
in this process is to carry out a performance analysis or ALS in ICUs in North India, South India, Nepal, and
efficiency assessment.[15] Measures such as bed occupancy the USA was 5.75, 6.22, 4.0, and 5.2 days, respectively.[19]
and length of stay provide an indication of the functional A possible explanation for the disparity found in the
status of a hospital.[16] The bed occupancy rate (BOR) is average LOS is due to the different patterns of illness
the percentage of patients occupying available beds in a and disease among the population of that particular
hospital at any given time. At BOR of 80%–90%, hospitals clinical area.[20]
can be considered to be operating efficiently.[17] In recent
years, BOR in South‑East Asian hospitals has been about The results of our study revealed that in intensive
80%, while in other countries like Indonesia it is between care units, the majority of activities occurred at night,
55% and 60% in both public and private hospitals.[15] followed by morning and evening shifts. In contrast,
However, in the present study, it was found to be below Williams, Harris, and Turner‑Stokes 2009, revealed that
80% in the medical ICU (72.73%). As data collection was direct care activities were primarily concentrated early
Journal of Education and Health Promotion | Volume 12 | February 2023 7
 Rani, et al.: Standard workload‑based estimation of nurses in the ICU

in the morning and to a lesser extent in the evening, inflate the total number of nurses. Similar to the NABH
as the proportions fluctuated throughout the day.[21] norms, this study estimated nurse staffing norms by
According to another study conducted in India, most taking into account all leaves and the number of working
activities are conducted during morning and afternoon days. It is noted that unadjusted staffing ratios tend to
shifts, rather than evening shifts, although the study did underestimate workloads and often overestimate staffing
not observe activities done during the night shifts.[22] requirements.[31]
The reason could be the result of the extended hours
of duty, the night shift is likely to have more activity Limitation and recommendation
than the morning and evening shifts, that is, 12 hours Despite its intuitive appeal, this time‑motion study has
during the night shift and 6 hours during morning and some limitations for setting nursing standards such as
evening shifts. Additionally, the nursing officer during the due to the Hawthorne effect. The multitasking of
the night shift handled some of the morning tasks, such nurses could not be accounted for time recorded for
as bedding and basic patient care. These responsibilities, activities performed by the nurses due to a single observer.
however, were handled by the morning shift nursing There are recommendations for replicating similar
officer in other clinical areas and hospitals. In our study studies in other clinical areas, such as wards, and it can
IV medications, documentation, and vitals taking were also be replicated with a very long observation period.
the most time‑consuming activities in the ICU. This is Furthermore, a multicentric study can be conducted that
likely due to the fact that medications must be carefully involves government and private hospitals to assess the
administered and monitored, and patients’ vitals must nursing manpower requirement based on the standard
be regularly checked in order to ensure their safety. workload. Mixed method studies can be done which also
A similar study showed three subcategories accounted include qualitative data regarding nursing perspectives
for most of nursing practice time: documentation, on the factors affecting the nurse‑to‑patient ratio. Other
medication administration, and care coordination.[23] technologically advanced methods of observation such
as CCTV and video recordings can be used instead of
One of the nursing’s strongest stakeholders and lobbyists the human observant.
include the American Nurses Association (ANA)
and the American Hospital Association (AHA), both Conclusion
opposing mandatory nurse‑to‑patient ratios. [24] As a
result of growing evidence, in 2018, the International The current study found that nurse staffing norms are
Council of Nurses released a position statement on safe almost identical to NABH norms, with minor variations.
staffing, urging nursing organizations and governments Considering available resources and workload in
to adopt evidence‑based staffing policies. [25] In our tertiary care hospitals in India, the study recommended
study, we attempted to estimate the nurse‑to‑patient a nurse‑to‑patient ratio of 1:1.2 in each shift for the
ratio based on standard workload and recommended medicine ICU of a tertiary care hospital. In addition,
the nurse‑to‑patient ratio as 1:1.2 in the medical ICU nurse incharge should have the flexibility to allocate
ICU. DH guidance (2003), British Association of nurses according to the workload in different shifts. It
Perinatal Medicine (2001), UK,[26] Canada MIS Database, is suggested that nurse staffing norms in hospitals be
CIHI (2014–2015),[27] European Federation of Critical estimated or selected with serious consideration of health
Care Nursing Associations (2007), UK[28] recommends care demands when employing nurse staffing norms.
a nurse‑to‑patient ratio of 1:1 in ICU, opposed to
California (2008), USA[29] laws and NNU RNs sponsor Acknowledgement
National Ratio Legislation, USA,[29] that support 1:2 ICU We would like to thank all participants for taking part
norms. A study conducted in Chandigarh, India, used in the study.
K. Hurst’s algorithm to calculate the nursing manpower
requirements and showed that CTVS ICU requires a Ethical consideration
nurse‑to‑patient ratio of 1:1.5, CTVS step‑down ICU This study is the part of the research project for which
requires a nurse‑to‑patient ratio of 1:1.3.[30] Using existing ethical approval was obtained from the institutional
SIU and NABH standards, a nurse‑to‑patient ratio of 1:1 ethics committee under the IEC reference letter
is almost consistent with our study, which found a 1:1.2 number‑ AIIMS/IEC/19/915, Reg. No. 246/IEC/
ratio for ventilator beds in ICUs. Ph.D./2019. Prior to the commencement of the study,
permission was also obtained from the Senior Nursing
Even though the SIU’s recommended nurse‑to‑patient Officers of each ward for the overall investigation.
ratio corresponds with this study, the SIU norms do not The participant information sheet was provided to
specify whether the suggested nurse‑to‑patient ratios are all participants and written informed consent was
for shifts or days. Furthermore, because of the additional taken after a complete explanation of the study. The
45 posts for offs and 10% leave reserves, SIU norms may participants were informed that the participation was
8 Journal of Education and Health Promotion | Volume 12 | February 2023
 Rani, et al.: Standard workload‑based estimation of nurses in the ICU

voluntary. Confidentiality of information and anonymity meta‑analysis. Eur J Cardiovasc Nurs 2018;17:6‑22.
of the participants were also assured. 13. King’s College London ‑ NPDS ‑ Nursing Dependency Scale/
NPCNA ‑ Care Needs Assessment. Kcl.ac.uk. 2022. Available
from: https://www.kcl.ac.uk/cicelysaunders/resources/tools/
Acknowledgements npds. [Last accessed on 2022 May 28].
We would like to thank all participants for taking part 14. Hatfield A, Hunt S, Wade DT. The northwick park dependency
in the study. score and its relationship to nursing hours in neurological
rehabilitation. J Rehabil Med 2003;35:116‑20.
15. Phkh.nhsrc.pk. 2022. Available from: https://phkh.nhsrc.pk/
Financial support and sponsorship sites/default/files/2020‑12/Manual%20for%20Workload%20
Nil. Indicators%20of%20Staffing%20Need%20WHO%202010.
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