The design of an estimation norm to assess nurses required for educational and non-educational hospitals using workload indicators of staffing need in Iran

The issues of human resource imbalance in healthcare facilities, as well as the justice in the health sector, are important criteria in the distribution of resources and access to healthcare services. Today, they have become one of the main concerns of health system managers in the world, especially in the developing countries [1, 2]. The human resource imbalance in the health sector usually affects the availability, distribution, and performance of human workforce [3]. Given that the healthcare sector is a labor-intensive industry and trained human resources, as the most important data in providing health care, account for the largest share in the health sector expenditure, hence, in most developed countries, the issue of planning human resources has received considerable attention in the health sector [4, 5]. The core of human resource planning is to estimate and predict the number and types of needed human resources to attain the organizational goals, which is the most important human resource management process that is often neglected [6]. Negligence in the human resource planning leads to many problems, including shortages or the excessive human workforce, the unequal human workforce distribution, and inappropriate use of staff in the organization. To prevent the unequal distribution of healthcare providers, some strategies have already been employed, such as the design and implementation of norm estimation of human resource [7, 8].

In the late 1990s, the World Health Organization (WHO) presented the Workload Indicators of Staffing Need (WISN) method to determine the required human resources. The WISN method is a versatile human resource management tool based on the work which is actually undertaken by health sector staff [9]. This method has several advantages including easy to operate, simple to use, technically acceptable, comprehensive, and realistic [10]. Application of WISN to determine the required human resources leads to the establishment of a new norm of the evidence-based human workforce [11]. This method has been used in some countries, such as Bangladesh, Turkey, Uganda, and Indonesia to improve health human workforce planning [3, 9, 12, 13].

Nursing staff planning is of central importance because of the governments’ commitment to patient safety and quality care, as well as the link between nursing workload and patient care quality [14]. In a health care system, among the clinical staff, nurses, who generally account for more than 50% of the total staff in a hospital, play the most important role in promoting community health [15‐17]. Therefore, the provision of desirable care services depends on the quantitative and qualitative development of nursing staff. Qualitative development of nursing care is achieved through continuous education, material and spiritual motivation, monitoring, and evaluation of nursing activities. On the other hand, the quantitative development of nursing staff are obtained through the use of appropriate estimation norms of nursing staff and on time supplying and distribution of them in healthcare facilities [18].

In Iran, different norms are used to estimate the number of nursing staff in hospitals. However, a considerable inconsistency in the distribution of nursing staff in different sectors exists due to the lack of a codified standard based on nursing workload indicators. The details of two main proposed models in hospitals are described as follows:

Furthermore, in Iran, one of the challenges facing the achievement of health system vision of 2025 is designing the norm estimation of nursing staff in hospitals. It should be mentioned that in Iran, public hospitals are either educational or non-educational. Educational hospitals are those which train health care professionals, such as medical interns [19]. The Ministry of Health and Medical Education of Iran aim to achieve the goals of Iran’s Vision 2025 by putting a compilation of the health care system reform plan on its agenda. Plan means a long-term reformatory program in the health care system including vision, mission, goals, principles, values, policies, and national reformation program [20]. Moreover, the development of national policies for human resources, the crossing from traditional staff management to strategic human resource management, the projection of health sector human resources particularly nursing staff in the hospitals are the other objectives of the Ministry of Health. Therefore, this study was conducted to design the estimation norm of the required number of nurses for educational and non-educational hospitals based on workload indicator in Iran.

Through interviews with matrons and reviewing documents (factors affecting available working time and annual available working time), the results of the FGDs and its test (main, support and additional activities and primary sub-activity standards), the results of the consensus (final sub-activity standards), the results of inpatient’s record study and corresponding calculations (main activity standards) and the output of management information system (service statistics) were identified and determined. Accordingly, the modified WISN and estimation norm was computed.

In general, in Iran, 10 factors influence the available working times of the nurses. These factors were identified and analyzed in this work (Table 2). The average of annual available working days is calculated after incorporating all influential factors. Based on the findings, the available working hours of nurses, except nurses in the burn and psychiatric wards, burn ICU, and pediatric psychiatry, were 1411 h and the working days were 166 days in a year.

Given the increasing demand for health care services on the one hand and the relationship between the quality of services and the number and mix of the professional workforce needed by health centers on the other, in this study, hospitals with the best performance in providing standard care were considered to estimate the required nursing force. Similarly, Namganda et al. chose hospitals with the best-quality services to determine the level of staff required for hospitals affiliated with Uganda Catholic Medicine Bureau [23]. Regardless of the method, reference standards are needed to calculate workforce requirement. Situation observed in a facility or region or part of the country can be set as a standard [24].

In this study, patient care, patient transfer out hospital, and cardiopulmonary resuscitation were identified as the workload components of the nurses’ main activities. In the quality-activity-dependence-based nursing staff planning, it is assumed that patient dependency is a precise scale of patient’s need for nursing care, and the need for human resources based on patient dependency has a relatively high accuracy [25]. In Western Australia, nursing hours per patient day (NHPPD) are used as a priority in determining the need for nursing staff [25]. In this study, the transferring patients are another part of the nursing workload. Patient transfer is inevitable and is a part of the treatment process [26], which is intended to improve the provision of health services and reduce mortality and disability in patients [27]. In Iran, given the patient’s condition, the trained nurse is designated as a member of the patient’s transfer team in consultation with the referring and receiving physician [28]. Hence, given that a relatively large number of patients are transferred to other health facilities to receive higher-level services, this has led to a great pressure for the health system including excessive use of human resources, especially nurses.

In the present study, CPR is another component of the workload for the main activities of nurses. Today, all hospitals have a CPR team that employs advanced technology during cardiopulmonary arrest [26]. Although patient resuscitation is carried out by different members of the rescue team with different specialties, the important role of nurses in the team of recovery and identification of patients with critical conditions and prevention of cardiac arrest is inevitable. Also, they have a crucial task in performing a timely and principled resuscitation and post-care support to improve the side effects of the recovery in the hospitalized patients. Since nurses are among the first members of the rescue team, they play a very critical role in the life of the patient [27].

In this study, the available working time for nurses in four burn wards, burn ICU, pediatric psychiatry, and psychiatry was less than that in other wards due to the productivity improvement act. Hence, staff working in those wards benefit from one extra month’s paid leave which cannot be stored and must be used during the year [21].

The result showed that the nurses’ working days were 166 days yearly. Hossain and Alam calculated that nurses work for 205 days per year in Bangladesh [12], while nurses work for 199 days in Turkey as reported by Ozcan and Hornby [9]. In this regard, Shipp used 228 days from the 248-day domain [10]. In 2004, Namagandar used 246 days in Uganda [23], and Mugisha obtained 227 days in Uganda in 2008 [13]. The findings of the current study and similar studies indicate that the available working time depends on the working conditions of the country and the organization under study.

In addition, in this study, we deigned the estimation norm for the number of required nursing staff in hospitals wards. The results showed that considering the various average time of nursing care per patient day in different wards and according to the type of the hospital (educational or non-educational), the coefficients of estimation of nursing staff is different than other studies [18, 29, 30]. Based on the system-oriented approach, the coefficient for all ICUs and neonatal ICUs is 4.04 and 2.9, respectively [18]. In another study, the estimation norm of nursing staff of 3.13 was obtained for all ICUs [30]. Bahadori et al. used a coefficient of 3.47 for all ICUs in their study [29]. However, the results of this study showed that due to the amount of nursing care needed in the intensive care units, a single coefficient could not be considered. According to the results, each of the specialized wards in the pediatrics hospital had its own nursing estimation coefficients; while based on the systematic approach, the selected coefficient for all specialized wards in the children’s hospital were equal to 0.9 [18]. In similar studies, the coefficient to estimate the required number of nurses needed in the pediatric surgery ward was 0.97 and 0.88 [29, 30]. In the present study, for the ophthalmology, nephrology, endocrinology, and bone marrow transplant sections, coefficients of 0.6, 1.48, 1.54, and 3.81, were obtained, respectively; while based on the system-oriented approach, the coefficient of 2.9 is proposed for all transplant wards [18]. Moreover, based on the systematic approach, the proposed coefficient for CCU, burn, and neurosurgery was 2.9, while these wards did not have the same coefficients in the present study. Several reasons contribute to this difference. In contrast to the previous studies, we used an evidence-based method based on the workload indicator to calculate the required number of nursing staffs. Another reason could be the new rules made by Iran’s health system, which resulted in the reduction of the working hours of nurses. In addition to that, the increase in the maternity leave from 6 to 9 months was taken into account in the calculation of nurses’ available time.

When the health care centers run into a severe shortage of professional staff due to lack of financial resources, strategies such as task shifting and the use of nursing students are raised to compensate this shortage. Using these strategies raises concern about the quality of nursing care [3]. In Iran, task shifting of the nursing staffs has been carried out with the training and employing of nurse assistant (called Behyar in Farsi) over the past years [31]. In 2012, the use of nursing students in hospitals was suggested by the Ministry of Health [32]. It is obvious that the implementation of such plans leads to a reduction of pressure on the nurses. The reuse of the WISN method is useful in the review of the nursing estimation norms.

According to the healthcare system reform plan, the health sector of Iran is constantly under pressure to increase efficiency and equality. Proper human resource management and planning can contribute greatly to improve the efficiency and equity in the health care sector. WISN has been estimated for nurses working in different inpatient wards of educational and non-educational hospitals in Iran. The different coefficient of WISN indicates that a general and constant coefficient cannot be used to estimate the required number of nursing staff.

The result of a study can be used as a tool for auditing the distribution of nurses throughout the country. The use of required nurse estimation norms based on the workload indicators along with eliminating the intuitive decisions of managers can be considered as an effective strategy to improve both nursing staff and patient care levels. Although the application of these norms initially increases staff costs due to the increased nursing staff, the overall costs are reduced by improving both the nurses and patients satisfaction and reducing the number of nurses resignation and eliminating its harmful consequences. Briefly, planning for nursing personnel can be done using WISN method for proper allocation and deployment; therefore, the workload can be distributed among nursing staff in all hospitals to improve the health care services.