INSTITIUTE OF LIVER AND

BILIARY SCIENCES
COLLEGE OF NURSING
M.Sc. NURSING

PANEL DISCUSSION ON
STAFFING NORMS CRITICAL
ANALYSIS OF BENCH
MARKS

SUBMITTED TO: Dr. Sunita Srivastava

Associate Professor
CON, ILBS

SUBMITTED BY: Priyanka Patel M.Sc. Nursing 2nd Year

CON, ILBS
STAFFING NORMS

Norm is a standard model or pattern that guides, controls, and regulates individuals and
communities. These standards or trends are related to staffing and used as measures for
forecasting the nursing workforce. These are known as normative methods for calculating
nurses required in various hospitals. For estimating the requirement of the nursing workforce,
multiple committees, nursing council, associations are recommended, and revised staffing
norms are defined from time to time for hospitals, communities, both rural and urban, and
nursing institutions in India.

1. According to the Bhore Committee (1946) report: According to the Health Survey and
Development Committee, that is, Bhore Committee, recommendations, human resources
required per nurse population is one nurse for 500 populations (targeted for 30 years). The
proposed remedy was to reach in due course of time an international standard of one nurse to
2½ beds.

2. According to Shetty Committee (1954) and Mudaliar Committee (1959-1961) report:

With the initiation of Union Minister of Health, Government of India constituted a committee
on May 19, 1954, to review conditions, compensations, etc. of the nursing profession. The
recommendation regarding the hospital staffing is one nurse (also qualified in midwifery for
women and maternity services), including students, to three patients in hospitals used for
training of nurses and midwives excluding the teaching and administrative staff.

Recommendations of staffing pattern have been endorsed by the Mudaliar Committee (1959-
1961) for Auxillary Nurse Midwife (ANM) as, one ANM for 5,000 population, and for
hospitals as mentioned below:

 One nurse including students: Three patients in teaching hospitals

 One nurse including students: Five patients in nonteaching hospitals
 One superintendent for nursing services in each state.

3. According to the Central Council of Health meeting: According to the Central Council of
Health meeting held at Bombay on October 16-17, 1968, under the agenda No. 13, resolution
(No.120) passed regarding nursing workforce that in conformity with the recommendation of
Health Survey and Planning Committee and special committees appointed by the Government
of India is as given below:

 For teaching hospitals: One nurse (qualified nurse/ midwife)-three patients.

 For nonteaching hospitals: One nurse (qualified nurse/midwife)-five patients.
For determining the nurse-patient ratio, nursing staff engaged in teaching and administration, etc.
should not be taken into consideration.

4. According to a Guide for Staffing Pattern: According to a Guide for Staffing, staffing
pattern recommended by the Government of India (1977) is as given below:

 For 100 beds: 1 matron, 6 sisters and 25 staff nurses.

 For 300 beds: 1 matron, 1 assistant matron, 17 nursing sisters, and 81 staff nurses.

5. Recommendations of Indian Nursing Council: Indian Nursing Council (INC) in 1965-

1975 has also recommended staffing pattern for hospitals according to nurse-patient ratio is
given below:

For every 100 beds and to cover 24 hours, the staff should be in the proportion of one sister to
25 beds and one staff nurse to 3 beds in teaching hospitals and one staff nurse to 5 beds in
nonteaching hospitals. In addition to the nursing superintendent, there should be one assistant
when the bed strength is 150-400 and additional assistant when the bed strength is 401-700 and
for every 300 beds over 700. There should be separate staff for special departments with a sister
in-charge of operating room and a sister in-charge of casualty department. The outpatient
department should have one sister in-charge and a minimum of one staff nurse for each
outpatient clinic operated daily, with not less than a total of two in department.

Table 1 shows a revised recommended staffing norm for teaching hospitals (1986) by INC.

Table 1: Revised prescribed staffing norms for nursing services (teaching hospitals).
Nursing superintendent One for every hospital with 150 beds
Deputy nursing superintendent One for every hospital with 150 beds
Two for every hospital with 150 beds
Assistant nursing superintendent For every 50 additional beds, 1 assistant nursing
superintendent
Sister per Departmental sister/ assistant
Department Staff nurse
shift nursing superintendent
Medical wards 1:3 1:25 One for three to four department
Surgical wards 1:3 1:25 One for three to four department
Orthopaedic department 1:3 1:25 One for three to four department
Paediatric ward 1:3 1:25 One for three to four department
Gynaecology ward 1:3 1:25 One for three to four department
Maternity ward
1:3 1:25 One for three to four wards
(including new-borns)
 Intensive care unit (24
1:1 One shift each
hours) One Department Sisters/ ANS
Coronary care unit (24 for 3-4 units Clubbed together
1:1 One shift each
hours)
Nephrology (24 hours) 1:1 One shift each -
Neurology and
1:1 One shift each -
Neurosurgery (24 hours)
Special wards- eye,
1:1 One shift each Departmental sister/ ANS
ENT, etc. (24 hours)
Three for 24
Operation theatre (24 One departmental sister/ ANS
hours per One shift each
hours) for 4-5 operation theatres
table
Two to three
Casualty and emergency depending on
- One departmental sister/ANS
unit the number of
beds

6. According to the Bajaj Committee (1987) recommendation: Table 2 presents the

workforce requirement for nursing services according to a report of the Expert Committee on
Health Manpower Planning, Production and Management, Ministry of Health and Family
Welfare, Government of India, New Delhi.

Table 2: Staffing pattern for hospital nursing service per recommendations by the
Bajaj Committee, 1987.
Categories Basis for Calculation
Nursing Superintendent 1:200 beds
Deputy nursing superintendent 1:300 beds
Department nursing supervisor/ sisters 7:1000 + 1 additional 1000 beds
(991*7+991)
Ward nursing supervisors/ sisters 8:200 + 30% leave reserve
Staff nurses for wards 1:3 (or 1:9 for each shift) + 30% leave
reserve
For OPD, blood bank, X-ray, diabetic clinic, 1:100 patients (1 bed: 50 patient) + 30%
etc. leave reserve
 For Intensive care units (8 beds ICU/ 200 1:1 (or 1:3 for each shift) + 30% leave
beds) reserve
For specialized departments and clinics such 8:200 +30% leave reserve
as OT, labor room

7. Recommendations of the Staff Inspection Unit (SIU): Table 3 shows the norms according
to the recommendations of the SIU, Department of Expenditure, 1992, staffing norms for
nurses working in central government hospitals [seven hospitals: Safdarjung Hospital, Dr. Ram
Manohar Lohia Hospital, Smt. Sucheta Kriplani Hospital, Kalawati Saran Hospital, all in Delhi;
Central Institute of Psychiatry in Ranchi; Jawaharlal Institute of Postgraduate Medical
Education and Research (JIPMER) in Pondicherry; and Central Leprosy Teaching and Research
Institute (CLTRI), Chengalpattu (Tamil Nadu), all under the administrative control of
the Ministry of Health and Family Welfare, Directorate General of Health Services (DGHS)].

Table 3: Norms for nurses in select central government hospitals.

Normal wards One staff nurse/nursing sister for every six
beds

Special wards One staff nurse/nursing sister for every four beds
Paediatric, burns/ burns plastic, neurosurgery,
cardiothoracic, neuromedicine, nursing homes,
tetanus, spinal injury, emergency wards
One staff nurse/nursing sister for every two
attached to the casualty
beds
Nursery
One staff nurse/nursing sister for every bed

ICU/ CCU/ ICCU, nephrology [Artificial

One staff nurse/nursing sister for every
Kidney Unit (AKU), dialysis]
labor/table
Labour room
Two staff nurse/nursing sister for every
functional operational table including
Major operation theaters
recovery room
Two staff nurse/nursing sister for every
functional operational table including
Minor operation theaters
recovery room

Casualty
a. Casualty main (attendance up to 100 Three staff nurse/nursing sister for 24 hours,
patients per day) i.e. one per shift
After that for every addl. attendance of 35 One staff nurse/nursing sister
patients per day
b. Burns (attendance up to 15 patients per day) Three staff nurse/nursing sister for 24 hours,
Thereafter for every addl. attendance of 10 i.e. one per shift
patients per day One staff nurse/nursing sister
c. Orthopedics patients (attendance up to 45 Three staff nurse/nursing sister for 24 hours,
patients per day) i.e. one per shift
Then for every addl. presence of 15 patients per One staff nurse/nursing sister
day
d. Gyne/obstetrics (attendance up to 40 Three staff nurse/nursing sister for 24 hours,
patients per day) i.e. one per shift
After that for every addl. attendance of 15 One staff nurse/nursing sister
patients per day
Injection room outpatient department (OPD)
Attendance up to 100 patients per day One staff nurses
Attendance up to 120-220 patients per day Two staff nurses
Attendance up to 221-320 patients per day Three staff
Attendance up to 321-420 patients per day nurses
Four staff nurses
OPD No. of staff nurse/nursing sister
Blood bank, central sample collection center, One in each OPD
cardiac lab, bronchoscopy lab, vaccination One in each OPD
antirabies, preanesthetic, medical, surgical,
dental, eye, ENT, neurology, psychiatry, and
OPDS
Gyne, family planning, immunization work, Two in each OPD
pediatric, orthopedic, skin, burns, microbiology
infection control, V.D center, and
chemotherapy OPDs
Obstetric OPD Three
8. Recommendation per High Power Committee on Nursing (1987): The High Power
Committee on Nursing appointed by the Government of India, Ministry of Health and Family
Welfare on July 29, 1989 (under the Chairmanship of Smt. Sarojini Vardappan) to review the
roles, functions, status, preparation of nursing personnel, nursing services, and other issues
related to the development of the profession and to make suitable recommendations to the
government. Table 4 the shows norms proposed/recommended for nursing services.

Table 4: Norms proposed for nursing service in the hospital setting by the High-Power
Committee, 1987.
Nursing superintendent 1:200 beds (hospitals with 200 or more beds)
Deputy nursing superintendent 1:300 beds
Assistant nursing superintendent 1:150 (7:1000 beds)
Ward sister/ ward supervisor 1:25 beds+ 30% leave reserve
Staff nurse for wards 1:3 (or 1:9 for each shift) + 30% leave reserve
Staff nurses for OPD and emergency, etc. 1 bed: 5 outpatients + 30% leave reserve
For ICU 1:1 (or 1:3 for each shift) + 30% leave reserve
For specialized department such as operation 1:25 + 30% leave reserve
theatre, labour room, etc.

E-Commendations of High-Power Committee on Nursing and Nursing

Profession Working conditions of nursing personnel

1. Employment: Uniformity in employment procedures to be made. Recruitment rules are

made for all categories of nursing posts. The qualifications and experience required or
these be made thought the country.
2. Job description: Job description of all categories of nursing personnel is prepared by
the central government to provide guidelines.
3. Working hours: The weekly working hours should be reduced to 40 hrs per week.
Straight shift should be implemented in all states. Extra working hours to be compensated
either by leave or by extra emoluments depending on the state policy. Nurses to be given
weekly day off and all the gazetted holidays as per the government rules.

4. Work load/ working facilities

Nursing norms for patient care and community care to be adopted as recommended by the
committee. Hospitals to develop central sterile supply departments, central linen services,
and central drug supply system. Group D employees are responsible for housekeeping
department.
Policies for breakage and losses to be developed and nurses not are made responsible for
breakage and losses.

5. Pay and allowances: Uniformity of pay scales of all categories of nursing personnel is not
feasible. However special allowance for nursing personnel, i.e.; uniform allowance, washing,
mess allowance etc should be uniform throughout the country.
6. Promotional opportunities: The committee recommends that along with education and
experience, there is a need to increase the number of posts in the supervisory cadre, and for
making provision of guidance and supervision during evening and night shifts in the
hospital.

* Each nurse must have 3 promotions during the service period. Promotion is based on
merit cum seniority.

* Promotion to the senior most administrative teaching posts is made only by open
selection. In cases of stagnation, selection grade and running scales to be given.
7. Career development: Provision of deputation for higher studies after 5 yrs of regular
services is made by all states. The policy of giving deputation to 5-10% of each category
be worked out by each state.
8. Accommodation: As far as possible, the nursing staff should be considered for priority
allotment of accommodation near to work place. Apartment type of accommodation is built
where married/unmarried nurses can be allowed to live. Housing colonies for hospital s
must be considered in long run.
9. Transport: During odd hours, calamities etc arrangements for transport must be made
for safety and security of nursing personnel.
10. Special incentives: Scheme of special incentives in terms of awards, special
increment for meritorious work for nurses working in each state/district/PHC to be
worked out.
11. Occupational hazards: Medical facilities as provided by the central govt. by extended
by the state govt to nursing personnel till such times medical services are provided free to all
the nursing personnel. Risk allowance to be paid to nursing personnel working in the rural $
urban area.
12. Other welfare services: Hospitals should provide welfare measures like crèche facilities
for children of working staff, children education allowance, as granted to other employees,
be paid to nursing personnel.
Additional Facilities for Nurses Working In the Rural Areas

 Family accommodation at sub centre is a must for safety and security of ANM'S
/LHV.
 Women attendant, selected from the village must accompany the ANM for visits
to other villages.
 The district public health nurse is provided with a vehicle for field supervision.
 Fixed travel allowance with provision of enhancement from time to time.
 Rural allowance as granted to other employees is paid to nursing personnel.

NURSING EDUCATION

Nursing education to be fitted into national stream of education to bring about uniformity,
recognition and standards of nursing education. The committee recommends that;
1. There should be 2 levels of nursing personnel - professional nurse (degree level) and
auxiliary nurse (vocational nurse). Admission to professional nursing should be with 12 yrs.
of schooling with science. The duration of course should be 4 yrs. at the university level.
Admission to vocational /auxiliary nursing should be with 10 yrs. of schooling. The
duration of course should be 2 yrs. in health-related vocational stream.
2. All school of nursing attached to medical college hospitals is upgraded to degree level in
a phased manner.

3. All ANM schools and school of nursing attached to district hospitals be affiliated
with senior secondary boards.
4. Post certificate B.Sc. Nursing degree to be continued to give opportunities to the
existing diploma nurses to continue higher education.
5. Master in nursing programme to be increased and strengthened. 6. Doctoral programme
in nursing have to be started in selected universities.

7. Central assistance be provided for all levels of nursing education institutions in terms
of budget (capital and recurring)

8. Up gradation of degree level institutions be made in a phased manner as suggested

in report.
9. Each school should have separate budget till such time is phased to degree/vocational
programme. The principal of the school should be the drawing and the disbursing
officer.
10. Nursing personnel should have a complete say in matters of selection of students.
Selection is based completely on merit. Aptitude test is introduced for selection of
candidates.
11. All schools to have adequate budget for libraries and teaching equipment’s.

12. All schools to have independent teaching block called as School of Nursing with
adequate class room facilities, library room, common room etc. as per the
requirements of INC.

Continuing Education and Staff Development

✓ Definite policies of deputing 5-10% of staff for higher studies are made by each state.

✓ Provision for training reserve is made in each institution.

✓ Deputation for higher study is made compulsory after 5 yrs.

✓ Each nursing personnel must attend 1 or 2 refresher course every year.

✓ Necessary budgetary provision is made.

✓ A National Institute for Nursing Education Research and Training needs to be

established like NCERT, for development of educational technology, preparation of
textbooks, media,
/manuals for nursing.
NURSING SERVICES: HOSPITALS/INSTITUTIONS (URBAN AREAS)

Definite nursing policies regarding nursing practice are available in each institution.
These policies include:
a) Qualification/recruitment rules

b) Job description/job specifications

c) Organizational chart of the institutions

d) Nursing care standards for different categories of patients.

1. Staffing of the hospitals should be as per norms recommended.

2. District hospitals /non-teaching hospitals may appoint professional teaching nurses in
the ratio of 1; 3 as soon as nurses start qualifying from these institutions.
3. Students not to be counted for staffing in the hospitals
4. Adequate supplies and equipment’s, drugs etc. be made available for practice of nursing.
The committee strongly recommends that minimum standards of basic equipment
needed for each patient be studied, norms laid down and provided to enable nurses to
perform some of the basic nursing functions. Also, there should be a separate budget
head for nursing equipment and supplies in each hospitals/ PHC. The NS and PHN
should be a member of the purchase and condemnation committee.
5. Nurses to be relieved from non -nursing duties.

6. Duty station for nurses is provided in each ward. 7. Necessary facilities like central
sterile supplies, linen, drugs are considered for all major hospitals to improve patient
care. Also, nurses should not be made to pay for breakage and losses. All hospitals
should have some systems for regular assessment of losses.
7. Provision of part time jobs for married nurses to be considered. (min 16-20hrs/week)

8. Re-entry by married nurses at the age of 35 or above may also be considered and
such nurse be given induction courses for updating their knowledge and skills before
employment.
9. Nurses in senior positions like ward sisters, Asst. nursing superintendents, Deputy NS;
N.S must have courses in management and administration before promotions.

10. Nurses working in specialty areas must have courses in specialties. Promotion
opportunities for clinical specialties like administrative posts are considered
for improving quality nursing services.

11. The committee recommends that Gazetted ranks be allowed for nurses working as
ward sister and above (minimum class II gazetted). Similarly, the post of Health
Supervisor (female) is medical/ health officers.
Community Nursing Services

a. Appointment of ANM/LHV to be recommended.

 1 ANM for 2500 population (2 per sub centre)

 1 ANM for 1500 population for hilly areas

  1 health supervisor for 7500 population (for supervision of 3 ANM's) 1 public
health nurse for 1 PHC (30000 population to supervise 4 Health Supervisors)

 1 Public Health Nursing Officer for 100000 populations (community health centre)

 2 district public health nursing for each district.

b. ANM/LHV promoted to supervisory posts must undergo courses in

administration and management.
c. Specific standing orders are made available for each ANM/LHV to
function effectively in the field.
d. Adequate provision of supplies, drugs etc. are made.

Norms recommended for nursing service and education in hospital setting.

1. Nursing Superintendent -1: 200 beds (hospitals with 200 or more beds).
2. Deputy Nursing Superintendent. - 1: 300 beds (wherever beds are over 200)
3. Assistant Nursing Superintendent - 1: 100
4. Ward sister/ward supervisor - 1:25 beds 30% leave reserve
5. Staff nurse for wards -1:3 (or 1:9 for each shift) 30% leave reserve
6. For nurses OPD and emergency etc. - 1: 100 patients (1 bed: 5 out patients)
30% leave reserve
7. For ICU -1:1(or 1:3 for each shift) 30% leave reserve
8. For specialized departments such as operation theatre, labor room etc-1: 25 30%
leave reserve.

Staffing pattern according to the Indian Nursing Council

Collegiate programme-A
Qualifications and experience of teachers of college of nursing-

1. Professor-cum-Principal

 Master’s Degree in Nursing

 Total 10 years of experience with minimum of 5 years of teaching experience
2. Professor-cum- Vice Principal

 Master’s Degree in Nursing

 Total 10 years of experience with minimum of 5 years in teaching

3. Reader/Associate Professor

 Master’s Degree in Nursing

 Total 7 years of experience with minimum of 3 years in teaching

4. Lecturer

 Master’s Degree in Nursing with 3 years of experience.

 5. Tutor/Clinical Instructor

 M.Sc. (N) or B.Sc. (N) with 1year experience or Basic B.Sc. (N) with post Basic diploma
in clinical specialty

For B.Sc. and M.Sc. nursing:

 Annual intake of 60 students for B.Sc. (N) and 25 for M.Sc. (N) programme

B.Sc. (N) M.Sc. (N)

 Professor cum principal-1

 Professor cum vice principal-1

 Reader/Associate professor-12

 Lecturer-23

 Tutor/clinical instructor-19

 Total-56

 5 -One in each specialty and the entire M.Sc. (N) qualified teaching faculty will participate
in both programs
 Teacher-student ratio = 1:10

GNM and B.Sc. (N) with 60 annual intakes in each programme

 Professor cum principal-1

 Professor cum vice-principal-1
 Reader/Associate professor-1
 Lecturer-4
 Tutor/clinical instructor-35
 Total-42

Basic B.Sc. (N)

 Admission capacity /Annual intake- 40-60 61-100

 Professor cum principal-1
 Professor cum vice-principal -1
 Reader/Associate professor-1
 Lecturer-24
 Tutor/clinical instructor19 /33
 Total-24 /40
 Teacher student ratio= 1:10 (All nursing faculty including Principal and Vice principal)
 Two M.Sc (N) qualified teaching faculty to start college of nursing for proposed less
than or equal to 60 students and 4 M.Sc (N) qualified teaching faculty for proposed 61
to 100 students and by fourth year they should have 5 and 7 M.Sc (N) qualified
teaching faculty respectively, preferably with one in each specialty.
Part time teachers and external teachers:

1. Microbiology

2. Bio-chemistry

3. Sociology.

4. Bio-physic
5.Psychology

6. Nutrition

7. English

8. Computer

9. Hindi/Any other language

10. Any other- clinical discipliners

11. Physical education

The above teachers should have post graduate qualification with teaching experience in
respective area.

School of Nursing-B

Qualification of teaching staff-

1. Professor cum principal

M.Sc. (N) with 3 years of teaching experience or B.Sc. (N)basic or post basic with 5 years of
teaching experience.

2. Professor cum vice principal

M.Sc. (N) or B.Sc. (N) (Basic)/Post basic with 3 years of teaching experience.

3. Tutor/clinical instructor
M.Sc. (N) or B.Sc. (N) (Basic) / Post basic or diploma in nursing education and Administration
with two years of professional experience.
For School of nursing with 60 students i.e. an annual intake of 20 students: Teaching
faculty No. required
Principal-1
Vice-principal-1 Tutor-4
Additional tutor for interns-1 Total-7
Teacher student ratio should be 1:10 for student sanctioned strength.
ESTIMATION OF NURSING STAFF REQUIRMENTS- ACTIVITY, ANALYSIS AND
VARIOUS RESEARCH STUDIES
INTRODUCTION
Staffing is certainly one of the major problems of any nursing organization, whether it be a
hospital, nursing home, health care agency, or in educational organization. Estimation of staff
requirements is important for rendering good and quality nursing care Patient Classification
Systems. Patient classification system (PCS), which quantifies the quality of the nursing care,
is essential to staffing nursing units of hospitals and nursing homes. In selecting or
implementing a PCS, a representative committee of nurse manager can include a representative
of hospital administration, which would decrease scepticism about the PCS.
The primary aim of PCS is to be able to respond to constant variation in the care needs of
patients.
Characteristics
→ Differentiate intensity of care among definite classes
→ Measure and quantify care to develop a management engineering standard.
→ Match nursing resources to patient care requirement.
→ Relate to time and effort spent on the associated activity.
→ Be economical and convenient to report and use
→ Be mutually exclusive, continuing new item under more than one unit. Be open to audit.
→ Be understood by those who plan, schedule and control the work.
→ Be individually standardized as to the procedure needed for accomplishment.
→ Separate requirement for registered nurse from those of other staff.
Purposes
 The system will establish a unit of measure for nursing, that is, time, which will be
used to determine numbers and kinds of staff needed.
 Program costing and formulation of the nursing budget.
 Tracking changes in patients care needs. It helps the nurse managers the ability
to moderate and control delivery of nursing service.
 Determining the values of the productivity equations
 Determine the quality: once a standards time element has been established, staffing
is adjusted to meet the aggregate times. A nurse manager can elect to staff below the
standard time to reduce costs.
Components
 The first component of a PCS is a method for grouping patient's categories: Johnson
indicates two methods of categorizing patients. Using categorizing method each patient
is rated on independent elements of care, each element is scored, scores are
summarized and the patient is placed in a category based on the total numerical value
obtained.
 The second component of a PCS is a set of guidelines describing the way in
which patients will be classified, the frequency of the classification, and the
method of reporting data.
  The third component of a PCS is the average amount of the time required for care of
a patient in each category. A method for calculating required nursing care hours is
the fourth and final component of a PCS.
Patient Care Classification
 Patient Care classification using four levels of nursing care intensity Area of care
Category I Category II Category III Category IV Eating Feeds self needs some help
in preparing
 Cannot feed self but is able to chew and swallowing Cannot feed self any may
have difficulty swallowing Grooming almost entirely self sufficient
 Need some help in bathing, oral hygiene... Unable to do much for self
 Completely dependent
 Excretion Up and to bathroom alone
 Needs some help in getting up to bathroom /urinal In bed, needs bed pan / urinal placed;
 Completely dependent
 Comfort Self-sufficient Needs some help with adjusting position/ bed. Cannot
turn without help, get drink and adjust position of extremities ... Completely
dependent
 General health
 Good Mild symptoms Acute symptoms Critically ill Treatment Simple -
supervised, simple dressing...
 Any Treatment more than once per shift, Foley catheter care, I&O Any treatment more
 than twice/shift...
 Any elaborate/delicate procedure requiring two nurses, vital signs more often than
every two hours.
Health education and teaching
 Routine follow up teaching
 Initial teaching of care of ostomies; new diabetics; patients with mild adverse
reactions to their illness...
 More intensive items; teaching of apprehensive/mildly resistive patients....Teaching of
resistive patients, Calculating Staffing Needs.
The following are the hours of nursing care needed for each level patient per shift: Category I
Category II Category III Category IV
NCHPPD for Day shift
2.3 2.9 3.4 4.6
NCHPPD for
P.M (Evening) shift
2.0 2.3 2.8 3.4
NCHPPD for night shift
0.5 1.0 2.0 2.8
A guide to staffing nursing services 1. Projecting Staffing Needs Some steps to be taken in
projecting staffing needs include:
Identify the components of nursing care and nursing service.
Define the standards of patient care to be maintained.
Estimate the average number of nursing hours needed for the required hours.
Determine the proportion of nursing hours to be provided by registered nurses and other nursing
service personnel.
V. Determine polices regarding these positions and for rotation of personnel.
Computing number of nurses required on a Yearly Basis
Find the total number of general nursing hours needed in one year. Average patient census X
average nursing hours per patient for 24 hours X days in week X weeks in year.
Find the number of general nursing hours needed in one year which should be given by
registered nurses and the number which should
be given by ancillary nursing personnel.
Number of general nursing hours per year X percent to be given by registered nurses.
Number of general nursing hours per year X percent to be given be ancillary nursing personnel.
Computing number of nurses assigned on weekly basis
Find the total number of general nursing hours needed in one week. Average patient censes X
average nursing hours per patient in 24 hours X days in week.
Find the number of general nursing hours needed in the week which should be given by
registered nurses and the number which could be given by ancillary nursing personnel.
Number of general nursing hours per week X percent to be given by registered nurses.
Number of general nursing hours per week X percent to be given by ancillary nurses.
One method for determining the nursing staff of a hospital
To determine the number of nursing staff for staffing a hospital involves establishing the
number of work days available for service per nurse per year.
Example: Analysis of how the days are used; Days in the year 365
Days off 1 day/week 52
Casual leave 12
Privilege leave 30
1 Saturday /month 12
Public Holidays 18
Sick Leave 8
Total non-working days 132
Total working days /nurse/year 233 So 1 nurse = 233 working days /year
Example, 20 nurse means 20X233= 4660 hours 4660/365 12.8 (13).
Work load measurement tools
Requirement for staffing are based on whatever standard unit of measurement for productivity
is used in a given unit. A formula for calculating nursing care hours per patient day
(NCH/PPD) is reviewed. NCH/PPD = Nursing hours worked in 24 hours
Patient Census
As a result, patient classification systems (PCS), also known as workload management or
patient acuity tools, were developed in the 1960s.
Important Factors of staffing
There are 3 factors: quality, quantity, and utilization of personnel.
Quality and Quantity: This factor depends on the appropriate education or training provided to
the nursing personnel for the kind of service they are being prepared for i.e., professional,
skilled, routine or ancillary.
Utilization of personnel: Nursing personnel must be assigned work in such a way that her/his
knowledge and skills learnt are based used for the purpose she was educated or trained.
Other factors affecting staffing
Acutely III: Where the life saving is the priority or bed ridden condition which might require 8-
10 hours / patient /day ie., direct nursing care in 24 hours or nurse patient ratio may have to be
1:1, 2:1,3:1...
Moderately III: here 3.5 HPD are required in 24 hours or nurse patient ration of 1:3 in teaching
hospitals and 1:5 non-teaching hospitals.
Mildly III: this required 1-2 HPD and for such patients 1:6 or 1:10.
Fluctuation of workload: workload is not constant.
Number of medical staff: In PHC, 30,000 to 50,000 population getting care from 3 to
4medical staff but only 1 PHN gives care for all... like in hospital the ratio is vary from
medical and nursing staff. Modified approaches to nurse staffing and scheduling
Many different approaches to nurse staffing and scheduling are being tried in an effort to satisfy
needs of the employees and meet workload demands for patient care. These include game
theory, modified workweeks (10 or 12hours shifts), team rotation, premium day, weekend nurse
staffing .Such approaches should support the underlying purpose, mission, philosophy and
objectives of the organization and the division of nursing and should be well defined in a
staffing philosophy, statement and policies.
Modified work week: This using 10 and 12 hour shifts and other methods are common place.
A nurse administrator should be sure work schedules are fulfilling the staffing philosophy and
policies, particularly with regard to efficiency. Also, such schedules should not be imposed on
the nursing staff but should show a mutual benefits to employer, employees and the client
served.
One modification of the worksheet is four 10 hour shifts per week in organized time
increments. One problem with this model is time overlaps of 6 hours per 24-hour day.
The overlap can be used for patient-centered conference, nursing care assessment and planning
and staff development. It can be done by hour or by a block of 3-4 hours.
Starting and ending time for the 10 hours shifts can be modified to provide minimal overlaps,
the 4- hour gap being staffed by part-time or temporary workers
A second scheduling modification is the 12 hour shift, on which nurses work even shifts, on
which nurses work seven shift in 2 weeks: three on, four off: four on, three off. They work a
total 84 hours and are paid of overtime. Twelve hour shifts and flexible staffing have been
reported to have improved care and saved money because nurses can better manage their home
and personal lives.
The weekend alternatives: another variation of flexible scheduling is the weekend alternative.
Nurses work two 12 hour shifts and are paid for 40 hours plus benefits. They can use the
weekdays for continued education or other personal needs. The weekend scheduled has several
variations. Nurses working Monday through Friday have all weekends off. ,,h Other modified
approaches: team rotation is a method of cyclic staffing in which a nursing team is scheduled as
a unit. It would be used if the team nursing modality were a team practice.
Premium day weekend: nursing staffing is a scheduling pattern that gives the nurse an extra day
off duty, called a premium day, when he/she volunteers to work one additional weekend.
worked beyond those required by nurse staffing policy. This technique does not add directly to
hospital costs.
Premium vacation night: staffing follows the same principle as does premium day weekend
staffing. An example would be the policy of giving extra 5 working days of vacation to every
nurse who works a permanent night shifts for a specific period of time,say 3, 4, or 6 months. A
flexible role: this programme has enabled the hospitals to better meet the staffing needs of
units whenever workload increases. Since establishment of the resources acuity nurse position,
nurses position, nurse's morale has improved because they know short term helps is more
readily available and will be more equitably distributed among units.
Cross training: It can improve flexible scheduling. Nurses can be prepared through cross-
training to function effectively in more than one area of expertise. To prevent errors and
incidence job satisfaction during cross training nurses assigned to units and in pools require
complete orientation and ongoing staff development.
Scheduling with Nursing Management Information Systems Planning the duty schedule does
not always match personnel with preferences. This is one major dissatisfaction among clinical
nurses.
Posting the number of nurses needed by timeslot and allowing nurses to put colored pins in
slots to select their own times can improve satisfaction with the schedule.
Hanson defines a management information system as an array components designed to
transform a collective set of data into knowledge that is directly useful and applicable in the
process of directing and controlling resources and their application to the achievement of
specific objectives..
The following process for establishing any MIS:
State the management objective clearly.
Identify the actions required to meet the objective.
Identify the responsible position in the organization.
Identify the information required to meet the objective.
Determine the data required to produce the needed information.
Determine the system's requirement for processing the data.
Develop a flowchart.
Productivity
Productivity is commonly defined as output divided by input. Hanson translates this definition
in to following:
Required staff hours
Provided staff hours Example 380 hours
X 100 95% productivity
400 hours
Productivity can be increased by decreasing the provided staff hours holding the required staff
hours constant or increasing them.
Measurement
In developing a model for an MIS, Hanson indicates several formulas for translating data into
information. He indicates that in addition to the productivity formula, hours per patient day
(HPPD) are a data element that can provide meaningful information when provided for an
extended period of time.
HPPD is determined by the formula Staff hours
Patient days For example, 52000
2883
Answer = 18 HPPD Another useful formula
Budget utilization Provided HPPD
X 100 budget utilization Budgeted HPPD Example
18.03 % so, answer is 112.7% Budget utilization. 16
Budget adequacy
Budgeted HPPD X100, this is known as Budget adequacy Required HPPD 16/18.03=88.74%
budget adequacy.
Nurse Staffing, Models of Care Delivery, and Interventions Nurse Staffing Measure
Definition
Nurse to patient ratio Number of patients cared for by one nurse ty specified by job category
(RN, Licensed Vocational or Practical Nurs or LPN); this varies by shift and nursing unit; some
researchers us term to mean nurse hours per inpatient day
Total nursing staff or hours per patient day
All staff or all hours of care including RN, LVN, aides counted per patient day (a patient day
is the number of days any one patient stays in the hospital, i.e., one patient staying 10 days
would be 10 patient days)
RN or LVN FTEs per patient day
RN or LVN full time equivalents per patient day (an FTE is 2080 hours per year and can be
composed of multiple part-time or one full-time individual)
Nursing skill (or staff) mix
The proportion or percentage of hours of care provided by one category of caregiver divided
by the total hours of care (A 60% RN skill mix indicates that RNs provide 60% of the total
hours of care)
Nursing Care Delivery Models Definition
Patient Focused Care A model popularized in the 1990s that used RNs as care managers and
unlicensed assistive personnel (UAP) in expanded roles such as drawing blood, performing
EKGs, and performing certain assessment activities
Primary or Total Nursing Care
A model that generally uses an all-RN staff to provide all direct care and allows the RN to
care for the same patient throughout the patient’s stay; UAPS are not used and unlicensed
staff do not provide patient care Team or Functional
Nursing Care
A model using the RN as a team leader and LVNs/UAPS to
perform activities such as bathing, feeding, and other duties common to nurse aides and
orderlies; it can also divide the work by function such as “medication nurse" or "treatment
nurse"
Magnet Hospital Environment/Shared governance Characterized as "good places for nurses to
work" and includes a high degree of RN autonomy, MD-RN collaboration, and RN control of
practice; allows for shared decision making by RNs and managers Jean Ann Seago, Ph.D., RN
VARIOUS RESEARCH STUDIES ESTIMATION OF DIRECT COST AND RESOURCE
ALLOCATION IN INTENSIVE
CARE: CORRELATION WITH OMEGA SYSTEM.
Department of Public Health & Medical Information, Hôpital Ambroise Parè, Boulogne,
France.
Comment in: Intensive Care Med. 1999 Feb; 25(2):245-6.
Abstract
OBJECTIVE: An instrument able to estimate the direct costs of stays in Intensive Care Units
(ICUs) simply would be very useful for resource allocation inside a hospital, through a global
budget system. The aim of this study was to propose such a tool.
DESIGN: Since 1991, a region-wide common data base has collected standard data of
intensive care such as the Omega Score, Simplified Acute Physiologic Score, length of stay,
length of ventilation, main diagnosis and procedures. The Omega Score, developed in France
in 1986 and proved to be related to the workload, was recorded on each patient of the study.
SETTING: Eighteen ICUS of Assistance Publique-Hôpitaux de Paris (AP-HP) and suburbs.
PATIENTS: 1) Hundred twenty-one randomly selected ICU patients; 2) 12,000
consecutive ICU stays collected in the common data base in 1993.
MEASUREMENTS: 1) On the sample of 121 patients, medical expenditure and nursing time
associated with interventions were measured through a prospective study. The correlation
between Omega points and direct costs was calculated, and regression equations were applied
to the 12,000 stays of the data base, leading to estimated costs. 2) From the analytic accounting
of AP-HP, the mean direct cost per stay and per unit was calculated, and compared with the
mean associated Omega score from the data base. In both methods a comparison of actual and
estimated costs was made.
RESULTS: The Omega Score is strongly correlated to total direct costs, medical direct costs
and nursing requirements. This correlation is observed both in the random sample of 121 stays
and on the data base' stays. The discrepancy of estimated costs through Omega Score and actual
costs may result from drugs, blood product underestimation and therapeutic procedures not
involved in the Omega Score. 07:07 SO.
CONCLUSIONS: The Omega system appears to be a simple and relevant indicator with
which to estimate the direct costs of each stay, and then to organise nursing requirements and
resource allocation.
THE IMPACT OF NURSING GRADE ON THE QUALITY AND OUTCOME OF
NURSING CARE.
Carr-Hill RA, Dixon P, Griffiths M, Higgins M, McCaughan D, Rice N, Wright K. Centre for
Health Economics, University of York, UK.
Abstract
The large industry which has grown up around the estimation of nursing requirements for a
ward or for a hospital takes little account of variations in nursing skill; meanwhile nursing
researchers tend to concentrate on the appropriate organisation of the nursing process to deliver
best quality care. This paper, drawing on a Department of Health funded study, analyses the
relation between skill mix of a group of nurses and the quality of care provided. Detailed data
was collected on 15wards at 7 sites on both the quality and outcome of care delivered by nurses
of different grades, which allowed for analysis at several levels from a specific nurse-patient
interaction to the shift sessions. The analysis shows a strong grade effect at the lowest level
which is 'diluted' at each succeeding level of aggregation; there is also a strong ward effect at
each of the lower levels of aggregation. The conclusion is simple; you pay for quality care.
PMID: 7780528 [PubMed - indexed for MEDLINE]
IMPACT OF SHIFT WORK ON THE HEALTH AND SAFETY OF NURSES AND
PATIENTS.
Berger AM, Hobbs BB.
College of Nursing, University of Nebraska Medical Center, Omaha, USA. aberger@unmc.edu
Abstract
Shift work generally is defined as work hours that are scheduled outside of daylight. Shift work
disrupts the synchronous relationship between the body's internal clock and the environment.
The disruption often results in problems such as sleep disturbances, increased accidents and
injuries, and social isolation. Physiologic effects include changes in rhythms of core
temperature, various hormonal levels, immune functioning, and activity-rest cycles.
Adaptation to shift work is promoted by re-entrainment of the internally regulated functions
and adjustment of activity-rest and social patterns. Nurses working various shifts can improve
shift-work tolerance when they understand and adopt counter measures to reduce the feelings
of jet lag. By learning how to adjust internal rhythms to the same phase as working time, nurses
can improve daytime sleep and family functioning and reduce sleepiness and work- related
errors. Modifying external factors such as the direction of the rotation pattern, the number of
consecutive night shifts worked, and food and beverage intake patterns can help to reduce the
negative health effects of shift work.
Nurses can adopt counter measures such as power napping, eliminating overtime on 12-
hourshifts, and completing challenging tasks before 4 am to reduce patient care errors.
PMID: 16927899 [PubMed - indexed for MEDLINE]
NURSE STAFFING AND PATIENT, NURSE, AND FINANCIAL OUTCOMES.
Unruh L.
Department of Health Professions, University of Central Florida, Orlando, FL, USA.
lunruh@mail.ucf.edu
Abstract
Because there's no scientific evidence to support specific nurse-patient ratios, and in order to
assess the impact of hospital nurse staffing levels on given patient, nurse, and financial
outcomes, the author conducted a literature review. The evidence shows that adequate staffing
and balanced workloads are central to achieving good outcomes, and the author offers
recommendations for ensuring appropriate nurse staffing and for further research. Policy Polit
Nurs Pract. 2009 Nov; 10(4):240-51.
Shift work generally is defined as work hours that are scheduled outside of daylight. Shift work
disrupts the synchronous relationship between the body's internal clock and the environment.
The disruption often results in problems such as sleep disturbances, increased accidents and
injuries, and social isolation. Physiologic effects include changes in rhythms of core
temperature, various hormonal levels, immune functioning, and activity-rest cycles. Adaptation
to shift work is promoted by re-entrainment of the internally regulated functions and adjustment
of activity-rest and social patterns. Nurses working various shifts can improve shift-work
tolerance when they understand and adopt counter measures to reduce the feelings of jet lag. By
learning how to adjust internal rhythms to the same phase as working time, nurses can improve
daytime sleep and family functioning and reduce sleepiness and work-related errors. Modifying
external factors such as the direction of the rotation pattern, the number of consecutive night
shifts worked, and food and beverage intake patterns can help to reduce the negative health
effects of shift work. Nurses can adopt counter measures such as power napping, eliminating
overtime on 12-hourshifts, and completing challenging tasks before 4 am to reduce patient care
errors.
PMID: 16927899 [PubMed- indexed for MEDLINE]

NURSE STAFFING AND OUTCOMES.

Unruh L.
PATIENT, NURSE, AND FINANCIAL
Department of Health Professions, University of Central Florida, Orlando, FL, USA.
lunruh@mail.ucf.edu Abstract
Because there's no scientific evidence to support specific nurse-patient ratios, and in order to
assess the impact of hospital nurse staffing levels on given patient, nurse, and financial
outcomes, the author conducted a literature review. The evidence shows that adequate staffing
and balanced workloads are central to achieving good outcomes, and the author offers
recommendations for ensuring appropriate nurse staffing and for further research. Policy Polit
Nurs Pract. 2009 Nov; 10(4):240-51.
AN APPLIED SIMULATION MODEL FOR ESTIMATING THE SUPPLY OF AND
REQUIREMENTS FOR REGISTERED NURSES BASED ON POPULATION
HEALTHNEEDS.
Tomblin Murphy G, MacKenzie A, Alder R, Birch S, Kephart G, O'Brien- Pallas L.
Dalhousie University, Halifax, Nova Scotia, Canada, University of Toronto, Toronto, Ontario,
Canada, gail.tomblin.murphy@dal.ca
Abstract
Aging populations, limited budgets, changing public expectations, new technologies, and the
emergence of new diseases create challenges for health care systems as ways to meet needs and
protect, promote, and restore health are considered. Traditional planning methods for the
professionals required to provide these services have given little consideration to changes in the
needs of the populations they serve or to changes in the amount/types of services offered and
the way they are delivered. In the absence of dynamic planning models that simulate alternative
policies and test policy mixes for their relative effectiveness, planners have tended to rely on
projecting prevailing or arbitrarily determined target provider-population ratios. A simulation
model has been developed that addresses each of these shortcomings by simultaneously
estimating the supply of and requirements for registered nurses based on the identification and
interaction of the determinants. The model's use is illustrated using data for Nova Scotia,
Canada.
PMID: 20164064 [PubMed - indexed for MEDLINE]
J Public Health Manag Pract. 2009 Nov; 15(6 Suppl):S56-61.
HEALTH HUMAN RESOURCES PLANNING AND THE PRODUCTION
OFHEALTH: DEVELOPMENT OF AN EXTENDED FRAMEWORK FOR NEEDS-
BASED HEALTH HUMAN RESOURCES PLANNING ANALYTICAL
Birch S, Kephart G, Murphy GT, O'Brien-Pallas L, Alder R, MacKenzie A.
Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario,
Canada. birch@mcmaster
Comment in:
J Public Health Manag Pract. 2009 Nov;15(6 Suppl):S62-3. Abstract
Health human resources planning is generally based on estimating the effects of demographic
change on the supply of and requirements for healthcare services. In this article, we develop
and apply an extended analytical framework that incorporates explicitly population health
needs, levels of service to respond to health needs, and provider productivity as additional
variables in determining the future requirements for the levels and mix of healthcare providers.
Because the model derives requirements for providers directly from the requirements for
services, it can be applied to a wide range of different provider types and practice structures
including the public health workforce. By identifying the separate determinants of provider
requirements, the analytical framework avoids the "illusions of necessity" that have generated
continuous increases in provider requirements. Moreover, the framework enables policy
makers to evaluate the basis of, and justification for, increases in the numbers of provider and
increases in education and training programs as a method of increasing supply. A broad range
of policy instruments is identified for responding to gaps between estimated future
requirements for care and the estimated future capacity of the healthcare workforce.
PMID: 19829233 [PubMed - indexed for MEDLINE]
Nurse-to-patient ratio and nurse staffing norms for hospitals in India: A critical analysis
of national benchmarks
Suresh K. Sharma1 Ritu Rani1 Abstract
Optimum nurse-to-patient ratio is the concern of most of the nurse leaders globally. It has
benefits both for nurses and patients; which is essential for patient’s safety and quality of care.
Some parts of the world such as California, USA, and Queensland, Australia
has passed the law for the minimum nurse-to-patient ratio, which has scientifically found to be
beneficial for the patients and healthcare system. Indian nurse staffing norms given by the Staff
Inspection Unit, Indian Nursing Council, and Medical Council of India are developed through
professional judgement models and are not updated. Five electronic databases were considered
for literature search; in addition, grey literature and books were also searched. The primary
outcome was to summarise exiting national nurse-to-patient norms and to find out the ideal
nurse-to-patient ratio and nurse staffing norms as per Indian resources.
It is concluded that nurse staffing norms must be immediately revised in the light of
international norms and research evidence available in this regard. Further, there is a need for
workload analysis-based research evidence to have true nurse-to-patient ratio estimation for
hospitals in India.
Conclusion • Nurse staffing norms in India are not updated since a long and they are far behind
from international norms and estimated ratios in some of the research studies conducted in
India. However, recommendations given by NABH are most recent and realist, practical and
feasible to use in India • A single norm for all the wards and hospitals cannot be used for a fair
estimation of nursing human resource needs. While estimating nurse-to-patient ratio estimation
different factors such as unit workload, patients’ dependency, skill mix, available proportion of
nurses’ productive and non-productive activities, and variations in time and nursing care
activities during the shift should be considered • Considering Indian resources, best
international norms and Indian research evidence, we recommend following nurse-to-patient ratio
in each shift for Indian hospitals.

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