Dimensionamiento de personal de enfermería de una unidad neonatal : utilización del Nursing Activities Score

Objetivo: estudio propone analizar la carga de trabajo de enfermería de los sectores de una unidad neonatal por medio del Nursing Activities Score NAS, y calcular el cuantitativo ideal del equipo, comparándolo con la actual. Método: el instrumento NAS fue aplicado en todos los recién nacidos internados por como mínimo 24 horas; la suma de los puntos del NAS suministró la carga de trabajo de la unidad, la cual fue utilizada para el cálculo del dimensionamiento del equipo por medio de la ecuación matemática. Resultados: El sector de Bajo Riesgo presentó carga de trabajo de 267 medidas NAS, y desfase de 8,8 profesionales diariamente; el Mediano Riesgo, carga de 446,7, y desfase de 22,3; el Alto Riesgo, carga de 359, y déficit de 17,9; el sector Aislamiento, demanda de 609, y desfase de 18,2; y UTI, 568,6 de carga, con déficit de 16,1 empleados. Conclusión: el estudio reveló desfase importante de profesionales con relación a la elevada demanda de trabajo a la cual están sometidos diariamente. La aplicación del Nursing Activities Score en unidades neonatales contribuyó a la evaluación de la carga de trabajo y dimensionamiento del equipo de enfermería.


Introduction
The quality in health is defined as the efficient use of the physical and human resources, with the minimum risk for the customer and a high degree of user satisfaction (1) .This concept presents particular characteristics for having the human dimension as basic aspect for reaching the established goals, since the deficiency of material resources generates precariousness regarding the work conditions, but the existence, in abundance, of the best material resources does not guarantee quality if there are not adequate human resources, quantitatively and qualitatively.
The efficient use of resources is widely discussed as form of reducing the costs of the health institutions, meaning that for the reduction of the expenses, both the material and the human resources are affected what worries the nursing team tremendously once this represents the quantitatively highest staff percentile of these institutions (2) .
The inadequate number of the nursing staff leads to a bigger workload, what causes the increase of the infection incidents in the hospital, of ulcers through pressure, of errors during the patient care giving, prolongs the hospitalization time and raises the costs of the patient treatment (2)(3) .It is also related to the incorrect assessment of the patient's needs, the inferior standard of the care of the nursing staff, the inappropriateness of the team supervision and the undueness of the registers in the documentation.High workload can generate occupational risks, once that the work requirements become high and the scope of decision taking low, what originates psychological tension (4) .
The workload is considered a basic element for the staff number forecast as it allows for identifying how much time is needed to carry out the necessary cares.Moreover, an adequate number of nursing staff is essential since beyond subjecting the team to a lower workload it fosters the accomplishment of an integral care, supplying the patient care necessities and the security of the patient.
There exist means which are capable to quantify this workload, among them the Nursing Activities Score (NAS).The NAS tool was elaborated in 2001, based on the Therapeutic Intervention Scoring System (TISS) (5) , this last one considered one of the pioneering instruments for the nursing workload quantification.
Its translation into Portuguese and validation was made in 2002 (6) .The NAS tool was applied in a neonatal Intensive Care Unit, presenting as result the effectiveness in quantifying the workload in these units and the support in sizing the nursing team (7) .
In light of this discussion, considering the managerial dimension of the nursing work process, which has as subject the work organization and the human resources in nursing, in order to implement adequate conditions of patient care and service for the staff (8) , the present study was carried out.

Objectives
Dimensioning the workforce of nursing professionals for the neonatal unit of a public teaching hospital, comparing it with the size of the current team.
Identifying the workload of the nursing professionals in each sector of the neonatal unit, verifying which of those presents the biggest work overload to the respective team.

Method
Exploratory  For the figure p, a viable productivity of 0.80 was considered, that means, the effective working time of the neonatal unit professionals is 80% of the daily workload, the ascertained value in scientific work (9) .
After the completion of the nursing team sizing calculation by means of NAS, a comparison of the team available in the institution with the ideal team estimated by resolution COFEN no.293/04 (10) , ordinance of the Health Ministry no.3432/98 (11) and resolution ANVISA (RDC) no.7/10 (12) was accomplished in each sector.

Results
The Boxplot (Figure 1) shows the variation of the daily NAS workload compared to the ideal NAS, calculated for the team available at work:  From the nursing staff sizing, calculated through measuring the workload by means of the NAS application, the comparison of the nursing staff quantity defined by effective legislations on the subject is conducted.Table 2 shows the results:

Discussion
The distribution of the newborns in the sample discloses that most of them were at EBEN which is a sector of low complexity where the detention time is EBEL and EBEA appear subsequently, whereas the EBEN sector presented the lowest workload and the lowest deficit of professionals.This shows that the complexity degree of the patient care intervenes directly in the workload which the nursing professional is submitted to.
In a similar study conducted in a University Hospital of São Paulo (7) in the Neonatal Unit, the available team was 20.7, while the NAS team got a figure of 27.The work overload in the nursing team is evidenced by several studies as risk factor for iatrogenesis, having the security of the patient placed at risk and increasing the mortality rate (13) .Also, the high workload affects the health of the nursing staff member, influencing the physical and mental wearout of the professional (14) .At NICU, nurses with qualification for performing in this unit have influence on the reduction of the mortality of premature and extremely underweight babies, evidencing that both the quantity and the quality of the health professionals influence the evolution of the patient (15) .
It was observed in all sectors that the average of nursing professionals calculated by means of NAS is superior to the available average in the unit and the average of professionals required by the legislation.The sizing with the lowest staff quantity was calculated by the RDC no.7/10 (12) , therefore this standardizes a lesser number of hours of assistance per patient in intensive care sectors.
The fact that the NAS team calculation is superior to the one of the team estimated by the legislation discloses that the accruing workload in the neonatal unit is underestimated by that legislation.Therefore, while resolution COFEN 293/04 (10) states 5.6 hours of nursing assistance in the sectors of intermediate care (EBEN and EBEL), the workload obtained by NAS shows an average of 29.1 and 32.6, equivalent to 7 and 8 hours, respectively.
The same resolution states for half-intensive care sectors (EBEA) 9.4 hours of assistance per patient, however the average yielded by NAS was 41.9, equivalent to 10 hours.
The EBEI and UBER sectors, considered intensive care units, present an average workload of 85.7 and 86.8, what is equivalent to 20.5 and 21 hours of assistance per patient, respectively; while resolution COFEN 293/04 (10) states for such cares 17.9 hours, the ordinance of the Health Ministry (11) 3432/98 states 19.2 hours and the RDC no.7/10 (12) 15 hours of assistance.The calculation of the staff quantity of the nursing team through standardized hours of given assistance proves to be inadequate, once

Conclusion
The application of a workload measurement tool (NAS) in the neonatal unit of this study showed that all the sectors presented an excessive workload due to an inadequate staff quantity and a high care demand; the high number of hours of assistance is superior to the hours stated by the legislation; the available team in the service presented a nursing staff quantity substantially inferior when compared with the workload calculation (NAS) or the effective legislation.
Therefore, the evaluation of the unit workload is essential for the adequacy of the number of nursing team professionals and consequent reduction of the workload which the staff members are submitted to, as well as for the quality improvement of the provided assistance.
used for calculating the team assessment by means of mathematical equation.Results: The sector of Low Risk presented a workload of 267 NAS points and an imbalance of 8.8 professionals daily; the Medium Risk sector a workload of 446.7 and an imbalance of 22.3; the High Risk sector a workload of 359 and a deficit of 17.9; the Isolation sector a demand of 609 and an imbalance of 18.2; and NICU a workload of 568.6 with a deficit of 16.1 professionals.Conclusion: The study disclosed an important imbalance of professionals in relation to the exalted work demand they are subjected to daily.The application of the Nursing Activities Score in neonatal units contributes to the evaluation of the workload and assessment of the nursing team.Descriptors: Neonatology; Nursing Human Resources; Nursing Staff; Workload.
NAS is composed of 23 items of therapeutic interventions subdivided into the following categories: basic activities; ventilation assistance; cardiovascular assistance; renal assistance; neurological assistance; metabolic assistance and specific interventions.The category of basic activities encloses the family support and care as well as the administrative activities, beyond other activities related to the cares.The NAS score shows how much working time (in percent) the patient required in the last 24 hours, saying a score of 100 means that the patient needed 100% of the working time of one nursing staff member in order to have the assistance carried out.Transforming into supplied assistance time, every NAS point corresponds to14.4 minutes.
patient records and requested information from the nursing staff who had been giving care directly to the newborns, in case some care had been given which was not registered in the patient record, was used.These professionals only participated in the research after signing the Term of Free Consent -Clarified.The workload of each sector was quantified by means of the sum of NAS points for each newborn.The statistic analysis of the data allowed for the average and standard divergence calculation, and due to dealing with a short research period, it was opted for executing the calculation of the 1 st quartile (25 percent of the data), 3 rd quartile (75 percent of the data), and graphical representation, by means of Boxplot, for providing statistical data which make for evaluating the variability of the workload in the sectors.For the accomplishment of the nursing team sizing, the mathematical equation below was used, consisting of the following variables: NAS punctuation of each day (in hours), the working hours and the staff productivity.Nursing staff sizing "Q" Legend: Q = daily nursing staff quantity ∑ NASi = total NAS (in hours) sector i per day of the data gathering t = nursing staff working hours (6 hours) p = productivity (0,80) For the figure t the balanced average calculation was carried out, considering the amount of health professionals and the quantity of their working hours in accordance with the type of employment contract, getting as a result the average amount of 6 working hours for each professional.
The boxes (plots) represent the difference between the percentiles 75 and 25 of the NAS obtained in each sector, the line inside each box indicates the median of the workload quantity obtained during the data collection period.The biggest plot regarding the daily NAS was at the EBEL sector, whereas the smallest one was at the EBEN sector.In this last sector, the point outside the plot refers to a day during the data collection where the workload quantity can be considered disparate (figure above the 3 rd quartile or below the 1 st quartile).The further sectors don't present such variations.The highest plot in the figure is from the EBEI sector, followed by the UBER sector, EBEL, EBEA and finally EBEN.It is as well to observe that the ideal NAS figures are all below the daily NAS, the biggest difference in the EBEI sector.Boxplot proves the fact that all the sectors have an excessive workload as the daily NAS plots are above the ideal NAS ones.At EBEI this difference is bigger, what characterizes it as the sector where the workload excess is bigger.Moreover, it is characterized as the sector with the biggest workload of the unit due to presenting the highest daily NAS plot.The biggest workload variability is presented at EBEL as it shows the biggest daily NAS plot, whereas EBEN got minor variability for showing the smallest plot and a smaller workload of the unit.

Figure 1 -
Figure 1 -Boxplot of the daily NAS in relation to the ideal NAS per sector.São Paulo, SP, Brazil, 2011 short, in general 3 days, generating a high newborn fluctuation in the sector, making the data collection from different newborns possible; whereas EBEI presented the lowest amount of newborns in the sample for being a sector where the interned children remain a long time.Although the unit has as one of its main characteristics assistance to preterm neonates, these patients present long time internment and therefore have little variation in the sample of the study, whereas the normal and late deliveries remain on average 3 days in the unit, representing a bigger variation and therefore constitute the biggest part of the newborns in the sample.The application of the NAS tool happened more times in the EBEL sector due to its high occupation level, whereas the UBER sector had the tool applied fewer times due to the lowest occupation level of the other sectors.It was to observe that all the sectors of the neonatal unit presented a workload superior to the available professionals.Moreover, the staff sizing calculated by means of NAS shows that all the sectors have an imbalance of nursing team professionals.Although the sectors of greater complexity (EBEI and UBER) presented a greater number of nursing team workers, these are the sectors which present a greater imbalance of professionals, EBEI and UBER, respectively, this because in these sectors there is a greater workload.
that each unit of a health institution presents a definitive workload which can have a superior or inferior figure to the one established by the legislation.For the time being, workload measurement tools, as for example NAS, make the accurate measuring of the unit demand, beyond that they make a more credible sizing possible.Therefore, the NAS tool proves adequate for the survey of the neonatal unit workload, what allows for its use as a parameter for the calculation of the nursing team quantity.

Table 1
shows the NAS application, and some derived measures, in the sectors of the neonatal unit: 33min) per newborn; the calculated NAS team was 30.43 professionals/ day, but the available daily team is 12.22, a deficit of 18.21 people.the current team the ideal NAS would be 244.44 points.The UBER sector had an average workload of 568.63 NAS points, being 86.78 (20h 50min) per newborn; the calculated NAS team was 28.41 staff members, whereas the daily team is 12.22, a divergence of 16.19 professionals.The ideal NAS for this sector would be 244.44 points.(8188.32minutes) are used, being 11.29 hours (677.68 minutes) per staff member, 9.04 hours considering the productivity.

Table 2
shows that during the 9 days which constitute the sample period of this study, EBEN presents an average of 9.2 newborns and an available team of 8.8 professionals/ 24 hours, yet the team NAS calculated has an average of 13.3 professionals/ day, and the resolution COFEN, 10.7 professionals, considering it an