NURSING WORKLOAD AT A GASTROENTEROLOGY UNIT

One of the biggest challenges nurses face is the need to justify the quantity and quality of staff for care delivery. For this, management instruments are available which help them to determine the staff needed in the nursing team. This descriptive study aims to evaluate the nursing workload at a specialized clinical and surgical gastroenterology unit. To collect data, the Nursing Activities Score (NAS) was used during 30 consecutive days, with 1080 comments, obtained from the records of 149 patients. The mean NAS score was 34.9% and, considering that each point of NAS corresponds to 0.24 hour, on the average, 8.4 hours of nursing care were required within 24 hours. This means that this profile is of patients who demand intermediate and semi-intensive care, which suggests that the NAS study can be used to evaluate the workload of nurses at that unit.


INTRODUCTION
One of the biggest challenges nurses face is the need to justify the quantity and quality of staff for care delivery to clients.This process can result in conflicts, however, as the growing need to decrease costs and increase nursing service delivery arouses questions about institutions' nursing staff (1) .
For service management to justify a given nursing staff, nowadays, nurses have management tools at their disposal to rank patients in terms of care complexity level, consequently helping to determine the nursing staff needed for quality care delivery.These include instruments developed in Brazil for adult hospitalized patients (2)(3)(4)(5)(6) , for residency nursing (7) and for pediatric patients (8) , as well as others validated for the Brazilian culture, such as the Therapeutic Intervention Scoring System (TISS-28) (9)   and the Nursing Activities Score (NAS) (10) .
Differently from the above instruments, the NAS assesses the number of nursing hours spent per patient during one work shift, based on its total score (10-11)   .that more than one nursing professional was needed to deliver care to the patient on a given day (11) .
Although the NAS was constructed for application to patients from critical care units, it is considered useful to assess nursing workload at tertiary and quaternary hospital units, where clients' care complexity level is high.It should be reminded that the NAS score does not depend on patient severity, as its construction and validation were based on nursing activities (11)   .
The Patient Classification System (PCS) (2,4) has been used for staff dimensioning at hospitalization units, classifying patients in care groups or categories.
While this type of tool identifies the patient's level of complexity, the NAS permits measuring the workload in terms of direct and indirectly related nursing care hours.However, studies using the NAS have been applied to ICU patients, evidencing its reliability to assess workloads for patients who require intensive care (12)(13)(14)(15) .
The choice of a patient classification instrument to identify the workload should not only be based on its specific indication, but should also take into account an institution's care delivery dynamics and complexity.
In view of difficulties to apply an instrument that permits classifying patients into care complexity levels, this research aims to measure the nursing workload at a clinical and surgical unit like gastroenterology.

RESULTS
The NAS was applied during 30 consecutive days to the 36 beds at the gastroenterology unit (gastroclinic and gastrosurgery nursing wards), totaling 1080 observations, obtained from 149 patients' records.To measure the workload at the unit, the researcher decided to consider the bed, independently from the subject occupying it.Hence, the collected data followed bed occupation dynamics.
In The observation of mean NAS scores per bed revealed that four beds, with generators, located in two rooms at the gastroclinical ward, obtained the highest mean workload scores, ranging between 44.9 and 68.3%, when compared with other beds at the unit.On the other hand, the four beds at the gastrosurgery ward, with the same characteristic, scored equal or lower than other beds at this ward.
As the NAS permits identifying nursing activities during 24-hour patient care, the recording frequency of instrument items and subitems can be calculated (Table 2).

DISCUSSION
Study data appoint the predominance of male patients, submitted to surgical treatment and hospitalized for less than five days.The greatest hospitalization turnover was found at the gastrosurgical ward.
At that ward, most patients were admitted for surgical patients, but patients for clinical treatment were also attended, as some of these, in the late postoperative period, are hospitalized for clinical compensation.At the gastroclinic, on the other hand, these percentages did not differ because the unit offers beds for clinical as well as surgical care.
According to the NAS, the mean workload at the gastroenterology unit was 34.9%.The comparison between both wards showed a difference, with a higher score for the gastroclinical than for the gastrosurgery ward.These results could not be compared with other studies, however, as the application of this instrument has been restricted to intensive care units, but some of the reasons for these differences can be due to the level of dependence and clinical procedures performed.Studies carried out at ICU appoint a higher mean workload (10,(12)(13)(14)(15) than what was found in this research, although one of those studies (14) reported a lower minimum NAS score than the mean score found at the gastroenterology unit.Performing routine tasks.
Unscored items are relatived to activities performed at a specialized intensive care unit (14)(15) , according to expectations for the gastroenterology patient profile.
To obtain NAS workload results comparable with the total nursing hours recommended by the Brazilian Federal Nursing Council (COFEN) (16) , according to the type of care the patient demands, the NAS score needs to be transformed into hours.
Each NAS point is equivalent to 0.24hr (14) and, on the average, 34.9% of the workload at the gastroenterology unit was measured, 8.4 hours of nursing service were delivered during 24-hour care.
In view of recommendations established in COFEN resolution No 293/2004 (16) , the obtained score evidences a profile of patients demanding intermediary and semi-intensive care, suggesting that the NAS can be used to assess the nursing workload at that unit.

CONCLUSIONS
This research permitted measuring the nursing workload at a specialized clinical and surgical gastroenterology care unit.The workload, according to the NAS, corresponded to 34.9% for the unit, with differences between the nursing wards, i.e. 37.2% for the gastroclinic and 32.63% for the gastrosurgical ward.
The total score resulted in an average 8.4 hours of nursing care during 24 hours, corresponding to the profile of patients demanding intermediary and semi-intensive care.Although the NAS is applicable to ICU, its utility to determine the nursing workload at the study unit could be demonstrated.
In view of these results, the importance of nurses assessing the nursing workload at their unit is highlighted, using instruments for this goal, either to make the nursing work process more oriented to patient demands or to help nurses to administer the staff in hospital service management.
As this was the first experience of using the NAS at a clinical and surgical unit, the researchers recommend its application in other studies with the same patient profile and hospital reality, as well as its validation for other than intensive care units.

Table 2 -
Frequency of item and subitem performance of Nursing Activities Score.Campinas, 2008