Restructuring the Nursing Staff and its Influence on Care Hours

This descriptive study aimed to calculate and compare the nursing staff at the medicalsurgical clinical units of a philanthropic hospital in current and projected situations, and to investigate how much time the nursing team delivers patient care in the current and projected situations. Gaidzinski’s method was used to calculate the nursing staff, and the equation proposed by the Hospital Quality Commitment (HQC) to estimate care hours. The findings showed an increase of 33% in the staff, with a 68.4% increase in the number of nurses and 15.6% in the number of technicians / nursing auxiliaries. According to the projected situation, the care hours varied from 5.7 to 7.2. The number of nursing and the mean care time provided to the patients were inadequate according to the clientele’s care needs. This could impair the quality of care.


Introduction
Continuous quality improvement has permeated work processes in health services.Quality can be defined as a set of attributes that include the level of professional excellence, efficient resource use, patient safety and user satisfaction (1) .To measure performance and signal activity irregularities, instruments known as indicators are used.These can be defined as a quantitative measure used to reassess, replan and reorganize activities at a service, offering support for decision making in care management (2) .
Another aspect that needs to be taken into account in health service assessment is related to personnel management.In the quality context, the human dimension is considered as the core of management discussions, as professional satisfaction is of fundamental importance to achieve organizational targets (3) .

Quantitative
and qualitative nursing staff assessment can be considered an essential management indicator, as it directly interferes in care humanization, health care efficacy and costs.The number of nursing staff makes it possible to determine the time this team spends (care hours) to see to patients' needs, reflecting the care standards health services want to provide (4) . www.eerp.usp.br/rlae Cucolo DF, Perroca MG.
Insufficient nursing staff has negatively influenced patient care quality, resulting in greater risk of adverse events (AE), such as medication errors, health carerelated infection, non-programmed removal of probes, drains and catheters, among others (5)(6) .It also affects patient morbidity and mortality rates and hospitalization time, with ethical-legal implications and high hospital costs (7)(8) .Work overload can lead to exhaustion and professional dissatisfaction, which increase absenteeism and turnover rates (7)(8) , jeopardizing the institution's goals and image.
As nurses need to continuously identify the quality of their team's professional practice and use the results found as a management tool for pertinent interventions in work processes (3) , the following study objectives were outlined.

Objectives
To calculate and compare the nursing staff at the medical-surgical clinical units of a philanthropic hospital in current and projected situations.
To investigate how much time the nursing team delivers patient care in the current and projected situations.

Method
This descriptive research was carried out at four medical-surgical clinical units of a philanthropic health institution in the interior of São Paulo State, with a total capacity of 196 beds.The study units represent 60% of installed beds.
Initially, the proposal to restructure the nursing staff was presented to the study institution's administration and nursing management.Next, the project was submitted to the Institutional Review Board, and data collection started after a favorable opinion.
For nursing staff calculations, Gaidzinski's equation (4) was used, with three variables: workload, working time and technical safety index (TSI).
Standard deviation was added to patients' mean score (4) .
Nine clinical nurses who worked at the units (five nurses in the morning shift and four in the afternoon shift) applied the instrument in June 2007.
The determination of the number of daily nursing care hours per care type and the distribution of the team per professional category were supported by Brazilian Nursing Council guidelines No 293/04, which fixes and establishes parameters for Nursing Staff Calculation (10) .
The proportion of the team per predominant workload and 85% of daily work time (6 hours) were considered as productive time (11) .
With regard to absences, data were collected retrospectively between January and December 2006, using documents from the Personnel Department (unforeseen absence records) and the monthly scale from the Nursing Department (foreseen absences).
Employees admitted until the fifth day and who worked until the 25th day of the month were included, considering a six-hour period for absences or days not worked (12) .
To calculate the percentage of foreseen absences, the following were considered: weekly leave, holidays not on Sundays and annual vacation.The sum of unauthorized absences, leaves and suspensions represented the percentage of unforeseen absences.
From that point, the TSI was determined, which represents the percentage of professionals to be added to the total number in each category, so as to cover for days of foreseen and unforeseen absences (11) .
Nursing team care hours were obtained by applying the equation proposed by the Hospital Quality Commitment Program (HQC) (13) for minimal and intermediary care.This equation was chosen due to the high number and diversity of hospitals that participate in this program, which periodically monitor this indicator, so as to allow for greater comparability among findings.
Where:  The analysis of monthly schedules and Personnel Department documents related to nursing staff absences led to the results below.

Unforeseen absences
For the nurse category, this type of absence ranged from 0.6% (unit IV) to 11.5% (unite I); for technicians and auxiliaries, from 2.8% (unit IV) to 6.7% (unit II).
TSI calculations for each hospitalization unit evidenced additions from 32 to 47% for nurses and from 35 to 40% for nurse technicians and auxiliaries (Table 2).The current nursing staff at the units under analysis consists of 77 professionals, including 12 nurses.Using the staff calculation method, the projected staff would comprise 115 nursing collaborators, with 38 nurses and 77 nurse technicians/auxiliaries (Table 3).In the current situation, care hours range from 4.2 to 4.9h.In the projected situation, a variation between 5.7 and 7.2h was evidenced (Table 4).

Discussion
In this study, the identification of the care clientele's profile showed that patients fit into the four care categories, showing their diversity and care complexity for the nursing team.Among the classified patients, the demand for minimal care predominated (65.8%), while some clients needed semi-intensive (7.4%) and intensive care (0.8%).Another study (12) carried out at hospitalization units also showed a higher percentage of patients in the minimal care category (68.7%), with lower percentages for semi-intensive (6.6%) and intensive care (1.5%).
Semi-intensive and intensive care patients' stay at the medical-surgical clinical units under analysis aroused reflections as to why those patients are allocated at these units, as they demand permanent attention from the nursing team, as well as more complex interventions and a higher workload.Causes can mainly be related with the insufficient number of beds at intensive care units (ICU) to respond to demands, or even to the inadequate assessment of care complexity.
In this research, percentages to cover for absences (TSI) ranged from 32 to 47% for the nursing category and from 35 to 40% for the nursing technician/auxiliary category.These levels are close to what was found at a university hospital (14) , i.e. from 39 to 43% (nurses) and from 38 to 46% (technicians and auxiliaries); but lower than levels in another research also carried out at a teaching hospital (12) , with 55 to 78% and 59 to 79.3%, respectively.It is important for each institution to express its reality with regard to coverage for absences.
And, in case the decision is to use the TSI recommended by the Brazilian Nursing Council (8.33% to cover for vacations and 6.67% to cover for the absenteeism rate) (10)   , the percentage of absences related to authorized leaves and holidays needs to be added with a view to additional staff (12) .
To reach the goal of 115 nursing collaborators at the units under analysis, 33% needs to be added to total staff.Research has shown different results, sometimes indicating the need to increase staff numbers by 17% (15) , sometimes maintaining the number of professionals (14) .
Findings in the present research evidenced greater demands for nurses, representing a 68.4% increase in comparison with the current team.Percentages found in literature for this category were 62% (15) and 50% (14) .For technicians and auxiliaries at the research institution, a 15.6% increase was projected in relation to current staff, as opposed to other studies that showed the need to reduce this category by 8.7% (15) and 27% (14) .
These percentages evidence the reality at the study institution which, like other health institutions in Brazil, still maintains a reduced number of nurses for financial reasons, jeopardizing the maintenance of quality care and service supervision.This situation also entails risks for patient safety, as exclusive nursing activities are delegated to technical staff, with ethicallegal implications for nursing professionals and for the institution.
Average nursing time available per patient-day ranged from 4.2 to 4.9h.Other studies at medicalsurgical clinical units presented 4.2h (16) , between 6 and 6.5h (17) and between 6.2 and 7h (5) .By adapting staff numbers, projected hours would vary between 5.7 and 7.2h, close to literature findings.As semi-intensive care patients were found at all units (1.9 to 12.3%), projected hours are also in line with the Brazilian Nursing Council's guidelines (10) .
In the current situation, average nursing care hours ranged from 0.5 to 1h; other authors presented 0.5h (16) and between 1.3 and 1.4h (17) .If the number of nurses ).

Table 2 -
General percentage of unforeseen absences

Table 3 -
Comparison between current and projected nursing staff according to hospitalization unit under study and professional category.São José do Rio Preto, 2007 *Nurses work at more than one unit during night shifts

Table 4 -
Comparison between number of care hours