Nursing workload in the emergency department : a methodological proposal

Objective: This study aimed to propose a methodology for identifying the nursing workload in the Emergency Department (ED). Methods: this is methodological research, undertaken in a public general hospital in the municipality of São Paulo, Brazil, in the areas: triage, shock room, emergency room, suturing room, and medication/procedures for adult and pediatric patients rooms, using different strategies and instruments. Due to the characteristics of the data collection, distinct samples were obtained in each of the areas. Results: The average daily workload, in hours, corresponded to: triage 48; shock room 30.9; emergency 170.6; observation of adult patients 293.6; observation of pediatric patients 108.7; medication/procedures in adult patients 175.5; medication/procedures in pediatric patients 60.4; and suturing 7.9. Conclusion: The instruments used for data collection were shown to be appropriate and made it possible to construct a methodological proposal for identification of workload of nursing professionals in E.D. in a general public hospital.


Introduction
In recent years, the growing demand for attendance in emergency departments has contributed decisively to overloading these services, turning them into some of the most problematic areas in the health system (1) .
Organized to provide immediate attendance, the Emergency Departments (ED) are often the "gateway" to the health system, receiving definite emergency patients, patients with clinical pictures seen as emergency, patients diverted from primary and specialized care, and social emergencies.Such demands blend in the ED services, overloading them and, because of the high workload, compromising the quality of the care given to the population (1) .This context is worsened, moreover, by organizational problems and by the lack of financial resources for adapting to local needs, whether these are to do with physical structure or human resources.
In this context, the health care professionals who work in these services, in addition to performing their activities in an atmosphere of unpredictability and uncertainty, which requires knowledge, speed of reasoning and promptness in carrying out the process of decision-making, frequently find themselves without sufficient staff to meet the patients' needs (2) .Thus, the characteristics of ED, allied with the insufficient numbers of nursing professionals, create an Rosseti AC, Gaidzinski RR, Fugulin FMT. and contributing to the calculation of the nursing professionals' needs in a general ED.For calculating the workload in each area of the ED, the equations shown in Figure 1 were applied.

Method
overload of work and are reported by the nurses as the principal source of stress (3)(4)(5) .
In addition to compromising the workers' health and quality of life, the lack of nursing personnel directly influences the results of the care given, prolonging the hospitalization time and increasing the costs of the patients' treatment (6) .
Various factors contribute to the shortage of nursing professionals for attending the patient in the ED services.Among these, one finds the small amount of information which nursing managers have about systematized criteria for planning and evaluating the quantity and quality of professionals, and the scarcity of parameters which could facilitate the operationalization of the conventional methods of dimensioning of nursing personnel.The adoption of a system for identifying the workload has been indicated as key to planning for the numbers of nursing professionals (7) .Therefore, it becomes necessary to investigate the indicators for nursing workload which allow nursing managers to apply methods for dimensioning the nursing professionals in a general ED unit, both to ensure the quality and safety of the care and the professionals, and for the sustainability of the health institution.
In this perspective, this study's objective is to propose a methodology for identifying workload were present, being characterized, therefore, as a convenience sample.In this way, the quantity of days observed was different in each of the areas of the ED.
In the shock room, suturing room and medication/ procedures with adult and pediatric patients rooms, the starting and finishing times of all the activities/ procedures carried out were recorded.In these areas, for calculating the average daily workload, the median in the equation proposed for determining value of h was applied, given that the average was affected by the extreme results and did not represent this variable adequately.
To measure the average time of assistance in the emergency room, the Nursing Activities Score (NAS) (8) was used.This instrument was considered appropriate in the face of the seriousness of the profile of this area's patients, who remain there awaiting transfer to the hospital's ICU or that of another service.
The NAS (8) contains 23 items which cover the nursing activities undertaken with the patients, with weights which represent the percentage of the nursing time dedicated to undertaking the activities, during the 24 hours.The sum of all the weights represents the percentage of the time taken up with the nursing activities for one patient in the day.To transform these weights in minutes, it is considered that 100% refers to 24 hours, or 1440 minutes, thus 1 point (or 1%) represents 14.4 minutes.
The NAS (8) was administered in a prospective way, that is, the patients were evaluated in the 23 items of the instrument, according to the care required for quality assistance.When the patient remained in the area for more than 24 hours, the NAS (8) score collected the night before was validated, by consulting the doctors' or nurses' notes in the patient file, referring to the presence of unforeseen events which occurred, such as: death, transference, resuscitation, and volemic reposition, among others.When necessary, the NAS (8) score was corrected to express the patients' care needs with greater reliability.
The areas of observation for adult and pediatric patients were considered similar to an inpatient unit, considering that the patients remain there for observation of their clinical picture or awaiting transfer to inpatient units.In this way, in the area for observation of adult patients, the average assistance time (h) was obtained through administering the Fugulin Patient Classification System (PCS) (9) , used by Resolution COFEN nº 293/04 (10) .
In the area where pediatric patients were observed, it was decided to use the Dini PCS (11) .
Both  (10) , it was decided to use the same hours of nursing care indicated for semiintensive patients.
All the beds occupied by patients in these areas were evaluated, by administering the above-mentioned instruments, at 8 am.
In addition, in these areas, the quantity of patients To calculate the productive work time, that is, the time that professionals dedicated during the work day to direct and indirect care, the percentage of 85% of productivity was considered (12) .The 15% of the day remaining is necessary for the pauses in which professionals attend to their personal needs.
For this, the following equation was administered: In which: r = nurse-patient ratio; h = average time of assistance spent per patient; r = productive time (85%).
To obtain the nurse-patient ratio it is necessary to transform the number obtained (r) into the fraction 1/r.
The result of this ratio represents the number of patients to whom each nursing professional provides ¯ www.eerp.usp.br/rlae Rosseti AC, Gaidzinski RR, Fugulin FMT.
care, expressed by 1:n, where 1 represents the nursing professional and n the quantity of patients for this professional.
The data collected was described in absolute and relative frequencies, in the case of the qualitative variables.For the quantitative variables, the description was undertaken by averages and standard deviations and medians, as well as minimum and maximum values.

The research obtained approval from the Research
Rosseti AC, Gaidzinski RR, Fugulin FMT.
which obtained 15.8 hr or 1:1.5 nurse-patient.This area's patients have the profile of critically-ill patients, therefore the average assistance time corresponded to the studies which administered the NAS (8) in different intensive care units (14)(15) , as well as with the time value for intensive care, recommended by the Ministry of Health (16) (15hr) and below the time for intensive care called for in Resolution COFEN nº 293/04 (10) , considered appropriate for the Brazilian context by a study (17) which evaluated the parameters proposed in this Resolution (10) .
In the area of observation of adult patients, the  (9) .
The average time of care per patient found in the observation of adult patients was 5.7 hr (1 nursing professional for 3.5 patients), which corresponds to the time of intermediate care recommended in the Resolution COFEN nº 293/04 (10) .Research carried out in the American context (13) obtained, in the ED studied, an average of 3.1 hr of nursing care per patient (that is, 1:8), a value below that called for in Resolution nº293/04 (11) for minimal care patients.
It should be emphasized that in the present research, the work time was identified by means of an instrument for classification of patients which shows the care time required by the patient, different from the study cited (13) which ascertained the work time given by the nursing professionals present on the shift.
The average work time per patient in the observation of pediatric patients was 7.9 hr (1:2.5).This average value is between the times for intermediate care and semi-intensive care established by Resolution COFEN nº 293/04 (10) .
With the exception of the area of triage, the present research had, as a limitation, the lack of indication of the proportion of the quantity of professionals, per category, necessary in each area of the ED.

Conclusion
The development of this research made it possible to analyze the differences between the areas of an ED and the relevancy of a methodology for identifying the nursing work load for each of these areas.
In the shock room, where the emergency attendances are, usually, carried out by more than one nursing professional, it was observed that the instrument used for data collection was limited to the time of assistance to the patient and did not take into account the quantity of nursing professionals who, simultaneously, provided care to the patient -which doubles or triples the care time.
The same occurred in the room for medication/ procedures for pediatric patients, where the nursing procedures are usually carried out by two professionals.
It is therefore understood that in these areas the workload identified may be affected by the limitation of the method used in collecting data.
It is recommended that research related to this issue should consider the need for more than one professional in patient care.
The use of the nurse-patient ratio to establish the workload may be considered a more comprehensible strategy in communication with management of hospital institutions.It is recommended that the quantity of these ratios be rounded to the nearest whole number, in line with each institution's characteristic.
The choice of differing instruments for identifying nursing workloads in the different areas of ED was necessary due to the peculiarities of each area.
The instruments used were shown to be appropriate for identifying the workload in the emergency room and in the observation of adult and pediatric patients, respectively.
The proposal of a methodology for measuring workload in ED allowed the identification of time indicators for different areas of a general ED and thus contributes to the calculation of the dimensioning of nursing professionals in this type of service.
This is methodological research, undertaken in the ED of a municipal secondary care hospital, managed by social organization, located in the municipality of São Paulo.The study was developed in all the areas of ED: triage (two clinic rooms), shock room (entrance area of emergency for adults and children first attendance, with three beds), emergency room (five beds), observation of adult patients (33 beds), observation of pediatric patients (22 beds), rooms for medication/procedures on adult patients (22 seats) and pediatric patients (16 seats) and the suture room.The average daily workload was calculated through the product of the average daily demand of patients (n) by the average time of the care spent per patient or per procedure h except for triage, where the references used were: quantity of work posts, in this case the clinics, and these clinics' uptime in 24 hours.

Figure 1 -
Figure 1 -Equations used for calculating average daily workload according to ED area.São Paulo, Brazil, 2010 (n) was recorded for four times of day: 8 am, 2 pm, 8 pm and 2 am, which correspond to the work shifts: morning (7 am to 1 pm), afternoon (1 pm to 7 pm), night 1 (7 pm to midnight) and night 2 (midnight to 7 am).Triage was considered a work place which must have one nurse available to gather, evaluate and classify the risk of the patients who arrive in ED.Thus, in this area, the two clinics were taken into account, with uninterrupted functioning (24 hours).The different areas' workloads, expressed in hours, were converted to average time of assistance per patient and, when possible, transformed into the ratio of quantity of health professionals per patient, by means of the ratio between average time of assistance spent per patient and the effective time of work in 24 hours.