REVIEW / REVISIóN / REVISÃO

Planning the required nursing personnel to respond to care needs

Planejamento do pessoal requerido de enfermagem para responder às necessidades de cuidado

Dora Lucia Gaviria Noreña¹

¹RN, M.Sc. Professor. Universidad de Antioquia, Colombia. email: dgaviria@udea.edu.co .

Receipt date: March 15^th 2012. Approval date: September 19^th 2012.

Subventions: None

Conflicts of interest: None

How to cite this article: Gaviria-Noreña DL. Planning the required nursing personnel to respond to care needs. Invest Educ Enferm. 2013;31(1): 116-124

ABSTRACT

An approach is undertaken of the concepts and methodologies concerning the planning of the nursing personnel required to respond to the care needs of individuals, families, and groups. Planning is evermore founded on the nature of caring for human beings within the context of life, which endows the existence of the person-patient with sense and significance, as well as the nursing personnel, according to the culture and the social setting in which it is developed. Knowing what and how much personnel is required to offer caregiving has been marked by the calculation of coefficients and time averages to execute activities, the description of the work load that includes studying times and movements, analysis of supply and demand of human resource, mediated by the profession's regulations in each country and by inquiry within the context of caregiving. However, consensus has not been reached with respect to this process, but it is concluded that it is a policy action that requires regulation, investigation, and group work by nursing to make caregiving visible and legitimate as a public service that maintains life and health and which also favors and mitigates processes of disease and death faced by human beings.

Key words: nursing staff; health personnel management; health management.

RESUMO

Se realiza uma aproximação dos conceitos e metodologias ao redor de planejamento do pessoal de enfermagem requerido para dar resposta às necessidades de cuidado de indivíduos, famílias e coletivos, que se fundamenta cada vez mais na natureza dos cuidados do ser humano no contexto da vida, que dota de sentido e de significado segundo a cultura e o desenvolvimento social no que se desenvolve. Conhecer qual e quanto pessoal se requer para brindar o cuidado, tem estado marcado pelo cálculo de coeficientes e médias de tempo para a execução de atividades, a descrição do ônus trabalhista que inclui o estudo de tempos e movimentos, a análise de oferta e demanda do recurso humano, mediado pelas regulamentações da profissão em cada país e pela indagação do contexto do cuidado. No entanto, ainda não existem consensos neste processo, mas se conclui que é uma ação política que requer da regulamentação, regulação, a investigação e do trabalho coletivo de enfermagem para visibilizar e legitimar o cuidado como um serviço público que mantém a vida e a saúde e favorece e mitiga os processos da doença e da morte que enfrentam os seres humanos.

Palavras chaves: recursos humanos de enfermagem; administração de recursos humanos em saúde; gestão em saúde.

INTRODUCTION

Now, more than ever, planning of nursing personnel requires having evidence that accounts for the relationship that exists among an adequate number of personnel and other variables like number of patients, actions to undertake, work schedule, among others, to achieve quality and security in the act of caring and satisfying the need to establish a closer interaction with the subjects of care, who are now more participant, have more knowledge and information on the maintenance of their health and recognize the adaptation processes as key to confront disease and death.

Planning of nursing personnel requires, among other aspects, analysis of the supply and demand of the nursing team to meet the caregiving needs within context; the determination of the number of personnel in financing from the healthcare sector; and, finally, awareness of the working conditions, rotation, flexibility and stability of personnel, different types of contracts, availability of a nursing team with high leadership training, regulations on nurse staffing to guarantee quality care. In this sense, the International Nursing Council in its document 'Reliable personnel lives saved'¹ urges all governments and nursing organizations to analyze and establish policies that guarantee 'healthy work environments, the health of nurses, and the adequate personnel to maintain and sustain healthy populations'; likewise, it establishes as principles to staff personnel knowing the patients' needs and the complexity of caregiving, the context, intensity of caregiving, diverse levels of nurses' preparation, experience of the nursing team, and support to management by nursing in operational and executive levels. This same organism, in 2009 in its Guidelines on human resource planning,² calls on the need to consolidate and establish efficient planning and development strategies of nursing human resources, which must be periodically revised, entailing political entities in charge of making decisions in this sense, supported by permanent analysis of supply and demand.

Consequently, the decisions on the size and combination of the nursing teams are a critical area for healthcare services; thereby, it has direct implications on quality, patient security, and caregiving costs. Also, satisfaction of nursing personnel, permanent education, development of levels of autonomy and recognition, as well as incentives policies are currently essential in health management.

The INC¹ asserts that in the investigations reviewed since the 1990s, a close relationship exists between the levels of personnel training and nurse staffing with the results in patient care in terms of quality and security, which show, in turn, decreased morbidity and mortality.

Minnick and Mion³ affirm, through an investigation, that the results of studies on nursing work have had different definitions, variants and methodological approaches, which is why in many instances the conclusions are contradictory as of the difficulties given by the information systems and the composition of databases, personnel assignment strategies, and design of analytical techniques. They highlight the importance of studies that reflect the amount of work nurses must perform not only with patients and with the results in the organization, but also their participation in continuous education activities, information, and other specific tasks that are not visible and which is necessary to evidence. McHugh et al., ⁴ analyzed, from 1997 to 2008, the application of the legislation that establishes the minimum nurse-per-patient ratio in California hospitals compared to other hospitals in the United States. This legislation did not reduce the level of skills of the nursing personnel, as was feared, and additionally permitted improving the level of certified expert nurses. Also, upon increasing a half hour of nursing per day, patient care is improved. In addition, Kutney-Lee et al.,⁵ evidenced that if the development of nursing personnel is maintained, this becomes a quality indicator of the patient's general care. In services like intensive care, instruments have been developed, among them the Therapeutic Intervention Scoring System (TISS),^6,7 which permit objectively measuring the complexity and severity of the patient, interventions, and time. With advance in research, the Nursing Activities Score (NAS)^8-10 was created, which seeks to analyze the needs of nursing care in intensive care, the daily evolution of patients according to the nursing activities that in the most recent versions includes actions like support and assistance to family members, patients, and administrative and management tasks; also, the NAS expresses the percentage of time dedicated by a nursing professional in direct care to critical patients in the Intensive Care Unit (ICU) during 24 hours. These studies have shown that using objective instruments that evaluate the nursing work load favors decision making and improves practices in this discipline.

Gaviria,¹¹ in the revision of the scientific evidence on the evaluation of care, confirms how nursing care requires adequate and suitable personnel, financial and technological resources, as well as definition of the processes and functions as appropriate matters to achieve high-quality results, which are free of risks. Briefly, never before had it been so important for nursing to have adequate instruments and information systems that permit efficient and effective planning of personnel as an essential aspect to guarantee the quality of care.

What is planning of nursing personnel?

Planning of nursing personnel requires understanding the nature of caregiving, hence, it demands placing them within the cultural and social context that endows them with sense and significance. As defined by Colliere:¹² 'Caring is, above all, an act of life, in the sense that caring represents an infinite variety of activities aimed at maintaining and conserving life and allowing it to continue and reproduce'.

The Pan-American Health Organization¹³ defines planning of the human resource as an analytical process that determines the personnel according to the patients' needs, that is, having the right number and type of individuals in the indicated place and time, with the skills to perform the actions that improve the health of the population and accomplish their wellbeing. In 2003, the World Health Organization¹⁴ established the guidelines for management of human resources in nursing and midwifery, through a conceptual framework that includes: healthcare policies and plans and nursing personnel, formation, development of nursing personnel, distribution and utilization of different categories of nursing, as well as regulations. These aspects, in general, are essential to plan and evaluate the situation of supply and demand of the human resource and become an imperative for nursing associations. In this sense, Rovere¹⁵ considers that the development of healthcare human resources must be understood as 'the complex educational process of individuals and groups that starts during the formation period and is prolonged throughout the professional life, determined by their social and cultural context where different institutions and players interfere. Additionally, it is an object of social transformation to improve the population's health and the quality and coverage of healthcare services'.

From nursing, the criteria that have guided the determination of the needs for personnel have been modified over time¹⁶. In fact, these have obeyed the scientific-technological and communication advances in healthcare, reforms of healthcare services that interfere in the organization, and the availability and qualification of personnel. Today, we have higher levels of formation, which has permitted transforming the scope in scenarios like research, teaching, and enterprise. In this sense, McGillis^17,18 considers that, besides the aforementioned, we must consider the work load, work environment, the complexity of each patient, level of skills of the nursing personnel, the combination of nursing personnel, economic efficiency and effectiveness, and the impact of nursing care upon the patient's health. Additionally, in his most recent work, the author highlights the value of the staff models of personnel linked to the results obtained in patients and to the combination the personnel's skills and to their retention to guarantee their stability.^19,20

The work carried out by Hurst,²¹ ratified by the INC¹, in reliable personnel lives saved, provides a complete report on the five methods for nursing human resource planning: professional judgment by experts, the method of nurses per bed occupied, the method analyzing dependency by the degree of caregiving complexity and the quality of the activities, the timed task-activity method, and - lastly - those based on regression analysis.

These systematic reviews, Greenberg,²² are of fundamental value for decision making within the context of nursing care, which is currently debated among the requisites to improve equity and access to healthcare services, as well as to overcome inequalities of most vulnerable and excluded people, families, and human groups; to the attention of pandemics and natural disasters that increasingly affect greater numbers of people throughout the world and economic recessions that have given way, on the one hand, to the scarcity of nurses and, on the other, to high healthcare costs.

In Colombia, the investigation by the Ministry of Social Protection²³ on the model of supply and demand of healthcare human resources emphasizes on the need to develop an appropriate system of healthcare personnel planning, which incorporates new methodologies that respond and are compatible with the characteristics and requirements of the nation's General Healthcare Social Security System. Also, the investigation defines as priority the need to create a Human Resource Planning Unit that meets the demands of the new institutional context, models of service and care delivery. By 2000, there were 23,063 nursing professionals and 82,406 nursing aides, for an estimated index in 2003 of 5.6 and 20.1 per 10,000 inhabitants, respectively. In the projections of this study, the authors conclude that the offer of nursing personnel will be evermore lower than the demand if healthcare coverage increases. In the study by Castrillón and Malvárez,²⁴ this same index shows big differences like that presented between Haiti (1.1) and the United States (97). The authors affirm that 'without enough nursing professionals in quality and quantity, the Objectives of the Millennium and Healthcare for All will be mere rhetorical expressions. It is necessary to have intense awareness action on the problem, in terms of the impact upon the lives and health of the people and upon the security of the people hospitalized and to make efforts and alliances to align nursing education and research to the healthcare needs and development of the people'.

According to the Colombian National Nurses Association (ANEC, for the term in Spanish),²⁵ in 2010 the country had 39,346 nursing professionals of which 62% were registered. Regarding the working conditions at that time, 38% were unemployed; in addition, of those who were employed, their job conditions were flexible in one of every two.

Nursing staff personnel: a perception from research

Planning of the nursing human talent is part of the complexity and uncertainty of healthcare services and is within the challenge of responding to the needs of human beings within the global, national, and local contexts. Kerouac et al.,²⁶ expressed that the environment in which nursing care operates presents numerous challenges and paradoxical situations. Among them, there are: the institution's financial survival and the human values that characterize nursing care, continuity of care and instability of the work teams, the hierarchical authority and the autonomy of the care personnel, the power struggles and intra- and inter-professional collaboration, standardization and respect to diversity and individuality. Also, technology and cost-effective decisions regarding values are the ethical dilemmas faced by nursing personnel during their daily practice.

In recent years, research^27-30 has focused on revealing the contexts of caregiving and its relation to the results. In this sense, research coincides in evidencing that nursing personnel is fundamental to guarantee quality and that it is possible to achieve better health levels of the population in general if there is higher training, retention, and maintenance of adequate numbers of nursing personnel.

Flynn L et al.,³¹ consider how the dependence on caregiving by elderly patients and handicapped individuals, or individuals with mental disorders, evidences the requirement of greater time for their care and greater support, which is still not contemplated in any healthcare system. Hanrahan et al.,²⁹ in a study on the adverse events associated to factors of the organization of caregiving for psychiatric patients, reveal verbal abuse against nursing personnel and family complaints as the most frequent adverse events (79%), associated to lack of hearing, a dimension that needs to be developed in security and quality.

Shimokura et al.,³² in a study on caregiving practices to patients with chronic hemodialisis, show that increased hepatitis C infection has been related to the little time available for nursing personnel to change gloves between patients. In this sense, they state that an inadequate number of personnel can cause a lower adhesion to the practices to control the infection. Miranda et al.,⁶ in their work on nursing activities with patients in ICU, using the NAS scale, demonstrate the importance of systematizing the work load in these units. Also, factors like age, gender, increased days of hospitalization, among others, are related to the high demand for caregiving by patients and their families.

Other concerns from research are related to stimuli and healthcare of the nurses.^33,34 This is one of the main motives why hospitals in the United States do not reach the optimal levels of nursing staff personnel, given that they do not receive wages according to the quality of care they provide. In another context, Buchan and Ball,³⁵ in their research to assess the impact of a new wage system for nurses in the United Kingdom, with a coverage of approximately 400,000 nurses and some objectives to improve the quality of caring for people, as well as recruiting, retaining, and motivating personnel, concluded that this system must be improved with efficient communication, adequate funding, and consistent direction of the system.

Baumann²⁸, regarding the repercussions of the rotation of nurses and the benefits of greater stability of nursing personnel, considers it important to have lower personnel rotation, analyze the high costs the rotation of nurses has had for organizations and the effects on the quality of care. The author considers it important to conduct an analysis stemming from national policies on healthcare human resources and establish guidelines and supervision from the political to guarantee adequate staffing with minimum personnel rotation. Consequently, she urges all nursing associations to permanently be aware of the analysis of the personnel's state of health, the phenomenon of migration, retirement processes, unemployment, and an updated information system for decision making. Similarly, Buchan³⁶ examines how personnel stability and retention of healthcare workers poses significant benefits for directors of sectoral policy in this sense and for the wellbeing of the people. Additionally, it has positive results in the complex interaction of the quality of care in the healthcare sector, as well as an impact upon costs, which could be more effective. Rothberg et al.,³⁷ corroborated how a cost-effective security intervention is related by the nursing personnel-patient ratio, analyzed the institutional profitability by comparing the patient-nurse ratios from 8:1 to 4:1, with the prior being less costly, but with the highest risk of death. The authors concluded that an intervention reflected on security care for patients has to do with ratios of 4:1. This is reasonably more profitable and is, generally, the most accepted.

Another one of the lines of research in this theme^6,31,38-40 is aimed at the construction of instruments that permit knowing the nursing activities and the time required. All authors coincide in that these instruments manage to detect over 40% of the nursing work.

In keeping with the aforementioned, Thorsell et al.,³⁸ performed a validity and reliability analysis with satisfactory results from the Time in Care Needs (TIC-n) version with 19 items to apply in two municipalities with elderly patients, who had greater dependency on care to support functions of daily living due to their decreased mobility and activity skills.

Gonçalves et al.,⁷ characterized patients hospitalized in ICU in function of the bio-social and admission data and verified the daily needs of nursing care according to the 'Nursing Activities Score -NAS-. The sample comprised 50 adults admitted to ICU in a University Hospital in the municipality of Sao Paulo. Most of them were over 60 years of age, with an average of 3.5 days in ICU, and NAS result of 66.5%, verifying that it remained over 50% during the course of the hospitalization in this service. This work evidences the work load of the ICU nursing personnel and the benefits of NAS to verify this. In Colombia, the multicentric study by ACOFAEN⁴¹ on the socio-demographic characteristics of nursing professionals graduating between 1995 and 2004 describe that 52% of the nursing professionals had between two and five years of experience, similarly, many of them had not entered the job market or ended up dedicated to other occupations, reflecting the effects of reforms to the healthcare sector. Of those working, 70% worked in a healthcare services provider institution (IPS), 27% worked in a second institution, and 4% also worked in a third institution to compensate for low wages. Additionally, half of those working with the normal Schedule had marked deterioration of the working conditions, given that a good proportion of them were hired through job cooperatives. Precisely, 60% of those surveyed considered that their work was not well paid.

The National Technical Nursing Counsil⁴² states, in its declaration, that in Colombia there is no adequate recognition of the fundamental role played by nursing services in the healthcare system, although this profession has the occupational profile with the lowest level of substitution among professions in healthcare. In addition, 'the social healthcare security model does not directly recognize nursing care within the skills and functions of the nursing professional, integrating such within the medical procedures, or within what is known as basic services'. While the systematic review of studies related to planning of nursing personnel has not been exhausted, it is revealed that incentives policies have been earmarked in recent years to evidencing the effects on the quality of care. Some of these policies include: retention - stability - and wages, the methodologies to measure the work load and the care needs, and studies of human resource supply and demand as a complex field of health management and nursing in particular.

Final considerations

Planning of human talent in nursing must be based on the patients' needs, the families, and the human groups in objective and pertinent manner and close to the context and conditions surrounding the act of caregiving. As expressed by Cuesta,⁴³ the conditions and the context indicate the problematic nature of the experience surrounding caregiving; consider it as that set of events and occurrences that create situations, themes, or problems and the responses individuals undertake to solve it. In this sense, Romero⁴⁴ states that the 'characteristics of caregiving within the current Colombian context is of adversity and defines it as the expropriation of the subject from the act of caring and the loss of the nurse-patient inter-subjective relationship.

The periodic analysis of nursing personnel, required in healthcare institutions, social organizations, and programs with groups, must be supported by an opportune and valid information system founded on the nursing diagnosis⁴⁵ as basis for the calculation and implementation of taxonomies, which identifies the actions by each of the members of the nursing team according to the categories regulated in the country. The combination of nursing personnel based on advanced training, an adequate incentives plan, and a patient-centered nursing management model improves quality and increases the satisfaction of all the players involved in the caregiving processes. At the same time, it must be the foundation for the legislation of the nurse-patient coefficient.^46,47

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