An exploratory study on "nursing manpower'' requirement for

coronary care unit of PGIMER, Chandigarh

Deepi, Sunita Sharma, Yash Paul Sharma

Abstract : In the present era nurse patient ratio has become a concern to the providers of the
health services. As the era of advanced technology has led to increased complexity of the patient's
status, so more number of competent nurses are required to care for these patients. Thus calculating
the adequate nurse patient ratio is mandatory to provide comprehensive and safe health care to the
patients, especially the critical ill patients of the intensive units. An exploratory study was conducted
to determine the nursing manpower for Coronary Care Unit. Data was collected by recording time
and frequency of all the direct and indirect nursing activities. Direct nursing activities included were
independently performed, activities assisted to the doctor and other activities needed to meet the
health needs of different dependency level patients admitted in the month of August 2008. Indirect
activities included were unit related nursing activities. A statistical formula has applied to convert the
total calculated time for nursing activities into number of required nurses. Findings revealed that total
number of required nurses to care for the cardiac patients in ten bedded Coronary Care Unit of
PGIMER, Chandigarh required was 23. Recommendations of study is that study can be replicated in
Coronary Care Unit with more number of beds and in different settings like in surgical wards, in
dialysis unit etc.

Key words : Introduction

Nursing Manpower, Competencies, Today's health care system and nursing
Coronary Care Unit. workforce issues are facing limited resources
and increasing demands on their services1.
The demand for competent and responsible
nurses in giving care to patients has also been
increased.2 Nurses, the largest group of health
Correspondence at : care providers, are experiencing significant
Deepi
changes in their work according to the
C/o National Institute of Nursing Education changing health needs of the society. Their
PGIMER, Chandigarh workload has been increased and the number

Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010 14

of nurses per patient is diminished, which
puts the patient's safety at risk. 3 In 1999
California became the first state in union to
impose mandatory nurse patient ratio. It had
given 1: 2 ratio for intensive care patients.4
According to Indian Nursing Council every
hospital should have adequate number of staff
nurses to provide better health services to the
patients.5 Research has proved the advantages
of adequate nurse patient. Their findings
revealed that adequate nurse patient ratio
ensures safe and quality patient care 6 ,
provides clear standards for nursing7, saves
money, improves patient care and allocates
fairer nursing workloads. It also allows nurses
to regain confidence and control over their
working conditions.8
Many research findings showed that
poor nurse patient ratio leads to poor quality
of nursing care, staff stress, poor patient care
& misuse of the budget9. Poor ratio of nurse
manpower pose a potential threat to continuity
& safety of patients and increases nursing
workload.10 Statistics show that over the past
decade the number of nurses has been
increased by 23%, and in-patients has been
increased by 25% i.e. a few more nurses are
caring for many more patients. So to keep
number of nurses pace with number of
patients11 and to facilitate the best nursing care
to individual patient, we need to calculate the
adequate nurse manpower.12
Consumer classification systems (e.g.
age groups) in 1970's, the introduction of
nursing care related to diagnostic groups in
1980s & technology and research increased
markedly in 1990's, was a move towards
Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010
greater consumer involvement. It contributed
to the development of more sensitive patient's
classification system (PCS's) to calculate
nursing workload on a shift basis in a practical
way, which was essential to find adequate
nurse manpower.13 Thus in this the average
number of nursing hours per month can be
used to find out the required number of full
time equivalent employees. The total hours
for full time equivalent employee consist of
both productive and non productive work. The
productive nursing work includes direct
nursing care and non productive nursing
work includes break, holidays, and leaves. 14
Later on advanced technology database was
used to find required nursing manpower13
Most of the time nursing pattern is
determined by the predetermined standards,
which may include hours per patient per day
like in medical units, visits per month like in
home health agencies or minutes per case like
in operation theatre. But the patient census,
number of patient visits or cases per day does
not remain constant forever. So staffing ratio
should be adjusted according to the decreased
or increased number of patients. The
standard formula for calculating nursing care
hours per patient per day is equal to nursing
hours worked in 24 hours divided by patient
census.15
There are two methods to calculate
required nursing manpower fall under two
methods i.e. Top-down' methods and 'Bottom
up' methods. 'Top-down' methods relate
number of nurses to cost or measures of
activity such as beds, visits, attendances etc.
Trent formula regression analysis and 'Bottom-
15
up' methods are on the basis of patient's
dependency levels, professional judgment of
nurses. e.g. Aberdeen formula, Telford
system, Rhys Hearn method.16 staffing pattern
also depends on the objectives of the hospital,
services provided by it, type of patient served,
number of beds, amount of suppor tive
services available etc. Indian Nursing Council
has laid down some specific staffing patterns
in different wards of the hospital to ensure
efficient functioning of the hospital and patient
satisfaction. For example for intensive care unit
of the Government hospital the staffing ratio
should be 1:0.8.17
It has been observed that, there is lack
of specific standards regarding the "required
nurse manpower" in Coronary Care Unit of
PGIMER, Chandigarh and according to the
continuous increasing complexity in the health
needs of cardiac patients as well as the
technological advancement; nurses need to
be more competent in providing care.
Therefore the proposed study is undertaken
with the objective to find the nursing
manpower requirement in Coronary Care Unit
of PGIMER, Chandigarh.
Methodology
The exploratory study was conducted
in multispeciality hospital of North India i.e.
PGIMER, Chandigarh. It has bed capacity of
1600. Coronary Care Unit of PGIMER,
Chandigarh was chosen for study. It is
situated at the 3rd floor in C block of Nehru
Hospital of PGIMER, Chandigarh. It is ten
bedded unit. There is separate cabin for each
patient and total ten cabins are there in
Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010
Coronary Care Unit for 10 patients. There is
nursing station for nurses facing the cabins
of patients. The patients admitted are mostly
with medical conditions like myocardial
infarction, sick sinus syndrome, hypertension
etc. Pre and post procedural cardiac patients
from catheterization laboratory and Cardiac
OT after cardiac catheterization are also
admitted. Target population consisted of sum
total of all the nursing activities performed in
the Coronar y Care Unit, including the
frequency of all nursing activities and the
patients admitted in Coronary Care Unit in the
month of June to August 08. Sampling
technique was purposive. Sample size was
each nursing care activity according to its
frequency and patient according to
dependency level.
Af ter reviewing literature, the
researcher prepared patient dependency tool,
a list of nursing activities, a Performa to record
observation of time and frequency for nursing
activities and patient's census record sheet.
Patients' classification tool to categorize the
patients admitted in Coronary Care Unit
according to the dependency level with
respective scores i.e. low dependent patients
(1-8), partially dependent patient (9-16) and
fully dependent patient (17-24)). The reliability
of tool was checked by inter rated method
and calculated by spearman rank correlation.
The calculated rs was 0.91 which shows, tool
was reliable. The nursing care activities list
prepared after one week unit activities
observation by researcher (included list of all
the possible unit activities according to the
patients' needs under each category of the
16
patients). An obser vation Per forma of
nursing care activities prepared to record the
time taken for performing each nursing
activity three times by researcher (consisted
of nursing procedures and columns for
recording the time for three times for each
category of the patients). The patient's
census record sheet was prepared to
maintain the daily record of number of
patients in each category of dependency
level.
Five nursing experts were given tools
for validation. Modifications were made as
per expert's suggestions and guidance of
guide and co-guide. Pilot study was
undertaken in July 2008 and result showed
that it was feasible to conduct the study. Data
was collected in the month of August 2008.
Patients were classified daily based by using
patients' classification tool. This helped the
researcher to know the total number of fully
dependent, partial dependent, low dependent
patients in one day and at the end of 30 days
the census of total number of patients in each
category of dependency.
Nursing care activities divided into:
Direct nursing care activities (Independently
performed, Assistance to doctor and others)
and Indirect nursing care activities (Unit
related). For nursing care activities, time is
noted by performing the each nursing activity
thrice by researcher herself. Then the average
of three readings was taken. Frequency of
routine and unit activities noted by observing
the number of time activities performed in
each shift, five patients of each dependency
category were observed for frequency of
Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010
activities in each shift and then calculated for
the 24 hours.
Frequency related to non routine nursing
activities, the total number of times each
nursing activity performed in 30 days was
recorded and then average was taken to find
the frequency of each activity in one day.
Average time and average frequency
were calculated for each nursing activity for
each dependency category patients and unit
activities. Then average time and average
frequency were multiplied for each nursing
activity of ward and patients to calculate the
total time for all nursing activities for all three
categories patients and unit activities. A
statistical formula was applied to convert the
total calculated time for nursing activities into
number of required nurses i.e. Total nursing
manpower = man hours taken for performing
direct+ indirect nursing care activities +break
divided by 8hrs which was multiplied by 30%
leave reserve.
Results
Table: 1 shows that the most of the
patients in CCU during 30 days were either fully
dependent (114) or partially dependent (116)
and only 46 patients were of low dependency
level.
Table-1: Number of patients of each
dependency level in 30 days in CCU
Dependency level of patients n
Fully dependent 114
Partially dependent 116
Low dependent 46
17
 Figure 1 shows the average frequency of taking vital signs, recording
frequency of nursing Care activities for one intake output, monitoring blood glucose level,
fully dependent, one partially dependent and bedding, insertion of invasive lines, removal
one low dependent patient in 24 hours. All of invasive lines and frequency of taking
nursing Care activities on x-axis comprised samples was low. For low dependent patient
of sub activities like medication includes oral frequency of taking vital signs was higher
medication, intravenous bolus, and followed by frequency of recording intake
intravenous infusions, subcutaneous, output, administering medication, monitoring
topical. It is clear from the figure that for fully blood glucose level, bedding, removal of
dependent patient, frequency of administering invasive lines, insertion of invasive lines and
medication was maximum followed by frequency of taking samples was low.
frequency of recording intake output, taking
Figure 2 shows the average frequency
vital signs, removal of invasive lines,
of direct and indirect nursing care activities in
monitoring blood glucose level, insertion of
Coronary Care Unit of PGIMER, Chandigarh in
invasive lines, bedding and frequency of
24 hours. It is clear from the figure that direct
taking samples was minimum. For partially
care nursing activities were having more
dependent patient frequency of administering
frequency (93.84%) than the frequency of
medication was higher followed by
Frequency of Nursing Activities in 24 hrs

20
18
16
14
12
10
8
6
4
2
0
Medication Intake/output Vital Signs Removal of Blood Insertion of Bedding Sampling
Recording Invasive Glucose Invasive
lines monitoring lines

Fully Dependent patients Partially dependent patients Low Dependent Patients

Figure 1: Frequency of nursing care activities as per dependency

level of patient in 24 hours

Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010 18

 6.17%

93.84%

Direct nursing activities . Indirect nursing activities

Figure- 2: Frequency of direct and indirect nursing care activities in

Coronary Care Unit of PGIMER, Chandigarh in 24 hours.

indirect care nursing activities (6.17%). Thus
direct care activities were performed more
than the indirect nursing care activities.
Figure 3 shows the average time taken
in minutes to perform the nursing activities for
one fully dependent, partially dependent and
low dependent patient in 24 hours. It is clear
from the figure that for fully dependent patient,
time of administering medication was
maximum followed by time taken in removal
of invasive lines, taking vital signs, recording
intake output, inser tion of invasive lines,
bedding, monitoring blood glucose level and
time for taking samples was minimum. For
par tially dependent patient time of
administering medication was maximum
followed by time taken in taking vital signs,
recording intake output, monitoring blood
glucose level, bedding, insertion of invasive
lines, removal of invasive lines and time for
taking samples was minimum. For low
dependent patient time of taking vital signs
was maximum followed by time taken in
administering medication, recording intake
output, monitoring blood glucose level,
bedding, insertion of invasive lines, removal
of invasive lines and time for taking samples
was minimum.
Figure- 3: Average time taken to
per form nursing activities for one fully
dependent, par tially dependent and low
dependent patient in 24 hours.
Table- 2 depicts the Average time taken
to perform nursing care activities for number
of patient in each dependency level in 24
hrs. It was observed that on an average in a
day fully dependent patient required 22.48
nursing care hours where as par tially
dependent patient required 8.00 nursing care

Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010 19

 210
nursing activities in 24 hrs for each dependency
Total Average time (minutes) taken to perform

195
180
165
150
135
120
105
90
level

75
60
45
30
15
0
Medication

Intake/output
Invasive lines

Invasive lines

Bedding
Vital signs

monitoring

Sampling
Removal of

Recording

Insertion of

Glucose
Blood
Fully Dependent patient Partially dependent patient Low Dependent Patient

Figure- 3: Average time taken to perform nursing activities for one fully dependent, partially
dependent and low dependent patient in 24 hours.

hours and low dependency patient required by 24 % nursing man hours were needed to
only 3.55 nursing care hours. Hence two care for par tially dependent patient and the
third (66 %) nursing man hours were needed only10 % nursing man hours were required
to care for fully dependent patient followed for low dependent patients.
Table - 2 Time required to perform nursing care activities in 24 hours

Dependency level Total number of patients in Average time taken to Total time taken to
of patient each dependency level in perform nursing care perform nursing care
30 days in CCU activities for one patient activities for all the
in 24 hours patient in 24 hrs

Fully dependent 114 22.48 2562.72 (66%)

Partially dependent 116 8.00 928.00 (24%)
Low dependent 46 3.55 163.30 (10%)

Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010 20

 Table 3 shows the average time taken
in hours to per form the direct, indirect
nursing care activities and for break. It is clear
from the table that the maximum time 94%
Table 3: Nursing man hours required to perform the different nursing care activities in 24
hrs in 10 bedded CCU.
Nursing care Activities
Direct care
• Independently performed
• Assistance to doctor
• Others
Indirect care
Break
Total Time
Hence total nursing man hours
required for direct (assistance to doctor +
independently done), indirect nursing care
activities and for break in Coronary Care Unit
were144.2 man hours in 24hours. If one
nurse provides 8 hours care then the number
of nurses required to care in a day = 18 By
keeping 30% reserve (according to INC)5 the
number of nurses required = 23 nurses.
Discussion
The present study was conducted in
CCU of PGIMER Chandigarh by considering
the patient's dependency level for care on
nurses. Patients were classified into three
categories of dependency i.e. fully dependent
patients, par tially dependent and low
dependent patients. Meyer G and James C
calculated the nursing manpower on the
Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010
was taken to per form direct nursing care
activities and least time was taken by the break
time (0. 52%) in ten bedded Coronary Care
Unit of PGIMER Chandigarh
Average nursing man hours taken in
hours in 24 hrs in 10 bedded CCU
136.33 (94.54%)
• 121.74 (89.29%)
• 8.42 ( 6.17%)
• 6.17 ( 4.52%)
7.12 ( 4.94%)
0.75 ( 0.52%)
144.2
basis of dependency level of the patients i.e.
high dependency level, medium dependency
level and low dependency level and found a
successful method to calculate the number of
nurses for unit. 19 Donnelly P used four
dependency categories of patient according
to the time needed to spent on the nursing
care to calculate the required nurses for a
children's unit.22 A study by Brien G used the
intuitive method of patient dependency to
classify the patients for calculation of required
nurses for the unit.23 Present study was also
used same methodology by considering the
patient's dependency level for care on nurses.
Findings revealed that the fully
dependent patients required maximum time i.e.
66% of the total time followed by the patients
in category of partially dependent i.e. 24% of
21
the total time and least time was required for
the patients in category of low dependent
patients i.e. 10% of total time. Thus more
nursing time was required for fully dependent
patients. This study also showed that if there
are more dependent patients in the unit, the
more is the workload and thus keeping in
the mind the needs of the unit the number of
staff required also increases.18
The Indian Nursing Council (2004)
recommended "the nurse patient ratio in
intensive coronary care unit should be 1:1.5
Present study results showed the total
number of required nurses in ten bedded
Coronary Care Unit of PGIMER were 23 which
makes the nurse patient ratio 1: 2 for ten
patients by keeping the 8 nurses reserve for
offs & holidays. It is recommended that in
intensive coronary unit the minimum number
of nurses in day time should be one nurse
per two beds and one nurse per three beds
in night time.19
In one of the study Reid calculated
nursing hours per patient by dividing the
number of nursing hours available by the
number of patients to calculate the required
nursing manpower. In present study
researcher also calculated the nursing hours
needed for each dependency categor y
patient. 20
Fagerstrom used a PAONCIL
methodology to find out required staff level
in hospital which is based on nursing staff's
professional conception of when the state of
the ward is such that it is possible to provide
good care to the patients. She emphasized
the impor tance professional estimates in
Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010
assessing the need for staff. 21
In United States and other developed
countries use of database software is practiced
to calculate required number of nursing
manpower in various units of the hospital. This
helps the nursing supervisor to calculate the
daily requirement of number of nursing
personnel in a particular ward.
Thus study concluded that in Coronary
Care Unit of PGIMER, Chandigarh, the nurses
were performing more, direct nursing care
activities than indirect nursing care activities
and the fully dependent patient required more
nursing care hours. Most of the nursing time
was consumed in providing patient care as
compared to ward related activities. In this unit
one nurse is required to nurse two patients
during day & three patients during night time.
Recommendations of study are that
study can be replicated in Coronary Care Unit
with more number of beds and in different
settings like in surgical wards, in dialysis unit
etc.
References
1. Unruh L. Employement conditions at the
bedside. A cause of and solution to the RN
shortage. Journal of Nursing Administration
2005;35(1):11-13.
2. Tzeng H. Nurse's self-assessment of their
nursing competencies, Job demands and job
performance in the Taiwan hospital system.
International Journal of Nursing Studies 2004;
41:487-496.
3. Akkadechanunt, Thitinut S, The
relationship between nurse staffing and patient
outcomes. Journal of Nursing Administration
2008;35(9):478.
22
4. Lang T, Margret H, Olson V, Romano P,
Richard K. Nurse-patient ratios: A systematic
review on the effects of nurse staffing on patient,
nurse employee, and hospital outcomes. Journal
of nursing Administration 2004;34(7/8):326
5. Indian Nursing Council. Guide for school
of nursing in India 2002. Indian Nursing Council
New Delhi 2002.
6. Khan Y. Factors affecting quality
assurance in nursing. Nursing Journal of
India1999;Lxxxx.8: 173.s
7. Spetz J. Public policy & nurse staffing:
what approach is best? Journal of Nursing
Administration 2005;35(1):14-16.
8. Welton M, Unruh L, Halloran E. Nurse
Staffing, nursing Intensity, staff mix, and direct
nursing care costs across Massachusetts
Hospitals. Journal Of Nursing Administration
2006;(36)9:416-424.
9. Welton M, Unruh L, Halloran E. Nurse
staffing, nursing intensity, staff mix, and direct
nursing care costs across Massachusetts
hospitals. Journal of Nursing Administration
2006;(36)9:416-424.
10. Dunton N, Gajewski B, Taunton R, Moore
J. Nurse staffing and patient falls on acute care
hospital units. Nursing Outlook 2004;52:53-59.
11. Tiffany B, Nutall P, Armstrong M, Clark J,
Boylan A. Lies, damn lies and nursing statistics.
Nursing Times 1984;(22):32.
12. Hogston R. Evaluating quality nursing
care through peer review and reflection; the
findings of a qualitative study. International
Journal of Nursing Study 1995;(32)2 :162-172.
Nursing and Midwifery Research Journal, Vol-6, No. 1, January 2010
13. O'Brien G. The intuitive method of patient
dependency, occasional paper. Nursing Times
1996; 8(82):57-61.
14. Ellis J. Rider. Hartley L. Celic. Managing
and coordinating nursing care. 4th edition.
Lippincott Williams and Wilkins publication
2005;78-79.
15. Marquis L, Huston J. leadership roles and
management in nursing theory and practice. 5th
edition, Lippincott Williams and Wilkins
Publications 2006;222-223.
16. Rushworth, Tacket, Bottoms Up? News
focus. Nursing Times 1984: 16-18.
17. Kumari S, Singh C. Staffing pattern in the
nursing department of selected hospitals.
Nursing Times. July 2008; 9 (4): 41-43, 63.
18. Meyer G, James C. Matching staff to
patient dependency. Nursing Times 1990; 86(40):
40-42.
19. Scott C. Setting safe nurse staffing levels,
an exploration of the issue. A report by research
fellow. Royal College of Nursing 2003.
20. Eid G, Melaugh M. Nurse hours per
patient : a method for monitoring and explaning
staffing levels. International Journal of Nursing
Studies 1987; 24:1-14.
21. Fagerstrom L, Rainio A. Professional
adjustment of optimal nursing care intensity level:
a new method of assessing resources for nursing
care. Journal of clinical nursing 1999; 8:369-379.
22. Donnelly P. Staffing a children's unit.
Nursing Times September 1986; 35-36.
23. O'Brien G. The intuitive method of patient
dependency, occasional paper. Nursing Times
1996; 8(82):57-61.
23