Utilization of time by administrative nurses in a large tertiary care teaching hospital

INTRODUCTION

Nurses and doctors form the backbone of the healthcare system. They constitute two-thirds of the health workforce in India. Their central role in healthcare delivery in terms of promotion, prevention, treatment, care, and rehabilitation is important.¹ Nursing can be described as an art and a science; a heart and a mind. At its heart lies respect for human dignity and intuition for patients’ needs. They are valued for specialized knowledge, care, and skill in improving the health status of the public and ensuring safe, effective, and quality healthcare to the sick and needy.

Nursing administration is a broad term that encompasses nursing professionals who have knowledge of leadership practices. Nursing administration or leadership may refer to many management, supervisory, and executive titles, including nurse manager (NM), nurse administrator, nursing supervisor (NS), director of nursing or chief nursing officer (CNO).

Nurses perform various activities grouped into basic nursing, technical care, ward administration, and other categories.² NMs play a key role in the coordination of patient care and ensuring its quality, in addition to ward management activities such as stock maintenance, communication with clinicians, and human resource management at the ward level. Considering all factors, it is imperative to evaluate the utilization of administrative nurses in any hospital. This can also be used to plan the staffing of nurses to provide effective and efficient nursing care to the community.

METHODS

We did a prospective observational study at the All India Institute of Medical Sciences, New Delhi for 2 years from 2017 to 2019. Data regarding the organization structure and job deployment of nurses were obtained from the CNO and the NS and deputy nursing superintendents (DNS) offices of various centres. Interviews with nurses and reviews of records such as office orders, duty registers, assignment registers, and other documents were done to enumerate the managerial role. The estimation of time utilization by administrative nurses in different tasks was done in two phases. In the first phase, a questionnaire was developed by referring to the current job description of nurses, the hospital manual for government hospitals developed by the Ministry of Health and Family Welfare, and considering inputs from different cadres of administrative nurses.

There were 478 administrative nurses in the hospital, and the sample size was calculated from this group using a sample size table. According to the reference table, the recommended sample size for a population of 500, with a 95% confidence interval and a 5% margin of error, corresponded to 217, and the same number was distributed across different centres with respect to the sample size proportion. A total of 246 responses were received from administrative nurses.

In the pilot study, we found found the prevalence of administrative activity was approximately 25%–30%; considering a 95% CI and an absolute error of 5%, the minimum sample size required for activity sampling was 300 hours. As per a literature review of similar studies, 300 hours of observations was the standard duration for activity sampling. This duration was helpful for adequate representation of all tasks and was proportionally distributed among various cadres of administrative nurses across the hospital. As per the literature, observation of nurses by using activity sampling was made; observations were made at multiple intervals at a stretch of 2 hours in a single setting. At a time, we observed 2–3 administrative nurses who were positioned nearby, and multiple tasks were recorded in a coded manner. The same activities were recorded as repeated activity after an interval of 10 minutes. A total of 316 hours of observation against the required sample size of 300 hours was made. Overall, 15 344 activities of administrative nurses were recorded during activity sampling.

Ethical approval for this study was obtained from the institute’s ethics committee (IECPG/319/6/2017). All participants provided informed consent for conducting the study and publication of the findings while ensuring their anonymity and confidentiality.

RESULTS

Out of 4449 nurses working in AIIMS hospital, the majority were junior nurses (nursing officers; NO), who were approximately 82.7% in strength, and the next highest cadre was senior nursing officer (SNO; 4.61%); these two categories looked after bedside patient care. A total of 7.6% of the nursing population were designated as ‘in-charge’, and they mainly performed store management along with patient care supervision, documentation, and management of subordinate staff. Assistant nursing superintendents (ANS) were 4.2% of the total strength, and they were the heads of patient care units, such as wards or ICUs. CNOs, NS, and DNS contributed 1% of the total nursing manpower, and they were responsible for human resource management, policy administration, and research.

Table 1 shows the division of nurses, both clinical and managerial, into various categories, such as bedside nurses, administrative nurses, and clinic-managerial nurses. Most were bedside nurses (almost 85%), and the rest were in administrative positions.

It was found that for every 13 bedside nurses, 1 ‘in-charge’ nurse was deployed. There was 1 ‘in-charge’ nurse for every 8 beds, 1 ANS for every 14 beds and 1 DNS for every 82 beds. The proportionate strength of various categories of nurses, both administrative and clinical, against bed strength in the hospital is given in Table 2.

DISCUSSION

Nursing at AIIMS hospital is a centralized professional cadre in terms of recruitment and other policies. We studied 478 administrative nurses from 5 major centres of the institute. While the government staffing norms recommend 1 staff nurse (nursing officer) for every 6 beds, AIIMS had 1.7 nurses for every bed. However, in the case of higher-level administrative nurses, AIIMS had a shortage of NS and CNO against the standard norms. In our study, nearly 61% of the study population was an ‘in-charge’ nurse, 30% were ANS, 6% were DNS, and NS was 1.5% of the total population.

Administrative nurses reported that they were spending more time in patient care, general administration, and teaching. However, during observation and activity sampling, it was found that the actual time spent in patient care and teaching was much less than that spent in staff management and documentation.

In-charge nurses spent a major portion of time in store management (28%) and documentation (16%), but much less time on patient care supervision and teaching activities (4%–8% of total available duty time in a day). ANS spent a major portion of their time in staff management (23%) and documentation (26%), but much less time in patient care supervision and teaching activities (4%–6%). DNS also followed the same pattern as ANS, i.e. 25%–30% of time for staff management and documentation, but negligible time in patient care supervision and academic or teaching activities. The managerial nurses spent a high amount of time on non-productive activities (12%–20%).

The actual time distribution was different from the self-reported pattern of time allocation. In every observation, the time for direct or indirect patient care, teaching, and research activities was very low. A time and motion study conducted with NMs in South Africa showed that nursing unit managers spent approximately 26% of their time on direct patient care, 16% on hospital administration, 14% on patient management, 4% on teaching, 13.4% on support and communication, 4% on managing stock and equipment, 11.5% on staff management, and 12% on miscellaneous activities.³

A comparable study in a medical ward in Australia found that nurses spent 33% of their time in direct patient care,⁴ while another Australian study in 2 wards of a teaching hospital found that nurses spent 37% of their time with patients.⁵ Similarly, a Belgian study found that nurses spent 32.2% of their time on direct patient care,⁶ while a similar proportion of 32.8% was found in a Montreal hospital study among surgical nurses.

We found that administrative nurses were not doing any direct patient care, as observed in the studies conducted outside, but the time distribution in staff management and teaching of the South African study was similar to the observations of our study. The time allocation for store and inventory management in our study was very high (25%–30%) when compared to the results of the South African study (4%).

This observational study of administrative nurses provides an overview of the activities executed by administrative nurses, but it may not reflect every activity undertaken, nor does it identify the time spent on more than one activity simultaneously. Occasionally, when a nurse was undertaking two or more tasks simultaneously, it was difficult to distinguish the primary activity, and clarification was required. Second, the activity sampling technique used was direct observation; however, it is possible that those being observed changed their behaviour because of the study. The same nurses were observed multiple times per observation period and were also observed multiple times during data collection. Classic inferential statistics could not be used to rule out chance as a reason for the observed differences.