A Delphi consensus study to determine the workload components and activity standards of dietitians in South Africa's central and tertiary public hospitals.

BACKGROUND: The global Human Resources for Health (HRH) strategy emphasizes the need to invest in HRH to meet population needs and improve the provision of quality health care services. In South Africa, dietitians are recognized as registered professionals who provide nutrition services. In this paper, we used 2 key steps (3 and 4) of the eight step World Health Organization (WHO) Workload Indicators of Staffing Need (WISN) methodology to determine the workload components and activity standards for dietitians at South African central and tertiary public hospitals. METHODS: All (9) provincial nutrition managers (phase one) and 21 out of a total 22 head dietitians at central and tertiary public hospitals (phase two) participated in an online survey. In phase one, the provincial managers provided the job descriptions (JDs) of dietitians in their provinces, and the JDs were analyzed to determine the baseline workload components. In phase two, dietitians participated in a multi-stage Delphi process to reach consensus on workload components and activity standards. Consensus was deemed to be agreement of 70% or more, while the median of participants' responses was used to obtain consensus on the activity standards. RESULTS: The JDs of dietitians were a useful baseline for the consensus exercise as there were no other suitable source documents. The response rate was 100% for all three rounds of the Delphi survey. Dietitians reached agreement (consensus ≥ 70%) on 92% of proposed workload components and activity standards. Following the removal of duplicate and certain administrative activities, a total of 15 health, 15 support and 15 additional service activities with aligned activity standards resulted from the consensus exercise. CONCLUSION: The Delphi technique was a suitable method for reaching agreement on workload components and activity standards for dietitians at South African central and tertiary public hospitals. The findings from this study can now be used to compile a standardized list of workload components and activity standards and ultimately to determine dietetic staffing needs for the central and tertiary public hospital level of care.

Use of the WISN method to assess the health workforce requirements for the high-volume clinical biochemical laboratories.

BACKGROUND: The clinical laboratory services, as an essential part of health care, require appropriate staff capacity to assure satisfaction and improve outcomes for both patients and clinical staff. This study aimed to apply the Workload Indicators of Staffing Need (WISN) method for estimating required laboratory staff requirements for the high-volume clinical biochemical laboratories. METHODS: In 2019, we applied the WISN method in all 13 laboratories within the Center for Medical Biochemistry of the University Clinical Centre of Serbia (CMB UCCS). A review of annual routinely collected statistics, laboratory processes observations, and structured interviews with lab staff helped identify their health service and additional activities and duration of these activities. The study outcomes were WISN-based staff requirements, WISN ratio and difference, and a recommendation on the new staffing standards for two priority laboratory workers (medical biochemists and medical laboratory technicians). RESULTS: Medical biochemists' and laboratory technicians' annual available working time in 2019 was 1508 and 1347 working hours, respectively, for the workload of 1,848,889 samples. In general, the staff has four health service, eight support, and 15 additional individual activities. Health service activities per sample can take from 1.2 to 12.6 min. Medical biochemists and medical laboratory technicians spend almost 70% and more than 80% of their available working time, undertaking health service activities. The WISN method revealed laboratory workforce shortages in the CMB (i.e. current 40 medical biochemists and 180 medical laboratory technicians as opposed to required 48 medical biochemists and 206 medical laboratory technicians). Workforce maldistribution regarding the laboratory workload contributes to a moderate-high workload pressure of medical biochemists in five and medical laboratory technicians in nine organizational units. CONCLUSIONS: The WISN method showed mainly a laboratory workforce shortages and workload pressure in the CMB UCCS. WISN is a simple, easy-to-use method that can help decision-makers and policymakers prioritize the recruitment and equitable allocation of laboratory workers, optimize their utilization, and develop normative guidelines in the field of clinical laboratory diagnostics. WISN estimates require periodic reviews.

Applying the workload indicators of staffing needs method in nursing health workforce planning: evidences from four hospitals in Vietnam.

BACKGROUND: Vietnam has encountered difficulties in ensuring an adequate and equitable distribution of health workforce. The traditional staffing norms stated in the Circular 08/TT-BYT issued in 2007 based solely on population or institutional size and do not adequately take into consideration the variations of need such as population density, mortality and morbidity patterns. To address this problem, more rigorous approaches are needed to determine the number of personnel in health facilities. One such approach is Workload Indicators of Staffing Need (WISN) developed by the World Health Organization (WHO), a facility-based workforce planning method that assists managers in defining the responsibilities of different workforce categories and improving the appropriateness and efficiency of a staff mix. METHODS: This study applied the WISN approach and was employed in 22 clinical departments at four hospitals in Vietnam between 2015 and 2018. 22 targeted group discussions involving nurses were conducted. Hospital personnel records have been retrieved. The data were analyzed according to WISN instructions. RESULTS: Of the 22 departments, there was a shortage of 1 to 2 nurses in 10 departments, with WISN ratios ranging between 0.88 and 0.95. Only 01 clinical colleges at Can Tho Hospital lacked 05 nurses, facing a high workload with a WISN ratio of 0.78. Administrative time represented 20-40% of the total work time of a nurse. In comparison, nurses at Can Tho Hospital spent time on administration from 24 onwards. 5-41.7% of their working time while nurses at Thanh Hoa Hospital spent 21-33%. CONCLUSIONS: The application of the WISN enabled health managers to analyze the workload of nurses, calculate staffing needs, and thus effectively contribute to the workforce planning process. It is expected that the results of this research will encourage the use of the WISN tool in other hospitals and health facilities across the health system. At provincial and national levels, this study provides important evidence to help policy makers develop guidelines for personnel norms for health facilities in the context of limited resources, while the existing regulation is no longer appropriate.

Estimating staffing requirements using workload indicators of staffing need at Braun District Hospital in Morobe Province, Papua New Guinea.

BACKGROUND: Papua New Guinea has seen some improvements in health indicators over the past years, but the pace of improvements is not as robust as expected. The Health Services Plan for Braun District Hospital redevelopment identified the importance of reflecting the hospital's role in the broader health system, particularly in upgrading the services to service a bigger population. In August 2020, the hospital was upgraded from a health centre-level 3 to a district hospital level 4. The need for assessing human resources for health requirements for this level of care was thus necessary. METHODS: The National Department of Health approved the use of the workload indicators of staffing need as the best tool to support in estimating staff requirements for the newly upgraded hospital. The focus was on clinical and non-clinical staff. Using already developed workload components and activity standards by the expert working groups for level 4 facilities, we visited the facility and collected data through interviews with the Lutheran Health Services representative, hospital management and staff. The technical task force reviewed daily registers, monthly reports and the data in the electronic national health information systems. The information collected was analysed using the workload indicators of staffing need software and interpreted. RESULTS: There were staffing shortages among the clinical staff like the medical officers, nursing officers, health extension officers, pharmacists, radiology staff unit and in the laboratory staff. Shortages among the non-clinical staff were recorded by the cashiers, security officers, drivers and boat skippers. The results showed that the facility lacks a medical laboratory technologist, pharmacists and a medical imaging technologist. The community health workers in this facility are utilized in all the areas where shortages are registered to multitask. CONCLUSION: The results from this WISN study provide evidence for basing staffing decisions on. The WISN results from Braun District Hospital show that the facility requires a total of 33 inpatient nurses against the existing 21 inpatient nurses thus giving a staff gap of - 12 and a WISN ratio of 0.67. It is thus recommended that the hospital management prioritizes recruitment of nurses or if no resources, reassign one of the outpatient nurses to alleviate the pressure among the inpatient nurses or the extra theatre nurses to offer some services in the inpatient wards. WISN results can help managers make decisions such as change of health facility status from a health centre to a district hospital.

How to make the best use of the workload indicators of staffing needs method in determining the proportion of time spent in each of the workload components and its implication in decision making: the experience of the Sultanate of Oman.

BACKGROUND: The Ministry of Health in the Sultanate of Oman decided to have better distribution of the health workforce among all health facilities through evidenced-based staffing norms. Four directorates worked together to develop the staffing norms through making use of the workload indicators of staffing needs (WISN) method. The aim of this study is to describe the process of applying the WISN method in Primary Health Care institutions and how to make the best use of method in determining the proportion of time spent in each of the workload components and its implication in decision making. METHODS: The WISN was applied for five priority categories, namely, doctors, nurses, pharmacists, laboratory technicians, and radiology technicians at PHC institutions. The WISN ratio has been translated into workload pressure as a percentage through applying the formula [workload pressure as % (in case of shortage) = (1 - WISN ratio) × 100%]. While the proportion of time spent in each of the workload components was calculated through making use of the category allowance standard, the individual allowance standard to determine the time spent in support and additional activities. The sum is subtracted from 100% to give the time spent in the health service activities. RESULTS: Determining the workload pressure as a percent and its interpretation is based on the fact that one cadre or as a group can bear up to 10% of extra workload. Thus, managers can undertake sensible short-term arrangements or decisions in redistributing the cadres among the health facilities on expectation of deploying more staff. DISCUSSION: Careful and detailed analysis of the proportion of time spent in each of the workload components will allow to have better understanding of the context and dynamics of work. CONCLUSION: Decision makers and planners can undertake rational short-term decisions in redistributing the cadres among the health facilities based on the workload pressure. In addition, they can as well as easily decide on the optimal proportions of time for each staff category, and hence choose what activities and tasks to be shifted or delegated to other staff category.

Assessing the staffing needs for primary health care centers in Cross River State, Nigeria: a workload indicators of staffing needs study.

BACKGROUND: A major human resources for health challenge for Nigeria is ensuring the availability and retention of adequate competent health workers in the right mix to provide health care particularly at primary health care facilities in remote and rural communities. This study applied the Workload Indicators of Staffing Need (WISN) method to determine the numbers of nurses, midwives, community health officers (CHOs), community health extension workers (CHEWs), and junior community health extension workers (JCHEWs) required to cope with health care service delivery at primary health care facilities in Cross River State; compare workloads of different cadres at selected health facilities, and identify facilities with highest workload pressure. METHODS: Cross River State in Nigeria has 18 local governments, 196 wards, and an estimated population of over three million people. We used the WISN method to estimate the numbers of nurses/midwives, CHOs/CHEWs, and JCHEWs required to cope with the workload in the 196 ward-level primary health care facilities. FINDINGS: Basic services provided by nurses/midwives, and CHOs/CHEWs were typical of the primary health care level. They are antenatal care, routine immunization, child welfare clinic, family planning, treatment of minor ailments, assisted and normal deliveries, postnatal care, emergencies, care of tuberculosis patients, and referrals. Findings show that available nurses/midwives for the 196 PHC facilities were 79, and the calculated requirement was 209, WISN ratio of 0.4 and difference of - 130; the existing number of CHOs/CHEWs was 808, the calculated requirement was 1,258, WISN ratio of 0.6, with a difference of - 450; and the number of existing JCHEWs was 258, the calculated requirement was 203, WISN ratio of 1.3 with a difference of 55. Cross River State had only 40% of required nurses and midwives; and 60% of CHOs/ CHEWs needed to provide health services in the ward-level PHC facilities. CONCLUSION: The findings from this study indicated marked shortages of needed health workforce particularly nurses and midwives at the primary level of care; and overlap in some of the tasks performed by nurses/midwives, CHO/CHEWs, and JCHEWs.

Multi-country case studies on planning RMNCH services using WISN methodology: Bangladesh, Ghana, Kenya, Sultanate of Oman and Papua New Guinea.

BACKGROUND: Globally, many countries are adopting evidence-based workforce planning that facilitates progress towards achieving sustainable development goals for reproductive, maternal newborn and child health. We reviewed case studies on workforce planning for reproductive maternal newborn child health services at primary care level facilities using workload indicators of staffing need in five countries. METHOD: Using available workload indicators for staffing need reports from Bangladesh, Ghana, Kenya, Sultanate of Oman and Papua New Guinea, we generated descriptive statistics to explore comparable workload components and activity standards, health service delivery models with an emphasis on the primary care levels and the specific health occupations offering interventions associated with reproductive maternal, newborn and child health services. RESULTS: The health services delivery models vary from one country to another. The results showed variability in the countries, in the workload components and activity standards of each regardless of facility level or occupational groups involved. All the countries have decentralized health services with emphasis on comprehensive primary care. Reproductive, maternal and new-born child health care services include antenatal, postnatal, immunization, family planning, baby wellness clinics, delivery and management of integrated minor childhood illnesses. Only Sultanate of Oman offers fertility services at primary care. Kenya has expanded interventions in the households and communities. CONCLUSION: Since the health care services models, health services delivery contexts and the health care worker teams vary from one country to another, the study therefore concludes that activity standards cannot be adopted or adapted from one country to another despite having similar workload components. Evidence based workforce planning must be context-specific, and therefore requires that each country develop its own workload components and activity standards aligned to their local contexts.

Determining staffing standards for primary care services using workload indicators of staffing needs in the Philippines.

BACKGROUND: Health services cannot be delivered without an adequate, competent health workforce. Evidence suggests a direct relationship between density of health workforce and health outcomes. The Philippines is faced with health workforce challenges including shortages, inequitable distribution and inadequate skill mix which hinder health service delivery. Evidence-based workforce planning is, therefore, critical to achieve universal health care. METHODS: The Philippines adopted the World Health Organization's workload indicators of staffing need methodology. Using a multistage sampling method, nine regions with poor health indicators in tuberculosis, family planning, and maternal child health were identified. Physicians, nurses, midwives, and medical technologists were prioritized in the study from 89 primary care health facilities (barangay health stations, rural health units, and city health offices). Data was collected using in-depth interviews, document reviews, observations, and field visits. The workload indicators of staffing need software were used for data analysis to determine staffing requirements and analyse workforce pressure. RESULTS: The study showed varied results in terms of staffing requirements and workload pressure across cadres and facility types. Some health facilities exhibited staff shortages and high workload pressure. Out of the 40 rural health units and city health offices, only three had the required physicians needed and 22 facilities had a shortage of physicians working under high workload pressure. Other facilities had excess staff compared to the calculated requirements. Nurses at the rural health units showed high workload pressure. Ten rural health units had no medical technologists. Midwives at barangay health stations exhibited extremely low workload pressures. CONCLUSION: The study identifies the need for the Philippine Health System, both through the Department of Health and the local governments to efficiently optimize the available health workers by revising the services offered at the primary health care facilities. The results provide evidence for staffing requirements at various levels of care based on workloads, scope of practice and time taken to undertake specific tasks at the barangay health stations, rural health units and city health offices to be integrated into the human resources for health management systems.

Estimating frontline health workforce for primary healthcare service delivery in Bauchi State, Nigeria.

BACKGROUND: In Nigeria, adoption of the primary healthcare approach led to the establishment of numerous primary healthcare facilities, and training of new cadres of community health officers (CHOs), community health extension workers (CHEWs) and junior community health extension workers (JCHEWs). These new groups complemented the work of nurses and midwives. METHODS: We conducted a workload indicators of staffing needs study in the 20 local governments of Bauchi State, from March 2016 to September 2018, in all 317 ward-level primary healthcare facilities. RESULTS: Findings show a total of 128 existing nurses/midwives, a calculated requirement of 402 and a shortage of 274 nurses/midwives. Existing CHOs/CHEWs were 735, a calculated requirement was 948 and a shortage of 213 CHOs/CHEWs. The JCHEWs were 477, a calculated requirement of 481, with a shortage of four JCHEWs. CONCLUSION: Results from this study highlight the unequal distribution of health workers; the abundance of some frontline workers in some communities and dire need of others. We emphasize the need to strengthen health workforce planning to deliver essential primary healthcare services, particularly in rural and remote communities with high levels of vulnerability to diseases.

Assessment of Staffing Needs for Frontline Health Workers in Selected Maternal and Child Health Services in 3 Countries of Sub-Saharan West Africa: Cote d'Ivoire, Burkina Faso, and Niger.

Sub-Saharan African countries health systems are generally faced with shortages and inequitable distribution of qualified health workers. The application of provider-population ratio or fixed staff establishments, not considering variation in workload, given contextual variations in service utilization rates, cannot adequately match the human resource needs of different health facilities. The Workload Indicators of Staffing Need (WISN) method uses workload to determine staffing needs in a given facility. The aim of this study was to assess the current workload and staffing needs of maternal and child health services in 12 primary healthcare facilities from Burkina Faso, Niger, and Cote d'Ivoire. We employed the WISN methodology, using document reviews, in-depth interviews with health providers, and observations, to obtain the data needed for estimating the required number of staff in a given facility. Then, we calculated both the WISN difference (current-required staff), and the WISN ratio (current staff/required staff). Using the WISN ratio, we assessed the work pressure that health workers experience. The results showed a shortage of health workers in most services in Cote d'Ivoire and Niger (WISN ratio <1), in contrast to Burkina Faso where services were either adequately staffed or overstaffed (WISN ratio ⩾1). The workload pressure was generally high or very high in Cote d'Ivoire, while in Niger, it was very high in maternity services but rather low in dispensary ones. There was also a geographic discrepancy in health workers staffing, rural areas services being more understaffed, with a higher workload pressure as compared to urban areas ones. This study results strengthens the body of knowledge on the shortage of health workforce in sub-Saharan Africa French speaking countries. Policies and strategies to increase students training capacities and the application of regular WISN studies for a better staff distribution are necessary to address the human resource needs of health facilities in these countries.

Determining staffing needs for improving primary health care service delivery in Kaduna State, Nigeria.

Background: The equitable distribution of a skilled health workforce is critical to health service delivery. Kaduna state has taken significant steps to revamp the primary health care system to ensure access to health care for its populace. However, these investments are yet to yield the desired outcomes due to health workforce shortages and the inequitable distribution of those available. Methods: A Workload Indicator for Staffing Need (WISN) study was conducted at Kaduna state's primary health care level. The study focused on estimating staffing requirements; Nurses/Midwives and Community Health Worker practitioners, Community Health Officers, Community Health Extension Workers, and Junior Community Health Extension Workers in all government-prioritised primary health care facilities. A total of ten focal primary health care facilities in Kaduna North Local Government Area (LGA) were included in the study. Results: Findings from the study revealed a shortage of Nurses/Midwives and Community Health Workers across the study facilities. For the Nurse/Midwife staffing category, nine of the ten PHCs have a WISN ratio < 1, indicating that the number of staff in the Nurse/Midwife category is insufficient to cope with the workload. In two of the ten primary health care facilities, there is an excess in the number of CHWs available; a WISN ratio > 1 was calculated. Conclusion: The WISN study highlights staffing needs in Kaduna State's government-prioritised primary health care facilities. This evidence establishes the basis for applying an evidence-based approach to determining staffing needs across the primary health care sector in the State to guide workforce planning strategies and future investments in the health sector. The World Health Organisation (WHO) WISN tool is useful for estimating staffing needs required to cope with workload pressures, particularly in a resource-constrained environment like Kaduna State.

Health Service Activity Standards and Standard Workloads for Primary Healthcare in Ghana: A Cross-Sectional Survey of Health Professionals.

The attainment of health system goals is largely hinged on the health workforce availability and performance; hence, health workforce planning is central to the health policy agenda. This study sought to estimate health service activity standards and standard workloads at the primary health care level in Ghana and explore any differences across health facility types. A nationally representative cross-sectional survey was conducted among 503 health professionals across eight health professions who provided estimates of health service activity standards in Ghana's Primary Health Care (PHC) settings. Outpatient consultation time was 16 min, translating into an annual standard workload of 6030 consultations per year for General Practitioners. Routine nursing care activities take an average of 40 min (95% CI: 38-42 min) for low acuity patients; and 135 min (95% CI: 127-144 min) for high dependency patients per inpatient day. Availability of tools/equipment correlated with reduced time on clinical procedure. Physician Assistants in health centres spend more time with patients than in district hospitals. Midwives spend 78 min more during vaginal delivery in health centres/polyclinics than in district/primary hospital settings. We identified 18.9% (12 out of 67) of health service activities performed across eight health professional groups to differ between health centres/polyclinics and district/primary hospitals settings. The workload in the health facilities was rated 78.2%, but as the workload increased, and without a commensurate increase in staffing, health professionals reduced the time spent on individual patient care, which could have consequences for the quality of care and patient safety. Availability of tools and equipment at PHC was rated 56.6%, which suggests the need to retool these health facilities. The estimated standard workloads lay a foundation for evidence-based planning for the optimal number of health professionals needed in Ghana's PHC system and the consequent adjustments necessary in both health professions education and the budgetary allocation for their employment. Finally, given similarity in results with Workload Indicators of Staffing Need (WISN) methodology used in Ghana, this study demonstrates that cross-sectional surveys can estimate health service activity standards that is suitable for health workforce planning just as the consensus-based estimates advocated in WISN.

Applying the workload indicators of staffing needs method in determining frontline health workforce staffing for primary level facilities in Rivers state Nigeria.

BACKGROUND: Nigeria faces health workforce challenges and poor population health indices resulting from disparities in health worker densities by geographical locations and levels of health care delivery. Nigeria is constantly reforming its health system with the primary aim of having the right number of health workers in the right place at the right time to meet the population's health needs. The majority of primary health facilities in the country are staffed using perceived needs. The Workload Indicators of Staffing Need (WISN) tool developed by the World Health Organization is used to determine staffing requirements for facilities. METHODS: The WISN tool was used in assessing the staffing requirements for nurses/midwives and community health practitioners in 26 primary health facilities in Port Harcourt City Local Government Area (PHALGA) and Obio Akpor Local Government Area (OBALGA). Documents were reviewed to obtain information on working conditions and staffing, and interviews conducted with key informants in 12 randomly selected facilities. We supported an expert working group that comprised of nurses/midwives and community health practitioners to identify workload components and activity standards and validate both. We also retrieved workload data from January 1-December 31, 2015 from the national district health information system. RESULTS: Findings showed varying degrees of shortages and inequitable distribution of health workers. Health facilities in PHALGA had a WISN ratio of 0.63 and a shortage of 31 nurses/midwives. There was also a shortage of 12 community health practitioners with a WISN ratio of 0.85. OBALGA had a shortage of 50 nurses/midwives and 24 community health practitioners; and WISN ratios of 0.60 and 0.79 for nurses/midwives and community health practitioners respectively. CONCLUSION: Our findings provide evidence for policies that will help Nigeria improve the population's access to quality health services and reduce inequities in distribution of the health workforce. Evidence-based health workforce planning and redistribution using WISN should be institutionalized. Review of scopes of practice of health workforce should be conducted periodically to ensure that the scope of practice matches the training received by the specific cadres and those skills are used to deliver quality services.