The deployment of nurses in different patient care and administrative cadres was assessed. Nursing at AIIMS hospital is a centralized professional cadre in terms of recruitment and other policies. During the study period, there were 4449 nurses employed in the institution to care for the patients reporting to this hospital and its specialty centers. Among them, 841 nurses were of cadre grade I, and 3438 were of cadre grade II. In the present study, 478 administrative nurses from five major centers of the institute were studied: Main Hospital, the Cardio-Nuero Centre, Dr. RP Centre for Ophthalmic Sciences, JPNA Trauma Centre and Dr. BRA Institute of Rotary Cancer Centre. While the government staff norms, the Staff Inspection Unit (S.I.U.) recommends one staff nurse for every six beds, AIIMS had 1.7 nurses for every bed. However, in the case of higher level administrative nurses, AIIMS had a shortage of Nursing Superintendent and Chief Nursing Officer against the standard norms. In the present study, nearly 61% of the study population was an in-charge sister (Sister grade 1HR), 30% was an ANS, 6% was a DNS and NS was 1.5% of the total population.
Self-reporting by administrative nurses regarding their time distribution was evaluated by a self-administered questionnaire that was distributed among all cadres of administrative nurses working in different centers of AIIMS. The time allocation (mean value) by administrative nurses in each and every managerial task was calculated, and it was found that sister in-charges spent more time in i) store and inventory management, which requires at least 90 minutes per day, i.e., approximately 19% of daily nursing time. ii) Patient care supervision, which contributes to 17% of the total time (80 minutes in a day), and iii) teaching activities, which consume 14% of the daily time (69 minutes). In the case of Assistant Nursing Superintendent (ANS), the time distribution was as follows; the major time-consuming activities were i) general administration and staff management, both of which consume approximately 80 minutes per day, i.e., approximately 17% of the total duty hours in a day. Patient care activities consumed 70 minutes, i.e., 15% of the total time.
Work sampling or activity sampling studies have been performed to evaluate the real-time distribution of different administrative tasks, such as patient care supervision, patient-related activities, store management, general administration, and teaching. In self-reporting, the administrative nurses reported that they were spending more time in patient care, general administration and teaching. However, during observation/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.
Sister in-charges expended their major portion of time in store management (28%) and documentation (16%) but spent much less time on patient care supervision and teaching activities (4–8% of total available duty time in a day). ANS spent a significant portion of its time in staff management (23%) and documentation (26%) but much less time in patient care supervision and teaching activities (4–6%). DNS also follows 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 nonproductive activities and idling (12–20%)
The actual time distribution was different from the self-reported pattern of time allocation. It was apparent that the foremost portion of time in the case of Sister in-charge nurses was spent in store management and documentation, while in the case of ANS and DNS, it was spent in staff management and documentation. 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 nurse managers in South Africa (2015) stated 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 (2008) found that nurses spent 33% of their time in direct patient care (4), while another Australian study in two 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.
In the present study, 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 correlated with the observations of the current study. The time allocation for store and inventory management in this study was very high (25–30%) when compared to the results shown in the South African study (4%).
Limitations
An observational study of administrative nurses provides an overview of activities executed by administrative nurses, but it may not reflect every activity undertaken, nor does it identify the proportion of time spent undertaking more than one activity at a time. Occasionally, when a nurse was undertaking two or more tasks at once, it was difficult to distinguish the primary activity, and clarification was needed. Second, the activity sampling technique used was direct observation; however, it was always possible that those being observed changed their behavior 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.