Study Design And Setting
This descriptive cross-sectional study was performed in three selected hospitals affiliated to Mashhad University of Medical Sciences in 2019. The study setting, Ghaem Hospital as a Centre Hospital, has 980 active beds that accommodates the obstetrician-gynecologist’s patients in the northeast of the country using the most advanced equipment and the most skilled medical staff. The Specialized Gynecology and Obstetrics Hospital Umm al-Banin had 136 active beds has been selected as a teaching hospital and Shariati Hospital with 155 active beds has been selected as a non-teaching hospital.
Study Population
The study population consisted of all full-time midwives working in the studied hospitals.
Data Collection Tools
In this study, the Workload Indicators of Staffing Need (WISN) method has been used for estimating the required workforce.
Data Collection
Holding experts working groups and observation methods were used to determine the components of workload (main, supportive and additional activities) as well as initial standard time. work study was used to verify the standard time of the main activities and was performed by three trained midwives. To eliminate the time factor, work study was performed three days a week (Saturday, Monday, and Tuesday) in three different shifts; it was repeated three times for each main activity. To determine the available working time, we have interviewed with aware experts such as midwifery experts, staffing personnel in the selected hospitals and HR planning expert in the MUMS, and studying the rules and regulations related to the midwifes attendance in the hospitals (i.e. rule of productivity promotion and administrative code of employment of non-academic Staff), as well as checking the personnel system information. management Information system and information registries were used to determine the actual workload.
To ensure the validity and reliability of the results, since experienced midwives are fully aware of the activities and duties of midwifery, it was decided to interview with the experienced midwives (with at least ten years of working experience) during the expert working groups meetings. In this case inclusion criteria were: 1) at least ten years of useful working experience in the maternity ward and 2) interesting in participating in the study. Based on the above criteria, the expert working group meetings consisted of 10 midwives (three midwives of selected hospitals, three midwives of Vice-chancellery of Treatment, three experienced midwives from each hospital selected by the head of the university midwifery department, and one experienced midwife who is a faculty member as a facilitator and a research fellow).
Before meetings, in order to introduce the process to the members a workshop had organized by the corresponding author and all questions and ambiguities were answered.
The WISN Method
The WHO’s WISN was used to compute the midwifes excesses or shortages at the hospitals. This method consists of 7 steps(6):
1) Estimating the available working time, which is the period of time that is available for a healthcare provider within a year. The available working time is calculated as follows:
AWT = [A-(B + C + D + E)] × F
Where A is the total number of working day in a year, B is the number of holidays per year, C is the number of annual paid leaves, D is the number of sick leaves, E is the other times that is taken off because of different reasons such as vacations and F is the total working hours per a normal day.
2) Identifying the workload components which include main, supportive and additional activities. These activities form an employee’s working hours per a day. The main activities are the activities performed by all the employees of the department and for which there are annual statistics. Supportive activities are performed by all employees but there are no specific statistics for them, and additional activities are performed by a certain number of employees and there are no annual statistics for them.
3) Defining activity standards, which is the whole time that a trained, skilled and motivated employee spend on performing an activity based on the professional standards. There are two types of activity standards: the service standard and the allowance standard.
Service standards are a set of occupational health care activities that are expressed in two ways. The first is the "time unit", which is the average time an employee needs to perform the activity. The second is the "work rate", which is the average number of activities performed over a specific period of time.
There are generally two allowance standards. The category allowance standard for supportive activities which is set by all members of a business group. The individual allowance standard is the amount of time that a certain number of members of a business group spend on additional activities.
4) Calculating workload standard, which represents the number of healthcare working units for primary care that each employee can perform annually. The standard workload is set for each workload component. To calculate the standard workload, it is assumed that a health workforce dedicates all of his annual working time to a workload component.
The formula for calculating the standard workload depends on whether the service standard is expressed as a unit of time or in terms of work rates. When the service standard is expressed as a unit of time, the standard workload is calculated as follow:
Standard workload = AWT in a year divided by unit time
When the service standard is expressed in terms of work rates, the standard workload is:
Standard workload = AWT in a year multiplied by rate of working
It is very important that the available work time, activity time unit and work rate are expressed in the same time units.
5) Calculating the allowance factors. There are two types of allowance standards for workload components that the annual statistics of them is not regularly available. Category allowance standards are designed for activities performed by all members of the target group and individual allowance standards designed for those activities performed by specific members of the target group. To calculate supportive and additional activities, allowance standards must be transformed into allowance factors. These factors are then used in the WISN method to calculate the total number of human resources required.
The category allowance factor is calculated as follows:
CAF = 1 / [1 – (Total CAS / 100)]
The individual allowance factor indicates how many full-time staff (or how much time a member of a particular occupational group) are needed to cover additional activities of a specific occupational groups. To calculate the individual allowance factor, the total annual allowance standard is divided by the available working time. At this point, it is important to make sure that both unit times are the same.
IAF = Total IAS/AWT
6) Determining the required staff based on the workload indicator. At this point, last year's facility service statistics that we want to calculate its required staff is needed. This data is required for any healthcare activity that has a standard workload defined. The number of human resources required for each of the three workload groups is calculated separately.
7) Analyzing the WISN results. At this point, first the difference between the number of available workforce and the number of required workforce is considered, then the ratio of these two values is examined.
Data analysis
Excel software was used to analyze the data collected from the WISN process and one-sample T-test and STATA software (version 19) were used to determine the relationship between the work study data and the activities standard.
According to the WISN method, the results were interpreted using two terms differences and ratios. The difference indicates the amount of surplus or shortage of midwifery staff and the ratio, which is calculated as the number of actual midwifery staff divided by the number of required midwifery staff, indicates the midwives’ working pressure.