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STAFF MIX AND PATIENT OUTCOME IN STATE AND FEDERAL TEACHING HOSPITALS
Background to the study
Health systems in both developed and developing countries are under pressure to improve service delivery in an ever increasing population with limited or reduced resources [Namgada 2008]. This is due to increased burden of diseases, desire to receive best quality care, advanced technology in health care, awareness of health rights, improved access to diverse health service. In health care systems, the following are needed for the provision of health services to patients/clients, efficient health polices, sufficient trained health personnel, appropriate equipments, finance [Olade, 2005]. The primary goal of all health systems is to render quality care; however, certain factors seem to hinder the efforts towards achieving this goal maximally. The global shortages of health professionals, as well as the caliber of health providers, for example, have been reported to affect the quality and outcome of care (Olade, 2005).
World Health Organization (2009) report shows that in some developed countries, the ratio of staff to the population is 1000 to 100,000. In developing countries, it is 100 to 100,000. A report on health workforce country profile for Nigeria revealed that there were 52,408 doctors on the medical register as at December 2010, and 128,918 registered nurses [Labran, Mafe, Onajole & Lambo, 2011]. According to World Health Organization (2009) , Nigeria has a population of about 160 million; based on the data above the ratio of health professionals to the populace is expected to be; doctors 1:3052 and nurses1:1241.
Ozcan and Horby  stated that in Africa like in several parts of the world, the number of trained health personnel has been inadequate, hence the need to use scarce resources adequately. According to Okoronkwo (2005), in most Nigerian hospitals today, there is acute shortage of health personnel; the available staff cannot meet the needs of the patients efficiently because of excessive workload. This indicates that though the demand for healthcare is increasing, the hospitals are not able to provide enough manpower to meet those health needs. The workload on existing staff therefore increases and quality of care suffers.
Aside from the shortage of health care providers, appropriate staff mix in health service delivery is another glaring problem facing most health systems in many developing countries (McGillis, 2005).Staff mix refers to the combination of different categories of health personnel/ workers [within same or across different professional discipline[s]] that are employed for the provision of healthcare to patients in healthcare facilities. In healthcare institutions, staff mix contributes to overall outcome of care [McGillis, 2005]. The standard practice as it concerns human resource management is to provide the right number of staff [health personnel], with the right knowledge, skills and attitude, performing the right tasks in the right place, at the right time to achieve the predetermined health targets [Mark and Staton, 2003: International Council of Nurses (ICN), 2006].
The ratio of staff mix to the patient is the factor on which the process of care in a given unit or facility depends This staff mix ratio could be in terms of proportion of available staff to the patient population, years of working experience, professional qualification, number of year staff worked in a unit, cadre of staff[junior/senior]. According to Needleman (2005), the standard staff mix to patient ratio depending on unit size is 1:4-6 patients. In more intensive care units, it is 1:2-3 patients. The Nursing and Midwifery Council of Nigeria (N&MCN, 2005) stipulates that the staff/patient ratio in Clinical practice for different cadres of staff and depending on the unit and type of patient managed, is 1:4-5,( for general wards) and 1:1-3 (for intensive care units).
Assigning the right number of staff to a unit ensures that patients are properly cared for and discharged the right time (Cheryl and Clark, 2007) Aiken states that higher staff mix to patient ensure that appropriate direct care is given to patients. Staff is also able to give in-depth assessment and surveillance of clinical changes on an ongoing basis. Staff has more time to monitor changes in patient’s condition and timely intervention given for identified problems. All these are expected to impact on the outcome of care.
According to Quan  patient’s outcome is an observable change which results from patient’s exposure to interventions or care environment. It is the result or consequence of an event, a disease, a drug or a treatment. The outcome for medical and surgical cases include; change in patient’s functional status positively or negatively within the period of hospitalization, occurrence of adverse events like death, infection, medical errors, pressure ulcer, urinary tract infection etc.
Studies have shown that there is a relationship between staff mix and outcome of care. Strasser (2005) reports that positive outcome is associated with well trained workers, staff experience and training, greater intensity of care, greater therapy, general staffing levels as well as team work, team order and organization. On the other hand, negative outcome is associated with poor recruitment and retention, delayed care or absent workers, lack of facilities and supplies, poor administrative management, severity of illness [chronic or acute] and co morbidity factors (Anderson, Weiner & Khatusky, 2006).
Bolton (2001) and Needleman (2005) also observed that there is a significant relationship between staff ratio and outcome of care. They stressed that assigning appropriate number of staff to patients result in reduced incidence of adverse events like the development of pneumonia, pressure ulcer, failure to rescue, deep venous thrombosis, mortality, urinary tract infection and shock. Others include reduced hospital stay, medical errors, hospital cost and surgical wound breakdown/infection. Suzanne and Smeltzer  further reported that outcome of care could be attributed to other factors such as risks inherent with specific surgery overall health status of the patient, concomitant conditions like diabetes mellitus which could affect wound healing, chronic smoking, unnecessary invasive procedure, post operative pain management, nutritional status, immune status of patient etc.
Most of these studies were conducted in developed countries. There is paucity of data on staff mix and patient outcome in Nigeria in particular and Africa in general. This study examined the staff mix and patient outcome in state and federal teaching hospitals in Enugu State.
Statement of the problem
Enugu State has two teaching hospitals, Enugu State University Teaching Hospital, Parklane Enugu (ESUTH) and University of Nigeria teaching hospital Ituku/ Ozalla (UNTH). They provide training, research and health services. Patients/clients within and outside the State patronizes these health facilities.
Since the relocation of UNTH in 2007 to its permanent site, which is about 21kilometers from Enugu urban, there have been increased number patients attending the hospitals for special and general care as shown in the 2008 medical records report. Before 2007, annual patient coverage in UNTH was 90,000. Subsequent years after the relocation to Ituku/Ozalla from 2008-2010, showed total increase of 200,000 cases in the health facility. The increase in patient patronage over the years invariably increased the overall workload in the hospital.
In ESUT, the gradual upgrading of Park-lane general hospital Enugu to specialist hospital in 2006 and subsequently to teaching hospital has also resulted in influx of patients. Before 2006, ESUT medical record showed that the patient number patronizing the health facility annually was 50,000. In 2009, the medical record report showed an annual average of 75,000 patients in special clinics and units.
Administrative personnel record  report reflects employment of 200 nurses and 150 doctors in UNTH from 2007 to 2009. ESUTH administrative personnel record  report shows employment of 104 nurses and 109 doctors from 2007 to 2010. However, these numbers of personnel are inadequate to meet the health needs of the increasing number of patients in these hospitals as evidence by the studies carried out by Okafor (2005), Ezeugwu (2007], Okaro, Ohagwu and Njoku  on adverse events in Nigerian hospitals. Their studies showed incidence of adverse events in patients managed in these health facilities. Such adverse events include; surgical wound infection, pressure ulcer, nossocomial infection and high mortality rate.
Anecdotal data revealed that in health institutions, high workload on available staff contributes to inability to meet up with some care obligation which ultimately could contribute to negative patient outcome.
Specifically, this study seeks to provide answers to these research questions: what is the number of available health providers providing care to patients in these health facilities? How many staff is deployed to surgical units based on professional qualification/area of specialization? Are expected workloads considered prior to staff deployment to units? Are patient outcomes specifically dependent on staff mix?
In seeking answers to these questions, the researcher examined the staff mix and patient outcome in state and federal teaching hospitals in Enugu State, Nigeria
Purpose of the study
This study examined the staff mix and patient outcome in state and federal teaching hospitals in Enugu State, Nigeria
Specifically, the objectives were to:
- Determine the staff mix of the health providers in surgical units of state and
federal teaching hospitals in Enugu State.
- Determine the patient outcome in surgical units of state and federal teaching
hospitals in Enugu State.
- Determine the difference in staff mix and outcome of care in surgical units
between state and federal teaching hospitals in Enugu State.
- Determine the association between staff mix and outcome of care in surgical
units of state teaching hospitals in Enugu State.
- Determine the association between staff mix and outcome of care in federal
teaching hospitals in Enugu state.
- Determine the difference in the association of staff mix to outcome of care in
surgical units between state and federal teaching hospitals of Enugu state.
- There is no significant difference in staff mix of health providers in surgical units of state and federal teaching hospitals in Enugu State.
- There is no significant difference in patient outcome in surgical units between state and federal teaching hospitals in Enugu State.
- There is no significant association between staff mix and outcome of care in surgical units of state teaching hospitals in Enugu state.
- There is no significant association between staff mix and outcome of care in surgical units of federal teaching hospitals in Enugu state.
- There is no significant difference in the association of the staff mix of health providers to outcome of care between surgical units of state and federal teaching hospitals in Enugu state.
Significance of the study
Findings of the study will help to determine the overall staff mix in the surgical unit of the state and federal teaching hospitals in Enugu State. This in turn when communicated to the administration and policy makers will help in sensitizing them towards ensuring or establishing the adequacy or otherwise of the staff in the hospitals. The findings will also be important to health care planners who are entrusted with the responsibility for determining the staff needs of their unit at any time. When deploying staff to specific unit, appropriate staff mix will be considered for more proficient care to be given to patient depending on the outcome of this study.
Findings from this study will also reveal the patient outcome in surgical units of these health facilities. Such data will be used to evaluate lapses in care outcome and subsequent improvement in patient care, thereby reducing the incidence of untoward occurrences and ensure proper patient care in future. Finding will add to the existing body of knowledge and may also provoke further studies in related areas.
Scope of the study
This study was delimited to staff mix [of doctors and nurses] and patient outcome in surgical units of state and federal teaching hospitals in Enugu State. Patients admitted from 1st October to 30th November 2011 for general, obstetric and gynecological surgery and discharged within the period of the study [1st October to 30th November 2011] were enlisted for the study. Patient’s outcome were delimited to length of hospital stay, development of pressure ulcer, surgical wound infection, mortality rate, urinary tract infection, and patients with no complications.
Operational definition of terms.
- Staff mix: refers to the distribution of nurses and doctors by number, professional qualification, years of working experience, number of years in surgical unit and cadre[senior/junior] in surgical unit of state and federal teaching hospitals in Enugu state.
- Staff mix index: Proportion of registered nurses/midwives or those with other specialties to patient [1:5], proportion of doctors with various specialties to patient in a team [1:5] and proportion of Junior to senior staff in a shift or call.
- Patient’s outcome: refers to length of hospital stay, mortality, development of complications like pressure ulcer, surgical wound breakdown/ infection, urinary tract infections during admission and patients who had no complications after surgery.
- Patient outcome index: Proportion of surgical patients who developed complications, stayed longer in hospital or had no complication.
- Surgical patient: Refers to adult male and female patients [aged 18 and above] who underwent major surgery, have stayed more than 5 days on admission and discharged within the period of study [1st October to 30th November].
- Length of hospital stay: Refers to number of days in hospital from day of admission till discharge.