2020, the International Year of the Nurse and the Midwife, elevated the worldwide recognition of the work performed by nurses and their demands for better working conditions, education, and professional development [12]. In line with this recognition is the fact that nursing plays a critical role in the successful implementation of PHC, which is recognized as the basis of an effective and responsive health system—key to universal coverage [13]. However, the results of this study show how RNs and LPNs working in PHC have been suffering from increasing workload pressure, and the need for better planning and implementation of staffing policies for PHC.
The study identified PCUs with high work pressure and a shortage of nursing professionals needed to meet the actual demand seen during the 3 years of analysis. This is a challenge that PHC must resolve in order to guarantee access and to be able to meet the population’s health needs [14]. The shortage of professionals and its impact should be reported and discussed with PHC teams, so that they can manage high work pressure in the best way possible, balancing access and to promote continuity of care [15]. This scenario of imbalance is known to impact access, generating longer waiting times, which in turn could result in higher mortality rates and other adverse outcomes [16].
In this study, we found no significant association between the number of registered patients and workload pressure. This could be explained not only by the size of PHC teams, but also by additional aspects, such as how frequently patients demand care from PCUs and their teams, which impacts the annual workload and consequently the required number of professionals based on the WISN method. Perhaps more elements, like detailed patient characteristics, are necessary to understand the demand for PHC.
The size of patient panels and the number of PHC teams per service also play an important role, and have been discussed in the literature, including its association with user satisfaction [17]. Ideally, patient panel size should be adjusted to balance the number of professionals on a team and the expected workload. Family physicians have been questioned about the number of patients that could be under their care [15] and the “ideal” patient panel size per physician [18] and advanced methods like machine-learning algorithms have even been tested to answer this question [19]. However, there is little evidence about the “ideal” patient panel size for nursing professionals working as part of a PHC team, such as those established in Brazil and there are investigation gaps about how nursing staff imbalance impact the quality of care in PHC scenario.
Additionally, the distribution of activities among the different professionals that compose the family health team, in spite of presenting common competencies described in the PNAB [6], shows that the actions with the largest impact on the nursing team’s workload, such as vaccination and consultations/appointments, are exclusive to the nurses. However, indirect care activities, such as documentation and administrative meetings related to organizing the work process, are common among team members [20], and can be distributed in such a way that the nurse can dedicate the larger part of their workload to caring for patients.
A study conducted in 2011 [21] that applied the WISN method at a single PCU in São Paulo, Brazil, found that the workload and the number of professionals available was balanced, with a ratio of 0.8 for RNs and 1.0 for LPNs. This study found very different results, and is probably more representative of the real situation, since it included 13 PCUs evaluated for a period of 3 years.
Another study that evaluated workloads of nursing professionals working in PHC teams in Brazil found an association between excessive demand, problems in the physical structure of the units, and gaps in the healthcare network to increased workloads among these professionals, which affected the quality of care and impacted the effectiveness of PHC [22].
The required number of professionals is influenced by a number of variables, including available working time, absences, leave, an adequate information system, the epidemiological background, and the structure of organizational processes at PCUs. These factors were recently put to the test in Brazil during the outbreaks of measles and yellow fever in 2018 and 2019. Nursing professionals working on PHC teams had to organize and implement vaccination strategies in an expedited manner in addition to their routine work [23, 24].
The study presents an increase in work pressure among LPNs between 2017 and 2019, especially in 2019, likely because LPNs started to allocate more of their time to organizing vaccination campaigns and performing household visits to vaccinate, activities that are not accounted for in their productivity evaluation. Moreover, the vaccination calendar has been expanded, and currently includes 19 vaccines for more than 20 diseases [25], with the introduction of new vaccines against the SARS-CoV-2 expected to put even more pressure on PCUs to deliver them in a timely fashion.
As described previously, in Brazil LPNs play a major part in the national immunization program and in preventive actions [26]. The number of nursing professionals can impact the health system’s response to public emergencies, such as vaccination campaigns for both scheduled and pandemic situations, like with COVID-19. This reinforces the importance of applying the WISN method to the planning and implementation of public policies.
Thus, to understand the current deficit of LPNs it would be relevant to plan staffing needs in the face of a probable high demand for vaccination campaigns, and for future analysis that could take into account seasonal variations and target coverage rates that can be used to plan, improve allocation, and when necessary, increase the number of professionals during strategic periods. Historical patterns that characterize an increase in demand or a reduction in AWT can be analyzed to determine strategic periods. This is why it is important for the WISN method to be applied dynamically and relevantly with periods of rapid and assertive actions throughout the year.
As in other parts of the world, an aging population and the shift of the disease burden from infectious to noncommunicable diseases are important factors impacting the demand for PHC services and the volume of RNs’ scheduled and unscheduled appointments in Brazil [27]. An observational study conducted in Brazil found that RNs working as part of a PHC team spent 11.6% of their working time with appointments [11], which matches the high volume found for the PCUs included in this study.
In addition, the reduction in activities over the years, probably associated with time spent on unscheduled appointments, is a notable finding. This could be explained by the implementation of advanced access scheduling at the PCUs included in the study, which began [14] in 2017, with RNs’ unscheduled appointments accounting for up to 70% of their agenda.
The evaluation of staffing needs could also work as an ongoing education and quality improvement strategy, since annual analyses provide an opportunity to reflect on the practice and organization of nursing professionals. A study that evaluated the implementation of the WISN method to two PHC teams in the state of São Paulo found that it promoted a change in the team’s attitude towards the correct recording of data in information systems, and prompted a reorganization of the territory covered by each team [28].
Thus, staff planning with the WISN method allows for an important reflection, considering that not all of the problems at the PCUs are related to the amount of professionals, just as the amount of professionals is not a solution to all of the problems. Analyzing the data that make up the calculation makes it possible to recognize the obstacles in organizing work, distributing activities among team members, the amount of activities performed annually, the amount of absences for health leave and/or other types of leave that historically contribute to understanding the pressure on the team’s workload due to dynamic patient demand.
In this way, staff planning at PHCs is a strategic process, balancing demand and supply through the analysis of the availability staff and their work process, and through a systematic planning method that aims for continual improvement in the process of ongoing education and implementation of public policy.
Studies using the WISN contribute prominently to the discussion on staff planning at PHCs as a tool for public policy that facilitates management decisions and thus allows for the strengthening of universal health coverage, considering the key role that professionals like RNs and LPNs play in the results and increase of health access.
One of the main limitations of this study is the fact that it only included data recorded for patients that accessed the PCUs during the study period. PHC in Brazil is organized geographically, with the assignment of catchment areas to PCUs and PHC teams, with no overlap or gaps between them. Although PCUs are responsible for the entire population living in their catchment area, some proportion of these individuals never or rarely access services, and are not represented in productivity-based analyses, such as those conducted in this study. Therefore, the study results reflect nursing staffing needs based on the population that accessed services, and not on the entire covered population, an additional challenge that needs to be addressed in future studies.
