Workload Indicators Of Staffing Need User's Manual

Posted : admin On 10/7/2021
  1. Workload Indicators Of Staffing Need (wisn) A Manual For Implementation
  2. Workload Indicators Of Staffing Need (wisn) A Manual For Implementation (version 2)
  3. Workload Indicators Of Staffing Need (wisn) Software Download
  1. This document, which complements the revised Workload indicators of staffing need (WISN): user’s manual, provides examples of how the WISN method has been applied in practice. The case studies described here come from Indonesia, Mozambique and Uganda.
  2. Data were analyzed using Workload Indicators of Staffing Need (WISN).The result showed direct productive activities amounted to 59.14%, indirect productive activities amounted to 17.22%, 16.99% of non-productive activities, and 6.65% of personnel private activities. Pharmacy staffing need is 26 people.

The Workload Indicators of Staffing Need (WISN), a method the World Health Organization has proposed for staffing at a health institution, signals great potential applicability at FHS and in a region's entire health service network. WISN - Workload Indicators of Staffing Need. User's manual. Geneva; 2010. Aug 31, 2015  To ascertain staffing levels, Uganda uses fixed government-approved norms determined by facility type. This approach cannot distinguish between facilities of the same type that have different staffing needs. The Workload Indicators of Staffing Need (WISN) method uses workload to determine number and type of staff required in a given facility. 3 Page Workload Indicators of Staffing Need (WISN) Application at Public Sector Health Facilities in Bangladesh Technical Brief Background Bangladesh has made commendable progress in the health sector; however, it is among the countries with a severe shortage of formally trained health workforce.

Published online 2016 Apr 29. doi: 10.1590/1518-8345.1010.2683
PMID: 27143538
This article has been cited by other articles in PMC.



verify the application of the Workload Indicators of Staffing Need method in theprediction of nursing human resources at a Family Health service.


descriptive and quantitative study, undertaken at a Family Health service in thecity of São Paulo. The set of sequential operations recommended in the WorkloadIndicators of Staffing Need method was used: definition of the professionalcategory, type of health service and calculation of Available Work Time;definition of workload components; identification of mean time for workloadcomponents; dimensioning of staff needs based on the method, application andinterpretation of the data.


the workload proposed in the Workload Indicators of Staffing Need method tonursing technicians/auxiliary nurses was balanced with the number of professionalsavailable at the Family Health service. The Workload Indicators of Staffing Needindex amounted to 0.6 for nurses and 1.0 for nursing technicians/auxiliary nurses.


the application of the Workload Indicators of Staffing Need method was relevant toidentify the components of the nursing professionals' workload. Therefore, it isrecommendable as a nursing staffing tool at Family Health services, contributingto the access and universal health coverage.

Keywords: Nursing Staff, Primary Health Care, Workload


Human resources are one of the central pillars for access and universal health coverage,but represent a permanent challenge for many countries in Latin America, in view ofdisequilibria in their availability, composition, distribution and productivity, mainlyin primary health care().

In view of the essential role health professionals play in the protection, promotion andrestoring of populations' health, it is fundamental for quantitative and qualitativeplanning and investment in the development of these professionals be done cautiously, soas to respond to the different and changeable health needs of the communities efficientand effectively().

The planning process of health professionals looks for a balance between what isavailable in terms of market and what is necessary to guarantee attendance to the users'health demands().

Workload Indicators Of Staffing Need (wisn) A Manual For Implementation

The dimensioning of nursing professionals, who representing the largest staff contingentin all health areas, has advanced in the discussion and enhancement of methods andparameters, mainly in hospital care. Nevertheless, in the Brazilian Primary Health Carecontext (PHC), specifically in the Family Health Strategy (FHS), few studies haveaddressed this theme.

A recent study presented data that provide a general view on the nursing interventionsand activities at Family Health services (FHS) that have the potential to influence andimprove the public policies regarding nursing staffing(4).

This research was undertaken among 27,846 observations of the work by 34 baccalaureatenurses and 66 nursing technicians/auxiliary nurses, working at 27 FHS in the fivegeographic regions of Brazil, showing that the nurses and nursing technicians spend, onaverage, 70% of their work time of direct and indirect nursing careinterventions(4).

Although scientific evidence() indicates a possible association between nursing staff density and maternalmortality, childhood mortality and immunization rates, predicting the number ofprofessionals needed to attend to the users' needs at a FHS has not been easy.

The Workload Indicators of Staffing Need (WISN), a method the WorldHealth Organization has proposed for staffing at a health institution(6), signals great potential applicability at FHS and in a region's entirehealth service network.

The WISN departs from the workload, using activity (time) standards that are applicableto each workload component and to each professional's available time. This methodprovides results like the difference between the real and calculated number of nursingprofessionals, identifying the lack or surplus of a certain professionalcategory(6).

In view of the insufficient number of studies to support nursing staffing in PHC, theobjective in this study is to verify the application of the WISN method in theprediction of nursing human resources at FHS.


In this descriptive study with a quantitative approach, a set of operations was used,recommended in the WISN, to calculate nursing professionals at a FHS in the city of SãoPaulo, Brazil, selected through a convenience sample, based on the criterion of beingconsidered best primary health care practices.

This service was responsible for a territory of 5,639 families, equivalent toapproximately 19,526 people, where care was offered from Mondays to Fridays (from 7 till18 hours).

The work team consisted of six health teams, totaling six physicians, six nurses, 12auxiliary nurses, 35 community health agents. Besides these professionals, there was aservice manager, a nurse and a nursing technician for epidemiological surveillance andmaterial sterilization, a physician for exclusive teaching and epidemiologicalsurveillance activities, 10 administrative professionals, four dentists, one oral healthaid, one oral health technician, one psychologist, one social worker, one occupationaltherapist, one pharmacist, three pharmaceutical technicians, three cleaning aids and oneguard. The weekly workload was 40 hours.

A Social Health Organization (SO) managed the service through a comprehensive managementcontract based on the FHS. The main risks present in the coverage area were: mostlylow-income living and work conditions, predominantly middle-class areas and twourbanized slums with illegal areas, drugs traffic, domestic violence, unemployment, riskof collapse and polluted creek. The most frequent health problems were arterialhypertension, diabetes mellitus and respiratory diseases. This service's status was dueto the fact that one of its strengths was the union and participation of the attendedpopulation.

Following the steps described in the WISN method, the goal was to identify the corevariables for nursing staffing.

1st Step: definition of professional category, type of health service andcalculation of Available Working Time

The WISN method can be applied to all categories of health professionals and all typesof services(6). In this study, the nursing professionals from one FHS were analyzed.

The Available Working Time (AWT) refers to how long a health professional has available,in one year, to perform his job, discounting established (holidays and vacation) andunexpected (medical leave and training) days of absence. It can be expressed as days orhours per year(6).

TTD = [A - (B + C + D + E ] x F


AWT = available work time per professional

A = number of possible workdays in one year (obtained by multiplyingthe number of weeks in one year (52) by the number of workdays in one week)

B = number of days of absence due to holidays in one year

C = number of days of absence due to vacation in one year

Workload Indicators Of Staffing Need (wisn) A Manual For Implementation (version 2)

D = number of days of absence due to medical leave in one year

Workload Indicators Of Staffing Need (wisn) Software Download

E = number of days of absence due to other leaves, such as training, inone year

F = number of hours worked in one day.

2nd Step: definition of workload components

This step consists of defining the work interventions/activities that occupy most of theprofessionals' daily time. The most important interventions/activities on a healthprofessional's daily agenda are considered as workload components, knowing that eachcomponent needs a specific amount of time(6). The workload components corresponded to the interventions/activities thenursing professionals performed at the FHS, described in the data collection tool andclassified according to the WISN method, as follows:

  • Health service activities - developed by all members of a professionalcategory, which identifies the particularity of the work and are generallyregistered;

  • Support activities - complement the health activities, developed by all membersof a professional category and generally are not registered;

  • Additional activities - complement the health activities, developed by somemembers of a professional category and whose statistics are not registeredregularly.

3rd Step: identification of mean time for workload components

Consists of the mean time needed for a trained, qualified and motivated professional todevelop an intervention/activity with satisfactory competence/sill and attitude,according to the conditions and circumstance of each service(6).

To identify the mean length of time the nursing staff spends to execute theinterventions/activities that are the workload components, the work sampling techniquewas used, referring to the direct, structured, non-participatory observation of sixnurses and 12 auxiliary nurses present at the service, during the eight-hour workday,every ten minutes, for five days (February 14th-18th 2011).

The interventions/activities observed were registered in the data collection tool,consisting of nursing interventions/activities that were identified and validated forFHS(), work-related activities and personal activities, by two previously trainedfield observers, who accompanied an average nine professionals throughout theworkday.

Intervention was considered as any treatment based on judgment and clinical knowledge,performed by a health professional to improve the results obtained by the users, familyand community(8); activity associated with activities of other professional categories, butwhich the health professional takes charge of and personal activity as the breaks neededin the workday to attend to the workers' physiological and personal communicationneeds.

The mean length of the interventions/activities was calculated per workload component.For the standard intervention/activity, that is, activities that are performed andregistered routinely, the mean time was calculated based on the total time (in minutes)spent on each intervention/activity, divided by the number of users attended in the sameperiod. In line with the WISN method, the survey of the number of users attended wasbased on available service statistics and reports. In this study, data for 2011 wereused.

For the other two workload components, support interventions/activities and additionalinterventions/activities, whose statistics are not always available as they are notalways registered, a mean length of time was calculated by adding up the frequencies (%)of the interventions observed plus the associated work activities, divided by the totalnumber of observations in the period(6), thus adding the adjustment factor the WISN method calls: CategoryAllowance Standard (CAS) and Individual Allowance Standard (IAS), numerically expressedas Category Allowance Factor (CAF) and Individual Allowance Factor (IAF),respectively.

To adapt to the proposed WISN terminology, the work-related activities and personalactivities that were considered in the data collection tool were considered as supportactivities for the category and, as they represent a significant number of hours, theywere allocated proportionately among the three workload components: standard, supportand additional interventions/activities.

In this step, the lengths of time can be expressed as actual work time or as apercentage of the work time.

The percentage distributions and mean lengths of the interventions found in this studywere used according to the professional category (nurse and nursing technician/auxiliarynurse) as nursing staffing parameters.

4th Step: staffing based on the method

For the purpose of staffing, the following procedure was adopted.

  • a) For the Health service activities : each workload component was divided bythe AWT. This result showed the number of nursing staff needed per category toaccomplish the workload component for the Health service activities at theFHS.

  • b) For the support interventions/activities, the result of item a) wasmultiplied by the category allowance factor. This procedure revealed the numberof staff needed for all Health service activities and complementaryinterventions/activities for the category.

  • c) For the additional interventions/activities, the IAF was calculated andadded up to the results of items a and b. Thus,

Staff need = Health service activities × CAF + IAF

5th Step: application and interpretation of the data in accordance with the WISNmethod

The difference between the number of staff available at the service and the staff neededwas verified by analyzing the index between these two. When bordering on one (~1), theavailable staff is balanced with the staff demands for the workload at the service. Anindex superior to one (>1) evidences too much staff in relation to the workload andinferior to one (<1) that the current staff is insufficient to cope with the workloadat the health service. Therefore, the lower the index, the greater the pressure atwork(6).

All participants were informed about the research objective, guaranteed anonymity,voluntary participation and signed the Informed Consent Form (ICF), with the approval ofthe Research Ethics Committee of the São Paulo Municipal Health Department, Process249/09.


The nursing interventions/activities were classified according to the workloadcomponent, as demonstrated in Figure 1.

- Distribution of interventions/activities according to nursing workloadcomponents at FHS. São Paulo SP, Brazil, 2011

The number of nursing professionals required, according to the professional category, isdemonstrated in Figures 2 and and3,3, which summarize the workload components, the steps proposed inthe WISN method and the analysis and interpretation of the data.

- Number of nurses required at a Family Health Service (FHS) according toWISN method. São Paulo, SP, Brazil, 2011
*CAS: Category Adjustment Standard; †IAS: Individual AdjustmentStandard
- Number of auxiliary nurses required at a Family Health Service accordingto WISN method. São Paulo, SP, Brazil, 2011
*CAS: Category Allowance Standard; †IAS: Individual AllowanceStandard


This research identified the nursing staffing needs at a FHS in the city of São Paulo toattend to the care demands through the application of the WISN method.

The use of this method presupposes the availability of routinely stored data on theinvestigated professionals and services' workload. These statistics need to be updated,complete and consistent.

In that sense, a study appointed that the information system at the FHS containsinsufficient spaces to report on the nursing team's work, showing the importance ofqualifying the information systems developed to support the planning of nursing staffingneeds(9).

Therefore, the nursing care records provided to the users need to be systemized inreports or worksheets that permit monitoring the information for decision making, suchas the service's annual production and data on professionals' expected and non-expectedabsences.

The AWT per professional category is calculated to find out how many work days or hoursare available per year, representing more objective information on the reality of theservice, which can facilitate negotiations with the health institutions' managers.

The results showed that there was disequilibrium between the nurse staffing needsidentified through the WISN method and the existing nurse staff at the service analyzed.The length of the interventions/activities used in the calculations expressed thereality at the service. It is highlighted, however, that the mere use of the productiondata may not picture the needs of the population covered. Therefore, planning is neededto integrate the repressed demand. Therefore, the annual work load should be calculatedbased on this population's needs, considering the primary health care actions theMinistry of Health proposes(10).

The direct observation and calculation of the mean lengths of the nursing professionals'interventions/activities performed were the differentials in this study, obtaining moreprecise time standards for the reality studied.

The introduction of the support interventions/activities, including both indirect careand work-related interventions, certainly constitutes a new aspect in staffing research,as it introduces activities the professionals generally refer to as time-consuming, butwhich can neither be demonstrated nor accounted for, as they lack formal registration,often making it difficult to measure the activity volume and their respectiveduration.

For the authors of the WISN method, adding workload components that are performed in ashort period of time will make little difference for the final calculation of the numberof professionals. Thus, this method highlights the importance of identifying theinterventions/activities that truly affect the nursing professionals' workload in healthcare, with a view to elaborating planning that supports the capacity of the healthsystem when attending to the population's needs.

In Brazil, the application of the WISN method at a FHS is a pioneering attempt topredict the number and quality of the nursing professionals.

Some experiences report on the successful application of the WISN method in differentcare realities.

In an Indonesian province, the midwives affirmed that the method was useful because ithelped to focus their work time more clearly on key activities, besides permitting ananalysis of their own work situation at the services(11) . The WISN showedthat the midwives were spending up to 50% of their time on activities not related to themidwife (elderly care, care for tuberculosis and malaria patients). Hence, the initialproposal that the number of midwives was insufficient for the category's specificworkload, without the necessary clarification the WISN provides, could have resulted inan increased number of midwives instead of nurses(11).

In provinces of Mozambique, the WISN was used to assessed its applicability, and thusexpand the use of workload measures for the decision process. As a result, based on thestaffing calculation, it was concluded that all health services had a lack of generalclinicians, nurses and midwives. Therefore, the activities were performed within muchless time than the minimum standard required, resulting in low quality. In addition, thedistribution of nurses was unbalanced in the city of Nampula, with great disequilibriumbetween the hospital and the health services(11) .

In a study developed in Namibia, the WISN results also appointed scarceness andinequality, showing that the nurses were distributed unequally among the different typesof services and clearly deviated to the hospitals. Hence, the authors suggest that thehealth services use to WISN method to estimate the health professionals required for arange of needs and scenarios, including workers' adjustments in response to theimplementation of new services, the decentralization or reconfiguration of primary careservices().

Evidences in the literature show that the use of a tool like WISN, when adapted to thelocal situation, improves the distribution of staff numbers among services, permitsidentifying the places where there is a lack of professionals and provides informationsupport for planning, training and allocation at local, regional and nationallevel().

In terms of efficiency, the WISN can be considered a tool with potential to show ways toequate this distribution. Nevertheless, some limitations should be appointed in the WISNmethod, such as the precision determined by the exactness of the statistics. From thatperspective, errors are almost always observed because of the insufficient registeringof the workload, resulting in the underestimation of the staffing needs.

This study is limited by the fact that it was developed at a single FHS, making itimpossible to generalize the obtained results, mainly related to the mean lengths of thenursing professionals' interventions/activities. Therefore, further research indifferent Brazilian realities will permit the identification of time parameters at thenational and regional levels, making it possible to apply the WISN and assess thenursing professionals in the FHS in qualitative and quantitative terms.


Different implementation contexts of primary health care in Brazil and the particularityof the FHS care model and the users' increasing demand make the effective planning ofhealth professionals urgent.

The main contribution of this study, original in the Brazilian reality, rests in theapplication and assessment of the WISN method in the FHS, as an objective and systematicmodel for nursing staffing in PHC. Its application was relevant to identify thecomponents of the nursing professionals' workload. Therefore, it is recommendable as atool for the planning and qualitative and quantitative assessment of nursingprofessionals in FHS, so as to contribute to the access and universal coverage inhealth.


1. Cassiani SHB. Strategy for universal access to health and universal health coverageand the contribution of the International Nursing Networks. Rev. Latino-Am Enfermagem. 2014;22(6):891–892.[PMC free article] [PubMed] [Google Scholar]
(Redirected from Health workforce)

Health human resources (HHR) – also known as human resources for health (HRH) or health workforce – is defined as 'all people engaged in actions whose primary intent is to enhance health', according to the World Health Organization's World Health Report 2006.[1] Human resources for health are identified as one of the core building blocks of a health system.[2] They include physicians, nursing professionals, midwives, dentists, allied health professions, community health workers, social health workers and other health care providers, as well as health management and support personnel – those who may not deliver services directly but are essential to effective health system functioning, including health services managers, medical records and health information technicians, health economists, health supply chain managers, medical secretaries and others.

The field of health human resources deals with issues such as planning, development, performance, management, retention, information, and research on human resources for the health care sector. In recent years, raising awareness of the critical role of HRH in strengthening health system performance and improving population health outcomes has placed the health workforce high on the global health agenda.[3]

  • 3Policy and planning

Global situation[edit]

Nations identified with critical shortages of health care workers

The World Health Organization (WHO) estimates a shortage of almost 4.3 million physicians, midwives, nurses and support workers worldwide.[1] The shortage is most severe in 57 of the poorest countries, especially in sub-Saharan Africa. The situation was declared on World Health Day 2006 as a 'health workforce crisis' – the result of decades of underinvestment in health worker education, training, wages, working environment and management.

Shortages of skilled for health workers are also reported in many specific care areas. For example, there is an estimated shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries.[4] Shortages of skilled birth attendants in many developing countries remains an important barrier to improving maternal health outcomes. Many countries, both developed and developing, report maldistribution of skilled health workers leading to shortages in rural and underserved areas.

Regular statistical updates on the global health workforce situation are collated in the WHO Global Health Observatory.[5] However, the evidence base remains fragmented and incomplete, largely related to weaknesses in the underlying human resource information systems (HRIS) within countries.[6]

In order to learn from best practices in addressing health workforce challenges and strengthening the evidence base, an increasing number of HHR practitioners from around the world are focusing on issues such as HHR advocacy, surveillance and collaborative practice. Some examples of global HRH partnerships include:


Workload Indicators Of Staffing Need User

Health workforce research is the investigation of how social, economic, organizational, political and policy factors affect access to health care professionals, and how the organization and composition of the workforce itself can affect health care delivery, quality, equity, and costs.

Many government health departments, academic institutions and related agencies have established research programs to identify and quantify the scope and nature of HHR problems leading to health policy in building an innovative and sustainable health services workforce in their jurisdiction. Some examples of HRH information and research dissemination programs include:

  • Human Resources for Health journal

Policy and planning[edit]

In some countries and jurisdictions, health workforce planning is distributed among labour market participants. In others, there is an explicit policy or strategy adopted by governments and systems to plan for adequate numbers, distribution and quality of health workers to meet health care goals. For one, the International Council of Nurses reports:[7]

The objective of HHRP [health human resources planning] is to provide the right number of health care workers with the right knowledge, skills, attitudes, and qualifications, performing the right tasks in the right place at the right time to achieve the right predetermined health targets.

An essential component of planned HRH targets is supply and demand modeling, or the use of appropriate data to link population health needs and/or health care delivery targets with human resources supply, distribution and productivity. The results are intended to be used to generate evidence-based policies to guide workforce sustainability.[8][9] In resource-limited countries, HRH planning approaches are often driven by the needs of targeted programmes or projects, for example, those responding to the Millennium Development Goals or, more recently, the Sustainable Development Goals.[10]

The WHO Workload Indicators of Staffing Need (WISN) is an HRH planning and management tool that can be adapted to local circumstances.[11] It provides health managers a systematic way to make staffing decisions in order to better manage their human resources, based on a health worker's workload, with activity (time) standards applied for each workload component at a given health facility.

Global Code of Practice on the International Recruitment of Health Personnel[edit]

The main international policy framework for addressing shortages and maldistribution of health professionals is the Global Code of Practice on the International Recruitment of Health Personnel, adopted by the WHO's 63rd World Health Assembly in 2010.[12] The Code was developed in a context of increasing debate on international health worker recruitment, especially in some higher income countries, and its impact on the ability of many developing countries to deliver primary health care services. Although non-binding on the Member States and recruitment agencies, the Code promotes principles and practices for the ethical international recruitment of health personnel. It also advocates the strengthening of health personnel information systems to support effective health workforce policies and planning in countries.

See also[edit]

  • Canada's Health Care Providers, 2007, published by the Canadian Institute for Health Information
  • Human Resources for Health, open access journal
  • Interprofessional education and collaborative practice in health care
  • NHS National Workforce Projects, part of the English National Health Service
  • Physician shortage / Nursing shortage


  1. ^ ab'The world health report 2006: working together for health'. World Health Organization. Geneva. 2006.
  2. ^'Health Systems Topics'. World Health Organization. Geneva.
  3. ^Grépin, Karen A; Savedoff, William D (November 2009). '10 Best Resources on ... health workers in developing countries'. Health Policy and Planning. 24 (6): 479–482. doi:10.1093/heapol/czp038.
  4. ^Scheffler, RM; et al. (2011). 'Human resources for mental health: workforce shortages in low- and middle-income countries'(PDF). World Health Organization. Geneva.
  5. ^'Global Health Observatory (GHO) data: Health workforce'. World Health Organization. Geneva. Retrieved 8 August 2017.
  6. ^Dal Poz, MR; et al., eds. (2009). 'Handbook on monitoring and evaluation of human resources for health'. World Health Organization. Geneva.
  7. ^'Health human resources planning'(PDF). International Council of Nurses. Geneva. 2008. Archived from the original on 22 March 2012. Retrieved 12 April 2011.CS1 maint: unfit url (link)
  8. ^Dal Poz, MR; et al. (2010). 'Models and tools for health workforce planning and projections'(PDF). World Health Organization. Geneva.
  9. ^'Health Human Resource Strategy (HHRS)'. Health Canada. Retrieved 12 April 2011.
  10. ^Dreesch, N; et al. (September 2005). 'An approach to estimating human resource requirements to achieve the Millennium Development Goals'. Health Policy and Planning. 20 (5): 267–276. doi:10.1093/heapol/czi036. PMID16076934.
  11. ^'Workload Indicators of Staffing Need (WISN): User's manual'. World Health Organization. Geneva. 2010.
  12. ^International recruitment of health personnel: global code of practice, Geneva: The Sixty-third World Health Assembly, May 2010

External links[edit]

  • World Health Organization programme of work on health human resources
  • Human Resources for Health Databases, Canadian Institute for Health Information
  • Human resources for health in developing countries – a dossier from the Institute for Development Studies
  • Compendium of tools and guidelines for HRH situation analysis, planning, policies and management systems
  • Online community of practice for HRH practitioners on strengthening health workforce information systems
  • Human Resources for Health Global Resource Center online collection of HRH research and materials, supported by the IntraHealth International-led CapacityPlus project
Retrieved from ''