Performance of Nursing Activities Score in intensive care units of a teaching hospital in a low-middle-income country: An observational study

BackgroundNursing workload in intensive care units (ICUs) plays a crucial role in determining patient outcomes, quality of care, and healthcare system efficiency. The Nursing Activities Score (NAS) is a validated tool used internationally to measure nursing workload and estimate the proportion of nursing time required for patient care. However, evidence regarding its application in low- and middle-income countries (LMICs) remains limited. High nursing workload has been associated with increased mortality, prolonged ICU stay, and compromised patient safety. This study aimed to assess nursing workload using NAS in an ICU of a teaching hospital and evaluate its predictive ability for patient outcomes. MethodsThis observational study included 501 ICU patients admitted to a teaching hospital. NAS scores were recorded for each patient, and outcomes were categorized as survivors and non-survivors. The predictive ability of NAS was evaluated using Receiver Operating Characteristic (ROC) curve analysis. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. Logistic regression analysis was performed to determine the association between NAS and mortality risk. The Mann-Whitney U test was used to compare NAS scores between survivors and non-survivors. ResultsThe median NAS score was 83.40 (IQR: 101.10-68.30; range: 39.2-134.4), indicating a high level of nursing workload in the ICU. ROC analysis showed that NAS had good predictive ability for patient outcomes with an AUROC of 0.838 (p < 0.001). The optimal cut-off value was 90.40, with 73.5% sensitivity and 73.1% specificity. The Hosmer-Lemeshow test (p = 0.422) indicated good model fit. Logistic regression analysis showed that higher NAS scores were significantly associated with increased mortality risk (Exp(B) = 0.937, p < 0.001). Non-survivors had significantly higher NAS scores (110.70) compared with survivors (76.20, p < 0.001). ConclusionNAS is a reliable tool for assessing ICU nursing workload and predicting patient outcomes. Higher NAS scores reflect greater patient severity and increased risk of mortality, highlighting the importance of optimized staffing and workload management in ICU settings. Author SummaryIntensive care units (ICUs) care for the most critically ill patients and require constant monitoring and complex nursing interventions. However, in many low- and middle-income countries, including Nepal, the number of available nurses is often insufficient compared with the high demand for intensive care services. This imbalance can increase nursing workload and may affect the quality and safety of patient care. Therefore, reliable tools are needed to measure nursing workload and help hospitals plan staffing more effectively. This study evaluated the Nursing Activities Score (NAS), a standardized tool used internationally to measure nursing workload, in the ICU of a teaching hospital. Data from 501 ICU patients were analyzed to determine the level of nursing workload and whether NAS could predict patient outcomes. The findings showed that the nursing workload was high, with a median NAS score of 83.4, indicating substantial nursing care requirements. Patients who did not survive had significantly higher NAS scores compared with survivors. NAS also showed good accuracy in predicting patient outcomes. These findings suggest that NAS is a useful tool for measuring nursing workload and identifying critically ill patients who require more intensive care. Using NAS in ICUs may help hospitals optimize staffing, improve patient safety, and support better critical care management in resource-limited settings.