The most commonly used unit-level workload measure is the nurse-patient ratio. The nurse-patient ratio can be used to compare units and their patient outcomes in relation to nursing staffing. Previous research provides strong evidence that high nursing workloads at the unit level have a negative impact on patient outcomes. These studies’ suggestions regarding improving patient care are limited to increasing the number of nurses in a unit or decreasing the number of patients assigned to each nurse. However, it may not be possible to follow these suggestions due to costs and the nursing shortage. The major weakness of this type of research is that it conceptualizes nursing workload at a macro level, ignoring the contextual and organizational characteristics of a particular health care setting (e.g., physical layout, information technology available) that may significantly affect workload. According to this conceptualization, the level of workload depends on the type of nursing job or specialty (ICU nurse versus operating room nurse). A job-level measure of workload to investigate the impact of workload on burnout and performance among ICU nurses. Previous research linked job-level workload (a working condition) to various nursing outcomes, such as stress and job dissatisfaction. Workload measures at the job level are appropriate to use when comparing workload levels of nurses with different specialties or job titles (ICU nurses versus ward nurses). However, workload is a complex, multidimensional construct, and there are several contextual factors in a nursing work environment (e.g., performance obstacles and facilitators) other than job title that may affect nursing workload. In other words, two medical ICU nurses may experience different levels of workload due to the different contextual factors that exist in each ICU. The workload at the job-level conceptualization fails to explain the difference in the workloads of these two nurses.
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This conceptualization assumes that the main determinant of nursing workload is the clinical condition of the patient. Several patient-level workload measures have been developed based on the therapeutic variables related to the patient’s condition (e.g., Therapeutic Intervention Scoring System) and have been extensively discussed in the nursing literature. However, recent studies show that factors other than the patient’s clinical condition (example in communication, supplies not well-stocked) may significantly affect nursing workload. As with the previous two workload measures, patient-level workload measures have not been designed to measure the impact of these contextual factors on nursing workload.
In discussing about the nursing workloads, I would like to look into the workload at the patient level. This conceptualization assumes that the main determinant of nursing workload is the clinical condition of the patient. Several patient-level workload measures have been developed based on the therapeutic variables related to the patient’s condition (e.g., Therapeutic Intervention Scoring System) and have been extensively discussed in the nursing literature. However, recent studies show that factors other than the patient’s clinical condition (e.g., ineffective communication, supplies not well-stocked) may significantly affect nursing workload. As with the previous two workload measures, patient-level workload measures have not been designed to measure the impact of these contextual factors on nursing workloads.
To remedy the shortcomings of the three levels of measures explained above and complement them, we have suggested using another way to conceptualize and measure nursing workload based on the existing literature on workload in human factors engineering: situation-level workload. In addition to the number of patients assigned to a nurse and the patient’s clinical condition, situation-level workload can explain the workload experienced by a nurse due to the design of the health care microsystem. In a previous study, we found that various characteristics of an ICU microsystem (performance obstacles and facilitators)-such as a poor physical work environment, supplies not well stocked, many family needs, and ineffective communication among multidisciplinary team members-significantly affect situation-level workload. For example, sometimes several members of the same family may call a nurse separately and ask very similar questions regarding the same patient’s condition. Answering all these different calls and repeating the same information about the patient’s status to different members of the family is a performance obstacle that significantly increases the (situation-level) workload of nurse.
It is important to note that the impact of this performance obstacle on nursing workload would not be apparent if we used a unit-level or patient-level workload measure. Compared to workload at the job level, situation-level workload is temporally bound: it explains the impact of a specific performance obstacle or facilitator on nursing workload over a well-defined and relatively short period of time (e.g., 12-hour shift), rather than using the overall experience of the nurse in a given microsystem. Situation-level workload is multidimensional, that is, different types of performance obstacles and facilitators affect different types of workload. Whereas the distance between the patients’ rooms assigned to a nurse affects physical workload, the condition of the work environment (noisy versus quiet, hectic versus calm) affects the overall effort spent by the nurse to perform her job. No prior study investigated the impact of the microsystem characteristics on situation-level nursing workload. In summary, by studying workload at the situation level, researchers can identify the characteristics of a microsystem that affects workload. This information is vital for reducing nursing workload by redesigning the microsystem. In the last section of this chapter, a human factors engineering approach based on the situation-level workload is described.
In workload of nurses ( Carayon,P, & Ayse ,P, pp.3) giving a 2004 report by the Agency for Healthcare Research and Quality (AHRQ) describes several AHRQ-funded studies on the relationship between hospital nurse staffing and quality of care (e.g., urinary tract infection, hospital-acquired pneumonia) and patient safety outcomes (e.g., failure to rescue).
A heavy nursing workload seems to be related to suboptimal patient care and may lead to reduced patient satisfaction. Much of the research investigating the impact of nursing workload on patient safety focused on linking nursing staffing levels with patient outcomes. There is strong evidence in the literature that nurse staffing levels significantly affect several nursing-sensitive patient outcomes. Several studies found a significant relation between lower nurse staffing levels and higher rates of pneumonia. For example, a multisite study in California found that an increase of 1 hour worked by registered nurses (RNs) per patient day correlated with an percent decrease in the odds of pneumonia among surgical patients. Another study found a significant relationship between full-time-equivalent RNs per adjusted inpatient day and rate of pneumonia: the rate of pneumonia was higher with fewer nurses. However, other studies have not confirmed these findings; for example, the evidence regarding the impact of nurse staffing levels on pneumonia is conflicting. As workload is affected by more than just staffing levels, a deeper understanding of nursing workload is required to better assess the impact of workload on patient outcomes. Later, a human factors engineering approach to nursing workload that can provide this deeper understanding of nursing workload and its causes will be described, allowing for the development and implementation of solutions aimed at reducing or dealing with workload.
Nursing staffing levels have been shown to have a significant impact on nosocomial infections. For example, Needleman and colleagues found that among medical patients, a higher number of hours of care per day provided by RNs was related to lower urinary tract infection rates. A retrospective cohort study in a neonatal ICU revealed that the incidence of E cloacae infection in the unit was significantly higher when there was understaffing of nurses. A prospective study in a pediatric cardiac ICU found a significant relation between the monthly nosocomial infection rate in the unit and the nursing hours per patient day ratio: there were more nosocomial infections when the number of nursing hours per patient day was lower.
Although not as strong, some evidence exists regarding the impact of nurse staffing levels on failure to rescue (death within 30 days among patients who had complications) and mortality .In a study of 168 nonfederal adult general hospitals in Pennsylvania, Aiken and colleagues found that each additional patient per nurse was associated with a 7 percent increase in the likelihood of mortality within thirty days of admission and in the likelihood of failure to rescue. An earlier study found that hospitals that had more RNs per admission had lower mortality rates.
Studies done by Pascale and Ayse, stated that there were four studies that found a relationship between nurse staffing and patient outcomes. One study found that having a nurse-patient ratio of less than 1:2 during evening shifts was associated with a 20 percent increase in length of stay in patients who had abdominal aortic surgery in Maryland hospitals between 1994 and 1996. Researchers conducted studies in 1992 and 1994 using hospital cost reports and discharge data in New York and California, finding that more nursing work hours were associated with reduced length of stay. Additionally, a critical incident study of Australian ICUs revealed that insufficient nursing staff was linked to drug administration or documentation problems, inadequate patient supervision, incorrect ventilator or equipment setup, and self-extubation.
A majority of the studies on nursing workload and patient safety used nurse-patient ratio as the measure of nursing workload. According to research on workload in human factors engineering (see section above), it is well known that workload is a complex construct, more complex than the measure of nurse-patient ratio. It is unlikely that the multidimensional, multifaceted structure of workload can be captured by one unique, representative measure. Therefore, the belief is that researchers who use the nurse-patient ratio as a measure of workload offer a limited contribution to understanding the impact of nursing workload and designing solutions for reducing or mitigating nursing workload. One reason for the extensive use of the nurseuser2010-10-12T23:18:00
-patient ratio may be that this measure is easy to use and is readily available in existing databases. But tools used by human factors researchers can comprehensively assess workload, facilitate the identification of the sources of excessive workload, and provide direction for corrective interventions.
Nevertheless, nursing workload do give an impact to patient safety. A statement or a survey by Systems Engineering Initiative for Patient Safety by Pascale and Ayse (chaper 30) in Nursing Workload and Patient Safety, stated that According to the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety,39, 40 structural/organizational characteristics of health care work systems, such as nursing workload, can affect quality of care and patient safety. In this section, a description of how nursing workload can affect patient safety will be offered .The first five mechanisms describe the impact of a heavy workload experienced by one nurse on that particular nurse. The last mechanism describes the systemic and organizational impact of a heavy workload experienced by a nurse’s co-workers and team members. Nursing workload does deteriorated motivation amongst nurses and health professional. Several studies have shown the relationship between nurses’ working conditions, such as high workload, and job dissatisfaction. Job dissatisfaction of nurses can lead to low morale, absenteeism, turnover, and poor job performance, and potentially threaten patient care quality and organizational effectiveness. Researchers have found positive associations between job satisfaction and job performance, and patient satisfaction and quality of care.
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Nursing workload gives impact to nurses on nursing stress and burnout. High workload is a key job stressor of nurses in a variety of care settings, such as ICUs and in Emergency and Trauma department. A heavy nursing workload can lead to distress (e.g., cynicism, anger, and emotional exhaustion) and burnout. Nurses experiencing stress and burnout may not be able to perform efficiently and effectively because their physical and cognitive resources may be reduced; this suboptimal performance may affect patient care and its safety.
Workload can be a factor contributing to errors in nursing. Errors have been classified as slips and lapses or execution errors, and mistakes or knowledge errors. High workload in the form of time pressure may reduce the attention devoted by a nurse to safety-critical tasks, thus creating conditions for errors and unsafe patient care.
Nursing workloads also influence violations are defined as deliberate deviations from those practices (i.e., written rules, policies, instructions, or procedures) believed necessary to maintain safe or secure operations. The literature on violations emphasizes the role of the social and organizational context, where behaviour is governed by operating procedures, codes of practice, rules, and regulations. This approach emphasizes factors in the work system that can contribute to violations. The health care field has begun to explore caregivers’ violations of protocols. A survey describing medical practice was administered to 315 nurses, doctors, and midwives and 350 members of the general public in the United Kingdom. The study examined two factors manipulated within nine scenarios of surgery, anesthetics, and obstetrics. The first factor, behavior, was described as an improvisation (no rule available), a violation of clinical protocol, or compliance with a clinical protocol. The second factor, patient outcome, was described as good, bad, or poor. Samples of health care providers and the general public were asked to evaluate the nine scenarios with regard to the inappropriateness of the behavior, the likelihood that they would take further action (i.e., reporting by health care provider and complaining by the public), and responsibility for the outcome (e.g., the health care professional, the patient, the protocol itself, the hospital). Results showed that violations of protocols and bad outcomes were judged most harshly. Whether outcomes were good or bad, violations were evaluated more negatively. The authors of the study warned against overreliance on procedures (or protocols) as a form of organizational defense against accidents or claims. Procedures may stifle innovation and make people less able to function in novel situations.
According to a survey done by Alper (Pascale,C,. & Ayse,P.) and colleagues conducted a survey of 120 nurses (59 percent response rate) in three units of a pediatric hospitals to assess self-reports of violations in the medication administration process. Between 8 percent and 30 percent of the nurses reported violations in routine situations, and between 32 percent and 53 percent of the nurses reported violations in emergency situations. The most frequent violations or work-arounds occurred in matching the medication to the medication administration record and checking the patient’s identification.
Further research is needed to understand the work system factors that lead to violations. Violations occur more frequently when nurses are under time pressure or high workload because of emergency situations. Under high workload, nurses may not have time to follow rules and guidelines for safe care, especially if following the rules and guidelines necessitate additional time, such as hand washing.
This final mechanism of the relationship between nursing workload and patient safety is based on the systemic, organizational impact of nursing workload: a heavy workload experienced by a nurse not only affects this nurse, but can also affect other nurses and health care providers in the nurse’s work system. Understaffing may reduce time nurses have to help other nurses and lacking of time may also result in inadequate training or supervision of new nurses.
Once the work system factors contributing to nursing workload have been identified, interventions aimed at reducing or mitigating the workload can be designed. The work system redesign interventions should follow the two basic principles of the Balance Theory of Carayon and Smith stated that eliminating the source of the excessive workload, or compensating or balancing out the workload. According to the Balance Theory, redesigning the work system should aim at eliminating the negative aspects of work; however, this is not always feasible or practical. The Balance Theory, therefore, proposes an alternative approach aimed at compensating for or balancing out the negative aspects of work. For instance, “making available to nurses resources and social support to assist them in accomplishing their duties” can be conceptualized as a compensating mechanism: different types of support, practical support, affective support) can be provided to help nurses deal with negative aspects of their work, such as workload.
Another key concept of the human factors engineering approach to nursing workload is the work system: any change in one element of the work system can affect other elements of the work system in negative and/or positive ways. For example, work hour limits for physicians have affected nurse schedules. Nurses are often required to work increased overtime to compensate for reduced physician hours. This is an example of how changing one element in the work system of physicians can negatively affect the work system of nurses.
With the implementation of Occupational Safety and Health Act,1994 and measures taken by national agencies such as the Department of Occupational Safety and Health and National Institute, the prevalence of reported workplace accidents in Malaysia has fallen from 21.4 per 1000 workers in 1993 to 6.7 in 2004. But, work-related accidents and occupational illness however remains a major problem (Lee, 2005 in Barnett, M. ( 2010). These findings also apply to the variety of clinical environments in nurses’ work; and whilst little is known about the impact many workplace hazards have on nurses. Thus, this situation actually giving the nurses a stressful job with the burden of workloads.
To conclude it, I would like to summarize that nursing workload is affected by staffing level and patients’ conditions, but also by the design of the nurses’ work system. The highly technology in nursing and health care department itself do give a great impact on nurses’ workloads and development.
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