Background

The heavy workload of hospital nurses is a major problem for the American health care system. Nurses are experiencing higher workloads than ever before due to four main reasons: (1) increased demand for nurses, (2) inadequate supply of nurses, (3) reduced staffing and increased overtime, and (4) reduction in patient length of stay.

First, the demand for nurses is increasing as a result of population aging. Between 2000 and 2020, the United States population is expected to grow by 18 percent (31 million), but the over-65 population, with more health care needs, is expected to grow by 54 percent (19 million).^{1, 2} Second, the supply of nurses is not adequate to meet the current demand, and the shortage is projected to grow more severe as future demand increases and nursing schools are not able to keep up with the increasing educational demand.^{3, 4} When a nursing shortage occurs, the workload increases for those who remain on the job.⁵ Third, in response to increasing health care costs since the 1990s, hospitals reduced their nursing staffs and implemented mandatory overtime policies to meet unexpectedly high demands, which significantly increased nursing workloads. Fourth, increasing cost pressure forced health care organizations to reduce patient length of stay. As a result, hospital nurses today take care of patients who are sicker than in the past; therefore, their work is more intensive.⁶

There are several important consequences of high nursing workload. Research shows that a heavy nursing workload adversely affects patient safety.⁷ Furthermore, it negatively affects nursing job satisfaction and, as a result, contributes to high turnover and the nursing shortage.⁸ In addition to the higher patient acuity, work system factors and expectations also contribute to the nurses’ workload: nurses are expected to perform nonprofessional tasks such as delivering and retrieving food trays; housekeeping duties; transporting patients; and ordering, coordinating, or performing ancillary services.⁹ A 1998–1999 survey of more than 43,000 nurses in five countries found that 17 percent to 39 percent of respondents planned to leave their job within a year because of job demands.⁹ Heavy nursing workload increases burnout and job dissatisfaction, which in turn contributes to high nurse turnover.¹⁰ This chapter focuses on the impact of nursing workload on patient safety. We first present different concepts and models of nursing workload, then discuss the impact of workload on patients and on nursing staff, presenting various mechanisms of the relationship between nursing workload and patient safety. Finally, we describe a human factors engineering approach on how work systems can be redesigned to reduce nursing workload or to minimize the negative impact of a heavy nursing workload.

Concepts and Models of Nursing Workload

Nursing workload measures can be categorized into four levels: (1) unit level, (2) job level, (3) patient level, and (4) situation level.¹¹ These measures can be organized into a hierarchy. The situation- and patient-level workloads are embedded in the job-level workload, and the job-level workload is embedded in the unit-level workload. In a clinical unit, for example, numerous nursing tasks need to be performed by a group of nurses during a specific shift (unit-level workload). The type and amount of workload of nurses is partly determined by the type of unit and specialty (e.g., intensive care unit [ICU] nurse versus general floor nurse), which is the job-level workload. When performing their job, nurses encounter various situations and patients, which are determinants of the situation- and patient-level workloads.

Research Evidence

How Does Nursing Workload Impact Patient Safety?

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 (see Table 1). 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 coworkers and team members.

Table 1

Relationship Between Nursing Workload and Patient Safety

Nursing workload and lack of time

Nursing workload definitely affects the time that a nurse can allot to various tasks. Under a heavy workload, nurses may not have sufficient time to perform tasks that can have a direct effect on patient safety. A heavy nursing workload can influence the care provider’s decision to perform various procedures.⁴¹ A heavy workload may also reduce the time spent by nurses collaborating and communicating with physicians, therefore affecting the quality of nurse-physician collaboration.⁴² A heavy workload can lead to poor nurse-patient communication.^{43, 44}

Nursing workload and deteriorated motivation

Several studies have shown the relationship between nurses’ working conditions, such as high workload, and job dissatisfaction.^{10, 45, 46} Job dissatisfaction of nurses can lead to low morale, absenteeism, turnover, and poor job performance, and potentially threaten patient care quality and organizational effectiveness.⁴⁷ Researchers have found positive associations between job satisfaction and job performance,⁴⁸ and patient satisfaction and quality of care.⁴⁹

Impact of workload on nursing stress and burnout

High workload is a key job stressor of nurses in a variety of care settings, such as ICUs.^{15, 16, 50} A heavy nursing workload can lead to distress (e.g., cynicism, anger, and emotional exhaustion)⁵¹ and burnout.¹⁰ 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.

Nursing workload and errors

Workload can be a factor contributing to errors.^{52, 53} Errors have been classified as (1) slips and lapses or execution errors, and (2) mistakes or knowledge errors.⁵² 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 workload and violations or work-arounds

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.⁵⁴ The literature on violations emphasizes the role of the social and organizational context, where behavior is governed by operating procedures, codes of practice, rules, and regulations.^{54, 55} 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.⁵⁶ 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.

Alper and colleagues⁵⁷ 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.

Systemic, organizational impact of nursing workload

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. This lack of time may also result in inadequate training or supervision of new nurses.

Practice and Research Implications

We propose a human factors engineering approach to nursing workload and patient safety, which is based on the SEIPS model of work system and patient safety.^{58, 59} This approach is based on the key principle of human factors engineering, i.e., work system design.^{60, 61} According to the work system model, several elements of the work system can affect nurses and their performance, safety, and well-being.⁵⁸ These work system elements are causes or factors contributing to nursing workload. The first step of the proposed approach is therefore to understand how the work system of nurses can contribute to their workload. Human factors engineers have developed and used various methods to assess each element of the work system model and the interaction between the elements,⁶² such as observations of the work situation;^{62, 63} direct measurement of the work environment and workstation; and interviews, focus groups, and survey of workers.^{40, 64} Once the human factors engineers have identified the elements and characteristics of the nurses’ work system that contribute to workload, they can redesign the work system to reduce the workload.

In a previous study,²³ the causes of situational workload experienced by nurses in 17 ICUs in Wisconsin were identified, demonstrating that there were differences in the factors that lead to a heavy nursing workload in different ICUs. For example, compared to their colleagues in other participating ICUs, a higher number of nurses of a 24-bed medical surgical ICU reported the following factors that led to high workload: difficulty finding a place to sit down and do paperwork, distance between patients’ rooms, poor condition of the equipment, spending a lot of time searching for patients’ charts, and a crowded and disorganized work environment. Since this ICU was larger than the other ICUs in the study and many specialties were involved in the care of patients in this ICU, it was not surprising to see such work system factors as a crowded and disorganized work environment, and spending a lot of time searching for patients’ charts (e.g., different specialties searching for the chart during the day).

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: (1) eliminating the source of the excessive workload, or (2) compensating or balancing out the workload.^{60, 61} 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”^{50, 51} can be conceptualized as a compensating mechanism: different types of support (e.g., informational 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.^{60, 61} For instance, work hour limits for physicians have affected nurse schedules. Nurses are often required to work increased overtime to compensate for reduced physician hours.⁶⁵ This is an example of how changing one element in the work system of physicians can negatively affect the work system of nurses. Table 2 summarizes the research implications of the proposed human factors engineering approach to nursing workload and patient safety.

Table 2

Research Implications on Nursing Workload and Patient Safety

Conclusion

Nursing workload is affected by staffing levels and the patients’ conditions, but also by the design of the nurses’ work system. In this chapter, a description of different levels of workload, including situational workload, was offered, and a proposal for a human factors engineering approach aimed at reducing workload or at mitigating or balancing the impact of workload on nurses and patient care was suggested.

Evidence Table

Nurse workload and patient safety

Acknowledgments

This chapter is partially based on a project funded by a Health Services Research Dissertation Grant (# R03 HS14517-01) from the Agency for Healthcare Research and Quality.

References

1.

General Accounting Office. Nursing workforce—recruitment and retention of nurses and nurse aides is a growing concern. Washington, DC: United States General Accounting Office; 2001. No. GAO-01-750T.

2.

General Accounting Office. Nursing workforce: emerging nurse shortages due to multiple factors. Washington, DC: United States General Accounting Office; 2001. No. GAO-01-944.

3.

US DHHS. HRSA Bureau of Health Professions National Center for Health Workforce Analysis. Projected supply, demand, and shortages of registered nurses: 2000–2020. Rockville, MD: U.S. Government Printing Office; 2002.

4.

Kuehn BM. No end in sight to nursing shortage: bottleneck at nursing schools a key factor. JAMA. 2007 October 10;:298, 1623–5. [PubMed: 17925507]

5.

Baumann A, Giovannetti P, O'Brien-Pallas L, et al. Healthcare restructuring: the impact of job change. Can J Nurs Leadersh. 2001;14:14–20. [PubMed: 15487309]

6.

Aiken L, Sochalski J, Anderson G. Downsizing the hospital nursing workforce. Health Aff. 1996;15:88–92. [PubMed: 8991258]

7.

Lang TA, Hodge M, Olson V, et al. Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Adm. 2004;34(7–8):326–37. [PubMed: 15303051]

8.

Duffield C, O'Brien-Pallas L. The causes and consequences of nursing shortages: a helicopter view of the research. Aust Health Rev. 2003;26(1):186–93. [PubMed: 15485390]

9.

Aiken LH, Clarke SP, Sloane DM, et al. Nurses' reports on hospital care in five countries. Health Aff. 2001;20(3):43–53. [PubMed: 11585181]

10.

Aiken LJ, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–93. [PubMed: 12387650]

11.

Carayon P, Gurses A. Nursing workload and patient safety in intensive care units: a human factors engineering evaluation of the literature. Intensive Crit Care Nurs. 2005;21:284–301. [PubMed: 16182125]

12.

Amaravadi RK, Dimick JB, Pronovost PJ, et al. ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. Intensive Care Med. 2000;26(12):1857–62. [PubMed: 11271096]

13.

Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346(22):1715–22. [PubMed: 12037152]

14.

Schaufeli W, Le Blanc P. Personnel. In: Miranda DR, Ryan DW, Schaufeli WB, et al., editors. Organisation and management of intensive care: a prospective study in 12 European countries. Berlin: Springer-Verlag; 1998. pp. 169–205.

15.

Crickmore R. A review of stress in the intensive care unit. Intensive Care Nurs. 1987;3:19–27. [PubMed: 3647073]

16.

Malacrida R, Bomio D, Matathia R, et al. Computer-aided self-observation psychological stressors in an ICU. Int J Clin Monit Comput. 1991;8:201–5. [PubMed: 1779183]

17.

Freeman T, O’Brien-Pallas LL. Factors influencing job satisfaction on specialty nursing units. Canadian J Nurs Adm. 1998;11(3):25–51. [PubMed: 9855884]

18.

Oates PR, Oates RK. Stress and work relationships in the neonatal intensive care unit: are they worse than in the wards. J Paediatr Child Health. 1996;32:57–9. [PubMed: 8652216]

19.

Carayon P, Gurses AP, Hundt AS, et al. Performance obstacles and facilitators of healthcare providers. In: Korunka C, Hoffmann P, editors. Change and quality in human service work Vol 4 Munchen. Germany: Hampp Publishers; 2005. pp. 257–76.

20.

Cullen DJ, Civetta JM, Briggs BA, et al. Therapeutic intervention scoring system: a method for quantitative comparison of patient care. Crit Care Med. 1974;2(2):57–60. [PubMed: 4832281]

21.

Keene AR, Cullen DJ. Therapeutic intervention scoring system: update 1983. Crit Care Med. 1983;11(1):1–3. [PubMed: 6848305]

22.

Gurses AP, Carayon P. Performance obstacles of intensive care nurses. Nurs Res. 2007;56(3):185–94. [PubMed: 17495574]

23.

Gurses AP. ICU nursing workload: causes and consequences—final report. Rockville, MD: Agency for Healthcare Research and Quality; 2005. Available at: http://hfrp​.umaryland​.edu/People/gurses_AHRQ​_final_report-06-15-05.pdf.

24.

Keijsers GJ, Schaufeli WB, LeBlanc PM, et al. Performance and burnout in intensive care units. Work Stress. 1995;9:513–27.

25.

Anderson FD, Maloney JP. A descriptive, correlational study of patient satisfaction, provider satisfaction, and provider workload at an Army medical center. Mil Med. 1998;163(2):90–4. [PubMed: 9503899]

26.

Stanton MW, Rutherford MK. Hospital nurse staffing and quality of care. Rockville, MD: Agency for Healthcare Research and Quality; 2004. AHRQ Pub No 04–0029.

27.

Hughes RG, Clancy CM. Working conditions that support patient safety. J Nurs Care Qual. 2005;20(4):289–92. [PubMed: 16177577]

28.

Cho SH, Ketefian S, Barkauskas VH, et al. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res. 2003;52(2):71–9. [PubMed: 12657982]

29.

Kovner C, Cheryl J, Chunliu Z, et al. Nurse staffing and postsurgical adverse events: an analysis of administrative data from a sample of U.S. hospitals, 1990–1996. Health Serv Res. 2002;37(3):611–29. [PMC free article: PMC1434654] [PubMed: 12132597]

30.

Kovner C, Mezey M, Harrington C. Research priorities for staffing, case mix, and quality of care in U.S. nursing homes. J Nurs Sch. 2000;32(1):77–80. [PubMed: 10819742]

31.

Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image J Nurs Sch. 1998;30(4):315–21. [PubMed: 9866290]

32.

Unruh L. Licensed nurse staffing and adverse events in hospitals. Med Care. 2003;41(1):142–52. [PubMed: 12544551]

33.

Harbarth S, Sudre P, Dharan S, et al. Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices. Infect Control Hosp Epidemiol. 1999;20(9):598–603. [PubMed: 10501256]

34.

Archibald LK, Manning ML, Bell LM, et al. Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. Pediatr Infect Dis J. 1997;16:1045–8. [PubMed: 9384337]

35.

Manheim LM, Feinglass J, Shortell SM, et al. Regional variation in Medicare hospital mortality. Inquiry. 1992;29(1):55–66. [PubMed: 1559724]

36.

Pronovost PJ, Jenckes MW, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281:1310–7. [PubMed: 10208147]

37.

Lichtig LK, Knauf RA, Milholland DK. Some impacts of nursing on acute care hospital outcomes. J Nurs Adm. 1999;29(2):25–33. [PubMed: 10029799]

38.

Beckmann U, Baldwin I, Durie M, et al. Problems associated with nursing staff shortage: an analysis of the first 3600 incident reports submitted to the Australian Incident Monitoring Study (AIMS-ICU). Anaesth Intensive Care. 1998;26:396–400. [PubMed: 9743855]

39.

Carayon P, Alvarado CJ, Brennan P, et al. Work system and patient safety. In: Luczak H, Zink KJ, editors. Human factors in organizational design and management. Vol. 6. Santa Monica, CA: IEA Press; 2003. pp. 583–9.

40.

Carayon P, Alvarado CJ, Hundt AS, et al. Patient safety in outpatient surgery: the viewpoint of the healthcare providers. Ergonomics. 2006;49:470–85. [PubMed: 16717005]

41.

Griffith CH, Wilson JF, Desai NS, et al. Housestaff workload and procedure frequency in the neonatal intensive care unit. Crit Care Med. 1999;27:815–20. [PubMed: 10321675]

42.

Baggs JD, Schmitt MH, Mushlin AI, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27:1991–8. [PubMed: 10507630]

43.

Davis S, Kristjanson LJ, Blight J. Communicating with families of patients in an acute hospital with advanced cancer: problems and strategies identified by nurses. Cancer Nurs. 2003;26:337–45. [PubMed: 14710794]

44.

Llenore E, Ogle KR. Nurse-patient communication in the intensive care unit: a review of the literature. Aust Crit Care. 1999;12(4):142–5. [PubMed: 11271028]

45.

Bratton RL, Cody C. Telemedicine applications in primary care: a geriatric patient pilot project. Mayo Clin Proc. 2000;75:365–8. [PubMed: 10761491]

46.

Darvas JA, Hawkins LG. What makes a good intensive care unit: a nursing perspective. Aust Crit Care. 2002;15(2):77–82. [PubMed: 12154701]

47.

Cavanagh SJ. Job satisfaction of nursing staff working in hospitals. J Adv Nurs. 1992;17:704–11. [PubMed: 1607503]

48.

McCloskey JC, McCain BE. Satisfaction, commitment and professionalism of newly employed nurses. Image: J Nurs Sch. 1987;19(1):20–4. [PubMed: 3644777]

49.

Tarnowski-Goodell T, Van Ess Coeling H. Outcomes of nurses' job satisfaction. J Nurs Adm. 1994;24(11):36–41. [PubMed: 7965180]

50.

Oates RK, Oates P. Stress and mental health in neonatal intensive care units. Arch Dis Child. 1995;72:F107–10. [PMC free article: PMC2528393] [PubMed: 7712267]

51.

Greenglass ER, Burke RJ, Moore KA. Reactions to increased workload: effects on professional efficacy of nurses. Appl Psychol: An International Review. 2003;52(4):580–97.

52.

Reason J. Human error. Cambridge, UK: Cambridge University Press; 1990.

53.

Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154–7. [PMC free article: PMC1112945] [PubMed: 9552960]

54.

Reason J, Manstead A, Stradling S, et al. Errors and violations on the roads: a real distinction? Ergonomics. 1990;33:1315–32. [PubMed: 20073122]

55.

Lawton R. Not working to rule: understanding procedural violations at work. Saf Sci. 1998;28:77–95.

56.

Parker D, Lawton R. Judging the use of clinical protocols by fellow professionals. Soc Sci Med. 2000;51:669–77. [PubMed: 10975227]

57.

Alper SJ, Karsh B, Holden RJ, et al. Protocol violations during medication administration in pediatrics. The Human Factors and Ergonomics Society; Proceedings of the Human Factors and Ergonomics Society 50th annual meeting; Santa Monica, CA: The Human Factors and Ergonomics Society; 2006. pp. 1019–23.

58.

Carayon P, Alvarado C. Workload and patient safety among critical care nurses. Crit Care Nurs Clin North Am. 2007;8(5):395–428. [PubMed: 17512468]

59.

Carayon P, Hundt AS, Karsh BT, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15(Suppl I):i50–8. [PMC free article: PMC2464868] [PubMed: 17142610]

60.

Carayon P, Smith MJ. Work organization and ergonomics. Appl Ergon. 2000;31:649–62. [PubMed: 11132049]

61.

Smith MJ, Carayon-Sainfort P. A balance theory of job design for stress reduction. Int J Ind Ergon. 1989;4:67–79.

62.

Wilson JR, Corlett N, editors. Evaluation of human work. 3rd ed. Boca Raton, FL: CRC Press; 2005.

63.

Carayon P, Wetterneck TB, Hundt AS, et al. Evaluation of nurse interaction with bar code medication administration technology in the work environment. J Patient Safety. 2007;3(1):34–42.

64.

Carayon P, Alvarado CJ, Hundt AS, et al. Employee questionnaire survey for assessing patient safety in outpatient surgery. In: Henriksen K, Battles JB, Marks E, et al., editors. Advances in patient safety: from research to implementation. 4 . Rockville, MD: Agency for Healthcare Research and Quality; 2005. pp. 461–73. [PubMed: 21250041]

65.

Lundstrom T, Pugliese G, Bartley J, et al. Organizational and environmental factors that affect worker health and safety and patient outcomes. Am J Infect Control. 2002;30(2):93–106. [PubMed: 11944001]