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High Nursing Workload: Definition and Causes

Question:

Discuss about the Professional Issues of Nursing Workload.

Burnout, medical errors and adverse events in nursing practice are some of the major challenges that affect nurse’s performance and influence their motivation and satisfaction with the nursing job. All the above mentioned issues are mainly caused by the situation of high nursing working load which acts as the main mediator of escalating injuries, poor health outcomes and deterioration in quality of care in health care setting (Koy et al. 2015). This essay provides a detailed insight into the professional issue of nursing workload and explains the negative impact of the issue on the nursing practice. With special emphasis on 

High workload is a critical professional issue in nursing practice. Heavy workload for the nurses is defined by the amount of nursing time, the amount of physical exertion in shift, complexity of care and level of nursing competency (Alghamdi 2016). Increase in any of these factors contributes to high workload and high burden for nurses. In short, nursing workload can be defined as the amount of time spend by nurses in direct or indirect care of patient, workplace and professional development (Alghamdi 2016). The overload experienced by nurses can be categorized into unit level, job level, patient level and situation level. The specialty of nurses and type of practice also determines the level of workload for nurses (Consiglio et al. 2014).

The changing health care environment has mainly contributed to heavy workload for nurses. With the increase in ageing population, the demand of nurses in health care system has increased. In addition, inadequate supply of nurses and reduced staffing levels had made it necessary for nurses to work overtime. The above trend in health care practice has influenced nursing workload, quality of care as well as patient safety. Work environment factors and staffing level also determines’ nurses satisfaction with their job and commitment towards delivering high quality care (Carayon and Gurses 2008). However, many nurses have reported their due to high workload, they have lost motivation in work as it has contributed to high number of errors and patients safety related issues. The complex work environment and the demand to work outside shift have increased the mental workload of nurses too (Caruso 2014). As high nursing workload can have an impact on nurse’s productivity, satisfaction level, turnover rate, work stress and patient safety, it is necessary to find strategies to reduce the workload burden of nurse in care.

Impact of High Nursing Workload on Nurses and Nursing Practice

The issue of nursing workload is of significant professional importance for nursing practice because it has direct impact both on the nurses individually as well as the nursing profession. High workload contributes to poor nursing performance, poor satisfaction with the job, burnout issues and high rate of nursing errors. The evidence by Hayes, Douglas and Bonner (2015) has shown that the performance of the nurse is highly affected by the work environment, stress level, work characteristics and job satisfaction. The study also pointed out that even when the work environment is favorable, then also nurses experience high level of burnout. This is mainly because of the complexity of the job and greater level of stress involved in delivering care. The nursing workload is also defined by nurse’s competency in the job and research has showed that younger nurse experience higher level of stress compared to experienced nurses. The lowest level of job satisfaction and highest level of burnout is mainly found in newly placed nurse as they are not accustomed to handling the complexities of the job (Flinkma and Salanterä 2015). As nurses are the one who spend the maximum time in the care of patient, it is very important to respond to the workload issue for nurses. Implementing strategies in the direction of addressing workload and high level of burnout in nurses is likely to increase job satisfaction level and turnover rate of nurses.

Association has also been found between nursing workload and the nursing profession. This can be said because the stress level or workload of nurses is also increased by decreased staffing ratio and increase in worse outcome for patients. Link has been found between nurse-staffs ratios and patient outcome. For example, the investigation about staffing level and mortality in patients has revealed that high workload/staffing ratios is associated with increased risk of death in critically ill patients (Shekelle 2013). Hence, the evidence mainly implies that maintaining the nurse staffing level is crucial to manage workload as well as improve patient outcome. Both competency to manage complex situation and promoting positive outcome of patient is an indication of quality nursing practice, however high workload has impact on these areas of the nursing profession.

 The nursing burnout is highly linked to nurse practice environment and nurse working characteristics. Van Bogaert et al. (2014) has shown that variation in perceived nurse practice work environment and burnout feelings results in adverse patient events and high rate of complains, medication errors and nosocomial infection. The nursing unit team particularly plays a role in quality of care and patient safety and treating sensitive issues of patients. However, there is plenty of evidence to prove the association between poor quality of care and feelings of burnout. For instance, Poghosyan et al. (2010) confirmed that dimension of practice environment determines practice outcome, quality of care variables and patient satisfaction with care. Nursing burnout is a direct consequence of high workload and nursing burning directly influences the quality of care. The explorative study regarding the relationship between the quality of care and nurse burnout among nurses in six countries has revealed that nurses experiencing burnout have lesser capability to deliver high quality care and increase in errors results in emotional distress and disengagement in nurses. Complex practice environment and longer shift time predispose nurses to burnout. This implies that nurse burnout and nursing shortage is a challenging issue in nursing practice as this mainly determines the patient safety level and quality of care. To improve the nurse related quality of care, addressing the nurse-patient ratio and work environment of nurse will be necessary (Humphries et al. 2017).

Association between Nursing Workload and Nursing Profession

As the issue of nursing workload and nursing practice has direct impact on the engagement of nurse and motivation in nursing practice, it will directly affect patient safety too. The main goal of nursing practice is achieve optimal health outcome for patient and maintain patent safety. Patient safety is defined by the reduction in the risk of adverse events for patient starting from diagnosis to treatment in health care setting. To achieve the culture of patient safety, special emphasis is paid on preventing errors, learning from errors and complying with safety protocols throughout the health care delivery process (Weaver et al., 2013).

The main role of nurse in patient safety is related to avoiding medication errors and preventing fall in patients. However, the opposite outcome has often been witnessed due to high workload and burnout experience in nurses. The study by MacPhee et al. (2017) gives an insight into the impact of heavy nursing workload on patient outcomes. The cross-sectional study with acute care nurses mainly investigated about the workload factors of staffing level, nurses perception of heavy workload, interruptions in work flow and compromise care standard. The patient outcomes that were evaluated included frequency of medication errors, patient falls and urinary tract infections. The study result gave the indication that heavy workload and task interruptions had a direct impact on patient and nurse outcomes. High patient-RN rations were weakly associated with adverse patient outcomes and heavy workload was independent predictor of adverse patient outcomes. This proves that different levels of nursing workload and workload demands have differential effects on patient and patient related outcomes.

The chances of patient adverse events increase when the number of patients allocated to single nurse is high. In the situation of insufficient nursing workforce and high workload, the likelihood of medication errors, patients falls, nosocomial infections, death, cardiopulmonary resuscitation failures and pressure sores increases (Cho et al. 2016). The study regarding nurse perception of workload and adverse events showed that nosocomial infection (57.1%) was most frequently experienced by patients followed by pressure sores (45.2%) and medication errors (40%). The nursing workload variable of performance of non-nursing task was mainly associated with high rate of falls and nosocomial infections in patients. Bed to nurse ratio had an impact on incidence of pressure sores in patients (Kan et al. 2016). Parry et al. (2015) also gave the insight that environmental domain of clinical workload and work environment and personal domain of Registered Nurse’s characteristics and lived experience of work had an impact on medication administrative behavior of nurses. Environmental domain was found to increase medication rates in nurses. There is a need to establish the link between the environment and nurse’s behavior to prevent adverse events and promote patient safety.

Nursing Burnout and its Link to Nursing Practice Environment and Working Characteristics

As patient related adverse events such as falls and medication is directly caused by high nursing workload, there is a need to identify the strategies that can minimize the impact of the nursing workload on patient safety. Two effective strategies include the following:

  1. The first strategy is to enhance the positive practice environment in clinical setting to retain skilful nurse and improve the quality of care. This can be done by addressing the staffing levels and resource adequacy in nursing practice. The workload and work demands needs to be balanced to ensure that appropriate number of nursing staffs are there to handle patients in particular units. This will ensure that nurses work according to role expectation and deliver care in an effective manner without causing any injury or adverse events for patients. As low nurse-patient ration and high work demand often results in burnout in nurses, there is also a need to maintain adequate staffing levels so that all leave requirement for nurses can be fulfilled and they can get breaks or rest in between shift (Twigg and McCullough 2014). This is vital for improving the retention rate as well as improving the patient safety.
  2. Medication error is one of the common patient related adverse outcome that is observed in clinical setting due to poor staffing level and high nursing workload. Several distractions and interruptions during the medication administration mainly results in medication errors and poor outcome for patients. The frequency of such errors can be significantly reduced by the creation of safe environment during medication preparation and administration. One of the effective strategies is to put ‘Do not disturb’ labels during drug administration to minimize disruptions and ensure full concentration of nurses during the procedures. There is also a need to support nurses in the implementation of five rights of medication administration to promote safety of patient (Kim and Bates 2013). Westbrook et al. (2017) proved the effectiveness of ‘Do not interrupt’ intervention on reducing interruptions during medication administration. It led to the declined in the non-medication related interruptions faced by nurses and promoted safety of patients. In addition, supportive environment to ensure compliance of nurses to five right of medication administration can reduce the error rates.

Conclusion

The essay summarized the professional issues of nursing workload on quality of nursing care and patient safety. The review of the impact of the professional issue on nursing practice gives the idea that high workload and poor nursing performance occurs due to low patient-staff ration, high work demand and lack of appropriate work environment to provide care. The strategy of maintain staffing levels and reinforcing the right to safe medication administration is crucial to minimize adverse events in nursing practice and reduce incidence of burnout in nurses.

References

Alghamdi, M.G., 2016. Nursing workload: a concept analysis. Journal of nursing management, 24(4), pp.449-457.

Caruso, C.C., 2014. Negative impacts of shiftwork and long work hours. Rehabilitation Nursing, 39(1), pp.16-25.

Cho, E., Chin, D. L., Kim, S., and Hong, O. 2016. The relationships of nurse staffing level and work environment with patient adverse events. Journal of Nursing Scholarship, 48(1), 74-82.

Consiglio, C., Borgogni, L., Vecchione, M., and Maslach, C. 2014. Self-efficacy, perceptions of context, and burnout: a multilevel study on nurses. La Medicina del lavoro, 105(4), 255-268.

Flinkman, M. and Salanterä, S., 2015. Early career experiences and perceptions–a qualitative exploration of the turnover of young registered nurses and intention to leave the nursing profession in Finland. Journal of nursing management, 23(8), pp.1050-1057.

Hayes, B., Douglas, C. and Bonner, A., 2015. Work environment, job satisfaction, stress and burnout among haemodialysis nurses. Journal of nursing management, 23(5), pp.588-598.

Humphries, N., Morgan, K., Catherine Conry, M., McGowan, Y., Montgomery, A. and McGee, H., 2014. Quality of care and health professional burnout: narrative literature review. International journal of health care quality assurance, 27(4), pp.293-307.

Kang, J.H., Kim, C.W. and Lee, S.Y., 2016. Nurse-Perceived Patient Adverse Events depend on Nursing Workload. Osong public health and research perspectives, 7(1), pp.56-62.

Kim, J., and Bates, D. W. 2013. Medication administration errors by nurses: adherence to guidelines. Journal of Clinical Nursing, 22(3-4), 590-598.

Koy, V., Yunibhand, J., Angsuroch, Y. and Fisher, M.L., 2017. Relationship between nursing care quality, nurse staffing, nurse job satisfaction, nurse practice environment, and burnout: literature review. International Journal of Research in Medical Sciences, 3(8), pp.1825-1831.

MacPhee, M., Dahinten, V.S. and Havaei, F., 2017. The impact of heavy perceived nurse workloads on patient and nurse outcomes. Administrative Sciences, 7(1), p.7.

Parry, A.M., Barriball, K.L. and While, A.E., 2015. Factors contributing to Registered Nurse medication administration error: A narrative review. International journal of nursing studies, 52(1), pp.403-420.

Poghosyan, L., Clarke, S. P., Finlayson, M., and Aiken, L. H. 2010. Nurse burnout and quality of care: Cross?national investigation in six countries. Research in nursing & health, 33(4), 288-298.

Shekelle, P.G., 2013. Nurse–Patient Ratios as a Patient Safety StrategyA Systematic Review. Annals of Internal Medicine, 158(5_Part_2), pp.404-409.

Twigg, D. and McCullough, K., 2014. Nurse retention: a review of strategies to create and enhance positive practice environments in clinical settings. International journal of nursing studies, 51(1), pp.85-92.

Van Bogaert, P., Timmermans, O., Weeks, S. M., van Heusden, D., Wouters, K., and Franck, E. 2014. Nursing unit teams matter: Impact of unit-level nurse practice environment, nurse work characteristics, and burnout on nurse reported job outcomes, and quality of care, and patient adverse events—A cross-sectional survey. International journal of nursing studies, 51(8), 1123-1134.

Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., and Dy, S. M. 2013. Promoting a Culture of Safety as a Patient Safety StrategyA Systematic Review. Annals of internal medicine, 158(5_Part_2), 369-374.

Westbrook, J.I., Li, L., Hooper, T.D., Raban, M.Z., Middleton, S. and Lehnbom, E.C., 2017. Effectiveness of a ‘Do not interrupt’bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study. BMJ Qual Saf, Published Online First: 23 February 2017. doi: 10.1136/bmjqs-2016-006123

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