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Workload and Patient Safety Among Critical Care Nurses
Crit Care Nurs Clin N Am 19 (2007) 121–129
Workload and Patient Safety Among Critical Care Nurses Pascale Carayon, PhDa,*, Carla J. Alvarado, PhD, CICb, Systems Engineering Initiative for Patient Safety a
Center for Quality and Productivity Improvement and Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 610 Walnut Street, 575 WARF, Madison, WI 53726, USA b Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 610 Walnut Street, 575 WARF, Madison, WI 53726, USA
Workload is a major characteristic of the work environment of critical care nurses [1]. It also is one of the most important job stressors among ICU nurses [2–6], which may have negative consequences for nurses and the patients they care for. An analysis of the Australian Incident Monitoring Study data for ICUs shows that a nursing staff shortage may lead to compromised quality of care [7]. The main cause of nursing staff shortage was inappropriate staffing for patient load (81% of the incidents). Insufficient nursing staff was linked to problems with incorrect matching of patient needs and staff experience, suboptimal standard of nursing care and patient supervision, inadequate supervision of inexperienced staff, and subsequent inadequate documentation. The nursing shortage and the resulting understaffing can create conditions of high workload for critical care nurses. A lot of work has been done to develop measures of workload in ICUs. These measures often are focused on ICU patient needs, patient acuity, or severity of illness [1]. These patient-level measures of workload include the Therapeutic Intervention Scoring System [8,9], Nursing Manpower Use Score [10], Nursing Activities Score [11], and Comprehensive Nursing Intervention Score [12]. There is increasing recognition that measures of nursing workload in ICUs at the patient level are not sufficient and need to include
* Corresponding author. E-mail address: [email protected] (P. Carayon).
measures of organizational and system factors [1,13]. Spence and colleagues [13] identified several system factors that contribute to nursing workload as measured by the Patient Dependency Score (an estimate of the nursing hours required for patient care at different levels of dependency). The most significant factors were related to the organization of work (ie, organization of managers, cooperation with doctors, cooperation with peer nurses, use of relief staff, and planning of shift schedules). This article describes the various types of workload faced by critical care nurses, including the physical workload of patient handling. The objective is to show that safe patient handling can be achieved by examining the entire work system of ICU nurses and the various types of workload they experience. The links between workload and patient safety also are described. Dimensions of workload Table 1 shows the various dimensions of workload of critical care nurses and provides examples of each of the dimensions. Physical workload Physical workload of ICU nurses not only is related to nursing practice, including moving, lifting, and bathing patients, but also to disjointed supply sources and missing and nonfunctioning equipment [14]. Disjointed supply sources (supplies or equipment needed for a task located in
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Table 1 Dimensions of workload Dimensions of workload
Definitions and examples
Physical workload Cognitive workload Time pressure Emotional workload
Amount of physical work, including patient handling Information overload Working under temporal constraints and tight deadlines Dealing with emotional issues, such as patient death, end-of-life care, and family demands Amount of work Difficulty of work Changes in workload: increase in workload (eg, code situation) and decrease in workload (eg, night shift)
Quantitative workload Qualitative workload Workload variability
another area of a unit or hospital) and missing or nonfunctioning equipment require repetitive travel around units or even to distant locations in the hospital, such as other patient care units or the central equipment reprocessing area, adding miles of walking to nurses’ activities. Almost all critical care nurses find their work physically strenuous. The physical and ergonomic layout of ICUs often is poor; the limited space between patient beds and ICU equipment is especially problematic. The causes of severest nurse physical workload distress are lifting, working in awkward postures, and stooping [15]. With an increase in bedside procedures and technologies in ICUs, nurses often are required to move heavy equipment in and out of patient areas. There is little or no acknowledgment that this type of task requires heavy lifting and moving; nurses under task and time constraints often find it easier to move equipment alone than to wait for additional help. Although most ICU nurses receive some nursing school education about ergonomics and body mechanics contributing to musculoskeletal injury, few nurses are aware of the amount of lifting they will do in ICUs and the safest ways to perform these tasks. The American Nursing Association believes that the essential functions for most nurses should depend on knowledge and care judgment not physical strength [16]. In defining the clinical role of critical care nursing practice, Brilli and colleagues [17] focus on nurses’ understanding and support for technical medical care, including diagnosis, treatment, care planning, and priority setting; no mention is made of the need for physical lifting and moving equipment. Trinkoff and colleagues [18] have examined a comprehensive array of nursing task physical demands, such as lifting and awkward postures.
Nurses practicing in hospital emergency, critical care, or operating room/post-anesthesia care specialties stated the highest level of physical demands in their work. As the number of selfreported physical demands increased so did the likelihood of inadequate sleep, pain medication use, and absenteeism. Cognitive workload Cognitive workload is related to the need for ICU nurses to process information, often in a short period of time. For instance, code situations require quick decision making and a lot of information that needs to be processed quickly [19]. Critical care nurses do the majority of family communication, patient assessment, evaluation, and care in ICUs. Through their cognitive skills, nurses readily recognize clinical changes that prevent further deterioration in patients [17]. Nurses perform many cognitive adjustments across patients throughout an assigned period of care. These adjustments are planned (eg, work shift changes or morning reports for assigned patients) and unplanned (eg, stable patients suddenly changing status to an unstable condition) [20]. This constant conscious shift in thinking from one patient to another extends far beyond actual bedside care. Nurses often perform cognitive tasks while waiting on other systems or processes (eg, delivery of medications, laboratory results, and retrieving necessary patient supplies). This cognitive and physical multitasking, although common in ICUs with high patient acuity, often is overlooked in management decisions addressing nurse staffing ratios. Additionally, interruptions disrupt nurses’ concentration and cognitive processing. Human beings find it difficult to stay attentive, vigilant,
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and productive, particularly when they are interrupted, fatigued, or in a work overload situation [21]. Nurses whose attention constantly is shifting from one item to another may not be able to formulate a complete and coherent picture of tasks at hand or complete assigned care activities [22]. Some interruptions are necessary, such as pointing out critical monitor changes or emergent needs of other patients assigned to a nurse’s care. Most interruptions are about communicating information or asking questions about patients, however; for instance, asking about information and questions about patients who are soon to be admitted to or discharged from a unit. The stream of constant interruptions disrupts nurses’ ability to identify and assess patient needs, increasing the cognitive workload [20], even potentially leading to patient error. Increased understanding of the work complexity in ICU environments and nurses’ cognitive workload are critical to successful patient safety improvement efforts and the recruitment and retention of critical care nurses [14].
Time pressure Time pressure relates to the need to work fast, under tight deadlines and temporal constraints. High time pressure is related to burnout experienced by ICU nurses [23]. Time pressure is related to the number of tasks ICU nurses have to perform under temporal constraints. ICU nurses perform a large variety of tasks, including assessments, measurements, documentations, and therapies on a regular or frequent basis. Changes in standards of care for ICU patients sometimes can introduce additional tasks for ICU nurses, therefore adding to the already high time pressure. One example is the introduction of glycemic control, which involves insulin infusions and monitoring of blood glucose levels. This requires additional work by ICU nurses, up to 2 hours for a single patient during a 24-hour period [24].
Emotional workload Emotional workload is prevalent particularly in critical care environments because of patient acuity and severity. Critical care nurses deal with very sick patients and are the main interface with the families of those patients. ICU nurses are educated and trained to provide highly technical expert care and also need to deal with end-of-life
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care [25]. Often, ICU nurses experience obstacles to providing end-of-life care that can add to their emotional workload. The following obstacles are reported by ICU nurses: continuing aggressive treatment even when advanced directives exist, physicians too optimistic to a families, and dealing with angry families. Critical care nurses report that dealing with family demands is related to increased workload [26]. Families play an important role in ICUs, such as watching out for the patients or just ’’being there.’’ Sometimes the perspectives of the nurses and the families are not aligned, however, and conflicts or problems may arise [27]. For instance, nurses may experience time limitations in their capacity to handle some of the family situations or demands. Verbal and physical assaults by patients and their families also can be a source of emotional workload [28]. A study by May and Grubbs [28] examines reports of verbal and physical assaults by a group of 86 emergency department, ICU, and general floor nurses. Approximately 85% of the ICU nurses reported verbal assaults by patients and family members and 78% reported physical assaults. Quantitative and qualitative workload Frankenhaeuser and Gardell [29] differentiate quantitative workload from qualitative workload: quantitative workload is defined as the amount of work, and qualitative workload is defined as the difficulty of the work. Quantitative workload of critical care nurses can be measured using the various patient-level measures of workload (discussed previously); these measures provide some measure of the amount of work critical care nurses have to perform. Quantitative workload also is related to work hours: the amount of work performed increases with increasing work hours. Scott and colleagues [30] found that critical care nurses tend to work much longer than their scheduled work shift: in a study of 502 nurses who provided data for 6017 work shifts, they found that in 86% of the shifts, nurses worked longer than scheduled. Longer work duration was related to increased risk for errors and difficulty in staying awake. Fatigue also can contribute to musculoskeletal injuries. Qualitative workload of critical care nurses is related to the rapid pace of knowledge in critical care medicine and nursing and implementation of new technologies and devices. Schaufeli and
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colleagues [31] found that intensive use of sophisticated technology was related to high burnout among ICU nurses. In addition, critical care nurses need to carry out procedures accurately and react to urgent situations efficiently [19]. This time pressure can add to the qualitative workload experienced by nurses.
Workload variability Workload variability is the extent to which workload continually changes during a period of time [32]. Among critical care nurses, one cause of workload variability is related to shifts (eg, day shift versus night shift). ICU nurses who work day shifts report higher levels of perceived workload than ICU nurses who work during night shifts [26]. The higher day shift workload may be correlated directly with other patient care services availability. Many hospital departments are closed or staffed only for emergency care during night shifts. Night shift nurses often describe the shifts as more relaxed, with more time spent with patients because there tend to be fewer interruptions and things are less hectic. Nurses report experiencing a greater sense of autonomy and independence on night shifts as they have control of their work and task time. Night shifts often leave the nurses with sedentary tasks, however, such as charting, organizing supplies, or monitoring sleeping patients. Many night shift nurses admit to developing bad eating patterns. They note that hospital cafeterias are closed at night, leaving them with high-calorie vending machine snacks or takeout pizza as typical meal options in addition to lack of physical exercise in their work tasks. Geliebter and colleagues [33] observed night shift nurses reported gaining more weight, exercising less, and increasing food intake than the day shift group since starting their jobs on their current shift. Code situations are another example of workload variability. Workload suddenly increases because health care providers need to concentrate on the patients in danger, therefore reducing the number of staff available to care for other patients. Additionally, critical care nurses’ role in the code may vary from finding and assessing patients, initiating cardiopulmonary resuscitation before a code team’s arrival, to then recording the events and interventions on the official resuscitation record that documents all events and interventions.
Relations between the dimensions of workload The various dimensions of workload are not independent of each other. For instance, quantitative workload, or the amount of work, is related to physical workload: the more work critical nurses have to perform, the more likely they are exposed to physical workload. The number of patients nurses care for and the nursing requirements of the patients also are related to physical workload. Time pressure combined with physical workload may increase the risk for musculoskeletal injuries significantly for critical care nurses. In rushing to perform a task, nurses may not have the time to use lifting devices. Moreover, a lifting device itself may add to nurses’ workload, as the device used must be decontaminated and made ready for the next patient in a physical environment not designed to facilitate optimal cleaning and disinfection. Nurses actually might choose not to use a safety device as its cleaning or decontamination seems too onerous a task given the physical environment and time pressure. The cognitive workload associated with consistent adherence to patient care guidelines may increase physical workload as nurses encounter problems and barriers to guideline compliance in an ICU. Critical care nurses often are the primary care providers responsible for ensuring compliance with these guidelines. The Institute for Healthcare Improvement [34] is conducting a nationwide effort to save lives by implementing strategies to facilitate guideline compliance. A significant attribute of this program is nurses’ role in monitoring care guideline compliance and taking corrective action with ICU care teams. Although the empowerment of nurses to ‘‘stop the procedure’’ is critical to guideline compliance, it also adds to their cognitive, quantitative, and qualitative workloads.
Sources of workload Understanding that the way work is organized can contribute to workload is critical for developing interventions aimed at reducing (or managing) workload and its impact on critical care nurses. A range of patient care factors also may contribute to high workload in ICUs, such as the number of postoperative events [35]. The authors propose that the work system model of Carayon and Smith [36–38] can be used to describe sources of workload and define the
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interrelationships between the dimensions of workload (Fig. 1). The work system comprises five elements [36,37]: Individual critical care nurses Performance of various tasks (ie, direct care, indirect care, and other tasks; patient care characteristics) Use of various tools, equipment, devices, and technologies Physical environment (eg, the patient room and the nursing station) Specific organizational conditions (eg, shift schedules, nursing management, teamwork, communication with physicians and other health care providers, and interruptions) Physical workload is related particularly to the tasks and their physical characteristics (eg, lifting patients), the availability of equipment and devices, and the layout of patient rooms. These microergonomic factors also are related to the macroergonomic characteristics of the work system, such as an organization’s management being committed to providing the right equipment to nurses. Cognitive workload is affected by the characteristics of the tasks of critical care nurses: those tasks, in particular operational tasks (eg, patient care and psychologic support of patients), can be demanding and at the same time satisfying [39]. Improving the design of nurses’ work system (eg, nurse-physician collaboration) is suggested as a strategy to reduce workload and deal with the nursing shortage crisis [40]. Laschinger and Finegan [41] identified ‘‘empowerment’’ as a predictor of nurses’ perception of workload. Empowerment was conceptualized as a characteristic of work environments that provide nurses with access to
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information, resources, and support necessary for accomplishing their work in a meaningful manner [42]. Organizational factors and other aspects of the work environment of critical care nurses can affect workload. Impact of workload Workload experienced by critical care nurses can lead to various outcomes: (1) impact on health of the nurses, (2) quality of working life (eg, job dissatisfaction, stress, burnout, and turnover intention), and (3) patient safety (see Fig. 1). Impact on health A major impact of working conditions on health of critical care nurses is work-related musculoskeletal disorders, such as back disorders. Physical workload is a working condition that is a primary contributor to work-related musculoskeletal disorders of critical care nurses [18]. The psychosocial aspects of work, however, such as time pressure and emotional workload, also can be contributors to work-related musculoskeletal disorders [43]. Time pressure and emotional workload are job stressors that could lead to increased risk for work-related musculoskeletal disorders via the following mechanisms [43]: (1) job stressors that could lead to physiologic changes (eg, increased muscle tension), which can make critical care nurses more vulnerable to work-related musculoskeletal disorders, (2) job stressors that may heighten the impact of physical workload, and (3) job stressors that may increase nurses’ sensitivity to pain and, therefore, increase the likelihood that nurses experience and report musculoskeletal pain.
Fig. 1. Model of workload of critical care nurses.
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Impact on quality of working life Workload also can affect the quality of working life experienced by critical care nurses, such as job satisfaction, stress, burnout, and attitudes, such as turnover intention. In particular, burnout is recognized as a problem among ICU nurses and is related to high workload [44]. Burnout may be contagious: ICU nurses who perceive that their colleagues are experiencing burnout more likely report burnout, even after controlling for the impact of job stressors (eg, workload) [45]. Physical workload experienced by nurses can affect not only physical health, such as musculoskeletal disorders, but also turnover intention or turnover. Fochsen and colleagues [46] conducted a longitudinal study to identify the predictors of turnover among Swedish nurses. Nurses who reported musculoskeletal problems of the neck and shoulder or knees and those who had limited use of transfer devices were more likely to leave their job. A multifaceted intervention aimed at reducing physical workload of patient handling and workrelated musculoskeletal disorders in nursing home care units and spinal cord injury units was shown effective (eg, decrease in musculoskeletal injuries) and to lead to increased job satisfaction [47]. Impact on patient safety Medical errors are widespread in critical care settings. A prospective observational study by Bracco and colleagues [48] of consecutive patients admitted during 1 year to an ICU examined 777 critical incidents. The cause of the incidents was classified as equipment, patient, or human related. The cause was classified as equipment related when the incident was attributed to a technical equipment failure not associated with human misuse. The cause was classified as human related when actions did not go as intended or an intended action was not the appropriate one. In all other cases, the incident was classified as patient related. Thirty-one percent of the incidents were human-related incidents, 2% equipmentrelated incidents, and 67% patient-related incidents. A recent study by Rothschild and colleagues [49] examined a total of 391 patients admitted over a 1-year period in a medical ICU and a coronary care unit. They found 120 adverse events among 79 patients (20%). The most serious medical errors were found in the category of medication ordering or execution of treatment. Several studies have examined specific types of error in ICUs, such as medication errors. Cullen
and colleagues [50] compared the frequency of adverse drug events (ADEs) and potential ADEs in ICUs and non-ICUs. Two medical and three surgical ICUs and four medical and two surgical general care units participated in the study. The rate of preventable ADEs and potential ADEs in ICUs was 19 events per 1000 patient days, nearly twice the rate in non-ICUs. When adjusting for the number of drugs used, however, no differences were found between ICUs and nonICUs. Several studies have linked medical errors and patient safety to nursing workload. Giraud and colleagues [51] conducted a prospective, observational study to examine iatrogenic complications. A total of 382 patients for 400 consecutive admissions provided data. Thirty-one percent of the admissions had iatrogenic complications. Human errors were involved in 67% of the major iatrogenic complications. The risk for ICU mortality was approximately twofold higher for patients who had iatrogenic complications. A major contributing factor was high or excessive nursing workload. A study of medication administration by Tissot and colleagues [52] detected 132 medication errors in a total of 2009 observed events (6.6%). The researchers attributed the errors not only to deficiencies in the overall organization of the hospital medication track but also to the nursing work overload. Scott and colleagues [30] examined the effects of critical care nurses’ work hours on their vigilance and risk for making an error. Longer shift durations (in particular more than 12.5 consecutive hours) were associated with increased risk for errors and near errors and with increased difficulty staying awake at work. This study did not find an association between decreased vigilance (eg, difficulty staying awake at work) and increased risk for errors. Longer shift durations increase the exposure of critical care nurses to the various dimensions of workload. Systemic impact of workload The impact of workload on various outcomes is systemic. According to the Systems Engineering Initiative for Patient Safety (SEIPS) model of work and patient safety [53], the various outcomes are affected by the characteristics of the work system and also are inter-related. Therefore, the various dimensions of workload likely affect more than one outcome, and the outcomes are related to each other. Nurses who experience back pain
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because of physical workload may not be able to dedicate their full attention to their tasks (cognitive workload) and, therefore, may be more likely to commit an error (impact on patient safety). Therefore, it is important to examine workload of ICU nurses using a systemic approach. A systemic approach to the assessment of workload should fulfill the following objectives: 1. Evaluate the different dimensions of workload experienced by critical care nurses. 2. Identify the work system factors contributing to different facets of workload. 3. Understand the relationships between the different dimensions of workload. 4. Assess the impact of workload on nurses’ and patient outcomes. In the introduction, various measures of patient-related workload were described. This article emphasizes the need to go beyond those measures and include measures of workload that represent the various dimensions of workload. The National Institute of Occupational Safety and Health has created a Web site where various measures of working conditions and job stressors are described [54]. This is a resource for many measures of workload, such as quantitative workload [32] and cognitive demands [55]. Gurses [26] has developed a questionnaire to assess performance obstacles experienced by critical care nurses; this questionnaire can be used to identify the various sources of workload in the work system (ie, performance obstacles). Summary Interventions aimed at improving the safety of care provided by nurses to critical care patients need to consider the work environment, in particular the various types of workload. Sluiter and colleagues [56] implemented a multidisciplinary structured process to evaluate work shifts to enhance team communication. Benefits of the intervention included increased satisfaction with team communication and reduction in emotional exhaustion. This multidisciplinary structured process was used to address the following issues: dealing with pressure of ICUs, teamwork, work roles, and organizational aspects. Such a process could be used to identify the work elements that contribute to different dimensions of workload, to propose interventions to reduce workload, and to plan implementation of these interventions. According to the model of workload of
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critical care nurses presented in Fig. 1, an intervention tackling workload should aim to understand the work system factors that contribute to workload and the various outcomes resulting from the different types of workload. References [1] 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. [2] 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. [3] 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. [4] Clifford C. Patients, relatives and nurses in a technological environment. Intensive Care Nurs 1986;2: 67–72. [5] Crickmore R. A review of stress in the intensive care unit. Intensive Care Nurs 1987;3:19–27. [6] Oates RK, Oates P. Stress and mental health in neonatal intensive care units. Arch Dis Child 1995;72: F107–10. [7] 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. [8] Miranda DR, De Rijk A, Schaufeli W. Simplified therapeutic intervention scoring system: the TISS28 itemsdresults from a multicenter study. Crit Care Med 1996;24(1):64–73. [9] Miranda DR. Quantitating caregiver work load in the ICU: the therapeutic intervention scoring system. Respir Care 1999;44(1):70–2. [10] Miranda DR. Nine equivalents of nursing manpower use score (NEMS). Intensive Care Med 1997;23(7):760–5. [11] Miranda R, Nap R, De Rijk A, et al. Nursing activities score. Crit Care Med 2003;31(2):374–82. [12] Yamase H. Development of a comprehensive scoring system to measure multifaceted nursing workloads in ICU. Nurs Health Sci 2003;5(4):299–308. [13] Spence K, Tarnow-Mordi W, Duncan G, et al. Measuring nursing workload in neonatal intensive care. J Nurs Manag 2006;14(3):227–34. [14] Ebright PR, Patterson ES, Chalko BA, et al. Understanding the complexity of registered nurse work in acute care settings. J Nurs Adm 2003;33(12):630–8. [15] Engels JA, van der Gulden JWJ, Senden TF, et al. Work related risk factors for musculoskeletal complaints in the nursing profesion: results of a questionnaire survey. Occup Environ Med 1996;53(9): 636–41.
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Workload and Patient Safety Among Critical Care Nurses Pascale Carayon, PhDa,*, Carla J. Alvarado, PhD, CICb, Systems Engineering Initiative for Patient Safety a
Center for Quality and Productivity Improvement and Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 610 Walnut Street, 575 WARF, Madison, WI 53726, USA b Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 610 Walnut Street, 575 WARF, Madison, WI 53726, USA
Workload is a major characteristic of the work environment of critical care nurses [1]. It also is one of the most important job stressors among ICU nurses [2–6], which may have negative consequences for nurses and the patients they care for. An analysis of the Australian Incident Monitoring Study data for ICUs shows that a nursing staff shortage may lead to compromised quality of care [7]. The main cause of nursing staff shortage was inappropriate staffing for patient load (81% of the incidents). Insufficient nursing staff was linked to problems with incorrect matching of patient needs and staff experience, suboptimal standard of nursing care and patient supervision, inadequate supervision of inexperienced staff, and subsequent inadequate documentation. The nursing shortage and the resulting understaffing can create conditions of high workload for critical care nurses. A lot of work has been done to develop measures of workload in ICUs. These measures often are focused on ICU patient needs, patient acuity, or severity of illness [1]. These patient-level measures of workload include the Therapeutic Intervention Scoring System [8,9], Nursing Manpower Use Score [10], Nursing Activities Score [11], and Comprehensive Nursing Intervention Score [12]. There is increasing recognition that measures of nursing workload in ICUs at the patient level are not sufficient and need to include
* Corresponding author. E-mail address: [email protected] (P. Carayon).
measures of organizational and system factors [1,13]. Spence and colleagues [13] identified several system factors that contribute to nursing workload as measured by the Patient Dependency Score (an estimate of the nursing hours required for patient care at different levels of dependency). The most significant factors were related to the organization of work (ie, organization of managers, cooperation with doctors, cooperation with peer nurses, use of relief staff, and planning of shift schedules). This article describes the various types of workload faced by critical care nurses, including the physical workload of patient handling. The objective is to show that safe patient handling can be achieved by examining the entire work system of ICU nurses and the various types of workload they experience. The links between workload and patient safety also are described. Dimensions of workload Table 1 shows the various dimensions of workload of critical care nurses and provides examples of each of the dimensions. Physical workload Physical workload of ICU nurses not only is related to nursing practice, including moving, lifting, and bathing patients, but also to disjointed supply sources and missing and nonfunctioning equipment [14]. Disjointed supply sources (supplies or equipment needed for a task located in
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Table 1 Dimensions of workload Dimensions of workload
Definitions and examples
Physical workload Cognitive workload Time pressure Emotional workload
Amount of physical work, including patient handling Information overload Working under temporal constraints and tight deadlines Dealing with emotional issues, such as patient death, end-of-life care, and family demands Amount of work Difficulty of work Changes in workload: increase in workload (eg, code situation) and decrease in workload (eg, night shift)
Quantitative workload Qualitative workload Workload variability
another area of a unit or hospital) and missing or nonfunctioning equipment require repetitive travel around units or even to distant locations in the hospital, such as other patient care units or the central equipment reprocessing area, adding miles of walking to nurses’ activities. Almost all critical care nurses find their work physically strenuous. The physical and ergonomic layout of ICUs often is poor; the limited space between patient beds and ICU equipment is especially problematic. The causes of severest nurse physical workload distress are lifting, working in awkward postures, and stooping [15]. With an increase in bedside procedures and technologies in ICUs, nurses often are required to move heavy equipment in and out of patient areas. There is little or no acknowledgment that this type of task requires heavy lifting and moving; nurses under task and time constraints often find it easier to move equipment alone than to wait for additional help. Although most ICU nurses receive some nursing school education about ergonomics and body mechanics contributing to musculoskeletal injury, few nurses are aware of the amount of lifting they will do in ICUs and the safest ways to perform these tasks. The American Nursing Association believes that the essential functions for most nurses should depend on knowledge and care judgment not physical strength [16]. In defining the clinical role of critical care nursing practice, Brilli and colleagues [17] focus on nurses’ understanding and support for technical medical care, including diagnosis, treatment, care planning, and priority setting; no mention is made of the need for physical lifting and moving equipment. Trinkoff and colleagues [18] have examined a comprehensive array of nursing task physical demands, such as lifting and awkward postures.
Nurses practicing in hospital emergency, critical care, or operating room/post-anesthesia care specialties stated the highest level of physical demands in their work. As the number of selfreported physical demands increased so did the likelihood of inadequate sleep, pain medication use, and absenteeism. Cognitive workload Cognitive workload is related to the need for ICU nurses to process information, often in a short period of time. For instance, code situations require quick decision making and a lot of information that needs to be processed quickly [19]. Critical care nurses do the majority of family communication, patient assessment, evaluation, and care in ICUs. Through their cognitive skills, nurses readily recognize clinical changes that prevent further deterioration in patients [17]. Nurses perform many cognitive adjustments across patients throughout an assigned period of care. These adjustments are planned (eg, work shift changes or morning reports for assigned patients) and unplanned (eg, stable patients suddenly changing status to an unstable condition) [20]. This constant conscious shift in thinking from one patient to another extends far beyond actual bedside care. Nurses often perform cognitive tasks while waiting on other systems or processes (eg, delivery of medications, laboratory results, and retrieving necessary patient supplies). This cognitive and physical multitasking, although common in ICUs with high patient acuity, often is overlooked in management decisions addressing nurse staffing ratios. Additionally, interruptions disrupt nurses’ concentration and cognitive processing. Human beings find it difficult to stay attentive, vigilant,
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and productive, particularly when they are interrupted, fatigued, or in a work overload situation [21]. Nurses whose attention constantly is shifting from one item to another may not be able to formulate a complete and coherent picture of tasks at hand or complete assigned care activities [22]. Some interruptions are necessary, such as pointing out critical monitor changes or emergent needs of other patients assigned to a nurse’s care. Most interruptions are about communicating information or asking questions about patients, however; for instance, asking about information and questions about patients who are soon to be admitted to or discharged from a unit. The stream of constant interruptions disrupts nurses’ ability to identify and assess patient needs, increasing the cognitive workload [20], even potentially leading to patient error. Increased understanding of the work complexity in ICU environments and nurses’ cognitive workload are critical to successful patient safety improvement efforts and the recruitment and retention of critical care nurses [14].
Time pressure Time pressure relates to the need to work fast, under tight deadlines and temporal constraints. High time pressure is related to burnout experienced by ICU nurses [23]. Time pressure is related to the number of tasks ICU nurses have to perform under temporal constraints. ICU nurses perform a large variety of tasks, including assessments, measurements, documentations, and therapies on a regular or frequent basis. Changes in standards of care for ICU patients sometimes can introduce additional tasks for ICU nurses, therefore adding to the already high time pressure. One example is the introduction of glycemic control, which involves insulin infusions and monitoring of blood glucose levels. This requires additional work by ICU nurses, up to 2 hours for a single patient during a 24-hour period [24].
Emotional workload Emotional workload is prevalent particularly in critical care environments because of patient acuity and severity. Critical care nurses deal with very sick patients and are the main interface with the families of those patients. ICU nurses are educated and trained to provide highly technical expert care and also need to deal with end-of-life
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care [25]. Often, ICU nurses experience obstacles to providing end-of-life care that can add to their emotional workload. The following obstacles are reported by ICU nurses: continuing aggressive treatment even when advanced directives exist, physicians too optimistic to a families, and dealing with angry families. Critical care nurses report that dealing with family demands is related to increased workload [26]. Families play an important role in ICUs, such as watching out for the patients or just ’’being there.’’ Sometimes the perspectives of the nurses and the families are not aligned, however, and conflicts or problems may arise [27]. For instance, nurses may experience time limitations in their capacity to handle some of the family situations or demands. Verbal and physical assaults by patients and their families also can be a source of emotional workload [28]. A study by May and Grubbs [28] examines reports of verbal and physical assaults by a group of 86 emergency department, ICU, and general floor nurses. Approximately 85% of the ICU nurses reported verbal assaults by patients and family members and 78% reported physical assaults. Quantitative and qualitative workload Frankenhaeuser and Gardell [29] differentiate quantitative workload from qualitative workload: quantitative workload is defined as the amount of work, and qualitative workload is defined as the difficulty of the work. Quantitative workload of critical care nurses can be measured using the various patient-level measures of workload (discussed previously); these measures provide some measure of the amount of work critical care nurses have to perform. Quantitative workload also is related to work hours: the amount of work performed increases with increasing work hours. Scott and colleagues [30] found that critical care nurses tend to work much longer than their scheduled work shift: in a study of 502 nurses who provided data for 6017 work shifts, they found that in 86% of the shifts, nurses worked longer than scheduled. Longer work duration was related to increased risk for errors and difficulty in staying awake. Fatigue also can contribute to musculoskeletal injuries. Qualitative workload of critical care nurses is related to the rapid pace of knowledge in critical care medicine and nursing and implementation of new technologies and devices. Schaufeli and
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colleagues [31] found that intensive use of sophisticated technology was related to high burnout among ICU nurses. In addition, critical care nurses need to carry out procedures accurately and react to urgent situations efficiently [19]. This time pressure can add to the qualitative workload experienced by nurses.
Workload variability Workload variability is the extent to which workload continually changes during a period of time [32]. Among critical care nurses, one cause of workload variability is related to shifts (eg, day shift versus night shift). ICU nurses who work day shifts report higher levels of perceived workload than ICU nurses who work during night shifts [26]. The higher day shift workload may be correlated directly with other patient care services availability. Many hospital departments are closed or staffed only for emergency care during night shifts. Night shift nurses often describe the shifts as more relaxed, with more time spent with patients because there tend to be fewer interruptions and things are less hectic. Nurses report experiencing a greater sense of autonomy and independence on night shifts as they have control of their work and task time. Night shifts often leave the nurses with sedentary tasks, however, such as charting, organizing supplies, or monitoring sleeping patients. Many night shift nurses admit to developing bad eating patterns. They note that hospital cafeterias are closed at night, leaving them with high-calorie vending machine snacks or takeout pizza as typical meal options in addition to lack of physical exercise in their work tasks. Geliebter and colleagues [33] observed night shift nurses reported gaining more weight, exercising less, and increasing food intake than the day shift group since starting their jobs on their current shift. Code situations are another example of workload variability. Workload suddenly increases because health care providers need to concentrate on the patients in danger, therefore reducing the number of staff available to care for other patients. Additionally, critical care nurses’ role in the code may vary from finding and assessing patients, initiating cardiopulmonary resuscitation before a code team’s arrival, to then recording the events and interventions on the official resuscitation record that documents all events and interventions.
Relations between the dimensions of workload The various dimensions of workload are not independent of each other. For instance, quantitative workload, or the amount of work, is related to physical workload: the more work critical nurses have to perform, the more likely they are exposed to physical workload. The number of patients nurses care for and the nursing requirements of the patients also are related to physical workload. Time pressure combined with physical workload may increase the risk for musculoskeletal injuries significantly for critical care nurses. In rushing to perform a task, nurses may not have the time to use lifting devices. Moreover, a lifting device itself may add to nurses’ workload, as the device used must be decontaminated and made ready for the next patient in a physical environment not designed to facilitate optimal cleaning and disinfection. Nurses actually might choose not to use a safety device as its cleaning or decontamination seems too onerous a task given the physical environment and time pressure. The cognitive workload associated with consistent adherence to patient care guidelines may increase physical workload as nurses encounter problems and barriers to guideline compliance in an ICU. Critical care nurses often are the primary care providers responsible for ensuring compliance with these guidelines. The Institute for Healthcare Improvement [34] is conducting a nationwide effort to save lives by implementing strategies to facilitate guideline compliance. A significant attribute of this program is nurses’ role in monitoring care guideline compliance and taking corrective action with ICU care teams. Although the empowerment of nurses to ‘‘stop the procedure’’ is critical to guideline compliance, it also adds to their cognitive, quantitative, and qualitative workloads.
Sources of workload Understanding that the way work is organized can contribute to workload is critical for developing interventions aimed at reducing (or managing) workload and its impact on critical care nurses. A range of patient care factors also may contribute to high workload in ICUs, such as the number of postoperative events [35]. The authors propose that the work system model of Carayon and Smith [36–38] can be used to describe sources of workload and define the
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interrelationships between the dimensions of workload (Fig. 1). The work system comprises five elements [36,37]: Individual critical care nurses Performance of various tasks (ie, direct care, indirect care, and other tasks; patient care characteristics) Use of various tools, equipment, devices, and technologies Physical environment (eg, the patient room and the nursing station) Specific organizational conditions (eg, shift schedules, nursing management, teamwork, communication with physicians and other health care providers, and interruptions) Physical workload is related particularly to the tasks and their physical characteristics (eg, lifting patients), the availability of equipment and devices, and the layout of patient rooms. These microergonomic factors also are related to the macroergonomic characteristics of the work system, such as an organization’s management being committed to providing the right equipment to nurses. Cognitive workload is affected by the characteristics of the tasks of critical care nurses: those tasks, in particular operational tasks (eg, patient care and psychologic support of patients), can be demanding and at the same time satisfying [39]. Improving the design of nurses’ work system (eg, nurse-physician collaboration) is suggested as a strategy to reduce workload and deal with the nursing shortage crisis [40]. Laschinger and Finegan [41] identified ‘‘empowerment’’ as a predictor of nurses’ perception of workload. Empowerment was conceptualized as a characteristic of work environments that provide nurses with access to
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information, resources, and support necessary for accomplishing their work in a meaningful manner [42]. Organizational factors and other aspects of the work environment of critical care nurses can affect workload. Impact of workload Workload experienced by critical care nurses can lead to various outcomes: (1) impact on health of the nurses, (2) quality of working life (eg, job dissatisfaction, stress, burnout, and turnover intention), and (3) patient safety (see Fig. 1). Impact on health A major impact of working conditions on health of critical care nurses is work-related musculoskeletal disorders, such as back disorders. Physical workload is a working condition that is a primary contributor to work-related musculoskeletal disorders of critical care nurses [18]. The psychosocial aspects of work, however, such as time pressure and emotional workload, also can be contributors to work-related musculoskeletal disorders [43]. Time pressure and emotional workload are job stressors that could lead to increased risk for work-related musculoskeletal disorders via the following mechanisms [43]: (1) job stressors that could lead to physiologic changes (eg, increased muscle tension), which can make critical care nurses more vulnerable to work-related musculoskeletal disorders, (2) job stressors that may heighten the impact of physical workload, and (3) job stressors that may increase nurses’ sensitivity to pain and, therefore, increase the likelihood that nurses experience and report musculoskeletal pain.
Fig. 1. Model of workload of critical care nurses.
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Impact on quality of working life Workload also can affect the quality of working life experienced by critical care nurses, such as job satisfaction, stress, burnout, and attitudes, such as turnover intention. In particular, burnout is recognized as a problem among ICU nurses and is related to high workload [44]. Burnout may be contagious: ICU nurses who perceive that their colleagues are experiencing burnout more likely report burnout, even after controlling for the impact of job stressors (eg, workload) [45]. Physical workload experienced by nurses can affect not only physical health, such as musculoskeletal disorders, but also turnover intention or turnover. Fochsen and colleagues [46] conducted a longitudinal study to identify the predictors of turnover among Swedish nurses. Nurses who reported musculoskeletal problems of the neck and shoulder or knees and those who had limited use of transfer devices were more likely to leave their job. A multifaceted intervention aimed at reducing physical workload of patient handling and workrelated musculoskeletal disorders in nursing home care units and spinal cord injury units was shown effective (eg, decrease in musculoskeletal injuries) and to lead to increased job satisfaction [47]. Impact on patient safety Medical errors are widespread in critical care settings. A prospective observational study by Bracco and colleagues [48] of consecutive patients admitted during 1 year to an ICU examined 777 critical incidents. The cause of the incidents was classified as equipment, patient, or human related. The cause was classified as equipment related when the incident was attributed to a technical equipment failure not associated with human misuse. The cause was classified as human related when actions did not go as intended or an intended action was not the appropriate one. In all other cases, the incident was classified as patient related. Thirty-one percent of the incidents were human-related incidents, 2% equipmentrelated incidents, and 67% patient-related incidents. A recent study by Rothschild and colleagues [49] examined a total of 391 patients admitted over a 1-year period in a medical ICU and a coronary care unit. They found 120 adverse events among 79 patients (20%). The most serious medical errors were found in the category of medication ordering or execution of treatment. Several studies have examined specific types of error in ICUs, such as medication errors. Cullen
and colleagues [50] compared the frequency of adverse drug events (ADEs) and potential ADEs in ICUs and non-ICUs. Two medical and three surgical ICUs and four medical and two surgical general care units participated in the study. The rate of preventable ADEs and potential ADEs in ICUs was 19 events per 1000 patient days, nearly twice the rate in non-ICUs. When adjusting for the number of drugs used, however, no differences were found between ICUs and nonICUs. Several studies have linked medical errors and patient safety to nursing workload. Giraud and colleagues [51] conducted a prospective, observational study to examine iatrogenic complications. A total of 382 patients for 400 consecutive admissions provided data. Thirty-one percent of the admissions had iatrogenic complications. Human errors were involved in 67% of the major iatrogenic complications. The risk for ICU mortality was approximately twofold higher for patients who had iatrogenic complications. A major contributing factor was high or excessive nursing workload. A study of medication administration by Tissot and colleagues [52] detected 132 medication errors in a total of 2009 observed events (6.6%). The researchers attributed the errors not only to deficiencies in the overall organization of the hospital medication track but also to the nursing work overload. Scott and colleagues [30] examined the effects of critical care nurses’ work hours on their vigilance and risk for making an error. Longer shift durations (in particular more than 12.5 consecutive hours) were associated with increased risk for errors and near errors and with increased difficulty staying awake at work. This study did not find an association between decreased vigilance (eg, difficulty staying awake at work) and increased risk for errors. Longer shift durations increase the exposure of critical care nurses to the various dimensions of workload. Systemic impact of workload The impact of workload on various outcomes is systemic. According to the Systems Engineering Initiative for Patient Safety (SEIPS) model of work and patient safety [53], the various outcomes are affected by the characteristics of the work system and also are inter-related. Therefore, the various dimensions of workload likely affect more than one outcome, and the outcomes are related to each other. Nurses who experience back pain
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because of physical workload may not be able to dedicate their full attention to their tasks (cognitive workload) and, therefore, may be more likely to commit an error (impact on patient safety). Therefore, it is important to examine workload of ICU nurses using a systemic approach. A systemic approach to the assessment of workload should fulfill the following objectives: 1. Evaluate the different dimensions of workload experienced by critical care nurses. 2. Identify the work system factors contributing to different facets of workload. 3. Understand the relationships between the different dimensions of workload. 4. Assess the impact of workload on nurses’ and patient outcomes. In the introduction, various measures of patient-related workload were described. This article emphasizes the need to go beyond those measures and include measures of workload that represent the various dimensions of workload. The National Institute of Occupational Safety and Health has created a Web site where various measures of working conditions and job stressors are described [54]. This is a resource for many measures of workload, such as quantitative workload [32] and cognitive demands [55]. Gurses [26] has developed a questionnaire to assess performance obstacles experienced by critical care nurses; this questionnaire can be used to identify the various sources of workload in the work system (ie, performance obstacles). Summary Interventions aimed at improving the safety of care provided by nurses to critical care patients need to consider the work environment, in particular the various types of workload. Sluiter and colleagues [56] implemented a multidisciplinary structured process to evaluate work shifts to enhance team communication. Benefits of the intervention included increased satisfaction with team communication and reduction in emotional exhaustion. This multidisciplinary structured process was used to address the following issues: dealing with pressure of ICUs, teamwork, work roles, and organizational aspects. Such a process could be used to identify the work elements that contribute to different dimensions of workload, to propose interventions to reduce workload, and to plan implementation of these interventions. According to the model of workload of
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