Elsevier

Collegian

Volume 26, Issue 1, February 2019, Pages 1-7
Collegian

Safety culture and an invisible nursing workload

https://doi.org/10.1016/j.colegn.2018.02.002Get rights and content

Abstract

Background

Nursing workload remains an issue in current health care contexts. The use of quantitative methodologies, methods and tools to measure workload has not produced adequate data to inform workforce policy to resolve workforce concerns about workload.

Objective

This study aimed to identify the influence of both culture and climate as factors in nursing workload.

Methods

This research used an overall critical ethnographic methodology to investigate the real lifeworkload issues of nurses. Methods included fieldwork observations and informal discussions over a 3 year period and 11 in-depth interviews.

Results

The study identifies the impact of safety mandates on nursing workload as an invisible phenomenon within current workload methodologies. Such mandates add to nursing roles and routines, and become a ‘taken-for-granted’ activity that is not always directly related to patient care, nor is a visible factor in workload measurement.

Conclusion

Given that workload measurements are formulated on direct patient care activities, indirect and unrecognised activities may create additional nursing workload.

Introduction

Contemporary health care research has focused on both nursing workload and patient safety, with links between these issues firmly established (Aiken et al., 2014; Duffield, Roche & Merrick, 2006). Adequate staffing and resources, administrative support, and teamwork collaboration have been shown to improve patient safety, and factors such as low job satisfaction, churn, and high workload increase risk to patient safety (Hui-Ying Chiang, Hsiao, & Lee, 2017; Aiken et al., 2014). Although this link is well established, current methods to measure workload have not yet resolved current workforce dissatisfaction or shown an improvement in patient safety. This article presents a study that explored why this is so.

Duffield et al. (2006) established the concept of workload as situations and activities that registered nurses are involved in everyday, in a particular context, as part of their normal work life in health care. de Cordova et al. (2010) stated that workload is a function of time, complexity, and volume of the interventions that must be performed in a given period with respect to a given set of patients and their nursing requirements. They draw on the work of Carayon and Alvarado (2007) who propose that nursing workload is made up of 6 dimensions: physical, cognitive, time pressure, quantitative (amount of work), qualitative (difficulty of work) and variability (workload fluctuation). de Cordova et al. (2010) state that nurse managers are challenged to collect data on the various dimensions of nurse workload to make informed staffing decisions.

The impact of nursing workload on both patient and nurse is well documented; increased workload leads to lower quality of patient care and safety, as well as higher rates of anxiety, stress, burnout, and attrition of nurses (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken et al., 2014; Caudros, Padilha, Toffoletto, Henriquez-Roldan, & Canales, 2017; Delgado, Upton, Ranse, Furness, & Foster, 2017; Lin, Chiang, & Chen, 2011). Negative effects for patients include adverse events and failure to rescue (Caudros et al., 2017). Negative effects for nurses include lower job satisfaction, emotional exhaustion, burnout and high nurse turnover (Lin et al., 2011; Hui-Ying Chiang et al., 2017).

One concept which has been particularly useful in exploring the impact of workload is ‘rationing’. Rationing occurs when nurses made decisions about how much care they are able to provide at any given time because of limits in time, staffing or skill mix (Papastavrou, 2008). Van den Heede et al. (2008) found that nursing care rationing is related to patient and nurse satisfaction, as well as nurse burnout. Papastavrou, Andreou, and Efstathiou, 2013 reviewed 17 quantitative studies and found that workload was a potential cause of rationing, and nurse-related outcomes included low job and occupational satisfaction, with rationing appearing to be an important organisational variable linked with patient safety and quality of care.

Workload measurement tools are designed to validate the deployment of nursing staff and identify trends (Dickson, Cramer, & Peckham, 2010). Nurse Managers are required to assess nursing staff supply in relation to demand, allocate resources appropriately and using workload measurement systems, have supporting data to alter staffing plans as required. In 2006, Duffield et al. (2006) conducted a critical review of the methods used for measuring nursing workload in Australia. Although they acknowledged that workload was one of the most significant factors in nursing retention, they concluded that methods to measure workload were nonexistent or inconsistently used in many Australian jurisdictions. Since this review, the use of workload measurement tools have significantly increased in Australia, however anecdotal evidence is that these tools are not always well respected as valid measures. A number of new tools have been developed, such as the Workload Measurement and Reporting System (WMRS) in the ambulatory environment (Dickson et al., 2010), Nursing Activity Systems (NAS) Nursing Care Classification System, Patient Classification Systems and RAFAELA System (Armstrong et al., 2015; Blay, Duffield, Gallagher, & Roche, 2014; De Cordova et al., 2010; Junttila, Koivu, Fagerström, Haatainen, & Nykänen, 2016; Myny et al., 2012; Rauhala and Fagerstrom, 2007; Twigg & Duffield 2009; Yu, Ma, Sun, Lu, & Xu, 2015).

Vincent and Amalberti (2016) present a useful way in which to understand safety strategies used in hospitals over the past two decades. They identified a series of three phases over time that show both success and limitations. These three phases can be seen in Table 1. The earlier strategies have continued as the new ones emerged.

Rounding is one safety strategy that has gained considerable attention with regard to research on nursing workload (Halm, 2009). This strategy places the patient at the centre of ward routines, and involves standardised checks by nurses on all patients within a ward at regular intervals (either hourly or every 2 h). Willis et al. (2015) suggests that rounding is located within a wider context of safety and quality in healthcare delivery with patient satisfaction paramount, highlighting the auditing nature of rounding and its impact on nursing workload.

The above overview of the literature related to workload and nursing workload sets the background for this study. The study was situated in an acute surgical unit in regional Australia. The research was triggered by a recognition that there was a disparity in opinions on workload between nursing management and unit nurses. For example, managers suggested that according to the workload management tool, the wards were adequately staffed, whilst the nurses reported that factors other than patient care created additional workload. To address this disparity, a request by all staff was made to conduct an independent study. In terms of the managerial brief to the researcher, the brief included references to reported ineffective decision-making and prioritisation skills that had led to patient safety issues, through failure to follow policy.

Section snippets

Design

This research used a critical ethnographic methodology to investigate the issues within, and relevance of, the real life workload of registered nurses in a regional hospital. Through an anthropological approach, participants’ viewpoints and understandings were described. A critical approach penetrates the descriptive ethnography interpretation of meanings by encouraging collaboration, awareness and identification of power imbalances and a change intent to the study. Critical ethnography

Results and discussion

A total of 8 major themes emerged through this research. Fig. 1 illustrates estimated times when these themes emerged and the increasing knowledge and depth, using the critical ethnography approach. Theme 1 emanated from what initially appeared as isolated findings to manifest as a recurring and predominant safety and protection category.

Below, each theme is presented and discussed in relation to its relationship to and impact upon workload. The themes are:

Conclusions and recommendations

The study identified that workload is seriously impacted by processes that seek to manage risk with little thought to consequences in nursing workload. The checks and balances for patient safety imposed by organisational policies, routinely undertaken by nurses were also noted to be interspersed with multiple workflow duties and tasks simultaneously. Such a concoction of events could threaten the intent of any safety processes. The nurses’ adopted strategies to manage the additional safety

Conflict of interest

The author/s has no conflict of interest or received any sources of outside support for the research.

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