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Contents lists available at ScienceDirect

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afety culture and an invisible nursing workload

heryl Rossa,∗, Cath Rogersa, Christine Kingb

School of Nursing & Midwifery University of Southern Queensland, Australia Medicine, Nursing and Health Sciences, Monash University, Australia

r t i c l e i n f o

rticle history: eceived 11 November 2016 eceived in revised form 6 February 2018 ccepted 8 February 2018

eywords: orkload

afety ursing orkforce

a b s t r a c t

Background: Nursing workload remains an issue in current health care contexts. The use of quantita- tive 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 lifework- load 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 phe-

ulture nomenon 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.

© 2018 Australian College of Nursing Ltd. Published by Elsevier Ltd.

. Introduction

Contemporary health care research has focused on both nursing orkload and patient safety, with links between these issues firmly

stablished (Aiken et al., 2014; Duffield, Roche & Merrick, 2006). dequate staffing and resources, administrative support, and team- ork collaboration have been shown to improve patient safety,

nd factors such as low job satisfaction, churn, and high workload ncrease risk to patient safety (Hui-Ying Chiang, Hsiao, & Lee, 2017; iken et al., 2014). Although this link is well established, current ethods to measure workload have not yet resolved current work-

orce dissatisfaction or shown an improvement in patient safety. his article presents a study that explored why this is so.

.1. Workload

Duffield et al. (2006) established the concept of workload as situ- tions and activities that registered nurses are involved in everyday, n a particular context, as part of their normal work life in health are. de Cordova et al. (2010) stated that workload is a function

∗ Corresponding author. E-mail address: [email protected] (C. Ross).

ttps://doi.org/10.1016/j.colegn.2018.02.002 322-7696/© 2018 Australian College of Nursing Ltd. Published by Elsevier Ltd.

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.

1.2. The impact of workload on patient safety

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).

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One concept which has been particularly useful in exploring the mpact of workload is ‘rationing’. Rationing occurs when nurses

ade decisions about how much care they are able to provide t any given time because of limits in time, staffing or skill mix Papastavrou, 2008). Van den Heede et al. (2008) found that nurs- ng care rationing is related to patient and nurse satisfaction, as

ell as nurse burnout. Papastavrou, Andreou, and Efstathiou, 2013 eviewed 17 quantitative studies and found that workload was a otential cause of rationing, and nurse-related outcomes included

ow job and occupational satisfaction, with rationing appearing to e an important organisational variable linked with patient safety nd quality of care.

.3. Methodologies, methods and tools to measure workload

Workload measurement tools are designed to validate the eployment of nursing staff and identify trends (Dickson, Cramer,

Peckham, 2010). Nurse Managers are required to assess nursing taff supply in relation to demand, allocate resources appropri- tely and using workload measurement systems, have supporting ata to alter staffing plans as required. In 2006, Duffield et al. 2006) conducted a critical review of the methods used for mea- uring nursing workload in Australia. Although they acknowledged hat workload was one of the most significant factors in nurs- ng retention, they concluded that methods to measure workload

ere nonexistent or inconsistently used in many Australian juris- ictions. Since this review, the use of workload measurement tools ave significantly increased in Australia, however anecdotal evi- ence is that these tools are not always well respected as valid easures. A number of new tools have been developed, such as

he Workload Measurement and Reporting System (WMRS) in the mbulatory environment (Dickson et al., 2010), Nursing Activity ystems (NAS) Nursing Care Classification System, Patient Classifi- ation Systems and RAFAELA System (Armstrong et al., 2015; Blay, uffield, Gallagher, & Roche, 2014; De Cordova et al., 2010; Junttila, oivu, Fagerström, Haatainen, & Nykänen, 2016; Myny et al., 2012; auhala and Fagerstrom, 2007; Twigg & Duffield 2009; Yu, Ma, Sun, u, & Xu, 2015).

.4. Safety strategies

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

Rounding is one safety strategy that has gained considerable ttention with regard to research on nursing workload (Halm, 009). This strategy places the patient at the centre of ward rou- ines, and involves standardised checks by nurses on all patients ithin a ward at regular intervals (either hourly or every 2 h). illis et al. (2015) suggests that rounding is located within a wider

ontext of safety and quality in healthcare delivery with patient sat- sfaction paramount, highlighting the auditing nature of rounding nd its impact on nursing workload.

The above overview of the literature related to workload and ursing workload sets the background for this study. The study was ituated in an acute surgical unit in regional Australia. The research as triggered by a recognition that there was a disparity in opin-

ons on workload between nursing management and unit nurses. or example, managers suggested that according to the workload

anagement tool, the wards were adequately staffed, whilst the

urses reported that factors other than patient care created addi- ional workload. To address this disparity, a request by all staff was

ade to conduct an independent study. In terms of the managerial

26 (2019) 1–7

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.

2. Methodology and methods

2.1. Design

This research used a critical ethnographic methodology to inves- tigate the issues within, and relevance of, the real life workload of registered nurses in a regional hospital. Through an anthro- pological approach, participants’ viewpoints and understandings were described. A critical approach penetrates the descriptive ethnography interpretation of meanings by encouraging collabo- ration, awareness and identification of power imbalances and a change intent to the study. Critical ethnography combines a crit- ical conception of a social and cultural phenomenon with the study of particular organisational or social settings (May, 1997). In this study, this approach and its associated field work forms the exploratory platform from which the workload of registered nurses in a regional hospital was examined. The design facilitates the voices of nurses in relation to their daily workload.

2.2. Participants

The study involved a purposive sample of Registered Nurses (RNs) who worked at least two days a week in the specific work unit, in a busy referral hospital in regional Australia. Despite 24 nurses consenting to participate in the research there was an attrition of 10 through staff mobility to other wards, illness or res- ignation. The researcher was unable to elucidate reasons for the turnover. 11 interviews were conducted. Although a small sample size of 11 participants, this is an adequate sample size for a qual- itative study. These approaches contrast quantitative approaches that have the capacity to include a large sample size but lack the capacity to elicit depth and assume the issue being explored is rel- atively known (King, 2000; Patton, 2002). Qualitative approaches are useful for gaining in-depth understanding of complex issues that are as yet not well understood. The interview strategy was to ask the participants to describe their views of the phenomena and for the interviewer to probe for further details and clarity. Specific demographic data of the participants was not collected as the infor- mation was not crucial to the research question, however, there was a broad representation of age and experience in nursing, and longevity in the setting, within the sampling.

2.3. Data collection

Data collection involved 60 h of fieldwork over a three-year period on both morning and afternoon shifts, with observation of routine daily workflow, discussions, group interactions and arte- facts being recorded as field notes. Fieldwork data collection also involved activities and interactions occurring in the ward. Field notes were written as a series of logs that captures the happenings during the observation period, researcher analysis and reflective notes. Artefacts as ‘social products’ contribute to the data collec- tion because of the subliminal messages of climate values, power, legitimacy and expectations (Silverman, 1997).

Unstructured interviews were then used to clarify and elaborate on observed issues from the fieldwork, to ensure that meanings

and perceptions were those of the participants. Interviews were transcribed verbatim by a professional provider, and analysed in tandem with field notes recursively to guide further exploration in subsequent field trips. Interview participants were asked to dis-

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Table 1 The 3 phases of safety strategies over time (developed from Vincent and Amalberti (2016)).

Phase Success Limitation

The Enthusiasm of the Early Years, 1995–2002

Began with broad concern with quality and a specific focus on harm.

Methods and assumptions of quality improvement; the aim was to identify and count errors and incidents and then find ways of preventing them; Reporting systems were established to detect and record incidents.

The Advent of Professionalism 2002–2005

Safety researchers, clinicians and managers took concepts and methods from industrial safety and applied them to healthcare. Led to the development of methods of incident analysis and attention being given to human factors (e.g. ergonomics, interface and equipment design, use of IT, stress management).

Although safety and risk management gained a high profile across the healthcare system, the impact on the safety of patients remained uncertain.

Safety Culture, Multifaceted Interventions, and Teamwork

Improving safety across organisations and populations has proved a great deal more challenging, and safety strategies

olisti

The major difference between current views and what was imagined in the mid–2000 s is that safety wins and

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uss and clarify particular topics that had been identified during eldwork.

.4. Data analysis

Field notes and Interview data were transcribed into NVIVO and atterns identified. Data analysis used Braun & Clarke’s (2006) the- atic analysis for both recursively and inductively recognising,

nalysing and correlating patterns emanating from the growing ata. In ethnographic research, data is used to direct the researcher o particular topics of interest within a cultural context. The inten- ion of this recursive analysis is then to focus further fieldwork to pecific topics for ‘digging deeper’ and identifying shared values nd beliefs of participants about this cultural context (LeCompte

Schensul, 1999). As the approach required ongoing analysis and eeper levels of inquiry, as well as ongoing checking of assumptions ith participants, themes emerged over time, with some themes

uilding on previously emerged themes.

.5. Ethics

Ethics approval was received from the relevant health service nd university human research ethics committees.

.6. Limitations

Qualitative results are not typically generalisable or transfer- ble. The study was small, and as an ethnography was of a particular ime and space. The findings do not necessarily apply across multi- le contexts. Another limitation may be that participants were RNs nd did not include the views of other nurses.

. Results and discussion

A total of 8 major themes emerged through this research. Fig. 1 llustrates estimated times when these themes emerged and the ncreasing knowledge and depth, using the critical ethnography pproach. Theme 1 emanated from what initially appeared as iso-

ated findings to manifest as a recurring and predominant safety nd protection category.

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

c way as rewards are now expected in the middle to long term rather than in the very short term.

3.1. Safety policies and procedures are often not seen as legitimate work that contribute to perceived workload or are accounted for in the tools used to measurement workload. (Theme 1)

The analysis identified that efforts to maintain compliance with safety requirements added to nursing workload yet were not included in assessments of nursing workload. Absorbing safety pro- cedures into nursing workload was essentially taken for granted by both nurses and managers. When questioned about this, RN participants acknowledged the prioritisation of this work as a pro- fessional standards requirement (NMBA, 2016) and also as a clinical governance mandate. This work included managing or mitigating environmental risks and hazards, managing fire and other emer- gency procedures, checking emergency equipment and following any other additional safety organisational policies and guidelines (Pearce et al., 2009).

A culture that accepts and adopts extra roles as a normal daily routine, may not articulate or perceive any impact of such addi- tional work, especially if the focus is on direct patient care as the basis of workload measurement (Silverman, 2000, Handwerker 2001, Pearce et al., 2009). Climate influences the social context of nursing work by dictating what work is to be done, how it is to be done, where, with whom and when. This then influences employee perceptions about organisational priorities and expectations of per- formance.

3.2. A safety agenda is not only about patient safety, but also incorporates environmental, organisational and professional safety (Theme 2)

A plethora of research suggests that the notion of a safety agenda is only about ‘patient’ safety (Dickson et al., 2010; Duffield et al., 2006). The findings from this study identified that a safety or pro- tection culture incorporates not only keeping the patient safe but multiple concepts of environmental, organisational and profes- sional safety. Activities such as safety of equipment management, medication processes, environment control and supervision were all identified as requiring safety and protection measures. There was a significant workload associated with monitoring, report- ing and follow-up actions within risk management governance requirements.

3.3. Workload associated with a safety agenda (including patient environmental, organisational and professional safety) is not

measured in current workload methodologies (Theme 3)

Previous studies have shown that patient safety that supports direct patient care is not necessarily measured in current workload

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Fig. 1. Emergent themes over time

ethodologies (Duffield et al., 2006, Pearce et al., 2009). This study, n finding that a safety agenda is also about environmental, organ- sational and professional safety, subsequently found that these spects were also rarely measured in current workload method- logies. This is addressed more in the themes that follow, as more epth emerged through the research process.

.4. Strategies to protect patients (Theme 4)

Delving deeper into safety strategies, this study found that trategies to protect patients increased nurses workload in a num- er of ways. For example, risk management was seen to include rotecting patient valuables. Nurses were observed to be managing

‘Valuables’ book to document patient belongings, which entailed wo nurses to check and confirm the specific patient valuables that ere taken for safe keeping to a security hold. The process could

ake up to thirty minutes for each nurse to complete. The tracking of atient belongings in tandem with patient churn (transfers in, out nd between wards or the hospital) was observed as creating addi- ional workload, when nurses were charged with the responsibility f finding ‘lost’ items (Interview 8).

As mentioned earlier, the intention of rounding is to increase fficiency and patient safety by regular patient checks, reducing he use of call bells and incidences. An assumption in this strat- gy is also that nursing workload will be reduced, as patient needs re continually pre-empted. Our study however showed the oppo- ite to be true, and is congruent with the findings of Willis et al. 2015) who found that in practice, rather than being an efficiency

easure, rounding was viewed by ward staff as increasing work ntensification. They found that rounds were not factored into urses’ workloads as they are designated by managers as ‘funda- ental care’. In summary, rounding contributes to the problem it as actually implemented to solve (i.e. missed care arising from ork intensification) and rationing care has moved to missed care. illis et al. (2015) note that managers respond to this by tightening

arious forms of audit and control. Additional documentation also incorporated processes and evi-

ence to meet accreditation mandates, with additional burdens elated to double-checks and intense procedures for greater patient afety. These processes then impact on actual allocated direct care ime allocations for nurses who as a matter of normal practice tend

ing increasing depth of knowledge.

to absorb the extra hours required (Krichbaum et al., 2007; Ebright 2010). The time required for these processes and checks and bal- ances can create a situation of reprioritisation in nursing work to accommodate that which is an organisational imperative, but not necessarily a task that is measured or recognised as commanding priority – for example ‘basic nursing tasks’ (Myny et al., 2012). The organistional imperative and higher prioritisation of these safety initiative areas has been previously cited as a factor contributing towards nursing workload as with this study.

3.5. Strategies to protect nurses (OH&S) (environmental safety and professional safety) (Theme 5)

3.5.1. Environmental safety Environmental safety and protection relates to the role of the

nurse in maintaining a safe place of work to meet corporate gover- nance and workplace health and safety legislation demands. Such roles include the mitigation of safety risks such as spills and equip- ment failures, reporting and monitoring risks and/or incidents, fire and safety evacuation training and drills, equipment and drug safety and management, and the less recognised intangible, surveil- lance role.).

An associated factor within the theme of protection of the organisation included the mandatory training for workplace safety legislation, or to meet accreditation requirements (Pearce et al., 2009). The nurses’ included equipment safety check measures as a routine function. For example, the tortuous process required for non-functioning equipment

‘if it goes wrong then the process is that it gets red taped so it’s out of working circulation, they’re supposed to write on a – there’s a little notebook for – in the repairs slot, yep. So they write on there what’s wrong with it so that then (the Administration Officer) or the plaster techs can log it onto the SAP (asset computer system] so that they can get it fixed’ (Interview 2).

When a patient brought in a personal television set, the nurses were seen to be organising the ‘test and tag’ ruling for workplace safety (Field Note 6). The routine uses of equipment such as patient

lifting devices, transfer or motorised lifters involved additional pro- cedural steps to ensure safety. Workload effort was increased with retrieval of the equipment, check process of proper functioning, use it, and then return it back to storage.

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.5.2. Professional safety During the study numerous observations identified the signifi-

ant time spent providing direction and guidance to new staff and tudents (Field note 2,4,5,7,12,14). An ‘unknown’ casual staff, trig- ered an increased vigilance during the shift and at times a change f work method. Terms such as higher alert, increased vigilance and ack of familiarity with routines were stated as increasing workload Interview 1 & 6).

Casual staff were seen to invoke added vigilance because of nfamiliarity with routines and documentary requirements, for xample

‘they (casual staff) blow in and out – you just have to remind them – so it’s another job that you take on to make sure that those things are being done’ (Interview 2).

Staff safety through mandatory training activities was also eported during the study as an organisational imperative (Inter- iew 8, 9, & 10). All nursing staff were rostered to undertake these ctivities annually, but they added that there was a requirement o complete the ‘pre-reading’ (of 50 pages) within any available ork time (Interview 2) or their own personal time (Interview 10). urses reported that such pre-reading was not always completed nd field notes established that these activities were an add-on fter the shift was finished (Field note 11, 12).

Safety and protection roles and activities were identified as a aken for granted part of nursing daily workload. These indirect are activities included equipment, drug administration and secu- ity issues, and protection of staff and environment, which are not ecessarily recognised in measuring nursing workload. In addition, he governance response to ‘safety issues’ that were identified and eported, saw extra measures and processes added onto nurses’ ask lists to mitigate further ‘risk’ (Krichbaum et al., 2007; Duffield t al., 2008). Nurses routinely and unconsciously adapted these xtra tasks within their daily workloads and did not recognise the asks as other than routine. The insidious nature of adopting extra oles mandated by climate factors then becomes a cultural attribute hat is handed onto new members of the group as a cultural norm.

.6. Strategies to protect the hospital (organisational safety) Theme 6)

Organisational safety refers to activities that protect the organ- sation from litigation. Nurses were required to enter data into a omputer system program (PRIME) to report safety issues within aily workload. The nurses consistently reported this process as a emanding drain on their time and afforded a low priority. Obser- ation and interview substantiated claims that this task was usually ndertaken at the end of the shift, not undertaken at all or creat-

ng unpaid overtime. Staff reported that they knew the necessity to eport, but that compliance was hampered by time to complete an rduous process not within an allocated workload.

In addition, Nurse Unit Managers indicated significant workload rom the PRIME process when they reported that the ensuing daily

anagement of such reports required further review, investigation, nd collaboration with the key stakeholders. The prioritisation and ffort of this safety reporting and management was recounted by he nurses as escalating to unmanageable levels.

Organisational safety reflects governance policy and procedure andates that may be designed to protect the organisation from

itigation. Examples of this included extra documentation require- ents for patient safety initiatives, extra indirect care roles and

ncreasing responsibilities related to coordination and system sup-

ort (Duffield et al., 2008; Ebright 2010). Additional documentation emands included multiple forms to target specific safety inter- sts – such as Falls Risk Assessment or Pressure Ulcer assessment. n addition, there were multiple checklists observed ranging from

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guidelines for treatment, preparation for procedures or processes for pharmacy or pathology.

3.7. The downward spiral of increasing workload causing reduced quality of care causing increased reporting, causing increase workload (Theme 7)

This study showed that adding safety procedures and the use of measurement tools added to nursing workload, which in turn had the potential to negate the intent of patient safety initiatives. For example, a workload grievance process to manage staff concerns about ‘unsafe’ workloads was identified during the study. Incon- gruously, the nurses reported that the additional time and effort to complete such documentation negated the effort to report. A cultural belief that reporting unsafe workloads would not change anything and merely added to significant workload stress with no foreseeable benefits was also prevalent (Interview 9, 10: Field Note 7,8).

This research identified the pivotal role of the Registered Nurse (RN) in maintaining patient safety standards. The impact that safety initiatives have on nurses’ workload, and consequently how this may override the proposed intent of such safety initiatives is less researched. Safety concepts within health care organisations can include patient, organisational, environmental or professional safety.

This study illuminated the impact of a safety agenda on nursing workload. Ironically, the drive for ‘patient safety’ creates additional nursing workload. The additional nursing workload potentially jeopardises the recognised role of nurses to countermand adverse events. Hence a safety agenda may create more harm than raising the safety process it purports to endorse.

3.8. Differentiating between safety culture reporting tools versus safety culture as values and beliefs (Theme 8)

This study also discovered that a priority focus on documen- tation population, rather than using expected professional critical thinking and analysis skills, also contributed to missed direct nurs- ing care. Safety policies required additional documentation for patient and organisational ‘quality’ audits. These include ‘tick and flick’ checklists, early warning observation sheets, falls risk assess- ments and multiple additional ‘tools’ that create duplication and/or require transcription. Field notes identified the nurses routinely focussed on laborious processes of checking and re-checking that the documents were appropriately done – to ensure audit compli- ance.

Steyrer, Schiffinger, Huber, Valentin, and Strunk, (2013) inves- tigated to which extent production pressure (i.e. increased staff workload and the use of staff capacity) and safety culture (consist- ing of safety climate among staff and safety tools implemented by management) influence the occurrence of medical errors. In their study they also explored if and how safety climate and safety tools interact. Their findings showed that it is difficult to increase effi- ciency at the same time as safety. Simply put, they found that a safety culture built on the use of tools and measurements ironi- cally increased workload and a safety climate based on values and beliefs reduced the effects of increased workload on safety.

3.9. The complexity of Drug management and safety (Theme 9)

Drug management and safety contributed to nursing work- load when the processes for counting drugs, accessing drugs, and

administering drugs involved additional documentation, checks and travel. Findings identified that the process for a Schedule 8 or Dangerous Drug (DD) medication administration demanded the attention of two nurses. Every daily field note repeatedly reflected

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he automatic rote like, labour intensive process for drug adminis- ration. Interview data supported the cultural belief that the process nd safety guidelines for drug administration were a significant afety issue by stating ‘you have to just cover your back because you’re o rushed you will go and give out a medication to the wrong patient’ Interview 3).

Paradoxically the intent to maintain patient safety was imple- ented in varying fashions in order to manage the drug checking

rocess for giving a DD to the patient. For example, one method nvolved one nurse who would write in the Register and the medi- al record while waiting for the other nurse to arrive, or one nurse ould be writing in the Drug Register while the other nurse did

he counting, or the nurse would complete multiple clients’ drugs t the same time by putting the drugs on top of the medical record, rior to preparation and delivery to patient.

Because of the central position of the DD cupboard in the nurses’ tation, there were issues related to congestion and access. A line- p of staff at the DD cupboard resembled a process line that was in erpetual motion all day (Interview 2; Field Note 1).

Another ritual observed on every field visit at shift changeover nvolved the DD safekeeping. This ritual involved the changeover f the DD cupboard key by the Team Leaders (TL). This ritual meant wo staff counted all of the stored DD drugs in the DD cupboard to nsure the count matched the register. There were multiple drug egisters being used which had to be manually checked each shift Field note 5). In this study there were over 58 different drugs in he DD cupboard that had to be counted three times a day at change f shift. Nurses had adapted a strategy to minimise this count and he workload by sealing a patient’s own DD drugs into a bag so that hey only needed to check the bag was sealed rather than count ll the drugs. This routine was seen as managing safety rules but educing time factors

‘you just look at the bag and go yep, I’ve got a sealed bag, number blah, blah’ (Interview 7).

Management of prescription drugs could also add to workload ver and above direct patient care expectations. This occurred hen stock levels did not meet demand. Stocks of these drugs was

ept in the Treatment Room cupboard or fridge. Technically the harmacist was responsible for maintaining an imprest (base stock evel) system where nurses could access this stock after hours or ntil individual prescription supplies were added into the cupboard eside their bed. Nurses were observed frequently accessing this

mprest cupboard and using a ‘flow sheet’ to order medications. In ffect the nurses were managing the imprest system with written irections from the Pharmacy staff.

The health care environment is renowned as being turbu- ent, complex and unpredictable (Vardaman, Cornell, & Clancy 012). The unpredictability contributes to increased needs for e-prioritisation of workflow, which then contributes to the recog- ised ‘shortcuts’ in nursing care, and likelihood of decreased patient afety (Hallin & Danielson 2007; Hegney, Plank, & Parker, 2003; aschinger, Finegan, Shamian, & Wilk, 2004). Such shortcuts and tacking of tasks were witnessed repeatedly throughout the study. n particular, the issue of safety and drug management within a haotic environment was highlighted.

. Conclusions and recommendations

The study identified that workload is seriously impacted by rocesses that seek to manage risk with little thought to conse-

uences in nursing workload. The checks and balances for patient afety imposed by organisational policies, routinely undertaken by urses were also noted to be interspersed with multiple work- ow duties and tasks simultaneously. Such a concoction of events

26 (2019) 1–7

could threaten the intent of any safety processes. The nurses’ adopted strategies to manage the additional safety procedures and processes but these appeared antithetical to the intent of safety ini- tiatives. Whilst policy and process were followed to meet clinical governance demands, there remain the multiple issues that have been devised to manage priorities, workflow and safety pressures.

A safety culture can cost nurses a considerable amount of time and energy on a daily basis. The invisible workload generated from increasing safety agendas can have deleterious outcomes for nurs- ing staff, and consequently patients and the organisation (Pearce et al., 2009). Current nursing workload tools need to consider the intangibles of managing and controlling the additional roles and responsibilities that are taken for granted within a safety culture, including patient, nurse, and organisational safety. Nurses need to reconsider the influence of a professional culture that adopts roles not recognised in workload measurement.

The findings of this study, represented as themes, help to pro- vide a basis for the following recommendations:

1. Workload methodologies and tools need to account for invisible workload factors.

2. A more systemic view is needed in further research exploring the impact of workload on patient safety, so that nurse and organi- sational safety are also considered.

3. The establishment of new ways in which patients, nurses, nurse managers and others can participate in developing new systems, including safety systems and workload management systems.

In conclusion, the emergent and inquiry-based nature of critical ethnography allowed for more in-depth understanding about the link between workload and safety strategies. It also enabled some surprises to emerge, such as the positive effect a safety culture based on values and beliefs has on workload compared with one based on tools and measurements (resulting in a negative effect). Comparing the findings with other research, this study provided a rich source of data of the ‘state of play’ of how safety strategies impact on the daily lives of nurses (and patients). It would be safe to say that the effectiveness of, and approaches to, workload method- ologies and safety strategies are extremely varied and diverse, with many successes and failures, and everything in between.

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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