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US Nursing Workload and Patient Safety—A Human Factors Engineering Perspective

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US Nursing Workload and Patient Safety—A Human Factors Engineering Perspective

Overview

Heavy workload for hospital nurses is an issue undermining the quality of services offered to patients. Some reasons attributed to this situation include higher demand for nurses augmented with less number of operating nurses, increase in work overtime, less staffing policies by healthcare providers, and reduced times for patient stay under hospitalization, and population aging. This discussion focuses on the effect that high US nursing workload has on patient safety. It also addresses continuous quality improvement from a nursing perspective.

Literature Review Concepts

Concept 1: Increasing US population is associated with the ever rising health costs and increased nurses’ workload in the US

The US population is projecting an increase in the elderly (over 65 years) by about 54 percent by the year 2020 (Scanlon & Karsh, 2010). Rising health costs have also been a reason for US hospitals pursuing a reduction in nursing staff. This cost factor has also reduced the length of time that hospitalized patients are allowed to stay in the hospital. Some other factors that increase the US nursing workload include expectations at the workplace and other healthcare work system factors.

Under such circumstances, US nurses end up handling additional non-professional tasks such as delivering food trays, transporting patients, and coordinating ancillary services are assigned to nurses. As a result, it increases their workload unnecessarily. High US nursing workload has in turn affected the levels of patient safety in hospitals. It also reduces the job satisfaction levels of nurses that may translate to increased nurse’s turnover.

A hierarchical approach can be used to classify nursing workload in distinct levels- unit, job, patient, and situation levels. The unit-level workload may be a case where many tasks are assigned to a section of nurses working in a shift. The job-level workload may be understood where different units and specialties determine the amount of work done by the nurses. The general floor nurses may have comparatively less workload than those assigned to the intensive care unit. The variations in the nurses’ line of work such as critically ill patients and situations of emergency may determine patient level and situational level workloads respectively (Holden, 2011).

Concept 2: High nursing workload in the US is associated with non-optimal patient care and rising patient dissatisfaction rates

A massive nursing workload is associated with less optimal patient care and patient dissatisfaction. Much research in this area tries to establish a link between nurse staffing levels and nursing-sensitive patient outcomes. A study across various hospitals in California found that if the registered nurses worked for one additional hour per in-patient day, there was a correlated reduction of 8.9 percent for factors associated with pneumonia for surgical patients. The rate of pneumonia was established to be significantly higher when few registered nurses attend duty.

One study of 799 hospitals across 11 counties in the US established a relationship between long hours of registered nurses’ care per day and low failure-to-rescue rates. Another study in non-federal hospitals across Pennsylvania indicated that any additional increase in patient per nurse correlated with a 7% growth in mortality after 30 days of hospitalization (Holden, 2011). It also increased the levels of failure to rescue. Insufficient US nursing staff is also linked to drug administration problems, improper patient supervision, self-extubation and poor documentation (Kimball & O'Neal, 2002).

Nurse-patient ratio still stands out as a preferred measure of nursing workload in most clinical studies. It is easy to use, but it limits several other dimensions in the human engineering approach. Following a human factors engineering approach is necessary for giving insights into the effect of nursing workload on patient safety, since there are many more factors at play other than the nurses’ staffing levels. It is imperative to note that workload is contributed by many factors that cannot be sufficiently measured by the nurse-patient ratio only. The SEIPS model for evaluating work healthcare systems and their impact on patient safety acknowledges organizational characteristics, including nursing workload, as determinants of patient safety (Holden, 2013).

Concept 3: High US nurses’ workload increases work burnout, stress and rampant procedure deviations among the nursing staff

A high workload leads to increased levels of stress and burnout among nurses. This situation may ultimately result in emotional exhaustion, anger, and inefficient performance occasioned by reduced cognitive and physical ability. In the end, the quality of patient care and safety is undermined. A high nursing workload is also associated with an increase in errors in the course of duty. Time pressure may reduce the concentration of nurses when they are performing safety-critical operations (Holden, 2013). This situation may lead to execution errors, lapses, and knowledge errors.

High nursing workloads may also result in deliberate deviations by nurses from established processes meant to ensure patient safety. Operating procedures and rules may be affected by the organizational and social context under which a nurse operates, causing violations in cases where nurses decide to work with the healthcare systems. Nurses may choose to violate protocols under routine or emergency situations when under pressure. Commonly, most nurses are likely to fail to match patient identification and medical administration records with their appropriate medication.

A high nursing workload is associated with lack of time for the nurses to attend to their tasks. A nurse may decide to choose certain tasks over others due to heavy workload, resulting in reduced patient safety (Holden, 2013). For example, the time for collaboration between physicians and nurses may reduce, resulting in less quality service. A high nursing workload is also connected to deteriorated motivation among nurses. Most nurses become dissatisfied under high workload, leading to high rates of absenteeism, low job morale, poor performance, and high nurses’ turnover. In turn, these aspects reduce the quality of care offered to patients and their levels of satisfaction.

References

Kimball, B., & O'Neal, E. (2002). Health care's human crisis: The American nursing shortage.

Holden, R. J., Scanlon, M. C., Patel, N. R., Kaushal, R., Escoto, K. H., Brown, R. L., ... & Karsh, B. T. (2011). A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. BMJ quality & safety, 20(1), 15-24.

Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & Rivera-Rodriguez, A. J. (2013). SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11), 1669-1686.

Scanlon, M. C., & Karsh, B. T. (2010). The value of human factors to medication and patient safety in the ICU. Critical care medicine, 38(6 0), S90.