Over-working Nurses Impact on Performance and Outcomes

Today in both developing and developed countries alike, healthcare workers now make up a growing and large segment of the labor force. A major problem for the healthcare system is the heavy workload on nurses working at hospitals and health care centers. There are four primary reasons due to which nurses continue to experience high workloads: Inadequate supply of nurses, an increase in demand for nurses, reduced the length of stay for per patient, and increased overtime and reduced staffing per patient. Furthermore, an aging population also increases the demand for nurses, and an inability to meet the growing demand leads towards shortage that is predicted to grow even further as nursing schools are not able to keep up with rising demands.

As a result of nurse shortage, those who are working nurse related jobs have their workloads increased. A common workload measure, in this case, is the nurse-patient ratio. It can be used to predict and compare patient outcomes. The workload can also depend on the type of nursing specialty or job. The workload is defined to be an entire make-up of the work that an employee experiences. It is a combination of the daily work that includes, personal, environmental, organizational, as well as situational factors. The paper therefore seeks to study the impact and effects of nurses that are under overworking or working under an increased workload, and identifying the different factors that lead towards nurse-outcomes and patient-outcomes, through a selection of multiple literary sources that provide broad insight into the issues from different perspectives, and to provide mediation of the matters discussed.

Overworked nurses are required to perform numerous tasks, which need to be executed by a group of nurses during assigned shifts. The job-workload they have is also determined by the specialty and type of unit they have. (Pascale Carayon) Categorizes the work into four levels: job level, unit level, situation level and patient level. Suboptimal patient care by nurses is related to a massive workload that leads to lesser patient satisfaction. Furthermore, there are correlations between nosocomial infections, the rate of pneumonia and lower patient-nurse levels. In contrast, a high number of care hours by nurses lead to lower UTI urinary tract infection rates, as well as a reduction in failure to rescue rates. Overworking in nurses lead towards more distress, anger, cynicism, burnout and emotional exhaustion. Those nurses that are experiencing burnout and stress may not be able to perform effectively and efficiently because their cognitive and physical resources may be inhibited or weakened that can profoundly affect patient safety and care due to sub-optimal performance (Pascale Carayon).

The workload of nurses increases from increasing work demands, a shortage of personnel and having to perform an array of varied duties (Rantanen). To determine accurate interventions that can mitigate the effects of excessive workloads, a systematic representation of the work domains of a nurse is required that can correlate particular aspects of work, performance, and outcomes with nurse workloads. The study by (Rantanen) defines workload drivers that include activity type, patient to nurse ratio, task load, time pressure and substantial expenditure to take a comprehensive, novel and a holistic approach to nurse workload. The analysis showed that as the number of tasks increases nurses make more rule-based and skillful decisions. The time pressure decreased as the number of subtasks increased, that backs up the view that given more complex tasks, nurses perform them in an environment with more time available. This, in turn, suggests that when they have less available time (time pressure high) to make decisions, they usually make more rule-based and skillful choices.

Therefore to manage the nurse workload, the tasks should be streamlined to reduce important subtasks. Less layered work and fewer subtasks cut the complexity of the nurse’s job, and the nurse management should monitor it routinely. Maintaining personal organization and following protocol are also essential to manage workload. If the administration implements tactics to aid private organization for nurses, increase worksheets and signage as policy reminders, this can allow them to remember easily what the protocol is, and follow it, thereby reducing time (Rantanen). This can mediate the effects of high workload, even if there are financial constraints on the organization that does not allow it to maintain the right patient-nurse ratio.

To measure nursing workload most studies use patient-nurse ratio, to analyze its effects on patient safety. In human-factors engineering research, a workload is a more complex construct. It is more multifaceted than patient-nurse ratios. (Pascale Carayon) Explains how it is improbable to consider only a patient to nurse ratio as a representative measure of a multifaceted, multidimensional structure of workload. Most studies attempt to quantify nurse workload through time-to-time-task measures or patient acuity, but there are several more factors that remain to be considered. Cognitive Load Theory, for instance, views decreased performance to be a result of an overload to the working memory capacity. Performance improves as the demands on working memory decrease with practice. Determining mental work or effort requires a distinction to be made between the total amount of work linked to a task’s completion and the momentary attempt that a job demands (Neill). Some variables related to nurse workload that can be easily measured include patient census, the number of admissions, turnover, procedures, case mix, and the average age of patients. Other factors that directly impact nurse workload but are less quantifiable include the institution’s nursing philosophy, environment, the individual characteristics of the nursing workforce such as their experience, skill level, and education, as well as the type of staffing such as team nursing or primary care, the patterns of medical treatment are also included as a factor (Neill).

According to the study (Rhulani C. Shihundla), a deep performance impact of overworking among nurses is the failure to maintain the patient’s information in the form of quality documentation, or poor recording of data, misplacing of documents or using the wrong stationery. Overworked health professionals lead towards increased patient morbidity and mortality in both secondary and primary facilities. It is often so that a physician’s working hours are decreased as a result of the intervention of professional medical associations, but that leads towards increasing working hours for nurses to compensate for that. The study (Rhulani C. Shihundla) observes professionals in many parts of the world be unable to cope with heaps of unmanaged records because of inadequate administrative and financial resources. Illegible documentation or incomplete documents were observed to be directly related to an increased workload on professional nurses at primary health care facilities.

The participants in the study conceded that nurses often fail to record readable and clear patient information due to carelessness, added work and fatigue. Under a call system, they were required actually to work 24 hours on a daily basis. It was often the case that during the night, they forgot to document relevant patient information accurately in the files or forms, as a result of overwork. The forms, files, and registers with blank spaces were also as a result of forgetfulness, tiredness and increased workload. Furthermore, (Li Fang Liu) showed through a survey on Taiwanese nurses how lower patient-nurse ratios and overtime, increased the workload of nurses that in turn affected physiological factors such as fatigue and increased work intensity. These system variables were studied and found to have contributed towards a high risk of error.

Additionally, (Li Fang Liu) pointed out that as a result of poor working conditions and work overload, nurses had started to avoid hospital work. Nurse Service quality is further reduced as hospitals and health care centers try to reduce costs by cutting down the nursing workforce. This resulted in adverse patient outcomes such as decubitus, falls, pressure ulcers near misses and medication errors. The mediation required in this case is to create a mentoring program for professional nurses, and an active follow up. Regular workshops can be arranged that relate to proper documentation of information relevant to the patient’s requirements (Rhulani C. Shihundla). To reduce these errors, the first nursing staff should have their real load cut, and Labor Standards Acts must be implemented to ensure compliance with adequate working hours. If there are any unreasonable hospital demands, the nursing leaders raise objections and assist nurses to ensure that overworking is avoided (Li Fang Liu).

In a study (Čedomirka Stanojevic) found that more frequent or longer shifts reduce the opportunity for nursing staff to get adequate sleep and therefore leads to a reduction in recovery time length between shifts. There are legal provisions that recommend that working shifts for nurses do not exceed 12 hours, but these are flexibly interpreted and slowly adopted or many times not adopted at all. These are particularly a point of concern because it not only affects the patient outcome but the degree of sleep loss is linked with adverse effects on the general health, safety, and well-being of the nursing staff. It also leads towards a neurocognitive dysfunction that can in turn lead towards negative consequences on not only the quality of care delivered to patients but also their safety. The study also found that prolonged night shift work on rotation basis for female nurses increases their risk of developing breast cancer 1.79 times compared to those nurses that did not work rotating shifts (Čedomirka Stanojevic).

To analyze turnover intention’s relation to nursing workload as an organizational outcome, a significant independent variable is job satisfaction that affects the employee’s behavior. The research by (Isik U. Zeytinoglu) suggests that the effects of external work environment on casual, part-time nor full-time nurses may be different, despite working in the same situation. This is important to our study in particular because although increasing workload affects patient outcomes and nurse burnouts, it reinforces the view that workload is a complex variable and is affected by multiple factors. In this case, the different career expectations and goals influence the behavioral responses from nurses working in different modes of work. As a result, the workload factors and reaction to external work environment may be different. For full-time nurses, in particular, a heavy workload is a significant factor in the perception of a deterioration in the external work environment and turnover intention. The part-time nurses, therefore, are more likely to stay in their employing centers and hold on to their jobs. Therefore job satisfaction is a mediating factor that affects turnover intention, and an increased workload only partially affects job satisfaction, because some other factors are involved. The effects of workload on the turnover intention are diminished mainly when job satisfaction is added to the equation (Isik U. Zeytinoglu). This shows that if other factors that contribute to positive job satisfaction are stressed, a hospitals’ financial constraints that lead towards a lesser nurse-patient ration may still be mediated and lead towards a less disruption in nurse performance.

To corroborate this, a study (Peter Van Bogaert) theorizes that when nurses are allowed an opportunity to make independent decisions, be actively involved in the decision-making process and are allowed to develop and use their personal and professional skills, leads towards positive outcomes, despite an increased workload. The management at the hospital administration level leaves an indirect yet substantial impact on the nurse’s emotional exhaustion through his or her workload, and it also directly leaves an effect on his or her sense of personal accomplishment. The unit level nurse manager has a mediating role between dimensions of the hospital’s environment, nurse-physician relations, organizational support and outcomes related to the nurse-assessed quality of care and job outcomes. Personal accomplishment as well as workload impact the variables related to outcomes and depersonalization showed a positive correlation with reduced job outcomes. Despite the fact that an increased workload leaves harmful effects on a nurse through causing burnouts, that in turn influence job outcomes and quality of care, a unit level supportive nursing management leaves a direct positive impact on both job outcomes, such as turnover intentions and job satisfaction as well as nurse-assessed quality of care (Peter Van Bogaert).

According to (Shahra Razavi), cost-cutting measures and pervasive labor market informality leads towards a devaluation of particular women who are involved in healthcare workers, such as nurses and leaves them vulnerable to exploitation, which has only increased in the recent decade. The resulting nurse shortage and overworking affect nurse retention and patient outcomes in healthcare centers (Linda H. Aiken). The study by (Linda H. Aiken), reinforces the traditional view that nurse staff ratios are important to explain outcomes in-hospital mortality but suggests that the effects can be mediated through the implementation of legislation that is a reliable way of increasing nurse retention and reducing patient mortality as was passed in the case of California. Furthermore, if hospital stakeholder groups make any demands in modifying ratios to be lower, their views are to be rejected to reduce not only dissatisfaction, burnouts and turnover intentions in nurses but to reduce patient mortality that occurs due to nurse fatigue.

In a study by (Maura MacPhee), the findings showed that poor nurse staffing ratios and the heavy workloads that occur. As a result into urinary tract infections, medication errors as well as falls. Burnouts affected the patient outcome variables but which can be mediated through managing decision latitude, workload, and social capital. It reinforces both views in the sense that despite nurse-patient rations leading towards negative patient outcomes, intervention by unit-level leaders can influence perceptions of nurse-assessed quality of care and job outcomes if they promote professional values in team members and respond to the nurse’s workload demands (Maura MacPhee).

In conclusion, a vast majority of nurses in various studies, whether they worked part-time or full-time, agreed that budget cuts and financial constraints affect nurse quality of care. The limitation in resources creates difficulty in meeting the needs of the patients. Factors that lead towards a greater understanding towards the mental workload experienced by nurses help mediate its effects and improves nurse’s safety and work quality, thereby driving towards improved patient outcomes. A reduced burnout, as a result of overworking, could be reduced by implementing measures that lead towards higher job satisfaction and allow nurses to take independent decisions and acquire an adequate amount of rest before beginning their shifts. As studies have noted that nurse perceptions of task-level interruptions and overwork negatively affect nurse and patient outcomes, it leaves us with a critical need to analyze the impacts of personal and environmental factors that lead towards these negative outcomes. However, as other studies have suggested, despite financial constraints and lower nurse-patient ratios, the effects of overwork and heavy workloads can still be mediated if appropriate measures are taken.
Works Cited

čedomirka Stanojević, Svetlana Simić, Dragana Milutinović. “Health Effects Of Sleep Deprivation On Nurses Working Shifts.” Med Pregl 6 (2016): 183-188.

Isik U. Zeytinoglu, Margaret Denton, Sharon Davies, Andrea Baumann, Jennifer Blythe, Linda Boos. “Deteriorated External Work Environment, Heavy Workload, And Nurses’ Job Satisfaction And Turnover Intention.” Canadian Public Policy-Analyse De Politiques 33 (2007): 32-47.

Li Fang Liu, Sheuan Lee, Pei Fang Chia, Shu Ching Chi, Yu Chun Yin. “Exploring the Association Between Nurse Workload and Nurse-Sensitive Patient Safety Outcome Indicators.” The Journal of Nursing Research 20.4 (2012): 300-309.

Linda H. Aiken, Sean P. Clarke, Douglas M. Sloane, Julie Sochalski, Jeffrey H. Silber. “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout and Job Dissatisfaction.” JAMA 288.16 (2002): 1987-1993.

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Neill, Denise. “Nursing Workload And The Changing Health Care.” Administrative Issues Journal: Education, Practice, and Research 1.2 (2011): 132-143. <http://www.swosu.edu/academics/aij/2011/v1i2-docs/neill.pdf>.

Pascale Carayon, Ayse P. Gurses. “Nursing Workload and Patient Safety—A Human Factors Engineering Perspective.” RG, Hughes. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville: Agency for Healthcare Research and Quality, 2008. 203-216. <https://www.ncbi.nlm.nih.gov/books/NBK2657/pdf/Bookshelf_NBK2657.pdf>.

Peter Van Bogaert, Christoph Kowalski, Susan Mace Week, Danny Van Heusen, Sean P. Clarke. “The relationship between nurse practice environment, nurse work characteristics, burnout and job outcome and quality of nursing care: A cross-sectional survey.” International Journal of Nursing Studies 50 (2013): 1667-1677.

Rantanen, Jonathan Umansky, and Esa. “Workload In Nursing.” Proceedings of the Human Factors and Ergonomics Society 2016 Annual Meeting. Rochester, NY: Human Factors and Ergonomics Society, 2016. 551-555.

Rhulani C. Shihundla, Rachel T. Lebanese, Maria S. Maputle. “Effects of increased nurses’ workload on quality documentation of patient information at selected Primary Health Care facilities in Vhembe District, Limpopo Province.” Curationis 39.1 (2016): 1-8.

Shahra Razavi, Silke Staab. “Underpaid and overworked: A cross-national perspective on care workers.” International Labour Review 149.4 (2011): 408-422.

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