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Nursing Workload and Patient Safety—A Human Factors Engineering

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Chapter 30. Nursing Workload and Patient Safety—A
Human Factors Engineering Perspective
Pascale Carayon, Ayse P. Gurses

Background
The heavy workload of hospital nurses is a major problem for the American health care
system. Nurses are experiencing higher workloads than ever before due to four main reasons: (1)
increased demand for nurses, (2) inadequate supply of nurses, (3) reduced staffing and increased
overtime, and (4) reduction in patient length of stay.
First, the demand for nurses is increasing as a result of population aging. Between 2000 and
2020, the United States population is expected to grow by 18 percent (31 million), but the over-
65 population, with more health care needs, is expected to grow by 54 percent (19 million).1, 2
Second, the supply of nurses is not adequate to meet the current demand, and the shortage is
projected to grow more severe as future demand increases and nursing schools are not able to
keep up with the increasing educational demand.3, 4 When a nursing shortage occurs, the
workload increases for those who remain on the job.5 Third, in response to increasing health care
costs since the 1990s, hospitals reduced their nursing staffs and implemented mandatory
overtime policies to meet unexpectedly high demands, which significantly increased nursing
workloads. Fourth, increasing cost pressure forced health care organizations to reduce patient
length of stay. As a result, hospital nurses today take care of patients who are sicker than in the
past; therefore, their work is more intensive.6
There are several important consequences of high nursing workload. Research shows that a
heavy nursing workload adversely affects patient safety.7 Furthermore, it negatively affects
nursing job satisfaction and, as a result, contributes to high turnover and the nursing shortage.8 In
addition to the higher patient acuity, work system factors and expectations also contribute to the
nurses’ workload: nurses are expected to perform nonprofessional tasks such as delivering and
retrieving food trays; housekeeping duties; transporting patients; and ordering, coordinating, or
performing ancillary services.9 A 1998–1999 survey of more than 43,000 nurses in five countries
found that 17 percent to 39 percent of respondents planned to leave their job within a year
because of job demands.9 Heavy nursing workload increases burnout and job dissatisfaction,
which in turn contributes to high nurse turnover.10 This chapter focuses on the impact of nursing
workload on patient safety. We first present different concepts and models of nursing workload,
then discuss the impact of workload on patients and on nursing staff, presenting various
mechanisms of the relationship between nursing workload and patient safety. Finally, we
describe a human factors engineering approach on how work systems can be redesigned to
reduce nursing workload or to minimize the negative impact of a heavy nursing workload.

Concepts and Models of Nursing Workload

Nursing workload measures can be categorized into four levels: (1) unit level, (2) job level,
(3) patient level, and (4) situation level.11 These measures can be organized into a hierarchy. The
situation- and patient-level workloads are embedded in the job-level workload, and the job-level

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

workload is embedded in the unit-level workload. In a clinical unit, for example, numerous
nursing tasks need to be performed by a group of nurses during a specific shift (unit-level
workload). The type and amount of workload of nurses is partly determined by the type of unit
and specialty (e.g., intensive care unit [ICU] nurse versus general floor nurse), which is the job-
level workload. When performing their job, nurses encounter various situations and patients,
which are determinants of the situation- and patient-level workloads.

Workload at the Unit Level

The most commonly used unit-level workload measure is the nurse-patient ratio. The nurse-
patient ratio can be used to compare units and their patient outcomes in relation to nursing
staffing. Previous research provides strong evidence that high nursing workloads at the unit level
have a negative impact on patient outcomes.7, 12, 13 These studies’ suggestions regarding
improving patient care are limited to increasing the number of nurses in a unit or decreasing the
number of patients assigned to each nurse. However, it may not be possible to follow these
suggestions due to costs and the nursing shortage. The major weakness of this type of research is
that it conceptualizes nursing workload at a macro level, ignoring the contextual and
organizational characteristics of a particular health care setting (e.g., physical layout, information
technology available) that may significantly affect workload. Research should examine the
impact on nursing workload of work factors in the health care microsystems.

Workload at the Job Level

According to this conceptualization, the level of workload depends on the type of nursing job
or specialty (ICU nurse versus operating room nurse). For instance, Schaufeli and LeBlanc14
used a job-level measure of workload to investigate the impact of workload on burnout and
performance among ICU nurses. Previous research linked job-level workload (a working
condition) to various nursing outcomes, such as stress15, 16 and job dissatisfaction.17 Workload
measures at the job level are appropriate to use when comparing workload levels of nurses with
different specialties or job titles (ICU nurses versus ward nurses).18 However, workload is a
complex, multidimensional construct, and there are several contextual factors in a nursing work
environment (e.g., performance obstacles and facilitators) other than job title that may affect
nursing workload.19 In other words, two medical ICU nurses may experience different levels of
workload due to the different contextual factors that exist in each ICU. The workload at the job-
level conceptualization fails to explain the difference in the workloads of these two nurses.

Workload at the Patient Level

This conceptualization assumes that the main determinant of nursing workload is the clinical
condition of the patient. Several patient-level workload measures have been developed based on
the therapeutic variables related to the patient’s condition (e.g., Therapeutic Intervention Scoring
System)15, 20, 21 and have been extensively discussed in the nursing literature. However, recent
studies show that factors other than the patient’s clinical condition (e.g., ineffective
communication, supplies not well-stocked) may significantly affect nursing workload. As with
the previous two workload measures, patient-level workload measures have not been designed to
measure the impact of these contextual factors on nursing workload.

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 Workload for Nurses

Situation-Level Workload

To remedy the shortcomings of the three levels of measures explained above and
complement them, we have suggested using another way to conceptualize and measure nursing
workload based on the existing literature on workload in human factors engineering: situation-
level workload.11 In addition to the number of patients assigned to a nurse and the patient’s
clinical condition, situation-level workload can explain the workload experienced by a nurse due
to the design of the health care microsystem. In a previous study, we found that various
characteristics of an ICU microsystem (performance obstacles and facilitators)—such as a poor
physical work environment, supplies not well stocked, many family needs, and ineffective
communication among multidisciplinary team members—significantly affect situation-level
workload.22 For example, sometimes several members of the same family may call a nurse
separately and ask very similar questions regarding the same patient’s condition. Answering all
these different calls and repeating the same information about the patient’s status to different
members of the family is a performance obstacle that significantly increases the (situation-level)
workload of nurse.
It is important to note that the impact of this performance obstacle on nursing workload
would not be apparent if we used a unit-level or patient-level workload measure. Compared to
workload at the job level, situation-level workload is temporally bound: it explains the impact of
a specific performance obstacle or facilitator on nursing workload over a well-defined and
relatively short period of time (e.g., 12-hour shift), rather than using the overall experience of the
nurse in a given microsystem. Situation-level workload is multidimensional, that is, different
types of performance obstacles and facilitators affect different types of workload. Whereas the
distance between the patients’ rooms assigned to a nurse affects physical workload, the condition
of the work environment (noisy versus quiet, hectic versus calm) affects the overall effort spent
by the nurse to perform her job.23 No prior study investigated the impact of the microsystem
characteristics on situation-level nursing workload.19 In summary, by studying workload at the
situation level, researchers can identify the characteristics of a microsystem that affects
workload. This information is vital for reducing nursing workload by redesigning the
microsystem. In the last section of this chapter, a human factors engineering approach based on
the situation-level workload is described.

Research Evidence
Impact of Nursing Workload on Patients

A heavy nursing workload seems to be related to suboptimal patient care10, 24 and may lead to
reduced patient satisfaction.25 A 2004 report by the Agency for Healthcare Research and Quality
(AHRQ) describes several AHRQ-funded studies on the relationship between hospital nurse
staffing and quality of care (e.g., urinary tract infection, hospital-acquired pneumonia) and
patient safety outcomes (e.g., failure to rescue).26
Much of the research investigating the impact of nursing workload on patient safety focused
on linking nursing staffing levels with patient outcomes. There is strong evidence in the literature
that nurse staffing levels significantly affect several nursing-sensitive patient outcomes.13, 26, 27

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Several studies found a significant relation between lower nurse staffing levels and higher
rates of pneumonia.28-30 For example, a multisite study in California found that an increase of 1
hour worked by registered nurses (RNs) per patient day correlated with an 8.9 percent decrease
in the odds of pneumonia among surgical patients.28 Another study found a significant
relationship between full-time-equivalent RNs per adjusted inpatient day and rate of pneumonia:
the rate of pneumonia was higher with fewer nurses.31 However, other studies have not
confirmed these findings;31, 32 for example, the evidence regarding the impact of nurse staffing
levels on pneumonia is conflicting. As workload is affected by more than just staffing levels, a
deeper understanding of nursing workload is required to better assess the impact of workload on
patient outcomes. Later, a human factors engineering approach to nursing workload that can
provide this deeper understanding of nursing workload and its causes will be described, allowing
for the development and implementation of solutions aimed at reducing or dealing with
workload.
Nursing staffing levels have been shown to have a significant impact on nosocomial
infections. For example, Needleman and colleagues13 found that among medical patients, a
higher number of hours of care per day provided by RNs was related to lower urinary tract
infection rates. A retrospective cohort study in a neonatal ICU revealed that the incidence of E
cloacae infection in the unit was significantly higher when there was understaffing of nurses.33 A
prospective study in a pediatric cardiac ICU found a significant relation between the monthly
nosocomial infection rate in the unit and the nursing hours per patient day ratio: there were more
nosocomial infections when the number of nursing hours per patient day was lower.34
Although not as strong, some evidence exists regarding the impact of nurse staffing levels on
failure to rescue (death within 30 days among patients who had complications) and mortality. A
study using administrative data from 799 hospitals in 11 States revealed that a higher number of
hours of RN care per day was associated with lower failure to rescue rates.13 In a study of 168
nonfederal adult general hospitals in Pennsylvania, Aiken and colleagues10 found that each
additional patient per nurse was associated with a 7 percent increase in the likelihood of
mortality within 30 days of admission and in the likelihood of failure to rescue. An earlier study
found that hospitals that had more RNs per admission had lower mortality rates.35
There were four studies that found a relationship between nurse staffing and patient
outcomes. One study found that having a nurse-patient ratio of less than 1:2 during evening shifts
was associated with a 20 percent increase in length of stay in patients who had abdominal aortic
surgery in Maryland hospitals between 1994 and 1996.36 Researchers conducted studies in 1992
and 1994 using hospital cost reports and discharge data in New York and California, finding that
more nursing work hours were associated with reduced length of stay.37 Additionally, a critical
incident study of Australian ICUs revealed that insufficient nursing staff was linked to drug
administration or documentation problems, inadequate patient supervision, incorrect ventilator or
equipment setup, and self-extubation.38
A majority of the studies on nursing workload and patient safety used nurse-patient ratio as
the measure of nursing workload. According to research on workload in human factors
engineering (see section above), it is well known that workload is a complex construct, more
complex than the measure of nurse-patient ratio.11 It is unlikely that the multidimensional,
multifaceted structure of workload can be captured by one unique, representative measure.
Therefore, the belief is that researchers who use the nurse-patient ratio as a measure of workload
offer a limited contribution to understanding the impact of nursing workload and designing
solutions for reducing or mitigating nursing workload. One reason for the extensive use of the

4
 Workload for Nurses

nurse-patient ratio may be that this measure is easy to use and is readily available in existing
databases. But tools used by human factors researchers can comprehensively assess workload,
facilitate the identification of the sources of excessive workload, and provide direction for
corrective interventions.11

How Does Nursing Workload Impact Patient Safety?

According to the Systems Engineering Initiative for Patient Safety (SEIPS) model of work
system and patient safety,39, 40 structural/organizational characteristics of health care work
systems, such as nursing workload, can affect quality of care and patient safety. In this section, a
description of how nursing workload can affect patient safety will be offered (see Table 1). The
first five mechanisms describe the impact of a heavy workload experienced by one nurse on that
particular nurse. The last mechanism describes the systemic and organizational impact of a heavy
workload experienced by a nurse’s coworkers and team members.

Table 1: Relationship Between Nursing Workload and Patient Safety

Mechanisms Description Examples

Time Nurses who have a heavy workload may No or little time to double-check
not have sufficient time to perform tasks medications
safely, apply safe practices, or monitor
patients, and may reduce their
communication with physicians and other
providers.
Motivation Nurses who have a heavy workload may be No or little motivation and commitment
dissatisfied with their job, thus affecting their to high levels of performance High
motivation for high-quality performance. workload creating frustration and
contributing to the development of
negative attitude toward one’s job.
Stress and burnout Nurses who have a heavy workload may Reduced physical and cognitive
experience stress and burnout, which can resources available for nurses to
have a negative impact on their perform adequately
performance.
Errors in decisionmaking High cognitive workload (one dimension of Forgetting to administer medications
(attention) nursing workload) can contribute to errors,
such as slips and lapses or mistakes.
Violations or work-arounds High workload conditions may make it more Inadequate hand washing
difficult for nurses to follow rules and
guidelines, thus compromising the quality
and safety of patient care.
Systemic/organizational The heavy workload of a nurse, nurse A charge nurse may not be available to
impact manager, or another provider could affect help other nurses with their patients
the safety of care provided by another when needed.
nurse.

Nursing workload and lack of time. Nursing workload definitely affects the time that a
nurse can allot to various tasks. Under a heavy workload, nurses may not have sufficient time to
perform tasks that can have a direct effect on patient safety. A heavy nursing workload can
influence the care provider’s decision to perform various procedures.41 A heavy workload may
also reduce the time spent by nurses collaborating and communicating with physicians, therefore
affecting the quality of nurse-physician collaboration.42 A heavy workload can lead to poor
nurse-patient communication.43, 44

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Nursing workload and deteriorated motivation. Several studies have shown the
relationship between nurses’ working conditions, such as high workload, and job
dissatisfaction.10, 45, 46 Job dissatisfaction of nurses can lead to low morale, absenteeism,
turnover, and poor job performance, and potentially threaten patient care quality and
organizational effectiveness.47 Researchers have found positive associations between job
satisfaction and job performance,48 and patient satisfaction and quality of care.49
Impact of workload on nursing stress and burnout. High workload is a key job stressor of
nurses in a variety of care settings, such as ICUs.15, 16, 50 A heavy nursing workload can lead to
distress (e.g., cynicism, anger, and emotional exhaustion)51 and burnout.10 Nurses experiencing
stress and burnout may not be able to perform efficiently and effectively because their physical
and cognitive resources may be reduced; this suboptimal performance may affect patient care
and its safety.
Nursing workload and errors. Workload can be a factor contributing to errors.52, 53 Errors
have been classified as (1) slips and lapses or execution errors, and (2) mistakes or knowledge
errors.52 High workload in the form of time pressure may reduce the attention devoted by a nurse
to safety-critical tasks, thus creating conditions for errors and unsafe patient care.
Nursing workload and violations or work-arounds. Violations are defined as deliberate
deviations from those practices (i.e., written rules, policies, instructions, or procedures) believed
necessary to maintain safe or secure operations.54 The literature on violations emphasizes the role
of the social and organizational context, where behavior is governed by operating procedures,
codes of practice, rules, and regulations.54, 55 This approach emphasizes factors in the work
system that can contribute to violations. The health care field has begun to explore caregivers’
violations of protocols.56 A survey describing medical practice was administered to 315 nurses,
doctors, and midwives and 350 members of the general public in the United Kingdom. The study
examined two factors manipulated within nine scenarios of surgery, anesthetics, and obstetrics.
The first factor, behavior, was described as an improvisation (no rule available), a violation of
clinical protocol, or compliance with a clinical protocol. The second factor, patient outcome, was
described as good, bad, or poor. Samples of health care providers and the general public were
asked to evaluate the nine scenarios with regard to the inappropriateness of the behavior, the
likelihood that they would take further action (i.e., reporting by health care provider and
complaining by the public), and responsibility for the outcome (e.g., the health care professional,
the patient, the protocol itself, the hospital). Results showed that violations of protocols and bad
outcomes were judged most harshly. Whether outcomes were good or bad, violations were
evaluated more negatively. The authors of the study warned against overreliance on procedures
(or protocols) as a form of organizational defense against accidents or claims. Procedures may
stifle innovation and make people less able to function in novel situations.
Alper and colleagues57 conducted a survey of 120 nurses (59 percent response rate) in three
units of a pediatric hospitals to assess self-reports of violations in the medication administration
process. Between 8 percent and 30 percent of the nurses reported violations in routine situations,
and between 32 percent and 53 percent of the nurses reported violations in emergency situations.
The most frequent violations or work-arounds occurred in matching the medication to the
medication administration record and checking the patient’s identification.
Further research is needed to understand the work system factors that lead to violations.
Violations occur more frequently when nurses are under time pressure or high workload because
of emergency situations. Under high workload, nurses may not have time to follow rules and

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 Workload for Nurses

guidelines for safe care, especially if following the rules and guidelines necessitate additional
time, such as hand washing.
Systemic, organizational impact of nursing workload. This final mechanism of the
relationship between nursing workload and patient safety is based on the systemic,
organizational impact of nursing workload: a heavy workload experienced by a nurse not only
affects this nurse, but can also affect other nurses and health care providers in the nurse’s work
system. Understaffing may reduce time nurses have to help other nurses. This lack of time may
also result in inadequate training or supervision of new nurses.

Practice and Research Implications

We propose a human factors engineering approach to nursing workload and patient safety,
which is based on the SEIPS model of work system and patient safety.58, 59 This approach is
based on the key principle of human factors engineering, i.e., work system design.60, 61
According to the work system model, several elements of the work system can affect nurses and
their performance, safety, and well-being.58 These work system elements are causes or factors
contributing to nursing workload. The first step of the proposed approach is therefore to
understand how the work system of nurses can contribute to their workload. Human factors
engineers have developed and used various methods to assess each element of the work system
model and the interaction between the elements,62 such as observations of the work situation;62, 63
direct measurement of the work environment and workstation; and interviews, focus groups, and
survey of workers.40, 64 Once the human factors engineers have identified the elements and
characteristics of the nurses’ work system that contribute to workload, they can redesign the
work system to reduce the workload.
In a previous study,23 the causes of situational workload experienced by nurses in 17 ICUs in
Wisconsin were identified, demonstrating that there were differences in the factors that lead to a
heavy nursing workload in different ICUs. For example, compared to their colleagues in other
participating ICUs, a higher number of nurses of a 24-bed medical surgical ICU reported the
following factors that led to high workload: difficulty finding a place to sit down and do
paperwork, distance between patients’ rooms, poor condition of the equipment, spending a lot of
time searching for patients’ charts, and a crowded and disorganized work environment. Since
this ICU was larger than the other ICUs in the study and many specialties were involved in the
care of patients in this ICU, it was not surprising to see such work system factors as a crowded
and disorganized work environment, and spending a lot of time searching for patients’ charts
(e.g., different specialties searching for the chart during the day).
Once the work system factors contributing to nursing workload have been identified,
interventions aimed at reducing or mitigating the workload can be designed. The work system
redesign interventions should follow the two basic principles of the Balance Theory of Carayon
and Smith: (1) eliminating the source of the excessive workload, or (2) compensating or
balancing out the workload.60, 61 According to the Balance Theory, redesigning the work system
should aim at eliminating the negative aspects of work; however, this is not always feasible or
practical. The Balance Theory, therefore, proposes an alternative approach aimed at
compensating for or balancing out the negative aspects of work. For instance, “making available
to nurses resources and social support to assist them in accomplishing their duties”50, 51 can be
conceptualized as a compensating mechanism: different types of support (e.g., informational

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

support, practical support, affective support) can be provided to help nurses deal with negative
aspects of their work, such as workload.
Another key concept of the human factors engineering approach to nursing workload is the
work system: any change in one element of the work system can affect other elements of the
work system in negative and/or positive ways.60, 61 For instance, work hour limits for physicians
have affected nurse schedules. Nurses are often required to work increased overtime to
compensate for reduced physician hours.65 This is an example of how changing one element in
the work system of physicians can negatively affect the work system of nurses. Table 2
summarizes the research implications of the proposed human factors engineering approach to
nursing workload and patient safety.

Table 2: Research Implications on Nursing Workload and Patient Safety

Research Implications Objectives

Measurement of situational workload Test and evaluate various methods for measuring nursing
workload at the situational level.
Identification of work system factors that contribute Identify the work system factors that contribute to nurses’
to situational workload situational workload under various conditions and in various
care settings.
Evaluation of the impact of situational workload on Evaluate the impact of situational workload on various
outcomes outcomes, such as nurses’ job satisfaction and stress,
nurses’ perceptions of quality and safety of care, and patient
outcomes. Conduct this research in various care settings and
organizational settings.
Development of strategies for reducing situational Develop, implement, and evaluate interventions for reducing
workload situational workload and its negative impact on nurses and
patients.
Evaluation of barriers to improving nurses’ work Identify the organizational and structural barriers to effective
system and reducing situational workload changes in nurses’ work system and the challenges in
reducing situational workload.

Conclusion
Nursing workload is affected by staffing levels and the patients’ conditions, but also by the
design of the nurses’ work system. In this chapter, a description of different levels of workload,
including situational workload, was offered, and a proposal for a human factors engineering
approach aimed at reducing workload or at mitigating or balancing the impact of workload on
nurses and patient care was suggested.

Author Affiliation
Pascale Carayon, Ph.D., Department of Industrial and Systems Engineering, Center for
Quality and Productivity Improvement, University of Wisconsin–Madison. E-mail:
carayon@engr.wisc.edu.
Ayse P. Gurses, Assistant Professor, Division of Health Policy and Management, School of
Public Health, University of Minnesota–Twin Cities. Email: gurse001@umn.edu.

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 Workload for Nurses

Acknowledgments
This chapter is partially based on a project funded by a Health Services Research Dissertation
Grant (# R03 HS14517-01) from the Agency for Healthcare Research and Quality.

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 Evidence Table. Nurse workload and patient safety

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Study Design
Safety Issue Design Type & Study Study Setting & Study
Source Related to Outcome Population Key Finding(s)
Clinical Practice Measure(s)
Aiken Hospital nurse Cross-sectional Risk-adjusted Linked data from 10,184 In hospitals with high patient-to-nurse
200210 staffing study patient nurses surveyed, 232,342 ratios, patients experience higher 30-
mortality, surgical patients discharged day mortality and failure-to-rescue
failure to from the hospital between rates, and nurses are more likely to
rescue, job 04/01/1998 and 11/30/1999, report burnout and job dissatisfaction.
dissatisfaction, and administrative data from
job-related 168 hospitals in
burnout Pennsylvania
Anderson & Nurse workload Cross-sectional Patient Survey data from 188 Patient satisfaction was negatively
Maloney and patient study satisfaction patients in a 250-bed Army correlated with average daily census,
199825 satisfaction medical treatment facility and positively correlated with the
number of nursing care hours required
and the number of registered nurses
available.
12

Archibald Nurse staffing Cross-sectional Rate of One pediatric cardiac Higher patient census was related to
199734 levels and patient study nosocomial intensive care unit; 782 higher rates of nosocomial infections.
census in ICU infections per admissions during one year There was an inverse correlation
1000 patient between the monthly nosocomial
days infection rates and the nurse/patient
ratio.
Beckmann Nursing staffing Noncomparative Incidents 89 nursing staff shortage Incidents involving nursing staff
199838 issues in incidents study associated incidents and 373 incidents shortage contributed primarily to
reported by ICU with nursing involving nursing staff problems in unit management (65%)
staff staff shortage shortage contributing factors and patient management (48%).
reported to the
Australian
Incident
Monitoring
Study-ICU
(AIMS-ICU)
project
 Study Design
Safety Issue Design Type & Study Study Setting & Study
Source Related to Outcome Population Key Finding(s)
Clinical Practice Measure(s)
Keijsers Burnout (emotional Cross-sectional Standardized 576 nurses from 20 ICUs High burnout of ICU nurses is related
199524 exhaustion and study mortality ratio to poor perceived unit performance and
depersonalization) for each of the poor perceived personal performance.
20 participating Nurses in well-performing ICUs (as
ICUs; measured by the standardized mortality
perceived ratio) reported higher burnout than
personal nurses in poor-performing units.
performance;
perceived ICU
performance
Lichtig Nurse staffing Cross-sectional Adverse Hospital cost reports and Higher nurse staffing and higher
199937 study patient patient discharge data from proportion of RNs were related to lower
outcomes hospitals in the States of length of stay. Lower rates of adverse
(pressure California and New York outcomes were related to a higher
ulcers, proportion of RNs.
pneumonia,
13

UTIs,
postoperative
infections),
length of stay
Manheim Regional variation Cross-sectional Severity- 3,796 hospitals in nine US The percentage of RNs per adjusted
199235 in hospital mortality study adjusted Census regions admission was a negative predictor of
Medicare mortality rates.
hospital
mortality rate
Needleman Hours of nursing Cross-sectional Rates of Administrative data from A higher proportion of hours of nursing
200213 care per patient study urinary tract 1997 for 799 hospitals in 11 care was related to better quality of
infections, States care outcomes, such as lower rates of
rates of failure- urinary tract infections among surgical

Workload for Nurses

to-rescue, in- patients and lower rates of pneumonia,
hospital death, shock or cardiac arrest and “failure-to-
rate of adverse rescue” among medical patients. There
outcomes was no association between hours of
nursing care per patient and the in-
hospital death rate and the rate of
adverse outcomes.
View publication stats

Study Design

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Safety Issue Design Type & Study Study Setting & Study
Source Related to Outcome Population Key Finding(s)
Clinical Practice Measure(s)
Pronovost Organizational Observational In-hospital All Maryland hospitals that Having an ICU nurse:patient ratio of
199936 characteristics of study with mortality and performed abdominal aortic less than 1:2 was associated with
ICUs patient data hospital and surgery from 1994 to 1996 increased resource use.
collected ICU length of
retrospectively stay
and ICU data
collected
prospectively
14