Introduction:
Nurses' workload is a major healthcare, economic, and social issue due to its consequences. As a result of increased physical and psychological workload among nurses, long-term stress, physical and mental exhaustion, and burnout syndrome may arise. Although subjective perception of excessive workload can cause physical and psychological difficulties for the nurse herself and undoubtedly impacts the quality of nursing care, patient safety, it is not given adequate attention.
The nursing profession has always been and will always be not only physically demanding, but foremost it carries a significant psychological burden, which arises from the very nature of the nursing profession itself, from social interactions, communication issues, and other problems that occur in daily nursing care (Komačeková, 2012). Today, in addition to the traditional factors/stressors, further trends are added, such as exceeding overtime limits, staff reduction, or workforce shortages, which can significantly impact the perceived workload. The shortage of nurses in the labor market affects migration of nurses, turnover, departure to other economically more advantageous sectors, and departure of a large number of nurses into retirement (the average age of working nurses is high), while population aging also places greater demands on caring personnel. The COVID-19 pandemic, the economic crisis, and also insufficient attention from competent leadership consistently contribute to the deepening of these trends.
According to NCZI data, nurses are the largest group of healthcare professionals in Slovakia (35.24% in the Slovak Republic); (NCZI, 2022). Nurses perform more than 80% of all activities related to the delivery of healthcare (SKSaPA, 2023). In Slovakia there are 5.7 actively working nurses per 1000 inhabitants, while the European average is 8.4 nurses per 1000 inhabitants. According to the OECD, we are the only European country with a continuous decrease in the number of nurses since 2009. In 2055, the system may lack more than 12,000 nurses (INEKO, 2023). Lukáš Kober (2023), director of the Office of the Slovak Chamber of Nurses and Midwives, points to a dramatic increase in depression, anxiety, and post-traumatic stress disorder among nurses, citing workload and burnout as the most common reasons for leaving the system.
Aim: Through a literature review, to map relevant tools that enable monitoring nurses' workload.
Materials and methods: We performed a content analysis of papers published in openly available databases over the last 5 years. Using a search with the keywords “nurse workload, measurement tools, objectification of workload, workload measurement,” and their combinations, more than 5,500 documents related to the subject matter were identified. Subsequently, using inclusion criteria (available data on psychometric properties of the tool, tools validated on a nurse sample) and exclusion criteria (duplicates, review studies, unavailability of full text, ambiguous interpretation of conclusions), 90 sources were selected for content analysis.
Results
The measurement tools enabling the assessment of nurses' workload can be divided into several categories:
- Questionnaire methods primarily assess the subjectively perceived level of workload, or psychological burden.
- Scoring systems are a kind of scoring system for nursing interventions, where points represent the time needed for nursing activities or staffing, skill requirements. Some scoring systems also take into account patient condition, specifically the degree of dependence on assistance, as factors affecting workload. This method of assessing workload is based on standardized procedures, classification of nursing interventions, and electronic documentation used in individual countries. Workload is assessed over 24 hours, a shift, or a specific time interval. Scoring systems are quite well used mainly in countries where electronic versions of nursing intervention classifications have been implemented in electronic nursing documentation. Scoring systems have proven particularly useful in intensive care.
- Predictive models use combinations of specific intervention time and measurement of the relative value of disease or condition (prototype models, patient classification models). One such system is, for example, the Safer Nursing Care Tool, which is the most widely used method for determining staffing requirements in England. Patients are assigned to one of five dependency categories, according to which the required number of staff is determined (Griffith et al., 2020). Because of the limited scope of this paper, a detailed review of predictive models is not provided in this study.
1. Questionnaire methods
Meister questionnaire It is validated and used primarily in European countries. The Ministry of Health of the Slovak Republic (Decree 542/2007) recommends the tool as the only standardized psychological method for assessing psychological workload. Evaluation of psychological workload using this method is valid only for a specific study group, because different psychosocial circumstances influence different occupational groups even with similar work characteristics. The questionnaire serves to identify specific problems in a specific workplace. It contains ten questions, by which three factors can be identified (overload, monotony, and non-specific workload factor). Individual factors are represented by corresponding items – time pressure at work, low job satisfaction, high responsibility, monotonous work, problems and conflicts, monotony, nervousness, overload, fatigue, and long-term strain tolerance. Respondents answer each item using a 5-point Likert scale, where the lowest value 1 represents complete disagreement and 5 complete agreement with the statement. The advantage of the questionnaire is its brevity and low time demand (Žídková, 2002).
Maslach Burnout Inventory (MBI)/ Maslach Burnout Inventory - Human Services Survey (MBI – HSS)/ Maslach Burnout Inventory - Human Services Survey MP (MBI-HSS-MP) Although this instrument does not directly measure workload level, it measures its consequence—risk of burnout—and is therefore often used in studies in combination with other tools for workload measurement, both in the MBI-HSS version designed for helping professions and in the MBI-HSS-MP version intended for healthcare professionals. It contains three scaled areas focused on emotional exhaustion, depersonalization, and personal accomplishment.
Working excessively questionnaire (WEQ) This is a 65-item scale consisting of three domains: 1. perfectionist work style, 2. general beliefs about work, 3. perceived pressure from the organization, with individual items rated on a 5-point agreement/disagreement scale. The tool was developed by Hornowska and Paluchowski in 2007. A benefit of the instrument is that it accounts for cognitive (belief), personality factors of the employee (perfectionism, obsessively compulsive traits), as well as situational factors of the work environment and work style (Hornowska, Paluchowski, 2013).
NASA Task Load Index (NASA-TLX) NASA-TLX represents a subjective workload assessment scale developed for use in aviation and increasingly applied in healthcare. The index is intended to measure total workload as a single variable computed as the sum of responses to six items:
- Mental demand - how much thinking, decision-making, or calculation was required to complete the task.
- Physical demand - the amount and intensity of physical activity needed to perform the task.
- Temporal demand - the degree of time pressure needed to complete the task.
- Effort - how hard the respondent had to work to maintain performance level.
- Performance - the level of success in completing the task.
- Frustration level - how uncertain, frustrated, safe, or satisfied the worker felt while performing the task.
Each subscale is presented to participants either during the experimental trial or afterward. Respondents are asked to rate their score on an interval scale from low (1) to high (20). TLX also uses pairwise comparison. This consists of presenting respondents with 15 paired combinations and asking them to select, from each pair, the scale with the greatest impact on workload during the analyzed task (Tubbs-Cooley, 2018).
Table 1 Overview of questionnaire methods for assessing nurses' workload
2. Scoring systems
The nursing activities score (NAS) NAS identifies 23 scored nursing activities. The score for an activity represents the average time required to provide that nursing care. Total score ranges from 0 to 177 NAS points, where a total score of 100 points corresponds to time spent by one nurse equivalent to a full-time position per shift (Almeida, 2021).
The Comprehensive Nursing Intervention Score (CNIS) It consists of 73 nursing interventions. Scoring is 4-point in 6 aspects per intervention (time, number of nurses, skill, psychological load, work intensity, muscular effort) (Cesare et al., 2024).
Therapeutic Intervention Scoring System (TISS) TISS quantifies types and numbers of intensive care treatments, which are divided into four categories according to complexity (based on complexity level, each activity is assigned a score from 1–4). It uses a system consisting of 76 interventions, or a shortened version with 57 scored activities. In several countries, a simplified version has been validated.
TISS-28
(remaining 28 interventions); (Padilha et al., 2005).
NEMS (Nine Equivalents of Nursing Manpower Use Score) It is a simplified version of TISS-28, containing only 9 monitored activities. It is the most well-known and most widely used worldwide, although it has limitations (e.g., it includes only dependency-related interventions or interventions related to medical procedures, it excludes direct nursing care, and the score is directly tied to severity of condition, while severity is far from the only variable associated with workload) (Braňa Marcos, 2007).
Scale of Workload and Nursing Times (VACTE) A scoring system based on estimated time in 13 categories of nursing interventions.
Nursing Intervention Classification (NIC) A scoring system for nursing interventions, based on their classification (NIC), where points represent time needed for nursing activity.
Table 2 Overview of scoring systems for assessing nurses' workload
Conclusion
The large number of identified source documents shows that this topic has received considerable attention. Despite the volume of studies in this area, all authors agree that no single tool exists that could fully and comprehensively cover the issue of nurses' workload across the whole spectrum of applied nursing specialties. Some tools estimated, for example, service time coverage above 80%, but did not register subjectively perceived workload, including emotional load and other variables that can influence workload perception. Experts dealing with nurse workload agree on the need for further research in this area using existing tools and various combinations of these tools. Ongoing development of various predictive systems also continues, which at least contribute to indicative estimates of staff numbers, and very often they are based retrospectively on detailed analysis of nursing documentation and the classification systems used there (most commonly the NIC classification or other intervention classification systems valid in the specific country). We recognize that this overview may not be exhaustive, given that we focused on papers with data on psychometric properties of tools and on tools that had already been validated, excluding studies where interpretation of results appeared ambiguous. Nevertheless, this overview can clearly represent a theoretical basis for further research and selection of relevant tools for assessing nurses' workload.
Authors: Mária LEHOTSKÁ, Jozef BABEČKA, Zuzana HUDÁKOVÁ, Viera SIMOČKOVÁ, Eva MORAUČÍKOVÁ, Lukáš KOBER
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