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Evaluate to manage resources. Analysis of literature on nursing work load


How to cite this article:
Hernández-Morquecho KG. [Evaluate to manage resources. Analysis of literature on nursing work load]. Rev Enferm Inst Mex Seguro Soc. 2016;24(3):217-22.

Evaluate to manage resources. Analysis of literature on nursing work load

Karla Guadalupe Hernández-Morquecho

Universidad de Guanajuato, Campus Celaya-Salvatierra, Área de Ciencias e Ingenierías, Celaya, Guanajuato, México

Correspondence: Karla Guadalupe Hernández-Morquecho

Email: station_girl42@hotmail.com

Received: February 19th 2016

Judged: May 25th 2016

Accepted: July 20th2016



Keywords: Nursing; Work; Workload; Occupational health nursing; Hospital nursing service


Work is an activity that people do for different reasons— to achieve, for fulfillment, and to accumulate worldly goods, among others. Of course, there could be other connotations to the word— slavery, exploitation, suffering, stress and the consequence of health problems.1

Present-day working conditions are accelerated and intense, following production and service provision models. Those models determine an increase in productivity, due to the rhythm of work, workload, responsibility load, and fewer breaks throughout the work day. These factors affect the employee’s health and safety and can cause exhaustion. On that note, nursing professionals endure tiring situations at work due to constant contact with suffering, pain and death. We can add the demanding schedules that health care workers tend to have, such as overtime hours. Such conditions can cause physical and emotional changes and lead to absences, accidents at work, and fatigue.2

The workload is the product of a measured quantity of patients served, according to their dependence on the nursing team. The term is an estimate of the demand for labor required in order to provide direct and indirect care.3 It relates to patient care needs and the standard of care provided; where having the right number of nursing staff can optimize the work load. In turn, an undersized staff increases the work load and the impact to all dimensions cyclically, because it can compromise the quality of care and affect the safety of patients and nursing professionals.3 The nursing workload is related to patient needs and the standard of care provided; having the right number of nursing staff can optimize the workload, while an undersized staff increases workload and impacts all aspects cyclically, because it can compromise care quality and the safety of patients and nursing professionals.4

Several studies are available to use for the translation, adaptation or construction of instruments that can measure workload, such as the Nursing Activities Score, by Karasek, the Scale of Perceived Overwork, by Moore (2000) and TISS 28, used in intensive care units; these instruments are valid and reliable for making decisions about workload management.

Workloads can be physical, chemical, organic, mechanical, physiological and psychological. Physical loads are derived primarily from what is needed technically to transform the object of labor, and they characterize a particular environment with which the worker interacts on a daily basis. Chemical loads are mainly derived from the object of labor and the auxiliary measures involved in its transformation. These take part in the workplace and interact daily with the worker. All chemicals present are in this group:  dusts, fumes, gases, vapors, liquids or pastes. Organic loads are derived from the object of work and workplace hygiene conditions, including any animal or plant organism that can cause damage to the health of workers. Mechanical loads come mainly from the operation or maintenance of machinery and equipment, loose materials in the environment, conditions of installation and maintenance of the means of production, and the work object itself. Physiological loads are derived from the different ways of carrying out the professional activity and are composed of elements such as visual or physical exertion, changes, positions, and movements required by the tasks, available work space, overtime or intensification of work, long work days, and night and rotating shifts. Finally, the psychic loads are elements that, above all, are the main source of stress and psychological wear and tear.5

Studies on the nursing workload in different hospital care units have shown that the use of a patient classification system (in proportion to the minimal, partial or total degree of a patient’s dependency on nursing care) to measure the burden of work required to care for patients of different ages.3 There is evidence that the nurses’ workload is a risk factor for patient safety: as  activities are overloaded onto staff, they become emotionally and physically exhausted, which gradually increases as overload exposure continues over time. Changes in staff health manifest themselves in difficulty with team relationships, decreased productivity, and physical and mental illness.5

On the administrative side, organization and human resource management, essential parts of the nurse’s work process are used to create and implement appropriate conditions for patient care and good employee performance. For management, the patient classification system (PCS) assesses the complexity level of required nursing care. The PCS includes the classification of patients in groups or care categories. These categories are qualified by measure of nursing effort required. It also makes it possible to determine, validate and monitor the care needs of patients, whose data can be used as indicators for determining human resources, planning costs and quality of care.6

In the present study, we investigative articles from indexed scientific journals to analyze the nursing workload and describe the article’s characteristics, insofar as their author, sample, hospital area, method, measuring instruments, and results.


An article search for nursing workload was conducted in indexed journals published in between 2006 and 2014 and in English, Portuguese, and Spanish. The PubMed, Elsevier and Biblioteca Virtual en Salud (BVS) databases were used, which led to searching in Literatura  Latinoamericana  en  Ciencias  de  la  Salud  (LILACS),  Índice Bibliográfico Español en Ciencias de la Salud (IBECS), Scientific Electronic Library Online (SCIELO), and International Health Sciences Literature (MEDLINE).

Health Sciences Descriptors (DeCS) were used, as well as "workload," the MESH term; "Nursing" for the PubMed search. In other databases, searches were done of title words. From each database, we obtained:  PubMed, 6 items, only two of which met the review requirements; LILACS, 37 articles; IBECS, 91 articles, and MEDLINE, 52 articles. In total, 182 articles were reviewed, of which 35 were selected, based on the following quality criteria:  full text; English, Spanish or Portuguese language; journal article format and publishing date between 2006 and 2014. Subsequently, 15 original articles were selected for analysis and comparison. Methodology, objectives, sample, results, keywords, measuring instruments, development area, authors, source, country, and date of publication were considered in the selection process.


Brazil tops the list of author nationalities, at 80%. Spanish authors made up 13.3%, while 6.6% were Mexican. It should be noted that 80% of authors are women and 20% men. A majority of the articles studied were published in 2013 (33.3%) and 2014 (20%), in the period 2006-2012 it was 6.6% per year. There is a predominance of research on the Intensive Care Unit (33.3%) compared to other areas of work (26.6%); the emergency room (13.3%) and neonatal units, chemotherapy, cardiological units, and sterilization and equipment center (6.6%).

The instruments used were: Nursing Activities Score (NAS) used in 46.6%; and Therapeutic Intervention Scoring System (TISS 28) for 13.3%. The simplified version of the latter, Nine Equivalents of Nursing Manpower Use Score (NEMS); Karasek; and Moore's Scale of Perceived Overwork, each with 6.6%. In addition, these specially developed questionnaires were used in 33.3%, interviews in 6.6% and medical records in 20%.

In general, the revised articles with the terms “nursing workload” (hereafter, NW) show that patient care needs in the various clinical settings increase the nursing workloads (Table I).

Table I. Review of literature on nursing workload (2006-2014)
Country and year
Sample Hospital Department Method Instrument Results
Trevisan-Martins Julia. Brazil, 2013 12 nurses Emergencies Qualitative Interview Work under high demand.
100% busy with serving patients.
Rita de Cássia-De
Marchi. Brazil, 2014
95 nurses Hospitalization Transversal
Specialized questionnaire Average work week 42.2 hours
Carpeta-Neis Marcia Elisa. Brazil, 2013 274 sterilized packets Sterilization and equipment center Descriptive Measuring packet processing, clinical records Insufficient or unqualified personnel
Rossetti Ana Cristina. Brazil, 2014 953 patients Pediatric emergency Transversal Specialized questionnaire Nurse-patient ratio 1:2.6
De Brito Ana Paula.
Brazil, 2013
156 patients Hospitalization Descriptive NAS Higher averages for patients requiring complicated care
Francisco Javier.
Spain, 2012
563 patients ICU Descriptive prospective NAS Average occupancy: 91.2
Average patients / day: 10.4
Andrade-Gonçalves Leilane.
Brazil, 2007
214 patients ICU Transversal
NAS 50.9% of patients with high labor demands; 49.1% normal to low labor demands
Pazetto-Balsanelli Alexander. Brazil, 2006 143 patients UCI Retrospective TISS-28 TISS-28: 27
Workload related to severity of the complaint
Adriana. Brazil, 2008
55 patients Cardiology unit Descriptive NAS TISS-28
Average workload: NAS: 73.7% TISS-28: 62.2%
NEMS: 59.7%
Cardoso de Sousa
Regina Márcia.
Brazil, 2009
600 patients UCI Prospective
NAS 56.19% of patients need bedside monitoring
Zago-Novaretti Marcia Cristina. Brazil, 2014 399 patients UCI Prospective cohort Specialized questionnaire Clinical records Approximately 78% of incidents and adverse events are due to nursing overload
Gil-Monte Pedro R. Spain, 2008 714 nurses Health unit Correlational Karasek Work overload significantly linked to emotional exhaustion
Patlán-Pérez Juana. México, 2013 637 healthcare workers Health unit Descriptive Overwork
perceived by Moore (2000)
Overload has a significant positive effect on burnout, creates work /family conflict.

Trevisan Martins et al.1 through a qualitative study with 12 nursing professionals from the emergency department defined NW and recognized themselves as high demand workers, delivering services 100% of the time.

In order to analyze the NW and physiological stress reactions, Rita de Cássia et al.2 conducted a correlational study in the area of hospitalization, and applied a specially developed questionnaire to 95 nurses. Their average work week was 42.2 hours; as well as overtime work in the same institution.

De Brito et al.6 evaluated NW with the Nursing Activities Score (NAS) over a period of 30 days. From 1080 observations, the 156 patients required nursing attention for an average of 11.35 hours per day. This considers that each point equals to 0.24 NAS hours. They also noted that the greater the complexity of patient needs, the greater the need for nursing care hours. Carmona Monge et al.7 studied the application of NAS in an Intensive Care Unit (ICU) and applied the NW to admission and discharge of 563 patients. The average occupancy was 91.2%. There was an average of 10.4 ± 2.2 patients per 24 hours. To analyze factors associated with NW, Andrade Goncalves et al.8 applied the NAS to 214 patients in the ICU; half of the patients (50.9%) required intense labor and the other half (49.1%) had normal to low labor requirements. In 143 post-surgical patients hospitalized in the ICU, Pazetto Balsanelli et al.9 determined the relationship between NW and the severity of the patient illness or complaint with the use of TISS 28 (Therapeutic and Intervention Scoring System). Janzantte Ducci et al.10 used three scales (NAS, TISS-28 and NEMS) to compare the workload of nursing in postoperative cardiac surgery. Her study looked at a total of 55 patients, and obtained 283 measurements of the workload, this variable was measured by NAS (73.7%); TISS 28 (62.2%) and NEMS (59.7%). Cardoso de Sousa et al.11 applied the NAS by age group in 600 patients hospitalized in the ICU, of which 59.1% of patients required a nurse at bedside for continuous control and monitoring. On the presence of incidents and adverse events in the ICU, Novaretti Zago et al.12 established the influence of NW through a cohort study with 399 patients, to which he applied a specialized questionnaire. This study also used indirectly collected data from clinical records, and found that approximately 78% of incidents and adverse events related to nursing professionals were attributable to work overload.

Rossetti et al.4 described NW indicators in pediatric emergency room patients, finding an 1:2.6 indicator in the nurse-patient ratio. To analyze NW in a neonatal unit, Kosar Nunez13 used the NAS instrument to study 144 newborns with a minimum stay of 24 hours in areas of low, medium, and high risk, as well as in isolation and in the Intensive Care Unit (ICU). For low-risk areas, a NW of 267 points was obtained with a shortage of 8.8 professionals per day; in the medium risk section this was 446.7 points and a shortage of 22.3 professionals.

A difference of almost 90 points less was observed in the high-risk section, with 359 points and a shortage of 17.9 staff. In the isolation area, 609 points were obtained with a shortage of 18.2, while in the ICU, it was 568.6 points, and shortage of 16.1 employees.

In another clinical nursing care scenario, Alvez de Souza et al.,14 measured NW in a chemotherapy unit through structured interviews with seven nurses and clinical record review. The study found that 43.2% of time was spent on indirect activities, 33.2% spent on direct care, and 12% on personal activities. In the sterilization and equipment center, Folder Nels et al.3 measured NW during sterilization of 274 packets; the finding was that the staff was insufficient or unqualified.

Gil Monte et al.15 analyzed the correlation between the influence of NW and self-reliance for work burnout using the Karesek instrument on 714 nursing professionals, and determined that the relationship between workload and emotional exhaustion was significant. On a related note, Patlán Perez,16 described the effects of NW and burnout syndrome regarding quality of life at work. She used the Scale of Perceived Overwork by Moore in 673 health workers; it was found that overload causes a positive, significant effect on burnout syndrome and creates conflict in work and family.


Study of the workload and the way that internal and external workload factors impact workers’ health and performance is essential in diverse complex clinical scenarios.

Based on this first study, a subsequent, thorough revision is needed to deepen investigation into intervention approaches, prediction, or control to constitute support for work-related disease prevention.

It’s pertinent to note that in the present review, the use of “workload” has two definitions. The first refers to a “group of worker-developed strengths used to satisfy occupational demands, including physical, cognitive, and emotional strengths.” The other definition of the term is, “elements of the labor process which interact dynamically with the worker’s body, resulting in mental and physical tire.”

The denomination of phenomena, possible only through reflection, is a fundamental reference to understand and characterize. Different names for the same phenomenon, although synonyms are used, can lead to the idea that they are used for different things and can start a debate over which is the most fitting. This debate hinders research and integration of knowledge in a particular field of study.

Prioritizing healthcare professionals' own health is essential to implementing strategies at three levels to manage time effectively. Strategies at the individual level include training in problem solving, assertiveness, and other recommended programs. At the group level, the strategy par excellence is the use of colleagues and supervisors for social support. Through this support at work, individuals obtain new information, acquire new skills or improve those that they have, receive social reinforcement and performance feedback, and get emotional support, advice, or other assistance. At the organizational level, it is important to consider that the origin of the problem is the employment context, and therefore the administration must develop prevention programs aimed at improving the work environment.17

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