A long-term critical care nurse friend and colleague recently spent time on a medical-surgical unit as part of her clinical rotation in her acute care nurse practitioner program. After this experience she shared with me:
“Debi, those nurses work so hard! They have four or five patients compared to our one or two, and they’re on the go constantly. They don’t have all the bells and whistles like we do to alert them something is wrong and their patients are so sick. They have to rely on their clinical judgment and critical thinking skills constantly. I had no idea how hard their work was.”
As I reflected on her commentary, I recalled several publications that further depicted the complexity of nursing practice, particularly as it relates to medical-surgical nursing and related specialties.
Swiger, Vance, and Patrician recently published a concept analysis of nursing workload in the acute care setting.1 These authors made some critically important statements about the lack of measures that accurately quantify and qualify nurses’ work. For example, they noted that existing metrics such as nurse-bed ratio, and DRG- and intensity-related staffing models, do not address the substantial nonpatient work requirements of nurses. These include time spent awaiting returned phone calls, troubleshooting, advocating for a specific intervention, clarifying a medication order, delegating, addressing discrepancies, preparing for procedures and cleaning up after them, adapting to distractions and interruptions, locating needed equipment, and finding policies. This paradigm has been described as “nursing the organization” versus nursing the patient. Unfortunately, this organizational care responsibility often dominates the nurses’ day.1
While the assumption of numerous responsibilities is the mainstay of daily nurse work, how these responsibilities are managed represents yet another complexity. Without conscious effort, nurses must make judgment calls about priorities, time required for tasks, and how to proceed accordingly. Ebright and colleagues2 used the term “stacking” to describe the cognitive load associated with nurses’ ongoing need to respond to multiple, competing demands. Case in point is this excerpt from The Shift:3
I absolutely should go in the see Sheila, but first I run my eyes down my papers. Dorothy has a med due and I need to find out if Mr. Hampton is any more “with it” than he was. I should also tell him about his son’s phone call and that we won’t start the Rituxan until at least 3pm. And now I have to tell Candace that her trip to IR will be delayed and hope she takes it well (p. 99).
Lastly, also not captured in staffing/workload models is the provision of psychosocial care, an often pressing and emotionally complex nursing intervention. I have also lamented for years how care of the dying patient and their family is considered “low acuity” when the time required for this nursing is both considerable and intense. And I would be remiss if I did not mention the unyielding nursing time required for documentation, probably the most universal curse of contemporary nurses everywhere. Again, Theresa Brown, RN, in The Shift lamented:3
I do understand why such thoroughness matters legally, but I sometimes wonder if sadists designed our software. It should not be easier to order a sweater from Land’s End than to chart on my patients, but it is (p. 117).
At present, the ability to clearly understand and measure nursing practice is a work in progress. Until an improved articulation of nursing workload is available and accepted, staffing paradigms will remain stagnant. Until staffing paradigms are aligned with the real work of nurses, critical quality patient and organizational outcomes may also falter. One way to change our current reality is to propose new ways of thinking. To that end, I leave you with Swiger, Vance, and Patrician’s proposed definition of nursing workload that arose from their in-depth concept analysis:1
Nursing workload is the amount of time and physical and/or cognitive effort required to accomplish direct patient care, indirect patient care, and non-patient care activities. Nursing workload is complex and nonlinear by nature and is influenced by nurse, patient, unit and organizational characteristics which can significantly increase or decrease the time and effort required to provide high quality nursing care and improved patient outcomes (p. 252).
An improved index of acute care nurse workload is in dire need. But let’s not wait for perfection. Clinicians, administrators, and researchers must collaborate on new tools to capture the essence, the mosaic of our unique role.
Swiger PA, Vance DE, Patrician PA. Nursing Workload in the Acute-Care setting: A Concept Analysis of Nursing Workload. Nurs Outlook., 2016 May-Jun;64(3):244-54.
Ebright PR, Patterson ES, Chalko BA, Render ML. Understanding the Complexity of Registered Nurse Work in Acute Care Settings. J Nurs Adm., 2003 Dec;33(12):630-8.
Brown T. The Shift: One Nurse, Twelve Hours, Four Patients’ Lives. Algonquin Books, 2015 Sep 22.
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