Chapter 30. Nursing Workload and Patient Safety—A Human Factors Engineering Perspective

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 over65 population, with more health care needs, is expected to grow by 54 percent (19 million). 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. 4 When a nursing shortage occurs, the workload increases for those who remain on the job. 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. There are several important consequences of high nursing workload. Research shows that a heavy nursing workload adversely affects patient safety. Furthermore, it negatively affects nursing job satisfaction and, as a result, contributes to high turnover and the nursing shortage. 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. 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. Heavy nursing workload increases burnout and job dissatisfaction, which in turn contributes to high nurse turnover. 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.