Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life

Health Services Research, April, 2009 by Ayse P. Gurses, Pascale Carayon, Melanie Wall

To accomplish the research objectives, the following hypotheses were tested:

[H.sub.1]. Performance obstacles increase nurses' workload.

[H.sub.2a]. Workload has a negative impact on quality and safety of care as perceived by nurses.

[H.sub.2b]. Workload has a negative impact on nurses' QWL. It leads to increased stress and fatigue and decreased job satisfaction among nurses.

[H.sub.3a]. Performance obstacles, mediated by workload, negatively affect perceived quality and safety of care.

[H.sub.3b]. Performance obstacles, mediated by workload, negatively affect QWL.

METHODOLOGY

Overall Study Design

A cross-sectional study design was used. The unit of analysis was the nurse over a shift. A structured questionnaire was used to collect data from ICU nurses regarding the shift they just completed.

Participating Organizations and Sample

Questionnaires were distributed to nurses in 17 ICUs of seven hospitals in Wisconsin between February and August 2004. One hospital was rural and nonacademic, five were urban and nonacademic, and one was urban and academic. The participating ICUs had different sizes and specialties, including medical, surgical, trauma, burn, cardiothoracic, cardiac, neurosurgery, adult, pediatric, and neonatal. Each nurse could fill out the questionnaire only once. The inclusion criteria were as follows:

(1) Being a staff nurse: Typically, nonstaff nurses have limited knowledge of a particular unit and may therefore experience additional obstacles that staff nurses do not.

(2) Having been assigned ICU-level patient(s): Rarely, patients who do not need ICU-level care stay in the ICU due to bed unavailability in other hospital units. Nurses who attended such patients were excluded.

A total of 364 questionnaires were distributed. Three hundred were filled out and returned, out of which only 26.5 were eligible to participate as 22 were not staff nurses and 13 were not assigned ICU-level patients in the shift just worked. Hence the response rate was 80 percent (265/329), ranging between 40 and 100 percent across ICUs. Six questionnaires were excluded, reducing the sample size to 259: Two were < 50 percent complete, and four were identified as outliers.

Study Procedures

Institutional Review Board approvals were obtained from Human Subjects Committees of all involved institutions. Participation in the study was voluntary. Methods used to inform nurses about the study included presentations at unit nursing meetings, meetings with ICU representatives, and e-mails or memos from nurse managers.

Data collection started two and a half hours before the end of the shift. The first author went to the units at randomly chosen shifts, distributed the questionnaire, and asked nurses to complete it based only on their experiences of that particular shift any time during the last two and a half hours of their shift or right after the shift. We believe that this flexibility ensured a high response rate while capturing most of the nurses' experiences during the shift. The first author waited outside the units during the majority of the data collection period, going inside the units every 30-45 minutes to answer questions.