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

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The [chi square] to degrees of freedom ratio (= 1.77) (Carmines and McIver 1981; Akaike 1987), the RMSEA (= 0.06, 90 percent CI = 0.04-0.07), and the CFI (= 0.90) measures were all within the recommended ranges (Hu and Bentler 1999), hence the proposed model had an adequate fit. Forty percent of workload was explained jointly by performance obstacles and demographic and background variables. Furthermore, a large amount of the variability in both perceived quality and safety of care and QWL were explained by the model ([R.sup.2] = 0.61 and 0.79, respectively), confirming that much of these variables are understood when workload is understood (Figure 2).

SEM analysis provided support for HI. Nurses who reported experiencing any of the following six obstacles also reported experiencing higher workload: poor physical work environment, dealing with many family-related issues, disorganized supplies area, seeking for patient charts, delay in getting medications from the pharmacy, and poorly stocked patient rooms. Furthermore, nurses who admitted a patient over the shift experienced higher workload, even after the effect of obstacles was taken into account. Workload was significantly related to both perceived quality and safety of care and QWL (H2a and H2b supported). As workload increased, nurses reported providing lower quality and less safe care and experiencing increased fatigue and stress.

Workload also mediated the relationships between the outcomes of perceived quality and safety of care and QWL and the following six obstacles: poor physical work environment, dealing with many family-related issues, disorganized supplies area, seeking for patient charts, delay in getting medications from pharmacy, and poorly stocked patient rooms. The effect of only the equipment-related issues obstacle on perceived quality and safety of care and QWL was not mediated by workload. Overall, Hypotheses 3a and 3b were supported.

Among the demographic and background variables, only gender, age, and shift type were significantly related to outcome variables (Figure 2). Female nurses reported providing higher quality and safety of care. Nurses 60 years or older reported providing higher quality and safety of care and experiencing lower fatigue and stress. Night shift nurses reported experiencing higher fatigue and stress. Total number of patients assigned to a nurse was not a significant predictor of workload once performance obstacles were taken into account; nor was it significantly related to perceived quality and safety of care and QWL once the workload variable was included in the model.

DISCUSSION

Our study showed that work system characteristics can play a significant role on nursing workload. Even without considering patient acuity, a large amount of variability in workload (40 percent) was explained by work system characteristics. This finding is significant because a majority of research studies on ICU nursing workload has focused on optimizing nurse/patient ratio primarily based on patient's clinical condition, and not on improving the ICU work system characteristics. Improvement solutions derived from these studies would typically involve either increasing the number of nurses or decreasing the number of patients, which may not be feasible given the nursing shortage in United States (Buerhaus et al. 2008) and the dramatic increases in the number and severity of ICU patients (Kelley et al. 2004). Our study provides an alternative approach by focusing on potential changes to the design of ICU nurses' work system for reducing workload and improving quality and safety of care and QWL.