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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234On-line version ISSN 1980-220X

Rev. esc. enferm. USP vol.53  São Paulo  2019  Epub June 03, 2019

http://dx.doi.org/10.1590/s1980-220x2018006503440 

ORIGINAL ARTICLE

Nursing workload: influence of indirect care interventions*

Carga laboral de enfermería: influencia de las intervenciones de cuidados indirectos

Priscilla de Souza1 
http://orcid.org/0000-0001-7661-7531

Danielle Fabiana Cucolo2 
http://orcid.org/0000-0002-9926-1192

Marcia Galan Perroca3 
http://orcid.org/0000-0003-2931-8429

1Hospital de Base, Setor de Qualidade, São José do Rio Preto, SP, Brazil.

2Universidade Federal de São Carlos, Departamento de Enfermagem, São Carlos, SP, Brazil.

3Faculdade de Medicina de São José do Rio Preto, Departamento de Enfermagem Especializada, São José do Rio Preto, SP, Brazil.

ABSTRACT

Objective:

To evaluate nurses’ perception of the degree of interference of indirect care interventions on the team’s workload and to verify the association between these interventions and the professional and institutional variables.

Method:

A research survey through e-mail conducted with clinical nurses, unit managers and service managers from eight Brazilian states. A questionnaire containing 28 indirect care interventions and their definitions proposed by the Nursing Interventions Classification was applied.

Results:

A total of 151 clinical nurses participated, and a response rate of 14.8% was obtained. The indirect care interventions reported as those which most increase the workload were: Preceptor: employee (M = 3.2), Employee Development (M = 3.1), Physician Support (M = 3.0) and Conflict mediation (M = 3.0). Statistically significant associations between the investigated interventions and the institutional variables (legal nature and size) were evidenced.

Conclusion:

Nurses in different practice scenarios perceive that indirect care interventions influence the workload in a differentiated way, with emphasis on the demands related to the monitoring and qualification of employees.

DESCRIPTORS: Workload; Workflow; Time Management; Nursing Staff, Hospital

RESUMEN

Objetivo:

Evaluar la percepción de enfermeros acerca del grado de interferencia de intervenciones de cuidados indirectos sobre la carga laboral del equipo y verificar la asociación entre dichas intervenciones y las variables profesionales e institucionales.

Método:

Investigación survey por vía correo electrónico, conducida con enfermeros clínicos, gerentes de unidades y de servicio de ocho estados brasileños. Se aplicó un cuestionario conteniendo 28 intervenciones de cuidados indirectos y sus definiciones, propuestas por la Clasificación de las Intervenciones de Enfermería.

Resultados:

Participaron 151 enfermeros clínicos. Se obtuvo índice de respuesta del 14,8%. Las intervenciones de cuidados indirectos relatadas como las que más aumentan la carga de trabajo fueron: Preceptor: funcionario (M=3,2), Desarrollo de funcionarios (M=3,1), Apoyo al Médico (M=3,0) y Mediación de conflictos (M=3,0). Asociaciones estadísticamente significativas entre las intervenciones investigadas y las variables institucionales (naturaleza jurídica y porte) fueron evidenciadas.

Conclusión:

Enfermeros en distintos escenarios de práctica se dan cuenta de que las intervenciones de cuidados indirectos influencian la carga laboral de modo distintivo, con énfasis para las demandas relativas al acompañamiento y calificación de funcionarios.

DESCRIPTORES: Carga de Trabajo; Flujo de Trabajo; Administración del Tiempo; Personal de Enfermería en Hospital

INTRODUCTION

In order for care management to take place there is an articulation of the dimensions of care and management, being equally important and complementary1. The care interface includes direct care interventions (patient/family interaction) and indirect care interventions (activities to support direct care interventions at a distance, involving unit management and interdisciplinary collaboration)2.

The time spent implementing these interventions determines the team’s workload, constituting an ongoing complex and challenging subject3. One of the criticisms is that the different approach forms do not include the complexity of the activities, the procedures, or the dynamics of nursing work4. It is also agreed that the concept is multifactorial, and researchers5)-(6 argue that the workload is not limited to direct patient care and have performed investigations to identify other factors which may interfere with it.

In an attempt to unify several existing concepts, the proposal for a new construct emerged and was therefore adopted as an object of analysis in this investigation. In it, workload is understood as the amount of physical and/or cognitive time and effort required to perform patients’ direct and indirect care, as well as non-patient activities (educational activities, problems with equipment and supplies, waiting time, among others)7.

The planning and quantitative-qualitative evaluation of the nursing team integrates important management tools in order to guarantee safe care to the patient/family, requiring adequate methods and instruments for its accomplishment3), (8. A lack of uniformity in concepts interferes with the way the workload is measured and generates discredit on the part of nurses. Many are dissatisfied with the traditionally-used instruments for their inability to capture the complexity of their work and provide quality in the care process5), (9.

The activities/interventions performed by the nursing team and the time required for their performance have become a widely discussed topic due to their impact on the quality of patient care/safety and staff working conditions10)- (12. Research on the distribution of work time in different practices and specialization settings shows a higher percentage of time consumed by indirect care interventions by nurses - 35%13 to 50%14. Even so, such interventions have not been adequately considered in the workload measurement instruments.

This investigation is part of the project entitled “Workload Dimensions: Factors not related to Patient Care Complexity” (“As Dimensões da Carga de Trabalho: Fatores não Relacionados à Complexidade Assistencial do Paciente”), linked to the Health Services and Nursing Services (GESTSAÚDE) research group, and was conducted in an attempt to fill gaps which still exist in this area. The study aims to evaluate the nurses’ perception on the degree of interference of indirect care interventions in the team’s workload and to verify the association between these interventions and professional and institutional variables. The questions to be investigated are: “What are the indirect care interventions that most influence the nursing team’s workload? With what intensity? Is there an association between these interventions and the professional and institutional variables?”

METHOD

STUDY DESIGN

The e-mail survey method was adopted in this study.

POPULATION

The convenience sample was composed of 151 clinical nurses, constituting managers of hospitalization and service units linked to hospitals of different sizes, legal characteristics and relationship with the health system in eight states of the national territory (Pará, Piauí, Ceará, Minas Gerais, Rio de Janeiro, São Paulo, Paraná and Rio Grande do Sul).

DATA COLLECTION

Professional social networks were used to establish contact (such as Linkedin), and the snowball sampling method. Of the 1,020 retained e-mails, 151 returned, thereby obtaining a response rate of 14.8%.

Constructing the instrument for data collection followed three steps:

  1. The list of indirect care interventions was based on the Nursing Interventions Classifications (NIC) and on Brazilian(13-17) and international(5-6) surveys on workload measurement.

  2. Elaborating the online questionnaire - mapping indirect care interventions made it possible to generate a self-administered online questionnaire in the Google Drive program, containing two parts. The first included the clear and Informed Consent Form (ICF), data on the institution, as well as personal and professional characteristics of the respondents. The next part had a Likert scale of four points (1 - does not increase, 2 - slightly increases, 3 - moderately increases and 4 - greatly increases the workload), containing a list of 28 indirect care interventions defined according to the NIC.

  3. Validation and application of the questionnaire - the constructed on-line questionnaire was evaluated by three clinical nurses and five doctor nurses in terms of the representativeness and clarity of its content. The agreement obtained varied from 98% to 100%, thus establishing the instrument’s content validity. A Cronbach’s alpha of 0.90 was found in the internal consistency calculation, considered to be very good.

A pre-test was carried out before the questionnaire was sent to the respondents by four nurses who professionally practice in different units of large hospitals. At this stage they were asked to respond to the instrument, evaluating their objectivity and clarity. Readjustments were performed on some items in order to allow greater understanding. An invitation with the access link was sent to the participants, establishing 15 days to return the questionnaires. The collection occurred from June to December 2015.

DATA ANALYSIS AND PROCESSING

The data were computed by the IBM SPSS Statistics v.22 program (IBM Corporation, Armonk, NY). The variables investigated were: 1. The 28 indirect care interventions; 2. Type of hospital: public, private, teaching; 3. Size of the institution: small, medium, large and extra capacity; 4. Position or function exercised by the participant: assistance, supervisor/coordinator, manager or teacher; 5. Action units: Hospitalization Unit (HU); Emergency, Intensive Care Unit (ICU), Diagnostic and Therapeutic Support Services (DTSS), Specialized Units (SPU) and Administrative Services (ADMS).

The open responses were categorized and grouped according to the study proposal. The Likert scale was considered as an ordinal level of measurement, and the median, quartiles (Q1 and Q3) and interquartile range (QA = Q3-Q1) were calculated. Percentages, mean, standard deviation and confidence interval (CI) of 95% were calculated for the descriptive analysis. The significance level was set at p≤0.05, and the following tests were conducted: 1. Chi-square to evaluate the association between the nominal variables and in each of the 28 interventions; 2. Kruskal-Wallis to compare three or more variables, and also to establish the differences between the subgroups of the workload graduations (1 - does not increase and 2 - increases little versus 3 - increases moderately and 4 - greatly increases) and associate them with professional and institutional variables. Those with a mean value of ≥ 3.0 (moderately increased or greatly increased workload) were considered as more representative to assess the impact on indirect care interventions on the nursing team workload.

ETHICAL ASPECTS

This study was approved by the Research Ethics Committee of the institution under Opinion n. 980.660/15, according to Resolution 466/12 of the National Health Council, on research involving human beings. Upon accessing the sent link, the respondent found the clear and Informed Consent Form and could only respond to the questionnaire if he/she accepted to participate in the study.

RESULTS

From the 67 health facilities included in the study, 38 (56.7%) were public, 18 (26.9%) were private and 11 (16.4%) were teaching. The majority were large (42; 62.7%) and 52 (77.6%) were concentrated in the Southeast region. Among the 151 nurses, the female gender predominated (136; 90.1%), with a mean age of 35 years (SD = 9.7, variation 21-64), mean time of professional performance of 10.6 years (SD = 9.2, ranging from 3 months to 38 years), with 112 (74.2%) working in the care function, and specialization (76; 50.3%) as the most frequent post-graduation. Excluding nursing professors and managers, professionals (n = 135) were predominantly in intensive care units (58; 42.9%) and in inpatient and specialized units (58; 42.9%).

In relation to the scores obtained in each of the 28 interventions (Table 1), we found a variation in the mean values of 2.3 (Control of sample for exams, Research data collection, Shift change and Management of financial resources) to 3.2 (Preceptor: employee). .

Table 1 Descriptive statistics of the investigated intervention scores - São José do Rio Preto, SP, Brazil, 2016. 

Intervention M(SD) MD(Q1-Q3)
Preceptor: employee 3.2(0.9) 3(4-3)
Employee development 3.1(0.9) 3(4-3)
Conflict mediation 3.0(0.9) 3(4-2)
Physician Support 3.0(0.9) 2(4-2)
Infection control 2.9(0.9) 3(4-2)
Supervision 2.9(0.9) 3(1-2)
Preceptor: student 2.9(0.9) 3(4-2)
Employee supervision 2.9(0.9) 2(4-2)
Technology control 2.9(0.9) 3(4-2)
Documentation 2.9(0.9) 3(4-2)
Health care information exchange 2.9(0.9) 3(4-2)
Interpretation of laboratory data 2.8(0.9) 2(3-2)
Control of supplies 2.8(0.9) 3(3-2)
Transcription of prescriptions 2.7(0.9) 3(3-2)
Quality control 2.7(0.8) 3(3-2)
Environment control 2.7(0.9) 3(3-2)
Delegation 2.6(0.9) 3(3-2)
Emergency cart check 2.6(0.9) 2(3-2)
Incident reports 2.5(0.9) 2(3-2)
Multidisciplinary care evaluation 2.5(0.9) 2(3-2)
Referral 2.5(0.9) 3(3-2)
Verification of controlled substance 2.5(0.8) 2(3-2)
Medication control 2.5(0.9) 3(3-2)
Product evaluation 2.4(0.8) 2(3-2)
Shift change 2.3(1.0) 2(3-1)
Management of financial resources 2.3(0.9) 2(3-1)
Control of sample for exams 2.3(0.9) 2(3-2)
Research data collection 2.3(0.9) 2(3-2)

The score varies 1-4. The higher the score, the higher the workload.

Statistically significant associations (p≤0.05) between the 28 interventions investigated and the professional variables (position/function of participants) and institutional variables (legal nature and size) will be presented below.

Regarding the legal nature of health facilities (Table 2), a greater workload was reported in private hospitals for indirect care interventions. Physician support and Preceptor employee (Md 4) and differences in relation to teaching hospitals in Medication control, Environment control, Verification of controlled substance and Interpretation of laboratory data (Md 2).

Table 2 Association between the workload generated by indirect care interventions and the legal nature of hospitals - São José do Rio Preto, SP, Brazil, 2016. 

Intervention Teaching Private Public
Md(Q1-Q3) Md(Q1-Q3) Md(Q1-Q3)
Legal Nature
Medication Control 2(2-3) 3(2-3) 3(2-3)
Environment Control 2(2-3) 3(2-3) 3(2-4)
Verification of controlled substances 2(2-3) 3(2-3) 3(2-3)
Interpretation of laboratory data 2(-) 3(2-3) 3(2-3)
Physician Support 3(2-3) 4(3-4) 3(2-4)
Preceptor: employee 3(2-4) 4(3-4) 3(3-4)

In the association with the size of health institutions, median values varying from 2 to 3 in the Intervention Referral (8,100) and from 2.5 to 4.0 in the Intervention Transcript of Prescriptions (8,060) (Figure 1).

Figure 1 Association between workload generated by the interventions Transcript of prescriptions (8,060) and Referral (8,100) and hospital size - São José do Rio Preto, SP, Brazil, 2016. 

The associations of the subgroups below are shown to increase/increase little (1,2) versus moderately increase/greatly increase (3,4). It is noted that the workload increases moderately or very much in private hospitals in relation to the legal nature of hospitals for the interventions Physician support, Employee supervision, Health care information exchange and Multidisciplinary care evaluation meeting. These findings and the degree of increase in workload associated with hospital size and units and services are presented in Table 3.

Table 3 Interference of the degree of change of workload on the legal nature, size and unit/service of health facilities - São José do Rio Preto, SP, Brazil, 2016. 

Intervention Increase in workload
None/little Moderate/high
Legal nature
Environment control Teaching Public*
Physician support Teaching Private*
Verification of controlled substance Teaching Public*
Interpretation of laboratory data Teaching Public**
Employee supervision Teaching Private*
Health care information exchange Teaching Private**
Multidisciplinary care evaluation meeting Teaching Private**
Size
Infection control Small/Extra Large*
Multidisciplinary care evaluation meeting Extra Medium*
Referral Extra Small*
Unit/service
Referral UESP Emergency*

*p≤0.05 ** p≤0.01.

DISCUSSION

In the perception of nurses, indirect care interventions of Preceptor employee (M = 3.2), Employee development (M = 3.1), Conflict mediation (M = 3.0) and Physician support (M = 3.0) most influence the nursing workload in the different practice scenarios.

Employee precepts refer to the guidelines and support planned to be provided to employees transferred from other units or services or newly admitted2. The qualification and the accompaniment of the new employee demand adequate time and space, so that there is no overlapping of educational and caring functions, thus increasing the workload18. This aspect was perceptible to the nurses in the study, and when the number of staff is reduced, the increase in workload may be even greater.

It is interesting to note that employee precepts do not appear in the list of the most frequent or medium-time interventions in Brazilian observational studies13)- (16. One explanation would be the inexistence or very small number of newly admitted employees and/or transferred from other units or services during the data collection period.

The intrainstitutional educational process is an important management tool associated with implementing safe care and retaining nurses in clinical practice19. Education also makes it possible to contextualize daily health work in facing scientific/technological innovations and concrete conditions for its effectiveness, significantly improving the professional competence of nursing20.Time planning for such activities has a direct influence on the adherence of professionals and teaching-learning21, and according to the study participants, there is an impact on nurses’ workload.

In the hospital setting, nurses experience problems in interpersonal relationships with the medical staff, and also internal conflicts among nursing professionals22)-(23. Among the factors which generate disagreements are: a lack of collaboration between the team members22, the problems left by the previous shift, the high turnover of professionals and the work overload23.

These issues interfere with motivation, professional performance and are predictors of occupational stress, being reflected in the care provided23. In the perception of the participants of this study, these are factors which require significant time in nurses’ routines. Leadership development strategies for a more participatory, interactive and dialogical management can support resolution of these situations24, optimizing the time and qualifying the work.

Support to the physician was identified among the four interventions which most require the nursing team’s time, since it refers to the medical visit follow-up to the patient/family, orientation of this team on routines of the unit, request of new materials/equipment, availability of printed matter/medical records, among other functions2), (15. This collaboration has been identified in national investigations15)- (16 and confirmed in an international study5 as an activity which generates nursing overload.

The interventions considered more representative differ from other studies and showed greater time-consuming values in: documentation13)- (17; supervision14)- (16; shift change13)- (15), (17; health care information exchange13), (16)- (17; and delegation13)- (15.

It was identified that Employee Precepts and Physician Support are activities which greatly increase the nurses’ workload in private hospitals. It can be questioned if the nursing staff turnover is more representative in these institutions, however, no studies were identified which confirm this argument.

Aiming at the service qualification and maintaining competitiveness, some hospitals invest in accreditation programs which require new dynamics in the nurses’ work, with effective communication, participation in clinical discussions and strategic management of the unit25. However, private hospitals have a lower number of professionals per bed and interventions such as Physician Support, Employee Supervision, Multidisciplinary Meetings and Patient Information Exchange can generate work overload. The latter has been identified among the indirect care activities which demand the nurses most time -5.4%13) to 12.2%16.

In the participants’ perception of this study, actions related to drug safety and control require a higher workload by the nurse, except in teaching hospitals. However, these hospitals still face challenges in relation to the barriers to prescription errors, dispensing, administration and safe maintenance of controlled substances11. Moreover, the infection control intervention only significantly increases the workload for nurses working in large hospitals (62.7%). International evidence26 points to a reduction in the number of nursing personnel (a situation experienced by most Brazilian health institutions) as a factor which can increase the number of infections related to health care.

Difficulties were encountered in contacting nurses due to the inexistence of a national database of this category being accessible to the researchers. The use of professional social networks and the snowball sampling method showed some efficiency, but it took time.

Several strategies (simple and attractive visuals, reminders to participants) were used to maximize the number of responses and thus reduce the risk of research bias, thus ensuring greater credibility of results27. Nevertheless, the response rate obtained was 14.8%, using 100% of the returned questionnaires.

Studies conducted via web/e-mail have lower response rates than postal forms27)-(28, generally around 12.9%28. Swedish researchers29 compared questionnaire response rates sent in two different ways - online and printed by post. The findings revealed response rates of 15% in the online form and 55% in the postal form.

It is known that the nursing workload is not restricted to direct care interventions to the patient, given the complexity of care management. This study brings evidence that supports this concept, and identifies activities indirectly related to the care process from the perception of nurses from different hospital practice scenarios, which have not been observed in previous research.

However, it is important to note that comparisons were made with direct observation studies using timekeeping. These different methods (timing vs. perception) can lead to different values in the results. In this way, future research is suggested for a more in-depth analysis of these interventions in measuring the time spent by the team, since some of them were not observed in previous studies.

CONCLUSION

This research has enabled us to rethink and rediscuss one of the components of workload: indirect care interventions to patients and the way these interventions impact the work dynamics from the perspective of nurses. Among the interventions investigated were: Conflict Mediation, Physician Support, Employee Development and Employee Preceptor.

These findings instrumentalize team management planning and refinement of workload measurement scales which may better reflect the nursing team’s work in the practice scenario.

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**Extracted from the dissertation: “Influência das intervenções de cuidados indiretos sobre a carga de trabalho de enfermagem”, Programa de Pós-Graduação da Faculdade de Medicina de São José do Rio Preto, 2018.

Received: March 07, 2018; Accepted: August 20, 2018

Corresponding author: Marcia Galan Perroca Av. Brigadeiro Faria Lima 5416 - Vila São Pedro CEP 15090-000 - São José do Rio Preto, SP, Brazil marcia.perroca@gmail.com

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