Nursing Activities Score: an updated guideline for its application in the Intensive Care Unit

Nursing activities score: manual atualizado para aplicação em Unidade de Terapia Intensiva

Nursing activities score: manual actualizado para su aplicación en la Unidade de Cuidados Críticos

Katia Grillo Padilha Siv Stafseth Diana Solms Marga Hoogendoom Francisco Javier Carmona Monge Om Hashem Gomaa Konstantinus Giakoumidakis Margarita Giannakopoulou Maria Cecília Gallani Edyta Cudak Lilia de Souza Nogueira Cristiane Santoro Regina Cardoso de Sousa Ricardo Luis Barbosa Dinis dos Reis Miranda About the authors

ABSTRACT

Objective

To describe nursing workload in Intensive Care Units (ICU) in different countries according to the scores obtained with Nursing Activities Score (NAS) and to verify the agreement among countries on the NAS guideline interpretation.

Method

This cross-sectional study considered 1-day measure of NAS (November 2012) obtained from 758 patients in 19 ICUs of seven countries (Norway, the Netherlands, Spain, Poland, Egypt, Greece and Brazil). The Delphi technique was used in expertise meetings and consensus.

Results

The NAS score was 72.8% in average, ranging from 44.5% (Spain) to 101.8% (Norway). The mean NAS score from Poland, Greece and Egypt was 83.0%, 64.6% and 57.1%, respectively. The NAS score was similar in Brazil (54.0%) and in the Netherlands (51.0%). There were doubts in the understanding of five out 23 items of the NAS (21.7%) which were discussed until researchers’ consensus.

Conclusion

NAS score were different in the seven countries. Future studies must verify if the fine standardization of the guideline can have a impact on differences in the NAS results.

Workload; Nursing; Team; Nursing care; Intensive Care Units; Handbooks

RESUMO

Objetivo

Descrever a carga de trabalho de enfermagem em Unidades de Terapia Intensiva (UTI) de diferentes países, segundo o Nursing Activities Score (NAS), e padronizar o manual do NAS para uso nessas Unidades.

Método

Estudo transversal realizado em 19 UTI de sete países (Noruega, Holanda, Espanha, Polônia, Egito, Grécia e Brasil) com um total de 758 pacientes adultos, em novembro de 2012.

Resultados

A média do NAS total da amostra foi 72.81%, com variação entre 44.46% (Espanha) e101.81% (Noruega). Nas UTI da Polônia, Grécia e Egito, as médias foram de 83.00%, 64.59% e 57.11%, respectivamente. As médias NAS no Brasil (53.98%) e na Holanda (50,96%) foram similares. Dos 23 itens da escala, houve dúvidas no entendimento de 5(21.74%), que foram solucionados por consenso entre os pesquisadores.

Conclusão

O estudo mostrou diferentes cargas de trabalho de enfermagem nas UTI estudadas. Um manual padronizado do NAS para uso nessas unidades contribuirá para sanar dúvidas em futuras aplicações.

Carga de Trabalho; Equipe de Enfermagem; Cuidados de Enfermagem; Unidades de Terapia Intensiva; Manuais

RESUMEN

Objetivo

Describir la carga de trabajo de enfermería en Unidades de Cuidados Intensivos (UCI) de diferentes países según el Nursing Activities Score (NAS) y establecer una guía estandarizada para su utilización en UCI.

Método

estudio observacional en 19 UCIs de siete países (Noruega, Países Bajos, España, Polonia, Egipto, Grecia y Brasil) incluyendo 758 pacientes adultos en Noviembre de 2012.

Resultados

La puntuación media total en la escala NAS fue de 72.81% com valores entre 44.46% (España) y 101.8% (Noruega). Las medias NAS en Polonia, Grecia y Egipto fue de 83.0%, 64.59% y 57.11% respectivamente. El NAS medio fue similar en Brasil (53.98%) y los Países Bajos (50.96%). De los 23 ítems de la escala hubo problemas en la interpretación de 5 de ellos (21.74%). Este problema se resolvió mediante el consenso entre los investigadores.

Conclusión

El presente estudio demuestra variación en la carga de trabajo en UCI de diferentes países. La guía estandarizada de puntuación del NAS puede servir como una herramienta para resolver dudas en futuras aplicaciones.

Carga de Trabajo; Grupo de Enfermería; Atención de Enfermería; Unidades de Cuidados Intensivos; Manuales

INTRODUCTION

There is evidence that nursing workload is associated with the quality of patient care and the health of workers(11. Penoyer DA. Nurse staffing and patient outcomes in critical care: a concise review. Crit Care Med. 2010;38(7):1521-8.

2. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007;45(12):1195-204.

3. Aiken L, Sloane DM, Bruyneel L, Griffiths P, Sermeus W, Busse R, et al. Staffing and education of nurses and hospital mortality in Europe-Authors’ reply. Lancet. 2014;384(9946):851-2.

4. Numata Y, Schulzer M, Van der Wal R, Globerman J, Semeniuk P, Balka E, et al. Nurse staffing levels and hospital mortality in critical care settings: literature review and meta-analysis. J Adv Nurs. 2006;55(4):435-48.
-55. Aiken L, Sermeus W, Heede KV, Sloane DM, Busse R, McKee M, et al. Patient safety, satisfaction and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;20(344):1-14.). Since the 1970s, the gold standard for nurse staffing levels in intensive care and subsequently critical care units has been one nurse for each patient(66. Bray K, Wren I, Baldwin A, Ledger US, Gibson V, Goodman S, et al. Standards for nurse staffing in critical care units. Nurs Crit Care. 2010;15(3):109-11.). However, critical care has changed substantially since that time and in recent years this standard has been challenged both in number of nurses and skill-mix.

In this context, tools for assessing nursing workload were developed(77. Italian Multicenter Group of ICU Research (GIRTI). Time Oriented Score System (TOSS): a method for direct and qualitative assessment of nursing workload for ICU patients. Intensive Care Med. 1991;17(6):340-5.

8. Fagerstrom L, Rauhala A. Benchmarking in nursing care by the RAFAELA patient classification system – a possibility for nurse managers. J Nurs Manag. 2007; 15(7):683-92.
-99. Intensive Care National Audit and Research Centre. System of Patient Related Activities (SOPRA). London: ICNARC; 1999.). Among these tools there are several models of the Therapeutic Interventions Scoring System (TISS)(1010. Cullen DJ, Civetta JM, Briggs BA, Ferrara LC. Therapeutic Intervention Scoring System: a method for quantitative comparison of patient care. Crit Care Med. 1974;2(2):57-60.

11. Keene AR, Cullen DJ. Therapeutic Intervention Scoring System: update. Crit Care Med. 1983;11(1):1-3.

12. Miranda DR, De Rijk A, Schaufeli W. Simplified therapeutic intervention scoring system: the TISS-28 items - result from a multicenter study. Crit Care Med.1996;24(1):64-73.
-1313. Miranda DR, Moreno R, Iapichino G. Nine equivalents of nursing manpower score (NEMS). Intensive Care Med. 1997;23(7):760-5.), one of which is the Nursing Activities Score (NAS) which was launched in 2003(1414. Miranda DR, Nap R, De Rijk A, Schaufeli W, Iapichino G. Nursing activities score (NAS). Crit Care Med. 2003;31(2):374-82.). The NAS has been validated by means of a study of 99 ICUs in 15 countries(1414. Miranda DR, Nap R, De Rijk A, Schaufeli W, Iapichino G. Nursing activities score (NAS). Crit Care Med. 2003;31(2):374-82.). It is a modified version of TISS-28 with an additional five items, namely monitoring and titration, hygiene procedures, mobilization and positioning of the patient, support and care of relatives/patients, and administrative and management tasks plus medical interventions. The NAS weightings measure the time consumed by nurse activities at the patient level and represent the percentage of nursing time (one in a 24-hour period) dedicated to the performance of the activities included in the instrument. The sum of the weights of the individual items scored reflects the amount of time spent by nursing staff in an ICU on performing activities during a particular day. Results indicated that the NAS accounts for 81% of the nursing time, whereas TISS-28 accounts for only 43%(1414. Miranda DR, Nap R, De Rijk A, Schaufeli W, Iapichino G. Nursing activities score (NAS). Crit Care Med. 2003;31(2):374-82.). Thus, NAS has been translated into many languages and is in use in 12 countries including Norway and Finland in the global north, and Brazil in the south(1515. Padilha KG, Sousa RMC, Queijo AF, Mendes AM, Miranda DR. Nursing Activities Score in the intensive care unit: analysis of the related factors. Intensive Crit Care. 2008;24(3):197-204 .

16. Stafseth SK, Solms D, Bredal IS. The characterisation of workloads and nursing staff allocation in intensive care units: a descriptive study using the Nursing Activities Score for the first time in Norway. Intensive Crit Care Nurs. 2011;27(5):290-4.

17. Ducci AJ, Zanei SSV, Whitaker IY. Nursing workload to verify nurse/patient ratio in a cardiology ICU. Rev Esc Enferm USP. 2008;42(4):673-80.

18. Giakoumidakis K, Baltopoulos GI, Charitos C, Patelarou E, Fotos NV, Brokalaki-Pananoudaki H. Risk factors for increased in-hospital mortality: a cohort study among cardiac surgery patients. Eur J Cardiovasc Nurs. 2012;11(1):23-33.

19. Adell AB, Abizanda Campos R, Yvars Bou M, Quintana Bellmunt J, Gascó Garcia C, Soriano Canuto M, et al. Care work load in critical patients. Comparative study NEMS versus NAS. Enferm Intensiva. 2006;17(1):67-77.

20. Adell AB, Abizanda CR, Cubedo RM, Quintana BJ, Sanahuja RE . Nursing Activity Score (NAS). Our experience with a nursing load calculation system based on times. Enferm Intensiva. 2005;16(4):164-73.

21. Deberg D, Myny D, Herzeele VI, Maele GV, Miranda DR, Colardyn F. Measuring the nursing workload per shift in the ICU. Intensive care Med. 2012; 38(9):1438-44.
-2222. Queijo AF, Martins RS, Andolhe R, Oliveira EM, Barbosa RL, Padilha KG. Nursing workload in neurological intensive care units: cross-sectional study. Intensive Crit Care Nurs. 2013;29(2):112-6.).

More than ten years of use and experiences have been published. However, some problems were observed in its application by intensive care nurses around the world. The main difficulties were related to the lack of clear operational explanations about certain items. Although NAS has its own specific instructions for use(1515. Padilha KG, Sousa RMC, Queijo AF, Mendes AM, Miranda DR. Nursing Activities Score in the intensive care unit: analysis of the related factors. Intensive Crit Care. 2008;24(3):197-204 .) the definitions do not solve all doubts arising from this “old” manual application and new methods, when used in interventions and treatments. This issue motivated the network to perform a multi-center study and explore the problem to provide an updated guideline.

The main objectives were to: describe NAS scores in different countries and verify the agreement among countries on the NAS guideline interpretation.

METHOD

This cross-sectional multicenter study was developed in 19 ICUs in seven countries: Norway, the Netherlands, Spain, Poland, Egypt, Greece and Brazil, considering 1-day measure of NAS (November 2012).

The eligibility criteria for ICU inclusion were adult patients, general or specialized type and current use of NAS.

The sample consisted of patients consecutively admitted to the ICUs, aged 16 years and more, undergoing medical or surgical treatment with a length of stay in the ICU for at least 24 hours.

Demographic and clinical variables included age, length of stay (LOS), severity of illness (Simplified Acute Physiologic Score II-SAPS II), discharge of the ICU (survival or non survival) and nursing workload (total NAS score and item by item score).

The project was approved by the hospital and research ethics committees of each country. Medical records were used to obtain demographic data, LOS, SAPS II and NAS indexes. All the indexes were collected in the first 24 hours in the ICU.

After the data collection and analysis, a second phase of the study, the Delphi technique involved a meeting of the group of researchers in Sao Paulo, Brazil, in earlyNovember 2014. The objective of this meeting was to discuss different interpretations of NAS items and to establish a consensus for the drawing up of an updated version of the NAS manual. As a reference for discussion, the instrument’s original manual was used(1515. Padilha KG, Sousa RMC, Queijo AF, Mendes AM, Miranda DR. Nursing Activities Score in the intensive care unit: analysis of the related factors. Intensive Crit Care. 2008;24(3):197-204 .). In light of the results gathered during data collection in the participating countries, each item from the instrument was discussed until a consensus was reached among all participants with regard to interpretation of the item. In cases of divergences, DRM (coordinator of NAS development and validation) was consulted to facilitate reaching a consensus.

Following on from this procedure, a second, electronic meeting was held among the researchers at the end of November 2014 to adjust the results. Subsequently a final meeting in-person took place in Valencia, Spain in January 2015 when the NAS manual was updated for application in clinical practice in the ICU.

Data were entered in Google Docs (Egypt, Poland, the Netherlands and Greece) and Excel (Sapin, Braxil and Norway) and afterwards submitted to descriptive analysis in Brazil, using version 19.0 of the SPSS software.

RESULTS

A sample of 758 patients from 19 ICUs in seven countries, of whom 61.1% were male, 53.7% were submitted to clinical treatment and 8,2% died in the Unit.

Demographic and clinical data are shown in Table 1.

Table 1
Number of patients, age, LOS, SAPSII, NAS score and death in the different countries.

Table 1 shows that a higher percentage of patients from the ICUs of Norway, Brazil and the Netherlands (37.6%, 24.0% and 14.4%, respectively), corresponding to 76.0% of the sample. These were followed by the ICUs in Greece, Spain, Egypt and Poland, that together admitted 24.0% of the patients.

The mean age of all patients was 63.5 years and ranged from 61.8 to 67.6 years in the units of all countries, except in Egypt where the patients were younger (mean age: 40.7 years).

The mean LOS ranged from 2.0 to 3.9 days in the ICUs from 3 of the 7 countries (Greece, Brazil and Norway). A higher mean LOS (about 6 days or longer) was observed in the ICUs in Spain, Egypt, the Netherlands and Poland.

Regarding the severity of illness, the mean SAPS II of the sample was 33.9 points and ranged from 30.9 to 37.8 points in most countries (71.4%). The lowest severity was observed in Greece (28.9 points) and the highest in Poland (65.0 points).

The highest mortality rates were observed at the Egyptian and Greek ICUs (33.3% and 24.2%), and lowest rates at the Brazilian and Norwegian ICUs (2.5% and 5.5%). The mortality rates at the ICU of other countries were: 10.2% in Spain, 9.5% in Poland and 8.3% in the Netherlands.

The mean nursing workload of the total sample was high, at 72.8% . The highest mean NAS score was obtained for the Norway ICU (101.8%), followed by Poland (83.0%) and Greece (64.6%). With the exception of the Spanish ICU which scored lowest (44.5%), scores ranged from 51.0% to 57.1% in the Netherlands, Brazil and Egypt.

Concerning the understanding of the 23 NAS items, there was a consensus among the researches on the interpretation and scores for the majority of items (18/78.3%): items 1a, b and c (monitoring and tritation); item 2 (laboratory); item 3 (medication: vasoactive drugs excluded), items 4a, b and c (hygiene procedures); item 5 (care of drains); items 6a, b and c (mobilization and positioning); items 7a and b (support and care of relatives and patient); item 9 (respiratory support); item 10 (care of artificial airways); item 11 (treatment for improving lung function); item12 (vasoactive medication); item 13 (intravenous replacement of large fluid losses); item 16 (hemofiltration techniques); item 17 (quantitative urine output measurement); item 18 (measurement of intracranial pressure); item 20 (intravenous hyperalimentation); item 21 (enteral feeding) and item 23 (specific interventions outside the intensive care unit; surgery or diagnostic procedures).

On the other hand, there was a disagreement concerning the interpretation of 5 items: item 8c (performing administrative and managerial tasks requiring full dedication for about 4 hours or more…); item 14 (left atrium monitoring); item 15 (cardiopulmonary resuscitation after arrest); item 19 (treatment of complicated metabolic acidosis/alkalosis) and item 22 (specific intervention(s) in the intensive care unit).

The main questions concerning these items were: must we consider item 8c if there are nursing students under supervision of the bedside nurse?; is it possible to consider in item 14 the use of procedures such as intra-aortic balloon pumping, extracorporeal life support (ECLS), ventricular assistance devices?; must we consider patients who suffered cardiac arrest (item 15) within the last 24 hours even when outside the ICU or only in the ICU?; must we consider in item 19 only acute treatments such as bolus of sodium bicarbonate or can we also consider when the patient is in hemofiltration, when the solution is buffered and in 24 hours the minimal amount is given, as laid out in the original manual?; can we include the procedures mentioned in item 22, if it takes more time or do we need to include an exhaustive list of possible procedures to include in this item as examples?

After orientation from the NAS author and discussion among the researchers in the meetings, consensus was reached in Valencia, in January 2015, and the NAS manual was concluded as follows.

Chart 1
Instruction manual for implementation of NAS

DISCUSSION

The workload of nurses in ICUs in countries that participated in the research, an average of 72.8%, was consistent with that found in other studies that applied the NAS in different ICUs(1616. Stafseth SK, Solms D, Bredal IS. The characterisation of workloads and nursing staff allocation in intensive care units: a descriptive study using the Nursing Activities Score for the first time in Norway. Intensive Crit Care Nurs. 2011;27(5):290-4.,1818. Giakoumidakis K, Baltopoulos GI, Charitos C, Patelarou E, Fotos NV, Brokalaki-Pananoudaki H. Risk factors for increased in-hospital mortality: a cohort study among cardiac surgery patients. Eur J Cardiovasc Nurs. 2012;11(1):23-33.,2424. Nogueira LS, Domingues CA, Poggetti RS, Sousa RMC. Nursing workload in intensive care unit trauma patients: analysis of associated factors. Plos One. 2014; 9(11):e112125.).

However, the NAS measures showed a great degree of variation between countries with a minimum of 44.5% (Spain) and a maximum of 101.8% (Norway), as well as average values of 83.0% (Poland), 64.59% (Greece) and 57.1%, 54.0% and 51.0% (Egypt, Brazil and the Netherlands, respectively). Although similar values have been reported by other researchers(2020. Adell AB, Abizanda CR, Cubedo RM, Quintana BJ, Sanahuja RE . Nursing Activity Score (NAS). Our experience with a nursing load calculation system based on times. Enferm Intensiva. 2005;16(4):164-73.-2121. Deberg D, Myny D, Herzeele VI, Maele GV, Miranda DR, Colardyn F. Measuring the nursing workload per shift in the ICU. Intensive care Med. 2012; 38(9):1438-44.,2525. Nogueira LS, Koike KM, Sardinha DS, Padilha KG, Sousa RMC. Nursing workload in public and private intensive care units. Rev BrasTer Intensiva. 2013;25(5):225-32.-2626. Carmona-Monge FJ, Jara-Perez A, Quirós-Herranz C, Rollán-Rodríguez G, Cerrillo-González I, García-Gómez S, et al. Assessment of nursing workload in three groups of patients in a Spanish ICU using the Nursing Activities Score Scale. Rev Esc Enferm USP. 2013;47(2):335-40.), it is possible to attribute these differences to the type of ICU, as well as to the characteristics of the patients.

Among the total sample of patients, the average age was 63.5, with a SAPS II score of 33.9 points, a length of stay in the ICU of 4.4 days and a mortality rate of 8.2%. These results, however, different varied among countries. These differences can explain at least partially the variation in the workload of nurses and need to be explored further.

The present study sought to go beyond just describing the workload of nurses in ICUs in the participating countries, and, through the application of NAS by experienced nurses, aimed to verify the consensus in the understanding of each item of the instrument and guideline, with the objective of providing an updated and standardized manual for use in clinical practice.

The analysis and discussion of the results of each item, separately, indicated that the researchers are in agreement in their understanding of the majority (78.26%) of items in the NAS. However, there were doubts relating to 5 (21.7%) items, whether because of a lack of clarity in the original manual or with regard to new processes and interventions that did not exist when the instrument was first established in 2003.

It is possible to conclude that the understanding shown by the researchers in relation to the majority of items about which no doubts arose occurred on account of previous communication between the researchers, mainly during the initial phase of implementation of the NAS in the ICUs. Nevertheless, independently of their understanding of these items, all of them were presented during discussions and consensus was reached by participants.

With regard to the five items for which there are doubts, these relate to item 8 (include or not the activities for accompanying students in the ICU as sub-item ‘c’); item 14 (consider or not new procedures); item 15 (score or not care for cardio-respiratory arrest in the previous 24 hours, when occurring outside of the ICU); item 19 (score or not bicarbonate repositioning and, if necessary, during the process of hemofiltration) and item 22 (draw up or not a list of the different procedures to be scored, exceptionally when more time was asked for to carry them out).

After discussion with the NAS author and further discussion between the researchers, consensus was reached by all regarding these doubts, and conclusions were included in the manual.

The updating of and proposal for a set of guidelines for completing the NAS in ICUs, after more than a decade of applying the instrument, arose due to a need for a better understanding and uniformity of its use among researchers and intensive care nurses. The correct application of the tool will make it possible to measure the real working demands of nurses in the ICU. Assessment of NAS do contribute towards a more effective investment of human and material resources at the unit, and as a result, improvements in the quality of care, greater job satisfaction and a reduction in costs.

CONCLUSION

The nursing workload observed in the ICUs of the seven countries that participated in the study showed a great degree of variation of average NAS, from a minimum of 44.5% to a maximum of 101.8%. Discussion on these results provided important input to the updated and standardized NAS instruction manual for use in clinical practice. The appropriate application of NAS will support the taking up of real measures in response to the working demands of nurses and will allow for improved investment in human and material resources at the ICU.

REFERENCES

  • 1
    Penoyer DA. Nurse staffing and patient outcomes in critical care: a concise review. Crit Care Med. 2010;38(7):1521-8.
  • 2
    Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007;45(12):1195-204.
  • 3
    Aiken L, Sloane DM, Bruyneel L, Griffiths P, Sermeus W, Busse R, et al. Staffing and education of nurses and hospital mortality in Europe-Authors’ reply. Lancet. 2014;384(9946):851-2.
  • 4
    Numata Y, Schulzer M, Van der Wal R, Globerman J, Semeniuk P, Balka E, et al. Nurse staffing levels and hospital mortality in critical care settings: literature review and meta-analysis. J Adv Nurs. 2006;55(4):435-48.
  • 5
    Aiken L, Sermeus W, Heede KV, Sloane DM, Busse R, McKee M, et al. Patient safety, satisfaction and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;20(344):1-14.
  • 6
    Bray K, Wren I, Baldwin A, Ledger US, Gibson V, Goodman S, et al. Standards for nurse staffing in critical care units. Nurs Crit Care. 2010;15(3):109-11.
  • 7
    Italian Multicenter Group of ICU Research (GIRTI). Time Oriented Score System (TOSS): a method for direct and qualitative assessment of nursing workload for ICU patients. Intensive Care Med. 1991;17(6):340-5.
  • 8
    Fagerstrom L, Rauhala A. Benchmarking in nursing care by the RAFAELA patient classification system – a possibility for nurse managers. J Nurs Manag. 2007; 15(7):683-92.
  • 9
    Intensive Care National Audit and Research Centre. System of Patient Related Activities (SOPRA). London: ICNARC; 1999.
  • 10
    Cullen DJ, Civetta JM, Briggs BA, Ferrara LC. Therapeutic Intervention Scoring System: a method for quantitative comparison of patient care. Crit Care Med. 1974;2(2):57-60.
  • 11
    Keene AR, Cullen DJ. Therapeutic Intervention Scoring System: update. Crit Care Med. 1983;11(1):1-3.
  • 12
    Miranda DR, De Rijk A, Schaufeli W. Simplified therapeutic intervention scoring system: the TISS-28 items - result from a multicenter study. Crit Care Med.1996;24(1):64-73.
  • 13
    Miranda DR, Moreno R, Iapichino G. Nine equivalents of nursing manpower score (NEMS). Intensive Care Med. 1997;23(7):760-5.
  • 14
    Miranda DR, Nap R, De Rijk A, Schaufeli W, Iapichino G. Nursing activities score (NAS). Crit Care Med. 2003;31(2):374-82.
  • 15
    Padilha KG, Sousa RMC, Queijo AF, Mendes AM, Miranda DR. Nursing Activities Score in the intensive care unit: analysis of the related factors. Intensive Crit Care. 2008;24(3):197-204 .
  • 16
    Stafseth SK, Solms D, Bredal IS. The characterisation of workloads and nursing staff allocation in intensive care units: a descriptive study using the Nursing Activities Score for the first time in Norway. Intensive Crit Care Nurs. 2011;27(5):290-4.
  • 17
    Ducci AJ, Zanei SSV, Whitaker IY. Nursing workload to verify nurse/patient ratio in a cardiology ICU. Rev Esc Enferm USP. 2008;42(4):673-80.
  • 18
    Giakoumidakis K, Baltopoulos GI, Charitos C, Patelarou E, Fotos NV, Brokalaki-Pananoudaki H. Risk factors for increased in-hospital mortality: a cohort study among cardiac surgery patients. Eur J Cardiovasc Nurs. 2012;11(1):23-33.
  • 19
    Adell AB, Abizanda Campos R, Yvars Bou M, Quintana Bellmunt J, Gascó Garcia C, Soriano Canuto M, et al. Care work load in critical patients. Comparative study NEMS versus NAS. Enferm Intensiva. 2006;17(1):67-77.
  • 20
    Adell AB, Abizanda CR, Cubedo RM, Quintana BJ, Sanahuja RE . Nursing Activity Score (NAS). Our experience with a nursing load calculation system based on times. Enferm Intensiva. 2005;16(4):164-73.
  • 21
    Deberg D, Myny D, Herzeele VI, Maele GV, Miranda DR, Colardyn F. Measuring the nursing workload per shift in the ICU. Intensive care Med. 2012; 38(9):1438-44.
  • 22
    Queijo AF, Martins RS, Andolhe R, Oliveira EM, Barbosa RL, Padilha KG. Nursing workload in neurological intensive care units: cross-sectional study. Intensive Crit Care Nurs. 2013;29(2):112-6.
  • 23
    Nursing Activities Score: instructions for use. Crit Care Med [Internet]. 2004 [cited 2015 Feb 22]. Available from: http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/CCM/A/00003246-920030200-00001.pdf
    » http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/CCM/A/00003246-920030200-00001.pdf
  • 24
    Nogueira LS, Domingues CA, Poggetti RS, Sousa RMC. Nursing workload in intensive care unit trauma patients: analysis of associated factors. Plos One. 2014; 9(11):e112125.
  • 25
    Nogueira LS, Koike KM, Sardinha DS, Padilha KG, Sousa RMC. Nursing workload in public and private intensive care units. Rev BrasTer Intensiva. 2013;25(5):225-32.
  • 26
    Carmona-Monge FJ, Jara-Perez A, Quirós-Herranz C, Rollán-Rodríguez G, Cerrillo-González I, García-Gómez S, et al. Assessment of nursing workload in three groups of patients in a Spanish ICU using the Nursing Activities Score Scale. Rev Esc Enferm USP. 2013;47(2):335-40.

Publication Dates

  • Publication in this collection
    Dec 2015

History

  • Received
    10 Apr 2015
  • Accepted
    14 July 2015
Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br