Nursing workload and patient safety – a mixed method study with an ecological restorative approach 1

Objective: The aim of this study was to analyze the potential association between nursing workload and patient safety in the medical and surgical inpatient units of a teaching hospital. Method: a mixed method strategy (sequential explanatory design). Results: the initial quantitative stage of the study suggest that increases in the number of patients assigned to each nursing team lead to increased rates of bed-related falls, central line-associated bloodstream infections, nursing staff turnover, and absenteeism. During the subsequent qualitative stage of the research, the nursing team stressed medication administration, bed baths, and patient transport as the aspects of care that have the greatest impact on workload and pose the greatest hazards to patient, provider, and environment safety. Conclusions: The findings demonstrated significant associations between nursing workload and patient safety. We observed that nursing staff with fewer patients presented best results of care-related and management-related patient safety indicators. In addition, the tenets of ecological and restorative thinking contributed to the understanding of some of the aspects in this intricate relationship from the standpoint of nursing providers. They also promoted a participatory approach in this study.


Introduction
Worldwide, the fields of health and nursing are beset by serious issues related to scarce workforce resources, lack of qualifications, excessive workloads, absenteeism, and providers leaving the profession (2)(3)(4) .
Healthcare in Brazil is no exception to this rule, where the complexity of the publicly funded Unified Health System (UHS) is compounded by a series of structural, political, economic, and cultural issues that must be overcome to sustain and improve the care Debate centered on the association between nursing workload and patient safety is one of the most persistent themes in the field of health, mobilizing resources from the World Health Organization (1) and nursing organizations worldwide.The debate surrounding this issue includes aspects related to staffing levels and to the role of managers as leaders of this process within the healthcare system and highlights the complexity of the challenge that lies ahead.www.eerp.usp.br/rlaeRev. Latino-Am.Enfermagem 2013 Jan.-Feb.;21(Spec):146-54.
environments.The media often reports on poor working conditions, limited resources, overcrowding and long waits at the emergency departments of public hospitals, and exposés on medical error and breakdowns in patient care are increasingly frequent.These reports can fuel a conception of healthcare providers as inefficient among the lay population.
Despite efforts undertaken to investigate the implications of nursing workload on patient safety, many knowledge gaps remain in this field.There is a pressing need for studies designed to ascertain the extent and nature of nurses' roles in patient safety improvement (5) .
Therefore, attempts to describe and analyze the factors involved in nurses' work that go beyond tracking the time spent on specific tasks are essential to form a more comprehensive understanding of all of the dimensions of care that require substantial time and energy from providers (6) .
One theoretical perspective that offers a more comprehensive approach to studying nurses' workload is found in the tenets of ecological and restorative thinking.
In this mode of research, eco-restorative thinking combines attention to socio-technical systems of care (such as medication, charting, and other care delivery systems) with close scrutiny of the overall ecology of the care environment.This requires close examination of how people relate to each other and to the places they collectively inhabit in order to develop best practices within continuous cycles of research, assessment, and adaptive management (7)(8)(9)(10) .
Although the literature warns of the hazards to patient safety posed by inadequate numbers of nursing providers (2)(3)(11)(12)(13) , the specifics of different practice settings and different group of providers who carry out care activities are key elements that must be explored in each situation. With atention to both systemic and local factors, the adoption of eco-restorative thinking may provide a more comprehensive understanding of the intricate association between nursing workload and patient safety from the standpoint of the healthcare providers who work in these settings.Within this context, the aim of this study was to analyze and nursing workload and its potential association with patient safety in the medical/surgical inpatient units of a teaching hospital.

Methods
This study was conducted at a very large (>500bed) teaching hospital in Southern Brazil using a mixed-methods approach, which consisted of a combination of quantitative and qualitative research stages within a sequential explanatory design (14)(15)(16) .The first stage employed a retrospective cross-sectional study design, which was followed by a three phase, second stage qualitative exploration of nurses' workload using participatory restorative photographic methods as outlined in related safety research (7)(8)10) .
During the initial quantitative stage, the study population consisted of all inpatients and all nursing professionals at the hospital's medical and surgical units.The sample size was 11,071 patients and 449 nursing providers across 11 inpatient units and the study period was January-December 2009.The hospital's minor surgery unit was excluded from analysis due to its peculiarities, e.g. it admits both pediatric and adult patients, provides care of a much lower complexity and is characterized by very short stays.Patients with a length of stay of <24h, regardless of admission unit, were excluded from the sample.The information processed at each admission unit on a monthly basis was based on a sample of the 11 units over the 12-month period (n=132).The 11 inpatient units included in the study accounted for 390 (49.62%) of the beds available at the  (7)(8)(9)(10) .Thirteen photos taken during the walkabout were then selected to serve as prompts for discussion and debate during a third phase (Phase C) photo elicitation focus group with four nurses and eight nurse's aides (n = 12), including some team members who worked the night shift.
To support the qualitative data analysis, the focus group and walkabout audio recordings were transcribed and organized into files in the NVivo 9 software alongside complementary field notes and photos.Using a protocol refined in previous ecorestorative visual research (7)(8) and qualitative rigor, the thematic analysis was guided by a systematic process of pre-analysis, exploration, data treatment, inference, and interpretation (17) .Initially, we sought to identify and codify preliminary themes, which were then grouped according to the nature and extent of overlapping content which explained one or more aspects of nurses' workload and related patient safety issues.A thematic categorization was then constructed to aid description and understanding of the study phenomenon.

This study has been approved by Institutional Ethics
Committee under the number 10-0037.Secondary data were covered by responsible data use forms, and all participants involved in the qualitative phase of the study (patients or relatives and nursing professionals) signed the written informed consent for participation at each stage (Focus groups, Photo walkabout, Digital photographs for patients and relatives, Digital photographs for providers).

Results
Analysis of the selected admissions units revealed a bed occupancy rate of 86.16±12.09and a mean number of 31.48±11.65 admitted patients per day.The mean number of nurses and nurse's aides/technicians across the various shifts of the day was 4.79±0.72 and 16.70±4.02respectively.On pooled analysis of all studied units, the ratio of patients to nurses was 6.44±2.01/day(range, 2.97-8.97),and the ratio of patients to nurse's aides/nurse technicians, 1.82±0.33/day (range, 1.13-2.17).
On the unit with the lowest patient-to-nurse ratio (2.97), each nurse was in charge of approximately 9 patients per shift, whereas the unit with the highest patient-to-nurse ratio (8.97)  B values, which measure the association between the study factor and outcomes of interest, showed that each one-unit increase in the patient-to-nurse ratio was associated with a 0.189 increase in the incidence of bedrelated falls, a 0.157 increase in central line-associated infections, a 0.171 increase in turnover and a 0.268 increase in absenteeism.The rate of patient satisfaction with the nursing team was the only outcome significantly associated with aide/technician workload (B, -10.799; p=0.024).There was a significant inverse association, that is, for each one-unit increment in the patient-toaide/technician ratio, there is a 10.799 decrease in patient satisfaction with the nursing team.These data are described in Table 2.    of each nurse, nurse's aide or nurse technician increases the incidence of these indicators and has a negative impact on patient safety.These findings are consistent with those of previous studies (11)(12)(13)18) , which suggested that adequate nurse staffing levels, with lower patientto-provider ratios, help reduce the incidence of adverse events, including bed-related falls and infections.

Unit
The differences in workload experienced by nursing teams on different inpatient study units that were identified in the quantitative portion of the research were also confirmed at the qualitative stage, where focus group participants reported that their unit is one of the most demanding at the study hospital due to its high occupancy rate, patient population and staffing level.These situations may increase the odds of adverse events.This is consistent with past studies (18)(19) that have shown excessive workload to be a significant driver of adverse events and human error due to haste.
Patient care such as bed bath, transport, and medication administration were pointed out in this study as some of the main factors, which have an impact on nursing workload and patient safety.These aspects should be studied further to decrease the risks to which inpatients are exposed.These findings support the results of previous studies (20)(21) , in which there was some concern about insufficient nursing staff and the occurrence of medication errors or other adverse events in Brazilian hospital wards.
The findings of this study and of previous investigations (22)(23) highlight the importance of analyzing absenteeism and provider turnover as critical management indicators of nursing service quality and inputs for the establishment of proper staffing levels.High absenteeism and turnover rates suggest that staffing levels are inadequate to maintain the continuity of patient care, which in turn contributes to the incidence of patient safety hazards due to nurse fatigue, illness, and turnover itself.The detection of an association between increased nursing team workloads -as expressed by higher patient-to-nurse ratios -and increases in these indicators, as shown in Table 2, is a red flag that reveals potential hazards to patient and provider safety alike.
The significant association between the workload of nurse's aides/nurse technicians and patient satisfaction rates is also consistent with the findings of other studies (24)(25) , in which increases in provider workload or assignment of greater numbers of patients to each nursing professional were found to decrease patient satisfaction with provided care.This topic was also addressed during focus groups, where participants expressed a concern with the expectations of patients and their relatives when care has to be rushed due to understaffing.
Although the relevance of the study results should not be understated, its limitations should be taken into

Conclusions
In this study we found that the increase in the number of patients assigned to nursing staff per day was significantly associated with the increase in incidence of falls from beds, incidence of central line-associated bloodstream infections, absenteeism and turnover.We also found that the more patients assigned to nurse's aides/technicians per day the lower the rate of patient satisfaction with the nursing team.
The adoption of the tenets of eco-restorative thinking in the study of the potential association between nursing team workload and patient safety in inpatient units proved to be a relevant approach, providing an understanding of some of the countless facets involved in the complex environment where patient care activities take place in the hospital setting, through the eyes of nursing providers themselves.This participatory approach, built on the foundations of eco-restorative photos of the unit based on the Phase A list and any other suggestions by participants as they explored the environment together.As images were collected, the nurse participant provided digitally recorded narratives of the workload and safety issues being photographed; the nurses' aide participant helped determine the best scenes for photography, and the research assistant documented notes on the photos using a form adapted from previous eco-restorative visual research(7)(8)(9)(10) .Thirteen photos taken during the

(Figure 2 -
Figure 2 -Photo #67: Moving a patient during a bed bath Discussion account in view of the complexity of the phenomenon under study and the constraints of the methodological approach employed.The use of a cross-sectional, single-center design over a limited study period restricts comparative analysis with other investigations.This is compounded by the lack of standardized patient safety indicators and outcomes within the Brazilian health system and the scarcity of national and international research in this field.These limitations notwithstanding, these findings provide innovative contributions toward a greater understanding of the intricate relationship between nursing workload and patient safety, and identify several areas that can be targeted for hazard prevention with respect to patient, provider, and environmental safety in a teaching hospital inpatient unit setting.Participants' committed engagement in the eco-restorative visual stage of the study also suggests that we can generate more meaningful knowledge of the relationship between nurses' workload and patient safety by actively involving practicing nurses in this line of research.They also pave the way for future research projects to explore this matter in different contexts and at other healthcare facilities.
Magalhães AMM, Dall'Agnol CM, Marck PB.thinking and implemented by means of photographic research methods and focus group debates, provided an opportunity for reflection on routine practices associated with the results of care-related and management-related patient safety indicators.
had approximately 27 patients per nurse per shift.The unit with the lowest patient-to-aide/technician ratio (1.13) had a distribution of approximately 3-4 patients per aide/technician per shift, whereas the unit with the highest ratio (2.17) had 6-7 patients per aide or technician per shift.These data are described in Table 1.www.eerp.usp.br/rlaeRev. Latino-Am.Enfermagem 2013 Jan.-Feb.;21(Spec):146-54.

Table 1 -
Daily nursing provider workload, calculated as the ratio of mean number of patients to mean number of providers per 24h, per unit, Porto Alegre, RS, Brazil, 2009 * Mean ± standard deviation Source: Study data, Magalhães AMM, Porto Alegre, RS, Brazil, 2012.

Table 2 -
Association between care-related and management-related patient safety indicators and nursing team workloads in medical and surgical inpatient units, Porto Alegre, RS, Brazil, 2010 *Generalized estimating equations describe the extent of association between the factors and outcomes of interest.Associations were considered significant