Journal of Nursing Management, 1999, 7, 317–322

Nursing workload: an unquantifiable entity

M. HUGHES rgn, ba (hons), msc, pgce

Senior Lecturer, University of West of England, Bristol, UK

Correspondence hughes m. (1999) Journal of Nursing Management 7, 317–322M. Hughes Nursing workload: an unquantifiable entityUniversity of West of EnglandBlackberry Hill Background In the increasingly prominent drives towards cost containment and eBciencyBristol BS16 1 DD nursing is under pressure to justify its value to healthcare. On the surface nursingUK workload assessment methods would appear to oCer a means to quantify the nursing

input to patient care.Aims To examine the validity of nursing workload methods with respect to nursingpractice and nursing knowledge.Findings Previous studies and the conclusions of subject reviews have cast doubt on thereliability and validity of most methods and indicate that they have no clear theoreticalbase.Conclusion It appears that nursing is more concerned with knowledge processing andnurses’ intentions than just with the activities of caring. It is suggested that patientscontrol the time element of nursing care. The need for nursing workload information,despite its validity problems, is discussed and a pragmatic solution is suggested.

Accepted for publication: 28 July 1999

The emphasis placed on eBciency and eCectiveness in deployed eBciently. The Resource Management Initiative(DHSS 1986) proposed that information technology wasrecent years has led to greater interest in the nursing

workload assessment of patient care. This paper intro- the tool to provide the supporting information. It alsoencouraged the use of workload assessment methods toduces common methods of assessment and analyses their

validity in the light of previous research, nursing practice determine skill mix requirements. Workload assessmentis an attempt to predict the nursing time and skillsand nursing knowledge.

Awareness of workload assessment and skill mix has required to provide nursing care. The Strategy for Nursing(1989) also promoted the use of computers to help quan-risen during the last two decades as the financial impli-

cations of healthcare have become apparent. Walker and tify nursing workload and ‘workload measurement ofnursing care’ was identified by the NHS ManagementWhynes (1990) argued that the proportionately high cost

of the nursing budget impinged heavily on the cost of Executive (1989) as one of seven information requirementsfor ward managers. By the early part of this decadetreatment costs. Nurses, as the largest staC group, make

up the highest labour cost while labour consumes a large these powerful influences (quantifying nursing input andeBcient deployment of nurses) had led to the adoption ofproportion of the healthcare budget. In an earlier report,

Wright-Warren (1986) concluded that ward sisters needed a variety of nursing workload assessment methods acrossthe UK.supporting information to determine the skill mix, level

and eBcient utilization of staC. The implication is that There are two main methods of assessing workload inthe UK: activity based and dependency based. These arenursing costs could be reduced or justified if nurses were

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M. Hughes

also referred to by Edwardson and Giovannetti (1994) as information. In this study it must be noted that the nurseswere aware of the imaginary nature of the assessed‘nursing task document’ and ‘critical indicators of care’

approaches. Activity methods involve an assessment of patients and that they were not familiar with the systems.Therefore the urgency for accurate assessment and thethe patient for the activities involved in providing the

nursing care required. Each activity has, through obser- nurses’ familiarity with the routine classification ofpatients were not present. Despite this the results were sovation, been allocated a time to carry it out. The sum of

a patient’s required nursing activity times should supply varied as to be unreliable.Carr-Hill and Jenkins-Clarke (1995) surveyed threethe total time required to care for that patient in that

shift or day. A skill level can also be assigned to each wards for the actual times worked by nurses and theestimated required times from four workload systems.activity thereby providing skill mix information. The sum

of all patients’ activities should give the required nursing They found significant diCerences between the estimatedhours required and the actual hours worked for two ofskill mix (time and skills required) for the clinical area

for that shift or day. In this way a ward manager can, the wards. Again this indicates that the informationsupplied is unreliable; correlation between the systemsfrom an initial assessment, identify any mismatch in

staBng levels or skills. showed that the estimate variations were outside a 5%level of confidence. In a survey of patients within diCerentNot requiring such detailed information, dependency

methods require a simpler assessment. One method uses categories of one dependency method Stillwell and Hawley(1993) found that the actual nursing care times werea simple classification or critical indicators tool that places

the patient in one of four categories. Numbered one to extremely varied between patients in the same category.They also found large overlaps of actual nursing carefour, the first category represents patients who care mostly

for themselves while category four patients require high times between patients who had been assigned to theextreme dependency categories. In eCect, the results indi-input of care. Each category has been assigned a nursing

time. In this way the total time required for nursing care cated that the method produced workload informationthat bore little resemblance to the timing of actualcan be identified for a 24-hour period from the number

of patients in each category. nursing care.It is suggested (Greenhalgh et al. 1990) that patientsA third approach, more a nursing requirement predictor

tool than a workload assessment method, is the statistical are becoming more homogenous in their dependencylevels as patient stays become shorter. If this is so thenmethod. Statistical methods base their predictions on

previous information from the clinical area itself. From the dependency workload methods have less use; if mostpatients are assigned to only one or two categories theneach shift, information is collected on the number of

significant patient events such as admission, discharge the associated workload requirements for these patientsstart to merge. Under these circumstances the number ofand patient-related procedures. The nurse in charge also

assesses the shift for any unsafe incidents and how much patients would become the workload indicator and assess-ment methods would provide little in the way of extra,of the work was achieved. In conjunction with the duty

roster, regression analysis is carried out to identify appro- useful information.In a study to assess the eCect of grade mix change onpriate grade mixes for diCerent permutations of patient

events. quality of nursing care Bagust et al. (1992) found that thequality assessment tool in a statistical method was notAll three of these methods lend themselves to com-

puterization and, on the surface, this provides a legitimate sensitive enough to distinguish between the middle rangesof patient care. Therefore, changes in the level of patientcontext for their acceptance. For a method to be easily

transferred to a computer to provide sensible, quantitative care were not always being identified. It would appearthat the criteria for assessment had not been suBcientlydata then it would seem that it must be based on a sound,

empirical framework. However, several studies that have defined.Using a diCerent set of criteria Campbell et al. (1997)been carried out to test this legitimacy have not found an

empirical framework. Four workload systems were com- tested the relationship between case mix groups (CMGs),resource utilization and nursing eCort to assess the use ofpared by Rees et al. (1991) using a quasi-experimental

approach. Nurses were asked to assess model patients on CMGs as an indicator of nursing workload. CMGsinvolve classifying patient cases of similar clinical naturefour imaginary wards with each ward using one of the

diCerent systems. Sixteen patients were common to all into groups that require similar healthcare resources.Although they found that there was a good relationshipfour wards. The results showed that there was a low

intra- and inter-system reliability that would suggest that between the number of patients and the resources used,they found that CMGs could not be used as an indicatorthis method does not necessarily produce useful workload

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of required nursing resources. They suggest that varying nurse is involved in patient care, thereby potentiallyimproving the accuracy of workload data input.severity of illness—not reported by CMGs—may be an

Although care-plans are based upon the nursing pro-influence in this.cess, the documentation and actual adherence to theIt would appear that no workload assessment methodprocess is suspect. In one USA study of 600 patientprovides reliable information; the intra- and inter-methodencounters, care-plan-reported interventions—related toreliability from each of them is low. This implies thatfluid volume—outweighed reported problems (Holzemereither the methods are not valid or that the operators ofet al. 1997). That is, there were more recorded inter-methods themselves are suspect. In a review of mainlyventions than there were recorded problems. This wouldNorth American methods of nursing workload measure-imply that the care-plan, because it was not kept accu-ment Edwardson and Giovannetti (1994) found that ‘mostrately, was not perceived as an important part of nursingof the studies in this review have selected variables orand does not accurately represent nursing care. If activityindicators without regard to a theoretical base.’ Theymethods are based upon the care-plan then they may bewent on to suggest that approaches with a more theoreti-based upon an inaccurate representation of nursing.cal base should be used. Procter (1992) noted that there

Another problem with the use of activity methods isis a tautology in the implementation of many systems.that nursing is seen as a linear activity. All activity timesTiming nursing activity will only allow predictions basedare added together as if they were discrete. This ignoreson nursing practice now; the predictions are then confinednurses’ ability to meet several needs simultaneously; thewithin the current, historical staBng patterns. Workloadability to help someone to the toilet while also assessingpredictions are therefore not based upon a theoreticaltheir ability to walk and discussing their home circum-analysis of nursing but on unspecified, vague notions ofstances regarding discharge referral. Procter (1992) referswhat nurses are doing at the time of measurement.to this as ‘multitasking’. However, this ability for concur-As operators of the methods the first problem may berent care issues is often dependant on the occasion as itthat nurses do not perceive the systems to be in thearises and cannot be predicted. There is therefore annursing domain. Bagust (1990), in claiming that theelasticity in activity timing that is not recognized in the

dependency method does not fit with any nursing philos-linear activity approach. A further problem is that the

ophy, indicated a tension in the perceptions of nursing.time required to carry out patient care tends to be

The tension centres on nursing activity and nursinggoverned by the patient, not the nurse (Edwardson &

behaviour. By attempting to define nursing by studyingGiovannetti 1994). Therefore the nurse is not able to

activities, Eaves (1989) and colleagues adopted a time andassign times to activities.

motions approach. It is possible that they chose this It appears that activity methods are concerned withapproach because of a care-planning approach widely what nurses appear to do, and related to a process ofused in the UK at this time. The Roper et al. (1990) providing a rationale for why they do it, but miss themodel of nursing closely followed Henderson’s (1969) other aspects of nursing behaviour. Nursing behaviour isdefinition of the nurse’s role. The Roper et al. model has concerned with skills and thinking as well as activities.been widely adopted throughout the UK. However, it is Each activity is developed from an assessment of circum-predominantly concerned with physical needs of patients. stances, a thought process. Procter and Hunt’s (1994)Therefore, the nursing interventions are predominantly Delphi study found that even what is called ‘basic nursingconcerned with physical activity. Eaves (1989) simply care’ involves much professional information processing.transferred these physical activities to a workload method. Their study indicated that the aim of a nursing inter-

The problem that Bagust (1990) identified is twofold. vention had greater validity than the timing of it.Firstly, nursing philosophies tend to revolve around the Emptying a catheter bag and testing the urine is annotion of the patient as an individual. This individuality activity that can be used to illustrate this; it is a moderatelyis removed by a crude categorization into dependency simple activity that can be taught to most healthcarelevels. Secondly, the activity methods were originally workers in a relatively short time. However, dependingimplemented as an extra to daily duties; therefore they on circumstances it will be carried out with quite diCerentwere not necessarily seen as part of nursing and, because intentions. A nurse working with elderly people mayof this, the accuracy of data input may have suCered. be assessing volume and eCectiveness of diuretics. ThisLater, they were integrated into nursing by way of care- patient may have been suCering from paroxysmal noctur-planning systems. The activities for workload assessment nal dyspnoea. The nurse is using knowledge of respiratorycan be drawn from the interventions section of a com- and renal function, along with symptoms, to assess eCec-

tiveness of care and prognosis. An intensive care nurseputerized care-plan thus collecting the data while the

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M. Hughes

may carry out the same activity but be as much concerned workload assessment focus remains on the activities ofnursing, the eCect of nursing will remain largely an unseenwith the concentration of the urine. This nurse is monitor-

ing for renal and neurological involvement. Caring for a factor of healthcare. Workload assessment is, ostensibly,concerned mainly with empirical knowledge. Ozbolt andpatient post-prostate surgery, a nurse will be monitoring

for blood clots and patency of catheter tubing. If the Graves (1993) claim that without reliable data it isimpossible to assess the nature, eCect and quality ofpatient has recently fractured a hip and is slightly confused

the nurse may be assessing the urine for the first signs of nursing. Without these it is impossible to argue againstskill dilution because it is impossible to argue for thea urinary tract infection.

Furthermore, nurses are taught the skills of prioritiz- retention of an intangible factor. Brennan and Fitzpatrick(1992) argue that nursing informatics is, because of itsation against a backdrop of ideal nursing care. Presuming

that they carry these skills into their careers it is reasonable concern with the other types of nursing knowledge,essential to the eCective representation of the nursingto assume that they will deliver the best care that they

can. Therefore, they will carry out procedures at diCerent understanding of the patient. In other words reliable dataabout the nature and eCect of nursing is essential tospeeds and in diCerent ways depending on the circum-

stances—as noted by Procter (1992). None of the work- making nursing, or nursing workload, visible.In the absence of reliable data or such a nursingload assessment methods appear to recognize that when

there is more to do nurses will probably work harder and understanding of the patient Duberly and Norman (1990)argue that all the workload assessment methods add afaster until a limit is reached. Therefore the timings of

the activities and dependency methods and the assessment scientific and statistical dressing to what is essentiallyprofessional judgement. At some point all these methodsof the nurse in charge only relate to an ideal.

Whatever the outcome it is likely that the nurses rely on a nursing judgement that can be labelled unre-liable. The methods appear to be modelled on falseinvolved will have adapted their care accordingly and yet

the initial activity can be seen as essentially the same; it premises and operated through professional judgement.Professional judgement can be seen as the result ofis the intention that varies. Although intentions may

overlap they are generally dependant on the context of information processing within the limitations of availableknowledge.care and the knowledge of the nurse. A study of require-

ments for information systems in nursing by Carty (1994) One of the problems has been the reliance on untestedmodels. In attempting to apply quantitative methodologyfound that nursing involves knowledge processing

rather than data processing. Furthermore, Brennan and to workload assessment, assumptions have been madeabout the chosen models of nursing and workload.Fitzpatrick (1992) argue that nursing is essentially an

information processing profession and that there is an Methods have been developed apparently without ques-tioning the models. Studies in nursing informatics (Gerdinessential integration of nursing and informatics. They

argue that nursing involves a currency of words, numbers et al. 1997) are now addressing this issue by exploringthe theoretical nature of nursing; qualitative studies areand phrases used to investigate and describe patients and

their state of health. Information is abstracted from this being carried out to draw out coding and classificationmodels from actual nursing practice. Although somedata and used in decision making about nursing inter-

ventions. Nursing knowledge is gained from these pro- headway has been made, it is recognized that there is stillmuch work to be done in this area (Henry & Mead 1997).cesses when information is transformed into knowledge.

When classifying knowledge Higgs and Titchen (1995) Arthur and James (1994) suggested that ‘a perfect toolfor measuring nursing workload is unlikely to exist.’ Ifidentified three major categories: propositional knowl-

edge, professional/craft knowledge and personal knowl- the workload assessment methods are, at present, unre-liable then their use needs to be questioned. If the purposeedge. The first two equate to ‘knowing that’ and ‘knowing

how’ while the third draws from life experiences. of nursing is to provide an agreed quality of care, andmanagers want to provide this as eBciently as possible,Therefore, diCerent life experiences, work experiences,

education and training will lead to great variations in then the two measures need to be the quality of nursingcare and nursing costs. Methodology for measuring theknowledge between individual nurses. Given the potential

extent of nursing experience it is unlikely that any two quality of nursing care is a large topic and is outside thescope of this paper. Nursing costs, however, can benurses will carry out procedures in exactly the same way.

Each will bring diCerent sets of knowledge to the circum- identified from the skill mix. Skill mix and quality of careis where the statistical methods start. Simple analysis canstance and will process it accordingly.

Knowledge and activity are integral to nursing and yet then be used to estimate the optimum skill mix. However,if the quality of care is identified as falling then questionsthe knowledge aspect is often disregarded. While the

320 © 1999 Blackwell Science Ltd, Journal of Nursing Management, 7, 317–322

Nursing workload

may be asked about the nurses involved in delivering the assumptions about nursing by drawing directly fromnursing practice. In the interim, until these studies havecare. It may be that there has been a higher workload,

and yet there is no way of proportioning this cause unless produced rigorous theoretical models from which nursingworkload can be reliably drawn, the pragmatic solutionworkload has been assessed. Thus nurses and nurse

managers face a paradox: workload methods provide is to use simple methods of workload assessment that canbe used in monitoring the relationship between skill mixunreliable information and yet workload information is

required. and the quality of nursing care.One answer may be to accept that the methods provide,

at best, an indicator of nursing workload. An indicatorReferencesis a poor form of measurement. However, if workload

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