Measuring the nursing workload per shift in the ICU

Purpose

In the intensive care unit (ICU) different strategies and workload measurement tools exist to indicate the number of nurses needed. The gathered information is always focused on manpower needed per 24?h. However, a day consists of several shifts, which may be unequal in nursing workload. The aim of this study was to evaluate if differences in nursing workload between consecutive shifts can be identified by a nursing workload measurement tool.

Methods

The nursing activities score (NAS) was registered per patient for every shift during a 4-week period in a prospective, observational research project in the surgical-pediatric ICU (SICU-PICU) and medical ICU (MICU) of an academic hospital.

Results

The NAS was influenced by the patient characteristics and the type of shift. Furthermore, the scores were lower during night shifts, in weekends and in MICU patients. Overall, the mean NAS per nurse per shift was 85.5?%, and the NAS per 24?h was 54.7?%.

Conclusion

This study has shown that the nursing workload can be measured per working shift. In the ICU, the NAS differentiates the nursing workload between shifts, patients and units.     

应用护理活动评估量表对ICU护理工作量的调查与分析

目的应用护理活动评估量表(NAS)评价ICU护理工作量,分析ICU护理工作量特征,为护理管理者合理配置人力资源提供依据。方法翻译英文版NAS,评价其信度、效度及文化相关性。2006年1～4月,对所有入住中国医科大学附属第一医院ICU的病人,应用NAS评价护理工作量。结果该院ICU病人因入住ICU时间不同、转归不同,其护理工作量也不同,并与疾病种类无关。结论中文版护理工作量评估表是一种具有较高信度和效度的ICU专用护理工作量评估量表,可以为护理管理者提供可靠的理论依据和数据支持。     

Nursing Activities Score in the intensive care unit: analysis of the related factors.

BACKGROUND: High costs of intensive care as well as quality of care and patient safety demand measurement of nursing workload in order to determine nursing staff requirements. It is also important to be aware of the factors related to high patient care demands in order to help forecast staff requirements in intensive care units (ICUs). OBJECTIVES: To describe nursing workload using the Nursing Activities Score (NAS); to explore the association between NAS and patients variables, i.e. gender, age, length of stay (LOS), ICU discharge, treatment in the ICU, Simplified Acute Physiology Score II (SAPS II) and Therapeutic Interventions Scoring System-28 (TISS-28). METHODS: NAS, demographic data, SAPS II and TISS-28 were analysed among 200 patients from four different ICUs in a private hospital in S?o Paulo, Brazil. RESULTS: NAS median were 66.4%. High NAS scores (> 66.4%) were associated with death (p-value 0.006) and LOS (p-value 0.015). Logistic regression analysis demonstrated that TISS-28 scores above 23 and SAPS II scores above 46.5 points, classified as high, increased 5.45 and 2.78 times, respectively, the possibility of a high workload as compared to lower values of the same indexes. CONCLUSION: This study shows that the highest NAS scores were associated with increased mortality, LOS, severity of the patient illness (SAPS II), and particularly to TISS-28 in the ICU.     

Nursing workload assessment in an intensive care unit: A retrospective observational study using the Nursing Activities Score

Background

Nursing Activities Score (NAS) is a promising tool for calculating the nursing workload in intensive care units (ICU). However, data on intensive care nursing activities in Portugal are practically non-existent.

Aim

To assess the nursing workload in a Portuguese ICU using the NAS.

Study Design

Retrospective cohort study developed throughout the analysis of the electronic health record database from 56 adult patients admitted to a six-bed Portuguese ICU between 1 June–31 August 2020. The nursing workload was assessed by the Portuguese version of the NAS. The study was approved by the Hospital Council Board and Ethics Committee. The study report followed the STROBE guidelines.

Results

The average occupancy rate was 73.55% (±16.60%). The average nursing workload per participant was 67.52 (±10.91) points. There was a correlation between the occupancy rate and the nursing workload. In 35.78% of the days, the nursing workload was higher than the available human resources, overloading nurse staffing/team.

Conclusions

The nursing workload reported follows the trend of the international studies and the results reinforce the importance of adjusting the nursing staffing to the complexity of nursing care in this ICU. This study highlighted periods of nursing workload that could compromise patient safety.

Relevance to Clinical Practice

This was one of the first studies carried out with the NAS after its cross-cultural adaptation and validation for the Portuguese population. The nursing workload at the patient level was higher in the first 24 h of ICU stays. Because of the ‘administrative and management activities’ related to the ‘patient discharge procedures’, the last 24 h of ICU stays also presented high levels of nursing workload. The implementation of a nurse-to-patient ratio of 1:1 may contribute to safer nurse staffing and to improve patient safety in this Tertiary (level 3) ICU.     

Factors associated with nursing workload in adult intensive care units

This study was aimed both at analyzing the nursing workload on the first day of admission of patients in Intensive Care Units (ICUs) and the factors associated with it. This is a qualitative, retrospective, cross-section study that was carried out in April of 2002 and October of 2004. The data were taken from a database that gathered information from 5 ICUs from two private hospitals and the sample was comprised of 214 adult patients that remained in the ICU for at least 24 hours. The total Nursing Activities Score (NAS) average was 69.9%, and the median 68.0%. According to the median, it was verified that 109 (50.9%) individuals required heavy nursing attention and the remaining 105 (49.1%) required less attention. The severity of the illness, the patient's age and the kind of treatment were not factors associated with nursing workload in the first 24 hours at the ICU.     

护理活动评分系统在ICU人力资源管理中的应用

目的探讨护理活动评分系统在ICU人力资源管理中的应用效果。方法采用护理活动评估量表（nursing activities scale,NAS）测量在本院ICU住院的149例病人的护理工作量,根据工作量计算护士人数,并预见性地合理安排每班护士人数。结果 ICU病人当天需要的护理工作量得分最低为30.50分,最高为129.70分,平均（53.23±18.12）分。所需护患比为1～2∶1的占了68.73%。实施护理活动评分系统后护理不良事件总发生率为18.12%,明显少于实施前33.12%,实施前后比较,χ2=8.909,P〈0.001,差异具有统计学意义。结论 ICU护士人力应以所收治病人实际需要的护理工作量进行动态合理分配。采用护理活动评分系统进行人力资源管理可提高ICU护理质量。     

Nursing activities score (NAS): A proposal for practical application in intensive care units

For over 30 years in an attempt to demonstrate the cost-benefit ratio of the intensive care unit (ICU) a variety of tools have been developed to measure not only the severity of illness of the patient but also to capture the true cost of nursing workload. In this context, the nursing activities score (NAS) was developed as a result of modifications to the therapeutic interventions scoring system-28 (TISS-28). The NAS is a tool to measure nursing workload ICU and it has been shown to be twice as effective in measuring how nurses spend their time caring for critically ill patients than the TISS-28. This paper discuss the introduction of the NAS into everyday use in an intensive care unit in Brazil and highlights the challenges of standardisation of operational definitions, training requirements and accurate completion of the documentation when using such a tool. The rationale and steps undertaken to achieve this are outlined and the benefits of such a process are highlighted.     

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

Objective

This study compares the Nine Equivalents of Nursing Manpower Use Score (NEMS) to the Nursing Activities Score (NAS) in terms of characterising the nursing workload by examining and calculating the per-nurse NAS% over a 24-h period.

Method

The sample consisted of 235 patients from four volunteered for the study multidisciplinary ICUs in Norway. The daily NEMS, NAS and number of nurses who were involved in patient care per ICU were measured over one month from 2008 to 2009.

Results

The average length of stay for the included patients was 5 days, and the mean patient age was 52.8 years. The mean NEMS was 32.7 points (S.D., 8.98 points), and the mean NAS was 96.24% (S.D., 22.35%). Several nurses exhibited mean NEMS points that ranged from 16 to 39.7 per ICU per day. The correlation between the NEMS and NAS could only be separately determined for each ICU. The correlation was r = 0.16–0.40 [significant at the 0.01 level (2-tailed)] per unit. Depending on which unit was investigated, each nurse was observed to perform of capacity with a NAS as high as 75–90%.

Conclusion

The study suggests that the actual numbers of nurses might explain the calculated NAS of 75–90% per nurse.     

不同量表在测量ICU护理工作量中的应用

目的 了解应用护理活动评估量表(nursing activities score,NAS)和治疗干预评分系统28版(simplified therapeutic intervention scoring system,TISS-28)测量ICU护理工作量情况,分析两种量表间的一致性.方法 选择在自贡市两所医院ICU住院治疗的305例患者,同时应用TISS-28量表和NAS量表测量ICU护理工作量,分析两种量表间的一致性及测算两所医院ICU护患比.结果 两所医院应用TISS-28量表和NAS量表测量ICU的护理工作量比较,r=0.808,P＜0.001;r=0.925,P＜0.001,两种量表具有一定的相关性.其所测得两所医院的护患比比较,均P＞ 0.05,差异无统计学意义.结论 TISS-28量表和NAS量表内在一致性较好,具有简单、快速、有效的优势,可选择任何一种量表测量ICU护理工作量,为ICU护理人力资源的有效管理提供数据支持.     

运用两种评分法对神经内科ICU急性期患者护理工作量的研究

目的通过两种评分方法评价神经内科重症患者的护理工作量。方法根据重症监护护理评分系统修订量表的内容与计时法,对入住神经内科ICU急性期的25例患者进行护理工作量和护理时间的评价。结果神经内科ICU患者不同班次的护理工作量差异具有统计学意义(P0.01);机械通气与非机械通气患者护理评分差异无统计学意义(P0.05),而每例患者护理所消耗的时间差异具有统计学意义(P0.01)。结论重症监护护理评分系统修订量表与计时法反映了神经内科不同班次、不同危重程度患者的护理工作量,为动态调配护士人力资源提供了有价值的数据支持。     

Nursing workload in intensive care units: a study using the Therapeutic Intervention Scoring System-28 (TISS-28).

The Therapeutic Intervention Scoring System-28 (TISS-28) is an instrument that has been used to measure severity of illness and nursing workload in intensive care units (ICUs). OBJECTIVES: To characterize the severity of illness and nursing workload using the TISS-28 in 11 ICUs of a university hospital in the city of S?o Paulo, Brazil. METHODS: In a prospective study, data were collected from 271 patients admitted to the ICUs in December 2000 and the patients were followed up for 1 week. RESULTS AND CONCLUSIONS: Most of the patients were males (60.0%) and their mean age was 51(+20.6) years. Surgical treatment (66.8%) and admissions from the operating room were predominant. The mortality rate was 25.0% and the average length of stay was 7.7 (+10.4) days. The mean TISS-28 score was 23 (range: 14-32 points). The lowest mean score was observed for patients from the Burn ICU and the highest mean score was obtained for patients from the Liver Transplant ICU. A change in TISS-28 scores was observed in the same ICU over the 7-day study period. Units differed in terms of severity of illness and nursing workload. Patients who died received a higher TISS-28 score than patients who survived (p=0.00). As the nursing staff are the largest economic investment in an ICU, so measuring nursing workload in different ICUs from different centres can contribute to the estimation of nursing staff required according to the specific demands of the units.     

Number of nurses and adverse events: the results of a study

. Number of nurses and adverse events: the results of a study. Introduction. Adverse events may be related to an higher workload and a lower nurse staffing level compared to patients needs. Objective. To assess the association between adverse events and lower nurse staffing level compared to patients workload, measured with the Nursing Activity Score (NAS). Method. The daily workload of patients admitted to the Intensive Care Unit of San Gerardo Hospital (Monza) from December 15, 2009 to May 9, 2010 was measured with the NAS. The scores were correlated with the number of nurses on shift over 24 hours, the bed occupancy rate and the adverse events occurred. Results. Out of a population of 240 patients for a follow-up period of 145 days, 45 adverse events were observed. In the days with events the difference between ideal and actual nurses requirement amounted to -7.68% (±8.84). On days without events, the difference was 0.44% (±7.96) (p value 0.0001). In the days with events patients received less minutes of care than needed -110.66 (±127), and on days without events an excess of minutes of care 6.40 (±115) minutes /patient. The average NAS score of patients with events was 81.88 (±10.00); 73.54 (±13.83) of those without events (p=0.001). Conclusions. In the period observed adverse events occurred mainly when the difference between patients workload according to NAS and minutes of care provided by nurses on shift was higher.     

Nursing workload and patient-focused outcomes in intensive care: A systematic review

The aim of this systematic review was to examine the association of nursing workload on patient outcomes in intensive care units. The primary outcome measure was patient mortality, with adverse events (AE), the secondary outcome measures. Electronic search of databases including MEDLINE, CINAHL, Cochrane, EMCARE, Scopus, and Web of Science were performed. Studies were excluded if they were in non-ICU settings, pediatric, neonatal populations, or if the abstract/full text was unavailable. Risk of bias was assessed by the ROBINS-I tool. After screening 4129 articles, 32 studies were identified as meeting inclusion criteria. The majority of included studies were assessed as having a moderate risk of bias. The nursing activities score (NAS) was the most frequently used tool to assess nursing workload. Our systematic review identified that higher nursing workload was associated with patient-focused outcomes, including increased mortality and AE in the intensive care setting. The varied approaches of measuring and reporting nursing workload make it difficult to translate the findings of the impact of nursing workload on patient outcomes in intensive care settings.     

Risk factors for prolonged stay in cardiac surgery intensive care units

Aims and objectives: To identify the factors that might affect the length of stay in the intensive care unit (ICU‐LOS) among cardiac surgery patients. Background: ICU‐LOS forms an important factor for assessing the effectiveness of the provided nursing care. A number of factors can be accused for increasing patient hospitalization. The nursing workload (NWL), among others, was found to play a significant role as it is closely associated with the quality of care. Design: An observational cohort study among 313 consecutive patients who were admitted to the cardiac surgery intensive care unit of a general, tertiary hospital of Athens, Greece from November 2008 to November 2009. Methods: Data collection was performed by using a short questionnaire (for basic demographic information) and two instruments, the Nursing Activities Score (NAS) and the logistic EuroSCORE, for assessing the NWL and the perioperative risk for each patient respectively. Results: ICU‐LOS of more than 2 days increased with age and was more common among females (p < 0·001 and p = 0·02, respectively). Multivariate logistic regression analysis revealed a positive association between increased perioperative risk and the increased ICU‐LOS [odd ratio (OR) 1·9, 95% confidence interval (CI) 1·0–3·5, p = 0·04], while patients with a first day NAS of more than 61·6% had an almost 5·2 times greater probability to stay in the cardiac surgery unit for more than 2 days (OR 5·2, 95% CI 3·0–8·8, p < 0·001). Conclusions: Increased level of NWL and patient perioperative risk are closely associated with increased ICU‐LOS. Relevance to clinical practice: The correlation between patient perioperative risk and ICU‐LOS encourages the early identification of high‐risk patients for prolonged hospitalization. Furthermore, the relationship between NWL and ICU‐LOS allows the early identification of these patients with the use of an independent nursing tool.     

全心舒张末期容积指数在慢性阻塞性肺疾病合并感染性休克患者中的应用价值

目的探讨全心舒张末期容积指数（global end-diastolic volume index,GEDI）指导的慢性阻塞性肺疾病（chronic obstructive pulmonary disease,COPD）合并感染性休克患者液体复苏的临床效果。 方法将苏北人民医院重症医学科2012年1月至2014年4月连续收治的71例COPD合并感染性休克的患者,按随机数字表法分为两组进行对照研究。对照组（n=37）根据严重感染/感染性休克指南制定的中心静脉压（central venous pressure,CVP）标准进行液体复苏,研究组（n=34）根据GEDI进行液体复苏,使GEDI达到800 ml/m²。观察两组患者6 h及24 h液体复苏量、去甲肾上腺素用量,24 h血乳酸清除率,72 h急性生理与慢性健康状况评分Ⅱ（acute physiology and chronic health evaluation,APACHEⅡ）和序贯脏器衰竭评分（sequential organ failure assessment,SOFA）,机械通气时间,ICU住院时间,ICU病死率,90 d存活率。 结果6 h及24 h平均液体复苏量,研究组均多于对照组（P<0.05）;6 h及24 h平均去甲肾上腺素用量,对照组均多于研究组（P<0.05）;治疗24 h后,对照组血乳酸（4.79±1.95）mmol/L,研究组（3.44±1.45） mmol/L,两组比较差异有统计学意义（t=2.59,P<0.05）,24 h血乳酸清除率对照组19.79%±8.95%,研究组48.74%±9.2%,两组比较差异有统计学意义（t=4.29,P<0.05）;72 h后APACHEⅡ评分、SOFA评分：对照组均高于研究组（P<0.05）;平均机械通气时间对照组（101.22±44.77） h,研究组（74.71±20.25） h （t=2.234,P<0.05）;ICU住院时间对照组（11.3±2.1）d,研究组（7.4±1.9） d（P<0.05）。在ICU治疗过程中,对照组有10例患者死亡（病死率27.0%）,研究组有7例患者死亡（病死率20.6%）,两组患者病死率无统计学意义（χ²=0.03,P>0.05）;两组患者90 d存活率比较无统计学意义（χ²=1.083,P>0.05）。 结论长期COPD的患者往往合并右心功能不全,CVP很难真实反映患者的容量状态,脉搏指示连续心输出量（puise indicator continuous cardiac output,PiCCO）监测的GEDI能正确指导此类患者进行液体复苏,明显降低患者升压药物的用量,改善组织缺氧状态,减少患者机械通气时间以及ICU住院时间,具有较好的临床应用意义。     

Consequences of medical errors in intensive and semi-intensive care units

This report was aimed at characterizing medication errors and evaluating their consequences for the patients' conditions and for the nursing workload in the Intensive Care Units (ICU) and Semi-Intensive Care Units (SICU) of two hospitals in the city of S?o Paulo. The sample was 50 patients, and data was gathered in record logs. The severity of the conditions and the nursing workload were assessed before and after the occurrence. Out of a total of 52 medication errors, 12 (23.80%), were non-administration of dosage, 11 (21.15%) were wrong medication, and 9 (17.31%) excessive dosage. There were no changes in patient conditions (p=0.316), but the nursing workload increased (p=0.009). As for the medication group, i.e, potentially dangerous or non-dangerous, there were no statistically significant differences either in the severity of the patients (p=0.456) or in the nursing workload (p=0.264) after the occurrence.     

Comparison of nurse workload approaches

beswick s. , hill p.d. & anderson m.a. (2010) Journal of Nursing Management 18, 592–598
Comparison of nurse workload approaches Background For hospitals in the United States, the number of patients who lie in beds at midnight is considered to be the standard indicator of nursing workload; relatively little attention is given to the total number of patients cared for in a 24-hour day. Staffing decisions are related to cost of care. Such decisions are made on a per-shift basis, calculating hours per patient day (HPPD) based upon midnight census provides little decision-making support about variable staffing needs over a 24-hour period. The discrepancy between nurse managers’ staffing based on real-time patient needs and financial analysts looking only at units of service captured at midnight clearly speaks to the need for a new metric of measurement. Objective To describe the variations in nursing workload across two medical units using a comparison of intra-day census recommendations for staffing and those projected based on the midnight census alone. Methods Data were retrieved from a primary data set that included: (1) the number of patients lying in beds at four different times during a 24-hour period: 06.00, 14.00, 22.00 hours and at midnight; (2) projected nursing hours needed based on the numbers of patients lying in beds at different times during the 24-hour period; and (3) the number of projected nursing hours needed for the numbers of patients lying in bed and those who were admitted and discharged in an 8-hour period of time. Results Statistically significant increases in 06.00 hour patient counts were found with statistically lower patient counts at both 14.00 and 22.00 hours compared with the midnight census alone. Nursing hour projections per day did not show any significance when projected based on intra day vs. midnight census alone. Statistically significant increases in nursing hour projections were seen on all three shifts when admissions and discharges and the nursing workload associated with those procedures were calculated. Conclusions Findings suggest that the midnight census alone may well not be the most precise measure to predict nursing workload or to cost out nursing care. To accurately capture the realities of a 24-hour nursing workload, the nursing work associated with patient admissions and discharges has to be a part of the equation. Implications for nursing management The tradition of using the midnight census to budget 24 hours of nursing services in the hospital setting does not capture the totality of nursing workload. A model that costs out direct nursing care in the hospital and ultimately bills separately for that care is needed to reflect the realities of hospital nursing workload.     

Patient severity as an indicator of nursing workload in the intensive care unit

The importance of measuring nursing workload in the intensive care unit (ICU) has been supported by both an increasing demand for nursing personnel and the relationship of nursing workload with patient safety. According to previous studies, the correlation between clinical severity of ICU patients and nursing workload measured by Therapeutic Intervention Scoring System has been estimated to be particularly high. The aim of this study was to investigate whether clinical severity of ICU patients can be used for the prediction of nursing workload on a daily basis. All patients admitted in the ICU of the General University Hospital of Patras for a 5-month period were enrolled in the study. Projet de Recherche en Nursing (PRN) Réa and Acute Physiology and Chronic Health Evaluation (APACHE) II scores of patients were calculated, the first on a daily basis and the second on the day of admission. Simple linear regression was used for statistical analysis of data. One hundred thirty-eight patients were studied. A progressive increase in mean daily PRN Réa of patients all along the amplitude of APACHE II values was shown. APACHE II could predict 25.6% (p < 0.01) of the daily variability of PRN Réa of patients. Regarding categories of PRN Réa, respiration, communication, diagnostic methods and treatments were significantly predicted by APACHE II. APACHE II explained higher proportions of PRN Réa in medical male patients aged >60 years. Clinical severity of the ICU patients measured by APACHE II is an important early indicator of daily nursing workload, especially of care demands associated with respiration, diagnostic methods and treatments.