Effects of interprofessional practice on nursing workload in hospitals: A systematic review.

OBJECTIVE: To synthesise scientific evidence on interprofessional practice in hospital care and the effects on nursing workload. METHODS: Systematic mixed method review, registered in PROSPERO (CRD42021225627) and conducted in the following databases: CINAHL, Medline, Web of Science and Scopus, with no restrictions on the publication period of the studies. Primary studies were recruited on nurses' interprofessional practice (actions and interactions with other professional categories) in hospitals and the effects on one or more dimensions of nursing workload (quantitative, qualitative, physical, cognitive, emotional, time and variation). Scientific articles available in open access, in English, Spanish or Portuguese, were included. The searches were carried out in January 2021. The studies were evaluated by pairs of independent researchers to verify methodological quality, through the Mixed Method Appraisal Tool, and data extraction. To summarise the studies, thematic analysis was adopted. RESULTS: A total of 1774 publications were assessed for eligibility and 17 studies were included. Of these, two were mixed methods, four were qualitative, and 11 were quantitative, published between 2011 and 2020. The main scenarios investigated were Intensive Care Units and/or Inpatient Units. During data analysis, three thematic categories emerged: Interprofessional practice in coping with emotional overload; Time dedicated by nurses to professional communication; and Working conditions and patient care. The third category consisted of three subthemes: Conflict and flexibility in the context of practice; Working conditions and interprofessional practice; and Effects on patient care. CONCLUSIONS: The evidence points to the emotional overload of nurses in the face of uncooperative practices. Interprofessional actions, especially communicative ones, demand nurses' time and impact the care provided. The results contribute to political decisions and health work management.

Interruptions and their effects on the dynamics of the nursing work. / Interrupções e seus efeitos sobre a dinâmica de trabalho do enfermeiro.

OBJECTIVES: To investigate the nurses' perception about interruptions during the workflow and their implications on the professional practice environment. METHODS: A survey was conducted with 133 nurses in a school hospital in the state of São Paulo from October 2015 to March 2016, through the use of a self-administered questionnaire. For data analysis, Chi-square and Fischer tests have been used. RESULTS: Most of the nurses have reported frequent and recurring interruptions during their work activities. The interruptive processes are more frequent during the documentation process (n=118; 91.5%) and guidance to the patient/family (n=58; 45%). They are caused by the ringing of the phone (n=114; 87%), and by problem solving in the unit (n=107; 81.7%). CONCLUSIONS: According to the nurses' opinion, the interruptive processes have repercussions on the working dynamics, on the caring process and on the patient's safety.

[Cost of nursing turnover in a Teaching Hospital]. / Custo da rotatividade da equipe de enfermagem em hospital de ensino.

OBJECTIVE: To map the sub processes related to turnover of nursing staff and to investigate and measure the nursing turnover cost. METHOD: This is a descriptive-exploratory study, classified as case study, conducted in a teaching hospital in the southeastern, Brazil, in the period from May to November 2013. The population was composed by the nursing staff, using Nursing Turnover Cost Calculation Methodology. RESULTS: The total cost of turnover was R$314.605,62, and ranged from R$2.221,42 to R$3.073,23 per employee. The costs of pre-hire totaled R$101.004,60 (32,1%), and the hiring process consumed R$92.743,60 (91.8%) The costs of post-hire totaled R$213.601,02 (67,9%), for the sub process decreased productivity, R$199.982,40 (93.6%). CONCLUSION: The study identified the importance of managing the cost of staff turnover and the financial impact of the cost of the employee termination, which represented three times the average salary of the nursing staff.

[Identification of care needs of patients with and without the use of a classification instrument]. / Identificação de necesseidades de cuidados dos pacientes com e sem uso de instrument de classificação.

OBJECTIVE: To analyze the agreement and disagreement between the assessments by applying or not a patient classification instrument, and to investigate the association between the agreement and personal and professional characteristics of the evaluators. METHOD: This is a descriptive exploratory study. 105 patients were hospitalized in a teaching hospital in the state of Sao Paulo, using the kappa statistic (weighted) and the Bootstrap method. RESULTS: The agreement between the assessments were​​: k(w) 0.87 (instrument x internal evaluator), k(w) 0.78 (instrument x external evaluator) and k(w) 0.76 (between evaluators) and the influence of some personal and professional characteristics. The assessments conducted through the use of an instrument contemplated a greater number of areas of care in relation to when the instrument was not applied. CONCLUSION: The use of this instrument is recommended in order to more effectively identify care needs of patients.

[Use of patients' classification instruments: analysis of the brazilian production of knowledge]. / Utilização de instrumentos de cassificação de pacientes: análise da produção do conhecimento brasileira.

OBJECTIVE: To analyze the production of scientific knowledge about the use of patients' classification instruments in care and management practice in Brazil. METHOD: Integrative literature review with databases search in: Latin American and Caribbean Literature on Health Sciences (LILACS), Medical Literature Analysis and Retrieval System on-line (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and SCOPUS, between January 2002 through December 2013. RESULTS: 1,194 studies were found, 31 met the inclusion criteria. We observed a higher number of studies in the category care plans and workload (n=15), followed by the category evaluation of psychometric properties (n=14). CONCLUSION: Brazilian knowledge production has not yet investigated some purposes of using instruments for classifying patients in professional nursing practice. The identification of unexplored areas can guide future research on the topic.


Measurement of nurses' workload in an oncology outpatient clinic.

The growing demand and the degree of patient care in oncological outpatient services, as well as the complexity of treatment have had an impact on the workload of nurses. This study aimed at measuring the workload and productivity of nurses in an oncological outpatient service. An observational study using a work sampling technique was conducted and included seven nurses working in an oncological outpatient service in the south-eastern region of Brazil. A total of 1,487 intervention or activity samples were obtained. Nurses used 43.2% of their time on indirect care, 33.2% on direct care, 11.6% on associated activities, and 12% on personal activities. Their mean productivity was 88.0%. The findings showed that nurses in this service spend most of their time in indirect care activities. Moreover, the productivity index in this study was above that recommended in the literature.

Repercussions of moving patients on the context of practice: perspectives of the nursing team.

OBJECTIVE: to examine the nursing team's view of the repercussions of moving patients (admissions, transfers and discharges) on the organization of work and the delivery of care. METHOD: this is a qualitative study using the focus group technique, conducted with 23 professionals - 12 nurses, eight nurse technicians and three nurse assistants working in three inpatient units at a teaching hospital in the countryside of Sao Paulo. Four meetings took place between November 2021 and March 2022. The reports were analyzed thematically using MAXQDA software. RESULTS: two thematic categories emerged: the influence of structural factors and work organization on the intra-hospital moving of patients; it demands time, generates work overload and interferes with the delivery of care. CONCLUSION: the volume of moving patient associated with unforeseen demands, care complexity and insufficient staff and resources have a negative impact on the delivery of care, with clinical risks and work overload. The findings make it possible to improve the regulation of patients entering and leaving the units, work organization and care management, avoiding clinical risks, delays, omissions and work overload. BACKGROUND: (1) Moving patients around the hospital requires structure and work organization. BACKGROUND: (2) Nursing estimates dedicating 10-15 minutes to 2-3 hours of work on these interventions. BACKGROUND: (3) Frequency, unpredictability and complexity of care have a negative impact on care. BACKGROUND: (4) Unfavorable conditions for moving generate care and occupational risks.

The new version of a patient classification instrument: assessment of psychometric properties.

AIMS: This paper assessed the reliability and construct validity of the new version of a patient classification instrument. BACKGROUND: In the development of patient classification instruments, monitoring validity and reliability is essential to assure that patient care requirements and nursing staff workload are appropriately measured. DESIGN METHOD: The sample included 194 patients (construct validity test) and 60 patients (inter-rater reliability test) at medical, surgical, and specialized wards of a teaching hospital in the south east of Brazil. The study was conducted in 2009-2010. For analysis purposes, Spearman's correlation and Cronbach's alpha (internal consistency) were used, and weighted kappa (inter-rater reliability), factor analysis with principal axis factoring extraction method (construct validity) and ordinal regression (instrument's predictive ability). RESULTS: A high level of inter-rater agreement was found. The importance of all care areas and their contribution to distinguish patient care needs and category in the new instrument were demonstrated. Results also showed the instrument's high predictive ability (99·6%). CONCLUSION: The findings give the evidence that the new scale is a reliable and valid tool to assess patient care needs and care category and that it can be used to guide nursing management practice in determining the nursing staff workload.

Interprofessional actions in responsible discharge: contributions to transition and continuity of care.

OBJECTIVE: To analyze the interprofessional team's perception of the actions carried out by means of responsible hospital discharge, and their contribution to improving the transition and continuity of patient care. METHODS: A qualitative study was carried out in two hospitalization units, in October - November 2020, interviewing health professionals from a teaching hospital in the state of São Paulo. The reports were transcribed and subjected to thematic content analysis. RESULTS: Twelve professionals participated (doctor, nurse, physiotherapist, nutritionist, speech therapist and social worker) and three thematic categories emerged from the interviews: 1. informational continuity in responsible discharge; 2. interaction between professionals and services for the transition of care; and 3. workload management for better transition and continuity of care. CONCLUSION: The team recognized interprofessional advances and challenges in responsible discharge related to the informational and relational continuity of patient care and highlighted the (over)workload as an unfavorable aspect in the transition process, generating impacts for patients, professionals and health services.

Responsible hospital discharge: content validation of nurse's activities.

OBJECTIVE: To develop and validate a list of activities to be performed by the nurse at the responsible hospital discharge. METHOD: Content validation study. The 14 generated items were organized on a Likert scale and submitted to judges' appreciation, using the Delphi Technique. Relevance, explicitness in the statements and the sequential order of execution were evaluated. The consensus for the answers was pre-established at 0.80 and the content validity index was calculated. RESULTS: Eight professionals participated in the validation of the created list. In Delphi 1, the content validity index ranged from 0.7 (post-discharge contact and home visit scheduling) to 1.0 and in Delphi 2, a range from 0.60 (post-discharge telephone contact) to 1.0. CONCLUSION: 13 of the 14 proposed activities were validated. The created list of activities can contribute to the safe discharge process, the continuity and comprehensiveness of care and, also, to the reduction of readmissions.

Transfer of patients in hospital units: impacts on nursing workload.

OBJECTIVE: To measure the average time spent by the nursing team in transferring patients; to compare the activities observed during the performance of this intervention with those described by the Nursing Interventions Classification and to investigate the intensity of its influence on the workload. METHOD: Observational study using timekeeping software conducted in two hospitals in the northwest region of the State of São Paulo. 200 patient transfers were monitored by the team using two validated instruments. RESULTS: The average time spent by nurses on transfers ranged from 9.3 (standard deviation = 3.5) to 12.2 (standard deviation = 2.5) minutes and by assistants/ technicians between 7.1 (standard deviation = 2,8) and 11.0 (standard deviation = 2.2) minutes. 63 transfers made by nurses and 87 by assistants/technicians were considered qualified (>70% of the score). The team expended 19.3 to 29% of the working day time in this intervention. CONCLUSION: The transfer of patients has an impact on the workload of the team and needs to be considered in the measurement of nursing activities for the calculation and distribution of personnel to improve the quality and continuity of care.

Hospital - primary care articulation in care transition: both sides of the process.

OBJECTIVE: To analyze how the articulation between hospital and primary health care related to patient discharge and continuity of care after hospitalization takes place. METHOD: Qualitative study, using the focus group technique to explore the experience of 21 nurses in hospitals (n = 10) and at primary care (n = 11) in a municipality in the northwest area of the State of São Paulo. Data collection took place between December 2019 and April 2020. Four focus groups were carried out (two in the hospital and two in the health units) and the findings underwent thematic analysis. RESULTS: The categories identified were: Patient inclusion flow in the responsible discharge planning, Patient/family member/caregiver participation, Care planning, Communication between services, and Challenges in the discharge process. According to reports, the discharge process is centered on bureaucratic aspects with gaps in communication and coordination of care. CONCLUSION: This research allowed understanding how nurses from different points of health care experience the discharge and (dis)articulation of the team work. The findings can equip managers in the (re)agreement of practices and integration of services to promote continuity of care.

Restructuring the nursing staff and its influence on care hours.

This descriptive study aimed to calculate and compare the nursing staff at the medical-surgical clinical units of a philanthropic hospital in current and projected situations, and to investigate how much time the nursing team delivers patient care in the current and projected situations. Gaidzinski's method was used to calculate the nursing staff, and the equation proposed by the Hospital Quality Commitment (HQC) to estimate care hours. The findings showed an increase of 33% in the staff, with a 68.4% increase in the number of nurses and 15.6% in the number of technicians / nursing auxiliaries. According to the projected situation, the care hours varied from 5.7 to 7.2. The number of nursing and the mean care time provided to the patients were inadequate according to the clientele's care needs. This could impair the quality of care.

[Monitoring performance indicators regarding the length of care by the nursing team]. / Monitorando indicadores de desempenho relacionados ao tempo de assistência da equipe de enfermagem.

The objectives of the present study were to: characterize medical-surgical clinic units of a philanthropic hospital and the nursing team performing in these units; identify the clientele's care profile, investigate the time length of care provided to the patients by the nursing team. Data were collected from documents of Personnel and Nursing Departments and the application of the classification instrument of patients. To calculate the care hours; the equation proposed by the Hospital Commitment Quality (HCQ) was used. The findings showed relationship of 1:1 nursing professional/bedside and variation from 0.10 to 0.21 nursing/bedside. The patients needed, mainly, minimum (47.1% to 79.6%) and intermediate (17.7% to 38.6%) care, and the average time spent by the nursing team ranged from 4.1 to 5.1 hours. The values showed that the care hours provided by the nursing team were not enough to assist to the patients' care complexity.

Impact of interruptions on the duration of nursing interventions: A study in a chemotherapy unit.

OBJECTIVE: To investigate interruptions during nursing interventions in a chemotherapy unit (sources and causes); measure their frequency, duration and the total elapsed time to complete the interventions. METHOD: This is an observational analytical study performed using a digital stopwatch. It was conducted in a teaching hospital between 2015/2016. The interventions performed and their interruptions were mapped and classified according to the Nursing Interventions Classifications (NIC) taxonomy. RESULTS: There were 492 interruptions recorded in the 107 hours observed, especially in indirect care interventions. They were mainly caused by nursing professionals (n = 289; 57.3%) to supply materials (n = 65; 12.8%) and exchange care information (n = 65; 12.8%). The duration of interruptions ranged from 0:08 to 9:09 (average 1:15; SD 1:03) minutes. On average, interventions took 2:16 (SD 0:27) minutes to complete without interruption; however, the average was 5:59 (SD 3:01) minutes when interrupted. CONCLUSION: The interruptions were constant during the nursing work in the chemotherapy unit, including during the preparation and administration of medications, and increased the time to complete the interventions by an average of 163.9%.

Approaches to workload in psychiatric and mental health nursing.

OBJECTIVE: to investigate approaches to workload in psychiatric and mental health nursing in Brazilian and international production of knowledge Methods: integrative literature review using six databases, covering January 2005 to March 2019. Articles in full in English, Spanish and Portuguese were included. RESULTS: the sample consisted of 23 original articles classified as quantitative or emotional. The quantitative dimension was addressed in 12 articles and included: assessing patient care needs, identifying activities performed by the team, measuring time spent and developing and validating a measurement instrument. The emotional dimension included 11 articles the focus of which was on identifying stressors in the workplace, psychosocial risks and coping strategies. CONCLUSION: strategies were found for measuring workload and assessing the impact of stressors on nursing teams.

Time and quality of admissions: nursing workload.

OBJECTIVES: to measure the average time spent by the nursing staff during patient admission and investigate their compliance with the activities described by the Nursing Interventions Classification; evaluate the degree of interference in the workload of the team. METHODS: observational with time measurement through software. We followed 199 admissions made by the nursing staff in seven units, using two validated instruments. Total scores ≥ 70% and 50% validated the process. RESULTS: the average time of nurses ranged from 5.5 (standard deviation = 2.3) to 13 (standard deviation = 1.1) minutes; and the auxiliary / technician, between 4.7 (standard deviation = 2.1) and 6.8 (standard deviation = 2.0) minutes (p ≤ 0.01). We qualified six admissions made by nurses and 33 by assistants/technicians. The intervention spent 16.3% to 31.5% of the working hours of the team. CONCLUSIONS: admission impacts nursing workload and needs to be considered both in the measurement of activities and in the sizing of the nursing staff.

Variability in the complexity of patient's nursing care needs.

The aim of this descriptive-exploratory study was to investigate the variability in the complexity of patients' nursing care needs during hospitalization and to identify the care indicators that most contribute to the transition between categories. The study was carried out at clinical and surgical inpatient units of a teaching hospital in the interior of São Paulo State. We included 80 patients from hospital admission to patient discharge, applying a classification instrument proposed and validated by Perroca. In both clinical and surgical inpatient units, patients who were classified into the minimal care category were predominant, 73% and 46%, respectively. Most of the clinical patients remained in the care category identified upon admission, while the surgical patients varied among the care categories, mainly in the post-operative period. Personal hygiene, locomotion and skin integrity were the most involved care indicators in the transition between care categories. The findings can support management decisions.

The qualitative dimension of Nursing workload: a measurement proposal.

OBJECTIVE: construct and test a proposal to measure the qualitative dimension of nursing workload; identify the workload cut-off point and its indicator as predictors of the good and optimal nursing care product score. METHOD: this is a descriptive study conducted in four inpatient units and four intensive care units of a Brazilian teaching hospital, considering 308 evaluations performed by 19 nurses. Four measurement instruments were used: three to assess the care demand in relation to nursing and the other to classify the care product delivered at the end of the shift. The workload was calculated and its indicator was constructed. RESULTS: a weak and inverse correlation was found between the care product score, workload and the workload indicator and the workload indicator in the units and moderate and inverse between Nursing care planning and Care needs assistance with the number of hospitalized patients. CONCLUSION: it is possible to associate workload and its indicator with the care product. Nursing workload ≤ 173 hours (24 hours) and indicator ≤ 12.3 hours / professional were associated with a higher probability of obtaining a "good" and "optimal" score in the care product in the inpatient units.

Interruptions and nursing workload during medication administration process.

OBJECTIVE: To investigate the sources and causes of interruptions during the medication administration process performed by a nursing team and measure its frequency, duration and impact on the team's workload. MÉTODOS: This is an observational study that timed 121 medication rounds (preparation, administration and documentation) performed by 15 nurses and nine nursing technicians in a Neonatal Intensive Care Unit in the countryside of the state of São Paulo. RESULTADOS: 63 (52.1%) interruptions were observed. In each round, the number of interruptions that happened ranged from 1-7, for 127 in total; these occurred mainly during the preparation phase, 97 (76.4%). The main interruption sources were: nursing staff - 48 (37.8%) - and self-interruptions - 29 (22.8%). The main causes were: information exchanges - 54 (42.5%) - and parallel conversations - 28 (22%). The increase in the mean time ranged from 53.7 to 64.3% (preparation) and from 18.3 to 19.2% (administration) - p≤0.05. CONCLUSÃO: Interruptions in the medication process are frequent, interfere in the workload of the nursing team and may reflect on the safety of care.