Keywords

1 Introduction

Nursing workload (patient care commitment) is a relevant part of the nursing care routine, significantly affecting the quality of care and the goals of nursing care plans. As a term, “nursing workload” (NW) has often been used in scientific literature, but frequently without a real reference background [1]. Many authors throughout the years have suggested possible definitions, according to development of the nursing professional’s role and nursing theoretical principles. In the past, NW concept was just patient-related tasks (nursing care and bedside activities) in connection with the time spent to carry out these activities. Recently, the same NW concept has been reviewed including the time spent by nurses to perform non-patient-related tasks (or bedside cares) such as continuing educations, clinical updates, and management processes [2]. Several authors have outlined that NW concept is not merely based on the physical efforts to perform nursing care, but as a comprehensive part of high-dependency patient care, it should consider the reflection process, urging time of maneuvers, and the related emotional involvement [3].

Lately also nursing managers and researchers have shown interest about new potential ways to define and measure NW concept. Researchers have investigated the relationship between clinical data and the events in order to improve quality and safety; on the other hand, nurse management is motivated and focused to find out tools and strategies able to promote the best use of nurse staff resources.

Most of the time, the existing relationship between financial budget cost, limited resources, and clinical/staff achievements has been analyzed by scientific literature. It is well recognized that there is a direct relation between patient’s outcomes and nursing staff levels: (understaffing with) high level of NW score produces an increase of mortality rate [4, 5], potential complications, and adverse events [6, 7]. From a nursing staff perspective, it could lead to potential job decline due to frustration or professional burnout phenomenon [4, 8, 9].

However, it is crucial to bear in mind that nursing staff represents the largest amount of professionals inside hospitals, and from a personnel-budget point of view, it remains one of the main cost items [2]. So, planning and matching the right amount of nurse staffing is a key point to provide the best cost-effective quality and safety of care.

Introducing tools to measure the NW can help in supporting the decision-making process with the latest evidence available, thus getting the best resources’ efficiency. Nevertheless, understanding and evaluating the NW concept appears to be complex and difficult [10].

Patient-specific nursing care, severity of illness, complexity of techniques, and the wide range of fields where nursing care is provided show only a part of the issues involved in the NW’s evaluating process. Several methods and tools have been developed according to specific features and approaches related to specific fields of work.

In the critical care setting, it is essential to evaluate the intensity of care, in order to provide adequate levels of care for high-dependency patients and to justify the high costs of human and technological investments. Since the early 1970s, inside ICUs, tools and procedures were tested and improved according to the evolution of clinical, technological, and organizational dimensions and the evolving nursing role. The new contest of limited financial resources for health-care providers requires to correctly estimate the right amount of nursing staff through correct tools.

When comparing all the available options in literature, the nursing activities score (NAS) seems to be the most useful tool across European ICUs [11,12,13,14,15] and worldwide [16].

2 Nursing Activities Score (NAS)

NAS [1] was developed on a basic principle: nursing care is not defined only by the gravity of illness and therapeutic procedures. This tool was realized from the basics of TISS 28 score [17]. Compared to TISS 28, NAS’ authors have pointed out the real-time evaluation of this tool, expression of the time taken to administer ICU’s patient care. NAS’ score is made up of 13 main areas (parts), split into 23 items (Table 18.1), able to describe patient-related and non-patient-related works, administrative tasks, and level of patient’s dependency as well. The resulting score, worked out by percentage, represents the total amount of time required to deliver nursing care. A NAS score of 100% corresponds to one nurse dedicated to a single patient over 24 h (nurse-to-patient ratio 1:1 equal to 1440 min of nursing care). The NAS average value for an ICU will determine the level of workload of the nursing staff.

Table 18.1 Nursing activities score: interventions and attributed weights
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This validation study involved 15 countries, 99 ICUs from Europe, the North American region, and Australia. In the first stage, a survey was submitted to ICU nurses and doctors, to find out what kind of items should have been considered; after this step, a wide validation process was performed. Research was focused on two main targets: to evaluate the relationship between TISS-28 and NAS and to analyze the way of employ of nursing care timing in the ICU setting (comparison of each item versus total score). The time spent to deliver nursing care was investigated by a registration method and then classified depending on (1) the amount of time to deliver patient-related care; (2) non-patient-related activities, e.g., management tasks; (3) supporting the staff’s requirements; and (4) every kind of activity not previously mentioned.

According to point (1), collection of data has shown as follows: using 6.451 data that were collected (2041 patients recruited), the average TISS-28 value was 26.9 (SD ± 9.9), with median value (the middle of the distribution) of 27, whereas mean NAS value was 56 (SD ±17.5), with median value of 54. The correlation TISS-28-NAS was 0.56 (r = 0.56–p < 0.001).

With reference to point (2), results have shown as follows: the tool’s reliability to describe/define NW was 81% of the total amount of time spent to deliver nursing care, while the 11% of it was referred to non-patient-care-related activities, 6% was referred to personal activities, and only 2% wasn’t recognized by the aforementioned categories.

A literature review [18] outlined that NAS score has been investigated on different levels of dependency (ITU, HDU) and different fields (adult, pediatric, neonatal), despite the tool being tailored for adults only. So far, the use of NAS in ICU for its accuracy is supported by scientific literature [14, 19]. In the last decade, NAS became the first choice to evaluate and analyze NW inside ICUs; however, Goncalves et al. outlined several limitations due to potential misinterpretations of the items [20]. Table 18.2 summarizes the results concerning the mean values of NAS in the studies of the past 10 years.

Table 18.2 Key studies on nursing workload
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3 Determining Factors in ICU Nursing Workload

Available studies evaluated the possible determinants of the NW in the ICU. The main factors can be summarized as follows:

  • Sociodemographic characteristics

  • Clinical features

  • Therapeutic treatments

  • Clinical trials

Tables 18.3 and 18.4 summarize the impact of these factors on the NW.

Table 18.3 Sociodemographic characteristics and nursing workloads
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Table 18.4 Determinants of nursing workload in ICU, quantitative studies
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4 ESICM (European Society of Intensive Care Medicine) Recommendations on Basic Nursing Requirements for ICU Units [34]

4.1 Head Nurse

The nursing staff is managed by a dedicated, full-time head nurse, who is responsible for the functioning and quality of the nursing care. The head nurse should have extensive experience in intensive care nursing and should be supported by at least one deputy head nurse able to replace him (her). The head nurse should ensure the continuing education of the nursing staff. Head nurses and deputy head nurses should not normally be expected to participate in routine nursing activities. The head nurse works in collaboration with the medical director, and together they provide policies and protocols and directives and support to the team.

4.2 Nurses

Intensive care nurses are registered nursing personnel, formally trained in intensive care medicine and emergency medicine. A specific program should be available to assure a minimum of competencies among the nursing staff. An experienced nurse (head nurse or a dedicated nurse) is in charge of education and evaluation of the competencies of the nurses. In the near future, a specific curriculum for ICU nurses should be available. In addition to clinical expertise, some nurses may develop specific skills (e.g., human resource management, equipment, research, teaching new nurses) and assume the responsibility for this aspect of unit management. Staff meetings together with physicians, nurses, and AHCP must be regularly organized in order to carry out the following [34,35,35]:

  • Discuss difficult cases and address ethical issues.

  • Present new equipment.

  • Discuss protocols.

  • Share information and discuss organization of the ICU.

  • Provide continuous education.

The number of intensive care nurses necessary to provide appropriate care and observation is calculated according to the levels of care (LOCs) in the ICU.

4.3 Levels of Care (LOCs) [38,39,40,41]

4.3.1 Level of Care III (Highest)

LOC III represents patients with multiple (two or more) acute vital organ failure of an immediate life-threatening character. These patients depend on pharmacological as well as device-related organ support such as hemodynamic support, respiratory assistance, or renal replacement therapy.

4.3.2 Level of Care II

LOC II represents patients requiring monitoring and pharmacological and/or device-related support (e.g., hemodynamic support, respiratory assistance, renal replacement therapy) of only one acutely failing vital organ system with a life-threatening character.

4.3.3 Level of Care I (Lowest)

LOC I patients experience signs of organ dysfunction necessitating continuous monitoring and minor pharmacological or device-related support. These patients are at risk of developing one or more acute organ failures. This category includes patients recovering from one or more acute vital organ failures but whose condition is too unstable or when the nursing workload is too high/complex to be managed on a regular ward (Tables 18.3–18.5).

Table 18.5 Nursing workload and clinical pathways
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Table 18.6 LOC and suggested nurse-to-patient ratio
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For these different LOCs, the following minimum nurse-to-patient ratios are considered to be appropriate (table 18.6) [34]:

5 Conclusions

The endless improvements of hospital strategies in order to provide the highest cost-effective quality of care in the intensive care setting justify the use of evaluating tools for NW supporting the management in the allotment process of limited resources. The aim of this literature’s review was to identify the available tools and describe the key factors of NW concept.

The NAS appears to be a precise tool for this task according to several studies [14, 19], although others [16, 23] have underpinned limitations related to misinterpretations of several items that affect feasibility and reliability to describe nursing work inside ICUs.

Data available from the last 6 years have pointed out a lack of knowledge about the intensity of nursing workload. Crucial factors able to affect NW are related to the severity of illness (e.g., respiratory distress), advanced therapies (e.g., ECMO support-advanced ventilatory strategies), and ICU LOS. Further investigations are needed to reinforce scientific evidence and longitudinal data analysis desirable in order to evaluate potential changes about determinant factors. Nearly 100% of this data review were performed inside ICUs; therefore, enhancing the use of NAS in different aspects of critical care fields appears as mandatory.

The regular daily use of NAS, especially for ICUs with eight or more bed spaces, is able to match the proper LOC, and then it becomes possible to match the variable nurse staffing requirements, modifying the nurse-to-patient ratio based on a proper evaluation of NW.

Take-Home Messages

  • NAS has been applied in clinical settings in various types of ICUs.

  • The NAS tool is a valuable tool, and its pervasiveness and degree of implementation worldwide indicate its relevance.

  • The analysis of the results indicates that NAS was used to test several variables that fall into the structure category (mainly age, sex, and severity of illness), but few variables are related to process.

  • With regard to outcome, the most frequently tested variables were mortality and LOS, which are not nurse-sensitive outcomes.