Analysis of the workload of nurses

Background: Nurses face many challenges due to the unclear job description and the excess and unequal nursing workload on them. The lack of fair distribution of workload among nurses negatively affect the quality of patient care and motivation level of nurses. Therefore, conducting studies to analyze the workload of nurses is very important. Objective: It was aimed to determine the workload score of each nurse in different clinics. Methods: This study was conducted retrospectively and descriptively. The retrospective data of it was collected from the files of 341 patients at the hospital in Turkey. For descriptive data, 136 nurses were applied “Socio-Demographic Form” and “A Likert Scale (1: the lightest, 9: the most severe)”. Results: In the present study, the maximum workload of a nurse was determined in the internal medicine clinics. While the most difficult nursing procedures were determined the time until the newborn is given to the mother (7.33 ± 2.25), giving O2 (2.77±2.04) were determined the lowest difficult nursing procedures. Conclusions: The results should be of interest to nursing in the areas of nursing procedure’s numeric values; and also, it may be a guide with which nurse manager may easily evaluate the workload of nurses. In addition, the importance of the record system was emphasized as well. Araştırma / Research Article


INTRODUCTION
Today, rapid developments and changes in the health services lead to the abandonment of the traditional understanding of healthcare and preferring more professional health services. In the health services managed with traditional methods, the quality of the services is not questioned and employees' mental state is ignored since the main purpose of these services is solving the problem. On the other hand, professional methods take maximum satisfaction of both patients and health personnel into account. While the traditional method does not give importance to the input and output costs, cost analyses are done by evaluating factors such as the duration and intensity of the work done by each individual in a professional method. This, in turn, requires the establishment of evidence-based and objective criteria (Turkkan, 2014).
However, nurses face many challenges due to the unclear job description and the excess and unequal nursing workload of them. In particular, the lack of fair distribution of workload among nurses negatively affect the quality of patient care and motivation level of nurses. Therefore, conducting studies to analyze the workload of nurses is very important.
In this study, which was conducted to determine the workload of nurse, answers were researched to the following questions: • What is the average degree of difficulty of the workload of a certain nursing procedure identified?
• What is the total workload score of nursing procedures presented in different clinics?
• What is the workload score of each nurse in different clinics?
In order to answer these questions, earlier studies conducted on the workload analysis of nurses in the literature were reviewed; and the general workload and the nursing workload procedures were identified; and then our study was conducted.

WORKLOAD
Although workload is a concept pointing to the density of the duties required to be completed by a certain job, it is also considered to be the source of stress. In addition, workload is considered to be as an opportunity for faster learning and development of staff (Gokkaya, 2014). The excessive workload may arise when workers are asked to fulfill too much duties in a limited time with limited resources (Ashfag et al., 2013). Similarly, Leung and Chang (2002) stated that the excessive workload arises due to the insufficient time and resources given to the workers to fulfill their duties. The workload of the worker is in association with several factors such as attention reduction, extension of the response time, failure to fulfill all the duties, stress, fatigue and reduced performance (Dagdeviren et al., 2005). Vanishre (2014), who support these results, determined that the excessive workload and uncertainties increase the stress at work.
The excessive increase in stress levels of employees in an organization undermines the physical and mental systems and increases absenteeism, the rate of making mistakes and accidents; and reduces the job satisfaction of the employees. Too much stress can reduce the efficiency of the employees and organization (Gumustekin & Oztemiz, 2005).
Excessive workload leads to unintended consequences especially in smaller organizations (Chipunza & Samuel, 2012). Furthermore, this can cause workers to become mentally distant from the work, and leads to insensitivity (Inandi & Buyukozkan, 2013). This can lead to fatigue and burnout of employees (Razak et al., 2011). However, employees will not be happy in a work environment with high stress and burnout caused by excessive workload, and they may leave their jobs since they will not be happy about their jobs, and their performance will be reduced (Celik & Cira, 2013).
As a result of the workload studies, job descriptions and job requirements should be well-defined by performing a work analysis in order to reduce the workload of the employees. After determining job descriptions and requirements, the number of employees required should be calculated and the rules should be created accordingly. Putting rules and conditions of the organization in writing, determining expectations of the employees hired and adaptation periods are the professional steps that can be used to prevent excessive workload.

WORKLOAD AND WORKLOAD ANALYSIS STUDIES IN THE NURSING PROCEDURES
In nursing, excessive workload, emotional stress, working with patients who are in need of intensive care and especially shift work make working conditions more difficult. Working in difficult conditions may increase the ratio of making mistakes by nurses (Demir Zencirci, 2010).
According to the studies conducted on shift work systems, such systems adversely affect physiological and psychological health, social life and personal safety of workers and patients (Eroglu, 2011). According to Carayon and Gurses (2008), one of the main problems of healthcare system in the world is heavy workload of the nurses working at hospitals. In addition, four main reasons of this heavy workload on nurses are stated as follows; constant increase in demand, insufficient number of nurses, decreasing the hospitalization days of the patients, reducing the number of employees and working overtime (Carayon & Gurses, 2008). The most important results caused by the heavy workload in nursing are patient safety violations and quitting the job. Therefore, one of the most critical steps is evaluating the workload in order to understand the relationship between them (Eroglu, 2011).
Studies on workload analysis regarding nurses in the world began in late 1950s. Considering the studies conducted on workload in our country, although many different models were developed in various professional groups, the number of workload analyses regarding nurses is very limited.
Considering the studies in the literature, the first workload scale was developed by Cooper and Harper [1969]. This scale was first used to assess the characteristics of an aircraft, and was then developed with a decision tree and co-dimensional 10-point scoring scale by Wierwille and Casali [1983]. This scale was used by Gomer et al. [1987] to examine the workload of an operator using keyboard, and by Hancock (1989) to examine the impact of workload on the intensity of interest (As cited, Dagdeviren et al., 2005). Keser (2006) investigated the relationship between workload levels and job satisfaction of employees working in a call center. Accordingly, it was determined that their job satisfaction was affected by the workload. Their workload was found to be high and correspondingly their job satisfaction levels were found to be low. There are various studies that are conducted to determine and analyze the workload of nurses. But, most of these studies were conducted to determine the workload of nurses working in special units, such as intensive care units, burn centers.
Yildirim and Yilmaz (2004) conducted a study in order to determine the number of scrub and circulating nurses depending on procedures performed in a private hospital. They have conducted this study in an operating room with 9 operation tables for 6 months as a cross-sectional study. As a result, they determined that 23 nurses should be on duty each day and the total number of the nurses should be 29. Avci et al.
(2013) conducted a study in order to determine the workload of nurses working at general, coronary and cardiovascular surgery intensive care units of a private hospital. As a result, it was reported that nurses spent 37% of their time on direct patient care procedures in the day shifts, whereas they spend 34% of their time on direct patient care procedures in the night shifts. On the other hand, they spent 15% of their time on duties out of their responsibility in the day shifts, and spent 19% of their time on duties out of their responsibility in the night shifts. Balanuye (2014) aimed to determine the effect of workload of nurses working at surgery clinics on patient safety. The effect of workload of nurses on patient safety is as follows: Reduced time spent for the patient, reduced precautions and fatigue due to the heavy workload, and increased risk of making mistakes caused by lack of attention. The average workload scores of responsible nurses were found to be lower than the scores of other nurses. Queeijo  Although there are different studies to determine nursing workload, no nursing workload score has been determined in any of these studies. We aimed to determine the workload of nurses in different clinics at the hospital in Turkey. In this study, both the workload score of each nursing procedures and the monthly workload score of a nurse who carries out the nursing procedures were calculated.

MATERIALS AND METHODS
This study was conducted retrospectively and descriptively in order to determine the workload analyses of nursing procedures of the state hospital in Turkey. This study received necessary ethics approval from the Ethics Board at the University where it was conducted.
This state hospital where data are retrospectively collected is located in the city center. The bed capacity of the hospital is 100, and there are 482 employees.
The inpatient departments at the hospital are internal medicine clinics, surgery clinics, gynecology and obstetrics clinic and pediatrics clinic. Internal medicine clinics consist of internal medicine, neurology, physical medicine and rehabilitation, gastroenterology, cardiology, pulmonology and psychiatry departments. Surgical clinics consist of general surgery, orthopedics and traumatology, thoracic surgery, cardiovascular surgery, neurosurgery, ophthalmology and otorhinolaryngology departments. The nursing procedures constituting the material of the study were determined by examining the nurse observation forms in files of 341 inpatients in September 2014 in the internal medicine clinics, surgery clinics, gynecology and obstetrics clinic and pediatrics clinic in the state hospital. This date chosen was used simple random sample. By using the nursing procedures in the nurse observation forms in 341 patient file, a 9-Point Likert scale (1: the lightest, 9: the most severe) was prepared to determine the degree of difficulty of the nursing procedures in which each nursing procedure took place. After clarifying the purpose of studying the 300 accessible nurses working in the city where the work was located, the socio-demographic forms and 9 Likert type scale were conducted by the approval of the 136 nurses who agreed to participate in the work between April and June 2015.
The degree of difficulty of each nursing procedure was determined by evaluating the scores given to each nursing procedure. The number of nursing procedures on the nurse observation forms in the patient files was multiplied by the degree of difficulty determined for each nursing procedure. Then, to determine the nursing workload, the total score for each clinic of all nursing procedures in the patient files was calculated; the total scores were divided into the number of nurses in these clinics in September 2014, and the number of nursing workload score per month was determined.
Between these dates, there were 14 nurses and 1 charge nurse in the internal medicine clinics, 15 nurses and 1 charge nurse in the surgery clinics, 4 nurses and 1 charge nurse in the gynecology and obstetrics clinic and 4 nurses and 1 charge nurse in the pediatrics clinic at the hospital. Charge nurses were excluded because of their managerial responsibilities while calculating the total score for each nurse.
The data of the research were assessed by using the SPSS 17.00 Statistical Software with frequency and average values.
The workload score of a nurse was calculated monthly according to the following formula (1):  The workload score per month for each nurse was found by dividing the multiplication of the degree of difficulty of each procedure and the number of implementing the procedure into the number of the nurses in each clinic. The number of clinics included in the study was 4 and the number of procedures were 77.

RESULTS
In this study, the responses of 136 nurses were used to determine the degree of difficulty of the nursing procedures in the hospital. Socio-demographic characteristics of the nurses are given in Table 1. The information about the clinics where patients were hospitalized in September 2014 is given in Table 2. The patients who were hospitalized in the clinics at the hospital are given in Table 2, and the majority of them were in surgery clinics with 46%, while 36.4% were in internal medicine clinics, 15.2% were in gynecology and obstetrics clinic, and 2.4% were in pediatrics clinic.
In Table 3, the descriptive statistics of the degree of difficulty of nursing procedures are given.
The most difficult procedures performed by nurses according to the degree of difficulty of these procedures were determined to be the time until the newborn is given to the mother (7.33 ± 2.25), vaginal exam (7.00 ± 2.21) and vaginal delivery (6.75 ± 2.89), respectively. The lowest averages according to the degree of difficulty of these procedures were determined to be giving O 2 (2.77±2.04), oral medication (2.89±2.32), blood glucose measurement (2.95±2.38), respectively.
In Table 4, the workload scores of nurses working in the internal medicine clinics, surgery clinics, gynecology and obstetrics clinic and pediatrics clinic are given. The formula given in the materials and methods section was used to calculate the workload scores.
As it can be seen in Table 4, internal medicine clinics have the maximum workload score per month as 1305 points, while the lowest score was found for pediatrics clinic with 99 points. Finally, workload score per month was found to be 761 points for surgery clinics and 617 for gynecology and obstetrics clinic, respectively.

DISCUSSION AND CONCLUSION
In this study, fundamentally, the nurse observation forms in patient files were evaluated using the results obtained from these forms. Considering the earlier studies in the national and international literature, the number of studies discussing this matter seems to be very limited. These studies seem to be conducted on closed systems such as intensive care and burn units as well as surgery rooms. One of these studies was determined that nurses spent 37% of their time on direct patient care practices in the day shifts, whereas they spent 34% of their time on direct patient care practices in the night shifts (Avci et al., 2013). In another study, the number of nurses that must work in operating rooms was determined (Yildirim & Yilmaz, 2004). These studies have not determined the nursing workload score. Our study determined the workload of the nurses. In addition, the difficulty ratings perceived by nurses for nursing procedures were determined. In the study by Kang et al. (2016) and Duffield et al. (2006) the nurse-patient ratios, the numbers of patient fall, and patient satisfaction were investigated. In these studies, there was only the patient benefit issue. In our study, it was revealed that the perceptions of the nurses are also important. In fact, in our work, we did not only quantitatively calculate the workload but also performed a qualitative assessment. Because, in calculating the nursing workload, the nurse is evaluated in terms of psychological characteristics. In these studies, usually only the patient benefit is evaluated. In our study, it was revealed that the perceptions of the nurses are also important. Every nurse participating in the study revealed the degree of difficulty perceived by them at work. Because the difficulty perceived for each nursing process is not merely related with what the process is. Such difficulties also involve the experiences of nurses throughout their professional lives.
In this study, it has been determined that the number of difficulties in each nursing procedure should be determined not by the number of procedures performed by nurses and by the number of patients, but by the nursing process itself. Although the number of nursing procedures in some cases is very high, it is necessary to evaluate each process together with the difficulty level since the difficulty level of these tasks is different.
According to the results of our research, comprehensive nursing interventions applied to patients and the interventions that have higher risks for the health of patient are more difficult. In addition, the difficulty level of the procedures for the mother and the baby was high, especially, in the concerns about birth dimension. However, the level of difficulty of some technical procedures such as oxygenation and oral medication was lower. For this reason, nurses should be assigned considering the results of workload analysis. This can increase patient satisfaction and patient safety, and reduce costs.
Considering the results of our study, it has been concluded that nurses working at internal medicine clinics have more workload compared to other nurses working in other clinics. There were some missing data about the procedures applied in surgery clinics. For instance, although the nurse observation forms showed the inpatients who received pre-operation or post-operation treatments, the data regarding this information were rarely recorded. Nurses have many responsibilities about the patient who will be operated. Some of these responsibilities are informing the patient, prosthesis control, urinary excretion (without follow-up) and checking the area of surgery. However, most of these procedures are not recorded in nurse observation forms. The higher workload of nursing procedures in the internal medicine clinics may be due to the necessity of recording recommendations of the doctors into nurse observation forms. Because chronic patients hospitalized and receiving treatments for long time in the internal medicine clinics are recommended to switch their positions regularly and this procedure is recorded in the nurse observation forms. Therefore, the workload score of these nurses increase. On the other hand, the number of the patients hospitalized in gynecology and obstetrics clinics and pediatrics clinics was very limited during the time when we conducted our study. In the earlier studies, some procedures such as answering the phone, creating the inventory and recording the data were considered as nursing procedures (Avci et al., 2013). In this study, these are not considered as nursing procedures.
This study was conducted by examining the workload scores of nurses working at the hospital. Therefore, the results obtained from this study cannot be generalized.
Recommendations that can be provided in line with this work are as follows: • Having better records of the patients by nurses and using technological tools that can facilitate to record the data; • With this study, especially a more equal workload to be provided is aimed by utilizing the difficulty grades and workload scores of the nursing procedures determined in the planning of nurse appointments to the clinics. Therefore, in the case of nurse in clinics, not only the number of nursing procedures performed but also the difficulty levels of nursing procedures should be considered; • As suggested by Giovannetti and Mayer (1984) as well as by Whitney and Killien (1987) and specified in the relevant literature, the workload of nurses in the clinics must be updated every six months; • This study will cast light on the way on which each nurse's workload score is calculated and the difficulty level of each nursing process is determined in the literature.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.