Patient care 'rationed' as nurses struggle under heavy workloads--survey: nurses are committed to their profession, but are often struggling under intense workloads, causing unsustainable levels of stress and the "rationing' of patient care, according to a survey at three district health boards.
Subject: Job stress (Management)
Nurses (Practice)
Nurses (Beliefs, opinions and attitudes)
Work environment (Management)
Patients (Care and treatment)
Patients (Management)
Workers (Beliefs, opinions and attitudes)
Workers (Evaluation)
Authors: Lawless, Jane
Wan, Lixin
Zeng, Irene
Pub Date: 08/01/2010
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: August, 2010 Source Volume: 16 Source Issue: 7
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 236247991
Full Text: Heavy workloads are the number one issue for nurses and are implicated in high rates of work-related stress and intention to leave the job, according to a survey of nurses in three district health boards (DHBs).

The survey also found that nurses responded to high work demand by working harder and taking fewer breaks. Also, nurses revealed they recognised unsafe staffing situations but did not often report it.

Background and demographic information

The safe staffing healthy workplaces survey was developed and conducted by the Safe Staffing Healthy Workplaces Unit (SSHWU) in conjunction with Counties Manukau, Bay of Plenty and West Coast DHBs and NZNO. The three DHBs are national demonstration sites for safe staffing and healthy workplaces and have shown a strong commitment to identifying and addressing the key issues. Areas examined in the survey included:

1) staffing, workload and quality of patient care;

2) job satisfaction; and

3) DHB responsiveness to the safe staffing healthy workplaces agenda.

Midwives were given a separate survey. This article provides the preliminary baseline results for the nursing survey, which was conducted in April this year. A total of 1003 staff responded--just over 25 percent of all possible respondents.

A wide range of nurses, from inpatient, community and non-clinical roles, participated. Just over 90 percent of respondents were female; 58 percent were New Zealand European, 5.2 percent Maori, 3.4 percent Pacifika, and the remainder were overseas trained. The average age was 46 (range 19-69). Eighty-five percent were registered nurses (RNs), five percent enrolled nurses and 10 percent health care assistants (HCAs). The majority were full-time (35-40 hours a week) shiftworkers; 85 percent worked in a hospital-based setting; 60 percent gave their job title as staff nurse. The average experience was 18 years.

The survey looked at a range of workplace factors known to be indicators of a quality work environment.

Key findings

* Being able to make a positive difference for patients is the most highly valued aspect of the job.

* Workload/work intensity is the number one issue and is implicated in high rates of work-related stress leave and intention to leave.

* Nurses typically respond to high work demand by increased work effort and decreased breaks.

* Excessive workload and work effort can have negative implications for nurses, patients and organisational functioning.

* Nurses recognise unsafe staffing situations but have low levels of reporting.

* The majority of nurses do not know what action has been taken following a safe staffing incident being reported.

* The majority of nurses are willing to be redeployed to support workload needs in other areas, but only if they have appropriate preparation and support and their "home" area is not left short of staff.

* The majority of nurses believe their organisations are taking steps to address safe staffing and healthy workplace issues.

Best things about being a nurse

One question had an overwhelming level of agreement: 92 percent agreed that making a positive difference for patients/clients was the best thing about their job. This is a strong indicator that our nursing workforce is dear about why they do what they do and that it is worthwhile and meaningful The survey also showed that, overall, those surveyed were generally satisfied with many aspects of their jobs and work life, principally working with the people in their team (84.6 percent),the ability to practise autonomously (70 percent), and effective team collaboration (67 percent). Taken together, these results indicated that the majority of respondents valued being a nurse, enjoyed the team they worked with, felt they had adequate professional development and could take annual leave when they needed to. Perceptions of the overall level of service were positive, with 71.5 percent rating the service as good or very good.

There's simply too much work

There was, however, a finding that stood out from within this positive picture. This related to the effect that work enlargement (taking on more functions) and work intensification (more work) was having on nurses, on patients and on the ability of the organisation to function effectively. Many respondents indicated there was simply too much work and often not enough time to complete it to a satisfactory standard.

Findings suggesting that work intensification was an issue included 61 percent reporting that patient complexity had increased in the last six months, 50 percent perceiving that the workload had become heavier and only 18.6 percent feeling under less pressure at work. When asked to rate the frequency of workplace conditions known to increase workload and stress, the four situations ranked as occurring often or very often were: high level of patient acuity (56 percent), high level of patient dependence (52 percent), taking more patients into the service than can be safely managed (38 percent) and too few staff to provide safe care (34 percent).

The four lowest frequency items were: staff working outside their scope of competency (12 percent), high staff turnover (18 percent), inadequate cover from doctors (21 percent--although this was significantly higher for one site), and miscommunication between staff (22 percent).

In a separate question, 25 percent said they were often or always pressured into taking on additional patients when they had indicated their workload had reached the limits of safety and more than half of respondents believed there were not enough staff to meet patient needs.

There were also some indicators to suggest that the DHBs were finding it difficult to respond to workload deficit. Only 24 percent said appropriate help was able to be provided often or always. It was also relatively common (27 percent) for an RN to be replaced with a less qualified staff member.

Care rationing

Implications for patients were examined by asking nurses to estimate the degree to which patient care was being rationed. Care rationing describes any situation where any aspect of patient care is either unduly delayed, unable to be completed to a satisfactory level or omitted due to workload pressures. Of 11 common patient care activities, ranging from carrying out planned care or treatment, monitoring the patient's condition to completing documentation, all were ranked as rationed often or very often by more than a quarter of respondents.

The data was analysed to see how nurses were responding to this situation. Compensating strategies involved working at an increased pace and/or increasing the time available to complete the work by missing breaks and working past the end of the day. Decompensating strategies included work-related stress leave, changing jobs or leaving nursing.


Some emergent research indicates that a common response of nurses to an increase in patient demand is to intensify work effort. (1,2) This is in contrast to research on workers generally, which shows the more common response is to take actions to limit the work effort required (known as soldiering). It has been hypothesised that an altruistic professional ethic causes the nurse to subordinate personal needs in favour of meeting the needs of those in his/her care. This can be seen as a positive employee trait if used to cover short-term critical spikes in workload, but if it becomes the "normal" way of working, is likely to eventually result in negative outcomes. The survey provided some evidence to support this hypothesis.



Comparing staff ratings of the current level of ser vice (a positive finding) with the staff's ratings of the work effort required to maintain these levels, a picture emerged of a workforce under significant and unsustainable stress. While 71.5 percent rated the level of service as good or very good, 65 percent said the level of effort required to sustain this was too hard or exhausting (see figure 1).

An analysis of missed meal breaks added to a picture of work intensification and corresponding increased work effort. A total of 80.5 percent of respondents reported having worked through or missed a meal break in the last six months. Of these, 42 percent missed two or more breaks per week.

A further area of concern is the amount of time being regularly worked past the end of the shift/normal work day--81 percent of respondents had worked past the end of the shift in the past six months and of these 65 percent were doing so once a week or more. The most common reason for working past the end of the shift was work still needing to be completed (79.5 percent) followed by covering staff shortages (25.2 percent). Sixty percent of those working past the end of the shift did not generally claim overtime or take lieu time. Reasons given for not claiming pay or time in lieu included a belief that working past the end of a shift was a professional obligation to meet patient needs, or being discouraged to claim overtime.

Rates of work-related stress leave and intention to leave in the next 12 months were also examined. Just over 20 percent of respondents indicated they had taken work-related stress leave in the last six months, compared to work-related injury leave of just over six percent for the same period. The main reasons for needing to take stress-related leave were mental and physical fatigue from the demands of the job, and roster fatigue, followed by co-worker conflict.

Over a quarter of the workforce who responded to the survey (26.4 percent) indicated they intended to leave their current job within the next 12 months. Of these, 32 percent indicated the main reason for leaving would be dissatisfaction with their job. If this statistic were representative of the entire 40,000-nurse workforce, this would represent 3380 nurses over the next year. The estimated cost of turnover for one RN is $45,000, so the cost to the health sector of nurses leaving because of job dissatisfaction is potentially $152 million per annum.

Other significant findings

We were interested to know if nurses agreed on what types of situations constituted unsafe staffing, how frequently they were occurring and the level to which they are reported to the organisation. The answers are: yes they do, quite a lot, and no they don't!

Respondents were very dear about what type of situations constituted unsafe staffing.

Respondents were also asked to identify how often unsafe staffing scenarios were occurring (see figure 2). With the exception of actual patient incidents (which were rated as occurring often or always by 18 percent of respondents), all of the scenarios were rated as occurring often or always by over a quarter of the respondents. The highest rated was staff becoming distressed due to high workloads (43 percent) followed by staff working overtime to complete work (40 percent) and inability to take planned breaks (38 percent).

Low levels of reporting

Given that respondents generally agreed on what constituted an unsafe staffing incident and could identify times when this had occurred, the low level of incident reporting was somewhat surprising. In the previous six months, only 21 percent of nurses had completed one or more incident forms relating to safe staffing. Of those who reported a safe staffing incident, the most common reason given was to report a staffing deficit (51 percent), followed by unsafe staff mix (44.4 percent).

Respondents were asked what was the outcome of reporting the incident. Only 16.8 percent felt the incident was dealt with appropriately, 27 percent were not satisfied with the outcome, white 56.8 percent did not know what action was taken.

Of the 79 percent of respondents who did not complete an incident form, the main reason for non-reporting was that no unsafe staffing incidents occurred during the Last six months (30.4 percent). The next most common reason was not having confidence that any action would be taken (19 percent), followed by not having time to complete the form (15 percent).

Workforce flexibility

A related finding concerned nurses' willingness to be redeployed to support workload needs in other areas. Anecdotally, health care managers often refer to nurses' resistance to being redeployed to assist in another area as a significant barrier to achieving safe staffing. The survey asked respondents whether they agreed that nurses should be required to help in other areas when there was a need. An overwhelming 77 percent agreed. The Large number of comments that accompanied this question clarified that white many felt this was a professional duty, for many this agreement was conditional on having sufficient preparation and support to feel confident and safe working outside their normal practice setting.

The actual rate of redeployment over the previous six months was somewhat tower than expected, with 49 percent having never been required to do so and a further 20 percent only being redeployed once or twice in six months.


The 2006 joint DHB/NZNO Committee of Inquiry identified a number of elements required to achieve safe staffing and healthy workplaces: all are important. Analysis of the findings showed statistically significant associations between key indicators--missed meat breaks, workload, ethnicity, and years of nursing--and work-related stress leave. There were also significant links between Levels of job satisfaction and any of the following: ethnicity, work area, organisational culture of reporting staffing incidents, anxiety about staffing levels, organisational attitude and responsiveness towards achieving safe staffing and healthy workplaces, and feeling valued by the organisation.

When measured across the three demonstration DHBs, there are signals that some progress is starting to be seen. Overall, staff were more Likely to agree than disagree that over the Last six months they had become more enthusiastic about their job, more committed to staying in their job, were somewhat more satisfied with their job and somewhat more likely to recommend their workplace to colleagues. Fifty-six percent of staff agreed that people in their organisation had a strong commitment to achieving safe staffing and healthy workplaces (16 percent disagreed); 58 percent felt the organisation was actively trying to make improvements in this area and 39 percent believed progress was being made. The survey showed these three DHBs had a committed nursing workforce which was welt disposed towards their organisation and the efforts that were being made.

The three DHBs did not agree to participate simply to generate further diagnosis about the issues. The survey provided an opportunity to hone in on the areas most likely to result in positive change.

As part of their activities as demonstration sites, the DHBs have been pirating new tools, strategies and work methods, designed to address many of the issues cited by nurses in the survey. All are actively working on more effective ways to manage the times when workload exceeds the capacity of staff--a process called variance response management. A tool to assist teams/services to accurately match patient demand and the number and mix of staff that the DHBs have been testing has just been released to all DHBs.

The unit and the three DHBs are working together to develop other resources to help nurses and DHBs make aspects of workload that should be measured and monitored, such as missed breaks, working past the end of shift, rote substitution, and patient care rationing, more visible. Together we are radically rethinking the way reporting safe staffing issues is managed, ideally moving away from having to complete a form on top of other pressing work, to a method where the system alerts itself.

Change is required now but these strategies take time if they are going to be workable and sustainable. The SSHW Unit has Learned through our work with the three DHBs that a critical factor for succeeding with this agenda is the collaboration between the DHBs and their union partners (principally NZNO at this stage); the trust and engagement on these sites is making it possible to make the necessary changes.

The healthy workplaces agreement negotiated by the parties to the National Terms of Settlement further embeds a joint commitment to working together to implement high quality solutions to workplace issues across the sector. The findings of this survey further endorse the need for this approach.

Acknowledgment: The authors would like to thank the staff who completed the surveys, as well as the participating DHBs and NZNO.


(1) Fagermoen, M. S. (1997) Professional identity: Values embedded in meaningful nursing practice. Journal of Advanced Nursing. 25:3, pp434-441.

(2) Lawless, J. (2009) Dignity in the work lives of clinical nurses. Unpublished thesis. Victoria University.

Jane Lawless, RN, MA Appld (Nsng), is the director of the Safe Staffing Healthy Workplaces Unit (SSHWU). Irene Zeng, MSc (Hons), is a biostatistician with the Centre for Clinical Research and Effective Practice. Lixin Wan, MA, was a research associate with SSHWU.
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