The association between nurse staffing and patient outcomes has been explored extensively in the nursing literature. A meta-analysis of 96 studies found that an increase of 1 registered nurse (RN) full-time equivalent per patient day was associated with a 9% reduction in the odds of a death in intensive care unit patients, a 16% reduction in the odds of a death in surgical patients, and a 6% reduction in the odds of a death in medical patients.1
Other researchers have demonstrated the economic value of improved quality of care achieved through higher staffing levels.2,3
Adequate nurse staffing is important in terms of both quality of patient care and fiscal responsibility.
Determining adequate nurse staffing may depend ultimately on workload. Generally, workload is a function of the time, complexity, and volume of the interventions that must be performed in a given period.4
Carayon and Alvarado5
propose several dimensions of nursing workload including physical, cognitive, time pressure, emotional, quantitative, qualitative, and variability. Physical workload
is defined as the manual direct tasks (ie, moving and lifting patients and bathing patients) and physical organization (ie, gathering intravenous pumps and vital signs monitoring equipment) associated with patient care.5
Cognitive workload is the intellectual processing of patient information that drives performance and decision making.6
Time pressure is the demand exerted by the number of tasks performed under temporal constraints (ie, necessary assessments, measurements, documentation, and therapies performed on a regular and/or frequent basis).5
Quantitative and qualitative workload are defined as the amount and difficulty of work, respectively.7
Finally, workload variability is the degree to which workload fluctuates during a period of time.7
These dimensions operate in tandem and yield the overall nursing workload for a given set of patients and their nursing requirements.
A challenge that nurse managers face is the ability to collect data on the various dimensions of nurse workload to make informed staffing decisions. With the increased use of health information technology in the hospital setting, measuring nursing workload by using these technologies would be ideal. A fundamental building block of most healthcare information technologies is standardized terminologies.
Standardized terminologies provide a foundation by which domain-specific information and data are transformed for knowledge generation and local aggregated use.8
The power of a standardized language compared to various local colloquial terms is that standardization allows for data aggregation and analysis across settings.9
A standardized nursing terminology not only provides a common language for nursing care plans but also may facilitate nursing communication and enhance continuity of care.10
The Nursing Interventions Classification (NIC) is a comprehensive standardized nursing terminology that has been used to systematically classify nursing care in clinical settings.11
The 514 NIC interventions are organized in 7 domains and 30 classes.11,12
The NIC terminology is often used in conjunction with the development of electronic health records (EHRs). Other nursing terminology classification systems include the Nursing Outcomes Classification (NOC) and standardized Nursing Diagnoses (NANDA).13
Currently, none of the nursing taxonomies mentioned above have been integrated in a health information system that captures entirely the care that nurses provide to patients.13
Researchers continue to develop and expand current classification systems, especially for use in EHR. Electronic tools that integrate standardized nursing terminology, such as NIC, enable the representation of nursing concepts (eg, interventions or outcomes) in a consistent manner. These electronic tools may be used to collect nursing specific workload data, including direct patient care, patient and family education, and counseling. These data are useful for nursing research, and nursing administration functions such as quality improvement and operations.9
An advantage of the NIC over other terminologies is its link to SNOMED (Systematized Nomenclature of Medicine), which is a more comprehensive controlled vocabulary for biomedical sciences. This link, or mapping, integrates the NIC with other healthcare classifications from different healthcare disciplines and is used in more than 25 countries.14
The NIC can also be linked to the International Classification for Nursing Practice, which provides a common structure for nursing diagnoses, interventions, and outcomes.
The NIC was developed to determine nursing costs based on standardized interventions.15
Interventions that make up the NIC were selected by small groups of research teams who identified nursing interventions in their area of expertise and rated the (1) education needed for the implementation of the intervention and (2) average time to provide the intervention.12
The nursing staff’s education level is categorized as either nursing assistant or RN. The time needed to provide an intervention is grouped in 15-minute intervals (ie, 15 minutes or less, 16–30 minutes, 31–45 minutes, 46–60 minutes, or more than 1 hour).10
While research has shown the usefulness of the NIC to represent nursing care activities, the NIC has not been used to measure nursing workload.16,17
However, the need for a measure of volume of nursing care was highlighted through the inclusion of nursing care intensity in the seminal work on the Nursing Minimum Data Set.18
With the rapid expansion of healthcare information technology in hospitals, nursing intervention taxonomies are increasingly being integrated into electronic systems for purposes such as nursing documentation. Therefore, understanding how these systems may inform measures of nurse workload is timely.19
Furthermore, reliable and valid measures of nurse workload should help inform nurse managers in making evidence-based staffing decisions.