By Rose O. Sherman, EdD, RN, NEA-BC, FAAN
I have been thinking a lot recently about the nursing workload conundrum. All of our recent workforce data indicate the same thing – nurses feel exhausted, burned out, and unable to manage the workloads assigned to them. I hear this in my work in Oregon and California as well, and they have mandated staffing ratios in place. Recently, a CNO talked with me about what she is experiencing:
I need help with articulating workload more effectively. Something is happening with our workloads and workforce – our nurses are struggling to keep up. Our staffing situation is better than it was a year ago, at least on paper, but it doesn’t matter. Nurses are exhausted, burned out, frequently calling in, and are shifting to part-time work. No one wants to work in acute care anymore because it is “too hard.” I explain to my C-Suite colleagues that we have a young workforce, our units are overwhelmed with their patient volumes, resulting in rapid ADT. The patients are sicker when admitted, have multiple co-morbidities, and are older, making them much higher risk for falls and other problems. The sheer volume of orders and documentation requirements is overwhelming for our young staff, who struggle with critical thinking and establishing priorities.
My C-Suite colleagues, none of whom are clinicians, don’t get it. Our healthcare system is still basing HPPD and allocated unit staffing on historic workload data, which does not accurately reflect the current clinical environment. I was recently accused of “not being a team player because just look at how much money we spend on nursing care.” How are other nurse leaders in executive roles managing this serious disconnect about workload between their C-Suites and what is actually happening on the front lines?
I assured this CNO that she is far from feeling alone in her concerns. Nursing workloads today are typically calculated by assessing various factors that influence the amount of work a nurse is required to perform. Common methods include:
Patient Classification Systems: Patients are categorized based on their acuity, complexity, and care needs (e.g., vital signs monitoring, medication administration, wound care). Each category is assigned a weight or score.
Time and Motion Studies: Observations are made to estimate the time required for specific tasks or patient care activities. Summing these times provides an estimate of workload.
Staffing and Patient Ratios: Calculations based on mandated nurse-to-patient ratios or adjusted ratios considering patient acuity levels.
Workload Measurement Tools: Instruments or software (like RAFAELA system, TISS, or NEMS) quantify workload by analyzing factors such as patient care complexity, documentation, and administrative tasks.
Patient Acuity-Adjusted Staffing Models: Models that multiply patient acuity scores by predetermined factors to estimate required nursing hours.
Even the most sophisticated systems don’t consider factors such as the impact of having a very high percentage of nursing staff who have not reached the competency level of practice. Historically, most nurse managers kept the percentage of relatively new graduates to less than 20% of their core staffing because they were well aware of the differences in mastery. Today, few have this luxury and the mix has actually been upended with many units now with 80% of their staff with less than three years of experience. Experience matters in a nurse’s ability to manage care – it always has in acute care.
Most patient classification systems also fail to account for the rapid turnover of patients on units today. ADTs are very nurse intensive which is why so many leaders now embrace virtual nurses as a way to add more support to their units. Patients today also have varying and often unpredictable care requirements, making standardized measurement difficult. Nurses spend significant time on documentation, electronic health records, and administrative duties, which can be hard to quantify accurately. Gathering accurate, real-time data on activities outside direct patient care (like discharge coordination or education) can be difficult.
Wise leaders recognize that we need to shift our thinking about workload. In her presentation at the 2025 AONL conference, Betty Jo Rocchio the Systems Chief Nursing Officer for Advocate Health talked about the need to move away from ratios and patient acuity as a way to staff and instead use Artificial Intelligence to help assess and decrease the cognitive and physical nursing workload in real time in order make better staffing decisions. She has taken the lead on helping Advocate move in that direction by designing an integrated workforce platform that incorporates data from many sources such as the EHR and staffing systems to address many of the problems noted above while improving care and optimizing resources.
This pioneering work will be groundbreaking and has the potential to completely upend how we think about staffing and workload.
© emergingrnleader.com 2025
Our Most Popular Right Now The New World of Work Workshop
Two Brand New Workshops for Your Team in 2025
*** Trending – Building Bridges Not Walls: Leading Multigenerational Work Teams – Click Here for More Information Building Bridges Not Walls
Nurse and Nurse Leader Work-Life Balance and Well-Being: Nursing Leadership Strategies for Success – Click Here for More Information WorkLife Balance and Wellbeing WS
New Book – Click Here to Buy
LinkedIn
Instagram