The integration of care ethics and nursing workload: A qualitative systematic review

Abstract

Aim

The aim of this review was to explore literature from January 2017 to December 2021 for specific aspects of care ethics related to nursing workload in the acute care setting.

Background

High nursing workload is associated with adverse outcomes for nurses as well as patients. Nursing workload goes beyond patient‐to‐nurse ratios and encompasses patient, nurse and organizational factors.

Evaluation

This qualitative systematic review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis. The four features of care ethics related to nursing workload guided the review of qualitative studies in MEDLINE, CINAHL and PsycINFO, and synthesized findings were presented in the four phases of caring.

Key Issues

Key issues include ethical dilemmas, time pressure, shared moral burden and managerial support.

Conclusion

To reduce nursing workload, a care ethics perspective can provide solutions through fortifying interprofessional relationships and enhancing empathetic actions.

Implications for Nursing Management

Situational, individual and team approaches to management allows for incorporation of personal values and ethics of care to support patient‐centred care. Leadership initiating conversations and being proactive about workload can lead to an improved work environment for both the nurse and the nurse manager.

1. THE INTEGRATION OF CARE ETHICS AND NURSING WORKLOAD: A QUALITATIVE SYSTEMATIC REVIEW

High nursing workload is associated with adverse outcomes for nurses as well as patients. Workload influences patient outcomes and is associated with less reporting of adverse events, workarounds, increased patient length of stay, increased patient falls, higher rates of in‐hospital mortality, hospital‐acquired infection, medication errors, abandonment of treatment, and needle‐stick and sharps injuries (Assaye et al., 2020; Carayon & Gurses, 2008; Granados‐Plaza et al., 2021). High nursing workload also impacts the nursing workforce as manifested by stress, burnout, the intent to leave and absenteeism (Aiken et al., 2001; Assaye et al., 2020; Berlinger, 2017; Carayon & Gurses, 2008). Compounding these workload challenges is the crises of current nurse shortage and COVID‐19 pandemic. Although the body of theoretical and empirical literature on nursing workload has significantly increased over the last two decades (Aiken et al., 2001; Assaye et al., 2020; Berlinger, 2017; Carayon & Gurses, 2008; Granados‐Plaza et al., 2021), an understanding of the multidimensionality of workload requires inclusion of qualitative approaches to the subject. The aim of this review was to explore the qualitative literature over the past 5 years related to nursing workload in the acute care setting. More specifically, qualitative findings about the care relationship between nurse managers and nurses were examined in regard to workload.

A preliminary search of PROSPERO, CINAHL and Cochrane Review Database of Systematic Reviews was conducted, and no current or underway systematic reviews on nursing workload and managers were identified. One literature review exists that examines the perceived and experienced role of the nurse unit manager in supporting the well‐being of intensive care unit nurses (Adams et al., 2019). The review presented here differs in that it reviewed qualitative studies only and focused on workload and acute care nurses.

2. BACKGROUND

2.1. Nursing workload

From a management perspective, workload is controlled through nurse staffing and involves patient‐to‐nursing staff ratios, hours of direct patient care and overtime use. Occasionally, the types of nurses, years of experience, availability of support staff and team interdisciplinarity are also considered. Nursing managers often track staff retention variables include workforce absenteeism, use of float teams and nurse turnover (Thériault et al., 2019) to evaluate nursing workload.

Organizational factors that contribute to workload consist of availability of resources, average daily census, patient turnover, caseload, mandatory reporting of data, documentation, use of technology and organizational decisions like mandatory education and meetings (Junttila et al., 2019; Lebet et al., 2021; Myny et al., 2012). Unfortunately, when workload exceeds care that can be reasonably provided by resources, organizational factors can potentially contribute to nurses' deliberate deviations from policies or written procedures (Jam et al., 2018). Also, cost constraints are ubiquitous in health systems, but these constraints increase pressure upon nurses to do more with less and sometimes with a reduced skill set that does not match patient acuity (Harvey et al., 2020).

Workload from a nurse's perspective not only encompasses the variables of staffing but also includes psychosocial and physical factors related to the organization, patient characteristics, cognitive burden (Ng & Curley, 2012), work interruptions (Myny et al., 2012) and perceptions of adequacy of resources and quality of care (Junttila et al., 2019). Patient factors include acuity of illness (Alghamdi, 2016), dynamic patient events like rapid responses and transporting patients for procedures (Moore et al., 2016), patient dependency, patient age and weight, number of medication doses per day, and overall complexity of care (Junttila et al., 2019). Overall, nurse workload is situational and dynamic. Health care organizations would benefit from a human‐factors approach to work systems by recognizing that benefits for both patients and nurses improve nurse well‐being and system performance (Carayon & Gurses, 2008).

2.2. Care ethics

Definitions of care ethics by theorists in the field are generally broad. In the early development of care ethics, Noddings (1988) identified caring as an ethical orientation and a form of relational ethics. Tronto (1993) devised a definition that views caring as a species activity that includes everything humans do to live as well as possible in a complex world. At the core of all the care ethics definitions is the notion that humans are a part of a system of associations and are fundamentally relational.

The care ethics criteria proposed by Klaver et al. (2014) place ethical emphasis on relationships as a source of knowing and the place to receive recognition and care. The criteria also describe care ethics as context bound and situation specific. Relationships are broader than personal relationships and involve institutional and systemic realities. Leget et al. (2019) expanded on criteria offered by Klaver et al. (2014) and proposed a view of limiting research of care ethics to qualitative methods studying lived experiences, practices of care and the way society is organized. Leget et al. (2019) did not consider their way as the only way but a fruitful epistemological approach for care ethics. More specifically, focusing on lived experiences and studying structures and power relations in society as a whole prevent political naivety and allow delivery of optimal care.

Although the onus of nurses' workload is not solely on nurse managers, analysis must include the understanding of the dependence of the nurse upon the nurse manager and the value of their relationship and shared world of patient care. By deliberately focusing on the relationships between nurse managers and nurses from this care ethics perspective, the issue of nursing workload can be addressed through shared experience. Therefore, the review question for this qualitative systematic review was, “What are the specific care ethics aspects related to nursing workload in the acute care setting?” Because care ethics is relational, the focus was on the nurse as the care receiver and the nurse manager as the caregiver. The review subquestions are found in Table 1.

TABLE 1.

Review subquestions with explanatory statements

Phases of caring	Subquestions	Explanatory statement
Caring about	Is there a need regarding workload? Should this need be met?	Care erosion and hardship on nurses due to heavy workload are two major needs.
Taking care of	What is the responsibility of nurse managers for the need? How do nurse managers respond?	Nurses and managers share a moral burden for decreased workload.
Caregiving	What is the actual, visible work done by the nurse managers in response to needs?	Nurses need support and role models from nurse managers for managing workload.
Care receiving	How are the nurses affected by the care they receive?	Due to lack of care received, nurses have adopted defensive and proactive strategies to get work done.

3. METHODS

3.1. Study design and strategy

This qualitative systematic review was conducted according to the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis (Figure 1) (Aromataris & Munn, 2020). The review is registered on PROSPERO (ID CRD42022302322). An initial review of MEDLINE, CINAHL and PsycINFO was conducted to determine appropriate subject headings, search words or phrases, and MESH terms. This informed the development of a search strategy that was tailored for each information source. A full search strategy for the databases is detailed in Table 2.

FIGURE 1.

Results of the search of databases and the study inclusion process

TABLE 2.

Search strategy of databases

Database	Search strategy
CINAHL	CINAHL subject headings: ‘workload’ and ‘nursing staff, hospital’ Key term in abstracts: ‘qualitative’
MEDLINE	MESH terms: ‘workload’, ‘nursing staff, hospital’ and ‘qualitative research’
PsychINFO	Key terms in abstracts: ‘workload’, ‘nursing’ OR ‘nurse’ OR ‘nurses’, ‘qualitative’, ‘acute care’ or ‘hospital’ or ‘inpatient care’

3.2. Inclusion criteria

Only studies published in English were included. Studies published from January 2017 to December 2021 were included because this systematic review was interested in capturing the current relational contexts between nurses and nurse managers. For review of the initial group of studies (n = 110), the four features of care ethics (Klaver et al., 2014) guided the inclusion criteria and were as follows: (1) concrete feedback of lived experiences by both nurses and managers of the relationship between nurses and nurse managers (i.e., relationship‐based programming); (2) context and situation details; (3) institutional and systemic realities; and (4) empirical evidence of care as a practice. Studies that reported findings related to any of these criteria were included in the study.

3.3. Study selection

Only English language published studies that reported first‐hand experiences, perceptions, perspectives or views on nursing workload from nurses or nurse managers in the acute care setting were included. This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research (Aromataris & Munn, 2020; Leget et al., 2019). Mixed method studies that reported rich qualitative descriptions were also included.

All identified citations were collated and uploaded into JBI System for the Unified Management, Assessment and Review of information (JBI SUMARI) (Aromataris & Munn, 2020) and duplicates removed. Titles and abstracts were then screened for assessment against the inclusion criteria for the review. Studies that met the inclusion criteria were retrieved in full and their details. The full text of selected studies was assessed in detail against the inclusion criteria. Full‐text studies that did not meet the inclusion criteria were excluded and reasons for exclusion are provided in Figure 1. There were 29 eligible studies. The settings of the studies included Australia (2), Belgium, Canada (3), China (2), Denmark, England, Finland, Greece, Iran (2), Japan, New Zealand, Norway (2), South Korea, Southwest Asia, Sweden (2), Taiwan, Turkey, United States (3) and Vanuatu. The methods for data collection included focus groups (6), individual interviews (15), both interviews and focus groups (3), ethnography (2), and open‐ended survey questions or incident reports (3).

3.4. Assessment of methodological quality

Eligible studies (n = 29) were critically appraised by the authors for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Research (Munn et al., 2019). The authors agreed a priori that if any studies scored ‘no’ or ‘unclear’ on three or more criteria, the two reviewers would meet to discuss whether these studies would be included. None of the studies met the criteria to be excluded.

3.5. Data extraction and synthesis

The data extracted included specific findings of nurses' perspective of workload in the context of any of the four features of care ethics. Findings and illustrations were extracted verbatim. Only findings and their corresponding illustrations relevant to the phenomena of interest and from participants who met the inclusion criteria were extracted (Tables 3, 4, 5, 6). The synthesized findings were then organized and presented in the four phases of caring—caring about, taking care of, caregiving and care receiving (Tronto, 1993) and expressed as statements of recommendations for policy or procedures regarding nursing workload (Tables 1 and 3, 4, 5, 6).

TABLE 3.

Extracted findings related to ‘caring about’ phase of caring

Authors (year)	Verbatim extracts of authors' analytic interpretations	Accompanying illustrations
Bishop and Macdonald (2017)	“Encountering roadblocks”	“… you have a limited amount of time … you have to cut the conversation off.”
Bryant et al. (2018)	“Perceived increase in workload for nurses.”	“… nowadays nurses don't have the time or the stomach to educate Drs who are in‐different or patronizing when their prescribing errors are pointed out to them or when they are asked to rewrite illegible medication prescriptions.”
Cengiz et al. (2021)	“Severe fatigue due to increased workload and insomnia”	“I used to get tired before. Now, I get tired twice as much.”
Cengiz et al. (2021)	“Environmental pressure caused depressive emotions and obsessive behaviours in many nurses”	“I feel like a robot that is worried about its own life”
Charette et al. (2019)	“Participants attributed this significant workload to the limited financial and human resources of the organization; some participants talked about a work overload that was even felt by experienced nurses.”	“Experienced nurses already have difficulty doing everything they have to do and finishing on time”
Charette et al. (2019)	“NGNs [new graduate nurses] should not have the same workload as other nurses, but that their load should be progressively increased over a few more weeks. However, according to participants, contextual factors preventing this are recurrent.”	“Because we are understaffed, the NGN must take on the same workload as the other nurses.”
Charette et al. (2019)	“One nurse manager said that the number of forms to complete constantly increases and can have a negative impact on direct care.”	“There are so many forms and paperwork. When a patient is admitted, they have 13 forms to fill out!” (nurse manager)
Harvey et al. (2020)	“Emotional exhaustion”	“There's nothing wrong with this nurse ‐ at times she is running, and she can't run anymore … she's had enough.”
Lee et al. (2021)	“Insufficient staffing and concerns about overtime”	“I feel like [I have to decide whether] to wait for one hour to [get a lift] team delivered to my room, [or whether to wait] for the second person to come here … just quick do this and get on with it rather than get in trouble.”
Martin and Bouchard (2020)	“Decrease in quality of care … increase the number of patients supported by each staff nurse”	“We do not have time to lift them up anymore. We put them in disposable incontinence adult diapers, to save time.”
Martin and Bouchard (2020)	“Hospital management is obsessed with economic imperatives that dictate all managerial behaviours … does not take into account the point of view of the staff nurses and fails to inform them of changes, even when these new procedures would affect them directly.”	“OK, this one work 12‐hour shifts on weekends, and it works for me.” “so, I will not move him/her to a different shift.” well, let's see, according to the convention, it's the youngest [that should be moved], this one is in surplus, and you say it works for you on a 12‐hour shift on weekends, so you will not move that person?”
Martin and Bouchard (2020)	“Fear‐based management”	“There is a coordinator who wanted to force me to work overtime. She threatened me to send an act of insubordination to the order. I do not know if you know, when you're a young person coming out of school, how scary it can be..”
Martin and Bouchard (2020)	“limited flexibility that nurse managers have to improve the prevailing working conditions in various hospital care units”	“More often than not, heads of care units in the throes of any situation of conflict, they have very little ammunition to battle with only just the back of a spoon…”
Stavropoulou et al. (2020)	“The routines seemed to continue without critical reflection and the management did not get involved.”	“The leadership on the ward does not get involved. When it comes to dying patients, treatment is not stopped in time. Medication continues. The physicians would like us to try this and that, and we do. Nutrition is started. Intravenous or by probe. We follow the treatment until the day before the patient dies.”
Tamata et al. (2021)	“Lack of support from the leaders causes low working morale and low motivation”	“We always confront our nursing managers … but they always give excuses and no action taken seriously which affects our morale of work.”
		“We hardly see the managers or supervisors doing regular visitation to support nursing staff and to assess nurses work performance, this causes low staff motivation.”

Note: With the JBI approach, the first step is to extract findings from the studies. Findings are verbatim extracts of the authors' analytic interpretation. Authors and year are in bold. Each verbatim finding is then accompanied by an illustration which is a direct quotation from the study (in italics).

TABLE 4.

Extracted findings related to ‘taking care of’ phase of caring

Authors (year)	Verbatim extracts of authors' analytic interpretations	Accompanying illustrations
Charette et al. (2019)	“[new graduate nurses] may not have sufficiently developed leadership skills, self‐confidence, and professional identity to be able to meet this requirement in the first months of their practice.”	“… the newly hired nurse freshly out of school doesn't have a well‐developed sense of leadership and she has little confidence in her actions and in herself.”
Charette et al. (2019)	“One [new graduate nurse] felt that, even though she learned a great deal from her floating experiences, she always felt excluded from the rest of the team and felt she was assigned a heavier workload than she would normally have.”	“Constantly changing units, teams, specialties, it is very stressful. When you go back on the same units, you start to know the teams, so it's easier … and sometimes you know that you have the heaviest patients and that you would not have that section if you were a part of the regular team.”
Chua et al. (2019)	“The perceived complexity, time and workload pressure, lack of confidence, and lack of role models to correct their practice were also seen as barriers to nurses use of ‘complex’ physical assessment skills.”	“We learnt [‘complex’] physical assessment in school, but I don't think we have the time to do [them]. I don't think we are empowered to do [‘complex’] physical assessments, and were not confident to do them as well.”
Chua et al. (2019)	“Missing the big picture – ‘Blinded’ by overwhelming workload … impaired their capabilities to ‘see’ clinical deterioration.”	“Sometimes, we are held up with something else. We won't know how the other patients are. We won't know that the patient deteriorates unless another staff passes by [and says], ‘patient XX doesn't look good.’”
Gao et al. (2020)	“Adjust shift patterns dynamically according to workload”	“At the beginning, [it was a] mess. We adjust[ed] our schedules dynamically. At first, we worked an 8‐hour shift, then we worked a six‐hour shift, finally we settled on a four‐hour shift…”
Gao et al. (2020)	“Communication should be strengthened to adjust shift patterns appropriately taking front line nurses perspectives into consideration”	“The head nurse should consider my physical and mental health and listen to my opinions, and then make appropriate scheduling, which is more conducive to my nursing work.”
Gao et al. (2020)	“Pay attention to nurses physical and psychological well‐being”	“I feel uncomfortable. I wear the protective gear all the time. And I have to wear diapers. I try to adapt to it both physically and mentally.”
Harvey et al. (2020)	“Emotional exhaustion”	“This low resource of nursing numbers doesn't take into account that actually people [nurses] are going over and above what they're required to do … for a … manager, what they see is actually these guys are doing relatively well on what they've got.”
Tamata et al. (2021)	“Work overload and work for long hours causes more physical and medical risks”	“Shortage of nurses affects our physical body very badly … we felt tired and cannot provide the best quality nursing care to our patients.”
Tamata et al. (2021)	“They dont have enough time to rest and eat or drink due to too much workload and limited nurses”	“Most of the time our ward is busy and those times I don't have enough time to rest and eat or even drink which affects my physical health.”
Tamata et al. (2021)	“Most nurses reported that high job demands increase physical and mental health problems.”	“When we have too many patients and lack of skills especially for us inexperienced nurses, it affects us psychologically as well which can affect our performance.”
Tamata et al. (2021)	“Medical errors are one of the common risks that occur due to stress from working long hours or work overload”	“Most of the time due to frustration and too much workload I don't practice infection control rules and regulations which cause more medical risk to my patients.”
Womack et al. (2019)	“Activity patterns … temporal shift rhythms”	“The morning is usually a very busy time because each of us has 4 patients that need something right off the bat. There are usually new orders coming in right at 6 or 7 am; all the meds are due, somebody needs something. And right when you're about to leave a patient room, something else happens….”
Womack et al. (2019)	“Signs of manageability—ability to address self‐care needs including hydration, nutrition and restroom breaks was the most frequently reported sign of a ‘good shift’.”	“I got to eat lunch, yeah, just 30 minutes.”
		“Got to go to the bathroom when I needed to.”
Womack et al. (2019)	“3.2.3. Demand bursts… Workload escalation may occur as a result of a single large event, multiple small events, or a gradual increase in aggregate patient demand.”	“Sometimes I'm having a great day, and all of a sudden it gets busy for 20 minutes, so I procrastinate those meds for 45 minutes.”

Note: With the JBI approach, the first step is to extract findings from the studies. Findings are verbatim extracts of the authors' analytic interpretation. Authors and year are in bold. Each verbatim finding is then accompanied by an illustration which is a direct quotation from the study (in italics).

TABLE 5.

Extracted findings related to ‘caregiving’ phase of caring

Authors (year)	Verbatim extracts of authors analytic interpretations	Accompanying illustrations
Charette et al. (2019)	“One new graduate nurse also believed that the nurse manager wanted her to finish her orientation as quickly as possible to be given a full workload.”	“The nurse manager wanted us to finish our orientation as quickly as possible … so, to be “functional” faster, well, I was switching from one preceptor to the other.”
Chua et al. (2019)	“The most challenging issue reported by nurses was struggling to provide close vigilance to patients during night shifts when there were significantly fewer staff.”	“We can't monitor patients so closely. … I had to accompany one patient to the toilet. My EN was on break and other staff were occupied. When my EN returned from break, she found [that] patient X [had] collapsed.”
de Casterlé et al. (2020)	“… to some nurses, doing the work in a routine manner offered structure and support when working under time pressure. Routine disruption, on the contrary, acted as a source of extra stress and time pressure.”	“Normally, you know that you can do it within that time frame because it's nothing new [it's routine]. And then you think, ‘yes, I can do it’. Unless, of course, something comes up, which interferes with that routine, and then the workload increases.”
Keers et al. (2018)	“Working environments that were noisy, chaotic, and/or busy. This type of environment led to distractions and interruptions, high workload and rushing …”	“Rushed, there were lots of people milling around in the corridor, there were doctors running on and off the ward requesting prescription charts … it was really crowded, it just felt … really rushed, I had to get the medication round finished to get on with the rest of the day.”
Keers et al. (2018)	“Low staffing was reported to be commonplace and appeared chronic in some cases, with causes including sickness, annual leave and wards acting as a staff ‘donor’ … to others requiring personnel.”	“… Which is another issue, agency staff only. They don't know the ward, they don't know the patients, so you're the only qualified with three or four agency staff only, who don't have the ward, who don't know the patients. So, you can't rely on them.”
Lee et al. (2021)	“At the beginning of the shift, you are assigned a ‘buddy’ nurse co‐worker [based] on the proximity of your patient assignments. So, when she needs help lifting, you go help, and vice versa. Without consideration for what your individual workload was, your availability [to help],… That system failed us.”	“I've been a nurse for 20 years, and I'm more and more frustrated every day at work because were expected to do more with less every day.”
Liang et al. (2021)	“Many hospitals implemented isolation and triage measures requiring additional training.”	“We had to conduct actual exercises after work in case the epidemic became serious.”
Lindgren et al. (2021)	“..Lack of time sometimes contributing to self‐harming incidents at the ward as patients sought the staffs attention.”	“..It had been possible to avoid many incidents if you had the opportunity to acknowledge them before they had harmed themselves.”
Martin and Bouchard (2020)	“… they no longer have access to their caregiver roles. These phenomena included the fact of constantly feeling like they are putting out fires and to be forced to omit certain nursing interventions, even essential ones.”	“A blood test …, it is prescribed and nurses will not do it. Or dressings,… Are not done three times a day, [but] once a day. Hence nurses are called to make professional mistakes.”
Martin and Bouchard (2020)	“Prioritizing care over others”	“The employer [tells you] to prioritize. … “If he wants to cut his veins, stop him, but leave it at that, for today.”
Najafi et al. (2018)	“… difficult for them to provide effective care to patients and caused dissatisfaction among patients/relatives and physicians.”	“… the more tired the nurses are, the more there is tension and conflict.”
Siyun Chen et al. (2017)	“Medical care and routine bedside care were prioritized over providing psychosocial care … they would only provide psychosocial care if there was extra time”	“We cannot sit down and talk to the patient and find out more.”“
Stavropoulou et al. (2020)	“Heavy workload and understaffing were … impeding factors for the integration of empathic care in practice. Elimination of these barriers, was considered essential for being able to integrate empathic care to practice.”	“…Most of the nurses think that (empathic care) it is a luxury…Time is not enough…”
Storaker et al. (2016)	“… only a marginal opportunity to live out their ethical values in their daily practice, and this led to ethical challenges. They characterized a general working day as a state of chaos without any opportunity to have a say concerning improvement.”	“It is inexhaustible, isn't it? As soon as the patient is discharged, I don't even have time to wish them a good recovery; three new patients are beside me, ready to be admitted and put in the room I haven't even had the time to clear out yet.”
Storaker et al. (2016)	“… professional nursing values seemed to fade and even vanish in the process of adapting to the existing culture.”	“… you learn almost to ignore the feeling that OK, ethics is not that important. Of course, it is terrible. It definitely is, but after a while, you do not bother. In the end, you will find that there are other things to worry about instead… it is tragic.”
Tamata et al. (2021)	“All the participants also reported that the workload is increasing because of the high number of patients admitted.”	“In the past, the population was less but now the population increases due to the high number of disease cases that causes more patients admission and more workload to us nurses.”
Tamata et al. (2021)	“… workload when only one nurse worked to cover for nurses who were on various leaves.”	“Workload is too much as most of the time only two nurses working in each shift is not enough, if one staff on sick leave or annual leave then we must double the shift.”
Tamata et al. (2021)	“Increased workload compared to a smaller number of nurses working in the hospitals causes nurses physical exhaustion leading to job dissatisfaction”	“Workload is too much in the hospital wards and we cannot do all our work at one time…I normally experienced tiredness and exhaustion and not interested to work due to incomplete jobs seen each day.”
Valizadeh et al. (2018)	“Unsupportive organizational culture … nurses value compassion, but there are many factors that can gradually destroy these values. ‘Excessive workload alongside inadequate staffing’ and ‘the lack of value on compassionate care.’”	“I I assess patients needs, control vital signs,… In this situation I ignore psychological aspects and compassionate care, I only focus on physical care.”
Valizadeh et al. (2018)	“As the number of patients is more, I can't communicate with them all … I have not more time to listen to them.”	“… the system gives more importance to paperwork, rather than giving importance on providing high quality care.”
Waltz et al. (2020)	“High priority … the ratio of nurses to patients, acuity levels, increasing numbers of tasks that they are being asked to complete and the number of nursing assistants available.”	“It is like they are always coming up with something new for you to do. It's like ‘just add that to my list’ (chuckling). … it is an extra weight on you to do those things so that really affects your job satisfaction. You feel more overwhelmed.”
Womack et al. (2019)	“… demand bursts that create unsafe patient situations or inability to provide high‐quality care result in workplace frustration. … time‐sensitive, technical tasks such as passing medications crowd out time for therapeutic interaction and whole‐person care.	“I think nursing attracts people with personalities that are a lot of times type A, or like gung‐ho, or like yeah, yeah, yeah. We just keep saying yes, I can do that, I can do that, I can do that. And then it's like, (whispers) ‘no, you can't.’”

Note: With the JBI approach, the first step is to extract findings from the studies. Findings are verbatim extracts of the authors' analytic interpretation. Authors and year are in bold. Each verbatim finding is then accompanied by an illustration which is a direct quotation from the study (in italics).

TABLE 6.

Extracted findings related to ‘care receiving’ phase of caring

Authors (year)	Verbatim extracts of authors analytic interpretations	Accompanying illustrations
de Casterlé et al. (2020)	“(pro)active strategies … belief in their own ability to influence the workload and its impact on care was at the heart of these nurses strategies.”	“I like to do a lot myself because then, I am in control over what happens… But you also have to – If you dont have time – Learn to distribute the work and reduce the workload for yourself … Handing tasks over to others so that you can do something else without rushing, while they can continue … “
Kang et al. (2018)	“Being busy with catching up with … frequently changing guidelines”	“We promptly communicated and shared updated information among nurses within the unit, thoroughpaced talk (a free mobile instant messaging application for smartphones with free texting).”
		“We had a notice note summarized about new information on MERS. We change shifts, we read the note and were also told what we have to be cautious because of what has been changed and it helped. It helped because we never had MERS …”
Liang et al. (2021)	“Participants believed robotics could reduce their workloads. An important factor affecting participants perception of the advantages of robotics was their sense that intelligent devices were ideal for performing repetitive actions and assisting with precision treatment.”	“Usually while new patients are admitted, we have to do a physical assessment and a family assessment. We also have to do a unit orientation; it usually takes a lot of time…. I think robotics can help us in this area.”
Martin and Bouchard (2020)	“Solution for management performance: Proximity and possibilities”	“It [would help] if administrators would be more present in the field and less often in meetings …. They could see the whole scheme of things [that are done by staff nurses]. It would help [to] give some feedback to people.”
Martin and Bouchard (2020)	“… administrators are not constantly monopolized by meetings. But these meetings, in her opinion, have the effect of making them lose contact with the reality in the field … the meetings should not be abolished, but they should be succinct and directly relate to what happens within the hospital wards.”	“It does not take money to do that … it just takes some administrators, who are able to drop their paperwork, to look at the reality and to say: “No, this way [to work], it doesn't make sense!” and probing around: “You, what are you thinking? [and you,] what do you think?
Martin and Bouchard (2020)	“…Nurse administrators, like other physicians, have the opportunity to adopt a mixed practice through which they would be able to act as nurse administrators while remaining active at the clinical level.”	“I find that interesting to see physicians who may have mixed practices will continue to … follow their patients and … will be able to manage at the same time. But for staff nurses … From that moment on, if we do nursing management … bygones would be bygones with respect to … the caring.”
Stavropoulou et al. (2020)	“Getting organizational support in terms of a good working environment, provision of training, less workload and more facilities were mentioned as means of enabling participants to integrate empathic care in practice.”	“…We need more facilities, more nurses…And the opportunity to study, to have a seminar, or some formal training…”
		“….Facilities to preserve patients dignity and intimacy are important” ”

Note: With the JBI approach, the first step is to extract findings from the studies. Findings are verbatim extracts of the authors' analytic interpretation. Authors and year are in bold. Each verbatim finding is then accompanied by an illustration which is a direct quotation from the study (in italics).

4. RESULTS

4.1. Caring about: Care erosion and hardship

The first phase of caring is “noting the existence of a need and making an assessment that this need should be met” (Tronto, 1993, p. 105). In the context of the relationship between the nurse manager and the nurse, the authors sought to first discover if there is a need regarding workload and should this need be met. Significant needs were found in the qualitative studies to decrease workload. Heavy workloads are often caused by time restraints, large patient‐to‐nurse ratios and lack of resources.

The cause and effect of time restraints on acute care nurses vary. In their study of capacity strain in the hospital workplace, Womack et al. (2019) reported multiple shifts between workload demand through a shift, adaptive strategies that may not be consistent with policies or procedures, and some tasks may be deferred. Time pressure on patient care sometimes forces nurses to ration care—to give up work that should be done in favour of work that must be done (Bishop & Macdonald, 2017; de Casterlé et al., 2020; Martin & Bouchard, 2020). Lack of time was also described as contributing to self‐harming incidents by patients to attract nurses' attention (Lindgren et al., 2021). In contrast, nurses indicate that capacity strain was manageable if they could address self‐care needs like eating, drinking and using the restroom and often clinical documentation while sitting at the computer doubled as time for rest and rehydration (Womack et al., 2019).

Large patient ratios have notable negative impacts on nurses and patients. This is often due to inadequate staffing (Cengiz et al., 2021; Chua et al., 2019; Lee et al., 2021; Tamata et al., 2021), but also an overall higher number of patients admitted and lack of coverage of sick calls or annual leave (Tamata et al., 2021). Contributing to the large patient ratios is the current coronavirus pandemic. Reflecting to the sustained influx of acute care patients due to the pandemic, one participant responded, “The number of patients has increased a lot. A 24‐hour shift is quite tiring, insomnia and insufficient rest are at the peak level! I used to get tired before. Now, I get tired twice as much” (Cengiz et al., 2021, p. 2008).

Time scarcity and inadequate staffing and resources lead to patient care erosion and hardship on the nurses. Nurses reported no longer having access to their role as caregivers (Martin & Bouchard, 2020) leading to ethical dilemmas. Psychosocial care of patients is deprioritized, and empathetic care is considered a luxury (Siyun Chen et al., 2017; Stavropoulou et al., 2020). These dilemmas create a gap for nurses between the anticipated and lived work experience (Womack et al., 2019). Further hardships included emotional exhaustion, fatigue, insomnia, lack of confidence, increased workplace violence, and other physical and mental risks and problems (Cengiz et al., 2021; Chua et al., 2019; Harvey et al., 2020; Liang et al., 2021; Najafi et al., 2018; Tamata et al., 2021).

Patient care erosion and medical errors are other unfortunate results of heavy workloads (Chua et al., 2019; Lindgren et al., 2021; Martin & Bouchard, 2020; Tamata et al., 2021; Womack et al., 2019). Minimal and deferred care was reported with blinding to clinical deterioration (Chua et al., 2019; Martin & Bouchard, 2020; Womack et al., 2019). Although current literature often focuses on the outcome of care left undone, the causative elements of resource and time scarcity and a lack of a normative framework for decision making by nurses to prioritize care have not been studied sufficiently (Scott et al., 2019). However, Renolen et al. (2018) studied nurses' struggle with maintaining workflow by task juggling and with implementing new scientific knowledge by “battling counter current” (p. 185) of insufficient support and lack of time.

4.2. Taking care of: Shared moral burden

The second phase of caring is “taking care of” or “assuming some responsibility for the identified need and determining how to respond to it” (Tronto, 1993, p. 105). This phase of caring about nursing workload means finding what the responsibility of nurse managers concerning the identified workload needs is and how do the nurse managers respond. In some instances, the values of a workplace differ from the values of the nurse. This can result in role conflict when incongruous organizational resources or expectations compromise professional standards (Harvey et al., 2020). Harvey et al. (2020) also reported nurses who described how they were treated as commodities to accomplish checklists and mandatory reporting and felt devalued. Nurse managers are also often in “the throes of any situation of conflict, [and] they have very little ammunition to battle with, only just the back of a spoon” (Martin & Bouchard, 2020, p. 312).

The moral burden of care compromising or care rationing needs to be shared at the organizational level and not solely placed on individual nurses (Scott et al., 2019). Pressures from patients, other professionals, supervisors, organizational demands and other environmental factors can shape ethical practice. At times, the logic of managers that prioritizes rationing efficiency clashes with the autonomy and expertise of professionalism (Livingstone et al., 2021). However, it is imperative to acknowledge that “nurse managers' consciousness is being bifurcated—what they know from experience, from being there, is overruled by authoritative institutional information” (Fast & Rankin, 2018, p. 8). Harvey et al. found a need among nurses to for managers to understand their exhaustion and their dilemmas like waiting on resources at the risk of overtime hours (Harvey et al., 2020). Managers who have reconciled the clash between professionalism and managerialism by prioritizing one over the other or blending the two may have lessened conflict and tension (Livingstone et al., 2021). Open communication between managers and nurses that takes the nurses' perspective into consideration can optimize and humanize shift patterns (Gao et al., 2020).

4.3. Caregiving: Need for support and role modelling

The third phase of caring is caregiving. This is the actual, visible work done in response to needs. To address nursing workload, staffing decisions need to be based on evidence regarding impact on the assigned nurses and patients. Unfortunately, this review found evidence of actual, visible actions by management that was uncaring. Nurses who are new graduates have reported a desire to finish orientation periods before working independently, but contextual factors sometimes do not allow for full orientation (Charette et al., 2019). Martin and Bouchard (2020) presented a predominantly negative impression of managers' behaviour with fear‐based management, forced overtime and obsession with finances. Ethical dilemmas occurred on the units without role modelling or involvement from managers, and organizational culture often emphasizes documentation or compassionate care (Chua et al., 2019; Stavropoulou et al., 2020; Valizadeh et al., 2018). Respondents indicated that this lack of support from the leaders causes low morale and low motivation (Tamata et al., 2021). Additionally, when nurses go above and beyond what they are required to do, managers often overlook the strain and conclude that nurses do well with what they have (Harvey et al., 2020).

4.4. Care receiving: Survival or proactive strategies

The final phase of caring is care receiving or recognizing that “the object of care will be affected by the care it receives” (Tronto, 1993, p. 107). This review sought to find how nurses are affected by the care they receive from nurse managers but found more adaptations due to lack of care received. If this final phase fails, nurses adopt survival strategies like increased pace of work, completion of care beyond allocated hours and sacrificing health and well‐being to do what needs to be done (de Casterlé et al., 2020; Scott et al., 2019). Care rationing compromises ethical values and leads to feelings of failures (de Casterlé et al., 2008, 2020) The resulting stress is known to lead to burnout that results in emotional exhaustion, depersonalization and lack of personal accomplishment (Andela & Truchot, 2017; Maslach & Leiter, 2008). Two solutions proposed were for management to not be monopolized by meetings to allow time for presence on the units and for management be encouraged to have mixed practices that allow for direct patient care (Martin & Bouchard, 2020).

5. CONCLUSION

Nursing workload is complex and contributing factors are sometimes not addressed in the workplace. Competing priorities for nurses cause ethical dilemmas that can compromise professional values, moral agency and patient‐centred care. Most nurses are nurses for the caring aspects. If the four phases of care succeed, nurses are allowed some control over their workload and can include in their patient care things they enjoy the most (de Casterlé et al., 2020; Gaudine, 2000). To reduce nursing workload, a care ethics perspective can provide solutions through fortifying interprofessional relationships and enhancing empathetic actions.

6. IMPLICATIONS FOR NURSING MANAGEMENT

The conflict between reducing health care costs and mandates of quality patient care has created on‐going decision making at the bedside and the managerial level. Care ethics challenge the depersonalization of nurse managers caring for nurses and encourage a view of the detailed, everyday experiences. Situational, individual and team approaches to management allow for incorporation of personal values and ethics of care to support patient‐centred care. Leadership initiating conversations and being proactive about time pressures, care rationing and managerial logic can lead to balanced workloads, reduced tensions and increased job satisfaction for both the nurse and the nurse manager. Bujacz et al. (2021) reported that nurses moving from early to mid‐career remain in jobs in which they experience increased control and support with a reduction of job demands. Conversely—in the same group of nurses—adverse health outcomes were associated with low autonomy, low support and moderated job demands.

Nurse autonomy can be expanded to a unit characteristic of collective efficacy that can guide manager efforts. Collective efficacy is defined as the capacity of a group of nurses to solve problems and correlates with an improved work environment and less missed care (Scott et al., 2019; Smith et al., 2018). Markey et al. (2022) show that this necessary problem‐solving environment is created when leadership fosters open, meaningful and respectful dialogue. Focus on dialogue, the work environment and collective efficacy aligns well with the relational aspects of care ethics that are quality of interactions, space for human connection and reflective practice for improvement (ORourke et al., 2019).

CONFLICT OF INTEREST

Both authors have no conflicts of interest to declare.

ETHICAL STATEMENT

No ethical approval was necessary because this is a review article.

Waterfield, D. , & Barnason, S. (2022). The integration of care ethics and nursing workload: A qualitative systematic review. Journal of Nursing Management, 30(7), 2194–2206. 10.1111/jonm.13723

DATA AVAILABILITY STATEMENT

Data sharing is not applicable—No new data are generated, or the article describes entirely theoretical research.