Abstract
Abstract
Objective
To estimate the workload of the nursing team and its associated factors during the intraoperative period for adult patients undergoing elective and urgent/emergency surgeries.
Design
Cross-sectional study.
Setting
Surgical units of two hospitals in Brazil.
Data sources and sample size
We prospectively assessed the workload using the National Aeronautics and Space Administration – Task Load Index (NASA-TLX) score and analysed the electronic medical records of patients who agreed to participate in the study, from November 2023 to February 2024. We included data from 116 nursing professionals and 402 surgeries.
Results
Among the procedures analysed, the median raw NASA-TLX score in cardiac surgery was significantly higher (60.8; IQR 40.0–72.5 points) compared with the others. We observed that in the generalised linear model procedures over minutes presented around 25% greater workload compared with 120 min surgeries (1.252; 95% CI 1.1018 to 1.549) and patients classified as American Society of Anesthesiologists (ASA) physical status classification (ASA) III and IV exhibited approximately 24% higher workload compared with those classified as ASA I (1.241; 95% CI 1.003 to 1.550).
Conclusions
Surgical length and ASA physical status influence the workload. Thus, we suggest that surgical unit leaders give special attention to long-term surgical procedures and patient severity on perioperative workload when dimensioning nursing staff.
Keywords: Decision Making, Health Services, HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Nursing Care, Health Workforce
STRENGTHS AND LIMITATIONS OF THIS STUDY.
This study includes data from over 400 surgical procedures to assess intraoperative nursing workload.
It encompasses both elective and urgent/emergency surgeries to reflect real-world intraoperative conditions.
Data were collected from two Joint Commission-accredited hospitals, enhancing the external validity of the findings.
The cross-sectional design limits the ability to assess temporal variations in nursing workload.
Background
In the context of intraoperative care, the nursing team interacts to carry out activities with other healthcare team members, the organisational structure and the patients and their families. Thus, there appears to be a significant workload, which can contribute to professionals' satisfaction levels, as well as impact safety in providing care to patients.1 2 Furthermore, the workload, when excessive, directly affects the quality of care provided to patients, as well as nursing professionals’ health and well-being, as there is a relationship between the worker and their work, which can generate well-being or suffering depending on the individual’s coping when facing the stimuli generated.3 4
Hart and Staveland define workload as “the perceived relationship between the amount of mental processing capability or resources and the amount required by the task” or as “the relationship between a group or individual and the work demands”.5 In the reality of nursing, the workload is associated with the volume of direct and indirect care that the professional is expected to perform.6
It is estimated that 234 million surgeries are performed annually worldwide, with a tendency to increase in the coming years due to the increase in life expectancy, in the incidence of health problems and in the technological advances that allow care for previously untreatable conditions. In this scenario, the nursing team plays an important role in forecasting and providing materials and providing direct care to patients and their families, as well as providing indirect care that involves the management of the surgical unit and operating room, which results in an important workload.7 8
Findings from systematic reviews and prospective studies conducted in intensive care units and central sterile services departments indicate that adequate nursing staffing is associated with reduced workload, improved clinical outcomes and a decreased risk of adverse events.9,12 At the same time, in perioperative nursing, an investigation evaluated the time required to carry out nursing activities in the intraoperative period according to the classification of nursing interventions.13 Another study, carried out in the post-anaesthesia care unit (PACU), in a university hospital, which assessed the nursing workload through the Nursing Activities Score of 160 patients, pointed out that the length of stay in the PACU and the surgical complexity influenced the nursing professionals’ workload. However, neither study measured the workload to which nursing professionals were exposed.14
In that regard, we observed that although nursing workload is a topic discussed in the scientific literature,9,14 the intraoperative nursing workload has yet to be investigated. In this complex context where nursing care is provided, professionals are exposed to stress, the need to make decisions quickly, the provision of direct care to vulnerable patients and the interaction with several health professionals simultaneously.15 Thus, the purpose of this study was to estimate the workload of the nursing team and its associated factors during the intraoperative period for adult patients undergoing elective and urgent/emergency surgeries.
Methods
Study design and setting
A cross-sectional study was conducted in the surgical units of Hospital Israelita Albert Einstein and Hospital e Maternidade Sepaco, both located in São Paulo, Brazil. These are tertiary-level institutions accredited by the Joint Commission International (JCI). Together, the operating units of the two hospitals are made up of 31 operating rooms and 55 post-anaesthesia recovery beds and have 37 perioperative nurses, 135 nursing technicians and 2 nursing assistants. These units serve patients requiring care in the following specialties: gynaecology, mastology, gastroenterology, otorhinolaryngology, orthopaedics, neurology, plastics, vascular surgery, adult and paediatric cardiac area, oncology, thoracic surgery, head and neck and urology. Accreditation by the JCI, along with the diversity of surgical specialties and the considerable number of operating rooms, recovery beds and nursing staff, positions these surgical units as an appropriate and representative setting for assessing nursing workload during the intraoperative period.
Population and sample
We collected data from all nursing professionals providing intraoperative care from the two institutions that agreed to participate in the study. Thus, the population consisted of 116 nursing professionals of both sexes, with work experience in the surgical unit for more than 6 months. We proposed a convenience sample to include 402 patients, of both sexes and aged 18 years or over, undergoing elective or urgent/emergency surgical procedures.
Nursing team members
In Brazil, nursing is represented by three categories: nurses, nursing technicians and nursing assistants, which account for more than half of the contingent of health professionals. They differ regarding training levels and responsibilities, which are established through hierarchical relationships and salary differences. It is estimated that 2.7 million nursing professionals are active in Brazil, of which 25% are nurses.15
In this study, we define nurses as those who have earned a bachelor’s degree in nursing after completing a 4-year to 5-year course. Nursing technicians are individuals who have completed a 2-year course and hold certificates, while nursing assistants have completed a 1-year course and also hold certificates. All these professionals are registered with the Regional Nursing Council at the state level, a regulatory body that ensures they are competent and qualified to carry out nursing activities according to their level of training.16
Surgical size
We classified the surgical sizes according to the duration of the surgery in minutes, as size 1, from 0 to 120 min; size 2, from 121 to 240 min; size 3, from 241 to 360 min; and size 4, over 360 min.17
Procedures for protection of participants’ rights
To carry out this study, we followed the Guidelines and Regulatory Standards for Research involving human beings, issued by Resolution No. 466/12 of the Brazilian National Health Council.18 Furthermore, nursing professionals and patients were invited to participate in the study, and those who agreed signed a written consent form prior to any data collection.
Ethics approval
The research project was approved by the Institutional Review Board of Hospital Israelita Albert Einstein (Reference No. 6.191.658) and by the Ethics Committee of Hospital e Maternidade Sepaco/Secretary of Health of the Municipality of São Paulo (Reference No. 6.502.283).
Data collection
Data collection took place from November 2023 to February 2024. After accepting to participate in the study and at the end of each surgical procedure, we applied an electronic collection form to the professionals. The instrument consisted of data from professionals and the National Aeronautics and Space Administration – Task Load Index (NASA-TLX).19 From patients, we made the prospective collection of data through access to the electronic medical record and consultation with family members through an electronic form (RedCap, Nashville, Tennessee, USA).20
Biosocial, health and professional data were collected from nursing professionals, including age, sex, body mass index, marital status, number of children, lifestyle habits, comorbidities, professional category, academic background and years of professional experience. For patients, biosocial and health data were collected, as well as characteristics of the surgical procedures, including age, body mass index, comorbidities, American Society of Anesthesiologists (ASA) physical status classification, surgical size, and the work shift during which the procedure was initiated.
Intraoperative workload assessment
We selected the NASA-TLX instrument for workload evaluation. Hart and Staveland developed the NASA-TLX in 1988, in the field of aviation, to assess mental workload during or after the performance of an activity/task.5 Currently, the instrument has been used by several authors to assess health professionals’ workload and has been validated for use in the context of healthcare in Brazil.5 19 The score consists of six dimensions: mental (how much thinking, deciding or calculating was required to perform the task), physical (the amount and intensity of physical activity required to complete the task), temporal (the amount of time pressure involved in completing the task), performance (the level of success in completing the task), effort (how hard does the participant have to work to maintain their level of performance?) and frustration (how insecure, discouraged, or secure or content the participant felt during the task). Each item can be evaluated on an intensity scale ranging from very little to very much, representing a score between zero and 100, with zero referring to the lowest workload and 100 to the highest workload after carrying out a task. We present the response scale using a horizontal line divided into 20 intervals, ranging from zero (low workload) to 100 (high workload). Therefore, for measurement, we ask participants to indicate the desired location for each dimension, considering the experience of the task performed. We obtained the scores for each dimension and calculated the average, therefore obtaining the raw workload. To date, there are no cut-off points in scores that can offer classifications; however, the results allow making comparisons between similar tasks.5 19
Data storage and analysis
We store the data to ensure secrecy, confidentiality and privacy of research participants in the RedCap system (Nashville, Tennessee, USA).20 Subsequently, we exported the anonymised data to RStudio Software V. 1.2.5019 (RStudio, Boston, Massachusetts, USA), for analysis by a statistician.
For categorical variables, we calculated absolute and relative frequencies. For numerical variables, we initially checked data normality using the Shapiro-Wilk test and inspection of the QQ chart. After detecting that all numerical variables presented a distribution other than normal, we calculated the medians and interquartile ranges and used the Brunner-Munzel test to compare variances. Furthermore, we calculated a generalised linear model, family gamma, logarithmic link function, with backward pruning, in which we included the variables potentially associated with workload, to estimate workload prediction coefficients. We evaluate model adjustment using Negelkerke’s Pseudo R2. For all hypothesis tests, we used a significance level of α=5%.
Results
We included data from 116 nursing professionals and 402 patients undergoing surgical procedures from November 2023 to February 2024. Therefore, to better understand the results, we will present the section in relation to professionals’ characteristics, patients submitted to surgical procedures and workload.
Characteristics of nursing professionals
The majority were female (82; 70.7%), with a median age of 34.6 (28.2–40.7) years, and 63 (54.3%) were married. Most of them were nursing technicians (106; 91.4%), followed by nurses (8; 6.9%) and nursing assistants (2; 1.7%). Regarding professional experience, the median was 24.0 (IQR 12.0–48.0) months. A total of 82.2% had another professional relationship, and 94% combined work with studies (table 1).
Table 1. Distribution of nurses, nursing technicians and assistants according to demographic and professional characteristics. São Paulo, 2024. (n=116).
| Variables | Values |
|---|---|
| Female sex, n (%) | 82 (70.7) |
| Age, years, median (IQR) | 34.6 (28.2–40.7) |
| BMI, kg/m2, median (IQR) | 27.0 (24.3–30.1) |
| Marital status, n (%) | |
| Single | 38 (32.8) |
| Married | 63 (54.3) |
| Divorced | 14 (12.1) |
| Widower | 1 (0.9) |
| Have children, n (%) | 59 (50.9) |
| Number of children, median (IQR) | 1.0 (0.0–2.0) |
| Smoking, n (%) | 12 (10.3) |
| Alcoholism, n (%) | 6 (5.2) |
| Comorbidities, n (%) | 23 (19.8) |
| Arterial hypertension | 12 (10.3) |
| Heart disease | 6 (5.2) |
| Depression | 4 (3.4) |
| Anxiety | 2 (1.7) |
| Type II diabetes mellitus | 2 (1.7) |
| Professional category, n (%) | |
| Assistant | 2 (1.7) |
| Nurse | 8 (6.9) |
| Technician | 106 (91.4) |
| Training, n (%) | |
| Nursing specialisation in OR | 3 (2.6) |
| Specialisation in other areas | 5 (4.3) |
| Time of professional experience, months, median (IQR) | 24.0 (12.0–48.0) |
| Other professional relationship, n (%) | 100 (82.2) |
| Conciliates work with studies, n (%) | 109 (94.0) |
BMI, body mass index; SU, surgical unit.
Characteristics of patients submitted to surgical procedures
The study involved 402 patients, with a median age of 42.1 years (32.6–54.0); the majority were female (230; 57.2%), 41.3% (166) were classified as ASA I and 49.7% (200) as ASA II, and general anaesthesia was the most used technique (242; 60.2%).
They underwent 402 surgical procedures, most frequently in the specialties of urology (89; 22.1%) and gynaecology (85; 21.1%) (online supplemental table 1). Among the surgeries, the majority (300; 74.6%) was size 1, and 91.8% (369) had an elective scheduling. Regarding the shift in which the procedure was performed, we observed the highest frequency in the morning (266; 56.2%), followed by the afternoon (165; 41%). We also found that in 54.7% of the procedures, there was a need to use consigned materials and the nursing technician in the operating room received support from a colleague during the procedure in 62.2% of cases (online supplemental table 2).
Workload
To measure workload, we applied the NASA-TLX index to nursing professionals (n=116) at the end of each surgical procedure (n=402). This scale provides an understanding of the workloads of nursing professionals in general and each of the six dimensions: mental demand, physical demand, temporal demand, performance, effort and frustration. We observed that the median raw score was 32.9 (IQR 23.3–57.5) points; however, we did not observe significant differences between the global scores in each of the specialties investigated. The cardiac surgery specialty had a higher median mental dimension than the others (65.0; IQR 55.0–95.0 points) (p=0.022). The oncology surgery specialty presented a higher effort dimension than the others with a median of 70.0 (IQR 25.0–77.5) points (p=0.05) and the ear, nose and throat surgery specialty presented a higher frustration dimension than the others with a median of 15.0 (IQR 5.0–60.0) points (p=0.008) (online supplemental table 3).
We observed that the median global score was higher in surgical procedures classified as size 4, namely 49.6 (IQR 40.6–60.6) points (p=0.001). The median of the performance dimension was higher than the others in procedures classified as size 1 (95.0; IQR 80.0–100.0 points) (p=0.004). Furthermore, we observed higher medians in size 4 in relation to the others: mental dimension (57.5; IQR 25.0–65.0 points) (p=0.001), physical dimension (50.0; IQR 22.5–58.7 points) (p=0.001), temporal dimension (52.5; IQR 45.0–63.7 points) (p=0.001), effort dimension (57.5; IQR 41.2–92.5 points) (p=0.001) and frustration dimension (12.5; IQR 5.0–47.5 points) (p=0.033) (table 2).
Table 2. Distribution of workloads, following NASA-TLX, according to surgical size. São Paulo, 2024. (n=402).
| Dimension/variables | Surgical size 1 (n=300) | Surgical size 2 (n=69) | Surgical size 3 (n=23) | Surgical size 4 (n=10) | P value |
|---|---|---|---|---|---|
| Mental, median (IQR) | 15.0 (5.0–40.0) |
35.0 (15.0–75.0) |
30.0 (12.5–50.0) |
57.5 (25.0–65.0) |
0.001 |
| Physical, median (IQR) | 20.0 (5.0–45.0) |
45.0 (20.0–70.0) |
30.0 (10.0–67.5) |
50.0 (22.5–58.7) |
0.001 |
| Temporal, median (IQR) | 20.0 (5.0–55.0) |
50.0 (15.0–80.0) |
45.0 (17.5–62.5) |
52.5 (45.0–63.7) |
0.001 |
| Performance, median (IQR) | 95.0 (80.0–100.0) |
85.0 (80.0–100.0) |
95.0 (70.0–100.0) |
60.0 (56.2–80.0) |
0.004 |
| Effort, median (IQR) | 20.0 (5.0–60.0) |
50.0 (20.0–80.0) |
35.0 (10.0–47.5) |
57.5 (41.2–92.5) |
0.001 |
| Frustration, median (IQR) | 5.0 (5.0–20.0) |
10.0 (5.0–30.0) |
5.0 (5.0–10.0) |
12.5 (5.0–47.5) |
0.033 |
| Global, median (IQR) | 30.0 (21.7–52.5) |
45.8 (31.7–70.0) |
35.0 (27.5–57.1) |
49.6 (40.6–60.6) |
0.001 |
NASA-TLX, National Aeronautics and Space Administration – Task Load Index.
We calculated the raw NASA-TLX score, considering the ASA physical status score. We found that the median global score was higher among patients classified as ASA III compared with the others (49.3; IQR 33.3–60.9 points) (p=0.015). We observed, among patients classified as ASA IV, mental dimension median (65.0; IQR 50.0–82.5 points) (p=0.035) and physical dimension median (50.0; 35.0–75.0 points) (p=0.008) higher than the medians of the other scores. Furthermore, the median of the effort dimension was higher in the ASA III score in relation to the others (50.0; IQR 25.0–75.0 points; p=0.013) (table 3).
Table 3. Distribution of workloads, following NASA-TLX, according to ASA physical status score. São Paulo, 2024. (n=402).
| Dimension/variables | ASA I (n=166) |
ASA II (n=200) |
ASA III (n=33) | ASA IV (n=3) | P value |
|---|---|---|---|---|---|
| Mental, median (IQR) | 15.0 (5.0–48.7) |
20.0 (5.0–45.0) |
30.0 (15.0–55.0) |
65.0 (50.0–82.5) |
0.035 |
| Physical, median (IQR) | 20.0 (5.0–55.0) |
20.0 (10.0–45.0) |
50.0 (25.0–70.0) |
50.0 (35.0–75.0) |
0.008 |
| Temporal, median (IQR) | 25.0 (5.0–65.0) |
25.0 (10.0–56.2) |
50.0 (30.0–60.0) |
45.0 (32.5–65.0) |
0.089 |
| Performance, median (IQR) | 95.0 (81.2–100.0) |
95.0 (80.0–100.0) |
100.0 (75.0–100.0) |
95.0 (75.0–97.5) |
0.314 |
| Effort, median (IQR) | 20.0 (5.0–68.7) |
27.5 (10.0–60.0) |
50.0 (25.0–75.0) |
45.0 (35.0–47.5) |
0.013 |
| Frustration, median (IQR) | 10.0 (5.0–20.0) |
5.0 (5.0–20.0) |
10.0 (5.0–35.0) |
5.0 (5.0–5.0) |
0.295 |
| Global, median (IQR) | 30.4 (21.7–60.8) |
33.3 (23.1–50.2) |
49.2 (33.3–60.8) |
40.0 (39.2–56.2) |
0.015 |
ASA, American Society of Anesthesiologists Physical Status Score; NASA-TLX, National Aeronautics and Space Administration – Task Load Index.
We computed the raw NASA-TLX score in the different work shifts and found a higher median for procedures performed in the afternoon shift (40.0; IQR 25.0–65.0 points; p=0.001). We also observed higher medians in procedures performed in the afternoon compared with the others: mental dimension (30.0; IQR 10.0–65.0 points; p=0001), physical dimension (30.0; IQR 10.0–65.0 points) (p=0.001), temporal dimension (40.0; IQR 10.0–80.0 points) (p=0.003), effort dimension (45.0; IQR 10.0–80.0 points) (p=0.001) and frustration dimension (10.0; IQR 5.0–30.0 points) (p=0.030) (table 4).
Table 4. Distribution of workloads, following NASA-TLX, according to the work shift. São Paulo, 2024. (n=402).
| Dimension/variables | Morning (n=226) | Afternoon (n=165) |
Night (n=11) |
P value |
|---|---|---|---|---|
| Mental, median (IQR) | 15.0 (5.0–35.0) |
30.0 (10.0–65.0) |
5.0 (5.0–47.5) |
0.001 |
| Physical, median (IQR) | 20.0 (5.0–40.0) |
30.0 (10.0–65.0) |
10.0 (5.0–60.0) |
0.001 |
| Temporal, median (IQR) | 20.0 (5.0–55.0) |
40.0 (10.0–80.0) |
25.0 (7.5–55.0) |
0.003 |
| Performance, median (IQR) | 95.0 (80.0–100.0) |
95.0 (80.0–100.0) |
95.0 (90.0–100.0) |
0.656 |
| Effort, median (IQR) | 17.5 (6.2–55.0) |
45.0 (10.0–80.0) |
10.0 (5.0–67.5) |
0.001 |
| Frustration, median (IQR) | 5.0 (5.0–15.0) |
10.0 (5.0–30.0) |
5.0 (5.0–27.5) |
0.030 |
| Global, median (IQR) | 30.8 (21.7–48.3) |
40.0 (25.0–65.0) |
25.0 (21.7–59.6) |
0.001 |
NASA-TLX, National Aeronautics and Space Administration – Task Load Index.
We grouped the NASA-TLX scores into procedures in which the professional received support from another during the intraoperative period and found that the median raw score was higher among those who received support (36.7; IQR 23.3–57.5 points) compared with those who did not (29.2; IQR 21.5–51.7 points) (p=0.016). Higher medians were observed in procedures in which professionals received intraoperative assistance in the following dimensions: mental (25.0; IQR 10.0–55.0 points; p=0.001), physical (25.0; IQR 10.0–60.0 points; p=0.021), temporal (32.5; IQR 10.0–65.0 points; p=0.027) and effort (35.0; IQR 10.0–75.0 points; p=0.016) (online supplemental table 4).
After performing the univariate analysis, the variables were included in a generalised linear model. Thus, we found that surgical procedures classified as size 3 and 4 had approximately 25% greater workload compared with those classified as size 1 (exponential of regression coefficient 1.252; 95% CI 1.018 to 1.549) and patients classified as ASA physical status III and IV exhibited approximately 24% higher workload compared with those classified as ASA I (exponential of regression coefficient 1.241; 95% CI 1.003 to 1.550). Moreover, professionals with up to 24 months of experience exhibited approximately 26% higher workload compared with those with more than 24 months of professional experience (exponential of regression coefficient 1.267; 95% CI 1.130 to 1.420) (table 5).
Table 5. Regression coefficients for workload prediction. São Paulo, 2024. (n=402).
| Variables | Exp (coef) | 95% CI | P value |
|---|---|---|---|
| Intercept | 34.030 | 26.393 to 44.329 | <0.001 |
| Professional category—nurse | 1 (Ref) | ||
| Professional category—nursing technician | 1.119 | 0.886 to 1.395 | 0.333 |
| Surgical size 1 | 1.00 (Ref) | ||
| Surgical size 2 | 1.165 | 0.986 to 1.386 | 0.077 |
| Surgical sizes 3 and 4 | 1.252 | 1.018 to 1.549 | 0.033 |
| ASA I | 1 | ||
| ASA II | 1.034 | 0.918 to 1.163 | 0.581 |
| ASA III and IV | 1.241 | 1.003 to 1.550 | 0.050 |
| Procedure performance shift—morning | 1 (Ref) | ||
| Procedure performance shift—afternoon | 1.051 | 0.931 to 1.189 | 0.417 |
| Procedure performance shift—night | 0.825 | 0.601 to 1.167 | 0.250 |
| Professional received support—no | 1 (Ref) | ||
| Professional received support—yes | 0.928 | 0.826 to 1.044 | 0.212 |
| Professional experience time >24 months | 1 (Ref) | ||
| Professional experience time ≤24 months | 1.267 | 1.130 to 1.420 | <0.001 |
Negelkerke’s Pseudo R2 0.128
ASA, American Society of Anesthesiologists Physical Status Score; Exp (coef), exponential of regression coefficient; Ref, reference category.
Discussion
In this study, a comprehensive analysis of approximately 400 patients undergoing surgical procedures and just over a hundred nursing professionals revealed that size 3 or 4 procedures and patients classified as ASA III or IV imposed a greater workload. Moreover, professionals with up to 24 months of experience reported higher workloads compared with their more experienced counterparts, suggesting that shorter perioperative nursing experience may be associated with higher perceived workload. These findings provide valuable insights into workload management in perioperative nursing, enlightening the healthcare community.
Studies seeking to elucidate the issue of workload in perioperative nursing are rare.13 21 However, an investigation evaluating the productivity of nursing professionals during the intraoperative period of patients undergoing oncological surgeries, which included 11 nurses and 25 nursing technicians, reported high productivity, in which professionals continued performing tasks for a period exceeding 90% of the time available on duty.13
The results of this study showed that the surgical size increased the workload. Size 3 and 4 surgeries are defined as those that require 4 hours or more to be finished.17 The increase in workload associated with sizes 3 and 4, demonstrated in the results of this study, may be due to the complexity of the procedure and the duration itself. Surgeries classified as size 1 normally involve patients receiving low-complexity care under sedation, non-invasive monitoring of vital signs, low-risk surgical positioning for injuries and the use of fewer surgical instruments and special materials.22 As the size increases, the characteristics of the procedures and patients change. Sizes 3 and 4 surgeries normally require general anaesthesia, temperature monitoring and prevention of hypothermia, invasive haemodynamic monitoring, surgical positioning at greater risk for the development of injuries, transfusion of blood components and the use of special materials, which may explain the increased workload.23,25 At the same time, an investigation conducted in a PACU that assessed nursing workload using the Nursing Activities Score (NAS) showed a moderate correlation between surgical size and the NAS score. Patients undergoing prolonged surgical procedures had a higher frequency of complications, such as hypothermia, pain or skin injuries related to surgical positioning and a greater risk of haemodynamic and ventilatory instability.14 Additionally, it was observed in the results of a study including 187 patients in the immediate postoperative period of cardiac surgeries, in an intensive care unit, which measured the workload using the NAS, that the patient’s severity scores, the need for specific care, the number of invasive artefacts, the high frequency of medication administration, the use of technologies for ventilatory and circulatory support, significantly increased the workload.26
Furthermore, the surgical size is considered for managing the surgical schedule and allocating of procedures in the operating rooms, because longer procedures often require more surgical instruments, special materials and medical equipment in the operating room. This represents a significant workload for nursing professionals, whether in setting up the room, managing various medical equipment, dismantling the operating room and preparing for the subsequent procedure.27
The results of this study indicated that patients classified as ASA III or IV represent a higher workload. Patients in the upper strata of the ASA score may present greater haemodynamic instability, technical difficulties during anaesthetic induction and surgical procedures, as well as the need for advanced haemodynamic monitoring. Furthermore, findings from a recently published Swedish cohort study that included data from approximately 500 000 patients undergoing elective and emergency surgical procedures demonstrated that patients classified as ASA III have up to a 14-fold higher risk of postoperative mortality, while those classified as ASA IV have up to a 62-fold higher risk compared with patients classified as ASA I. In addition, surgical procedures performed in patients classified as ASA III to IV were longer than those in the other groups.28
The results of this investigation also showed that shorter perioperative nursing experience may be associated with higher workload among nursing professionals. This can be explained by the fact that professionals with longer experience have greater practical knowledge in different types of procedures, available technologies and unit routines, which allows them better planning and decision-making, and frequent contams, which favours better interpersonal skills.29 A study carried out in Sweden, which included 10 operating room nurses, identified that less experienced professionals feel under pressure with the demands of daily activities and report a lack of time to carry out tasks and insufficient rest breaks, which can lead to errors.30 In this same study, the results showed that tasks are performed in less time by more experienced professionals; it also reports greater ease in establishing priorities for care provision, including in unexpected situations, providing greater patient safety.30
Another survey of 13 critical care nurses, including perioperative nurses who recently graduated, in three hospitals in Iran, pointed out that the lack of knowledge at work, the difficulty in decision-making, the fear of making mistakes and the unfriendly behaviour of other more experienced health professionals were factors that caused insecurity. It was also highlighted that this situation increases the workload, hinders new professionals’ adaptation to the workplace and can compromise patient safety.31
Strengths and limitations
The study was conducted in two health institutions, which expands the possibility of generalising its results and, to our knowledge, this is the first study on the workload of the nursing team during the intraoperative period. However, the study design may be a limitation, since the phenomenon was investigated in a single period and the workload of nursing professionals in the perioperative period may suffer interference linked to variations in the occupancy rate of the operating room. Moreover, the results of the generalised linear model should be interpreted with caution, as some variables included categories with a small number of observations, such as ASA IV and surgical size 4, as well as the limited number of nursing professionals included, which may have affected the analysis of the effects of professional experience on workload.
Implications for perioperative management
The findings of this study demonstrated that surgical centre management should consider characteristics related to surgical procedures and professionals. We recommend adjusting nursing staff allocation for size 3 and 4 procedures and for patients classified as ASA III or IV, ensuring the presence of more than one nursing professional to carry out the required activities in the operating room. Furthermore, it is emphasised that training and development policies for new professionals are necessary to increase their self-confidence, mitigate the risk of errors and make the workload compatible. Finally, we suggest that training programmes be developed that address patient safety; handling of medical equipment; workflows, such as environmental cleaning, preparation and circulation of the operating room, opening of materials using aseptic technique, surgical attire, control and packaging of surgical specimens; risk prevention; and effective communication.31 32
Conclusion
This study estimated the nursing workload in the intraoperative period of adult patients undergoing surgical procedures using NASA-TLX instrument in two hospitals’ surgical units. The surgical size, patient ASA status and professionals’ experience were identified as factors associated with higher workload.
Therefore, we suggest that surgical unit leaders give special attention to long-term surgical procedures and to patients’ perioperative health status when dimensioning nursing staff.
Supplementary material
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Prepub: Pre-publication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-095352).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and was approved by the Institutional Review Board of Hospital Israelita Albert Einstein (Reference No. 6.191.658) and by the Ethics Committee of Hospital e Maternidade Sepaco/Secretary of Health of the Municipality of São Paulo (Reference No. 6.502.283). Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability free text: The raw data for this study will be available upon request from the authors.
Data availability statement
Data are available upon reasonable request.
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