Article Text

Download PDFPDF
A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life
  1. Richard J Holden1,2,
  2. Matthew C Scanlon3,
  3. Neal R Patel4,
  4. Rainu Kaushal5,
  5. Kamisha Hamilton Escoto6,
  6. Roger L Brown7,
  7. Samuel J Alper1,
  8. Judi M Arnold8,
  9. Theresa M Shalaby8,
  10. Kathleen Murkowski9,
  11. Ben-Tzion Karsh1
  1. 1Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
  2. 2Psychology, University of Wisconsin-Madison, Madison, Wisconsin, USA
  3. 3Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  4. 4Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
  5. 5Pediatrics and Public Health, Weill Cornell Medical College, New York, USA
  6. 6Analytics & Research Unit, Ingenix, Eden Prairie, Minnesota, USA
  7. 7Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
  8. 8Pediatric Critical Care, Vanderbilt Children's Hospital, Nashville, Tennessee, USA
  9. 9Critical Care, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
  1. Correspondence to Dr Ben-Tzion Karsh, Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, Room 3218, Madison, WI 53706, USA; bkarsh{at}


Background Nursing workload is increasingly thought to contribute to both nurses' quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualising and measuring the effects of workload in healthcare. In contrast, we conceptualised a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes.

Methods To test this model, we analysed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care paediatric hospitals.

Results Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading=0.31) and burnout (path loading=0.45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading=0.25) and medication error likelihood (path loading=1.04). Job-level workload was not uniquely and significantly associated with any outcomes.

Discussion The human factors engineering model of nursing workload was supported by data from two paediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.

  • Workload
  • mental workload
  • patient safety
  • medication error
  • quality of working life
  • human factors
  • nurses
  • medication safety

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding This work was supported in part by a grant from the Agency for Healthcare Research and Quality (1 R01 HS013610) to author B-TK. The Agency for Healthcare Research and Quality had no role in the study or publication except for providing funding for the study. Author RJH is supported by a training grant from the US National Institutes of Health (1 TL1 RR025013-01).

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the University of Wisconsin IRB, IRBs at each of the two participating hospitals.

  • Provenance and peer review Not commissioned; externally peer reviewed.