Abbey M, Chaboyer W, Mitchell M. Understanding the work of intensive care nurses: a time and motion study. Aust Crit Care.. 2012; 25:(1)13-22

Abdellah FG, Levine E. Work sampling applied to the study of nursing personnel. Nurs Res.. 1954; 3:(1)11-6

Armstrong E, de Waard MC, de Grooth HJS Using nursing activities score to assess nursing workload on a medium care unit. Anesth Analg.. 2015; 121:(5)1274-1280

Australian Institute of Health and Welfare. Australian hospital statistics 2014-2015. Admitted patient care. Series number 68 AIHW. 2016. (accessed 9 November 2020)

Australian Institute of Health and Welfare. Hospital resources 2017–18: Australian hospital statistics. 2019. (accessed 9 November 2020)

Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf.. 2014; 23:(2)116-125–001767

12-hour shifts: prevalence, views and impact. 2015. (accessed 19 November 2020)

Battle C, Temblett P. 12-Hour nursing shifts in critical care: a service evaluation. J Intensive Care Soc.. 2018; 19:(3)214-218

‘The pure hard slog that nursing is …’: a qualitative analysis of nursing work. 2014.

Chaboyer W, Wallis M, Duffield C A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: an observational study. Int J Nurs Stud.. 2008; 45:(9)1274-1284

Chan EA, Jones A, Wong K. The relationships between communication, care and time are intertwined: a narrative inquiry exploring the impact of time on registered nurses' work. J Adv Nurs.. 2013; 69:(9)2020-2029

Cooper H M. Synthesizing research: a guide for literature reviews, 3rd edn. London: SAGE; 1998

Cornell P, Herrin-Griffith D, Keim C Transforming nursing workflow, part 1: the chaotic nature of nurse activities. J Nurs Adm.. 2010; 40:(9)366-373

Debergh DP, Myny D, Van Herzeele I, Van Maele G, Miranda DR, Colardyn F. Measuring the nursing workload per shift in the ICU. Intensive Care Med.. 2012; 38:(9)1438-1444

DeCola PR, Riggins P. Nurses in the workplace: expectations and needs. Int Nurs Rev.. 2010; 57:(3)335-342

Desjardins F, Cardinal L, Belzile É, McCusker J. Reorganizing nursing work on surgical units: a time-and-motion study. Nurs Leadersh.. 2008; 21:(3)26-38

Doyle L. Synthesis through meta-ethnography: paradoxes, enhancements and possibilities.London: SAGE; 2003

Duffield C, Gardner G, Catling-Paull C. Nursing work and the use of nursing time. J Clin Nurs.. 2008; 17:(24)3269-3274

Estabrooks CA, Cummings GG, Olivo SA, Squires JE, Giblin C, Simpson N. Effects of shift length on quality of patient care and health provider outcomes: systematic review. Qual Saf Health Care.. 2009; 18:(3)181-188

Farquharson B, Bell C, Johnston D Frequency of nursing tasks in medical and surgical wards. J Nurs Manag.. 2013; 21:(6)860-866

Finkler SA, Knickman JR, Hendrickson G, Lipkin M, Thompson WG. A comparison of work-sampling and time-and-motion techniques for studies in health services research. Health Serv Res.. 1993; 28:(5)577-597

Griffiths P, Dall'Ora C, Simon M Nurses' shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety. Med Care.. 2014; 52:(11)975-981

Hendrich A, Chow MP, Skierczynski BA, Lu Z. A 36-hospital time and motion study: how do medical-surgical nurses spend their time?. Perm J.. 2008; 12:(3)25-34

Jones TL. A holistic framework for nursing time: implications for theory, practice, and research. Nurs Forum.. 2010; 45:(3)185-196

Monahan T, Fisher JA. Benefits of ‘observer effects’: lessons from the field. Qual Res.. 2010; 10:(3)357-376

Moher D, Liberati A, Tetzlaff J, Altman DG Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.2009

Length of hospital stay (indicator). 2019;

von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med.. 2007; 4:(10)

Westbrook JI, Duffield C, Li L, Creswick NJ. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals. BMC Health Serv Res.. 2011; 11:(1)

The examination of nursing work through a role accountability framework. 2015.

Are we measuring nursing workflow correctly? A literature review

26 November 2020
18 min read
Volume 29 · Issue 21


When it comes to determining what constitutes nursing workload, there are a number of approaches that represent and characterise the work of nursing across the three traditional shift patterns (morning/day, afternoon/evening and night). These are observational, self-reporting and work-sampling techniques. A review of the quantitative and qualitative literature to examine workload distributions between the three nursing shifts was undertaken. Using data sourced from the CINAHL, Scopus and Medline databases, the findings suggest that there is an inadequacy in establishing nursing productivity that is perhaps representative of the methods used to decipher nursing workload. This may contribute to poor quality care, and the high cost of excess nursing time contributes to the increasingly high costs of care. Linked to this is the nurse's job satisfaction. Quality of care and job satisfaction are important factors for the sustainability of the nursing workforce. There are few high-quality nursing articles that detail the workload distributions across the three nursing shifts and this is a potential area for further research.

In most cases, hospital nurses provide 24-hour care that can encompass a variety of roles and set procedures that are required to support patients during each nursing shift. Undoubtedly, time is a limited resource, it is dynamic and it costs healthcare services money (Jones, 2010). The Australian Institute for Health and Welfare (2016) identified the need to improve the productivity of the workforce and the need to address growing service demands as key areas for healthcare reform and cost reduction.

Historically, hospital-based nursing shifts traditionally worked on an 8-hour shift pattern (Ball et al, 2014) with a day/morning (7am–3.30pm), afternoon/evening (2.45pm–11.15pm) and night shift (10.45pm-7.15am). However, over the past 25 years, there has been a change in the nursing shift pattern to include 12-hour shifts, which were seen as a means of improving work satisfaction, increasing continuity of care (Battle and Temblett, 2018) and lowering healthcare costs (Estabrooks et al, 2009). However, Griffiths et al's (2014) review of quality of care and patient safety relative to nursing shift pattern across 12 European countries found that not all countries were adopting the 12-hour shift pattern, with many opting instead for the more traditional 8-hour shift pattern. For example, in surveying 33 659 nurses from 488 hospitals, only 14% of nurses were contracted to work 12-hour shifts; in just two countries, the Republic of Ireland and Poland, 12-hour shifts were the norm (Griffiths et al, 2014). Additionally, Ball et al's (2015) review of nursing patterns in the UK identified a 20% increase over a 4-year period in the use of 12-hour shift patterns, similar to the reasons identified previously—a shortage of nurses, continuity of care, managing home life more effectively and shorter shift rotations.

Register now to continue reading

Thank you for visiting British Journal of Nursing and reading some of our peer-reviewed resources for nurses. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to clinical or professional articles

  • Unlimited access to the latest news, blogs and video content