A systematic review of Registered Nurses; experiences of the influence of workplace culture and climatic factors on nursing workloads.

Background: Nursing workload is an issue that effects both the recruitment and retention of nurses, and patient safety. Historically, measurement has focussed on the delivery of direct patient care and excluded workload of facilitating hands-on care and supporting the organisation via duties that reflect organisation cultural and climate needs. Qualitative research is appropriate to understand this complexity.

Objective: To determine the best available evidence in relation to registered nurses experiences of workplace cultural and climatic factors that influence nursing workloads, in an acute health care setting.

Inclusion Criteria: This review sought high quality studies which explored registered nurses' experiences of the influence of cultural and climatic factors on their workloads. Qualitative research studies and opinion-based text were considered.

Search Strategy: An extensive search of the literature was conducted to identify published and unpublished studies between January 1990 and June 2011 in English, and indexed in the following databases: CINAHL, Medline, Medline-In Process, PsychINFO, Emerald, Current Contents, TRIP, JSTOR Nursing Consult Psychology & Behavioural Sciences collections, Emerald Management Reviews, Emerald Full Text Journals, Embase, Dissertation Abstracts, ERIC, Proquest and MedNar, EBSCOhost, Science Direct, Wiley Interscience.

Methodological Quality: Two independent reviewers (CRW and CRC), using appraisal tools from the Joanna Briggs Institute (JBI), assessed fifteen articles; one was excluded.

Data Collection: Data were extracted from included papers using standardised tools developed by the JBI.

Data Synthesis: Data from qualitative studies and textual/opinion papers were meta-synthesised separately using standardised instruments. Data synthesis involved the pooling of findings, then grouped into categories on the basis of similarity of meaning. The categories were further aggregated into synthesised findings.

Results: 14 papers were identified as high quality and meeting the inclusion criteria. 81 findings were identified from the 10 qualitative research papers and 39 conclusions from the 4 text/ opinion papers. While the research and non research evidence was analysed separately, both sets of evidence gave the same synthesised findings. The qualitative research findings were grouped into eight categories and textual data into six categories; all textual categories were also identified in the qualitative synthesis. These categories were aggregated into two synthesised findings.

Conclusions: Nursing workloads are influenced by the largely immeasurable cultural factors within hospital environments. These factors signify 'how we do things around here'. Organisational climate influences nursing workloads because of inter-professional relationships, clinical governance, workplace support, non-nursing duties, organisational structure and organisation, work redesign, workflow and diversity within nursing roles.

Implications For Practice: The component of registered nurses' workloads that are not patient-care should be recognised. Reviewing nursing roles to remove unnecessary work unrelated to patient care would positively influence nursing workloads, giving time for cognitive workload and clinical education and mentorship.

Implications For Research: Further qualitative research should explore the complexity of clinical nurses' roles in a diversity of settings, to address the responsibilities that registered nurses routinely assume, but which do not involve direct patient care. New workload models, which capture the non-measurable aspects of a registered nurse's role, should be developed and evaluated.