Marga Hoogendoorn

83 nurse. This confirms our expectation that in daily Dutch practice the objective workload is taken into account in the allocation of patients to nurses in case of more than one patient is allocated to nurse. This is also in line with a recent publication in Belgium where they suggested that differences in Nursing Activities Score could be explained by the organization of the ICU, i.e. the Nurse to Patient ratio 28 . However, the patients’ severity of illness (measured by the APACHE-IV Acute Physiology Score) is significantly associated with the experienced nursing workload. Every increase of the APACHE-IV Acute Physiology Score with 1 point gives an increase of 0,03 on the NASA-Task Load Index scale. This means that the workload of a complex severely ill patient has a bigger impact on the perceived nursing workload of the Intensive Care nurse compared to the less-complex patient. Also the graduation level of the nurse appeared to be associated with the perceived workload: student nurses experience higher workload compared to certified nurses. The lower maximum Nursing Activities Score points per student nurse also has shown that in practice less complex and intensive patients are assigned to student nurses because these nurses are in an educational situation and are not as competent as certified nurses. Student nurses do not yet have all skills to take care for the more complex patients in clinical practice. The impact of graduation level is an important factor for perceived nursing workload and a risk for distress or even a burn-out 23 . So being a student nurse on the Intensive Care, taking care for severely ill patients is an indication for a higher perceived nursing workload. The higher perceived nursing workload in student nurses can also occur in less experienced certified nurses. Due to the low number of nurses with < 2 years’ experience (N=9) we were not able to analyze the impact of this factor on the perceived nursing workload. However, research has shown that a short work experience is significantly related to emotional distress 26 . Due to the lack of skills the cognitive workload is not only higher for student nurses but also for nurses with a lack of experience. This finding must be taken into account by those responsible for planning nursing capacity, those who assign patients to nurses at the start of the shift, and the certified nurse counseling those students. A strength of this study is the multifactorial analysis of different potential factors influencing the perceived nursing workload. As far as we know this has not been investigated before in Intensive Care. Another strength of this study is the completeness of data about the Nursing Activities Score, NASA-Task Load Index, and data about patient-, nursing-, or contextual factors. The NASA-Task Load Index was filled in by all the nurses included in our study. We had to exclude only 8 patients due to missing Nursing Activities Score data. Those patients did not appear to be different with respect to the baseline characteristics, compared to the included patients.