Vol. 5, No. 10, October 2024
E-ISSN: 2723 - 6692
P-ISSN:2723- 6595
http://jiss.publikasiindonesia.id/
Journal of Indonesian Social Sciences, Vol. 5, No. 10, October 2024 2574
Systematic Literature Review: Nurses' Work Hours and
Workload Impact on Patient Safety Incidents
Edi Kurnawan, Farida Yuliaty
Universitas Sangga Buana YPKP, Bandung, Indonesia
Email: edikurnawan29@gmail.com, farida.yuliaty@usbypkp.ac.id
Correspondence: edikurnawan29@gmail.com
*
KEYWORDS
ABSTRACT
Nurse working hours; nurse
workload; patient safety; nurse
fatigue; medical errors; quality
of care
Patient safety is a key indicator in assessing the quality of healthcare
services in hospitals, and nurses play a crucial role in maintaining
that safety. However, long working hours and high workloads can
affect nurses' performance, increasing the risk of fatigue, stress, and
burnout, ultimately contributing to medical errors and decreased
quality of care. This study aims to conduct a systematic literature
review on the effect of nurses' working hours and workload on
hospital patient safety incidents. Patient safety is a key indicator in
assessing healthcare quality, and nurses play an essential role in
maintaining patient safety during daily care. However, long working
hours and high workloads can affect nurses' performance,
increasing the risk of fatigue, stress, and burnout, ultimately
contributing to medical errors and decreased quality of care.
Through the analysis of various relevant studies, this review
suggests that more flexible working hour arrangements and
balanced workload management can reduce the risk of patient
safety incidents and improve the quality of care provided. This study
also recommends that hospital human resource management to
create a healthier and safer working environment for nurses and
patients.
Attribution-ShareAlike 4.0 International (CC BY-SA 4.0)
Introduction
Changes in the level of education and social status of the community at this time increase their
awareness of getting health services that are not only of high quality but also safe. One of the most
important quality indicators is patient safety. Hospital patient safety is a system by which hospitals
make patient care safer, which includes risk assessment, identification and management of matters
related to patient risk, incident reporting and analysis, The ability to learn from incidents and their
follow-up and implementation of solutions to minimize the incidence of risk and prevent injury
caused by errors due to acting or not taking action that should be taken Patient safety incidents are
part of patient safety which is any unintentional event and condition that results in or has the
potential to cause preventable injury to patients, consisting of Unexpected Events (KTD), Nearly
Injured Events (KNC), Non-Injury Events (KTC) and Potential Injury Events (KPC) (Darimis et al., 2022).
Patient safety is one of the key indicators in assessing the quality of healthcare services in
hospitals. The high incidence of incidents related to patient safety, such as medication errors,
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nosocomial infections, or injuries from falls, remains a major challenge in various health systems
around the world. In a hospital setting, nurses are crucial in maintaining patient safety as they are
directly involved in the daily care process. However, high workloads and long working hours are often
considered factors that can affect nurses' performance, which ultimately impacts patient safety.
(Sholeh & Chalidyanto, 2021).
Research shows that nurses' working conditions, including the duration of working hours and
level of workload, significantly affect the quality of healthcare provided. Excessive working hours and
unbalanced workloads can result in physical and mental fatigue, which can reduce focus, increase the
risk of errors, and negatively impact clinical judgment. Therefore, identifying the influence of nurses'
working hours and workload on patient safety incidents is an important topic that deserves more
attention.
In the context of health care, nurses are often faced with high job demands in terms of the
quantity of patients to be handled and the complexity of tasks to be completed. In many hospitals,
nurses have to handle more patients than is ideal, resulting in limited time to provide individualized
attention to each patient. These demands can cause nurses to feel pressure, reduce the quality of
interactions between nurses and patients, and potentially neglect the specific health needs of each
patient. In this situation, hospital management must be aware of nurses' challenges and find effective
solutions.
Long working hours, especially in a shift system, can increase the risk of fatigue, stress, and
burnout. Nurses who work irregular or excessively long shifts are likely to experience sleep
disturbances and physical and mental fatigue. This fatigue can reduce nurses' alertness and
concentration, crucial in providing safe and effective care. With high levels of fatigue, nurses may be
unable to function at optimal capacity, potentially leading to medication administration errors or
crucial clinical decisions (Pogorzelska & Chlabicz, 2022).
Heavy workloads also often contribute to medical errors. When nurses attempt to complete
tasks in a limited time, they may miss important steps in care procedures (Taneja et al., 2021). For
example, in a rushed situation, nurses may not check the patient's medical history thoroughly or miss
important observations regarding the patient's condition. These kinds of mistakes jeopardize patient
safety and can increase nurses' emotional and psychological burden, exacerbating burnout issues.
Therefore, hospitals and healthcare institutions need to evaluate and adjust nurses' work
systems. Implementing more flexible work schedules, reducing the number of patients nurses handle
at a time, and providing adequate psychological support can Tanaem help reduce stress and improve
nurses' well-being. Thus, these measures will support nurses' mental and physical health and
improve the quality of patient care, reduce the risk of safety incidents, and ultimately create a safer
and more efficient healthcare environment.
Many studies have shown that nurses who work more than 12 hours per shift or experience
excessive workloads tend to have a higher risk of making errors that can harm patients
(Santhoshkumar et al., 2022). This not only jeopardizes patient safety but can also affect nurses' well-
being. However, while the relationship between workload, working hours, and patient safety
incidents has been recognized, there are still differences in research results regarding how much
influence they have and how they can be effectively managed to reduce risk.
Thus, the objective of this study is to explore the impact of Lean and Continuous Improvement
methodologies on hospital financial management. This study will review the existing literature to
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understand how these methodologies contribute to operational efficiency, cost savings, and the
overall improvement of patient care. The results of this review are expected to provide valuable
insights that can guide hospital administrators in implementing these methodologies effectively to
meet the financial and operational challenges of modern healthcare systems.
Materials and Methods
The research design was a systematic literature review that collected and analyzed research on
the effect of nurses' working hours and workload on patient safety incidents. The inclusion criteria
were studies published between 2019 and 2024 focusing on nurses as subjects. These studies
examined the relationship between working hours, workload, and patient safety, and were conducted
in English or Indonesian. Exclusion criteria included non-peer-reviewed articles, studies irrelevant to
the topic, and studies in languages other than English and Indonesian.
The data search was conducted using PubMed, Scopus, and Google Scholar databases. These
databases were chosen due to their broad coverage in health research, ensuring a comprehensive
collection of relevant studies. Keywords used included "nurse working hours," "nurse workload,"
"patient safety," and "patient safety incidents." In addition to journals, book materials and relevant
regulations were also used.
The selection of reviewed studies involved a multi-step process. Initially, articles were screened
based on titles and abstracts to identify relevance to the research topic. Subsequently, full-text articles
were assessed to determine if they met the inclusion criteria. The quality of the selected articles was
evaluated using the PRISMA method to ensure that only high-quality and relevant studies were
included in the review. Extracted data included the title, year of publication, study design, sample size,
and key findings related to working hours, workload, and patient safety incidents. Data were then
systematically analyzed to identify research consistency and draw conclusions.
Results and Discussions
Nurse Working Hours
Nurses' working hours are one important factor affecting the quality of health services
provided. They are usually organized by shift to ensure continuous care for patients. However, long
shifts or excessive working hours can negatively impact nurses' health and patient safety (Riau, 2024).
Long working hours in the healthcare sector, especially among nurses, can lead to significant
physical and mental fatigue. Working more than 12 hours a day or more than 60 hours a week
consistently increases the risk of medical errors, decreases focus, and increases patient safety
incidents by up to 3 times patient safety. It is explained that fatigue due to long working hours affects
nurses' performance, decreases cognitive capacity, and increases the likelihood of errors in decision-
making (Rahman, 2020; Bahuguna et al., 2023). Other studies have shown that nurses who work long
shifts, especially more than 12 hours, are likelier to report low job satisfaction and a desire to leave
their profession (Afrashtehfar, Assery, & Bryant, 2020).
Nurse Workload
Health Law No.36 of 2009 states that workload is the product of the number of jobs with time
and the amount of work that must be beaten by a position/organizational unit. Every worker can
work without endangering himself and the community around him, so it is necessary to adjust the
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workload, work capacity, and work environment to obtain optimal work productivity (Manzoor, Wei,
Hussain, Asif, & Shah, 2019).
Workload (Asif et al., 2019) is the average frequency of each job activity within a certain period.
Workload is a record of work results or volume of work results that can show the volume produced
by several employees in a particular section. A group or a person must complete a certain amount of
work in a certain time or workload, which can be seen objectively and objectively. Subjective
workload is a statement of the measure a person uses to measure feelings of work overload, job
pressure, and job satisfaction. Objectively, it is the number of activities performed or the overall time
used (Jiang, 2020).
A high workload can result in poor communication between nurses and patients, failure of
collaboration between nurses and doctors, nurse turnover, and job dissatisfaction. According to the
results of research (Miao, Zhang, Wu, Zhang, & Jiang, 2020),Click or tap here to enter text. indirect nurse
activities are activities that are carried out in the inpatient room, and the factors that affect workload
are the number of patients, the number of nurses, and the number of activities.
According to the study (Hussain et al., 2019) Factors that affect workload
a. The number of nurses is a problem that often arises in hospitals, one of which is the
unbalanced workload of nurses. It is often difficult for managers to determine the quality of
workload because it is more based on subjective complaints. This situation usually starts from
the planning stage when the need for nurses is not by the work capacity of a health care
institution.
b. Work environment conditions The work environment can be a source of workload, including
work demands, work demands, relationships between nurses and work responsibilities,
relationships between nurses are not good enough.
c. Leadership should also be able to coordinate a conducive and dynamic work environment and
actively plan nurses' career development. Motivate nurses to be good nurses and have the
foresight to improve their professionalism.
d. Nurses' responsibilities Nurses are responsible for both their own patients and the patients
of other nurses. Working with a new nurse in a particular room, or a newly graduated nurse
can increase the workload of other nurses, it can also be because they feel responsible for the
safety of the patients being handled by the new nurse.
Nurses' workload certainly affects the time nurses can devote to various tasks. (Kalaja, 2023).
With a heavy workload, nurses may not have enough time to perform tasks that can have a direct
impact on patient safety. A heavy nurse workload may affect the provider's decision to perform
various procedures.
Patient Safety
Hospital patient safety is a system where hospitals make patient care safer. Patient safety
consists of six goals, namely, correct patient identification, improving effective communication,
preventing medication errors, preventing procedural errors, appropriate location and patients in
surgery, preventing the risk of infection and preventing the risk of patient falls, but of these six goals
the incidence of patient falls is still a worrying issue throughout hospital inpatients (Okafor & Chen,
2019).
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Hand hygiene, washing hands properly before and after contact with patients (Jian Nan Chen,
Ren, Xu, Zhang, & Xia, 2022). Use of appropriate protective equipment (e.g., gloves) before patient
contact. Respiratory hygiene (e.g., covering mouth when coughing and sneezing). Safety against
injections and sharps and proper disposal.
According to (Qinyu Chen et al., 2019)the patient safety standard consists of seven standards,
namely:
1. Patient rights Patients and their families have the right to obtain information about service
plans and outcomes including the possibility of adverse events.
2. Educating patients and families Hospitals should educate patients and their families about
patient obligations and responsibilities in patient care.
3. Patient safety and continuity of care The hospital ensures continuity of care and ensures
coordination between personnel and between service units.
4. Use of performance improvement methods to conduct patient safety evaluation and
improvement programs Hospitals should design new processes or improve existing
processes, monitor and evaluate performance through data collection, intensively analyze
adverse events, and make changes to improve performance and patient safety.
5. The role of leadership in improving patient safety
6. Educate staff on patient safety
7. Communication is key for staff to achieve patient safety.
According to the National Hospital Patient Safety Guidelines of the Ministry of Health of the
Republic of Indonesia (2015), in implementing patient safety standards, hospitals must implement
seven steps towards patient safety (Zhang, Xu, Chen, Li, & Chen, 2022). According to (Nguyen & Nagase,
2019) The seven steps to patient safety are as follows.
1. build awareness of the value of Patient Safety;
2. leading and supporting staff;
3. integrate risk management activities;
4. develop a reporting system;
5. engage and communicate with patients;
6. learning and sharing experiences on Patient Safety; and
7. injuries through the implementation of the Patient Safety system
Individual characteristics are the first level of factors that have a direct impact on the service
and the service may still be considered acceptable or substandard (Feleke, Demise, & Garedew, 2020).
Individual characteristics include all the qualities that individuals bring to the job such as knowledge,
skill level, experience, intelligence, detectability, education and training, state of organism and even
attitudes such as alertness, fatigue, and motivation. Knowledge and skills through training programs
are essential for them (Umoke et al., 2020).
The nature of the job refers to the characteristics of the job itself and includes the extent to
which the procedures used are well defined, the nature of the workflow, the patient load at peak or
not, the presence or absence of teamwork, the complexity of care, functional tools and depreciation
period, interruptions and competing jobs and the physical/cognitive requirements to perform the job
(Sinyiza et al., 2022).
The physical environment includes the design of the workplace and equipment, temperature,
humidity, ventilation, lighting, noise, distractions, and hazards. The relationship between the physical
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environment and health services is important. Hospital building management must pay close
attention to patient safety and staff safety (Haque et al., 2019). With good management, it will be more
effective, safe, efficient and patient-centered (Arief, Fahriati, & Kartikasari, 2022).
Interaction between systems and humans is two systems that interact or communicate within
the scope of the system. Interactions between systems and humans include the location or placement
of tools, medical equipment or equipment, control of tools, mastery of work papers, and mastery of
information technology. Health information technology plays an important role in efforts to improve
patient safety and quality of care, and more supervision of the use of technology is needed (Akunne,
Okonta, Ukwe, Heise, & Ekwunife, 2019).
This external environment includes government policies, economic pressures, health policies,
public awareness, political climate, basic knowledge, demographics, and the latest technology. The
external environment is a demand for something that is needed by the organization as a form of high
commitment in implementing quality through patient safety. This external pressure can have an
impact on efforts to improve patient safety (Ivanova & Glukhova, 2020).
Nurses' Role in Maintaining Patient Safety
The Legal Basis for the role of nurses in the implementation of Patient Safety and the protection
of patient rights in hospitals The 1945 Constitution of the Republic of Indonesia Related to patient
safety which is one of the patient's rights, the patient has the right to receive health services that are
fair and in accordance with the values of a civilized nation, contained in Article 28H paragraph (1)
and Article 34 paragraph (3) To realize the right to health for patients there must be health care
facilities, and one of the health care facilities is the hospital (Dubey & Sahu, 2019). In supporting health
services in hospitals, it is necessary to have health workers who support the implementation of the
Patient Safety program. One of the health workers is a nurse (Ramayah et al., 2022).
In the implementation of Patient Safety and protection of patient rights in the Hospital involves
several health workers who carry out health services including doctors, nurses, midwives,
pharmacists and other health workers who support the implementation of Patient Safety and
protection of patient rights Santhoshkumar (Elbaz et al., 2023). Nurses have a position as one of the
members of the Patient Safety Committee Team, where their duties and responsibilities are as a
provider of nursing care in health services. Nursing care that is applied must be based on the six goals
of patient safety so that it supports the implementation of the Patient Safety Committee Team
program (Rum, Muchtar, & Arif, 2019).
The procedure for implementing the role of nurses must already have STR (Registration
Certificate) and SIKP (Nurse Work Permit) in a preventive manner to be a requirement as a
professional nurse in accordance with their competence. Nursing services provided by nurses are
based on knowledge and competence in the field of nursing science (Usman, 2020). So that nurses carry
out nursing care safely because this evidence states that nurses have been declared competent in
accordance with their profession and have the authority to carry out nursing actions. Nurses who
work at Panti Rahayu Yakkum Purwodadi Hospital already have STRs and SIKPs, including 16 nurses
who are research respondents.
Nurses have a very important role in maintaining patient safety in various health settings
(Rahmawati, 2020). Here are some key aspects of the nurse's role in this context:
1. Providing Safe and Quality Care
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Nurses are responsible for providing safe and quality care to patients. They must follow
established clinical protocols and guidelines to ensure that the actions taken are not only
effective but also safe for the patient. This includes the administration of medications at the
correct dosage, as well as the proper execution of medical procedures (Harisa et al., 2022).
2. Patient Health Monitoring
Nurses routinely monitor the patient's health condition, including vital signs, response to
treatment, and symptom progression. Through this monitoring, nurses can detect changes in
the patient's condition early and take necessary actions to prevent complications (Elbaz et al.,
2019a).
3. Patient and Family Education
Education is an integral part of the nurse's role in maintaining patient safety. Nurses must
provide clear and easy-to-understand information about the patient's health condition,
treatment plan, as well as preventive measures that can be taken to avoid risks. Patient and
family involvement in the care process is essential to increase their awareness and
participation in maintaining safety.
4. Health Team Collaboration
Nurses work closely with other members of the healthcare team, including doctors,
pharmacists, and other healthcare personnel, to ensure that all aspects of a patient's care are
addressed holistically. Good collaboration can reduce the risk of medical errors and improve
coordination in the management of care.
5. Incident and Error Reporting
Nurses have the responsibility to report any incidents or errors that occur during the care
process. This reporting is important for further analysis and to identify areas that require
improvement. By understanding the cause of the error, the healthcare team can take steps to
prevent similar occurrences in the future.
6. Implementation of Evidence-Based Nursing Practice
Nurses should implement evidence-based practice in all aspects of their care. By
following the latest guidelines and current research, nurses can ensure that they are using the
most effective and safe methods and techniques to treat patients.
7. Promoting a Safe Environment
Nurses also play a role in creating a safe care environment, both physically and
psychologically. This includes fall prevention, infection control, as well as supporting patients'
mental health. By creating a safe environment, nurses can help reduce the risk of injury or
complications that may occur.
Through their various roles, nurses contribute significantly to maintaining patient safety and
improving the quality of care provided (Fuadah, Helena, & Tazkiyah, 2023). First of all, nurses not only
act as care providers, but also as liaisons between patients and the rest of the medical team. In
situations where the patient has an urgent change in condition, the nurse is the first person who can
identify the problem and take appropriate action. With their knowledge and skills, nurses are able to
conduct an in-depth evaluation of the patient's condition and provide accurate reports to doctors or
other healthcare professionals. This is crucial in ensuring patients receive prompt and appropriate
care.
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In addition, nurses have a key role in educating patients and their families about their health
conditions and treatment plans. This education not only involves medical information, but also
involves preventive measures that can be taken to avoid risks that may occur (Marzel, 2020). By
improving the understanding of patients and their families, nurses can encourage them to actively
participate in self-care and follow the medical instructions given. This involvement not only increases
the patient's self-confidence, but also potentially reduces the number of medical errors that can occur
due to the patient's lack of understanding of care instructions.
Nurses also play an important role in creating a safe and comfortable environment for patients.
A positive and supportive environment can reduce patients' stress and anxiety levels, which in turn
can speed up the healing process (Aini & Yanti, 2021). By minimizing the risk of injuries, such as falls
or infections, nurses help maintain overall patient safety. For example, strict implementation of
infection prevention protocols can reduce the risk of nosocomial infections, while close supervision
of patients at risk of falling can reduce the incidence of injuries.
Furthermore, by consistently carrying out these responsibilities, nurses not only protect
patients, but also contribute to efforts to improve safety and quality in the health system as a whole
(Lestasi, Fatimah, Siti, & Koeswandari, 2020). Nurses serve as active change agents within healthcare
institutions, proposing process and policy improvements that can enhance patient safety. For
example, participation in safety audits or quality improvement initiatives can provide valuable
insights into areas for improvement. In addition, nurses' collaboration with other members of the
healthcare team in quality improvement efforts can create a stronger safety culture within the
organization.
Finally, by implementing evidence-based nursing practice, nurses continuously update their
knowledge and skills to provide the best care possible. In the ever-evolving information age, nurses
are required to always learn and keep up with the latest developments in clinical practice (Hutauruk,
2021). By doing so, they can ensure that the approach taken in patient care is the most effective and
in line with current standards. With a high commitment to professionalism and quality of care, nurses
actively contribute to the achievement of patient safety goals and overall health system improvement.
The Relationship of Nurses' Working Hours and Workload to Patient Safety Incidents
Hospitals are services that play an important role in people's lives. Hospitals are very complex
places, there are hundreds of drugs, hundreds of tests and procedures, many tools and technologies,
various professions and non-professions that provide services to patients for 24 hours continuously.
(Xaverius Jimmie Mantow, 2022) The diversity and routine of these services if not managed properly
can cause unexpected events and can also harm patients and threaten patient safety. Nurses as one
part of the nursing service provider have the longest time at the patient's side, allowing work fatigue
to occur (Annisa et al., 2024).
People who experience health problems certainly go to the hospital hoping to get help,
treatment and recovery from doctors, nurses, and other medical personnel, in the healing process of
course supported by medication, hospital equipment and other facilities (Mastur & Budiyono, 2020).
However, there are several incidents in the hospital that harm patients, injure patients so that they
make the patient's illness worse and instead of getting a cure, some result in death. These events are
termed adverse events (Fadlian et al., 2021).
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The relationship between nurses' working hours and workload and patient safety incidents is
an important topic that has been widely researched in the healthcare context. Research shows that
long working hours and high workload can contribute to an increased incidence of medical errors and
injuries to patients. When nurses work long shifts, they are at risk of fatigue which can affect their
concentration and thoroughness in performing nursing tasks. Fatigue can lead to decreased
performance, increase the likelihood of negligence, and reduce nurses' ability to identify and respond
to emergency situations quickly.
A high workload can also affect the quality of care provided. When nurses have to handle more
patients than they can effectively manage, they may not be able to give each patient enough attention.
This can result in delays in providing treatment, lack of adequate monitoring of the patient's
condition, and difficulty in performing necessary interventions (Syari Tanejafuddin et al., 2021).
Research shows that nurses who face excessive workloads tend to feel stressed and depressed, which
in turn can contribute to poor quality of care and increased patient safety incidents.
Conversely, studies have also shown that more flexible working hour arrangements and
balanced workloads can contribute to improved patient safety. With more regular working hours and
manageable workloads, nurses have a better opportunity to rest and recharge, thus providing better
and safer care. In addition, a supportive and collaborative work environment can improve nurses' job
satisfaction, directly related to the quality of care provided to patients (Zalianty, 2024).
Overall, the association between nurses' working hours and workload and patient safety
incidents demonstrates the importance of human resource management in health systems. Nurses'
irregular working hours and high workload may contribute to an increased risk of patient safety
incidents. Fatigue due to long working hours can reduce nurses' concentration and alertness, thereby
increasing the likelihood of medical errors. In this context, it is important for hospital management to
evaluate and design adequate work schedules, give nurses enough time to rest, and ensure that they
are not overburdened with excessive tasks (Mukrodi, Catio, & Sutoro, 2022).
The right strategy in setting working hours and adjusting workload can improve the quality of
care and reduce the risk of patient safety incidents. One approach that can be implemented is the use
of a more flexible work schedule rotation system, so that nurses can have adequate rest time between
work shifts (Pardede & Mustam, 2020).
Thus, managers of hospitals and healthcare institutions need to consider these factors in
workforce planning and management. In addition to setting rational working hours, it is important to
provide the necessary training and resources to help nurses manage their workload effectively. By
adopting an evidence-based approach to human resource management, hospitals can create a work
environment that supports nurses and improves patient safety. (Putri et al., 2022). These efforts will
not only benefit patients, but also contribute to nurses' job satisfaction, which is important for
maintaining the availability and quality of healthcare services (Koniswara & Lestari, 2019).
Ultimately, attention to the relationship between working hours, workload, and patient safety
is a strategic step that healthcare management should take. By creating an adequate work
environment, where nurses can work optimally, we can achieve the common goal of improving the
quality of healthcare. Patient safety should be a top priority in every policy and practice implemented
in healthcare institutions, to ensure that every individual receiving care gets safe, effective and high-
quality services.
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Conclusion
The relationship between nurses' working hours and workload and patient safety incidents is
significant, suggesting that effective human resource management is key to improving healthcare
quality. Regular working hours and a balanced workload can reduce the risk of medical errors and
increase nurses' focus and alertness. Therefore, it is important for hospital management to implement
appropriate strategies in work schedule planning and workload adjustment to create a supportive
work environment for nurses and ensure the safety and quality of patient care. This study
recommends that healthcare institutions adopt more flexible shift rotation systems, provide adequate
training for workload management, and offer psychological support for nurses. For future research,
it is suggested to explore specific interventions that can be more effective in reducing workload and
improving nurse well-being across different types of healthcare institutions
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