An overview of the literature highlights that there are a number of approaches to measuring nursing workload. Studies show that nursing workload is not necessarily limited to the nurse-patient ratio. Traditionally in the literature, job demands have been measured based on the time required for nurses to provide care, patient acuity, and patient-to-nurse ratio. For example, Upenieks, Kotlerman, Akhavan, Esser, and Ngo (2007) report data collected from 40 medical-surgical and telemetry units regarding the time nurses spend on direct patient care and indirect care activities. Evidence has shown that nurses spend approximately 30-55% of their time on direct care activities, while the remainder of the time is spent on indirect activities (i.e., chart review, rounds). care, communication with family, etc.). Therefore, a nurse's workload, in terms of time spent performing nursing activities, includes not only direct patient care factors, such as administering medications, but also indirect care and not related to patients.