An overview of the literature highlights that there are numerous approaches to measuring nursing workload. Studies show that nursing workload is not necessarily represented only by nurse-patient ratios. Traditionally in the literature, job demands have been measured as the amount of time nurses spend providing care, patient acuity, and patient-nurse ratio. For example, Upenieks, Kotlerman, Akhavan, Esser, and Ngo (2007) report data collected from 40 medical-surgical and telemetry units regarding the amount of time nurses spend in direct patient care and outreach activities indirect. Evidence has shown that nurses spend approximately 30-55% of their time in direct care activities, while the remaining percentage is involved in indirect activities (e.g. reviewing medical records, taking care rounds, communicating with family, etc.). Therefore, a nurse's workload, with regards to the time spent carrying out nursing activities, consists not only of direct patient care factors, such as administering medications, but also of indirect, non-patient care.