[Skip to Content]
[Skip to Content Landing]
Views 3,515
Citations 0
Original Investigation
Caring for the Critically Ill Patient
November 12, 2018

Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Unit

Author Affiliations
  • 1Center for Women, Children, and Youth, The Ohio State University College of Nursing, Columbus
  • 2Department of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 3Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 4Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
  • 5James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 6Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, Ohio
  • 7School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill
  • 8Martha S. Pitzer Center for Women, Children, and Youth, The Ohio State University College of Nursing, Columbus, Ohio
JAMA Pediatr. Published online November 12, 2018. doi:10.1001/jamapediatrics.2018.3619
Key Points

Question  Does the workload of neonatal intensive care unit nurses influence the likelihood that a nurse will miss necessary care for assigned infants?

Findings  In this study of 136 nurses caring for 418 infants during 332 shifts, increased infant-to-nurse ratio during a shift was associated with increased missed nursing care in about half of the measured missed care items. When a measure of subjective workload was considered, the associations of ratios were mostly attenuated; increased subjective workload was consistently associated with increased missed care.

Meaning  Focusing exclusively on infant-to-nurse ratios to address missed care may be limiting; nurses’ subjective workload is typically unmeasured but has promise for tailored workload interventions.

Abstract

Importance  Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in clinical and safety outcomes in neonatal intensive care units (NICUs); when core care is missed, outcomes can worsen.

Objective  To evaluate the association of NICU nurse workload with missed nursing care.

Design, Setting, and Participants  A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assigned infants from March 1, 2013, through January 31, 2014, at a 52-bed level IV NICU in a Midwestern academic medical center. A convenience sample of registered nurses who provided direct patient care and completed unit orientation were enrolled. Nurses reported care during each shift for individual infants whose clinical data were extracted from the electronic health record. Data were analyzed from January 1, 2015, through August 13, 2018.

Exposures  Workload was assessed each shift with objective measures (infant-to-nurse staffing ratio and infant acuity scores) and a subjective measure (the National Aeronautics and Space Administration Task Load Index [NASA-TLX]).

Main Outcomes and Measures  Missed nursing care was measured by self-report of omission of 11 essential care practices. Cross-classified, multilevel logistic regression models were used to estimate associations of workload with missed care.

Results  A total of 136 nurses provided reports of shift-level workload and missed nursing care for 418 infants during 332 shifts of 12 hours each. When workload variables were modeled independently, 7 of 12 models demonstrated a significant worsening association of increased infant-to-nurse ratio with odds of missed care (eg, nurses caring for ≥3 infants were 2.51 times more likely to report missing any care during the shift [95% credible interval, 1.81-3.47]), and all 12 models demonstrated a significant worsening association of increased NASA-TLX subjective workload ratings with odds of missed care (eg, each 5-point increase in a nurse’s NASA-TLX rating during a shift was associated with a 34% increase in the likelihood of missing a nursing assessment for his or her assigned infant[s] during the same shift [95% credible interval, 1.30-1.39]). When modeling all workload variables jointly, only 4 of 12 models demonstrated significant association of staffing ratios with odds of missed care, whereas the association with NASA-TLX ratings remained significant in all models. Few associations of acuity scores were observed across modeling strategies.

Conclusions and Relevance  The workload of NICU nurses is significantly associated with missed nursing care, and subjective workload ratings are particularly important. Subjective workload represents an important aspect of nurse workload that remains largely unmeasured despite high potential for intervention.

×