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

JAMA Pediatr. 2019 Jan 1;173(1):44-51. doi: 10.1001/jamapediatrics.2018.3619.


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.

Publication types

  • Research Support, Non-U.S. Gov't
  • Video-Audio Media

MeSH terms

  • Critical Care Nursing / organization & administration*
  • Critical Care Nursing / statistics & numerical data
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal / organization & administration*
  • Intensive Care Units, Neonatal / statistics & numerical data
  • Intensive Care, Neonatal / organization & administration*
  • Intensive Care, Neonatal / statistics & numerical data
  • Logistic Models
  • Medical Errors / statistics & numerical data*
  • Neonatal Nursing / organization & administration*
  • Neonatal Nursing / statistics & numerical data
  • Nursing Staff, Hospital / organization & administration*
  • Nursing Staff, Hospital / statistics & numerical data
  • Prospective Studies
  • Quality of Health Care / organization & administration
  • Quality of Health Care / statistics & numerical data
  • Self Report
  • Workload / statistics & numerical data*