Dataset Information

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

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.

SUBMITTER: Tubbs-Cooley HL

PROVIDER: S-EPMC6583427 | biostudies-literature | 2019 Jan

REPOSITORIES: biostudies-literature

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Publications

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

Tubbs-Cooley Heather L HL Mara Constance A CA Carle Adam C AC Mark Barbara A BA Pickler Rita H RH

JAMA pediatrics 20190101 1

<h4>Importance</h4>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.<h4>Objective</h4>To evaluate the association of NICU nurse workload with missed nursing care.<h4>Design, setting, and participants</h4>A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assig ...[more]

PMID: 30419138

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Project description:Background: The satisfaction of parents of infants in neonatal intensive care is important to parent-infant bonding and parents' ability to care for their baby, including after discharge. Given the principal caregiver role of nurses in this setting, parent satisfaction is influenced by high quality nursing care. Nursing care that is required but missed, such as counseling and support, might influence parent satisfaction. How missed nursing care relates to parent satisfaction is unknown. Objective: To describe the satisfaction of parents of infants in neonatal intensive care and to determine how satisfaction relates to missed nursing care in a sample of USA nursing units. Methods: The design was cross-sectional and correlational. Thirty neonatal intensive care units that participate in the National Database of Nursing Quality Indicators were recruited. To maximize sample variation in missed care, the highest and lowest quartile hospitals on missed nursing care, measured by nurse survey, were eligible. Ten parents of infants who were to be discharged were recruited from each site to complete a survey. Parent satisfaction was measured by the EMPATHIC-38 instrument, comprising five subscales: information, care and treatment, organization, parental participation, and professional attitude, and a total satisfaction score. Multivariate regression models were estimated. Results: Parent satisfaction was high (5.70 out of 6.00). The prevalence of missed care was 25 and 51% for low and high missed care units, respectively, and 40% for all units. On average, nurses missed 1.06 care activities; in the low and high missed care units the averages were 0.46 and 1.32. Over 10% of nurses missed activities that involved the parent, e.g., teaching, helping breastfeeding mothers, and preparing families for discharge. One standard deviation decrease in missed care activities at the unit level was associated with a 0.08-point increase in parent satisfaction with care and treatment (p = 0.01). Conclusion: Parents in USA neonatal intensive care units are highly satisfied. Neonatal intensive care nurses routinely miss care. Parent satisfaction with care and treatment is related to missed nursing care. Nursing care that is missed relates primarily to the care of the baby by the parents, which could have long term health and developmental consequences.

Project description:BackgroundNeonates in the neonatal intensive care unit (NICU) undergo a multitude of painful and stressful procedures during the first days of life. Stress from this pain can lead to neurodevelopmental problems that manifest in later childhood and should be prevented.ObjectiveTo determine the number of painful procedures performed per day for each neonate, to verify documentation of painful procedures performed, and to, subsequently, note missed opportunities for providing pain relief to neonates.MethodsWe conducted a cross-sectional study at a level III NICU located in a rural part of western India. A total of 69 neonates admitted for more than 24 h were included. Twenty-nine neonates were directly observed for a total of 24 h each, and another 40 neonatal records were retrospectively reviewed for the neonate's first 7 days of admission. All stressful and painful procedures performed on the neonate were recorded. Also recorded were any pharmaceutical pain relief agents or central nervous system depressants administered to the neonate before or at the time of the procedures. Average nurse-patient ratio was also calculated. Data were analyzed using descriptive statistics.ResultsA documentation deficit of 2.2% was observed. The average nurse-patient ratio was 1.53:1. A total of 13711 procedures were recorded, yielding 44.1 (38.1 stressful, 3.8 mildly painful, and 2.2 moderately painful) procedures per patient day. Common stressful procedures were position changing (2501) and temperature recording (2208). Common mildly and moderately painful procedures were heel prick (757) and endotracheal suctioning (526), respectively. Use of pharmacological agents coincided with 33.48% of the procedures. The choice of drug and time of administration were inappropriate, indicating that the pharmacological agents were intended not for pain relief but rather for a coexisting pathology or as sedation from ventilation with no analgesia.ConclusionStressful procedures are common in the NICU; mildly and moderately painful procedures fairly common. Almost two-thirds of the times, no pharmaceutical pain relief methods were used, and when administered, the pharmaceutical agents were seldom intended for pain relief; this implies poor pain management practices and emphasizes the imperative need for educating NICU nurses, residents, fellows, and attendings.

Dataset Information

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

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Conclusions and relevance

Publications

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

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