Nurse staffing ratios and subjective workload were found to be directly associated with missed care in a neonatal intensive care unit (NICU), according to a study published in JAMA Pediatrics.

Researchers collected data from a 52-bed level IV NICU. Eligibility criteria included registered nurses who completed unit orientation, provided direct patient care for >80% of their clinical effort, and were permanently employed in the NICU. Data were included from all infants during active NICU cycles. Missed care was assessed by asking nurses to report the omission of 11 essential neonatal nursing care practices. Nurses reported the frequency of missed care based on a Likert-type scale: never, rarely, occasionally, or frequently missed, or not applicable. The researchers then created a dichotomous missed care indicator for each infant on each shift if a nurse reported missing any of the 11 practices during a shift.

Objective measures of workload included infant-to-nurse staffing ratio and infant acuity scores. Infant acuity scores were estimated based on clinical indicators of nursing care intensity such as ventilation modality, frequency and mode of feedings, number and type of infusions, and procedures. Higher scores were indicative of higher nursing care intensity.

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Subjective workload was assessed during each shift using a paper version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX), which is a measurement of how an individual experiences situational demands of work, including cognitive and mental demands, physical demands, time pressure, and overall required effort to accomplish goals. At the end of each shift, nurses reported subjective workload experienced during the course of the shift, infant-to-nurse ratio, and missed care for assigned infants.

Data were assessed from January 1, 2015, through August 13, 2018. Of 202 eligible nurses, 136 (67.3%) reported care for 418 infants during 332 shifts of 12 hours each, resulting in 10,428 nurse-infant shifts of workload and missed care data available for analysis. Mean infant-to-nurse ratio was approximately 2:1 and ranged from 1 to 4 infants per nurse.

Missed care was reported on 326 (98.2%) of the 332 shifts and in 2502 (24.0%) of 10,428 corresponding nurse-infant shifts. The most frequently reported missed nursing care involved hourly checks of intravenous line sites (1066 [20.4%] of applicable shifts) and adherence to the central-line associated bloodstream infection prevention bundle (695 [15.5%]). Least frequently reported were missing standard safety checks of alarms and equipment (188 [1.8%] of applicable shifts).

Out of 12 ratio models of missed care outcomes, 7 showed a statistically significant worsening effect of an increased infant-to-nurse ratio on the odds of missed care; these effects were more prominent when nurses cared for 3 or more infants during a shift compared with a 1:1 assignment (ie, nurses caring for ≥3 infants were 2.51 times more likely to report missing any care during the shift). All 12 models demonstrated worsening effects of increased subjective workload ratings on the odds of missed care (ie, a 5-point increase in a nurse’s NASA-TLX rating during a shift was associated with a 34% increase in the likelihood of missing an infant assessment).

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Increased staffing ratios were associated with a worsening effect of missed care in 9 of 12 models; small increases in acuity were found in 5 models, including any missed care (1.07), missed patient assessment (1.03), missed parent involvement (1.05), and missed verification of 6 rights of medication administration (1.05).

“Consistent with our hypothesis, we found a statistically significant association between nurse workload and the odds of missed nursing care for individual infants, although the effects varied across workload measures and modeling strategies,” the authors concluded.


Tubbs-Cooley HL, Mara CA, Carle AC, Mark BA, Pickler RH. Association of nurse workload with missed nursing care in the neonatal intensive care unit [published online November 12, 2018]. JAMA Pediatr. doi: 10.1001/jamapediatrics.2018.3619