​Increased subjective workloads for neonatal intensive care unit (NICU) nurses were consistently associated with missed nursing care for infants, according to a November 12, 2018, study published in JAMA Pediatrics. Objective workloads were also significantly associated with missed care in the study of 136 nurses caring for 418 infants across 332 shifts, the authors said. Subjective workload was measured in the study using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). Researchers asked nurses to self-report on care provided during a shift, and interpreted the results through 12 models. Researchers found that across all 12 models, the higher the self-reported subjective workload was, the higher the odds that care was missed. For instance, each 5-point increase in a nurse's NASA-TLX rating was associated with a 34% increased chance that the nurse would miss an infant's nursing assessment during that shift. Subjective workload is typically not measured in other studies, according to the authors. However, as this study shows, it is an important part of understanding quality improvement efforts in nursing care, the authors said.

HRC Recommends: Healthcare organizations should consider taking a systems thinking approach to staffing and scheduling. Steps may include mapping workloads on each shift, determining what skills are needed and when they are needed, designing the system to respond to those needs, monitoring performance indicators (which may include indicators that capture the perspectives of healthcare personnel), and redesigning the system when things change. In addition, the organization should establish a culture in which providers and staff feel comfortable reporting situations in which excessive workload may negatively impact quality and patient safety.