How nurses rate daily job difficulty plays key role in patient care

Pressure on nurses extends beyond number of patients, researchers say

By Misti Crane, Ohio State News

A neonatal intensive care unit nurse’s ability to provide optimal patient care is influenced by a variety of factors – not just how many babies he or she is caring for or how sick they might be, a new study led by TDAI affiliate Heather Tubbs Cooley suggests.

Heather Tubbs Cooley

The study, which appears in the journal JAMA Pediatrics, highlights the importance of considering multiple pressures that nurses experience and developing a broader toolkit of workload strategies that enable high-quality nursing care at the bedside, said Tubbs Cooley, an associate professor of nursing who is also a member of the Ohio State College of Nursing’s Martha S. Pitzer Center for Women, Children & Youth.

The study found that a nurse’s perception of the difficulty of the workday – everything from being squeezed for time to the mental pressures of the shift – had a bearing on his or her ability to provide the best care possible, regardless of how many patients the nurse was tending to.

“We were surprised to discover how important subjective workload is to care quality, and it’s something we typically don’t measure in health care. This is really the nurse’s voice telling us how intense things were,” said Tubbs Cooley.

The study included data collected during 332 12-hour shifts from 136 neonatal intensive care nurses.

During each shift, the researchers collected objective measures of infant-to-nurse staffing ratios and infant acuity – a measure of the severity of a patient’s illness.

Nurses also filled out a simple questionnaire that measured perceived workload based on mental demand, physical demand, temporal demand (how hurried a nurse felt during a shift) and overall effort needed to accomplish patient care. The tool, called the NASA Task Load Index, was developed in the aeronautics industry and is used to assess workload in other industries where a performance lapse can have catastrophic results, including aviation and some health care settings.

The nurses in the study also gave the researchers reports on tasks considered “essential care” that they missed during shifts.

The research team compiled all of that information and created multiple statistical models to evaluate the relationships between objective and subjective workload measures and quality of care.

Regardless of the model, the nurses’ perceived workloads had a consistently strong influence on missed essential care – activities that included hourly assessments of the patients’ intravenous sites, oral feedings, collection of laboratory results and safety checks of equipment and alarms. This study did not evaluate patient outcomes, but other research has established that missing the type of essential care tracked in this study is linked to poorer patient outcomes.

Some of the models showed that higher patient ratios contributed to missed care, which has been demonstrated in other studies. But the researchers saw little connection in this study between the severity of patients’ health status and missed care.

“Subjective workload was the one variable that was consistently and strongly associated with missed care. Staffing ratios get a lot of attention – and they’re important – but nurses’ in-the-moment workload judgments matter as much or more,” she said.

NICU nurses care for the most fragile infants but the study’s implications likely extend far beyond that setting, said Tubbs Cooley. “I think this is likely a universal phenomenon among front-line caregivers in hospitals and even those in outpatient and community settings.”

Rita Pickler of Ohio State and researchers from Cincinnati Children’s Hospital Medical Center and the University of North Carolina at Chapel Hill also collaborated on the study.

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