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Analysis

Nurse Stressors: It's Not Just Patient Volume and Acuity

By John Commins  
   November 12, 2018

A study examines 'subjective workload' among NICU nurses, and finds a number of perceived stressors that take time away from essential care and could lead to sub-optimal outcomes.

Patient volume and acuity play a role in a nurse's ability to provide optimal care, but they aren't the only factors, a new study shows.

Researchers at The Ohio State University found that a nurse's "subjective workload"—which could include everything from the mental pressures of the job to relentless time constraints—affects her or his ability to provide optimal care, no matter how many patients they're attending.

The study, in the journal JAMA Pediatrics, calls for developing broader workload strategies to ease nurses' stress and improve care quality.

"We were surprised to discover how important subjective workload is to care quality, and it's something we typically don't measure in healthcare. This is really the nurse's voice telling us how intense things were," said study lead author Heather L. Tubbs-Cooley, RN, an associate professor of nursing at Ohio State.  

The study examined data collected during 332 12-hour shifts from 136 neonatal intensive care nurses caring for 418 infants. Researchers during each shift collected objective measures of infant-to-nurse staffing ratios and infant acuity. 

The NICU nurses were asked to fill out the NASA Task Load Index to measure perceived workload based on mental demand, physical demand, time constraints, and overall effort needed to accomplish patient care.

The nurses also gave the researchers reports on "essential care" that they missed during shifts—including hourly assessments of the patients' intravenous sites, oral feedings, collection of laboratory results and safety checks of equipment and alarms.

The researchers used the data to create multiple statistical models to evaluate the relationships between objective and subjective workload measures and quality of care. They found that, regardless of the model, the nurses' perceived workloads had a consistently strong influence on missed essential care.

Some of the models showed that higher patient ratios contributed to missed care, which has been demonstrated in other studies. However, 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," Tubbs-Cooley said. "Staffing ratios get a lot of attention—and they’re important—but nurses' in-the-moment workload judgments matter as much or more."

While NICU nurses are under tremendous stress while caring for the sickest, most-fragile patients, Tubbs-Cooley says her study's implications suggest "a universal phenomenon among front-line caregivers in hospitals and even those in outpatient and community settings."

“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.”

John Commins is a senior editor at HealthLeaders.


KEY TAKEAWAYS

Mental pressures and time constraints affect care quality as much as patient volume and acuity.

Researchers saw little connection between the severity of patients' health status and missed care.

Findings suggest 'subjective workload' could be 'a universal phenomenon among front-line caregivers in hospitals and even those in outpatient and community settings.'


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