Nurse Workload and Missed Nursing Care in Neonatal Intensive Care Units

Importance High nurse workload can compromise quality of care in neonatal intensive care units, leading to preventable harm and worsening clinical outcomes. Objective To evaluate differential effects of objective and subjective nurse workload on missed nursing care. Design, Setting, and Participants The prospective, observational, longitudinal design of this cross-sectional study was used to evaluate associations between shift-level workload of participating nurses and missed care for assigned infants from April 2021 to May 2023. This study was conducted at 10 level II, III, and IV neonatal intensive care units among a convenience sample of registered nurses who provided direct patient care at least 16 hours biweekly, completed unit orientation, owned a smartphone, and did not work in a supervisory capacity. Deidentified electronic health record data from infants assigned to nurse participants were extracted through an honest broker arrangement. Data analysis was conducted from July 2023 to July 2025. Exposure Nurse workload was assessed each shift based on objective (maximum number of assigned infants, infant acuity score) and subjective (National Aeronautics and Space Administration [NASA] Task Load Index) measures. Main Outcome and Measures The primary outcome, infant-specific missed nursing care on a shift, was measured by nurse self-report of omission of 17 essential types of neonatal nursing care. Results A total of 247 nurses involved in direct care provided reports of staffing and workload corresponding to the care of 1468 individual infants across 11 364 matched nurse-infant shifts. Nurses were 98% female, and nurses’ mean (SD) neonatal intensive care unit experience was 5.7 (7.1) years. When modeling workload variables separately, a shift-level staffing ratio of 3 infants per nurse was significantly associated with increased odds of missed care for individual infants in 9 of 17 types of care; a 2:1 ratio was associated with increased odds in 2 of 17 types of care. Higher subjective workload ratings were associated with increased odds of missed care in all 17 types of care. Negative effects of higher subjective workload persisted across all types of care in joint workload models, while effects of staffing ratios diminished. Few clinically meaningful effects of infant acuity scores on missed care were observed. Conclusions and Relevance In this cross-sectional study, nurses’ subjective workload and shift-level staffing ratios exerted direct effects on reliable care delivery. High subjective workload and staffing ratios greater than 2 infants per nurse should be targets for workload reduction in neonatal intensive care units.