NICU Nursing Workload and Patient Outcomes

Sandy Sundquist Beauman, MSN, RNC-NIC / February 2019


Who among us has not experienced that shift where more than 1 or 2 nurses called in sick – and no one was available to replace them? When patients were admitted faster than extra nurses could be found? Or one or more patients become sicker during the shift, requiring more of your time than first expected?

Concerns about balancing staffing levels with needs are common. While many nurses would like to have staffing for every “what if,” we know that this is not practical in today’s healthcare environment. Staffing must be estimated as best we can to ensure adequate resources are available to care for the patients who depend on us, while also making certain sufficient dollars are also available for other items and personnel to meet patient care needs.

NICU Nursing hours and patient care

Acuity systems attempt to measure how many nursing hours are required to care for a patient. Many of us have experienced the discrepancy between acuity levels and actual workload. For instance, an infant learning to feed with no medications or IV therapy often scores quite low on the acuity scale. However, those infants may need lots of nursing time to work with, not only the infant but also parents, who are learning to care for their infant.

Nursing workload is often thought of as nurse-patient ratios, or number of patients assigned per nurse based on the illness level of the patient. It doesn’t account for other duties that nurses may have. In some NICUs, nurses clean equipment, run lab samples to the lab, prep milk for feeding, and may pick up medications from the pharmacy. They may also stock bed spaces or need to go in and out of the patient care area to obtain supplies. All of this adds time and stress to the workload, and potentially, valuable time away from the patient.

Nursing workload and patient outcomes in the NICU

There have been several studies about nursing workload and patient outcomes in many different areas of nursing.  The neonatal unit is perhaps a unique area in this respect though.

Patients vary from truly intensively and acutely ill and requiring high tech care, multiple medications and rapidly changing conditions, to infants who need what might be compared to usual medical or surgical care, on to those infants preparing for discharge, and learning to eat and grow, while avoiding complications like sepsis.

Infants on the intensive end of care are often staffed at a higher level, often one nurse per patient, or at most, one nurse for two patients. One study found that staffing at a higher nurse to patient ratio, e.g. more patients assigned to a specific nurse, led to better outcomes, specifically a lower mortality rate.1 That is an unusual finding. The authors theorized that it might be related to the need for sicker infants to have less disturbance. Nurses who were busy with other patients were less likely to disturb the infants who benefited from more quiet time. We know from many years of developmental care research that it is indeed true in many situations.

However, these infants may require immediate intervention when things don’t go right! And, only an alert nurse (who isn’t preoccupied with too many other patients) is most likely to pick up on these subtle changes that could indicate a deteriorating condition.

The study authors also indicated that the high use of temporary or registry help in this NICU might contribute to their findings. That speaks to the need to consider experience levels and consistency of care as it contributes to patient outcomes. There are many registry and traveling nurses with extensive patient care experience and skill. However, consistency of care and familiarity with unit protocols is also important. If a large proportion of the staff are unfamiliar with this, including how best to contact primary providers when needed, patients are at higher risk.

In addition, the experience level and/or organizational skills of any specific nurse need to be considered.  We’ve all worked with nurses that are always busier than anyone else, and usually stay past the end of their shift to get everything finished up. As well, there are those nurses who finish their patient care duties with time to offer to assist others or take on other duties while still providing excellent care.

Perceived nursing workload

Tubbs-Cooley et al2 studied the association between nurse workload and missed care. Nurses were asked to evaluate their workload using the NASA-TLX (National  Aeronautics and Space Administration Task Load Index). This workload index was developed for areas outside healthcare, as the name implies, but is used more and more often in healthcare. This index demonstrated that years of experience and training impact perceived workload. And, perceived workload is important!


While a charge nurse or experienced nurse may perceive a workload as manageable, a nurse with less than 1 year experience may find the workload unmanageable, and be missing important care that will impact the infant’s outcome.  We see this as well in teaching hospitals, where new residents come on board in July. Without the astute attention of experienced nurses and other healthcare providers, many more errors would happen than actually do! Yet, the extra efforts of experienced nurses at this time are not built into any staffing model.

Missed care

In addition, missed care was specifically reported by each individual nurse per shift in the Tubbs-Cooley study. Items most frequently missed were things like checking an IV site hourly, and elements of a central line associated blood stream infection (CLABSI) prevention bundle. Other items reported as missed included parental involvement, nurse hand-off, and even feedings. As expected, these missed items were higher for infants with a lower acuity.

An infant staffed in a 1:3 assignment was more likely to have care items missed than infants in a 1:1 or 1:2 assignment. Importantly, missing patient care items like checking an IV site every hour won’t consistently affect the outcome. We know checking the site when there is no infiltration means nothing. It’s the one or two times out of 50 when the IV is beginning to leak or infiltrate that this measure becomes important! The risk of missing elements of a CLABSI bundle are more concerning since many studies have shown an increase in infection rates related to understaffing.3-6 While there may not be a direct cause and effect between lapses in following a CLABSI bundle and infection, we know that the bundle exists because all elements performed together and consistently have been shown to lead to lower infection rates.

Unrelated to CLABSI specifically, higher infection rates are associated with understaffing and overcrowding. Rogowski, Staiger et al7  found in their survey of several hospitals within the Vermont Oxford Network that 31% understaffed in general and 68% understaffed high-acuity infants when compared to recommended staffing guidelines. There are also recommendations about training and experience level for staff working in the NICU.8 While this was not evaluated in the study by Rogowski et al,7 lower than recommended staffing levels were correlated with significantly higher infection rates.

While much of the study related to infant outcomes and staffing levels or experience have to do with infections, the examples of missed care in the study by Tubbs-Cooley et al2 demonstrate that there is indeed an opportunity for other bad outcomes to occur, perhaps even after discharge if parent involvement opportunities are missed as well. In addition, the study shows that these missed cares may be as related to experience or other stressors as to acuity levels.  We should pay attention to not only the number of nurses working matched to number of patients and illness level, but to experience and training of those nurses on shift.

It is not acceptable to just have “warm bodies” to meet staffing guidelines. As suggested by Sherenian et al,9 perhaps future research should focus on how to optimize outcomes related to nurse staffing and experience levels rather than just avoiding bad outcomes.




  1. Callaghan LA, Cartwright DW, O’Rourke P, Davies MW: Infant to staff ratios and risk of mortality in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2003; 88:F94–F97.
  2. 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. JAMA pediatrics. 2018 Nov 12.
  3. Stone PW, Pogorzelska M, Kunches L, Hirschhorn LR. Hospital staffing and health care–associated infections: a systematic review of the literature. Clin Infect Dis. 2008; 47(7):937–944. [PubMed: 18767987]
  4. Cimiotti JP, Haas J, Saiman L, Larson EL. Impact of staffing on bloodstream infections in the neonatal intensive care unit. Arch Pediatr Adolesc Med. 2006; 160(8):832–836. [PubMed: 16894083]
  5. Andersen BM, Lindemann R, Bergh K, et al. Spread of methicillin-resistant Staphylococcus aureus in a neonatal intensive unit associated with understaffing, overcrowding and mixing of patients. J Hosp Infect. 2002; 50(1):18–24. [PubMed: 11825047]
  6. Haley RW, Bregman DA. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis. 1982; 145(6):875–885. [PubMed: 7086199]
  7. Rogowski JA, Staiger D, Patrick T, Horbar J, Kenny M, Lake ET. Nurse staffing and NICU infection rates. JAMA pediatrics. 2013 May 1;167(5):444-50.
  8. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Inpatient perinatal care services. In: Lemons, JA.; Lockwood, CJ., editors. Guidelines for Perinatal Care. 6th. Washington, DC: American Academy of Pediatrics and American College of Obstetricians and Gynecologists; 2007
  9. Sherenian M, Profit J, Schmidt B, Suh S, Xiao R, Zupancic JA, DeMauro SB. Nurse-to-patient ratios and neonatal outcomes: a brief systematic review. Neonatology. 2013;104(3):179-83.


About the Author

Sandy Sundquist Beauman has over 30 years of experience in neonatal nursing. In addition to her clinical work, she is very active in the National Association of Neonatal Nurses, has authored or edited several journal articles and book chapters, and speaks nationally on a variety of neonatal topics. She currently works in a research capacity to improve healthcare for neonates. Sandy is also a clinical consultant with Medela LLC. You can find more information about Sandy and her work and interests on LinkedIn.