A Safety II Approach to NICU Nursing Workload: Unanticipated Workload Challenges and Self-Initiated Mitigation Strategies

Objective

Heavy nursing workload presents a significant challenge in the neonatal intensive care units (NICU) since it is closely associated with adverse patient safety outcomes such as missed care (Tubbs-Cooley et al., 2018), medication errors (Nawwar et al., 2015), hospital-acquired infections (Stone et al., 2008) and mortality (Callaghan et al., 2003). While multiple studies examined the challenges encountered by intensive care unit (ICU) nurses that contribute to their high workload (Gurses et al., 2009; Mohammadi et al., 2015; Rivera et al., 2021), most of these studies were done in adult ICUs, with limited investigation in the NICUs that have their own unique complexities of caring for critically ill infants. These infants, whether premature or full-term but unwell, are susceptible to even minor variations in care due to their fragility, underdeveloped organs, weight-dependent medication requirements, limited communication abilities, and susceptibility to environmental stressors (Raju et al., 2011). Although there has been research focused on the subjective measurement of perceived nursing workload in the NICU (Hoogendoorn et al., 2021; Hoonakker et al., 2011; Tubbs-Cooley et al., 2018), there is a research gap in comprehensive and contextual understanding of work system-based challenges that may lead to unanticipated increases in nursing workload in the NICU. In this study, we implemented a qualitative research approach guided by a conceptual framework of nursing workload (Carayon & Gürses, 2005) to identify these unanticipated challenges experienced by NICU nurses that may increase their workload unexpectedly. Additionally, using a Safety-II approach (Hollnagel, 2018), this study explores strategies that these frontline care professionals self-develop and employ to mitigate the effects of these challenges. Moreover, this is also the first study looking at overall “ICU nursing workload management” from a Safety-II perspective.

Approach

The study involved a 3-hour observation of 12 bedside NICU nurses at an academic hospital, followed by a 30-minute semi-structured interview. Observations were conducted across weekdays and weekends, with each session randomly distributed over the beginning, middle, and end of the participant’s selected 3-hour work shifts. The median of experience in years among nurses was 4.5, ranging from one to 25 year. The observation data was collected using an observation tool developed and pilot-tested in previous research (Gurses & Carayon, 2007) combined with handwritten descriptive notes. Semi-structured interviews were conducted with the participants within 1 to 7 days after the observation. The interview guide consisted of two major subsections: (1) questions on unanticipated changes/challenges that contributed to high workload during the particular observation session, and (2) questions on challenges that increase workload unexpectedly based on overall past work experience of the participating nurse. Additionally, participants were asked about any strategies they have either self-developed or learned from others and used to overcome these unexpected challenges and spikes in their workload. Handwritten observation notes were typed immediately after each observation session, and interviews were audio-recorded and transcribed. A blend of deductive and inductive approaches were utilized to analyze the data: A deductive approach was crucial as an established conceptual framework (Gurses & Carayon, 2007) to steer our study and an inductive approach is indispensable for capturing concepts that may not be explicitly articulated within existing framework.

Findings

Analysis revealed 10 major categories of challenges in the NICU work system that consistently contributed to high nursing workload in the NICU: (1) Seeking for supplies/equipment, (2) Being have to attend to non-routine/unforeseen patient-care events (e.g., sudden need for sterile line change), (3) Challenges with floor plan or workspace (e.g., patient rooms not close enough), (4) High number of potentially avoidable interruptions, (5) Competing demands with no clear guidance on how to prioritize, (6) Breakdown in communication with clinicians, (7) Handoff report taking too long, (8) Ineffective communication with the milk inventory team, (9) Usability issues in electronic milk inventory system, (10) Lack of tools to help with team coordination. Our results indicate that NICU nurses strategize to mitigate the effects of these high workload challenges. Examples to major strategies include (i) asking for help from the NICU unit, specially from nurses in the same hallway or the resource nurse on the shift, (ii) establishing strong rapport with the family members early in their NICU journey, (iii) making small modifications in their workspace, (iv) planning ahead for scheduled events as early as possible to have buffer, (v) prioritizing clinical tasks over others (e.g., documenting), (vi) taking primary role in clarifying communication between parents and other healthcare professionals in the NICU (see Table 1 for details). Future steps include collecting additional data for a thorough and detailed analysis, where we will aggregate observational and interview data and develop a comprehensive coding scheme to systematically categorize challenges and strategies for overcoming them.

Table 1.

Workload Challenges and Mitigating Strategies Developed by NICU Nurses to Overcome Their Effects.

Challenges in the NICU work system	Strategies	Sample data excerpts for challenges and strategies
		* C denotes Challenges
		** S denotes Strategies
Seeking for supplies/equipment- Patient carts not properly stocked with needed supplies, nurses having to make numerous trips to supply center- leaving patient rooms	Communicating with co-workers particularly those who are in the same hallway to cover for them while they look for needed supplies or equipment	C*: “I think supply is just been a big issue for years now. It’s definitely been a big issue for years.” (Interview #9)
		S**: Nurse asked her trainee to start the patient care while she went looking for supplies (Observation session #9)
Unforeseen non-routine events- Nurses having to do unplanned tasks such as sudden sterile line changes, unplanned immediate intubation, patient transportation	Asking for assistance from resource nurse, charge nurse, and/or parents who can take care of the baby independently	C and S: “We have the resource nurse who doesn’t have an assignment, and she should be available to help with things such as getting an IV, and that was hugely helpful to my workflow.” (Interview #11)
Challenges with floor plan or workspace- Patient rooms are not close to each other, monitors not visible from the nursing workstation	Letting the family know where their workstations are, communicating with the nurses down the hall, pulling out the monitor in a room closer to the workstation if there is no other patient in that room	C and S: “I had a patient in like the pod and then I had another patient that was further down the hall, which was kind of further from where I was sitting, but I think as a nurse, you like adjust to make sure you let the families know sitting and like that you’re available to them and where you’re located.” (Interview #3)
High number of potentially avoidable interruptions- Multiple members of same family contacting bedside nurse independent of each other and asking similar questions. First- time parents and acute infants’ parents being anxious and asking for too detailed assessments	Establishing a strong rapport with the parents, creating a supportive environment to reduce their stress, providing them with resources for neonatal care education and guidance	C: “With the patient’s parents to go over things, and do a whole assessment because they’re a little bit more critical, and then I do think the beginning of my shift was a little bit busier”(Interview #8)
		S: Nurse introduced herself to the parents, included them in discussions during handoff report (Observation #8)
Challenges in task prioritization- Multiple tasks being due at the same time: patient care, medication delivery, PICC line procedure	Focusing on the patient care first: feeding, administering medication, checking vitals, changing diapers and clothes. Asking for parent’s help if they are comfortable taking care of the baby.	C and S: “We didn’t want to start something if two other things were going to happen at the same time, because that’s not safe for any of the three things going on.” (Interview #6)
Breakdown in communication with other clinicians- New medical order not confirmed in EHR, delay in medication delivery	Reaching out to the provider team to confirm orders, contacting pharmacy to get real-time updates on medication	C: “For a medication to be delayed and not be in the drawer requires us to connect with pharmacy, explain that the dose is missing, and then wait for a delivery, which takes a start on the 12th floor and they go down. We are the eighth floor. So we have to wait hourly for our delivery after the medication has been reordered, which is quite frustrating.” (Interview #2) S: “You’re allowed to give a medication an hour before or an hour after. So technically the medication was delayed, but it’s a daily medication. . .So the medication delivery didn’t affect the patient. But a medication like that every eight hours definitely impacts the timing” (Interview #2)
Handoff report taking too long- Unnecessarily detailed information given by previous shift’s nurse during handoff report	Focusing on the big picture and asking questions about major changes in care or patient condition	C: “I was a little bit late and she took about 15 to 20 minutes, which is kind of long for a report. I would say like five is about normal, just doing the important stuff.” (Interview #8)
		S: Nurse asked questions about the critical issues, what happened with the baby, and re-navigating the conversation. (Observation #8)
Miscommunication with the milk inventory team- Ineffective communication between parents and the NICU milk depot team, causing a feed shortage and, consequently, nurses having to spend time to resolve these issues	Investigating the reason behind miscommunication immediately, acting as the bridge of communication between parents and milk depot	C: “There’s still just so much miscommunication between what the milk bank needs to do and what nursing needs to do, and trying to figure that all out, because it’s hard to add more and more tasks onto your job, when we already have so much.” (Interview #7)
		S: “I investigated it further and I found out mom wasn’t signed up for text messages. So I signed her up for the texts and everything” (Interview #7)
Usability issues in electronic milk inventory system- Actions within the electronic system are irreversible, resulting in nurses spending substantial additional time for amendments	Preparing handwritten notes for updating information about milk feed, and documenting them with manual entry in EHR for information verification on the milk bottles.	C: “At the moment you can’t undo it. So once it’s done, it’s disposed. You can’t ever get it back. You can’t scan the entirety of the bottle.” (Interview #8) S: “You have to write down what is the fortifier, how many calories, the patient, make sure it’s the right patient, that kind of stuff. So you have to chart all that instead of just it populating itself.” (Interview #8)
Lack of effective tools to help coordination among team members- Bedside nurses play the central role in scheduling the visitation of the lactation nurse, speech-language pathologist, and occupational therapist, as per parents’ visit schedule, because no tools or formal mechanisms exist to assist them in the process	Contacting everyone involved and start planning the visit schedules earlier during the shift so that it does not delay patient care	C: No existing tool for scheduling parent meet-up with clinicians, nurse spending time texting and calling everyone involved to find a suitable time for everyone to be available. (Observation #1)
		S: Communication with lactation nurse through EHR early morning, set up a time for her to visit the mom and the baby, when the mom comes to visit the baby. (Observation #1)

Takeaways

The theoretical contributions of this study lie in the exploration of the perspectives of the Safety-II framework (Provan et al., 2020) for workload management at the frontline by emphasizing the different ways of adapting to gaps, challenges, and surprises and by identifying strategies to overcome or mitigate the impact of high workload. Further, by uncovering specific unanticipated changes or spikes in workload and their implications for workload management, this study sheds light on where intervention efforts should focus to reduce nursing workload in the NICUs. Research efforts are ongoing to uncover challenges and strategies to reduce workload in the healthcare environment and our study provides further empirical evidence for this type of research. Collectively, the systematic examination of tailored workload management strategies presented in this study contributes to field discussions on healthcare system efficiency, resource allocation, interventions to optimize nurse performance, and efforts to reduce stress and improve job satisfaction.