Nurses' Perceptions of Workload Burdenin Pediatric Critical Care

Ruth M. Lebet, PhD, RN; Natalie R. Hasbani, MPH; Martha T. Sisko, RN; Michael S. D. Agus, MD; Vinay M. Nadkarni, MD; David Wypij, PhD; Martha A. Q. Curley, PhD, RN


Am J Crit Care. 2021;30(1):27-35. 

In This Article

Abstract and Introduction


Background: Quantifying nurses' perceptions of workload burden when managing critically ill patients is essential for designing interventions to ease nurses' workday.

Objectives: To explore pediatric intensive care unit (PICU) nurses' perceptions of their workload when caring for critically ill patients and managing protocolized therapies.

Methods: This study was embedded in a multicenter randomized clinical trial where participants were assigned to receive either lower-target or higher-target glucose control. Nurses from 35 participating PICUs completed a baseline survey containing questions about their perceptions of PICU workload in general. They completed an intervention survey after caring for a study patient. Two workload measurement instruments, the Subjective Workload Assessment Technique (SWAT) and the National Aeronautics and Space Administration–Task Load Index (NASA-TLX), were embedded in these surveys.

Results: Baseline surveys were completed by 1476 PICU nurses, predominantly female with a bachelor's degree and a median (interquartile range) of 6 (3–11) years of nursing experience and 4 (2–9) years of PICU experience. Most nurses (65%) rated time burden as the most important component of their workload, followed by cognitive (22%) or psychological stress (13%) burden. Work performance was selected most often as contributing to workload, followed by cognitive demand, time pressure, effort, and physical demand. Intervention surveys were completed by 73% of enrolled participants (505 of 693). Nurses managing the lower glucose target group reported higher levels of workload burden as measured by the SWAT (P = .002) and NASA-TLX (P < .001).

Conclusions: This study describes the workload burden perceived by PICU nurses when managing critically ill patients in general and when managing protocolized therapies.


Caring for critically ill children and their families is hard work. Given the challenges associated with the recruitment and retention of pediatric intensive care unit (PICU) nurses, perceived workload burden is important to understand. Clinical protocols are now routinely used in critical care, with the goal of decreasing variation in clinical decisions while allowing individualized care.[1,2] Depending on the patient population, ICU nurses manage between 5 and 29 protocols per patient each day.[3] As the provider directly responsible for managing the patient's daily care, the nurse plays a key role in successfully implementing these protocols.[4,5] However, although protocols are intended to streamline nurses' work, they may actually add to nursing workload, particularly cognitive burden.

Cognitive burden is the amount of working memory needed to carry out one's work.[5–7] Cognitive burden results from the complexity of new information to be learned, other activities that must be completed but are unrelated to the current task, and the cognitive processes required to complete the task.[7] This burden increases when there is a change in the focus of attention, particularly related to interruptions or distractions.[5,8] Cognitive burden theory holds that individuals have a finite working memory capacity,[7] limiting how much information can be taken in, processed, and remembered.[9] Individuals can hold between 5 and 9 tasks in their mind at any one time.[2,5] When an individual faces multiple competing priorities, they must choose where to focus their attention and what tasks and information they will remember.[6]

Currently, little is known about PICU nurses' perceptions of their workload related to the care of critically ill children in general and, more specifically, when managing a critically ill child on a clinical protocol. Glycemic control (GC) protocols are an example of a frequently implemented protocol in ICUs. Previous studies have shown that nurses perceive an increased workload related to these protocols, particularly in terms of the frequent glucose monitoring and infusion rate changes required.[10–16] The purpose of this descriptive, observational study was to explore PICU nurses' perceptions of workload when managing a patient on a GC protocolized therapy using 2 well-known workload measurement instruments. Understanding nurses' perceptions of workload burden is important so that effective interventions can be designed to decrease that burden.