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


In total, the 35 enrolling sites trained 3278 nurses on the HALF-PINT protocol, of whom 1476 completed baseline surveys (45% response rate). Respondents had a median age of 31 years and were mostly female, White, and not Hispanic or Latino (Table 1). Most had a bachelor's degree and worked full time as a staff nurse, with a median (interquartile range [IQR]) of 6 (3–11) years of nursing experience and 4 (2–9) years of PICU experience. Attitudes toward and comfort level with technology were rated high, with a median attitude score of 8 of 10 and comfort level score of 9 of 10, with higher scores indicating a more positive response.

Table 2 summarizes nurses' perceptions of workload in general. In response to the SWAT baseline survey questions, 65% of nurses rated time burden as the most important component of their daily workload. Of the 6 possible ways to order the 3 SWAT components, time (most important), cognitive, and psychological stress burden (least important) was the most frequent ranking (38%), followed by time, psychological stress, and cognitive burden (27%). Of the 6 factors contributing to general workload identified in the NASA-TLX, performance was most commonly selected as contributing more to workload, selected in a median (IQR) of 4 (3–5) of 5 pairwise comparisons involving performance. Cognitive demand, time pressure, and effort were each selected first in a median (IQR) of 3 (2–4) of 5 pairwise comparisons.

Complete intervention surveys, pairable with baseline surveys, were completed by 424 nurses (see Supplemental Figure 1—available online only) for 505 of the 693 (73%) randomized HALF-PINT patients (250 from the lower-target group and 255 from the higher-target group) (see Supplemental Figure 2—available online only). There were no significant differences in demographic, educational, or clinical experience characteristics between nurses who completed intervention surveys and those who did not. The total number of shifts during which nurses in our study cared for a HALF-PINT patient was, on average, 3.5 (range, 2–10). There were no significant differences in average baseline NASA-TLX and SWAT scores for many demographic variables (see Supplemental Table—available online only). After adjusting for potential site effects, nurses with an associate's degree had a lower SWAT or NASA-TLX score compared with individuals with a bachelor's degree. No significant relationship was found between perceived workload and time on HALF-PINT (SWAT, P = .90; NASA-TLX, P = .12), unit size (SWAT, P = .05; NASA-TLX, P = .89), severity of illness (SWAT, P = .05; NASA-TLX, P = .43), or patient age (SWAT, P = .61; NASA-TLX, P = .32). Comparisons of nurses' perceptions of workload between the lower-target and higher-target groups are shown in Figure 1 and reported in Table 3. As measured by the SWAT, nurses caring for a patient in the lower-target group reported higher cognitive (P = .01), time (P = .02), and psychological stress burden (P = .02) and had a higher overall paired SWAT score, indicating higher perceived workload (P = .002). Results for the NASA-TLX similarly showed higher perceived workload for the lower-target group, with all elements significantly higher (P < .001 for 5 of the 6 elements [cognitive demand, physical demand, time pressure, effort, and frustration] and P = .02 for performance). The paired overall NASA-TLX score was also higher for the lower-target group (P < .001). When comparing HALF-PINT workload to other PICU therapies using the NEMS, nurses managing the lower-target group were more likely to compare HALF-PINT protocol management to the management of patients receiving single or multiple vasoactive medications (44%). Nurses managing the higher-target group most frequently selected intravenous medication (41%) or mechanical ventilator support (22%).

Figure 1.

Comparisons of nurse perceptions of workload by workload dimension between lower-target and higher-target groups. Error bars represent standard error.

Figure 2.

Elements of the Heart and Lung Failure–Pediatric Insulin Titration Trial (HALF-PINT) protocol contributing most to workload by lower-target vs higher-target group. Error bars represent standard error.

Although nursing activities were the same in both groups, there were significant differences between the 2 groups in terms of which elements of the HALF-PINT protocol contributed most to workload (Figure 2). When rating the experience of managing the protocol, nurses caring for participants in the lower-target group identified more difficulty managing a patient on the protocol (median rating, lower target vs higher target, 7 vs 6 out of 10), keeping blood glucose levels within range (median rating, 6 vs 4 of 10), and more concern about hypoglycemia (median rating, 5 vs 3 of 10) (P < .001 for all comparisons). This group reported that more concentration, cognitive effort, and attention were required (P < .001). The lower-target group perceived repetitive blood draws (median percent effort, 30%) and adjusting the insulin infusion (median percent effort, 15%) as the highest contributors, whereas the higher-target group reported managing the glucose sensor (median percent effort, 10%) and using the HALF-PINT computer (median percent effort, 20%) as having the highest impact on their workload. Overall, nurses' perception of workload did not change with nurse age, years of PICU nursing experience, number of times the nurse had cared for a patient on the protocol, or comfort level or attitude toward technology.