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


This large study of nursing workload, embedded in a randomized controlled trial in which patients in the 2 arms were similar in terms of criticality, sheds light on the workload burden placed on PICU nurses when managing critically ill children in general and when managing protocolized therapies. Few studies have systematically described the invisible workload of clinical nursing, particularly in PICU nurses. In this study, using 2 different workload measurement tools, PICU nurses rated the time needed to get their work done and their individual success in completing assignments as the most important components of their daily workload. Nurses' perception of workload did not change with the nurse's age or years of PICU nursing experience. We also found that PICU nurses identified an increased and moderately high workload burden when implementing a GC clinical protocol, and their perceptions of factors contributing to workload differed by the perceived patient risk and vigilance required by the protocol.

Intensive care unit nursing is known for its fast pace, with patients' lives often depending on nurses' completion of preventive and lifesaving care activities throughout the day. Given the complexity of ICU patients, interruptions are common, as bedside nurses often provide the common communication link among numerous subspecialty teams supporting the patient's care. Spare time is rare when providing family-centered care to critically ill children and their families. "Down" time is often filled with documentation and teaching parents about what to expect next in their child's trajectory of illness.

In this study, although the pragmatic nursing care was similar in both GC groups, nursing workload associated with managing the lower-target group was attributed to patient-focused issues such as protocol management, the need to keep glucose levels within range, and concerns about hypoglycemia. Nurses in the lower-target group monitored blood glucose measurements and adjusted the insulin and glucose infusions more frequently and reported more concern about hypoglycemia, which is reflected in their higher reported concentration, multitasking, and cognitive effort. Nurses managing the higher-target group reported increased workload related to protocol management such as troubleshooting and managing equipment. This group reported less concern about negative patient outcomes and greater attention to managing the technology, which in most cases was new to nurses in both groups. Nurses frequently reported difficulties with the continuous glucose monitoring sensor, echoing the findings of Boom et al.[31]

Acceptance of patient-care technology is affected by several factors: usefulness of the technology in providing patient care, how easy it is to learn and remember, how error-prone the user feels it is, and overall user satisfaction.[7,19,22,32–34] Usefulness in patient care and ease of use are the 2 best predictors.[32,34] As noted previously, factors that have been identified as affecting technology acceptance[2,33,35,36] were built into the protocol in an effort to minimize the impact of the technology on workload. Using the NEMS, nurses were able to compare the work of the tested intervention with the work required for other ICU therapies. As with previous studies in adult patients examining nurses' perceptions of workload related to tight GC protocols, we found that PICU nurses perceived an increased workload related to protocol implementation.[10,12,14,35] This perception is supported by the time-in-motion study of Gartemann et al,[37] who found that implementation of a tight GC protocol required approximately 7% of time during a shift.

The protocol compliance rate was much higher in this study than in previously reported studies.[12,38] Chase et al[35] reported that protocol compliance was negatively impacted when the patient was critically ill, but in our study the compliance rate was very high regardless of patient acuity. In a small study of 21 nurses, Thompson et al[38] reported that 57% of nurses found that protocol implementation required as much or more time as caring for patients who are receiving mechanical ventilation (similar to our findings for nurses managing the higher-target group) or receiving vasoactive medication (similar to nurses managing the lower-target group). Nurses in this study reported that the protocol had little impact on work left undone or care for other patients, similar to the findings of Thompson et al.[38]

The use of technology was an important element of this protocol and was identified by nurses as a factor that increased workload. This finding has important implications for clinical practice in that technology is often thought to decrease nursing workload, when in fact the opposite might be true, at least initially. Others have shown that the perception of technology usefulness changes over time as users become more experienced, decreasing the burden attributed to the technology.[6,34,39] When implementing new protocols, especially those requiring the use of technology, it is important to ensure that the nursing staff is well prepared and that adequate resources are available. We were unable to assess whether familiarity with the protocol and technology would lead to a decreased perception of workload. This phenomenon would be useful to assess in a future study.


This study has limitations. The SWAT and NASA-TLX are designed to evaluate workload intensity after completion of a specific task, and we assessed workload intensity of the PICU in general and after managing a HALF-PINT patient over a 12-hour shift. Some nurses did not complete the intervention survey until after their shift was completed, which may have affected their perceptions. An increased intensity of workload at the very end of a shift may also have influenced nurses' perceptions. In addition, it is difficult to distinguish whether cognitive burden was attributable to the technology or the protocol itself, as we did not have a third arm with GC without assistive technology. The SWAT and NASA-TLX are subjective and therefore may not be consistent across individuals; however, an individual's perception is their reality, so perception of workload was the measure we felt was most meaningful. Finally, we did not capture whether other bedside protocols were concurrently in use, for example, ventilator weaning or sedation protocols.