title: A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study.
abstract: OBJECTIVE
  We describe an innovative research protocol to test the role of missed nursing care as a mediator of the association between nurse workload and patient outcomes in the neonatal intensive care unit.
  
  
  BACKGROUND
  Increases in nurses' workloads are associated with adverse patient outcomes in neonatal intensive care settings. Missed nursing care is a frequently hypothesized explanation for the association between workload and outcomes. Few studies to date have tested missed care as a variable that mediates the workload-outcomes relationship.
  
  
  METHODS
  We use a longitudinal, observational study design.
  
  
  METHODS
  We will recruit approximately 125 nurses (80% of target population) providing direct patient care in one neonatal intensive care unit. Four, 6-week data collection cycles occur over 1 year. At the end of every shift, nurses report on their workloads and the frequency with which specific patient care activities were missed for each infant cared for during the shift. Infant-specific nurse reports of missed care are linked to shift-level infant outcomes data extracted from the electronic health record. Funding for the study began in July 2012; Research Ethics Committee approval was granted in December 2012.
  
  
  CONCLUSIONS
  Missed care may explain the effects of nurse workload on patient outcomes. This research will generate preliminary evidence regarding the causal relationships among nurses' workloads, missed care and infant outcomes that we will confirm in a future multi-site study.
authors.affiliation: Research in Patient Services/Division of Nursing & James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Ohio, USA.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Tubbs-Cooley
authors.forename: Rita H
authors.initials: RH
authors.lastname: Pickler
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Mark
authors.forename: Adam C
authors.initials: AC
authors.lastname: Carle
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D006801:Humans; D007231:Infant, Newborn; D015931:Intensive Care, Neonatal / Q000592:standards; D008137:Longitudinal Studies; D017283:Neonatal Nursing / Q000592:standards*; D063868:Patient Outcome Assessment; D061214:Patient Safety; D011787:Quality of Health Care / Q000592:standards*; D016526:Workload
keywords: electronic health record; health services research; missed care; neonatal intensive care; nurse staffing; nurse workload; outcomes; quality; safety