Performance Shaping Features of Intermediate Care Nursing Workload - Project Summary
This is a resubmission (original December 2022). Work on SA1 and didactic training is underway.
Demand for intensive care unit (ICU) beds in the United States is high and frequently exceeds supply.
This leads to delays or denials of ICU admission, which are associated with increases in patient morbidity and
mortality. In over 60% of US hospitals, intermediate care (i.e., step-down care, progressive care) is an
alternative to intensive care for some patients. While the organization, provider staffing models, and monitoring
and interventions available in Intermediate Care Units (IMCUs) varies, a consistent feature distinguishing
intensive care, intermediate care, and acute ward care is the nurse-to-patient ratio (NPR). Whereas the
standard NPR in the ICU is 1:1 or 1:2, it is usually 1:3 in IMCUs, and 1:5 or 1:6 on acute care wards. These
different ratios reflect an assumption that intermediate care is associated with less workload per patient than
ICU patients, and more than ward patients. However, there are concerns that nurse workload in some models
of intermediate care exceeds that of ICU nurses. Importantly, excessive workload is tightly linked to increased
patient morbidity and mortality, low nurse job satisfaction and high burnout. It is essential to understand what
features of intermediate care nursing work modify (e.g., amplify or decrease) workload in different models of
intermediate care.
In this mixed methods proposal, we will conduct in-depth qualitative assessments to identify
performance shaping features (PSFs) of intermediate care nursing work. These qualitative assessments are
guided by the Systems Engineering Initiative for Patient Safety (SEIPS) conceptual framework, a well-
established human factors engineering approach, to guide ethnographic observations, semi-structured
interviews, and focus groups of intermediate care nurses to identify PSFs that amplify or decrease nursing
work. We will then conduct a quantitative assessment to characterize the strength of association between
these PSFs and perceived nursing workload among intermediate care nurses in the Johns Hopkins Health
System (JHHS). Perceived nursing workload will be measured using the National Aeronautics and Space
Administration Task Load Index (NASA-TLX), a short (< 5 minute) and well validated measure (in many work
systems including nursing) of perceived workload.
This proposed research and training, including didactic instruction in statistics, epidemiology, human
factors engineering, qualitative methods, and survey design will provide the applicant with the experience and
skill needed to continue his professional goal of becoming an independent investigator studying intermediate
and critical care delivery within health systems. These findings will provide important insight into planning and
supervising this level of care and will provide preliminary data for a planned K23 proposal to be submitted in
his fourth year of fellowship.
