Missed Nursing Care in Neonatal Intensive Care Units for Infants Experiencing or at Risk of Experiencing Substance Withdrawal

Caring for infants experiencing or at risk of substance withdrawal often increases nursing workload and may contribute to missed nursing care (MNC). This study examined the relationship between infants' substance withdrawal status and the occurrence of MNC in neonatal intensive care units (NICUs). We conducted a secondary analysis of data from a longitudinal observational study involving 249 nurses and 1477 infants across 10 U. S. NICUs between April 2021 and May 2023. Nurses completed shift-level surveys reporting infant conditions and MNC for assigned infants, including whether infants were actively experiencing or at risk of substance withdrawal. Missed nursing care was measured using a 16-item instrument, and a global indicator captured whether any care was missed. Nurse characteristics were collected at enrollment using a researcher-developed questionnaire, and infant demographic and clinical characteristics were obtained from the electronic health record. Cross-classified multilevel logistic regression models were used to account for the clustering of nurses and infants. Compared with infants not identified as at risk of or experiencing withdrawal, infants identified as at risk of or experiencing withdrawal had significantly higher odds of MNC in eight areas, including developmental care, hourly surveillance, airway tube position assessment, high-risk medication assessment, oxygen titration per protocol, communication during handoffs, pain assessment, and overall missed nursing care. These findings suggest that infants experiencing or at risk of substance withdrawal are particularly vulnerable to MNC, underscoring the importance of accounting for withdrawal risk in nursing workload and staffing decisions to support high-quality care in NICUs.