Subjective and Objective Measurement of Neonatal Nurse Practitioner Workload

Workload In Neonatology (WORKLINE): Validation and feasibility of a system for measuring clinician workload integrated into the electronic health record

OBJECTIVE

The purpose of the study was to validate WORKLINE, a NICU specific clinician workload model and to evaluate the feasibility of integrating WORKLINE into our EHR.

STUDY DESIGN

This was a prospective, observational study of the workload of 42 APPs and physicians in a large academic medical center NICU over a 6-month period. We used regression models with robust clustered standard errors to test associations of WORKLINE values with NASA Task Load Index (NASA-TLX) scores.

RESULTS

We found significant correlations between WORKLINE and NASA-TLX scores. APP caseload was not significantly associated with WORKLINE scores. We successfully integrated the WORKLINE model into our EHR to automatically generate workload scores.

CONCLUSION

WORKLINE provides an objective method to quantify the workload of clinicians in the NICU, and for APPs, performed better than caseload numbers to reflect workload. Integrating the WORKLINE model into the EHR was feasible and enabled automated workload scores.

Utilization and Meaningfulness of National Association of Neonatal Nurse Practitioners' Mentoring Toolkit Activities

BACKGROUND

Mentoring is a process in which a more skilled or experienced person builds a supportive relationship with a less experienced person to promote the latter's professional development. The National Association of Neonatal Nurse Practitioners (NANNP) supports the establishment of formalized mentoring programs for neonatal nurse practitioners (NNPs) and published a mentoring toolkit in 2017. Completing suggested activities outlined in the toolkit promotes the incorporation of evidence-based practice into the NNP professional role.

PURPOSE

This quality improvement project's purpose was to measure utilization and meaningfulness of NANNP mentoring toolkit activities.

METHODS

A convenience sample of 21 nurse practitioners was paired in 2 mentoring cohorts. Dyads were encouraged to meet monthly to complete NANNP mentoring toolkit activities in the context of a formalized mentoring program. Monthly data were collected to evaluate use and meaningfulness of the toolkit activities. Quantitative data included frequency and length of mentoring meetings, activities completed, and ratings of meaningfulness on a Likert-type scale.

RESULTS

Six of the 9 (67%) NANNP mentoring activities completed by the 2 cohorts were rated as "meaningful" or "very meaningful" by participants.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Activities from the NANNP mentoring toolkit provide structure to mentoring relationship development. Recognizing the challenge to recruit and retain NNPs, organizations are encouraged to explore creative solutions to develop and support formalized mentoring programs. Further research is warranted to validate use of NANNP toolkit activities in the establishment and evaluation of a formalized mentoring program in various neonatal intensive care unit settings.

Examining Job Satisfaction and Intent to Stay for Neonatal Nurse Practitioners: The Impact of Mentoring

BACKGROUND

In 2017, the National Association of Neonatal Nurse Practitioners (NANNP) recommended that organizations implement formalized mentoring programs for neonatal nurse practitioners (NNPs). There is significant evidence to support that mentoring positively impacts nurse practitioners' job satisfaction and retention. However, there is a lack of evidence-based literature specific to NNP mentoring.

PURPOSE

Determine the impact of participation in the NANNP formalized mentoring program on job satisfaction and retention for novice and experienced NNPs in an academic medical center in Tennessee.

METHODS

This quality improvement project utilized a secure online survey that included the Misener Nurse Practitioner Job Satisfaction Scale (MNPJSS) and 2 intent-to-stay items prior to implementation of a 6-month mentoring program. Neonatal intensive care unit nurse practitioners completed the same electronic survey at 3 intervals after program implementation to determine the impact of the mentoring program on job satisfaction and intent to stay.

RESULTS

Project results identified a significant difference in MNPJSS scores for participants in a 6-month formal mentoring program using the NANNP tool kit. The MNPJSS scores moderately correlated with intent to stay at 1 year and strongly correlated with intent to stay at 3 years.

IMPLICATIONS FOR PRACTICE

The results of this project support the positive impact of a formalized mentoring program on job satisfaction for new graduate nurse practitioners. Recognizing the challenge to recruit and retain NNPs, organizations should explore creative solutions to develop and support formalized mentoring programs.

IMPLICATIONS FOR RESEARCH

Further research is warranted to validate use of the NANNP tool kit in the establishment and evaluation of a formalized mentoring program.Video abstract available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Nurses' Perceptions of Workload Burden in Pediatric Critical Care

BACKGROUND

Quantifying nurses' perceptions of workload burden when managing critically ill patients is essential for designing interventions to ease nurses' workday.

OBJECTIVES

To explore pediatric intensive care unit (PICU) nurses' perceptions of their workload when caring for critically ill patients and managing protocolized therapies.

METHODS

This study was embedded in a multicenter randomized clinical trial where participants were assigned to receive either lower-target or higher-target glucose control. Nurses from 35 participating PICUs completed a baseline survey containing questions about their perceptions of PICU workload in general. They completed an intervention survey after caring for a study patient. Two workload measurement instruments, the Subjective Workload Assessment Technique (SWAT) and the National Aeronautics and Space Administration-Task Load Index (NASA-TLX), were embedded in these surveys.

RESULTS

Baseline surveys were completed by 1476 PICU nurses, predominantly female with a bachelor's degree and a median (interquartile range) of 6 (3-11) years of nursing experience and 4 (2-9) years of PICU experience. Most nurses (65%) rated time burden as the most important component of their workload, followed by cognitive (22%) or psychological stress (13%) burden. Work performance was selected most often as contributing to workload, followed by cognitive demand, time pressure, effort, and physical demand. Intervention surveys were completed by 73% of enrolled participants (505 of 693). Nurses managing the lower glucose target group reported higher levels of workload burden as measured by the SWAT (P = .002) and NASA-TLX (P < .001).

CONCLUSIONS

This study describes the workload burden perceived by PICU nurses when managing critically ill patients in general and when managing protocolized therapies.

What Keeps Neonatal Nurses Up at Night and What Gets Them Up in the Morning?

BACKGROUND

Occupational stress in neonatal nursing is a significant professional concern. Prolonged exposure to morally distressing patient care experiences and other healthcare issues may lead to worry among nurses. When worry becomes excessive, nurses and advanced practice registered nurses may lose joy that gives meaning to their work. Enhancing meaning in work may have a positive impact on nurse satisfaction, engagement, productivity, and burnout.

PURPOSE

To explore neonatal nurses' top professional satisfiers and top professional worries and concerns.

METHODS

A descriptive study was conducted in a convenience sample of neonatal nurses to identify the top professional satisfiers that get them up in the morning and the top professional worries and concerns that keep them awake at night.

RESULTS

Complete data were available for 29 neonatal nurses. The top professional satisfiers were caring for infants and families, making a difference, witnessing resilience, intellectual challenge of specialty, positive working relationships with colleagues, and educating parents and families. The top professional worries and concerns were staffing, missed care, workload, making a mistake, and failure to rescue.

IMPLICATIONS FOR PRACTICE

Healthcare and professional organizations must develop strategies to address occupational stress in today's complex healthcare environment. Identifying professional worries and concerns may help nurses navigate challenging and distressing situations. Furthermore, understanding nurses' professional satisfiers may promote personal and professional resiliency and help organizations create healthier workplace environments.

IMPLICATIONS FOR RESEARCH

Future studies are needed to test effective interventions that may promote professional satisfaction and help neonatal nurses cope with occupational stressors.

Development and Validation of a Web-Based Pediatric Readmission Risk Assessment Tool

OBJECTIVES

Accurately predicting and reducing risk of unplanned readmissions (URs) in pediatric care remains difficult. We sought to develop a set of accurate algorithms to predict URs within 3, 7, and 30 days of discharge from inpatient admission that can be used before the patient is discharged from a current hospital stay.

METHODS

We used the Children's Hospital Association Pediatric Health Information System to identify a large retrospective cohort of 1 111 323 children with 1 321 376 admissions admitted to inpatient care at least once between January 1, 2016, and December 31, 2017. We used gradient boosting trees (XGBoost) to accommodate complex interactions between these predictors.

RESULTS

In the full cohort, 1.6% of patients had at least 1 UR in 3 days, 2.4% had at least 1 UR in 7 days, and 4.4% had at least 1 UR within 30 days. Prediction model discrimination was strongest for URs within 30 days (area under the curve [AUC] = 0.811; 95% confidence interval [CI]: 0.808-0.814) and was nearly identical for UR risk prediction within 3 days (AUC = 0.771; 95% CI: 0.765-0.777) and 7 days (AUC = 0.778; 95% CI: 0.773-0.782), respectively. Using these prediction models, we developed a publicly available pediatric readmission risk scores prediction tool that can be used before or during discharge planning.

CONCLUSIONS

Risk of pediatric UR can be predicted with information known before the patient's discharge and that is easily extracted in many electronic medical record systems. This information can be used to predict risk of readmission to support hospital-discharge-planning resources.

Role of the Neonatal Nurse Practitioner in the Community Hospital

BACKGROUND

The role of the neonatal nurse practitioner (NNP) is well established in the neonatal intensive care unit. The level IV NNP is traditionally supported by large multidisciplinary teams while the level I to III NNP may be the sole in-house provider with limited resources.

PURPOSE

The purpose of this research project is to identify the NNP role, responsibilities, and barriers to practice in the level I, II, and III newborn care settings.

METHODS

This study used a descriptive, exploratory design to examine NNP roles and responsibilities in level I, II, and III care centers via an online survey.

RESULTS

Of the respondents (171), the majority (71.3%) work 24-hour shifts, 51.5% being the single NNP during the day with 67.8% being alone at night. Nearly 27% have limited or are without ancillary support while 29.8% cannot meet some standards of care due to inadequate resources. Almost 22% lack written protocols and procedural opportunities are limited or a concern for 15.8% of the NNPs.

IMPLICATIONS FOR PRACTICE

A better understanding of the responsibilities of the level I to III NNP will assist with developing staffing guidelines, influence practice models, and guide recruitment and retention of the NNP.

IMPLICATIONS FOR RESEARCH

A systematic literature review yielded articles on the value of nurse practitioners and their ability to deliver safe, effective and cost-conscience care but not on what the role entails on a daily basis. Further studies are needed to specifically compare the role of the level IV NNP to the level I, II, and III NNP to further delineate NNP functionality according to level of care.

Regulation of the Nurse Practitioner Workforce: Implications for Care Across Settings

Introduction

The current shortage of physicians in the United States has potential to dramatically limit access to healthcare. Nurse practitioners (NPs) can provide a cost-effective solution to the shortage, yet few states allow NPs to practice independently.

Purpose

The purpose of this study was to provide an up-to-date description of the NP workforce and to identify the professional and organizational factors associated with NP care quality.

Methods

Cross-sectional survey data from a sample of NPs actively employed in four states with reduced or restricted practice (California, Florida, New Jersey, and Pennsylvania) was used. NPs were categorized into acute and primary care. Regression models were fit to estimate the odds of three measures of care quality: overall quality of patient care, NP confidence that patients and their caregivers can manage their care at home, and whether NPs would recommend their practice facility to family and friends.

Results

Receiving support from administrative staff and physicians was associated with an increase in the three measures of quality. The greatest effects were seen in primary care settings.

Conclusion

It is imperative that legislators and healthcare administrators implement policies that provide NPs with an environment that supports clinical practice and enhances care delivery.