Evaluation of advanced neonatal nurse practitioners: confidential enquiry into the management of sentinel cases

Subjective and Objective Measurement of Neonatal Nurse Practitioner Workload

BACKGROUND

Neonatal nurse practitioner (NNP) workload is not well studied, and metrics specific to NNP practice are lacking. Factors such as changes in resident duty hours, increasing neonatal intensive care unit admissions, and a shortage of NNPs contribute to NNP workload. Increased workload has been shown to be detrimental to providers and can affect quality of care.

PURPOSE

This study quantified NNP workload using a subjective workload metric, the NASA Task Load Index, and a newly developed objective workload metric specific to NNP practice.

METHODS

The NNP group at a level IV academic medical center was studied. The sample included 22 NNPs and 47 workload experiences.

RESULTS

A comparison of scores from the NASA Task Load Index and objective workload metric showed a moderate correlation (r = 0.503). Mental demand workload scores had the highest contribution to workload. Feelings of frustration also contributed to workload.

IMPLICATIONS FOR PRACTICE

The NASA Task Load Index can be utilized to measure the workload of NNPs. The objective workload metric has potential to quantify NNP workload pending further validation studies and is a simple, straightforward tool.

IMPLICATIONS FOR RESEARCH

Additional research is needed regarding NNP workload and methods to quantify workload. Larger studies are needed to validate the objective workload metric.

The role of the neonatal nurse practitioner in the community hospital level I nursery

Neonatal nurse practitioners (NNPs) have played a significant role in providing medical coverage to many of the country's Level III neonatal intensive care units (NICUs). Extensive education and experience are required for a nurse practitioner (NP) to become competent in caring for these critically ill newborns. The NNP can take this competence and experience and expand her role out into the community Level I nurseries. Clinical care of the infants and close communication with parents, pediatricians, and the area tertiary center provide a community service with the goal of keeping parents and babies together in the community hospital without compromising the health of the baby. The NNP service, with 24-hour nursery and delivery coverage, supports an ongoing obstetric service to the community hospital. The NNP's experience enables her to provide a neonatal service that encompasses a multitude of advanced practice nursing roles.

A literature review of principles, policies and practice in extended nursing roles relating to UK intensive care settings

AIMS

To provide an overview of the literature relating to the principles, policy and practice of extended nursing roles in UK intensive care settings to date; to review and critically assess evidence of impact, outcomes and effect on practice and provide suggestions for future research.

BACKGROUND

It is known that career development opportunities, new technologies, patient needs, as well as the reduction in junior doctors' hours, are driving the development of new roles for nurses. Policy initiatives aim to expand nursing roles to support professional substitution. In adult, neonatal and paediatric intensive care, specialist trained nurses and designated advanced nursing practitioners are increasingly taking on extended practice of clinical tasks previously undertaken by medical staff. As yet there are no statutory regulations on the perceived scope and definition of the role of extended and advanced roles.

DESIGN

Systematic review.

METHODS

Search of electronic databases and selection of policy and peer-reviewed reports and reviews of extended nursing roles or advanced nursing practitioners in UK intensive care settings.

RESULTS

Chronological review shows policy development proceeding in a relatively ad hoc way. There is limited information available about how extensively or effectively extended nursing roles are being implemented in intensive care settings in the UK, particularly in adult and paediatric intensive care. To test local initiative findings for reliability and generalisability, a more robust evidence base is required.

CONCLUSIONS

More data are needed on definition and outcomes of extended nursing roles in intensive care and care process measures should be developed to better inform implementation of nurse role development in the UK.

RELEVANCE TO CLINICAL PRACTICE

The review of policy and research evidence in this paper may better inform clinicians working in adult, neonatal or paediatric intensive care, as they continue to be challenged by expansion and development of their role. It may also help to form a basis and evaluation for future research into extended and advanced nursing roles in intensive care settings.

Impacts of participating in confidential enquiry panels: a qualitative study

OBJECTIVE

To describe the impacts of participating in confidential enquiry panels for the Confidential Enquiry into Stillbirths and Deaths in Infancy.

DESIGN

Qualitative interview study.

SETTING

The former northern health region of England.

SAMPLE

Eighteen health professionals who had participated in at least one confidential enquiry panel.

METHODS

Semistructured one-to-one interviews using purposive sampling; transcripts were analysed by identifying recurring themes. Data were organised and coded using NUD*IST.

MAIN OUTCOME MEASURES

Views on the impacts of participation on clinical practice and views on the strengths and limitations of confidential enquiries.

RESULTS

Participants valued attendance at panels as a learning experience that provoked reflection on their own clinical practice. Participants felt that taking part had a positive impact on their clinical thinking and practice by increasing their awareness of standards of care. These impacts occurred through both the detailed examination of cases and the interaction with colleagues from different disciplines and hospitals. Learning impacts were cascaded to colleagues through informal discussion and teaching. Concrete examples of changes in practice at the organisational level, stimulated by panel attendance, were reported.

CONCLUSIONS

The confidential enquiry approach was supported not only as an effective way of assessing care but also as a valuable learning experience that motivated change in clinical practice. Local benefits of nationally coordinated confidential enquiries should be valued and supported in their future development. Wide multidisciplinary participation in enquiry panels coordinated through regional clinical networks should be promoted.

Can all neonatal resuscitation be managed by nurse practitioners?

AIM

To assess the ability of nurse practitioners to manage the care of all babies requiring resuscitation at birth in a unit without on site medical assistance.

METHOD

A prospective review, and selective external audit, of the case records of all 14 572 babies born in a maternity unit in the north of England during the first eight years after nurse practitioners replaced resident paediatric staff in 1996.

RESULTS

Every non-malformed baby with an audible heart beat at the start of delivery was successfully resuscitated. Twenty term babies and 41 preterm babies were intubated at birth. Eight term babies only responded after acidosis or hypovolaemia was corrected following umbilical vein catheterisation; in each case the catheter was in place within six minutes of birth. Early grade 2-3 neonatal encephalopathy occurred with much the same frequency (0.12%) as in other recent studies. Independent external cross validated review found no case of substandard care during the first hour of life.

CONCLUSION

The practitioners successfully managed all the problems coming their way from the time of appointment. There was no evidence that their skill decreased over time even though, on average, they only found themselves undertaking laryngeal intubation once a year. It remains to be shown that this level of competence can be replicated in other settings.

Quality of care by neonatal nurse practitioners: a review of the Ashington experiment

The Ashington experiment, an innovative neonatal service run entirely by advanced neonatal nurse practitioners (ANNPs), has been evaluated. This is a report of that evaluation and a review of the benefits, hazards, and implications of nurse practitioner led services.

Evaluating a nurse-led model for providing neonatal care

AIMS

The paper presents an overview of a multi-dimensional, prospective, comparative 5-year audit of the quality of the neonatal care provided by a maternity unit in the UK delivering 2000 babies a year, where all neonatal care after 1995 was provided by advanced neonatal nurse practitioners, in relation to that provided by a range of other medically staffed comparator units.

METHODS

The audit includes 11 separate comparative studies supervised by a panel of independent external advisors. Data on intrapartum and neonatal mortality is reported. A review of resuscitation at birth, and a two-tier confidential inquiry into sentinel events in six units were carried out. The reliability of the routine predischarge neonatal examination was studied and, in particular, the recognition of congenital heart disease. A review of the quality of postdischarge letters was undertaken alongside an interview survey to elicit parental views on care provision. An audit of all hospital readmissions within 28 days of birth is reported. Other areas of study include management of staff stress, perceived adequacy of the training of nurse practitioners coming into post, and an assessment of unit costs.

RESULTS

Intrapartum and neonatal death among women with a singleton pregnancy originally booked for delivery in Ashington fell 39% between 1991-1995 and 1996-2000 (5.12 vs. 3.11 deaths per 1000 births); the decline for the whole region was 27% (4.10 vs. 2.99). By all other indicators the quality of care in the nurse-managed unit was as good as, or better than, that in the medically staffed comparator units.

CONCLUSION

An appropriately trained, stable team with a store of experience can deliver cot-side care of a higher quality than staff rostered to this task for a few months to gain experience, and this is probably more important than their medical or nursing background. Factors limiting the on-site availability of medical staff with paediatric expertise do not need to dictate the future disposition of maternity services.