Assessment of Neonatal Nurse Practitioner Workload in a Level IV Neonatal Intensive Care Unit: Satisfaction

Newborn & Infant Nursing Reviews 16 (2016) 138–148

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Assessment of Neonatal Nurse Practitioner Workload in a Level IV Neonatal Intensive Care Unit: Satisfaction☆ Carol Buck Jaeger, DNP, RN, NNP-BC a,⁎, Cynthia Acree-Hamann, DNP, APRN, NNP-BC b, Joyce Zurmehly, PhD, DNP b, Jacalyn Buck, PhD, RN b, Thelma Patrick, PhD, RN b a b

3143 Cranston Drive, Dublin, OH, 43017 The Ohio State University College of Nursing

a r t i c l e

i n f o

Keywords: Neonatal nurse practitioner (NNP) Neonatal intensive care unit (NICU) Workload Caseload Acuity Satisfaction

a b s t r a c t There are limited evidence-based standards for determining workload assignments of the neonatal nurse practitioner (NNP) in the neonatal intensive care unit (NICU). The purpose of this project was to describe the assignment pattern of the NNP, based on workload. The aim was to identify the level of satisfaction reported by the NNP relative to performance, patient outcome, and safety. During the project period, the NNPs responded to an electronic survey at the end of each worked shift. The following objective measures were utilized to describe workload: (a) number of NNPs assigned to the shift, (b) caseload, (c) patient acuity, (d) experience and competence of the NNP, (e) perception of safety, and (f) level of satisfaction of the NNP in relation to assignment factors. The implication of this project for NNP practice was to design a process to monitor a baseline of activity from which change can be implemented. © 2016 Elsevier Inc. All rights reserved.

Infants cared for in the neonatal intensive care unit (NICU) are the most vulnerable of the hospitalized infants. 1,2 Because of their fragile medical status, appropriate care is highly dependent on knowledgeable, qualified and experienced nurses. Historically, the shortage of neonatologists in the NICU during the 1970s created a need for nurses with advanced skills to manage infant stabilization, transportation, and crisis events. As a result, the neonatal nurse practitioner (NNP) in the NICU evolved and continues today as an important role functioning within a dramatically changing healthcare workforce.3,4 The demand and responsibilities for NNPs have been affected by the resident work hour restrictions beginning in 2011 which resulted in a reduction in hours on duty and the number of infants that may be assigned to medical residents in the NICU.5 In a survey of 114 freestanding children's hospitals or children's hospitals within a larger hospital, 42% (N = 27) of the respondents reported increasing the NNP workforce to compensate for the medical resident work hour restrictions, and 43% (N = 27) plan to hire additional NNPs over a 2-year period to further address the changes.6 Over time, the traditional presence and direct patient care responsibilities performed by the physician, fellow and resident in the health care environment have decreased. Subsequently, the NNP has evolved as an essential role to fill the critical gaps in care within the NICU. 5–8 Unfortunately, with the decline in resident duty ☆ The authors acknowledge the time, effort, commitment, and support given to this project by Heather Ryle, DNP, APRN, Ashley Warfel, MSN, APRN, Nancy Roberto, MSN, and the dedicated NNPs at Cincinnati Children's Hospital Medical Center, Cincinnati, OH. ⁎ Corresponding author. E-mail address: [email protected] (C.B. Jaeger). http://dx.doi.org/10.1053/j.nainr.2016.07.007 1527-3369/© 2016 Elsevier Inc. All rights reserved.

hours and increase in neonatal admissions, NNPs are often experiencing increased workload ratios within the NICU setting. The term workload, as defined by the National Association of Neonatal Nurse Practitioners (NANNP), are the responsibilities that are managed and performed by the professional within a given time period within the authorized scope of practice. This includes responsibilities and activities related to clinical care, education, research, professional development, management, coordination, and/or administration. 4 Whereas, caseload is the term that defines the number and type of patient managed by the professional. In the NICU, caseload is the term that defines the number and type of patient managed by the professional. In the NICU, caseload for a provider is the number of complex patients (described by diagnosis, acuity/severity of illness, or category) managed within the worked hours.2 Currently, there are practice standards that recommend the number of direct nurse caregivers, and resident/fellow physicians to the number of infants that can be managed.5,9 These standards were established to enhance the safety of the infants and the well-being of the staff. Surprisingly, there are no standards, and a limited understanding of the factors that guide the allocation of NNP workload in relation to number of infants that can be managed. Unfortunately, with the absence of standards of care, combined with an increasing demand of care, NNPs have a potential for burnout and job dissatisfaction. Therefore, it is important to assess the satisfaction of the NNP and give serious consideration to retention, recognition and value of the NNP as a stakeholder in the NICU workforce. This can be accomplished, in part, by acknowledging the factors that influence and/or constrain the effectiveness and well-being of the NNP.

C.B. Jaeger et al. / Newborn & Infant Nursing Reviews 16 (2016) 138–148

Significance of the NNP Workforce Given the changes, the quality of care delivered to complex patients in the NICU by NNPs has been well documented in the literature as early as the 1990s.10–14 Further, the literature has described the NNP with the appropriate level of didactic knowledge and performance skill can manage the needs of complex neonatal patients and their families in a safe and cost-effective manner. 6,15–18 Unfortunately, with positive patient and healthcare cost outcomes, NNP workload ratios have been increasing. Therefore, it would seem that the NNP role has evolved and assumed additional responsibility without appropriate consideration to workload. A survey published by the National Association of Neonatal Nurses (NANN) in 2012 reported that NNP caseloads exceed ten (10) patients per shift in a tertiary service; and, NNP worked shift lengths are equally divided between 12 and 24 h, generally exceeding 40 h in a week.19 Extended work hours and large patient caseloads in the NICU can lead to mental fatigue and diminished physical agility for the NNP when required to make timely critical decisions. Potential distractors for the NNP were reported as additional workload responsibilities and activities performed during the shift, to include: (a) precepting students and orientees, (b) supervising residents, (c) performing procedures, (d) transporting babies to procedures, (e) responding to crisis events, (f) admitting and discharging infants, (g) providing consultations, (h) attending high risk deliveries, (i) managing and coordinating NNP group activities/scheduling, (j) leading improvement projects, and (k) conducting continuing education sessions for staff and colleagues. A more recent survey of 1300 NNPs from across the United States, indicated patient caseload exceeded a level the respondents considered to be safe. Greater than half of the respondents from level IV NICUs indicated that an average caseload of 6 patients was unsafe.20 Several studies support additional workload responsibilities and activities expected of the NNP during the work shift make it difficult to concentrate on the complexity of the patient situation, and the simultaneous interaction of two or more patient situations.3,17,21,22 Compounded by the fact there is currently a reported shortage of NNPs in the workforce,6 it is not uncommon that NNPs complete a shift at one organization and relocate to another to work consecutive shifts. Kaminski et al.23 reported that forty-seven percent (47%) of NNPs responding to the 2014 NANNP survey, worked more than one advanced practice role in clinical, education, and/or administration. Some NNPs (42%) cover more than one unit. Forty-seven percent (47%) of respondents conveyed that their practice was understaffed due to: lack of budget (48%), lack of qualified candidates (47%), and unfilled positions (41%), whereas the hospital did not consider the NNP workforce understaffed (38%). Sleep deficit, whether planned or unplanned, combined with distractions can negatively influence the process of decision-making, prioritization, and time management; consequently, affecting patient safety,24 thereby causing the NNP to become less satisfied potentially affecting performance and outcomes. Allocation of NNPs in the Work Environment The position statement, Neonatal Nurse Practitioner (NNP) Workforce, published by the National Association of Neonatal Nurse Practitioners,4 recognizes the NNP as a direct provider of health care in the NICU with a large patient caseload and significant workload responsibilities. Supported by the NANN Board of Directors and the NANNP Council, based on Benners 25 adapted Dreyfus Model of Skill Acquisition, 26 an NNP caseload of 6–10 for the advanced beginner through expert level of competence was recommended, with adjustments made to caseload based on the following considerations: (a) patient acuity, (b) potential for crisis events, (c) concurrent leadership activity, (d) patient rounds, (e) parent/family education and communication, and (f) other patient areas to be covered. 4,7,19 The position statement and open discussion with NNPs at the annual National Association of Neonatal Nurses Conference 27 further stipulates that there is limited evidence to

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recommend a safe and appropriate patient caseload or workload for an NNP in the NICU, and further study is needed. Current practice in many organizations is to budget resources based on the historic (usually previous year) census and NNP-to-patient ratio. Schedules allocate the budgeted number of NNPs per shift, minus vacant positions, illnesses, leaves of absence, and vacations. Shift schedules and daily assignments are prepared from the number of available NNPs. There are times when there are unfilled needs for NNPs in a specific clinical setting based on the current patient number and status and the number of scheduled NNPs. To address these needs, requests are made for extra-time/overtime from the employed part-time, full-time and contingent NNPs. Patient acuity and additional responsibilities are not planned for in scheduling NNP caseload/workload assignments. Other factors that are not generally considered include the experience, competence and skill performance level of the NNP. The measure of productivity by the NNP is difficult because the NNPs are not evaluated as a separate group. Provider productivity is generally linked with physicians; and physician productivity is associated with patient charges and overall census related to the specialty. The majority of NNPs do not bill directly for patient services.19 Since neonatal charges are bundled and can be billed directly by only one provider, the responsibility is allocated to the admitting physician. Consequently, the revenue for the professional fee is routed to medicine specialty services to support physician salaries and expense. Since the publication of the NNP Workforce position statement, NICU NNP groups are initiating unit projects to describe the caseload and/or workload of the NNP. The foci of the descriptors vary, such as charge indicators or procedures/skills, based on the tools that are utilized, adapted, or developed. Findings are difficult to compare. The results of the projects have been reported at national meetings during poster sessions and abstract presentations; few have been published. The lack of consistency or standardization in the use of descriptors, metrics, tools and process makes it impossible to compare the assessments of caseload and/or workload from unit-to-unit, or group-to-group. However, a baseline of real-time NNP caseload and workload activity at the unit level can help the organization to gain a system perspective of what it takes to meet the demand/needs of the actual patient capacity with optimal efficiency.28 Continual monitoring and comparison with the valid and reliable evidence provides opportunity for incremental adjustment. Over the long-term, change can be strategically designed, implemented and evaluated to establish best practice. Purpose of the Project The purpose of the project was to describe the process of planning and assigning workload to the NNP as a primary provider of complex care management in one level IV NICU. The aim of the project was to assess the level of satisfaction of the NNP regarding performance and patient outcome during the shift worked within the standard practice method of assigning patients. Strategies to engage the NNP in the project were used to prompt the NNP to own the process by actively evaluating activity—self and group. This can be a powerful stimulus for the NNP to better understand process and be proactive in transforming infrastructure operations, including patient assignment, outcome monitoring, problem identification, and practice improvement implementation. Objectives of the Project The objectives of the project were to obtain a short-term representation of the dynamic process of patient care management by the NNP in a level IV NICU. The objectives include: (a) identify the NNP workload using objective measures; (b) recognize the perception of NNP satisfaction relative to performance, patient outcome, and safety; and (d) compare the findings to professional recommendations.

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Review of Literature The review of the evidence in CINAHL, MEDLINE and the Cochrane Databases, was done using the key words: advanced practice nurse, neonatal nurse practitioner, physician, neonatologist, fellow, medical resident, nurse, advanced nursing practice, neonatal intensive care, neonate, workload, workforce, caseload, neonatal acuity, competence, skill acquisition, quality, and safety. The search included published evidence from 1990 to the present. Over 9000 total articles were identified, 112 were selected as supporting evidence that was pertinent to NNP workload and was further categorized into relevant review topics including: (a) role effectiveness, (b) experience, (c) measurement of patient acuity, (d) workload, and (e) satisfaction. Role Effectiveness Role effectiveness has been outlined as one method to evaluate the NNP provider in the NICU. Brooten et al. 29 suggest that there are three (3) components of this concept: (a) dose, expressed as the number and the amount of care measured in time or number of contacts, (b) described by education, expertise and experience, and, (c) host and response, indicating the receptiveness to practice. Using the concept of “dose effect”, APRN effectiveness in relationship to patients, families, interprofessional team, and the operation of the organization may be evaluated 29 in subsequent work. Brooten et al.30 further identify the level of severity of illness and the complexity of care required by the patient as important factors in describing the “dose”. Experience The monitoring of performance, continued learning, and competency maintenance are critical processes to sustain the functional capacity of the NNP as an autonomous care provider.26,31,32 In their publication entitled Competencies and Orientation Toolkit for Neonatal Nurse Practitioners, the National Association of Neonatal Nurse Practitioners (NANNP) outlined the need to evaluate competencies essential to the role of the practicing NNP. Using the Dreyfus model of clinical problem-solving, a tool kit is presented that includes evaluation guides and evaluation tools to objectively assess the performance of the individual NNP based on the behaviors and skills applicable to each stage from novice to expert. Measurement of Patient Acuity Currently, a standardized tool or method to describe the complexity of patient care in order to determine effective workload has not been published. However, there are instruments that have been published that may be effective to predict mortality by measuring neonatal acuity/severity of illness and providing an assessment of resource utilization, including staff workload. One of the more commonly used is the Neonatal Therapeutic Intervention Scoring System (NTISS). Medlock et al.33 and Dorling et al.34 have published systematic reviews of neonatal severity scoring systems. They concluded that multivariate instruments predicted mortality better than the common singular indicators of birth weight or gestational age. One such instrument is the Neonatal Therapeutic Intervention Scoring System (NTISS) which consists of 63 therapeutic interventions performed in the neonatal population to include: (a) respiratory, (b) cardiovascular, (c) drug therapy, (d) monitoring, (e) metabolic/nutrition, (f) transfusion, (g) procedural, and (h) vascular access. 35 By assessing treatment received by neonates, the scale can accommodate variation in practice. Developed in the early 1990s, the NTISS has been determined to be a valid and reliable instrument to measure therapeutic intensity and neonatal illness severity, and resource utilization.36 As a predictor of severity of illness for the very low birthweight (VLBW) and extremely low birthweight (ELBW) babies in the NICU, Oygur et al. 36 evaluated the accuracy of the NTISS using area under the curve

(AUC) to predict performance for the overall indicators of the instrument. The strengths noted for the NTISS include: (a) multivariate, inclusive of the patient's physiology, intervention, and hemodynamic status; (b) reflective of the dynamic nature of severity, (c) effective evaluation of patients across all weight categories, extreme low birthweight (ELBW) to term newborn weight, through the NICU stay; (d) clear and logical, and (e) sustainable. Even though the acuity scoring systems were developed as predictive measures, to qualify performance and the information about acuity can be used at the unit and organizational level, to define, distribute and budget operational resources. A majority of the studies are designed to utilize the acuity scores to describe a population retrospectively and not workload.33,34 However, the frequent (daily) use of a scoring system with indicators to predict the patient's severity of illness can serve to forecast the resources needed to allocate staffing as necessary to meet the anticipated care needs of the patient. Provider Workload Since nurses comprise the largest resource of the workforce in most healthcare facilities, evidence to describe and quantify workload among the nurse caregiver role is abundant. However, descriptive and/or quantitative evidence about the advanced practice workload is limited. As health organizations transform to meet the increasing volume of insured and informed consumers, there is greater emphasis on understanding the role of the provider.37 There is an abundance of evidence in recent years to support and sustain the improvements made to the learning environment and the well-being of medical residents.38–43 Resident fatigue and overload has been shown to negatively affect patient outcome and safety. Work shifts greater than 16 h have been recommended to be reduced or eliminated. By doing so, resident education has not been found to be compromised, and the resident quality of life has been reported to improve. Subsequently, the recommendation for patient load has been reduced. Currently, ACGME7(p12) recommends a maximum number of new admissions and transfers per day for first, second, and third year residents, and maximum assignment loads in a 48 h period per first, second, and third year residents. For the NICU, ACGME offers a minimum of 4 patients per resident.5(p57) The caseload and workload of the nurse caregiver and the medical resident differ from the NNP. The job responsibilities of the nurse as a direct caregiver are to fulfill the plan-of-care designated for the specific patient by the health care team. The recommended staffing is based on nurse– patient ratios, and predicated on the level of diagnosis acuity defined by the American Academy of Pediatrics (AAP).1,2,7 The ratios and diagnostic levels of acuity do not account for the NNP responsibilities as a provider to multiple critical care patients. Practicing within an academic role that requires supervision recommendations of caseload for the medical resident do not apply to the NNP. However, they can serve as a platform to begin to frame workload recommendations for the NNP. Role Satisfaction A search of the evidence using the key words satisfaction and neonatal nurse practitioner, revealed few articles published within the decade that describes the level of satisfaction of the NNP regarding role performance in the NICU. McDonald, Rubarth, and Miers44 reported moderate overall job satisfaction in a small sample of midwest nurses working in the NICU, including NNPs. The influencing factors identified included: (a) caring for patients in a stressful situation, (b) level of autonomy, and (c) communication between nurses and NNPs. Timoney and Sansoucie 19 described a positive correlation between job satisfaction and advanced educational preparation among 679 NNP respondents across the United States. Job satisfaction was slightly effected at the highest level of patient caseload, but was unrelated to shift length or structure. There was no identified relationship between practice size, years of experience, shift length, or patient acuity.

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Profit et al.45 reported significant associations with job satisfaction, teamwork climate, safety climate, perceptions of hospital management and working conditions among nurses, nurse practitioners, respiratory care providers, and physicians in 44 California NICUs when exploring links between burnout and adverse events. In summary, the evidence regarding NNP job satisfaction is limited; and the relevant studies are biased by small sample sizes, geographic areas/regions and/or the inclusion of multiple professional roles/disciplines. Furthermore, satisfaction with the job/position is not the same as satisfaction with the perception of performance when managing a caseload of patients. Methods The descriptive measures derived from the evidence include: (a) number of NNPs on a worked shift, (b) number of patients (contacts) in the NNP caseload on a worked shift, (c) acuity of the patients using the NTISS instrument, (d) additional responsibilities and activities performed during the worked shift, (e) education, experience, competence and skill acquisition of the NNP based on Benner's25,32 stages, (f) NNP response, or perception, to practice performance and patient outcome during the shift (host response/satisfaction), and (g) worked hours in a shift. The objective data collected from the NNPs provide a baseline of the NNP workload in the NICU during the worked shift for a 28-day period. Tools were selected from the evidence, and surveys were designed, to electronically capture the relevant data from the NNP during the worked shift. Setting The NICU is a 59-bed capacity level IV NICU with service to more than 16 maternity and newborn centers in a tri-state regional area. The unit provides on-site specialty and sub-specialty support in the management of high-risk deliveries through the maternal–fetal center, extracorporeal membrane oxygenation (ECMO), surgical repair of complex conditions including heart; and provides a regional transport and back-transport service.2 Over 700 high-risk babies are admitted annually. The NNP interacts as a collaborative member of each of the specialty and sub-specialty teams to manage the care and outcome of the high-risk infant and family. NNP Caseload Assignment Faced with decreases in resource utilization and allocation, health organizations struggle to manage operational quality, safety and efficiency, and to be transparent to organization associates, external regulators, and consumers. Utilizing evidence, process, and objective criteria to assess, change and evaluate current practice in workforce utilization and workload distribution can posit opportunities to improve effectiveness and value among the roles. The evidence shows that the NNP is a key stakeholder in the NICU workforce, thus suggesting that the NNP workload needs to be assessed using objective factors, continuously monitored, evaluated, and changes implemented over time to fully recognize and sustain the role. This project is the initial effort in this process. During the project period, the process to assign a caseload of patients to the scheduled NNP was done by an NNP colleague from the previous shift. Typical caseloads were 6 patients on weekday day shift, 7–8 patients on weekend day shift, and 15 patients on weekday and weekend night shift. The continuity of patient care was a priority in making the assignment from shift-to-shift. Generally, it was a preference of the NNPs who work several consistent (linked) days, or days in one week, to manage the same caseload because they were familiar with the plan, and they could maintain the continuity of care for the patient and family. Another significant factor in assigning a patient caseload was the NNP who was precepting students or orientees. NNPs rotated day and night shifts, and worked scheduled weekends. Many of the NNPs worked additional shifts in other city-wide level III NICUs, as the result of a management agreement between those units and the freestanding children's hospital neonatal service. It was possible

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that an NNP may have worked night shift in another unit, and day shift in the children's level IV NICU. The worked hours recorded for this project include only those performed in the freestanding children's hospital level IV NICU, and there was no survey question that inquired as to the number of continuous hours worked by the NNP, regardless of location. Process Application was made to the university institutional review board (IRB) for expedited review of the project. It was approved, and submitted through a reliance agreement to the IRB at the collaborative implementation site. The survey forms and tools for the project were reviewed, and the involvement of the NNP participant during the implementation was articulated. Privacy and confidentiality of the NNP and the patient recorded medical information was deliberated. The presentation was given 2weeks prior to the implementation, to solicit thoughtful consideration, discussion, comment, and inquiry by the intended participants, the NNPs. A key driver diagram was presented to illustrate the “big picture” perspective of the project. The key driver diagram is a familiar process format used within the organization, so the NNPs were able to visualize the plan. The improvement aim to assess workload was articulated, the objective measures of the project were the key drivers, and possible change interventions were proposed (Appendix A). Project Implementation At the initiation of the project, each NNP received a packet, including a copy of the verbal script of consent agreement, and contact information for the investigators and key personnel. The NNP received a unique project identifier (UPI) to use to code their identity when completing the shift survey and the patient acuity instrument on each worked shift, and to link the patients managed in the NNP caseload each shift with the NNP direct care provider. In addition, each NNP completed a form noting their years of experience in the NICU as a registered nurse (RN) and an NNP, and the individual's self-reported level of NNP competence. A total of 26 NNPs participated in the NNP Workload Project. The NNP participants represented 100% of the full-time and part-time workforce in the NICU, excluding those in orientation and on leave-of-absence. Input from the NNPs was encouraged through the project implementation to monitor their perspective, and to clarify concepts and points relevant to the evidence framework and the ongoing data collection process. The NNPs voluntarily completed an electronic shift survey and NTISS tool for each patient managed by the NNP for each worked shift over a consecutive 28-day period. Each patient was assigned a unique project identifier (UPI) so that the patient acuity assessment recorded on the electronic NTISS tool could be linked from shift-to-shift throughout the duration of the project. The NTISS is a 63-item intervention rating system used as a numeric acuity scale with points ranging, 1 to 4, for each item. The points were totaled and sorted from lowest to highest to indicate the gradient severity of illness. The highest score is the most acute.35 The electronic daily shift survey and the NTISS was reviewed and discussed with the NNPs for input and familiarity prior to the implementation of the project. A notebook containing paper copies of all project materials was made available during the project. Additional information posted in the office area included reminders to complete the survey and NTISS at the end of the shift, paper tools to use for review, the definition of the NTISS items, schedule of the author's onsite time, and contact information. Each participant completed the data from the daily shift activity/ workload during the worked shift for the 28-day period, submitted electronically, encrypted, and on-line for the author to review and collate. The estimated time for completion was approximately 20 min for a workload of 8 patients, and up to 40 min for 15 patients. The objective data-points recorded and compiled include: (a) number of NNPs, (b) worked hours in a shift, (c) caseload number per NNP, (d) acuity of each patient in the caseload noted by the NTISS numeric score,

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(e) additional responsibilities and activities performed during the worked shift, (f) perception of NNP performance and patient outcome during the shift using a Likert scale, (g) concern for safety during the shift because staffing resources may not have met the need of patients, and (h) staffing adjustments made during the shift due to safety concern(s) communicated by the NNP. Descriptive statistics and correlations were used to analyze the resulting data. Findings The data were collated and analyzed by individual factor and statistically summarized. The measures, including: years of experience, satisfaction with performance and patient outcome, average NTISS score per patient, and patient caseload number per NNP on each shift, were statistically analyzed to determine the relationship to the NNP perception of satisfaction.

Table 2 Summary statistics of the objective measures. Summary statistics of the objective measures based on survey response Factor

N

Years RN experience Years NNP experience NNP satisfaction w/ performance NNP satisfaction w/ patient outcome NTISS score average Patient caseload number

164 11.31 6.75 11.00 164 7.22 6.94 6.00 164 1.93 0.78 2.00

Mean STD

Median Minimum Maximum 3.00 0.50 1.00

23.00 25.00 5.00

164

1.85 0.75

2.00

1.00

4.00

164 164

8.87 2.25 7.88 3.72

8.56 6.00

3.33 1.00

14.80 15.00

NTISS score = 0–9 (low risk); 10–19 (mildly ill); 20–29 (moderately ill); 30–39 (extremely ill); and ≥40 (imminent death) (Gray et al., 1992). Satisfaction scores = Likert-type scale with 1 (very satisfied) and 5 (very dissatisfied).

number of times each NNP worked. Approximately 79% of the daily shift surveys were completed by the NNPs for inclusion in the database. Daily shift reports with missing NNP and patient identifiers were eliminated.

Characteristics of the NNP Demographic information was collected from NNPs employed fulltime and part-time in the NICU at the initiation of the project implementation. Recently hired NNPs were not enrolled in the project until orientation was complete, and the NNP was managing a caseload independent of the preceptor. The 26 NNP participants reported an average of 9.1 years of experience in the NICU as an NNP; and, 12.4 years in the NICU as an RN. The range was 1 to 25 years, and 3 to 25 years, respectively. The level of competence reported by the majority of the NNPs was competent, proficient and expert. Two NNPs, with limited experience as an NNP and advanced practice experience in a level IV NICU, described themselves as novice and advanced beginner. Eighteen (18) of the 26 NNPs (69.2%) identified themselves as proficient and expert, and reported a total of 25.3 average years of experience in the NICU as an RN and NNP (Table 1). The pattern exhibited by the years of NNP experience and selfreported level of competence was compared with Benner's description of the levels of skill acquisition. The 23.1% (N = 6) of the NNPs who reported themselves as competent averaged 10.7 years as an RN and 3.8 as an NNP; 26.9% as proficient (N = 7) averaged 12.3 years as an RN and 6.9 as an NNP; and, 42.3% as expert (N = 11) averaged 14.3 years as an RN and 15 as an NNP. The number of years as an NNP seemed to influence the reported level of competence. There were exceptions that may have been motivated by the individual's level of confidence (Table 1). It is interesting to note that the competence level self-reported by the NNPs is inconsistent with the suggested NNP years of experience that Benner34 has associated with each level. According to the reported years of NNP experience, there were more expert and advanced beginner NNPs and fewer proficient and competent NNPs. The likelihood that a nurse would identify as a novice was reduced by design, in that those NNPs being oriented were not included in the project. Based on the summary statistics of 164 individual NNP survey responses collected electronically by shift during the 28-day implementation period of the project, the mean years of NNP experience in the NICU was 7.22; the years of RN experience in the NICU was 11.31. The range was 0.5 to 25 years of NNP experience and 3 to 23 years as an RN, respectively (Table 2). The slight variation in years between the initial demographic data and the survey response summary is the reflection of the experience level of the individual NNP working the shifts and the

Shift Length The NNPs reported an average of 12.54 worked hours during a shift. Often times, shift report from NNP-to-NNP would extend the worked hours. The survey and NTISS tool was completed prior to the shift handoff using an estimated end-time. NNPs are salaried at the organization so exact start and end shift hours were not available by other means. There was no appreciable difference between worked shift hours reported on days, nights or weekends. The range was 12.0 to 13.5 h per shift. Satisfaction With Shift There was little variation between NNP satisfaction with performance and patient outcome. The majority of NNPs experience rotation among the shifts. In general, the NNPs reported very satisfied or satisfied with their performance and the patient outcome on the majority of shifts, despite the time of the shift—week day shift, night shift or weekend day shift. There was slight acknowledgement of dissatisfaction with performance and with patient outcome. It is understandable that NNPs would experience a sense of dissatisfaction if the outcome of the patient was less than desirable. During the 28 days of this project, the NNPs verbalized that there seemed to be less acuity in the NICU compared to the overall annual activity; and fewer unexpected events and parents in crisis. This may account for the positive level of satisfaction relative to shift (Table 3). Caseload The patient caseload number varied by weekday, night, and weekend day shifts. The assignment schedule showed that week day shifts were generally staffed with 5 NNPs giving an average caseload of 5.51 patients; weekend day shift with 4 NNPs averaging 6.93 patients per caseload; and, night shift with 2 NNPs averaging 13.71 patients per caseload. The goal of care in the NICU on night shift is to limit disturbances, such as treatment/intervention(s), to the baby and parents so they can experience recovery quiet time and/or sleep. One way to

Table 1 Summary of NNP demographics. Level of competence (self-reported)

Number

Level of competence using Benner Model

Years of experience: NICU RN

Years of experience: NICU NNP

Years of experience: total

Expert Proficient Competent Advanced beginner Novice Total

N N N N N N

N N N N N N

157 (Av = 14.3) 86 (Av = 12.3) 64 (Av = 10.7) 11 3 321 (Av = 12.4)

165 (Av = 15.0) 48 (Av = 6.9) 23 (Av = 3.8) 1 0.5 237.5 (Av = 9.1)

322 (Av = 29.3) 134 (Av = 19.1) 87 (Av = 14.5) 12 3.5 558.5 (Av = 21.5)

= = = = = =

11 (42.3%) 7 (26.9%) 6 (23.1%) 1 (3.9%) 1 (3.9%) 26

= = = = = =

16 (61.5%) 3 (11.5%) 2 (7.7%) 5 (19.2%) 0 26

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change. Availability is the primary consideration. Daily shift NNP caseload assignments are made by a peer on the previous shift.

Table 3 NNP satisfaction as a function of shift. NNP satisfaction factor

Shift Day

Performance 1 - Very satisfied 2 - Satisfied 3 - Neutral 4 - Dissatisfied 5 - Very dissatisfied Total Patient outcome 1 - Very satisfied 2 - Satisfied 3 - Neutral 4 - Dissatisfied Total

Night

Weekend

N

%

N

%

N

%

22 44 17 1 0 84

26.19 52.38 20.24 1.19

16 22 6 1 0 45

35.56 48.89 13.33 2.22

12 15 6 1 1 35

34.29 42.86 17.14 2.86 2.86

27 42 13 2 84

32.14 50.00 15.48 2.38

18 22 4 1 45

40.00 48.89 8.89 2.22

11 16 7 1 35

31.43 45.71 20.00 2.86

Satisfaction score = Likert-type scale with 1 (very satisfied) and 5 (very dissatisfied).

achieve this is through late evening rounds by the interprofessional team. Patient condition is reviewed and critical interventions are prioritized. This allows time to manage unexpected patient events, such as admissions, status deterioration, and crises. Shift call-offs due to illness or an emergent situation further reduce the staffing, and increase caseload per provider for the shift. An on-call NNP is scheduled, but resources or circumstance may preclude availability. If an NNP is serving in another role during the shift, such as educator or manager, and is available, she may take a caseload, or assist with caseload management. The summary statistics of 164 NNP survey responses showed a mean caseload of 7.88 for the NNP across all shifts of the 28-day project period. The range was 3.33 to 14.80 (Table 2). Some NNP caseloads were divided when NNPs left the shift due to illness. In those instances, an NNP scheduled to work the subsequent shift came in early, or an educator and/or NNP leader stepped-in to manage patients for the remainder of the shift hours. Caseload Comparison With NANNP Recommendation Based on the NANNP position statement, NNP Workforce, 4 the recommended caseload per NNP is 6–10 allowing for the level of patient acuity and NNP competence. The recent executive summary of the 2014 NNP Workforce Survey20 indicates that NNPs managing patients in a level IV NICU feel that it is unsafe to provide for an average caseload of 6 complex patients. Average caseload number, patient acuity, and NNP level of competence are not formally planned for in the development of the NNP schedule or shift assignment. Generally, the scheduler does make an attempt to balance newer NNPs with experienced NNPs. Scheduling is completed weeks to months in advance, and subject to Table 4 Average NTISS scores.

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Patient Acuity This project is the first to use the NTISS acuity tool in a prospective manner to assess provider workload. More commonly, the tool is utilized retrospectively to measure the intensity of therapy, such as the acuity/severity of illness among NICU patients. Some pediatric and adult critical care units have reported the use of a similar tool prospectively to assess patient acuity and resource utilization among nurse (RN) caregivers. The numeric scoring of acuity/severity of illness using the NTISS tool yielded an overall average point total of 8.87. The range of average total point scores was 3.33 to 14.80 (Table 2). The range of point-score per NTISS indicator was 1 to 45; the higher the point-score, the more acute the patient. During the project, NNPs were intermittently asked about their intuitive sense of the overall patient acuity. Their response was reflective of the pattern generated by the daily averages of the NTISS scores over the 28-day period—slightly higher at the initiation of the project, then a dip, followed by another slight increase (Table 4). Gray et al. 35(p563–564) reported five (5) NTISS score ranges with an equal number of assessments in each category: (a) 0–9, (b) 10–19, (c) 20–29, (d) 30–39, and (d) 40 and above. Physician risk assessments that were compared to the NTISS scores used the descriptive categories: (a) low-risk except for low-probability catastrophic event, (b) mildly ill, still at small risk, (c) moderately ill, but excellent chance for survival, (d) extremely ill, but with good chance for survival, and (e) virtually certain death, now or delayed. In this project, the higher scores in the range (31, 44, and) were indicative of the scores for extremely ill and imminent death categories reported by Gray et al. 35 The average NTISS score of 8.87 reported in this project suggested low risk. Given the nature of the patient diagnoses, therapies and condition during the 28-days of this project, and the scope of the tool, this author found the point-score ranges and the NTISS averages to be plausible. There were 61 patients assessed for 2-shifts per day for the duration of their hospitalization. This produced a total of 1383 completed accounts over the 28-day period. The pattern of the NTISS scores, when grouped by increasing severity of illness, showed a progressive decline in the number of accounts per shift (Table 5). The NNPs in the NICU manage patients assessed at all levels of acuity. Within the scope of the role, the NNP functions autonomously to perform direct care and to coordinate the activities of the team members so that the patient is effectively stabilized and managed to discharge. The NNP actively communicates with the parents/family, supports their needs, and encourages their presence. The NTISS is comprised of 8 categories of indicators and 63-items for which a patient is assessed. The categories include: (1) monitoring, (2) respiratory, (3) metabolic/nutrition, (4) vascular access, (5) drug therapy, (6) procedure, (7) cardiovascular, and (8) transfusion. The categories are organized by highest to lowest scoring category. This pattern was consistent through the 28-day period. The tool is developed to account for multiple configurations of items with associated point scores, but it is impossible to have a patient that would score points for every item. Patients that exhibited higher scores were babies at greater risk with severe hypoxemia, crisis events and whole body system deterioration, extracorporeal membrane oxygenation (ECMO), complex congenital diaphragmatic hernia (CDH), and a high-risk delivery of babies with twin-to-twin transfusion. Since the NTISS was developed in the early 1990s, item definitions were written specifically for this project that associate with current practice norms. However, some practice therapies have become less common, such as exchange transfusion and aminophylline administration, and others have been introduced. Examples of items not accounted for in the tool include: high flow oxygen, inhaled nitric oxide, pain control and sedation, and cerebral hypothermia.

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Table 5 NTISS score by severity-of-illness category. NTISS patient score by severity-of-illness category NTISS score 0 to 9 10 to 19 20 to 29 30 to 39 ≥40 Total

Severity-of-illness category Low-risk Mildly ill Moderately ill Extremely ill Imminent death

N 935 390 34 14 10 1383

% 67.61 28.20 2.46 1.01 0.72 100

NTISS score = 0–9 (low risk); 10–19 (mildly ill); 20–29 (moderately ill); 30–39 (extremely ill); and ≥40 (imminent death) (Gray et al., 1992).

Relationship Between the Measures There was weak correlation between NNP satisfaction with performance and the measure of NNP satisfaction with patient outcome (r = 0.81, p ≤ 0.001), between years of RN experience in the NICU and the measures of years of experience as an NNP (r = 0.48, p ≤ 0.001) and NTISS average scores (r = −0.28, p ≤ 0.001), and between years of experience as an NNP in the NICU and the measures of NTISS average scores (r = −0.22, p ≤ 0.01) and patient caseload number (r = −0.26, p ≤ 0.001). Though the participation of the NNPs was strong, there were limited data to yield significant relationships between the objective measures (Table 6). Additional Duties The shift workload of an NNP includes the expectation and performance of duties and responsibilities in addition to the management of a patient caseload. Though important, the activities may serve as distractors to the NNP on a busy shift when the NNP is juggling patient status changes, diagnostic tests and procedures to manage the condition of the patient, orientees and/or students, traveling with the patient, and integrating sub-specialist consultation recommendations. Some professional activities, if not completed during the shift, must be done on personal, unpaid time. This serves as an interruption to downtime, sleep, and family time, which contributes to building personal resilience—a much needed quality for the NNP who is expected to assume the caseload and workload of the decreasing presence of the residents in the NICU. The additional duties most frequently reported by the NNP included: (a) consulting with a sub-specialist; (b) covering the caseload of another NNP; (c) precepting students and orientees; (d) performing a QI activity (exclusive of this project); (e) management, coordination and scheduling; (f) traveling with a patient; (g) responding to and/or managing a crisis event to include resuscitation codes, death, safety situations; and (h) supervising residents. There are many more duties, responsibilities and activities that the NNP identified as consuming

their time and attention. Meier and Staebler suggest that the combination of managing the patients in the caseload and additional responsibilities may “pose a challenge in the provision of safe patient care”. 20(p.4) Little, if any, time was dedicated to the restorative care of the NNP, such as meals, breaks, or a walk out of the unit to get a beverage. NNP Satisfaction The NNP has become the dependable qualified provider of care to patients in the NICU as the role of the attending physician, fellow and resident shifts from less clinical involvement to one of educator/administrator/researcher. Consequently, the retention of the NNP as a stakeholder in the workforce is critical. Factors that influence NNP job satisfaction include: (a) sense of value and caring for patients in a stressful situation, (b) autonomy, (c) communication with team members, such as the NICU nurse, and (d) effectiveness. 30,44 For this project, NNP satisfaction was assessed by using a Likert-type scale to measure the NNP's perception of performance and patient outcome given a description of the NNP workload in the NICU. Overall, the NNPs reported satisfaction (1-very satisfied to 5-very dissatisfied) with their performance during the shift and the outcome of the patients. The mean score for satisfaction with performance was 1.93 (N = 164, S.D. = 0.78). The mean score for satisfaction with patient outcome was 1.85 (N = 164, S.D. = 0.75) S.D. = 0.8). The years of experience in the NICU as an RN (mean = 11.31, N = 164, S.D. = 6.75) and an NNP (mean = 7.22, N = 164, S.D. = 6.94) provide the NNP a foundation of familiarity with roles, and confidence in navigating the situations and physical environment of the NICU. The NNPs manage patients that are low-risk and low probability of a catastrophic event, to patients with total body system failure and the likelihood of death. The NTISS score average was 8.87 (N = 164, S.D. = 2.25). The NNPs manage patient caseloads greater than the caseload number recommended by NANNP, perform additional responsibilities to guide and mentor professionals, and lead initiatives to improve practice. The NNP caseload average was 7.88 (N = 164, S.D. = 3.72). Even with a heavy load of responsibility and accountability, they report satisfaction in their performance during the shift. This would suggest that NNPs like what they do and use matured coping mechanisms to energize themselves through stressful times with a positive attitude (Table 7). NNP Perception of Safe Staffing The shift survey invited participants to respond to questions about safe staffing. Was the scheduled staffing compromised or inadequate to meet the needs of patients? Was action taken to improve the staffing? Who provided the staffing support, i.e. physician, NNP, other? Over the 28 day period, there were a total of 6 responses indicating concern for safety, 4 on the week day shift, 1 on the night shift, and 1 on the weekend day shift. Adjustments were made in all but one of the

Table 6 Correlation estimates for NNP satisfaction, NTISS scores, and patient outcomes.~, * Correlation estimates for NNP satisfaction, years of experience, NTISS scores, and patient caseload numbers Measure

NNP satisfaction w/ performance

Weeks 1 through 4 (28 days) NNP satisfaction Years of experience w/ patient outcome as RN in NICU

NNP satisfaction w/ performance NNP satisfaction w/ patient outcome Years of experience as RN in NICU Years of experience as NNP in NICU NTISS scores - average Patient caseload number

1 0.81⁎⁎⁎ −0.08 0 −0.02 −0.04

1 −0.09 −0.02 −0.03 −0.05

~

p ≤ 0.10. ⁎ p ≤ 0.05. ⁎⁎ p ≤ 0.01. ⁎⁎⁎ p ≤ 0.001.

1 0.48⁎⁎⁎ −0.28 ⁎⁎⁎ −0.09

Years of experience as NNP in NICU

1 −0.22⁎⁎ −0.26⁎⁎⁎

NTISS scores - average

Patient caseload number

1 0.08

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instances. The staffing support was an NNP in 5 of the 6, and none was indicated in the remaining instance. One response did not identify a safety concern, however an adjustment was made without mention of what role fulfilled the need. In general, staffing adjustments are often made as concerns surface, however, there may have been more attention paid to meeting needs since the process was part of a focused project.

Discussion The findings represent baseline data that objectively describe the dynamic, complex, and interactive process of NNP patient assignment based on activity in the NICU and the NNP perception of performance and patient outcome. The NNP is a primary provider of health care to a vulnerable critical care population, the high-risk infant and family. The selected descriptors to characterize the process include: (a) experience and competence of the NNP, (b) NNP workload, (c) caseload number, (d) neonatal patient acuity, and (e) perception of the NNP regarding safety and satisfaction. The analysis of the data indicates that the current workforce of NNPs manage caseloads that are equal to or exceed the level of 6 patients NNPs report to be unsafe in a level IV NICU. The overall caseload average was 7.88 which is within the recommendation standard cited by the NANNP position statement. 4,20(p.4) Unlike the evidence cited in the NNP Workforce4 position statement, the data for the baseline description of this unit identify an objective measure of acuity for each patient managed by an NNP in the assigned caseload using a valid and reliable instrument. There is no benchmark, so internal monitoring and comparison of the data over time can produce a pattern of activity. The acuity of the patients managed by the NNP varies from low-risk to extremely complex with the likelihood of death. The combined years of experience and the competence level of the NNP seem to be assets to enable the NNP to manage distraction, stress, emotion and constraints. The NNPs reported the challenge of responding to the acute nature of the patient management; performing skills under pressure with precision and concentration; handling the constant interruption of inquiries; reflecting a calm confident appearance for distraught parents and families; and multitasking while thinking clearly and moving rapidly. Specific comments indicated that activity was high, the shifts were busy, parents were reacting with great stress to the declining health status of their infant, and time was extremely limited to manage and respond effectively to situations. This author observed that when interventions were required, the NNP reacted to the need with flexibility, thoughtfulness, and innovation. NNPs demonstrate the ability to balance the intellectual stimulation with a clear focus, manage the chaos with patience and prioritization, and contain the emotion with grace. NNPs function

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in a high-stress job and rarely decline the challenge to do the right thing for the patient and family. When the measures of NNP satisfaction with performance, NNP satisfaction with patient outcome, years of NICU experience as an RN and NNP, NTISS patient score average, and the average of the patient caseload number were statistically estimated, there were weak correlations among the measures. Despite the challenges of the job, the NNPs are satisfied with how they perform managing NICU patients, and the overall outcome of the patients. The analysis of the data indicates that the NNPs were satisfied with their performance during the worked shift and the outcome of the patients. There was no survey question that specifically addressed NNP satisfaction with the caseload number. This should be added to future surveys. There were a limited number of responses that stated concern for safety because the NNP scheduled staffing compromised or was inadequate to meet patient needs. Support by an NNP was made available during those instances so it can be assumed that the concern was resolved. The data from the project were used in the justification of an incremental increase in budgeted NNP positions for the NICU. The staffing model was adjusted so that the NNPs cover the majority of the census in the NICU with less than half of the previously assigned number of residents. The NNP caseload has increased. The recruitment of NNPs is a priority. It is recommended that the project be replicated to compare the prechange baseline with the data of the current model. The differences between the models, noted from the data analysis, will alert leaders to opportunities for improvement, specifically, issues that could impact patient safety and/or NNP retention. The continuous monitoring of metrics is essential regardless of whether the project process is replicated. NNP satisfaction with performance and patient outcome, within the context of workload and caseload, may be better indicators of overall workforce satisfaction than general employee surveys. Healthcare providers value the commitment and intellectual effort that they give through their performance to patients and their families. They strive to be effective by achieving a positive outcome for patients and their families. Limitations A limitation of this project was the small number of NNP participants and the small size of the patient population in one NICU over a short period of time. This is baseline data that cannot be generalized or compared. However, with further analysis, interpretation and study, there is more information to be gleaned from the baseline data of this unit project. Multiple objective factors used to describe the assignment process made the project complex. NNP participants demonstrated understanding

Table 7 NNP satisfaction. Average NTISS score and patient caseload number as a function of NNP satisfaction NNP satisfaction factor

Average NTISS N

Performance 1 - Very satisfied 2 - Satisfied 3 - Neutral 4 – Dissatisfied 5 - Very dissatisfied Total Patient outcome 1 - Very satisfied 2 - Satisfied 3 - Neutral 4 - Dissatisfied Total

Patient caseload number Mean

STD

N

Mean

STD

50 81 29 3 1 164

8.78 9.02 8.63 8.97 7.33

1.8 2.2 3 1.8 0

50 81 29 3 1 164

8.00 7.85 8.00 7.33 3.00

4.1 3.6 3.5 5.1 0

56 80 24 4 164

8.78 9.15 7.91 10.16

1.9 2.2 3 1.5

56 80 24 4 164

8.02 7.95 7.46 7.25

3.9 3.7 3.3 4.7

NTISS score = 0–9 (low risk); 10–19 (mildly ill); 20–29 (moderately ill); 30–39 (extremely ill); and ≥40 (imminent death) (Gray et al., 1992). Satisfaction scores = Likert-type scale with 1 (very satisfied) and 5 (very dissatisfied).

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and compliance in completing the surveys, but found it difficult to comprehend exactly what they would learn and receive in deliverables from their participation in the process. The key driver diagram helped explain the steps of the process. Given the time needed to work through the steps, the process was a test of the patience and commitment of the NNPs. Fortunately, response rate during the project did not suffer appreciably. Approximately, 79% of the shift surveys were completed. Interpretation of the large amount of data analyzed from the project implementation can be challenging. Were the factors selected to describe the NNP assignment process the right ones? There was no strong statistical significance noted between the measures. The weak correlations between NNP satisfaction, years of experience in the NICU, patient NTISS score, and caseload number suggest that further study with a larger participant population is necessary to clarify which factors, or combination of factors, show stronger relationships. NNPs may have felt compelled to respond positively to the survey inquiries about satisfaction with performance and patient outcome. Though the identity of the NNP was coded using a UPI, the small size and homogeneity of the group may have negatively influenced the trust of the NNP in the confidentiality of the process. Additionally, the lower sense of acuity during the 28-days of the project may have positively influenced the self-confidence of the NNP regarding performance and perception of patient outcome. Continuously monitoring NNP activity and perception of satisfaction over time can show changes in level of satisfaction based on workload, safety and patient status. This NNP workload project was not a short-term, or rapid-cycle, improvement initiative. The project developed a framework from which to collect baseline data needed to identify gaps and/or improvement opportunities. The continuous monitoring of data provides a platform for the implementation of strategic improvement plans and incremental rapid-cycle aims. It can be speculated that high activity and/or patient acuity during the shift, or at the end of the shift, and/or NNP fatigue, may have negatively influenced the completion of the surveys by individual NNPs. It is understandable. Participation in the project was voluntary. The NTISS acuity tool is a reliable and valid instrument from which to objectively describe the physiologic status of the patient. However, the NTISS instrument is outdated. The tool was published in 1992. Many of the indicators could be easily defined and/or interpreted for current practice, but others have limited use, and could potentially be eliminated from the tool. Some frequently used interventions of current practice were not included as indicators. The NTISS with 63-items required concentration to complete, and often, a review of the patient's electronic medical record. Limiting the responses to a simple “yes” at the applicable item, as opposed to a “yes” or “no” at each item, would increase efficiency in completing the form. This change may reduce the likelihood of error. Further, it may be as effective to complete the NTISS once every 24 h rather than once every 12-h shift. The electronic entry of response by the NNP on each shift provided an ease of submission, though the amount of data was time consuming. There were continuous interruptions throughout the shift, so the NNP was multitasking while completing the survey instruments. As updated survey software becomes available, there may be improved formats from which to organize the indicators to ease submission, and allow the timely download of collated data for analyzation and interpretation. An Internet technologist, computer programmer, and/or informatics specialist is necessary to guide formatting of the tools and the processing of data input, throughput, output, analyzation, and storage. Implications for Nursing Practice The primary implication for nursing practice that the NNP workload project offers is an opportunity to monitor the scope of function performed by the NNP as a provider within a complex critical care subspecialty, and assess the NNP's perception of his/her performance and patient outcome during the worked shift. Comprehending the scope of

practice from the perspective of the workforce provider at the time of performance is a critical component to building a resilient workforce to serve a vulnerable population. Using informatics to gather, monitor and evaluate an ongoing work process can lead to improvements that can be translated to metrics of value, thus contributing to the sustainability of the workforce in an evolving healthcare system. If the NNPs, or the neonatal department, use a patient acuity scale, it may be more feasible and expeditious to simply add a shift survey tool for the NNPs to complete, and thus implement the process of collecting baseline data. Based on the findings of this project, it is recommended that a standardized method/tool to assess patient acuity in the NICU be used in all NICUs. Productivity measures are of little value unless there is an objective indicator of the acuity from which to gauge differences. Time and task tools and relative value units (RVUs) used by organizations to equate activity as a quantitative unit that analyzes, cost, such as patient charge, workforce expense, and revenue do not adequately describe the process of direct care management of complex patients/situations to which the RVU is applied. Furthermore, the prioritization of decisionmaking and emergent response of the workforce to achieve an outcome is not taken into consideration.

Summary Workforce staffing models are changing. Unfortunately, organizations tend to make changes reactively as opposed to proactively. Workforce should be strategically designed to meet the health care needs of patients and families within the context of the subspecialty system. Consequently, it is important to develop a workforce allocation plan based on a sound understanding of the operation and outcome of the system. Strategies to implement change can be developed from the gaps, barriers and/or implications derived from the continuous monitoring of the objective data. Monitoring the level of satisfaction perceived by the workforce can go a long way to sustain limited resources, preserve well-being and resiliency, and implement changes to remove barriers that distract recruitment. The scheduling and shift assignment of NNPs is traditionally developed by the executive leadership of the organization using historical operational budget data. Patterns of the past do not always meet the needs of the present and future. Roles evolve over time to keep pace with the science and practice standards, though operations tend to lag with convention instead of advancing with evidence-based change. The objective factors used in this project were derived from Brooten's 29,30 explanation of dose effect to describe the effectiveness of the advanced practice nurse. The NNP is a master's prepared nurse with sub-specialty education in the area of neonatology, certified and credentialed to practice as a competent provider of neonatal health care. Benner's25 level of skill acquisition was used to describe the competence of the NNP. 32 The NTISS instrument provided a numeric score assessment of patient severity of illness. 35 A shift workload assessment tool was developed to measure NNP caseload, additional responsibility, and the perception of safety, performance and patient outcome. The results of shift data reported by NNPs in one level IV NICU over a 28-day period indicated satisfaction with performance and patient outcome, and limited concern for safety because staffing was not compromised nor was it inadequate to meet patient needs. Further study is needed to assess the effectiveness and satisfaction of the NNP given the context of the workload and caseload of the NNP in the NICU. The continuous monitoring of internal baseline data describing the pattern of workforce and patient activity can be compared over time. Improvement opportunities can be identified and initiatives can be implemented. A culture of safety begins with an understanding of current operations, and a strategic vision of best practice.

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Appendix A. NNP Caseload Project - Key Driver Diagram

Neonatal Nurse Practitioner (NNP) Workload Project Key Driver Diagram (KDD) Interventions (LOR#)

Key Drivers

LOR1: Adjust number of NNPs to meet care management needs of the patient census.

Workforce – number of NNPs working in the NICU.

LOR2: Allocate patients & resources based on experience, competence & developmental opportunities.

SMART Aim Workforce – experience and competence level of the NNPs.

Assess the workload of the NNP in the NICU using a patient acuity instrument, the NTISS, compared to the NNP workload recommendation of NANNP.

Global Aim Improve the process of planning and assigning NNP workload in the NICU.

LOR3: Adjust caseload number & patient acuity to experience & competence of the NNP.

Workload – number of patients in the NNP caseload.

LOR4: Distribute patients to NNP based on experience & competence level of the NNP.

Workload – acuity of patients in caseload using the NTISS.

LOR5: Adjust additional responsibilities & activities based on patient acuity & caseload number.

Workload – responsibilities performed by NNP during the worked shift.

LOR6: Allocate workforce to accomplish patient management within the scheduled shift hours.

Workload – actual worked hours compared to scheduled shift hours. Key

Gray shaded box = completed intervention Blue shaded box = what we’re working on right now LOR# = Level of Reliability Number, e.g., LOR 1

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