- Email: [email protected]
Neonatal Issues in Japan
INTERNATIONAL CONNECTIONS
Neonatal Issues in Japan Wakako Eklund, MSN, APN, NNP-BC and Carole Kenner, DNS, RNC-NIC, FAAN
Our world is shrinking due to computerized linkages and the mobility of society. Information is shared rapidly around the world. Issues surrounding newborn and infant nursing are global. In efforts to acknowledge the international community, each Newborn and Infant Nursing Review issue will feature a column that highlights care and educational-related issues from a featured country or region of the world. This article focuses on Japan. Keyword: Neonatal
Newborn And Infant health issues are global ones. To review issues occurring in different areas of the world, a different area of the globe that addresses Newborn and Infant Nursing Review's theme-oriented topic will be featured. This month Japan will be featured. Our guest author is Ms Wakako Eklund, MSN, APN, NNP-BC, Regional Network Contact for the Council of International Neonatal Nurses for Japan. This month's article focuses on the current issues impacting neonatal outcomes.
What has changed is that technology increased as it did in neonatology globally, and the neonatal viability limit has been pushed downward, thus resulting in an increase in the number of premature births. The ability for prenatal diagnosis has increased too. Therefore, the demand for NICU beds has risen accordingly, putting more pressure on an already stressed system. The shortage of neonatologists and dwindling financial resources are limiting the ability to expand care.
Japan: Current Issues Impacting Neonatal Outcomes
Recent Events
Japan has a well-established record of good infant outcomes. In 2007, its reported infant mortality rate was 2.6 per 1000 live births, placing them number 4 globally as of 2005.1,2 However, recently, the Japanese media has widely reported growing concerns that the country faces a health care crisis in relationship to neonatal/perinatal care.3-5 Most issues arise from the mismatch of supply and demand of the neonatal care workforce and the neonatal intensive care unit (NICU) beds. For the Japanese who are known for attention to detail, this brings the same quality to the bedside. Recent threats to this confidence in Japanese neonatal/perinatal capacity are distressing to those who strive for excellence at the bedside. What has changed, or has it?
From the Mid Tennessee Neonataology Associates, 2300 Patterson Street, Nashville, TN 37203. From the University of Oklahoma, Edmond, OK 73034. Address correspondence to Carole Kenner, DNS, RNC-NIC, FAAN, President Council of International Neonatal Nurses, Inc. 708 Capri Place, Edmond, OK 73034. E-mails: [email protected], [email protected]. © 2009 Elsevier Inc. All rights reserved. 1527-3369/09/0903-0315$36.00/0 doi:10.1053/j.nainr.2009.06.005
Main referral centers both in and out the metropolitan areas are often forced to create bed spaces by transferring infants to convalescent care beds who, in reality, probably need to stay in high-risk beds. Nursing staffing as might be expected is different in the lower acuity site, thus potentially leading to inadequate provision of care.6 The acute care facility that faces bed juggling on a daily basis finds it difficult to predict care needs or provide continuity of care. The situation leads to some families with twins facing a separation of the duo, placing the parents in a difficult, stressful situation to shuttle between two units. These two units are physically not in the same facility, thus leading to increased costs to the family and sometimes a division of the parents with one at one facility and one at another at the very time they need spousal support. Many parents show emotional reluctance and, however, willingly agree to the transfer of the infants because they are keenly aware of the bed shortage. Japan's maternal transport system poses another obstacle in continuity of care leading to potentially poor maternal-infant outcomes and causes a delay in maternal transports. In addition to the NICU bed shortage, high-risk perinatal centers have maintained high census and shortage of physicians creating a difficulty to accept transports. Maternal transports may take hours before an accepting facility can be found where an NICU bed is available.
Another area of shortage is staff itself. Because of the acute shortage of qualified nurses, especially in step-down or intermediate care, nurses are resorting to bottle propping or infant self-feeds, a practice that has been long noted to have potentially deleterious effects.7
Impact on Families Reports of practices that may compromise infant care shocked the Japanese young families. The Japanese perceived that they lived in a nation where an inexpensive national insurance allowed everyone to access high quality of medical/ nursing care. It is true that Japan has enjoyed the hightechnological quality in every aspect of life for quite some time. This includes the state-of-the-art neonatal intensive care facilities with top technology run by highly qualified physicians and dedicated nurses throughout Japan. Unfortunately, the same is not true when it comes to nurses and nursing care. The nurses want to give excellent care, but the shortage is forcing them to sometimes use less than desirable practices.
Japan Versus the United States Currently, there are approximately 2200 NICU beds and 900 physicians who are specialized in neonatal medicine in Japan.5,8 According to the reported birth number of 1 092 000 live births for 2008, there is one neonatologist per 1213 births and one NICU bed per 500 births.1 According to Goodman et al, 9 US total births per neonatologist ranged from 390 to 8197 (median, 1722) showing wide differences in the neonatologist availability. However, in the United States, many NICU patients are seen by a group of neonatologists and neonatal nurse practitioners (NNPs). Although the practice style varies, it is not uncommon to see only two neonatologists and additional several NNPs attending to a total of 60 infants in the tertiary NICU. The presence of NNPs to handle the NICU capacity is noteworthy. As for the births per NICU bed comparison, the US total births per NICU bed ranged from 72 to 1319, with a median of 317, but in Japan, this is higher at a level of 500 births. Although, Japan has seen a decreasing birth rate, the number of low-birth-weight infants has increased. During the period of 1991 to 2006, there were low-birth-weight births per 10 000 live births showing an increase of 46.9% from the years before this time. The extremely low-birth-weight infants increased by 64% during this same time frame.7
What Is Needed The Ministry of Health, Labor, and Welfare has suggested the need for an additional 1000 NICU beds, which would bring the total number to 3000. Expansion plans are being made, which include discussions about staffing. The expansion of NICU staff to meet the demand and improve the health professional/patient ratio, primarily the physicians and nursing staff, is urgently needed, but it will take 5 to10 years because of shortages in
NEWBORN
these health professionals. The government has begun searching for ways to consider using human resources to share responsibilities in areas that may allow skill mixing. In other words, professionals similar to the US model, which expands services by using a mix of physicians or neonatologist and NNPs, are now being considered. In addition, the current nursing force is not meeting the present NICU staffing condition, so to consider expanding to an advanced practice role may even make the staff nursing shortage worse. The cause of the bedside nurse shortage is due, in part, to the lack of regulatory oversight or support for staffing ratios, especially in the NICU setting. The issues of recruitment and retention of both physicians and nurses become problematic because the morale diminishes when care cannot be rendered in the manner in which the professionals would like. Patient outcomes suffer as the turnover increases and more inexperienced people care for the very sickest of infants. So what will turn this situation around? Using the US model as just one example, lawmakers, health professionals, hospital administrators, and the public must work together to create policies to enhance the recruitment and retention of people into nurses. Then the issue of working conditions and patient outcomes must be addressed. Globally, there is more emphasis on the Institute of Medicine's core competencies, which are as follows: interdisciplinary teams, informatics, evidence-based practice, quality improvement, and patient-centered care.10 These competencies are aimed at increased quality and patient safety throughout the world. Part of the quality issue also addresses creating a positive workplace environment, something that is needed in Japan as it is in the United States.
Contributing Factors to the Physicians and Nursing Shortage Neonatologists in Japan carry a load that is beyond most of our understanding. These physicians burn out quickly; however, many continue to maintain the quality medical care the infants receive at the sacrifice of their personal life and at somewhat less financially attractive arrangements when compared with neonatologist in the United States. New residents will not readily select this field, thus leading to increasing shortages. However, some of this “burden” could be reduced if certain tasks were turned over to nurses like what is done in other countries. For example, the initiation of or restarting an infiltrated intravenous line, drawing blood from umbilical catheter, changing ventilator settings within protocols, participating in infant transports, and attending as part of a team for high-risk deliveries. There seems to be fear that quality of care will suffer if nurses take on more of the current physician responsibilities. However, statistics bear out that the quality is already suffering. It is unknown why nursing's scope of practice remains narrow. Generally, the staff nurse performs noninvasive care, even though nursing has always been a vital part of the team in
& INFANT NURSING REVIEWS, SEPTEMBER 2009
133
NICUs. Transferring some of the responsibilities named previously could make a change that can be positive. One such example would be that nursing will be able to take better hold of the total care of the infant by being able to organize the infant's day according to the nursing plan instead of the physician's availability. Lack of physician availability can also impact patient safety and quality because they are spread too thin to always come in a timely fashion.
Positive Steps Recent efforts made to strengthen nurse's abilities to meet the challenges in the NICU include the initiation of neonatal intensive care certification system in 2004. This certification is available for those who desire the in-depth understanding in neonatal nursing theory and practice. Three years of experience in NICU and a total of 5-years' nursing practice are required before one can begin the certification process. The duration is typically 6 months long, and the course is only offered at a designated location. Individuals must take a leave from work for 6 months to attend the program. There is also a 6-week clinical experience to put the learning experience into practice at the end of the program. The curriculum covers wide areas of neonatal topics such as physiology, developmental issues, family care issues, risk management topic, or nursing leadership concepts.11,12 Although some of the contents mirror what may be included in the NNP program, components such as in-depth pathophysiology intended to diagnose and medically manage infants or a course in advance procedure are not included in the certification curriculum. The description of the certified nurse's role provided by the Japanese Nursing Association includes but is not limited to the following: (1) provides quality care for infants in critical and acute condition by promoting physiologically stable environment to minimize future sequelae and (2) provides care to promote optimal bonding between the infant and the parents to prevent pathological parenting behavior in the future.13 There are currently 113 Japanese nurses who are certified in neonatal intensive care nursing.14 Because the establishment of this certification process is relatively new, the direct outcome is not known. Varying sense of satisfaction seems to exist among those who are certified in regard to their expected role, level of contribution to the unit, amount of additional responsibility expected in addition to the regular staff role, and the reception by others. With adequate education and training, Japanese NICU nurses are capable and ready to face the challenge of the increased responsibility, which has a greater impact for the positive experience for the patients and their families. Underlying the current of interest toward the expanded role for nursing is a concern that requires immediate attention. As neonatologists struggle with their working environment, with long hours, and heavy responsibilities, nurses find themselves often forced to care for far too many infants as mentioned earlier because of the lack of clear regulatory provision for NICU. According to Dr Amizuka, who collected data from 97 facilities, step-down unit nurse/patient ratio varies from 4:1 to 25:1.7
134
VOLUME 9, NUMBER
More than half of the responder facilities admitted to allowing the infant feed in a crib with a bottle propped with nurses attending to multiple feeding infants at the same time. The most frequently given reason for this unsafe practice was an excessive number of patients to nurse ratio observed in the step-down section of the NICU.7 The nursing and the physician staff both are greatly in distress, clearly for the safety concerns for infants who are feeding without adequate supervision. It is not an accepted practice, and many neonatal health care professionals wish to abolish this practice. Ironically, Japan's staffing guideline for day care agencies that only have healthy infants is 3:1, and committed professionals are addressing this inconsistency with the larger number of sick, vulnerable infants per nurse. These efforts are aimed at the hospital and national levels with emphasis on gaining national regulatory support.
Future Changes and Challenges for the Neonatal Nursing Many nurses desire additional responsibilities such as starting an intravenous line or drawing blood and taking on more tasks related to standard neonatal care. These changes will impact the workload of physicians and may increase the attractiveness of residents to neonatology. On the nursing side, more responsibilities, coupled with more education such as the certification process, will increase the knowledge and skills of nurses. Nurses' abilities to specialize and become nurse experts will add to a sense of accomplishment and provide a motivation for future development. Turnover in nurses may decrease. However, the practice of many Japanese hospitals to move the most experienced and educated nurses out of units and rotate them to another hospital area diminishes the motivation for nurses to gain expert knowledge and dilutes the collective expertise available for care. If this practice were stopped along with encouraging better training for neonatal nurses, ultimately there would be better use of physicians, and increased education of nurses and interdisciplinary team approach to care could be enhanced and patient safety and quality should increase. These changes are in line with the Institute of Medicine competencies.10 Staffing patterns must be addressed through policy and regulations. For the future, an expanded role similar to that of NNP in the United States may become a pillar of NICU care. Use of this new role will increase the collaborative nature of the physician/nurse commitment to the neonates and their families. Recently, Health Ministry officially appointed a perinatal/neonatal physician team to conduct research on the topic of role of the NNP within the cultural context of Japan. Although this will take 5 to10 years before the number of neonatologists can be substantially increased, NNPs, on the other hand, could be educated in 1 to 2 years.
Conclusion Japan has an incredible opportunity to advance the role of nurses at the staff and advanced practice level while improving
3, www.nainr.com
neonatal outcomes. Ironically, it does not seem that either party, nursing or medicine, fully recognizes the full extent of each other's contribution. Japan, with its unique cultural background, may bring their nursing to a level that is refined and world class in every aspect. To achieve this goal, it will take a group of committed people—lawmakers, policy experts, nursing, medicine, and consumers—to join together in one voice. The question remains, “Is Japan ready to take on the challenge?” The answer is YES!
References 1. Summary of Vital Statistics, Ministry of Health, Labor and Welfare. Available: http://www.mhlw.go.jp/english/database/ db-hw/populate/pop3.html [Accessed February 25, 2009]. 2. International Comparison-Infant Mortality Rates: March of Dimes Peristats. Available: http://www.marchofdimes.com/ Peristats/im.aspx. [Accessed June 30, 2009]. 3. Kyodo World News Service, 2009. Pregnant Woman Dies After Rejected by 7 Hospitals. The Blackship Japan News, Views and Features; 2008. Available: http://theblackship. com/news/categories/national/706-pregnant-womanrejected-by-7-hospitals-dies-after-delivery.html [Accessed February 25, 2009]. 4. No author. Refused by 7 hospitals, a premature infant dies. Yomiuri Online, 2009. Available: http://www.yomiuri.co.jp/ iryou/news/iryou_news/20081202-OYT8T00446.htm; 2008 [Accessed Feb 27, 2009]. 5. Yamazaki K. Perinatal emergency, Report to be submitted by the Ministry of Health Soon. Yomiuri Online. Available: http://www.yomiuri.co.jp/iryou/news/iryou_news/
NEWBORN
20090114-OYT8T00443.htm; 2009 [Accessed February 17, 2009]. 6. Amizuka T. Issues related to management of neonates: staffing issue. Perinat Med (Japanese) 2004;34:1876-1880. 7. Amizuka T. Problems and solution for the perinatal medicine in Japan. Perinat Med (Japanese) 2008;38:105-110. 8. Sakurai Y. NICU Life line for babies, NICU expansion needs. The Need for Trained Professionals - Nippon Keizai Shinbun; 2009. 9. Goodman D, et al. Are neonatal intensive care resources located according to need? Regional variation in neonatologists, beds and low birth weight newborns. Pediatrics 2001;108:426-431. 10. Institute of Medicine (IOM). Keeping Patients Safe. Transforming the Work Environment of Nurses. Washington DC: National Academies Press; 2004. 11. Development of human resources with advanced specialization. Japanese Nursing Association. Available: http:// www.nurse.or.jp/jna/english/nursing/development.html [Accessed February 26]. 12. Course description and location for each certification program. Japanese Nursing Association. Available: http:// www.nurse.or.jp/nursing/qualification/nintei/ichiran.html [Accessed February 26, 2009]. 13. The role of certified registered nurse. Japanese Nursing Association. Available: http://www.nurse.or.jp/nursing/ qualification/nintei/knowhow.html [Accessed February 26, 2009]. 14. List of certified registered nurses. Japanese Nursing Association. Available: http://www.nurse.or.jp/nursing/ qualification/nintei/touroku/show_unit.cgi [Accessed February 26, 2009].
& INFANT NURSING REVIEWS, SEPTEMBER 2009
135
Neonatal Issues in Japan Wakako Eklund, MSN, APN, NNP-BC and Carole Kenner, DNS, RNC-NIC, FAAN
Our world is shrinking due to computerized linkages and the mobility of society. Information is shared rapidly around the world. Issues surrounding newborn and infant nursing are global. In efforts to acknowledge the international community, each Newborn and Infant Nursing Review issue will feature a column that highlights care and educational-related issues from a featured country or region of the world. This article focuses on Japan. Keyword: Neonatal
Newborn And Infant health issues are global ones. To review issues occurring in different areas of the world, a different area of the globe that addresses Newborn and Infant Nursing Review's theme-oriented topic will be featured. This month Japan will be featured. Our guest author is Ms Wakako Eklund, MSN, APN, NNP-BC, Regional Network Contact for the Council of International Neonatal Nurses for Japan. This month's article focuses on the current issues impacting neonatal outcomes.
What has changed is that technology increased as it did in neonatology globally, and the neonatal viability limit has been pushed downward, thus resulting in an increase in the number of premature births. The ability for prenatal diagnosis has increased too. Therefore, the demand for NICU beds has risen accordingly, putting more pressure on an already stressed system. The shortage of neonatologists and dwindling financial resources are limiting the ability to expand care.
Japan: Current Issues Impacting Neonatal Outcomes
Recent Events
Japan has a well-established record of good infant outcomes. In 2007, its reported infant mortality rate was 2.6 per 1000 live births, placing them number 4 globally as of 2005.1,2 However, recently, the Japanese media has widely reported growing concerns that the country faces a health care crisis in relationship to neonatal/perinatal care.3-5 Most issues arise from the mismatch of supply and demand of the neonatal care workforce and the neonatal intensive care unit (NICU) beds. For the Japanese who are known for attention to detail, this brings the same quality to the bedside. Recent threats to this confidence in Japanese neonatal/perinatal capacity are distressing to those who strive for excellence at the bedside. What has changed, or has it?
From the Mid Tennessee Neonataology Associates, 2300 Patterson Street, Nashville, TN 37203. From the University of Oklahoma, Edmond, OK 73034. Address correspondence to Carole Kenner, DNS, RNC-NIC, FAAN, President Council of International Neonatal Nurses, Inc. 708 Capri Place, Edmond, OK 73034. E-mails: [email protected], [email protected]. © 2009 Elsevier Inc. All rights reserved. 1527-3369/09/0903-0315$36.00/0 doi:10.1053/j.nainr.2009.06.005
Main referral centers both in and out the metropolitan areas are often forced to create bed spaces by transferring infants to convalescent care beds who, in reality, probably need to stay in high-risk beds. Nursing staffing as might be expected is different in the lower acuity site, thus potentially leading to inadequate provision of care.6 The acute care facility that faces bed juggling on a daily basis finds it difficult to predict care needs or provide continuity of care. The situation leads to some families with twins facing a separation of the duo, placing the parents in a difficult, stressful situation to shuttle between two units. These two units are physically not in the same facility, thus leading to increased costs to the family and sometimes a division of the parents with one at one facility and one at another at the very time they need spousal support. Many parents show emotional reluctance and, however, willingly agree to the transfer of the infants because they are keenly aware of the bed shortage. Japan's maternal transport system poses another obstacle in continuity of care leading to potentially poor maternal-infant outcomes and causes a delay in maternal transports. In addition to the NICU bed shortage, high-risk perinatal centers have maintained high census and shortage of physicians creating a difficulty to accept transports. Maternal transports may take hours before an accepting facility can be found where an NICU bed is available.
Another area of shortage is staff itself. Because of the acute shortage of qualified nurses, especially in step-down or intermediate care, nurses are resorting to bottle propping or infant self-feeds, a practice that has been long noted to have potentially deleterious effects.7
Impact on Families Reports of practices that may compromise infant care shocked the Japanese young families. The Japanese perceived that they lived in a nation where an inexpensive national insurance allowed everyone to access high quality of medical/ nursing care. It is true that Japan has enjoyed the hightechnological quality in every aspect of life for quite some time. This includes the state-of-the-art neonatal intensive care facilities with top technology run by highly qualified physicians and dedicated nurses throughout Japan. Unfortunately, the same is not true when it comes to nurses and nursing care. The nurses want to give excellent care, but the shortage is forcing them to sometimes use less than desirable practices.
Japan Versus the United States Currently, there are approximately 2200 NICU beds and 900 physicians who are specialized in neonatal medicine in Japan.5,8 According to the reported birth number of 1 092 000 live births for 2008, there is one neonatologist per 1213 births and one NICU bed per 500 births.1 According to Goodman et al, 9 US total births per neonatologist ranged from 390 to 8197 (median, 1722) showing wide differences in the neonatologist availability. However, in the United States, many NICU patients are seen by a group of neonatologists and neonatal nurse practitioners (NNPs). Although the practice style varies, it is not uncommon to see only two neonatologists and additional several NNPs attending to a total of 60 infants in the tertiary NICU. The presence of NNPs to handle the NICU capacity is noteworthy. As for the births per NICU bed comparison, the US total births per NICU bed ranged from 72 to 1319, with a median of 317, but in Japan, this is higher at a level of 500 births. Although, Japan has seen a decreasing birth rate, the number of low-birth-weight infants has increased. During the period of 1991 to 2006, there were low-birth-weight births per 10 000 live births showing an increase of 46.9% from the years before this time. The extremely low-birth-weight infants increased by 64% during this same time frame.7
What Is Needed The Ministry of Health, Labor, and Welfare has suggested the need for an additional 1000 NICU beds, which would bring the total number to 3000. Expansion plans are being made, which include discussions about staffing. The expansion of NICU staff to meet the demand and improve the health professional/patient ratio, primarily the physicians and nursing staff, is urgently needed, but it will take 5 to10 years because of shortages in
NEWBORN
these health professionals. The government has begun searching for ways to consider using human resources to share responsibilities in areas that may allow skill mixing. In other words, professionals similar to the US model, which expands services by using a mix of physicians or neonatologist and NNPs, are now being considered. In addition, the current nursing force is not meeting the present NICU staffing condition, so to consider expanding to an advanced practice role may even make the staff nursing shortage worse. The cause of the bedside nurse shortage is due, in part, to the lack of regulatory oversight or support for staffing ratios, especially in the NICU setting. The issues of recruitment and retention of both physicians and nurses become problematic because the morale diminishes when care cannot be rendered in the manner in which the professionals would like. Patient outcomes suffer as the turnover increases and more inexperienced people care for the very sickest of infants. So what will turn this situation around? Using the US model as just one example, lawmakers, health professionals, hospital administrators, and the public must work together to create policies to enhance the recruitment and retention of people into nurses. Then the issue of working conditions and patient outcomes must be addressed. Globally, there is more emphasis on the Institute of Medicine's core competencies, which are as follows: interdisciplinary teams, informatics, evidence-based practice, quality improvement, and patient-centered care.10 These competencies are aimed at increased quality and patient safety throughout the world. Part of the quality issue also addresses creating a positive workplace environment, something that is needed in Japan as it is in the United States.
Contributing Factors to the Physicians and Nursing Shortage Neonatologists in Japan carry a load that is beyond most of our understanding. These physicians burn out quickly; however, many continue to maintain the quality medical care the infants receive at the sacrifice of their personal life and at somewhat less financially attractive arrangements when compared with neonatologist in the United States. New residents will not readily select this field, thus leading to increasing shortages. However, some of this “burden” could be reduced if certain tasks were turned over to nurses like what is done in other countries. For example, the initiation of or restarting an infiltrated intravenous line, drawing blood from umbilical catheter, changing ventilator settings within protocols, participating in infant transports, and attending as part of a team for high-risk deliveries. There seems to be fear that quality of care will suffer if nurses take on more of the current physician responsibilities. However, statistics bear out that the quality is already suffering. It is unknown why nursing's scope of practice remains narrow. Generally, the staff nurse performs noninvasive care, even though nursing has always been a vital part of the team in
& INFANT NURSING REVIEWS, SEPTEMBER 2009
133
NICUs. Transferring some of the responsibilities named previously could make a change that can be positive. One such example would be that nursing will be able to take better hold of the total care of the infant by being able to organize the infant's day according to the nursing plan instead of the physician's availability. Lack of physician availability can also impact patient safety and quality because they are spread too thin to always come in a timely fashion.
Positive Steps Recent efforts made to strengthen nurse's abilities to meet the challenges in the NICU include the initiation of neonatal intensive care certification system in 2004. This certification is available for those who desire the in-depth understanding in neonatal nursing theory and practice. Three years of experience in NICU and a total of 5-years' nursing practice are required before one can begin the certification process. The duration is typically 6 months long, and the course is only offered at a designated location. Individuals must take a leave from work for 6 months to attend the program. There is also a 6-week clinical experience to put the learning experience into practice at the end of the program. The curriculum covers wide areas of neonatal topics such as physiology, developmental issues, family care issues, risk management topic, or nursing leadership concepts.11,12 Although some of the contents mirror what may be included in the NNP program, components such as in-depth pathophysiology intended to diagnose and medically manage infants or a course in advance procedure are not included in the certification curriculum. The description of the certified nurse's role provided by the Japanese Nursing Association includes but is not limited to the following: (1) provides quality care for infants in critical and acute condition by promoting physiologically stable environment to minimize future sequelae and (2) provides care to promote optimal bonding between the infant and the parents to prevent pathological parenting behavior in the future.13 There are currently 113 Japanese nurses who are certified in neonatal intensive care nursing.14 Because the establishment of this certification process is relatively new, the direct outcome is not known. Varying sense of satisfaction seems to exist among those who are certified in regard to their expected role, level of contribution to the unit, amount of additional responsibility expected in addition to the regular staff role, and the reception by others. With adequate education and training, Japanese NICU nurses are capable and ready to face the challenge of the increased responsibility, which has a greater impact for the positive experience for the patients and their families. Underlying the current of interest toward the expanded role for nursing is a concern that requires immediate attention. As neonatologists struggle with their working environment, with long hours, and heavy responsibilities, nurses find themselves often forced to care for far too many infants as mentioned earlier because of the lack of clear regulatory provision for NICU. According to Dr Amizuka, who collected data from 97 facilities, step-down unit nurse/patient ratio varies from 4:1 to 25:1.7
134
VOLUME 9, NUMBER
More than half of the responder facilities admitted to allowing the infant feed in a crib with a bottle propped with nurses attending to multiple feeding infants at the same time. The most frequently given reason for this unsafe practice was an excessive number of patients to nurse ratio observed in the step-down section of the NICU.7 The nursing and the physician staff both are greatly in distress, clearly for the safety concerns for infants who are feeding without adequate supervision. It is not an accepted practice, and many neonatal health care professionals wish to abolish this practice. Ironically, Japan's staffing guideline for day care agencies that only have healthy infants is 3:1, and committed professionals are addressing this inconsistency with the larger number of sick, vulnerable infants per nurse. These efforts are aimed at the hospital and national levels with emphasis on gaining national regulatory support.
Future Changes and Challenges for the Neonatal Nursing Many nurses desire additional responsibilities such as starting an intravenous line or drawing blood and taking on more tasks related to standard neonatal care. These changes will impact the workload of physicians and may increase the attractiveness of residents to neonatology. On the nursing side, more responsibilities, coupled with more education such as the certification process, will increase the knowledge and skills of nurses. Nurses' abilities to specialize and become nurse experts will add to a sense of accomplishment and provide a motivation for future development. Turnover in nurses may decrease. However, the practice of many Japanese hospitals to move the most experienced and educated nurses out of units and rotate them to another hospital area diminishes the motivation for nurses to gain expert knowledge and dilutes the collective expertise available for care. If this practice were stopped along with encouraging better training for neonatal nurses, ultimately there would be better use of physicians, and increased education of nurses and interdisciplinary team approach to care could be enhanced and patient safety and quality should increase. These changes are in line with the Institute of Medicine competencies.10 Staffing patterns must be addressed through policy and regulations. For the future, an expanded role similar to that of NNP in the United States may become a pillar of NICU care. Use of this new role will increase the collaborative nature of the physician/nurse commitment to the neonates and their families. Recently, Health Ministry officially appointed a perinatal/neonatal physician team to conduct research on the topic of role of the NNP within the cultural context of Japan. Although this will take 5 to10 years before the number of neonatologists can be substantially increased, NNPs, on the other hand, could be educated in 1 to 2 years.
Conclusion Japan has an incredible opportunity to advance the role of nurses at the staff and advanced practice level while improving
3, www.nainr.com
neonatal outcomes. Ironically, it does not seem that either party, nursing or medicine, fully recognizes the full extent of each other's contribution. Japan, with its unique cultural background, may bring their nursing to a level that is refined and world class in every aspect. To achieve this goal, it will take a group of committed people—lawmakers, policy experts, nursing, medicine, and consumers—to join together in one voice. The question remains, “Is Japan ready to take on the challenge?” The answer is YES!
References 1. Summary of Vital Statistics, Ministry of Health, Labor and Welfare. Available: http://www.mhlw.go.jp/english/database/ db-hw/populate/pop3.html [Accessed February 25, 2009]. 2. International Comparison-Infant Mortality Rates: March of Dimes Peristats. Available: http://www.marchofdimes.com/ Peristats/im.aspx. [Accessed June 30, 2009]. 3. Kyodo World News Service, 2009. Pregnant Woman Dies After Rejected by 7 Hospitals. The Blackship Japan News, Views and Features; 2008. Available: http://theblackship. com/news/categories/national/706-pregnant-womanrejected-by-7-hospitals-dies-after-delivery.html [Accessed February 25, 2009]. 4. No author. Refused by 7 hospitals, a premature infant dies. Yomiuri Online, 2009. Available: http://www.yomiuri.co.jp/ iryou/news/iryou_news/20081202-OYT8T00446.htm; 2008 [Accessed Feb 27, 2009]. 5. Yamazaki K. Perinatal emergency, Report to be submitted by the Ministry of Health Soon. Yomiuri Online. Available: http://www.yomiuri.co.jp/iryou/news/iryou_news/
NEWBORN
20090114-OYT8T00443.htm; 2009 [Accessed February 17, 2009]. 6. Amizuka T. Issues related to management of neonates: staffing issue. Perinat Med (Japanese) 2004;34:1876-1880. 7. Amizuka T. Problems and solution for the perinatal medicine in Japan. Perinat Med (Japanese) 2008;38:105-110. 8. Sakurai Y. NICU Life line for babies, NICU expansion needs. The Need for Trained Professionals - Nippon Keizai Shinbun; 2009. 9. Goodman D, et al. Are neonatal intensive care resources located according to need? Regional variation in neonatologists, beds and low birth weight newborns. Pediatrics 2001;108:426-431. 10. Institute of Medicine (IOM). Keeping Patients Safe. Transforming the Work Environment of Nurses. Washington DC: National Academies Press; 2004. 11. Development of human resources with advanced specialization. Japanese Nursing Association. Available: http:// www.nurse.or.jp/jna/english/nursing/development.html [Accessed February 26]. 12. Course description and location for each certification program. Japanese Nursing Association. Available: http:// www.nurse.or.jp/nursing/qualification/nintei/ichiran.html [Accessed February 26, 2009]. 13. The role of certified registered nurse. Japanese Nursing Association. Available: http://www.nurse.or.jp/nursing/ qualification/nintei/knowhow.html [Accessed February 26, 2009]. 14. List of certified registered nurses. Japanese Nursing Association. Available: http://www.nurse.or.jp/nursing/ qualification/nintei/touroku/show_unit.cgi [Accessed February 26, 2009].
& INFANT NURSING REVIEWS, SEPTEMBER 2009
135