Grantee Profiles
Eileen Lake
How much do nurse training, staffing levels and work environments influence the health outcomes of high-risk babies? INQRI researcher Eileen Lake and colleagues are trying to find the reasons why babies do better in some neonatal intensive care units (NICU) than others. This study is the first large scale effort to look at nursing as it relates to survival rates and other indicators of quality of care.
The good news, says Lake, is that tiny babies who weigh less than 3.5 pounds are now living much longer than even a decade ago, thanks to advances in neonatal care. She and her team are attempting to find the workplace issues, staffing and training that nurses need to keep these tiny babies alive and stave off complications such as bleeding in the brain, lung disease, and deadly infections – all of which can lead to death, lengthy hospital stays or lifelong disabilities.
High-risk babies account for half of all infant deaths in the United States. Researchers have been urgently searching for ways to lower that toll but little research has examined how nurse staffing levels or the work environment might explain why some NICUs are more successful than others.
Questions the team is asking:
• Does a NICU with more highly trained nurses deliver a higher standard of care?
• Does a work environment that fosters teamwork between nurses and physicians have better survival statistics?
Lake at the University of Pennsylvania and her interdisciplinary team from four other universities hope to answer those questions and others. Lake says that nurses in these highly specialized units have specific skills, like being able to closely monitor a very tiny baby and step in if a problem, like signs of an infection, crop up. Nurses on a general medical ward do not take care of very ill patients on life support machines. But NICU nurses frequently care for more than one tiny baby with multiple health issues.
These nurses are on the front lines of intensive care nursing and their experience can make the difference between life and death, Lake says.
For example, NICU nurses must monitor and adjust a mechanical ventilator that helps a small baby breathe. They must look for signs of an infection or other health issues that can quickly turn lethal. But what happens when NICU nurses work in a poorly managed or under-staffed unit? What happens when nurses don't have the critical supplies they need on hand or when they have to juggle non-nursing duties, like answering the phone, when a small baby starts to develop a serious health problem, such as a sudden bleed in the brain?
To examine this issue, Lake and her colleagues are studying 104 NICUs in hospitals in 36 states throughout the United States. The team is also analyzing data from 6,060 nurses who completed an on-line survey on staffing levels and the work environment in the NICU. Interest in the study was so great that 77% of eligible nurses participated in the survey.
The survey also looks at how many babies nurses care for per shift and how sick the babies are. Knowing the acuity levels of infant patients is important. A nurse treating a very sick baby might be able to handle just one infant per shift. On a poorly managed NICU, the nurse might be given several very sick infants and in combination with other workplace issues, like a lack of support staff, that could increase the risk that the overtaxed nurse will miss a key change in the infant status or make an error, Lake says.
As a sociologist, Lake is also interested in how work environment affects nurses' efficacy and the health of patients. Lake and her team are asking nurses whether they had management support, such as adequate staffing of the unit, to carry out their duties efficiently. They also have been examining the kinds of relationships NICU nurses have with physicians. A non-collegial relationship might mean nurses don't feel comfortable challenging prescribed treatments or care orders from a physician on the team.
Lake says an environment in which nurses can speak their mind and be a key part of the health care team is critical for good patient care. Being able to question an order can prevent some mistakes, like prescribing the wrong drug or dosage. It also can increase the standard of care simply by fostering an open working environment in which a nurse's opinion matters.
Early findings from the study have revealed some interesting information. The average NICU nurse cares for two infants per shift. But the average caseload varies based on the acuity of the infants involved. Nurses caring for a very sick baby might have just that one case in a shift. However, preliminary results so far suggest that severity of illness and staffing levels do not seem to explain the variation in how well babies do.
The team did find that nurses with more experience and training do affect patient outcomes. For example, hospitals that had staffed the NICU with more highly qualified nurses seemed to perform better, at least on certain measures. NICUs that had more nurses who had earned a bachelor's degree had better survival rates than NICUs with fewer of such nurses.
"The more nurses with a bachelor's degree the lower the chance of infant death," Lake says, adding that so far that finding is a trend. Additional research must be done to solidify that association and find out if other training support, like getting certification to be a NICU nurse, can also make a difference.
Lake thinks that highly trained nurses, or those with lots of experience in the NICU, have a better chance of keeping very small, unstable infants alive and out of trouble. She says hospitals need to appreciate how much nursing skill matters when it comes to patient care. Some hospitals with nurse staffing shortages in the NICU throw a non-NICU nurse on a shift and expect the nurse to keep up with the demanding workload and severely ill infants. But Lake wonders if that practice leads to quality problems, like a higher risk of medical error. Additional research by the team might shed some light on this important question, she says.
In addition, nurses who worked in the best environments also seemed to provide a high standard of care. If working conditions in the NICU were supportive and collegial, then high risk babies were less likely to suffer from infections. Very small babies can get life-threatening infections despite the best of medical care. For example, nurses are often the first to notice the signs of an infection, like a high fever, and in a well-run NICU nurses can and do work together with physicians to treat the infection quickly. A disrespectful atmosphere in the NICU can mean nurses are reluctant to speak up at the first sign of a problem and the infection might get worse and harder to treat, Lake says.
The study results likely will be used by policymakers and regulators to set standards for all hospitals to follow when staffing a NICU. If research can identify best practices, then hospital managers ultimately will be able to set up a NICU that fosters the kind of environment that will help these infants survive the risky newborn period.
State and federal policymakers are looking for ways to reduce society's cost of caring for these small, pre-term babies. A 2006 report by the Institute of Medicine suggests that pre-term babies, those born too small to survive on their own, cost society nearly $26.2 billion in 2005 and two-thirds of the cost was for medical care, including the high-cost care delivered in the NICU.
Better organized nursing services combined with high quality nurses in the NICU could potentially prevent some medical complications and might lower the overall cost of caring for some of these infants.
"These babies are so small they usually fit in the palm of your hand," Lake says, adding that often they require extensive life support just to stay alive. The INQRI-funded research by Lake and her team will help nurses on the front lines deliver the best care possible--care that helps send a healthy baby home at last.