Preparing Community Level II Neonatal Intensive Care Unit Nurses to Deliver Level IIIA Care Lynne Marie Keegan, RN, MSN, NNP-BC, CNS Willa Fields, RN, DNSc, FHIMSS
T
As a California community hospital with a Level IIIA NICUs in community hospitals and the complex- NICU, we had acutely ill and VLBW infants being born in ity of cases treated in these NICUs has grown nationwide our delivery rooms. Our dilemma was how to safely care for since the 1990s.1 Studies have these infants and assure that our evaluated the effects of neonaNICU nurses were competent Abstract tal services provided in comto care for them. The purpose munity hospitals on mortality of this quality initiative was to The purpose of this quality initiative was to increase NICU nurse competency to meet the care needs of and morbidity of very low birth increase the NICU nurses’ comhigher acuity infants. A multifaceted educational approach weight infants (VLBW), those petency level to meet the care with individual bedside education, a clinical practicum, weighing 1,500 g. Although needs of higher acuity infants. inservices, and case presentations was based on results Phibbs and colleagues recomfrom a needs assessment, observational feedback, and mended that VLBW infants BACKGROUND chart audits. Results of this educational intervention should be cared for in higher The American Academy of included increased nurse competency and a change in volume—higher level of care Pediatrics defined a Level IIIA admission criteria to care for higher acuity infants without NICUs of at least a Level IIIB, NICU as a unit that provides transporting them to another hospital miles away. As the IIIC, or IIID—in California, ventilation without restrictions admission criteria changed, the volume of higher acuity fewer than 25 percent of VLBW to high-risk newborns and those infants increased, and the nurses were able to maintain infants are delivered in hospiwith critical illnesses includtheir competency in caring for these infants. tals with these types of units.1 ing infants with gestational Keywords: NICU level of care; nurse competency; Chung and colleagues studied ages 32 weeks and weights inservice education; performance improvement the effects of NICU level of care 1,500 g. 3 Level III NICUs and annual delivery volume on must have the capability to VLBW infant outcomes. 2 They provide ongoing assisted ventilafound that between 1997 and 2002, when deregionalization, have ready access to pediatric medical subspecialists, and tion of perinatal care in California had stabilized, about 20 can facilitate transfer to higher-level facilities, as well as back percent of VLBW infants were born and received care in transport recovering infants as clinically indicated. Level IIB lower volume, lower level of care community hospital Level I NICUs can provide mechanical ventilation of brief durations and Level II NICUs. Outcomes of the Chung study revealed 24 hours and should be limited to caring for infants who that lower level, lower volume NICUs were associated with are greater than 32 weeks gestation and weighing more than higher odds of mortality, with the highest odds of death 1,500 g. associated with Level I NICUs with annual VLBW volumes of ten or fewer infants. In addition, Chung and colleagues Disclosure The author has no relevant financial interest or affiliations with any found that, overall, the influence of hospital volume within commercial interests related to the subjects discussed within this article. each level of care was a stronger predictor of outcomes than No commercial support or sponsorship was provided for this educational level of care.2 activity. he n um ber of n ew or ex pa nded lev el of ca r e
Accepted for publication February 2013.
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Sharp Grossmont Hospital, located in La Mesa, California, has a 24-bed, Level IIIA NICU. Although our NICU was licensed as a Level IIIA, we were functioning as a Level IIB NICU because our admission criteria required us to transfer infants to our sister hospital for a higher level of NICU care. Prior to 2007, these transferred infants included those who required mechanical ventilation, or who had a gestational age 32 weeks or a weight 1,500 g. These restrictions were implemented after Sharp Grossmont Hospital became part of the larger Sharp HealthCare system because of our neonatology coverage. Our sister hospital was 11 miles away and imposed a challenge for the families to visit and participate in their ill infant’s care. When we decided to change the admission criteria to allow higher acuity infant management in our NICU, we realized there had been limited opportunities for the registered nurses to participate in the patient care management of VLBW or other acutely ill infants requiring ongoing supportive therapies such as ventilation. Maintaining a nurse’s confidence and competence in providing patient care is directly related to the amount of handson experience available to them.4 The goal for this quality initiative was to provide increased opportunities for the nurses to participate in the continuum of ongoing patient care management required to move acutely ill infants to a stable phase. One of the problems we identified in meeting this goal was the difficulty in maintaining staff nurse confidence and competence when caring for higher acuity infants because of their lack of consistent hands-on experience. We believed that, with increased opportunities for patient care management, the NICU nurses would experience a movement away from short-term task orientation, such as focusing on preparation for transport, and increase their abilities for more advanced patient assessments, planning, interventions, and evaluation. When the project began in 2007, Sharp Grossmont Hospital had 3,670 deliveries, with 481 NICU admissions. The NICU’s average daily census was seven to nine, and the average length of stay was seven days. Infant gestational ages ranged from 25 to 40 weeks, approximately 5 percent were VLBW, and 10 percent required ventilation or continuous positive airway pressure (CPAP) greater than four hours. The infants who were to be transported were stabilized, and, if indicated, surfactant was administered. The NICU clinical staff included a manager, clinical nurse specialist (CNS), and 35 registered nurses, including eight advanced life support (ALS) nurses. All NICU nurses were required to maintain the Neonatal Resuscitation Program certification. Specialty certification was encouraged, although voluntary. On hire, and then annually, NICU nurses were required to complete a competency evaluation that included self-learning modules with written examinations and demonstration of high-risk, low-volume skills such as chest tube maintenance, use of a blood warmer, and mock cardiac and respiratory codes. The nurses’ experience level ranged from new hires with no previous NICU experience to veteran nurses with more than 25 years’ experience in our NICU. The ALS nurses had
advanced training in stabilization and resuscitation and functioned under the direction of the neonatologist or standardized procedures in their absence. In the state of California, the Standardized Procedure Guidelines are the legal mechanism for registered nurses to perform functions that might otherwise be considered the practice of medicine. The unit was staffed with at least one ALS nurse on each shift.5 The neonatologists and Committee on Interdisciplinary Practice approved the ALS standard procedures, which included initiation of oxygen, management of resuscitation, intubation, umbilical arterial and venous line placement, radial artery puncture for blood gases, emergent thoracentesis, and management of neonatal hypoglycemia. The ALS nurses maintained ongoing competence working individually with the neonatologists and demonstrating to them the earliermentioned procedures at least annually. When a high-risk delivery of a VLBW infant was anticipated, a NICU ALS nurse and respiratory care practitioner (RCP) were dispatched to attend the delivery. Their role immediately after delivery was to stabilize the infant according to the Neonatal Resuscitation Program and California Perinatal Quality Care Collaborative (CPQCC) toolkit.6,7 For example, for stabilization of VLBW infants, the ALS nurse initiated measures to prevent hypothermia by placing the infant’s body in a plastic warming bag, on top of a portawarmer pack, on a preheated radiant warmer, with a servo probe in place.7 The RCP attached an oxygen saturation probe on the infant’s right wrist and blended the oxygen concentration to meet the infant’s oxygen saturation goal, which was determined by gestational age and minutes of life.6
Conceptual Framework
This project applied Benner’s model of novice to expert to categorize the NICU nurses’ skill level to determine who were the appropriate preceptors and who needed additional education and support.8 Benner postulated that skill development and increased understanding of patient care occurred over time through education and clinical experiences.8 The five levels within the novice to expert model included novice, advanced beginner, competent, prof icient, and expert. Kaminiski applied Benner’s model to change processes in nursing through detailed descriptions of supervision required at beginning levels and the hallmark behaviors and skills of advanced nursing levels.8,9 A novice has little knowledge and needs policies and procedures for actions, consistent monitoring, and explicit instructions, usually from their nurse preceptor. Advanced beginners still function under policies and procedures, but, as they gain more experience in patient situations, they are able to apply what they have learned previously. They still need consistent monitoring by their preceptors but function at a more expanded level of nursing practice. Both the novice and advanced beginner focus on the technical aspects of care and rely on their preceptor’s guidance to help them gain proficiency and confidence in their abilities to problem solve. Competent nurses understand the policies and procedures and
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are able to use their clinical judgment in problem solving and decision making. Proficient nurses are characterized by their ability to view their patient’s needs from a holistic perspective, rather than a set of tasks that must be accomplished. Expert nurses have immediate intuitive situational awareness, which allows them to respond automatically to the problems they encounter. Expert nurses possess two characteristics that assist in propelling them to this level: a willingness to take risks and their ongoing approach to continuously developing their skills and knowledge. Those at the expert and proficient levels were best suited to be preceptors for the novice and advanced beginner nurses. The categorization of NICU nurses into one of Benner’s five levels was based on direct, bedside, clinical observation by the multidisciplinary administrative team.8 The results of this categorization demonstrated that 20 percent of the NICU nurses functioned at the expert and proficient levels. Another 75 percent of the nurses functioned at the competent level and 5 percent at the advanced beginner or novice levels. Our challenge was to transition the advanced beginner and novice nurses to at least the competent level, while ensuring those who were currently functioning at the expert, proficient, and competent levels maintained their level of proficiency. Burch and colleagues described the seasoned NICU nurse as having the experience to guide other nurses to intervene quickly when there is a change in an infant’s status.10 These repeated experiences promote expansion from initial task orientation to critical thinking, helping to develop confidence, competence, and accountability. Adult learners must go through a process of self-directed learning, with or without help from others, where they develop skills to help them identify their learning needs and take the initiative for their own learning.11 Adult learners benefit from repeated exposure to real cases, where errors in information, judgment, and reasoning are pointed out and discussed, leading to improvement in management priorities, increased clinical reasoning, and skill level.12
DEVELOPMENT OF THE NICU EDUCATION PLAN
Our goal was to ensure that the NICU nurses were competent to care for higher acuity patients. The expert and proficient nurses functioned as preceptors for less experienced nurses. The nursing education plan was based on results from the NICU nurses’ needs assessment, observational feedback, and chart audits.
NICU Needs Assessment
A voluntary needs assessment survey was distributed to the nursing staff for input on future NICU educational topics and preferred modality for the educational sessions. Suggested topics included disease states such as respiratory distress syndrome, disseminated intravascular coagulation, and shock with the expected medical management and nursing interventions. Nurses could also write in a topic. Nurses were asked
to rate their top five educational topics on a scale of 1 5 most important to 5 5 least important. Paper copies of the survey were available in the nurses’ conference area, along with a box for submission. Nurses who included their names on the survey form were eligible to win prizes of hand lotion and shower gel. Nurses also were asked to check how they wanted the inservice programs presented from a list that included lecture, selflearning module, group discussion at staff meeting, poster, and case presentation. These results were taken into consideration when preparing inservice programs.
Observational Feedback
The ALS nurses and neonatologists had opportunities to directly observe nurse and RCP practice. If their practice was not congruent with established NICU guidelines of care and the Neonatal Resuscitation Program guidelines, the ALS nurses and neonatologists provided bedside education and also reported these findings to the NICU manager, CNS, or respiratory clinical specialist for further follow-up.6
Chart Audits
The NICU CNS conducted concurrent chart audits on NICU infants who had code blue events, were intubated, or were transported to a higher level of care. The purpose of the audits was to determine nursing and RCP compliance with the NICU guidelines of care, Golden Hour Stabilization practices, infection prevention practices, and family education. Those areas not in compliance were incorporated into the education program. The chart audit began with the infant’s care in the delivery room and concluded with NICU discharge. The chart audit results for this project focused on the results from the delivery room care through the transition period. The transition period is the time from birth until the infant’s systems stabilize and adapt to life outside of the womb, which can occur over minutes to hours. Normal infant transition requires the infant to initiate respirations with the first breaths, increasing the blood flow to the lungs that supports gas exchange, while overcoming the pulmonary vascular resistance useful during fetal life. Also, during this time, the peripheral vascular resistance increases to a level higher than the pulmonary pressures, supporting increased blood pressure and causing the umbilical arteries and vein to constrict and the three major fetal shunts to close.13 Guidelines of Care. The NICU guidelines of care are evidence-based documents that include unit standards for nursing assessments, positioning, critical value reporting, and nursing interventions. The guidelines of care are nursing care resources available in the computer system and in a binder on each nursing unit. The chart audit included an evaluation of whether or not the nurses followed the guidelines of care. Golden Hour. The Golden Hour focused on multidisciplinary team preparation and communication in the first hour of life.14 Golden Hour scripting supported better communication among team members that led to identification
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of infant risk factors and implementation of processes that decreased complications from stress, pain, hypothermia, hypoglycemia, and hypoxemia, while maintaining cardiovascular stability, optimizing respiratory support, and monitoring oxygen use to prevent complications such as retinopathy of prematurity, chronic lung disease, and intraventricular hemorrhage in the first hour of life.14,15 The Golden Hour audit tool evaluated nursing stabilization priorities and components of the STABLE program: Sugar and safe care, Temperature, Airway, Blood pressure, Lab/antibiotics, and Emotional support.16 Specific nursing actions evaluated were based on documentation from the electronic health record for the infant’s clinical presentation and birth history. Infection-Prevention Practices and Family Education Chart audits for infection-prevention practices included a review of the documentation for the ventilator-associated pneumonia bundle (e.g., disinfection of high-touch surfaces and respiratory equipment, separate suction setups for endotracheal tube and oral suction systems, changing suction canisters and tubing).17,18 Chart audits also included a review of documentation for family education for central-line, multidrug-resistant organisms and surgical incision site infection-prevention practices.19
EDUCATIONAL PLAN AND EVALUATION
The NICU needs assessment results (Figure 1), observational feedback, and chart audits demonstrated that the nurses would benefit from further education on disease states (e.g., pulmonary and cardiac diseases), medical management, nursing interventions, prioritization of care, and team communication. Results from the needs assessment also demonstrated that the nurses preferred case presentations over other
educational modalities. The educational plan included individual bedside education, a clinical practicum, inservices, and case presentations. Evaluation of the educational program had two components: nurse competency and the educational sessions. Nurse competencies were formally evaluated during the individual bedside education, clinical practicum, chart audits, NICU admission criteria, and NICU transfer-out data. The CNS and medical director rounded together at least weekly and queried the nurses about how the various components of the educational plan were progressing, including a self-evaluation of their clinical skills and knowledge. The NICU nurses evaluated the inservices and case presentations on how well the objectives were met.
Individual Bedside Education
The administrative team assigned the ALS nurses to function as a preceptor and provide one-on-one, hands-on training at the bedside and in the delivery room for all non-ALS NICU nurses. Each ALS nurse was provided a list of five NICU nurses to precept and a monthly topic to review (e.g., Neonatal Resuscitation Program guidelines to guide highrisk delivery patient management, assisting with intubation, and admission and stabilization priorities). The hands-on component for education included supervised attendance at high-risk and cesarean section deliveries with an ALS nurse, care of the infant from admission through stabilization, and participation in mock code blue exercises. The ALS nurses evaluated the preceptee on a sign-off sheet that listed the monthly topics and clinical skills. For example, the preceptee needed to demonstrate the skills and clinical judgment to successfully admit and stabilize a NICU admission. The specific actions required were from the NICU guidelines of care.
FIGURE 1 ■ Needs assessment results.
5
Numerical Ra ng
4 3 2 1 0 Assisted Ven la on
Shock
Cardiac Disease Disseminated Intravascular Coagula on
Respiratory Distress Syndrome
Ra ng
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Clinical Practicum
A 36-hour, three-shift clinical practicum was held at our sister Level IIIA NICU for all NICU nurses, including the ALS nurses. For new hires, the clinical practicum became a component of the orientation program after they had at least six months of NICU Level III experience and were able to safely manage a patient care assignment with an unstable infant. If at all possible, the NICU nurses were assigned the same two patients during the entire practicum. The clinical practicum was modeled after a program described by Burch called Critical Thinking Week, which was designed for novice nurses as a means to foster advanced skills acquisition and critical thinking.10 In the Burch program, novice nurses
were paired with expert nurses who served as preceptors. The expert nurses functioned as a clinical resource and did not provide patient care, allowing the NICU nurses the opportunity to completely care for the infant. In our clinical practicum, the clinical leads at the sister hospital identified nurses with clinical expertise, past precepting experience, and willingness to participate as preceptors. Our hospital paid the salaries for both the preceptors and preceptees. Preceptor/preceptee pairs were given a packet of information with the expected experiences, minimum expectations for performance, descriptions of methods to measure competency, and an area for preceptor evaluation and comment (Table 1). Experiences included care for at least
TABLE 1 n Sample Section of the NICU Clinical Practicum Preceptor Evaluation Tool Competency (Skills)
Methods to Measure
Met
Not Met
Comments
I. Pulmonary system Performs a pulmonary assessment and reviews data for infants at risk A. Cares for a high-risk infant on respiratory support, reviews the diagnosis, examines the infant, and recognizes normal and abnormal findings
Preceptor confirms assessment findings. Preceptee verbalizes potential etiologies of findings.
Refers to NICU Respiratory Guidelines of Care for additional resources
B. Monitors the respiratory status of the infant using the following: • Cardiac/respiratory monitors • Oximeter preductal and postductal • Transcutaneous monitoring (TCM) • Arterial blood gases • Chest x-ray results
Preceptee demonstrates competency to the preceptor. Preceptor reviews findings with preceptee.
1. Peripheral arterial line line draw 2. Umbilical artery catheter line draw
C. Assists with intubation per Neonatal Resuscitation Guidelines
Preceptor confirms.
D. Defines the following modes of ventilation and demonstrates nursing management of a ventilated infant on two of these modes: • Nasal continuous positive airway pressure (NCPAP) • Nasal intermittent mandatory ventilation (NIMV) • Synchronized intermittent mandatory ventilation (SIMV) • Pressure support • Assist control • Volume guarantee
Preceptee verbalizes indications for use and demonstrates nursing management for infants on two of these modes, including one which uses flow loops and graphics.
E. Collaborates with the RCP/physician to evaluate ventilator settings and changes based on individual status
Preceptee verbalizes understanding of ventilation strategies.
F. Identifies ventilator-related complications and nursing interventions: • Infection • Air leaks • TCO2 changes per TCM • Atelectasis • Decreased tidal volumes
Preceptee verbalizes potential ventilator complications and nursing interventions to identify and manage changes in infant status.
G. Identifies and intervenes prn for potential postextubation complications
Preceptee verbalizes to preceptor and demonstrates care prn.
RCP and preceptor to review modes of ventilation Preceptor to review nursing management of mode of ventilation with the preceptee Dates: 1. 2. 3.
Abbreviations: NICU 5 neonatal intensive care unit; prn 5 as needed; RCP 5 respiratory care practitioner; TCO2 5 transcutaneous carbon dioxide.
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two ventilated infants with central lines and critical drips. Minimum expectations were organized by body system and included items such as recognizing normal and abnormal cardiovascular and pulmonary findings; obtaining arterial blood gases, reviewing results, and identifying appropriate interventions based on gestational age; and managing the care of a ventilated infant. Measurement descriptions included items such as “preceptor confirms assessment findings, preceptee verbalizes possible etiologies of abnormal findings.” If the preceptee had no opportunity for a particular experience or skill, the preceptee was required to describe the diagnosis, pathophysiology, and nursing interventions. The preceptor evaluated the nurses’ performance as met or not met, and there was space for additional comments so the CNS could follow up with the preceptee.
Inservices
The mandatory inservice education included published evidence-based practice guidelines and toolkits from CPQCC, National Association of Neonatal Nurses, and Core Curriculum for Neonatal Intensive Care Nursing. 20 Initial inservices included a review of central-line care, blood gas interpretation, ventilator strategies and surfactant administration, care of infants on high-f low nasal cannula and nasal CPAP (NCPAP), and calculation and bedside management of critical drips such as dopamine, epinephrine, and alprostadil. Later, the topics included persistent pulmonary hypertension of the newborn, admission priorities and use of the Golden Hour script, and how to report a change in infant status using closed-loop communication. Inservice sessions were presented at multiple times and days to facilitate nurse participation. Attendance was taken, and those nurses unable to attend received make-up sessions. Although knowledge was not evaluated after the inservice sessions, participants completed an evaluation of the content, applicability to practice, and how well the session objectives were met on a scale of 1–4 (1 5 poorly and 4 5 very well).
Case Presentations
The NICU Medical Director, respiratory clinical specialist, and NICU CNS conducted quarterly staff case presentations of complex diagnoses. Attendance at the case presentations was voluntary. The presentation began with a patient’s diagnosis, pathophysiology, and subsequent care and concluded with a critique of the care: those things that were done well and those that could have been done better. The educational goal was an understanding of the patient’s condition, exemplary care, and areas for improvement for future patients. Case presentations were evaluated in the same manner as inservices.
RESULTS
Nurse Competency
All nurses who participated in the individual bedside education with the ALS nurses and the clinical practicum at our sister hospital demonstrated successful completion of the topics and clinical skills. Chart audit data demonstrated that, as the nurses cared for infants with lower gestational ages and more complex ventilation needs, the guidelines of care continued to be met. The nurses demonstrated a level of comfort and competence to the neonatologists, which led to changes in the admission criteria. As the nurses’ skill level improved, the neonatologists supported changing the admission requirements (Table 2). Prior to 2007, infants were transported to our sister hospital if they were ventilated or had a gestational age of 32 weeks or a weight 1,500 g. By 2010, the infants were only transported if they had a gestational age 28 weeks. There were no longer any transport requirements for weight, ventilation time, or NCPAP. These transport criteria changes resulted in more ventilated and NCPAP infants (Figure 2). As NCPAP support increased, as was the trend in neonatology, the frequency of infants on ventilators decreased. From October 2007 to August 2012, the percentage of infants transferred to another facility has varied, although the log trend line is in a downward direction (Figure 3).
TABLE 2 n Sharp Grossmont Hospital NICU Transport Criteria Transport Criteria
2007
2008
2009
2010
Gestational age
,29 wk or ,32 wk requiring mechanical ventilation
,30 wk
,28 wk
,28 wk
Weight
,1,000 g nonventilated ,1,500 g ventilated
No weight restriction
No weight restriction
None
Ventilation time
Anticipated ventilation time .48 h
Anticipated ventilation time .48 h
No ventilation time restriction
None
Neonatologist in house
Yes, while infant on assisted ventilation or unstable condition
Yes, while infant on assisted ventilation or unstable condition
Yes, while infant on assisted ventilation or unstable condition
No, if infant stable on ventilator
Note: Prior to November 2007, all infants who were 29 weeks or required mechanical ventilation and were 32 weeks gestation or 1,500 g were transported. a After November 2007, infants who did not meet the criteria listed earlier were transported.
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FIGURE 2 n Nasal CPAP and ventilated infants.
16 14 12 percent
10 8 6 4 2
Nasal CPAP
Jul-12
Apr-12
Jan-12
Oct-11
Jul-11
Jan-11
Linear (Nasal CPAP)
Apr-11
Oct-10
Jul-10
Apr-10
Jan-10
Jul-09
Ven lator
Oct-09
Apr-09
Jan-09
Oct-08
Jul-08
Jan-08
Apr-08
Oct-07
0
Linear (Ven lator)
Education Session Evaluations
Results from the chart audits for adherence to the guidelines of care, Golden Hour practices, infection-prevention practices, and family education demonstrated that the nurses consistently met the criteria for everything, except timeliness of obtaining laboratory samples and subsequent antibiotic administration (Table 3). The nurses did not necessarily value the importance of timely laboratory samples and subsequent antibiotic administration.
Evaluations of the inservice education and case presentation sessions were outstanding. All but one session was rated at the highest score of 4 (very well) for content, applicability to practice, and how well the objectives were met. For the session on blood gas interpretation, 83 percent rated the items at 4 (very well), and 17 percent rated them at 3 (well).
FIGURE 3 n Infants transported to another facility for higher-level care.
30% 25% 20% 15% 10% 5%
percent transported out
Jul-12
Apr-12
Jan-12
Oct-11
Jul-11
Apr-11
Jan-11
Oct-10
Jul-10
Apr-10
Jan-10
Oct-09
Jul-09
Apr-09
Jan-09
Oct-08
Jul-08
Apr-08
Jan-08
Oct-07
0%
Linear (percent transported out)
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TABLE 3 n Chart Audit Results for Golden Hour Practices
Month/Year
Number of Audited Charts
Sugar Met Criteria % (n)
Temperature Met Criteria % (n)
Airway Met Criteria % (n)
Blood Pressure Met Criteria % (n)
Lab/Antibiotics Met Criteria % (n)
Emotional Support Met Criteria % (n)
1
100 (1)
100 (1)
100 (1)
100 (1)
100 (1)
100 (1)
Sep 2011 Oct 2011
0
NA
NA
NA
NA
NA
NA
Nov 2011
1
100 (1)
100 (1)
100 (1)
100 (1)
0 (0)
100 (1)
Dec 2011
2
100 (2)
100 (2)
100 (2)
100 (2)
100 (1)
100 (2)
Jan 2012
3
100 (3)
100 (3)
100 (3)
100 (3)
0 (0)
100 (3)
Feb 2012
4
100 (4)
100 (4)
100 (4)
100 (4)
0 (0)
100 (4)
Mar 2012
4
100 (4)
100 (4)
100 (4)
100 (4)
67 (2)
100 (4)
Apr 2012
3
100 (3)
100 (3)
100 (3)
100 (3)
33 (1)
100 (3)
May 2012
2
100 (2)
100 (2)
100 (2)
100 (2)
0 (0)
100 (2)
Jun 2012
1
100 (1)
100 (1)
100 (1)
100 (1)
100 (1)
100 (1)
Jul 2012
5
100 (5)
80 (4)
100 (5)
80 (4)
80 (4)
100 (5)
Aug 2012
6
67 (4)
100 (6)
100 (6)
100 (6)
67 (4)
100 (6)
Abbreviation: NA 5 not applicable.
DISCUSSION
The purpose of this quality initiative was to increase the nurses’ competency level to meet the needs of higher acuity, lower gestational age infants that were being cared for in our NICU. The goal was met as evidenced by results from chart audits that demonstrated, as the nurses cared for higher acuity infants, the nursing standard of care continued to be met. The neonatologists recognized the nurses’ increasing competence in caring for higher acuity infants and changed the transport criteria to permit lower gestational age infants with no weight or ventilator time restrictions to be cared for in our NICU. The program focused more on the needs of novice nurses. Experienced nurses functioning in a new position or expanded role will inevitably assume a novice role during the change.21 Some of our nurses were unable to adapt to these changes, and one ALS nurse and two staff nurses resigned shortly after the new program was being implemented. The educational plan was based on results from the nurses’ needs assessment, observational feedback from the neonatologists and preceptors, and by conducting concurrent chart audits on NICU infants who had code blue events, were intubated, or transported to a higher level of care. The needs assessment gave the nurses an opportunity to communicate their priorities for educational content, whereas the observational feedback and chart audits provided data on actual nurse knowledge, time management, and compliance to NICU guidelines of care, Golden Hour Stabilization practices, infection-prevention practices, and family education. Because higher acuity infants were cared for in the NICU, nurses who had been functioning at an expert level found that now they were responsible for new skills. It would have been helpful to have included content on Benner’s work to better prepare the nurses on their transition from expert to novice and then back again to expert.8 Although the experienced nurses
were no longer considered novices, with this new skill acquisition, they, too, found themselves in a partially novice situation. The experienced nurse functioning in a new position will inevitably assume a novice role during this change and may have fears of inadequacy.21 We failed to anticipate how the expansion of the nurses’ skill set and responsibilities affected them emotionally. The nurses attempted to maintain the appearance of confidence, and many did not disclose their need for support. Although the chart audits demonstrated that the standards of care were maintained, the nurses verbalized how stressful the change in patient acuity was for them. The nurses were feeling overwhelmed by the new clinical situations and were having difficulty managing the increased workload, although staffing was still determined by acuity. We underestimated the impact, stress, and insecurities of new skill acquisition. Ongoing chart audits provided valuable data on an improvement opportunity for timeliness of obtaining laboratory samples and subsequent antibiotic administration. Without these data, we would not have been aware of the need to reeducate the nurses and provide unit and individual feedback on the importance of meeting the Golden Hour practices.
CONCLUSION
Community hospitals serve the health needs of the community they serve, which include the increasing incidence of VLBW and lower gestational age infants who are delivered in them. Because our patient acuity in the NICU increased, we needed to identify ways to increase nurse competency so these infants could be cared for in our hospital and not be transported to another hospital miles away. Through a multifaceted evaluation of the educational needs of our nurses, we were able to develop various strategies to better prepare the nursing staff to care for higher acuity infants. As nurse competency increased, the admission criteria changed to permit these higher acuity infants to be
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cared for in our NICU. As the admission criteria changed, the volume of higher acuity infants increased, and the nurses were able to maintain their competency for caring for these infants.
ACKNOWLEDGMENT
We would like to thank the Grossmont Hospital NICU Administration Team, the neonatologists, and the NICU nurses for their ongoing commitment to clinical excellence.
REFERENCES
1. Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in verylow-birth-weight infants. N Engl J Med. 2007;356(21):2165-2175. http://dx.doi.org/10.1056/NEJMsa065029 2. Chung JH, Phibbs CS, Boscardin WJ, Kominski GF, Ortega AN, Needleman J. The effect of neonatal intensive care level and hospital volume on mortality of very low birth weight infants. Med Care. 2010; 48(7):635-644. 3. American Academy of Pediatrics Committee on Fetus and Newborn. Levels of neonatal care. Pediatrics. 2012;130(3):587-597. 4. Hallin K, Danielson E. Registered nurses perceptions of their work and professional development. J Adv Nurs. 2007;61(1):62-70. 5. Department of Consumer Affairs, Board of Registered Nursing. Title 16, California Code of Regulations. http://www.rn.ca.gov/regulations/ title16.shtml#1470. Accessed February 12, 2013. 6. American Academy of Pediatrics, American Heart Association. Neonatal Resuscitation Textbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011. 7. California Perinatal Quality Care Collaborative. Delivery room management of the VLBW infant and perinatal HIV prevention and management. Presented at: CPQCC Workshop: Successful Strategies for Implementing Neonatal Practice Improvements; March 3, 2006; Coronado, CA. 8. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice (commemorative edition). Upper Saddle River, NJ: Prentice Hall Health; 2001. 9. Kaminski J. Theory applied to informatics-novice to expert [editorial]. Can J Nurs Informs. 2010;5(4):967. 10. Burch T, Napier R, Altimier L. Teaching novice neonatal intensive care unit nurses to think critically. Newborn Infant Nurs Rev. 2009;9(2):124-127. 11. Knowles MS. Self-Directed Learning: A Guide for Learners and Teachers. Englewood Cliffs, NJ: Prentice Hall/Cambridge; 1975. 12. Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85(7):1118-1124. 13. Verklan MT. Adaptation to extrauterine life. In: Verklan MT, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 4th ed. St. Louis, MO: Elsevier Saunders; 2010:72-90. 14. Mikas N, Rhine W. The golden hour: a gentle approach to resuscitation of the extremely premature infant. Paper presented at: 2004 Neonatal Resuscitation Program Current Issues Seminar for the American Academy of Pediatrics; October 2004; San Francisco, CA. 15. Reynolds RD, Pilcher J, Ring A, Johnson R, McKinley P. The golden hour: care of the LBW infant during the first hour of life one unit’s experience. Neonatal Netw. 2009;28(4):211-219. 16. Kendall AB, Scott PA, Karlsen KA. The S.T.A.B.L.E. Program: the evidence behind the 2012 update. J Perinat Neonatal Nurs. 2012;26(2):147-157. 17. Bowles S, Pettit J, Mikas N, et al., for the California Perinatal Quality Care Collaborative. Hospital-acquired infection prevention. http://cpqcc .org/quality_improvement/qi_toolkits/hospital_acquired_infection_ prevention_rev_march_2008. Accessed December 4, 2012.
18. Centers for Disease Control and Prevention. Ventilator-associated pneumonia (VAP) event. In: July 2013 CDC/NHSN Protocol Clarifications. Atlanta, GA: Centers for Disease Control and Prevention; July, 2013. http://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf. Accessed October 7, 2013. 19. Agency for Healthcare Research and Quality. http://www.innovations. ahrq.gov/content.aspx?id=3068. Accessed October 7, 2013. 20. Verklan MT, Walden M. Core Curriculum for Neonatal Intensive Care Unit. 4th ed. St. Louis, MO: Elsevier Saunders; 2010. 21. Dellasega C, Gabbay R, Durdock K, Martinez-King N. An exploratory study of the orientation needs of experienced nurses. J Contin Educ Nurs. 2009;40(7):311-316.
About the Authors
Lynne Marie Keegan, RN, MSN, NNP-BC, CNS, is a certified parent-child clinical nurse specialist and has more than 31 years of nursing experience in neonatal intensive care units. For the past ten years, she has been at Sharp Grossmont Hospital, where she has led education, performance improvement, and competency programs. Willa Fields, RN, DNSc, FHIMSS, is a professor in the School of Nursing at San Diego State University and has a diverse background in clinical nursing, education, research, performance improvement, management, and information systems. Her research area of interest is exploration of practices that improve patient safety and the provision of patient care. For further information, please contact: Lynne Marie Keegan, RN, MSN, NNP-BC, CNS Sharp Grossmont Hospital La Mesa, CA 91942 E-mail: [email protected]
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As a California community hospital with a Level IIIA NICUs in community hospitals and the complex- NICU, we had acutely ill and VLBW infants being born in ity of cases treated in these NICUs has grown nationwide our delivery rooms. Our dilemma was how to safely care for since the 1990s.1 Studies have these infants and assure that our evaluated the effects of neonaNICU nurses were competent Abstract tal services provided in comto care for them. The purpose munity hospitals on mortality of this quality initiative was to The purpose of this quality initiative was to increase NICU nurse competency to meet the care needs of and morbidity of very low birth increase the NICU nurses’ comhigher acuity infants. A multifaceted educational approach weight infants (VLBW), those petency level to meet the care with individual bedside education, a clinical practicum, weighing 1,500 g. Although needs of higher acuity infants. inservices, and case presentations was based on results Phibbs and colleagues recomfrom a needs assessment, observational feedback, and mended that VLBW infants BACKGROUND chart audits. Results of this educational intervention should be cared for in higher The American Academy of included increased nurse competency and a change in volume—higher level of care Pediatrics defined a Level IIIA admission criteria to care for higher acuity infants without NICUs of at least a Level IIIB, NICU as a unit that provides transporting them to another hospital miles away. As the IIIC, or IIID—in California, ventilation without restrictions admission criteria changed, the volume of higher acuity fewer than 25 percent of VLBW to high-risk newborns and those infants increased, and the nurses were able to maintain infants are delivered in hospiwith critical illnesses includtheir competency in caring for these infants. tals with these types of units.1 ing infants with gestational Keywords: NICU level of care; nurse competency; Chung and colleagues studied ages 32 weeks and weights inservice education; performance improvement the effects of NICU level of care 1,500 g. 3 Level III NICUs and annual delivery volume on must have the capability to VLBW infant outcomes. 2 They provide ongoing assisted ventilafound that between 1997 and 2002, when deregionalization, have ready access to pediatric medical subspecialists, and tion of perinatal care in California had stabilized, about 20 can facilitate transfer to higher-level facilities, as well as back percent of VLBW infants were born and received care in transport recovering infants as clinically indicated. Level IIB lower volume, lower level of care community hospital Level I NICUs can provide mechanical ventilation of brief durations and Level II NICUs. Outcomes of the Chung study revealed 24 hours and should be limited to caring for infants who that lower level, lower volume NICUs were associated with are greater than 32 weeks gestation and weighing more than higher odds of mortality, with the highest odds of death 1,500 g. associated with Level I NICUs with annual VLBW volumes of ten or fewer infants. In addition, Chung and colleagues Disclosure The author has no relevant financial interest or affiliations with any found that, overall, the influence of hospital volume within commercial interests related to the subjects discussed within this article. each level of care was a stronger predictor of outcomes than No commercial support or sponsorship was provided for this educational level of care.2 activity. he n um ber of n ew or ex pa nded lev el of ca r e
Accepted for publication February 2013.
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Sharp Grossmont Hospital, located in La Mesa, California, has a 24-bed, Level IIIA NICU. Although our NICU was licensed as a Level IIIA, we were functioning as a Level IIB NICU because our admission criteria required us to transfer infants to our sister hospital for a higher level of NICU care. Prior to 2007, these transferred infants included those who required mechanical ventilation, or who had a gestational age 32 weeks or a weight 1,500 g. These restrictions were implemented after Sharp Grossmont Hospital became part of the larger Sharp HealthCare system because of our neonatology coverage. Our sister hospital was 11 miles away and imposed a challenge for the families to visit and participate in their ill infant’s care. When we decided to change the admission criteria to allow higher acuity infant management in our NICU, we realized there had been limited opportunities for the registered nurses to participate in the patient care management of VLBW or other acutely ill infants requiring ongoing supportive therapies such as ventilation. Maintaining a nurse’s confidence and competence in providing patient care is directly related to the amount of handson experience available to them.4 The goal for this quality initiative was to provide increased opportunities for the nurses to participate in the continuum of ongoing patient care management required to move acutely ill infants to a stable phase. One of the problems we identified in meeting this goal was the difficulty in maintaining staff nurse confidence and competence when caring for higher acuity infants because of their lack of consistent hands-on experience. We believed that, with increased opportunities for patient care management, the NICU nurses would experience a movement away from short-term task orientation, such as focusing on preparation for transport, and increase their abilities for more advanced patient assessments, planning, interventions, and evaluation. When the project began in 2007, Sharp Grossmont Hospital had 3,670 deliveries, with 481 NICU admissions. The NICU’s average daily census was seven to nine, and the average length of stay was seven days. Infant gestational ages ranged from 25 to 40 weeks, approximately 5 percent were VLBW, and 10 percent required ventilation or continuous positive airway pressure (CPAP) greater than four hours. The infants who were to be transported were stabilized, and, if indicated, surfactant was administered. The NICU clinical staff included a manager, clinical nurse specialist (CNS), and 35 registered nurses, including eight advanced life support (ALS) nurses. All NICU nurses were required to maintain the Neonatal Resuscitation Program certification. Specialty certification was encouraged, although voluntary. On hire, and then annually, NICU nurses were required to complete a competency evaluation that included self-learning modules with written examinations and demonstration of high-risk, low-volume skills such as chest tube maintenance, use of a blood warmer, and mock cardiac and respiratory codes. The nurses’ experience level ranged from new hires with no previous NICU experience to veteran nurses with more than 25 years’ experience in our NICU. The ALS nurses had
advanced training in stabilization and resuscitation and functioned under the direction of the neonatologist or standardized procedures in their absence. In the state of California, the Standardized Procedure Guidelines are the legal mechanism for registered nurses to perform functions that might otherwise be considered the practice of medicine. The unit was staffed with at least one ALS nurse on each shift.5 The neonatologists and Committee on Interdisciplinary Practice approved the ALS standard procedures, which included initiation of oxygen, management of resuscitation, intubation, umbilical arterial and venous line placement, radial artery puncture for blood gases, emergent thoracentesis, and management of neonatal hypoglycemia. The ALS nurses maintained ongoing competence working individually with the neonatologists and demonstrating to them the earliermentioned procedures at least annually. When a high-risk delivery of a VLBW infant was anticipated, a NICU ALS nurse and respiratory care practitioner (RCP) were dispatched to attend the delivery. Their role immediately after delivery was to stabilize the infant according to the Neonatal Resuscitation Program and California Perinatal Quality Care Collaborative (CPQCC) toolkit.6,7 For example, for stabilization of VLBW infants, the ALS nurse initiated measures to prevent hypothermia by placing the infant’s body in a plastic warming bag, on top of a portawarmer pack, on a preheated radiant warmer, with a servo probe in place.7 The RCP attached an oxygen saturation probe on the infant’s right wrist and blended the oxygen concentration to meet the infant’s oxygen saturation goal, which was determined by gestational age and minutes of life.6
Conceptual Framework
This project applied Benner’s model of novice to expert to categorize the NICU nurses’ skill level to determine who were the appropriate preceptors and who needed additional education and support.8 Benner postulated that skill development and increased understanding of patient care occurred over time through education and clinical experiences.8 The five levels within the novice to expert model included novice, advanced beginner, competent, prof icient, and expert. Kaminiski applied Benner’s model to change processes in nursing through detailed descriptions of supervision required at beginning levels and the hallmark behaviors and skills of advanced nursing levels.8,9 A novice has little knowledge and needs policies and procedures for actions, consistent monitoring, and explicit instructions, usually from their nurse preceptor. Advanced beginners still function under policies and procedures, but, as they gain more experience in patient situations, they are able to apply what they have learned previously. They still need consistent monitoring by their preceptors but function at a more expanded level of nursing practice. Both the novice and advanced beginner focus on the technical aspects of care and rely on their preceptor’s guidance to help them gain proficiency and confidence in their abilities to problem solve. Competent nurses understand the policies and procedures and
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are able to use their clinical judgment in problem solving and decision making. Proficient nurses are characterized by their ability to view their patient’s needs from a holistic perspective, rather than a set of tasks that must be accomplished. Expert nurses have immediate intuitive situational awareness, which allows them to respond automatically to the problems they encounter. Expert nurses possess two characteristics that assist in propelling them to this level: a willingness to take risks and their ongoing approach to continuously developing their skills and knowledge. Those at the expert and proficient levels were best suited to be preceptors for the novice and advanced beginner nurses. The categorization of NICU nurses into one of Benner’s five levels was based on direct, bedside, clinical observation by the multidisciplinary administrative team.8 The results of this categorization demonstrated that 20 percent of the NICU nurses functioned at the expert and proficient levels. Another 75 percent of the nurses functioned at the competent level and 5 percent at the advanced beginner or novice levels. Our challenge was to transition the advanced beginner and novice nurses to at least the competent level, while ensuring those who were currently functioning at the expert, proficient, and competent levels maintained their level of proficiency. Burch and colleagues described the seasoned NICU nurse as having the experience to guide other nurses to intervene quickly when there is a change in an infant’s status.10 These repeated experiences promote expansion from initial task orientation to critical thinking, helping to develop confidence, competence, and accountability. Adult learners must go through a process of self-directed learning, with or without help from others, where they develop skills to help them identify their learning needs and take the initiative for their own learning.11 Adult learners benefit from repeated exposure to real cases, where errors in information, judgment, and reasoning are pointed out and discussed, leading to improvement in management priorities, increased clinical reasoning, and skill level.12
DEVELOPMENT OF THE NICU EDUCATION PLAN
Our goal was to ensure that the NICU nurses were competent to care for higher acuity patients. The expert and proficient nurses functioned as preceptors for less experienced nurses. The nursing education plan was based on results from the NICU nurses’ needs assessment, observational feedback, and chart audits.
NICU Needs Assessment
A voluntary needs assessment survey was distributed to the nursing staff for input on future NICU educational topics and preferred modality for the educational sessions. Suggested topics included disease states such as respiratory distress syndrome, disseminated intravascular coagulation, and shock with the expected medical management and nursing interventions. Nurses could also write in a topic. Nurses were asked
to rate their top five educational topics on a scale of 1 5 most important to 5 5 least important. Paper copies of the survey were available in the nurses’ conference area, along with a box for submission. Nurses who included their names on the survey form were eligible to win prizes of hand lotion and shower gel. Nurses also were asked to check how they wanted the inservice programs presented from a list that included lecture, selflearning module, group discussion at staff meeting, poster, and case presentation. These results were taken into consideration when preparing inservice programs.
Observational Feedback
The ALS nurses and neonatologists had opportunities to directly observe nurse and RCP practice. If their practice was not congruent with established NICU guidelines of care and the Neonatal Resuscitation Program guidelines, the ALS nurses and neonatologists provided bedside education and also reported these findings to the NICU manager, CNS, or respiratory clinical specialist for further follow-up.6
Chart Audits
The NICU CNS conducted concurrent chart audits on NICU infants who had code blue events, were intubated, or were transported to a higher level of care. The purpose of the audits was to determine nursing and RCP compliance with the NICU guidelines of care, Golden Hour Stabilization practices, infection prevention practices, and family education. Those areas not in compliance were incorporated into the education program. The chart audit began with the infant’s care in the delivery room and concluded with NICU discharge. The chart audit results for this project focused on the results from the delivery room care through the transition period. The transition period is the time from birth until the infant’s systems stabilize and adapt to life outside of the womb, which can occur over minutes to hours. Normal infant transition requires the infant to initiate respirations with the first breaths, increasing the blood flow to the lungs that supports gas exchange, while overcoming the pulmonary vascular resistance useful during fetal life. Also, during this time, the peripheral vascular resistance increases to a level higher than the pulmonary pressures, supporting increased blood pressure and causing the umbilical arteries and vein to constrict and the three major fetal shunts to close.13 Guidelines of Care. The NICU guidelines of care are evidence-based documents that include unit standards for nursing assessments, positioning, critical value reporting, and nursing interventions. The guidelines of care are nursing care resources available in the computer system and in a binder on each nursing unit. The chart audit included an evaluation of whether or not the nurses followed the guidelines of care. Golden Hour. The Golden Hour focused on multidisciplinary team preparation and communication in the first hour of life.14 Golden Hour scripting supported better communication among team members that led to identification
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of infant risk factors and implementation of processes that decreased complications from stress, pain, hypothermia, hypoglycemia, and hypoxemia, while maintaining cardiovascular stability, optimizing respiratory support, and monitoring oxygen use to prevent complications such as retinopathy of prematurity, chronic lung disease, and intraventricular hemorrhage in the first hour of life.14,15 The Golden Hour audit tool evaluated nursing stabilization priorities and components of the STABLE program: Sugar and safe care, Temperature, Airway, Blood pressure, Lab/antibiotics, and Emotional support.16 Specific nursing actions evaluated were based on documentation from the electronic health record for the infant’s clinical presentation and birth history. Infection-Prevention Practices and Family Education Chart audits for infection-prevention practices included a review of the documentation for the ventilator-associated pneumonia bundle (e.g., disinfection of high-touch surfaces and respiratory equipment, separate suction setups for endotracheal tube and oral suction systems, changing suction canisters and tubing).17,18 Chart audits also included a review of documentation for family education for central-line, multidrug-resistant organisms and surgical incision site infection-prevention practices.19
EDUCATIONAL PLAN AND EVALUATION
The NICU needs assessment results (Figure 1), observational feedback, and chart audits demonstrated that the nurses would benefit from further education on disease states (e.g., pulmonary and cardiac diseases), medical management, nursing interventions, prioritization of care, and team communication. Results from the needs assessment also demonstrated that the nurses preferred case presentations over other
educational modalities. The educational plan included individual bedside education, a clinical practicum, inservices, and case presentations. Evaluation of the educational program had two components: nurse competency and the educational sessions. Nurse competencies were formally evaluated during the individual bedside education, clinical practicum, chart audits, NICU admission criteria, and NICU transfer-out data. The CNS and medical director rounded together at least weekly and queried the nurses about how the various components of the educational plan were progressing, including a self-evaluation of their clinical skills and knowledge. The NICU nurses evaluated the inservices and case presentations on how well the objectives were met.
Individual Bedside Education
The administrative team assigned the ALS nurses to function as a preceptor and provide one-on-one, hands-on training at the bedside and in the delivery room for all non-ALS NICU nurses. Each ALS nurse was provided a list of five NICU nurses to precept and a monthly topic to review (e.g., Neonatal Resuscitation Program guidelines to guide highrisk delivery patient management, assisting with intubation, and admission and stabilization priorities). The hands-on component for education included supervised attendance at high-risk and cesarean section deliveries with an ALS nurse, care of the infant from admission through stabilization, and participation in mock code blue exercises. The ALS nurses evaluated the preceptee on a sign-off sheet that listed the monthly topics and clinical skills. For example, the preceptee needed to demonstrate the skills and clinical judgment to successfully admit and stabilize a NICU admission. The specific actions required were from the NICU guidelines of care.
FIGURE 1 ■ Needs assessment results.
5
Numerical Ra ng
4 3 2 1 0 Assisted Ven la on
Shock
Cardiac Disease Disseminated Intravascular Coagula on
Respiratory Distress Syndrome
Ra ng
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Clinical Practicum
A 36-hour, three-shift clinical practicum was held at our sister Level IIIA NICU for all NICU nurses, including the ALS nurses. For new hires, the clinical practicum became a component of the orientation program after they had at least six months of NICU Level III experience and were able to safely manage a patient care assignment with an unstable infant. If at all possible, the NICU nurses were assigned the same two patients during the entire practicum. The clinical practicum was modeled after a program described by Burch called Critical Thinking Week, which was designed for novice nurses as a means to foster advanced skills acquisition and critical thinking.10 In the Burch program, novice nurses
were paired with expert nurses who served as preceptors. The expert nurses functioned as a clinical resource and did not provide patient care, allowing the NICU nurses the opportunity to completely care for the infant. In our clinical practicum, the clinical leads at the sister hospital identified nurses with clinical expertise, past precepting experience, and willingness to participate as preceptors. Our hospital paid the salaries for both the preceptors and preceptees. Preceptor/preceptee pairs were given a packet of information with the expected experiences, minimum expectations for performance, descriptions of methods to measure competency, and an area for preceptor evaluation and comment (Table 1). Experiences included care for at least
TABLE 1 n Sample Section of the NICU Clinical Practicum Preceptor Evaluation Tool Competency (Skills)
Methods to Measure
Met
Not Met
Comments
I. Pulmonary system Performs a pulmonary assessment and reviews data for infants at risk A. Cares for a high-risk infant on respiratory support, reviews the diagnosis, examines the infant, and recognizes normal and abnormal findings
Preceptor confirms assessment findings. Preceptee verbalizes potential etiologies of findings.
Refers to NICU Respiratory Guidelines of Care for additional resources
B. Monitors the respiratory status of the infant using the following: • Cardiac/respiratory monitors • Oximeter preductal and postductal • Transcutaneous monitoring (TCM) • Arterial blood gases • Chest x-ray results
Preceptee demonstrates competency to the preceptor. Preceptor reviews findings with preceptee.
1. Peripheral arterial line line draw 2. Umbilical artery catheter line draw
C. Assists with intubation per Neonatal Resuscitation Guidelines
Preceptor confirms.
D. Defines the following modes of ventilation and demonstrates nursing management of a ventilated infant on two of these modes: • Nasal continuous positive airway pressure (NCPAP) • Nasal intermittent mandatory ventilation (NIMV) • Synchronized intermittent mandatory ventilation (SIMV) • Pressure support • Assist control • Volume guarantee
Preceptee verbalizes indications for use and demonstrates nursing management for infants on two of these modes, including one which uses flow loops and graphics.
E. Collaborates with the RCP/physician to evaluate ventilator settings and changes based on individual status
Preceptee verbalizes understanding of ventilation strategies.
F. Identifies ventilator-related complications and nursing interventions: • Infection • Air leaks • TCO2 changes per TCM • Atelectasis • Decreased tidal volumes
Preceptee verbalizes potential ventilator complications and nursing interventions to identify and manage changes in infant status.
G. Identifies and intervenes prn for potential postextubation complications
Preceptee verbalizes to preceptor and demonstrates care prn.
RCP and preceptor to review modes of ventilation Preceptor to review nursing management of mode of ventilation with the preceptee Dates: 1. 2. 3.
Abbreviations: NICU 5 neonatal intensive care unit; prn 5 as needed; RCP 5 respiratory care practitioner; TCO2 5 transcutaneous carbon dioxide.
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two ventilated infants with central lines and critical drips. Minimum expectations were organized by body system and included items such as recognizing normal and abnormal cardiovascular and pulmonary findings; obtaining arterial blood gases, reviewing results, and identifying appropriate interventions based on gestational age; and managing the care of a ventilated infant. Measurement descriptions included items such as “preceptor confirms assessment findings, preceptee verbalizes possible etiologies of abnormal findings.” If the preceptee had no opportunity for a particular experience or skill, the preceptee was required to describe the diagnosis, pathophysiology, and nursing interventions. The preceptor evaluated the nurses’ performance as met or not met, and there was space for additional comments so the CNS could follow up with the preceptee.
Inservices
The mandatory inservice education included published evidence-based practice guidelines and toolkits from CPQCC, National Association of Neonatal Nurses, and Core Curriculum for Neonatal Intensive Care Nursing. 20 Initial inservices included a review of central-line care, blood gas interpretation, ventilator strategies and surfactant administration, care of infants on high-f low nasal cannula and nasal CPAP (NCPAP), and calculation and bedside management of critical drips such as dopamine, epinephrine, and alprostadil. Later, the topics included persistent pulmonary hypertension of the newborn, admission priorities and use of the Golden Hour script, and how to report a change in infant status using closed-loop communication. Inservice sessions were presented at multiple times and days to facilitate nurse participation. Attendance was taken, and those nurses unable to attend received make-up sessions. Although knowledge was not evaluated after the inservice sessions, participants completed an evaluation of the content, applicability to practice, and how well the session objectives were met on a scale of 1–4 (1 5 poorly and 4 5 very well).
Case Presentations
The NICU Medical Director, respiratory clinical specialist, and NICU CNS conducted quarterly staff case presentations of complex diagnoses. Attendance at the case presentations was voluntary. The presentation began with a patient’s diagnosis, pathophysiology, and subsequent care and concluded with a critique of the care: those things that were done well and those that could have been done better. The educational goal was an understanding of the patient’s condition, exemplary care, and areas for improvement for future patients. Case presentations were evaluated in the same manner as inservices.
RESULTS
Nurse Competency
All nurses who participated in the individual bedside education with the ALS nurses and the clinical practicum at our sister hospital demonstrated successful completion of the topics and clinical skills. Chart audit data demonstrated that, as the nurses cared for infants with lower gestational ages and more complex ventilation needs, the guidelines of care continued to be met. The nurses demonstrated a level of comfort and competence to the neonatologists, which led to changes in the admission criteria. As the nurses’ skill level improved, the neonatologists supported changing the admission requirements (Table 2). Prior to 2007, infants were transported to our sister hospital if they were ventilated or had a gestational age of 32 weeks or a weight 1,500 g. By 2010, the infants were only transported if they had a gestational age 28 weeks. There were no longer any transport requirements for weight, ventilation time, or NCPAP. These transport criteria changes resulted in more ventilated and NCPAP infants (Figure 2). As NCPAP support increased, as was the trend in neonatology, the frequency of infants on ventilators decreased. From October 2007 to August 2012, the percentage of infants transferred to another facility has varied, although the log trend line is in a downward direction (Figure 3).
TABLE 2 n Sharp Grossmont Hospital NICU Transport Criteria Transport Criteria
2007
2008
2009
2010
Gestational age
,29 wk or ,32 wk requiring mechanical ventilation
,30 wk
,28 wk
,28 wk
Weight
,1,000 g nonventilated ,1,500 g ventilated
No weight restriction
No weight restriction
None
Ventilation time
Anticipated ventilation time .48 h
Anticipated ventilation time .48 h
No ventilation time restriction
None
Neonatologist in house
Yes, while infant on assisted ventilation or unstable condition
Yes, while infant on assisted ventilation or unstable condition
Yes, while infant on assisted ventilation or unstable condition
No, if infant stable on ventilator
Note: Prior to November 2007, all infants who were 29 weeks or required mechanical ventilation and were 32 weeks gestation or 1,500 g were transported. a After November 2007, infants who did not meet the criteria listed earlier were transported.
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FIGURE 2 n Nasal CPAP and ventilated infants.
16 14 12 percent
10 8 6 4 2
Nasal CPAP
Jul-12
Apr-12
Jan-12
Oct-11
Jul-11
Jan-11
Linear (Nasal CPAP)
Apr-11
Oct-10
Jul-10
Apr-10
Jan-10
Jul-09
Ven lator
Oct-09
Apr-09
Jan-09
Oct-08
Jul-08
Jan-08
Apr-08
Oct-07
0
Linear (Ven lator)
Education Session Evaluations
Results from the chart audits for adherence to the guidelines of care, Golden Hour practices, infection-prevention practices, and family education demonstrated that the nurses consistently met the criteria for everything, except timeliness of obtaining laboratory samples and subsequent antibiotic administration (Table 3). The nurses did not necessarily value the importance of timely laboratory samples and subsequent antibiotic administration.
Evaluations of the inservice education and case presentation sessions were outstanding. All but one session was rated at the highest score of 4 (very well) for content, applicability to practice, and how well the objectives were met. For the session on blood gas interpretation, 83 percent rated the items at 4 (very well), and 17 percent rated them at 3 (well).
FIGURE 3 n Infants transported to another facility for higher-level care.
30% 25% 20% 15% 10% 5%
percent transported out
Jul-12
Apr-12
Jan-12
Oct-11
Jul-11
Apr-11
Jan-11
Oct-10
Jul-10
Apr-10
Jan-10
Oct-09
Jul-09
Apr-09
Jan-09
Oct-08
Jul-08
Apr-08
Jan-08
Oct-07
0%
Linear (percent transported out)
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TABLE 3 n Chart Audit Results for Golden Hour Practices
Month/Year
Number of Audited Charts
Sugar Met Criteria % (n)
Temperature Met Criteria % (n)
Airway Met Criteria % (n)
Blood Pressure Met Criteria % (n)
Lab/Antibiotics Met Criteria % (n)
Emotional Support Met Criteria % (n)
1
100 (1)
100 (1)
100 (1)
100 (1)
100 (1)
100 (1)
Sep 2011 Oct 2011
0
NA
NA
NA
NA
NA
NA
Nov 2011
1
100 (1)
100 (1)
100 (1)
100 (1)
0 (0)
100 (1)
Dec 2011
2
100 (2)
100 (2)
100 (2)
100 (2)
100 (1)
100 (2)
Jan 2012
3
100 (3)
100 (3)
100 (3)
100 (3)
0 (0)
100 (3)
Feb 2012
4
100 (4)
100 (4)
100 (4)
100 (4)
0 (0)
100 (4)
Mar 2012
4
100 (4)
100 (4)
100 (4)
100 (4)
67 (2)
100 (4)
Apr 2012
3
100 (3)
100 (3)
100 (3)
100 (3)
33 (1)
100 (3)
May 2012
2
100 (2)
100 (2)
100 (2)
100 (2)
0 (0)
100 (2)
Jun 2012
1
100 (1)
100 (1)
100 (1)
100 (1)
100 (1)
100 (1)
Jul 2012
5
100 (5)
80 (4)
100 (5)
80 (4)
80 (4)
100 (5)
Aug 2012
6
67 (4)
100 (6)
100 (6)
100 (6)
67 (4)
100 (6)
Abbreviation: NA 5 not applicable.
DISCUSSION
The purpose of this quality initiative was to increase the nurses’ competency level to meet the needs of higher acuity, lower gestational age infants that were being cared for in our NICU. The goal was met as evidenced by results from chart audits that demonstrated, as the nurses cared for higher acuity infants, the nursing standard of care continued to be met. The neonatologists recognized the nurses’ increasing competence in caring for higher acuity infants and changed the transport criteria to permit lower gestational age infants with no weight or ventilator time restrictions to be cared for in our NICU. The program focused more on the needs of novice nurses. Experienced nurses functioning in a new position or expanded role will inevitably assume a novice role during the change.21 Some of our nurses were unable to adapt to these changes, and one ALS nurse and two staff nurses resigned shortly after the new program was being implemented. The educational plan was based on results from the nurses’ needs assessment, observational feedback from the neonatologists and preceptors, and by conducting concurrent chart audits on NICU infants who had code blue events, were intubated, or transported to a higher level of care. The needs assessment gave the nurses an opportunity to communicate their priorities for educational content, whereas the observational feedback and chart audits provided data on actual nurse knowledge, time management, and compliance to NICU guidelines of care, Golden Hour Stabilization practices, infection-prevention practices, and family education. Because higher acuity infants were cared for in the NICU, nurses who had been functioning at an expert level found that now they were responsible for new skills. It would have been helpful to have included content on Benner’s work to better prepare the nurses on their transition from expert to novice and then back again to expert.8 Although the experienced nurses
were no longer considered novices, with this new skill acquisition, they, too, found themselves in a partially novice situation. The experienced nurse functioning in a new position will inevitably assume a novice role during this change and may have fears of inadequacy.21 We failed to anticipate how the expansion of the nurses’ skill set and responsibilities affected them emotionally. The nurses attempted to maintain the appearance of confidence, and many did not disclose their need for support. Although the chart audits demonstrated that the standards of care were maintained, the nurses verbalized how stressful the change in patient acuity was for them. The nurses were feeling overwhelmed by the new clinical situations and were having difficulty managing the increased workload, although staffing was still determined by acuity. We underestimated the impact, stress, and insecurities of new skill acquisition. Ongoing chart audits provided valuable data on an improvement opportunity for timeliness of obtaining laboratory samples and subsequent antibiotic administration. Without these data, we would not have been aware of the need to reeducate the nurses and provide unit and individual feedback on the importance of meeting the Golden Hour practices.
CONCLUSION
Community hospitals serve the health needs of the community they serve, which include the increasing incidence of VLBW and lower gestational age infants who are delivered in them. Because our patient acuity in the NICU increased, we needed to identify ways to increase nurse competency so these infants could be cared for in our hospital and not be transported to another hospital miles away. Through a multifaceted evaluation of the educational needs of our nurses, we were able to develop various strategies to better prepare the nursing staff to care for higher acuity infants. As nurse competency increased, the admission criteria changed to permit these higher acuity infants to be
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cared for in our NICU. As the admission criteria changed, the volume of higher acuity infants increased, and the nurses were able to maintain their competency for caring for these infants.
ACKNOWLEDGMENT
We would like to thank the Grossmont Hospital NICU Administration Team, the neonatologists, and the NICU nurses for their ongoing commitment to clinical excellence.
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About the Authors
Lynne Marie Keegan, RN, MSN, NNP-BC, CNS, is a certified parent-child clinical nurse specialist and has more than 31 years of nursing experience in neonatal intensive care units. For the past ten years, she has been at Sharp Grossmont Hospital, where she has led education, performance improvement, and competency programs. Willa Fields, RN, DNSc, FHIMSS, is a professor in the School of Nursing at San Diego State University and has a diverse background in clinical nursing, education, research, performance improvement, management, and information systems. Her research area of interest is exploration of practices that improve patient safety and the provision of patient care. For further information, please contact: Lynne Marie Keegan, RN, MSN, NNP-BC, CNS Sharp Grossmont Hospital La Mesa, CA 91942 E-mail: [email protected]
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