Our research, which we presented last month at the Academy-Health Annual Research Meeting in Chicago, gives hospital managers a blueprint for improvements in the NICU. In preliminary findings from a national study of 104 hospital NICUs funded by the Robert Wood Johnson Foundation, we found that babies in units where nurses have less support and limited professional practice are at higher risk of developing infections.
What's an NICU with inadequate support for nurses? We define it as a unit that comes up short when it comes to staffing and other resources. Nurses on such units are often caring for too many critically ill infants. In addition, they're often pulled away from direct nursing care and are juggling too many non-nursing duties, like answering the phone, running to pick up a prescription or transporting a patient.
A suboptimal unit is also one where nurses' authority doesn't match their responsibility. When they speak up with an urgent concern about a tiny baby, they may not get a rapid response or credit for their assessment. In some cases, nurses delay calling doctors because they're concerned about getting an angry response: Over time, such strained relationships can lead to inefficient or suboptimal care.
NICU babies, especially the very tiny ones, often need constant nursing care just to prevent complications like infections or bleeding in the brain. But hospital managers struggling to stay afloat in a deepening recession might be tempted to cut nursing staff or other services.
In fact, a June survey by the Association for Professionals in Infection Control and Epidemiology suggests that many hospitals have cut back on infection control. More than 40% of infection-control professionals in hospitals said they'd experienced cuts in staffing or other resources in the last year and a half.
But this research, and other evidence, suggests that infection control cutbacks are a shortsighted solution that might cost managers more in the long run. As Medicare and other payers stop paying for preventable infections, the NICU might be one area they'll hone in on for payment reductions.
This study isn't the only one to link nursing care to outcomes in the NICU. For example, a 2007 study found that 65% of the NICUs in the U.K. were understaffed and the lack of nursing care put babies at risk of death.
Another study by Jeannie Cimiotti, a nurse researcher at the University of Pennsylvania, also makes the case that, at least in some NICUs, babies who get less nursing care are at greater risk of developing infections.
So what should hospitals do? CEOs should fully staff the NICU and other hospital service units so that nurses aren't called away from a critically ill infant to answer the phone. Fully staffing an NICU might mean hiring more registered nurses to make sure that critically ill infants have one-on-one nursing care. Or managers might have to keep support staff, like secretaries, on duty—even at night or on the weekend.
Hospitals should also make sure that they don't leave lots of relatively young nurses on duty without support, including a seasoned supervisor. Without adequate supervision, a short-staffed young nurse might turn too quickly from one very sick newborn to another—and fail to wash up. That one misstep could spread a lethal bug from one baby to the next.
Managers must also work to create a professional atmosphere in the NICU so that nurses and doctors work together as a team. They must include nurses in hospital rounds and encourage nurses to speak up when they have concerns about a patient.
For example, in a professional, well-run NICU, a nurse might notice subtle signs that could be an infection and won't hesitate to call the doctor on call. The baby gets prompt attention and a crisis is averted.
Hospitals that put such steps in place will get results in the form of fewer infections. And they're likely to have fewer cases of complications like bleeding in the brain. Such complications are expensive to treat, lead to long-term developmental problems, and can push up hospital costs if insurers like Medicaid don't pay the entire bill.
Eileen Lake is the associate director of the Center for Outcomes and Policy Research at the University of Pennsylvania, Philadelphia. Thelma Patrick is a nurse researcher at Ohio State University in Columbus.
