Acta Pædiatrica ISSN 0803-5253
REGULAR ARTICLE
Staff and parents are discriminators for outcomes in neonatal intensive care units Verena Pick1*, Katrin Halstenberg ([email protected])2*, Anja Demel3, Valerie Kirchberger4, Rainer Riedel5, Rolf Schl€oßer6, Caroline Wollny7, Christiane Woopen8, Ludwig Kuntz1†, Bernhard Roth2† 1.Department of Business Administration and Healthcare Management, University of Cologne, Cologne, Germany 2.Neonatology and Paediatric Intensive Care, University Hospital of Cologne, Cologne, Germany €bingen, Tu €bingen, Germany 3.Department of Neonatology, University Hospital Tu 4.Neonatology, University Hospital Munich (Großhadern), Munich, Germany 5.Institute for Medical Economics and Health Services Research, University of Applied Sciences, Cologne, Germany 6.Neonatology, University Hospital Frankfurt, Frankfurt, Germany 7.Department of Paediatrics, Saarland University Medical Centre, Homburg, Germany 8.Institute for the History of Medicine and Medical Ethics, Research Unit Ethics, University Hospital of Cologne, Cologne, Germany
Keywords Neonatal health, Nutrition, Outcome variables, Parent experience, Ventilation
ABSTRACT Aim: We investigated the associations between staff work characteristics, parents’
Correspondence Dr Katrin Halstenberg, Neonatology and Paediatric Intensive Care, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany. Tel: +49 221 478 5054 | Fax: +49 221 478 3618 | Email: [email protected]
Methods: This explorative multicentre study took place in the neonatal intensive care units
Received 13 February 2014; revised 6 June 2013; accepted 23 July 2014. DOI:10.1111/apa.12762 *Co-first authorship. † Co-supervisors.
experiences and a number of medical outcome measures. (NICUs) of five German university hospitals between 2009 and 2011. We assessed staff work characteristics by surveying 126 NICU nurses and 57 physicians and asked 214 parents about their relationships with staff. The outcome variables of 230 premature infants with birth weights of less than 1500 g were collected over a period of 18 months. We used analysis of variance (ANOVA) and regression analyses for statistical purposes. Results: We found differences in outcome measures between the NICUs, particularly parameters of respiratory support, weight gain and length of stay. When we controlled for the NICUs’ baseline factors, perceptions of the relationship between staff and parents (empathy, p < 0.001; conversation duration and frequency, p < 0.05; familiarity, p < 0.05) and staff work characteristics (workload, p < 0.05) were associated with at least one of these outcome measures. Conclusion: Staff and parents were discriminators for neonatal outcomes through perceptions of work characteristics and the relationship between staff and parents, respectively. Respiratory support and nutrition measures were particularly sensitive. This research has prompted a nationwide, multicentre study of 66 NICUs.
INTRODUCTION Premature birth is a major cause of perinatally acquired morbidity and mortality. Interhospital differences in outcomes for very low birth weight (VLBW) infants are well known (1,2). Recent studies in neonatology focus on single factors that influence outcomes, such as current medical research on the influence of hospital volume on neonatal mortality (3). The findings show that volume can only
explain some of the variations in mortality across hospitals (4). There is evidence that two aspects play a key role in explaining these differences: organisational factors and patient-centred medicine (5). Reviewing the literature, we
Key notes
Abbreviations ANOVA, Analysis of variance; BPD, Bronchopulmonary dysplasia; CARE, Consultation and relational empathy; CPAP, Continuous positive airway pressure; FiO2, Fraction of inspired oxygen; FTE, Full-time equivalent; IUGR, Intra-uterine growth restriction; IVH, Intraventricular haemorrhage; NEC, Necrotising enterocolitis; NICU, Neonatal intensive care unit; ns, Not significant; PVL, Periventricular leukomalacia; ROP, Retinopathy of prematurity; SGA, Small for gestational age; SpO2, Blood oxygen saturation; VLBW, Very low birth weight.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. e475–e483
This study investigated the associations between staff work characteristics, parents’ experiences and a number of medical outcome measures in the NICUs of five German university hospitals. It showed differences in outcome measures between the NICUs, particularly in parameters of respiratory support, weight gain and length of stay. We concluded that staff and parents were discriminators of neonatal outcomes, and further research is now being carried out with 66 NICUs.
e475
Outcomes in neonatal intensive care units
Pick et al.
found that the impact of organisational factors on patient outcomes has been recognised, but detailed information about the underlying causal relationship and its implications for neonatal intensive care is lacking. Two key studies have taken the first step towards exploring this relationship. Pollack and Koch showed that organisational processes as rated by NICU staff were associated with mortality and severe morbidity, whereas Nembhard and Edmondson emphasised the significance of leadership and professional status on process improvements (6,7). In this study, we considered two aspects that have recently become more prominent: staff perceptions of the work environment and the role of the patient. A poor work environment, as perceived by hospital staff, may be characterised by a high level of dissatisfaction and other negative characteristics that are likely to be associated with problems in patient care (8). Because of the positive influence, it is believed to have on medical and social outcomes, patient-centred medicine is growing in importance. As defined by the Institute of Medicine, patient-centred care is respectful of, and responsive to, individual patient preferences, needs and values and the demands that patient values guide all clinical decisions (5). In the field of neonatology, the patient-centred approach is even more difficult to achieve as staff and parents can only assume infants’ interests. To preserve these interests, excellent communication between parents and staff is essential. Previous studies have shown that communication between parents and staff and parents’ informational needs differ widely, and the effect of this factor on medical outcomes remains unclear (9). Having reviewed the literature, we could infer that there is a possible link between factors relating to organisations, staff and parents and the medical outcomes of very low birth weight (VLBW) infants in different neonatal intensive care units (NICUs). To better understand these factors, we initiated an interdisciplinary research group to explore the association between staff work characteristics, parents’ experience and neonatal outcomes.
METHODS The study was conducted in the NICUs of five German university hospitals. The institutional review boards and staff councils of all the hospitals approved the study protocol. The characteristics of the participating NICUs are shown in Table 1. Outborns often experience a higher rate of nonroutine interventions and different communication patterns between staff and parents, independently of morbidity. Therefore, we excluded 28 outborns and 39 infants that died within 28 days of birth, resulting in 596 eligible infants. The mean mortality rate for the inborns was 6.1%, ranging from 3.9% to 10.3% between NICUs. Furthermore, we excluded infants where staff members felt that the German language ability of both parents was too low to allow them to complete the questionnaire. We did not measure this number exactly, but based on interviews with the centres we estimated that this applied to around 10% to 15% of the 596 children. Data
e476
were collected over a period of 18 months, including 12 months retrospectively and 6 months prospectively at the time of the staff survey. A document to obtain the informed consent of both parents and questionnaires on the NICU experience was sent to parents after hospital discharge (retrospective) or given around the discharge period (prospective). This resulted in a sample of 230 infants, with a birth weight less than 1500 g and medical outcome data, out of a possible 596. In total, 176 parents, including 162 mothers, 13 fathers and one gender-unspecified parent, of 214 children, representing 93% of the children included, completed the questionnaire. Differences in the characteristics of the parents and infants surveyed were small. Similarly, medical outcomes did not differ significantly between the 230 infants for which consent was given, and the 214 infants for which we had parental information. As the two groups were fairly homogenous, we chose to report the findings for the smaller group of 214 infants. Maternal and infant characteristics The data collected comprised of maternal, perinatal and neonatal characteristics. Morbidity parameters included intraventricular haemorrhage (IVH), periventricular leukomalacia (PVL), retinopathy of prematurity (ROP), ROP plus disease, necrotising enterocolitis (NEC) and bronchopulmonary dysplasia (BPD). Other outcome parameters were length of stay, hours of mechanical ventilation, hours of continuous positive airway pressure (CPAP), overall hours of respiratory support, nutritional parameters and whether they had received antibiotic treatment. BPD was defined as the sustained need for supplemental oxygen at 36 weeks’ postmenstrual age to maintain blood oxygen saturation (SpO2) of more than 90% (10,11). We differentiated between two degrees of BPD severity: moderate, with a fraction of inspired oxygen (FiO2) between 0.22 and 0.29, Table 1 Characteristics of participating NICUs and study population Total (range) NICUs (n = 5) NICU admissions in 2008 Physicians (FTE) in 2008 Nurses (FTE) in 2008 Number of discharged infants with birth weight
REGULAR ARTICLE
Staff and parents are discriminators for outcomes in neonatal intensive care units Verena Pick1*, Katrin Halstenberg ([email protected])2*, Anja Demel3, Valerie Kirchberger4, Rainer Riedel5, Rolf Schl€oßer6, Caroline Wollny7, Christiane Woopen8, Ludwig Kuntz1†, Bernhard Roth2† 1.Department of Business Administration and Healthcare Management, University of Cologne, Cologne, Germany 2.Neonatology and Paediatric Intensive Care, University Hospital of Cologne, Cologne, Germany €bingen, Tu €bingen, Germany 3.Department of Neonatology, University Hospital Tu 4.Neonatology, University Hospital Munich (Großhadern), Munich, Germany 5.Institute for Medical Economics and Health Services Research, University of Applied Sciences, Cologne, Germany 6.Neonatology, University Hospital Frankfurt, Frankfurt, Germany 7.Department of Paediatrics, Saarland University Medical Centre, Homburg, Germany 8.Institute for the History of Medicine and Medical Ethics, Research Unit Ethics, University Hospital of Cologne, Cologne, Germany
Keywords Neonatal health, Nutrition, Outcome variables, Parent experience, Ventilation
ABSTRACT Aim: We investigated the associations between staff work characteristics, parents’
Correspondence Dr Katrin Halstenberg, Neonatology and Paediatric Intensive Care, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany. Tel: +49 221 478 5054 | Fax: +49 221 478 3618 | Email: [email protected]
Methods: This explorative multicentre study took place in the neonatal intensive care units
Received 13 February 2014; revised 6 June 2013; accepted 23 July 2014. DOI:10.1111/apa.12762 *Co-first authorship. † Co-supervisors.
experiences and a number of medical outcome measures. (NICUs) of five German university hospitals between 2009 and 2011. We assessed staff work characteristics by surveying 126 NICU nurses and 57 physicians and asked 214 parents about their relationships with staff. The outcome variables of 230 premature infants with birth weights of less than 1500 g were collected over a period of 18 months. We used analysis of variance (ANOVA) and regression analyses for statistical purposes. Results: We found differences in outcome measures between the NICUs, particularly parameters of respiratory support, weight gain and length of stay. When we controlled for the NICUs’ baseline factors, perceptions of the relationship between staff and parents (empathy, p < 0.001; conversation duration and frequency, p < 0.05; familiarity, p < 0.05) and staff work characteristics (workload, p < 0.05) were associated with at least one of these outcome measures. Conclusion: Staff and parents were discriminators for neonatal outcomes through perceptions of work characteristics and the relationship between staff and parents, respectively. Respiratory support and nutrition measures were particularly sensitive. This research has prompted a nationwide, multicentre study of 66 NICUs.
INTRODUCTION Premature birth is a major cause of perinatally acquired morbidity and mortality. Interhospital differences in outcomes for very low birth weight (VLBW) infants are well known (1,2). Recent studies in neonatology focus on single factors that influence outcomes, such as current medical research on the influence of hospital volume on neonatal mortality (3). The findings show that volume can only
explain some of the variations in mortality across hospitals (4). There is evidence that two aspects play a key role in explaining these differences: organisational factors and patient-centred medicine (5). Reviewing the literature, we
Key notes
Abbreviations ANOVA, Analysis of variance; BPD, Bronchopulmonary dysplasia; CARE, Consultation and relational empathy; CPAP, Continuous positive airway pressure; FiO2, Fraction of inspired oxygen; FTE, Full-time equivalent; IUGR, Intra-uterine growth restriction; IVH, Intraventricular haemorrhage; NEC, Necrotising enterocolitis; NICU, Neonatal intensive care unit; ns, Not significant; PVL, Periventricular leukomalacia; ROP, Retinopathy of prematurity; SGA, Small for gestational age; SpO2, Blood oxygen saturation; VLBW, Very low birth weight.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. e475–e483
This study investigated the associations between staff work characteristics, parents’ experiences and a number of medical outcome measures in the NICUs of five German university hospitals. It showed differences in outcome measures between the NICUs, particularly in parameters of respiratory support, weight gain and length of stay. We concluded that staff and parents were discriminators of neonatal outcomes, and further research is now being carried out with 66 NICUs.
e475
Outcomes in neonatal intensive care units
Pick et al.
found that the impact of organisational factors on patient outcomes has been recognised, but detailed information about the underlying causal relationship and its implications for neonatal intensive care is lacking. Two key studies have taken the first step towards exploring this relationship. Pollack and Koch showed that organisational processes as rated by NICU staff were associated with mortality and severe morbidity, whereas Nembhard and Edmondson emphasised the significance of leadership and professional status on process improvements (6,7). In this study, we considered two aspects that have recently become more prominent: staff perceptions of the work environment and the role of the patient. A poor work environment, as perceived by hospital staff, may be characterised by a high level of dissatisfaction and other negative characteristics that are likely to be associated with problems in patient care (8). Because of the positive influence, it is believed to have on medical and social outcomes, patient-centred medicine is growing in importance. As defined by the Institute of Medicine, patient-centred care is respectful of, and responsive to, individual patient preferences, needs and values and the demands that patient values guide all clinical decisions (5). In the field of neonatology, the patient-centred approach is even more difficult to achieve as staff and parents can only assume infants’ interests. To preserve these interests, excellent communication between parents and staff is essential. Previous studies have shown that communication between parents and staff and parents’ informational needs differ widely, and the effect of this factor on medical outcomes remains unclear (9). Having reviewed the literature, we could infer that there is a possible link between factors relating to organisations, staff and parents and the medical outcomes of very low birth weight (VLBW) infants in different neonatal intensive care units (NICUs). To better understand these factors, we initiated an interdisciplinary research group to explore the association between staff work characteristics, parents’ experience and neonatal outcomes.
METHODS The study was conducted in the NICUs of five German university hospitals. The institutional review boards and staff councils of all the hospitals approved the study protocol. The characteristics of the participating NICUs are shown in Table 1. Outborns often experience a higher rate of nonroutine interventions and different communication patterns between staff and parents, independently of morbidity. Therefore, we excluded 28 outborns and 39 infants that died within 28 days of birth, resulting in 596 eligible infants. The mean mortality rate for the inborns was 6.1%, ranging from 3.9% to 10.3% between NICUs. Furthermore, we excluded infants where staff members felt that the German language ability of both parents was too low to allow them to complete the questionnaire. We did not measure this number exactly, but based on interviews with the centres we estimated that this applied to around 10% to 15% of the 596 children. Data
e476
were collected over a period of 18 months, including 12 months retrospectively and 6 months prospectively at the time of the staff survey. A document to obtain the informed consent of both parents and questionnaires on the NICU experience was sent to parents after hospital discharge (retrospective) or given around the discharge period (prospective). This resulted in a sample of 230 infants, with a birth weight less than 1500 g and medical outcome data, out of a possible 596. In total, 176 parents, including 162 mothers, 13 fathers and one gender-unspecified parent, of 214 children, representing 93% of the children included, completed the questionnaire. Differences in the characteristics of the parents and infants surveyed were small. Similarly, medical outcomes did not differ significantly between the 230 infants for which consent was given, and the 214 infants for which we had parental information. As the two groups were fairly homogenous, we chose to report the findings for the smaller group of 214 infants. Maternal and infant characteristics The data collected comprised of maternal, perinatal and neonatal characteristics. Morbidity parameters included intraventricular haemorrhage (IVH), periventricular leukomalacia (PVL), retinopathy of prematurity (ROP), ROP plus disease, necrotising enterocolitis (NEC) and bronchopulmonary dysplasia (BPD). Other outcome parameters were length of stay, hours of mechanical ventilation, hours of continuous positive airway pressure (CPAP), overall hours of respiratory support, nutritional parameters and whether they had received antibiotic treatment. BPD was defined as the sustained need for supplemental oxygen at 36 weeks’ postmenstrual age to maintain blood oxygen saturation (SpO2) of more than 90% (10,11). We differentiated between two degrees of BPD severity: moderate, with a fraction of inspired oxygen (FiO2) between 0.22 and 0.29, Table 1 Characteristics of participating NICUs and study population Total (range) NICUs (n = 5) NICU admissions in 2008 Physicians (FTE) in 2008 Nurses (FTE) in 2008 Number of discharged infants with birth weight
