Haifa A. Samra, PhD, MSIM, RN-NIC, CNL ❍ Section Editor

Professional Growth and Development Subjective and Objective Measurement of Neonatal Nurse Practitioner Workload Eva Dye, MSN, APRN, NNP-BC; Nancy Wells, DNSc, RN, FAAN

ABSTRACT Background: Neonatal nurse practitioner (NNP) workload is not well studied, and metrics specific to NNP practice are lacking. Factors such as changes in resident duty hours, increasing neonatal intensive care unit admissions, and a shortage of NNPs contribute to NNP workload. Increased workload has been shown to be detrimental to providers and can affect quality of care. Purpose: This study quantified NNP workload using a subjective workload metric, the NASA Task Load Index, and a newly developed objective workload metric specific to NNP practice. Methods: The NNP group at a level IV academic medical center was studied. The sample included 22 NNPs and 47 workload experiences. Results: A comparison of scores from the NASA Task Load Index and objective workload metric showed a moderate correlation (r = 0.503). Mental demand workload scores had the highest contribution to workload. Feelings of frustration also contributed to workload. Implications for Practice: The NASA Task Load Index can be utilized to measure the workload of NNPs. The objective workload metric has potential to quantify NNP workload pending further validation studies and is a simple, straightforward tool. Implications for Research: Additional research is needed regarding NNP workload and methods to quantify workload. Larger studies are needed to validate the objective workload metric. Key Words: mental demand, NASA Task Load Index, neonatal intensive care, neonatal nurse practitioner, work, workload

N

eonatal nurse practitioners (NNPs) perform important work in neonatal intensive care units (NICUs) and outpatient clinics. In the United States, the NNP role was developed to address a national provider shortage during the expansion of neonatal care in the 1970s.1 Today, NNPs play a vital role in acute care settings and outpatient clinics by performing day-to-day management of infants, advanced procedures, delivery room resuscitation, and care during neonatal transport.2 Workload has implications for provider health and the quality and safety of care provided in the NICU.3-14 As the NNP role expanded and encompassed work previously performed by resident physicians, studies to examine the quality of NNP care were conducted. These studies demonstrated that NNP care was comparable with or exceeded care that was Author Affiliations: Vanderbilt University School of Nursing, Nashville, Tennessee (Ms Dye); The Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee (Ms Dye); University of Tennessee at Chattanooga (Ms Dye); and Vanderbilt University Medical Center, Nashville, Tennessee (Dr Wells). Original research conducted at The Monroe Carell Jr Children’s Hospital at Vanderbilt. The authors have no conflicts of interest to report. Correspondence: Eva Dye, MSN, APRN, NNP-BC, Vanderbilt Children’s Hospital, 2200 Children’s Way, VCH 2521, Nashville, TN 37232 ([email protected]). Copyright © 2017 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000353

provided by resident physicians with regard to delivery room resuscitation, neonatal assessment, and care of extremely low birth-weight infants.15-18 In studies comparing an NICU run entirely by NNPs with traditional physician-supported NICUs, outcomes of the NNP unit were comparable or favorable with control units.19-21 While these studies examined the patient care outcomes and quality of the work of NNPs, they did not address the workload itself. Investigating NNP workload is timely. The National Association of Neonatal Nurse Practitioners sponsored a recent NNP Workforce Survey of 1300 NNPs in the United States.2 Forty-three percent of the NNPs surveyed worked more than 40 hours per week, and 47% of NNPs in level IV NICUs reported that their actual hours worked exceeded scheduled hours. The American Academy of Pediatrics defines a level IV NICU as a unit that can care for infants less than 32 weeks’ gestation and weighing less than 1500 g, has the ability to sustain life support, provides subspecialty medical and surgical services, and provides regional transport and education.22 More than half of NNPs who practiced in level IV NICUs also reported their patient loads were unsafe.2 Concerns also have been raised regarding fatigue and the necessary shift work of NNPs.23,24 Most NNPs surveyed as part of the NNP Workforce Survey worked day and night rotations of 12-hour shifts or 24-hour shifts.2 The combination of

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extended hours, shift work, fatigue, and heavy patient loads is concerning for its potential to cause excessive workload for NNPs. Increased workload affects both the care provider and the patient. Increased workload has been linked to stress, burnout, anxiety, and increased turnover by nurses.5,11,13 Furthermore, job strain and stress in the workplace have been linked to an increased risk of depression, diabetes, stroke, and other cardiovascular diseases.3,7,10 The level of NNP workload specific to patient outcomes in the NICU has not been studied. However, studies of bedside nursing workload have shown that increased staffing levels and workload are associated with increased infection rates in very low birth-weight infants, increased mortality, and delayed or missed nursing care tasks.4,6,8,9,12,14 Workload is a multifactorial phenomenon with no simple conceptual framework.25 Workload is objective, involving a specific task to be completed, yet also subjectively based on the perception of the worker.26 The subjective perspective of workload can be influenced by the work environment, time pressure to complete the task, and the individual’s prior experiences.26 Ead27 described a framework of nursing workload incorporating both exogenous and endogenous variables. Exogenous variables are external factors that include the complexity of the patient, staffing ratios, interruptions, and the presence of change. Endogenous or internal variables include the nurse’s own coping ability, knowledge, experience, energy level, and organizational skills.27 Development of conceptual frameworks specific to the NNP role and research regarding NNP workload is lacking. However, factors affecting NNP workload are evident. External circumstances outside the NNP’s individual practice have a cascade effect on NNP workload and include changes in resident physician duty hours, shortage of NNPs, and increasing admissions to NICUs. In 2011, the Accreditation Council for Graduate Medical Education introduced new guidelines for resident physician training including a reduction in duty hours for all resident physicians and the elimination of nighttime coverage in hospitals by first-year resident physicians.28 This resulted in the need for additional providers to provide inpatient care. Surveys of pediatric residency program directors and children’s hospital chief executive officers found that many hospitals are increasing the number of NNPs and transferring work to NNPs to address provider shortages.29,30 As the demand for NNPs grows, concern has been raised that the available workforce of NNPs is not keeping up and has regional differences.31,32 In 2013, NNP workforce data indicated a shortage of NNPs that was expected to increase with changes in resident physician duty hours.32 Workload can be viewed through the lens of supply and demand. The shift of responsibility of care from other providers to NNPs, combined with

increasing NICU admissions, leads to increased demands for NNPs. This demand, in conjunction with a limited supply of NNPs, creates a concerning framework for increased workload. Metrics to measure NNP workload and guidelines for appropriate NNP staffing are lacking. Bedside nursing metrics have been developed, but the caregiving role of the NNP differs significantly from that of the bedside nurse and workload metrics that focus on bedside nursing tasks are not transferable to the NNP.33,34 Patient acuity is a contributor to workload, and several metrics have been developed for the neonatal population to quantify severity of illness of the infant. The Score for Neonatal Acute Physiology (SNAP), Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE-II), Clinical Risk Index for Babies (CRIB), and the revised CRIB II use patient data to determine the severity of illness to predict in-hospital mortality.35-40 See Table 1 for the specific scoring variables included in these metrics. Scores from these measures are often used for epidemiological studies, benchmarking, and quality improvement37,41 The metrics are intended for use in the first hours of life and therefore have little applicability to the convalescing NICU patient or infant with an acute change in status some days after admission.35,37 While severity of the patient’s illness is an important aspect of workload, it does not fully describe the care provided. The purpose of this project was to quantify NNP workload using a previously validated subjective measure of workload (NASA Task Load Index [NASA TLX]) and an objective workload metric developed by the first author specific to the role of the NNP. An additional goal of the project was to provide construct validity to the objective workload metric by comparing the objective scores with the subjective scores. The purpose stated another way: Is the objective metric measuring what it intends to measure (ie, the workload the NNPs are experiencing)?

What This Study Adds • The NASA Task Load Index can be used to measure neonatal nurse practitioner (NNP) workload. • Workload is a multifactorial phenomenon. Mental and time pressure demands, effort, and feelings of frustration contribute to NNP workload. • Objective workload metrics can be used to quantify NNP workload. Further research to validate NNP workload metrics is needed.

METHODS Design and Sample The workload study was a descriptive study of the factors influencing NNP workload in an NICU. The www.advancesinneonatalcare.org

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TABLE 1. Comparison of Variables of CRIB, CRIB II, SNAP, and SNAPPE-II Metricsa CRIB (in the First 12 h of Life)

CRIB II (in the First Hour of Life)

SNAP (Worst Value in the First 24 h of Life)

SNAPPE-II (in the First 12 h of Life)

Congenital malformation Gender Gestational age

Gestational age

Birth weight

Birth weight

Maximum base excess

Birth weight

Temperature on admission Temperature

Lowest temperature

Base excess

Lowest serum pH

Maximum and minimum FIO2 level

Serum pH Mean blood pressure

Mean blood pressure

PO 2

PO2/FIO2 ratio

PO2/FIO2 ratio PCO2 Oxygen index Apnea Respiratory and heart rates Seizure

Multiple seizures

Urine output

Urine output

Blood urea nitrogen Creatinine Small for gestational age Apgar score at 5 min Complete blood count Direct and indirect bilirubin Electrolytes Stool guaiac Abbreviations: CRIB, Clinical Risk Index for Babies; SNAP, Score for Neonatal Acute Physiology; SNAPPE-II, Score for Neonatal Acute Physiology Perinatal Extension. aFrom Parry et al,38 Zupancic et al,39 Manktelow et al,40 De Felice et al,41 Young et al.42

study was conducted at a 96-bed, level IV NICU at an academic medical center that includes both a freestanding children’s hospital NICU and an NICU adjacent to a busy perinatal center. At the time of this study, the NNP group consisted of 35 nurse practitioners, and all NNPs willing to participate in the study were included.

Outcome Measures Data were collected using 2 metrics: an objective workload metric developed as part of the research project and the NASA TLX. Demographic information of NNPs including gender, age, number of years of experience as a nurse and an NNP, and number of years at the institution was also collected. Objective Workload Metric Development The objective workload metric was developed on the basis of patient characteristics of neonates commonly

cared for in the NICU and common tasks specific to the NNP role (see Figure 1). The metric was designed to provide a workload score for an individual patient capturing both the acuity of the patient and other factors affecting workload. The specific divisions in scoring categories for weight and respiratory and nutritional support were based on documentation categories used by our neonatologists in their daily progress notes. During the development of the objective metric, NNPs in the NICU completed Web-based surveys at the end of their shift to gather data regarding the type of patients cared for and tasks completed during their shift. Factors contributing to workload derived from this survey, along with input from experienced NNPs, provided content validity for items on the metric such as the need for inotropic or insulin infusions, nitric oxide, body cooling, postoperative care, bereavement care, procedures, and discharge and admission processes. The metric comprised

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FIGURE 1

Objective workload metric. The figure is a copy of the metric that includes 11 weighted patient characteristics evaluated by the objective workload metric. CMV indicates conventional mechanical ventilation; CPAP, continuous positive airway pressure; DNR, do not resuscitate; IVF, intravenous fluids; NC, nasal cannula; NCPAP, nasal continuous positive airway pressure; NPO, nothing by mouth; POD, post operative day; RA, room air; VT, vapotherm.

11 scoring categories. Scores were determined on a weighted scale, with lower weights indicating less workload and higher weights indicating a heavier workload. Items such as infusions and procedures could be scored multiple times depending on the number of infusions and frequency of procedures. Procedures were defined as advanced procedures requiring special provider credentialing such as intubation, umbilical catheter placement, lumbar puncture, or chest tube placement. The minimum score on the scale was 3 points. No maximum score was designated because an infant could undergo multiple procedures or required multiple infusions. Our NICU also uses other weighted scales to measure pain and neonatal withdrawal, so the concept of determining a score based on weighted categories was familiar to the NNP group.

NASA Task Load Index Researchers studying nursing workload have looked beyond the nursing profession to utilize workload metrics from other fields.42,43 One of the most wellknown measures of workload is the NASA TLX, a subjective workload tool.26 The NASA TLX is “widely regarded as the strongest tool available for reporting perceptions of workload.”42 As its name implies, the NASA TLX was developed for the aeronautics industry but has been validated and used extensively in various other industries including agriculture, education, transportation, and nursing.42,44 Subjects completing the NASA TLX indicate their perception of the workload necessary to complete a task based on 6 factors: mental demand, physical demand, temporal demand, performance, effort, and frustration. See Table 2 for specific aspects of each workload factor. Subjects completing the paper-and-pencil version of the NASA TLX mark their score on a 20-point visual analog scale (see Figure 2). The minimum score for each workload factor is zero, and the maximum score for each factor is 100. The overall workload score is determined by the sum of all 6 individual factor scores; the range of possible overall scores is 0 to 600. The NASA TLX does not have a “red line” score indicating that a particular workload is too high.44 However, higher scores indicate an increased workload compared with lower scores. The original NASA TLX also weighted the 6 workload factors by asking the subject to compare the importance of the 6 factors in relation to the completion of the task. However, the Raw NASA TLX is a pared-down and simplified version of the NASA TLX, which eliminates the weighted portion of the metric and is more commonly used.44 The benefit of a subjective metric of workload is that it takes into account the experiences of the worker and extraneous factors such as time pressure. During this study, a paper-and-pencil version of the raw form of the NASA TLX was www.advancesinneonatalcare.org

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TABLE 2. NASA Task Load Index Workload Factorsa Workload Factor Mental demand

Concepts Measured by Workload Factors Amount of mental and perceptual activities such as thinking, deciding, calculating, or searching

Physical demand

Amount of physical activity required such as pushing, pulling, or turning

Temporal demand

Pace of the activity and how much time pressure was felt

Performance

Perceived success of activity and satisfaction with performance

Effort

Level of work (both mental and physical) required to complete the activity

Frustration level

Feelings of insecurity, irritation, discouragement, or stress compared with feelings of security, gratification, contentment, and relaxation

From Human Performance Research Group.26

a

adapted, so the workload task referred to care of an infant in the NICU (see Figure 2).

Procedures and Data Collection Approval for this study was provided by the institutional review board of our institution. The NNPs interested in participating in the study were given a brief verbal overview of the purpose of the study and a description of the metrics and were assured confidentiality of responses. Consent was implied if the

NNP agreed to complete the metrics and demographic information. The NNPs participating in the study were asked to choose an individual patient that they cared for during their shift for workload evaluation. One NNP agreed to evaluate 2 different infants during her shift, but this was not the norm. The choice of patient was determined by both the first author and the NNP, with a goal of having a robust study sample that represented all categories on the objective

FIGURE 2

NASA Task Load Index. The figure is the paper-and-pencil subjective metric that was administered to NNPs in the study. NNP indicates neonatal nurse practitioner.

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RESULTS

workload metric. For example, our unit infrequently has infants undergoing body cooling, so that type of infant was preferentially chosen for study. Patients were chosen who represented the spectrum of workload to include both well, convalescing infants and acutely ill infants. The NNPs were unaware at the time they chose the infant to evaluate if that infant had been included in the study previously by another NNP. No NNP evaluated the same infant twice. To encourage participation in the study, if the NNPs expressed they had an “interesting” patient they wanted to evaluate, that infant was included. Both patients and NNPs were de-identified and assigned study numbers. The NNP group at our institution works both 12- and 24-hour shifts. To provide consistency in evaluation of workload and to avoid the influence of fatigue and recall bias at the end of a 24-hour shift, scores were collected after approximately 12 hours of work for both shift lengths. Participants were informed of the purpose of the study and asked to consider the workload for only a single patient, as opposed to considering the workload for their entire patient load. The NASA TLX was completed first. The handbook of the NASA TLX paperand-pencil version includes specific verbiage and instructions to use with participants.26 Instructions included a brief description of the workload factors and how to mark the workload score on the NASA TLX scale. The objective workload metric was completed by the first author; pertinent information was obtained from the NNP caring for the patient. The sum of the NASA TLX workload factors was calculated by the first author and designated as the NASA TLX score. Similarly, the sum of the objective workload categories was tabulated and designated as the objective workload score. Additional demographic data for the NNPs including age and experience were obtained.

A total of 47 workload experiences were evaluated over 16 different shifts by 22 NNPs. Half of the NNPs participating completed only 1 workload evaluation, with the remaining half completing between 2 and 5 workload evaluations on unique patients. Four patients were evaluated twice on different shifts and by different NNPs, resulting in 43 different patients who were included in the study. All NNPs were females, with an average age of 40 years and 10.72 years of experience as an NNP (see Table 3 for demographic information). The majority of the workload metrics were completed during 24-hour shifts; only 5 were completed during 12-hour shifts. See Figure 3 for information regarding patient characteristics. A Pearson product–moment correlation coefficient was calculated to examine the relationship between the NASA TLX and the objective metric scores. A moderate correlation coefficient was found (r = 0.503, P ≤ .01). See Figure 4 for a scatterplot of NASA TLX scores and objective metric scores. Years of experience were not correlated with either the NASA TLX scores (r = 0.062) or the objective metric scores (r = −0.040). The individual NASA TLX workload factors also were evaluated. Figure 5 displays the distribution of NASA TLX factor scores using a bubble plot. The size of the bubble and numeral on the bubble indicate the frequency of that score. Not surprisingly, given the size of the patients in the NICU, the physical workload scores were low. In general, the NNPs evaluated their performance as high, which is indicated as a low score on the NASA TLX. The mental demand and effort workload factors had the highest workload score, with means of 45.6 and 36.7, respectively. Temporal demands (M = 30.2), which represent a feeling of time pressure, and feelings of frustration (M = 27.7) had similar scores on the metric.

Analytical Plan Data analysis was conducted with SPSS version 23. Descriptive statistics (mean and median) were determined for demographic information and NASA TLX scores. Correlation between the objective metric and NASA TLX was determined by calculating a Pearson product–moment correlation coefficient. Correlation coefficients were also calculated comparing years of experience and workload scores.

DISCUSSION This study supports the utilization of NASA TLX to assess and address workload among NNPs. The correlation between the NASA TLX metric and the newly developed objective workload metric provides a measure of construct validity to the objective

TABLE 3. NNP Demographic Information Age

Years as RN

Years as NNP

Years at Institution

40.45

6.36

10.72

10.82

Median

40

4

10

10

Minimum

30

2

2

2

Maximum

63

21

29

26

Mean

Abbreviation: NNP, neonatal nurse practitioner.

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FIGURE 3

Patient characteristics. The figure includes 3 pie graphs illustrating the weight, ventilatory support, and nutritional support of infants evaluated with the objective workload metric. CMV indicates conventional mechanical ventilation; FEN, Fluids, Electrolytes, and Nutrition; IVF, intravenous fluids; NC, nasal cannula; NCPAP, nasal continuous positive airway pressure; NPO, nothing by mouth; RA, room air; VT, vapotherm.

metric. Construct validity indicates that a test or metric is actually measuring what it intends to measure. The objective metric captures the workload that the NNP is experiencing. The lack of correlation between experience or age and either workload metric indicates that the metrics can be used by both novice and experienced NNPs. The objective workload metric is simple to complete and provides information regarding workload throughout the continuum of the infant’s hospital stay. Measures of acuity of the infant are included, but other factors contributing to NNP workload, such as procedures, discharges, and admissions, are also included to provide a more complete measure of NNP workload. Not surprisingly, the NASA TLX scores indicate that mental demand and effort are a large contributor to NNP workload. Much of the NNP role involves cognitive effort to develop and coordinate an infant’s plan of care, calculate medications, and write orders. Time demands in the NICU where this study was

completed such as start of morning rounds and deadlines for order entry are reflected in the moderate temporal demand scores. Frustration scores also had a sizable contribution to the total workload score.

Limitations The small sample size of this study is a limitation. Some categories on the objective workload metric, such as metabolic disease, body cooling, and do not resuscitate status, are relatively uncommon in the NICU and were not well represented in the sample. Future studies of the objective workload need to include a large sample size and a wider variety of patients. The weighting of the objective workload scores was chosen arbitrarily by the first author, and the weight of some scores may underrepresent or overrepresent the amount of workload required. The NNPs in the study generally self-selected which patient to evaluate and may have chosen patients they perceived as having a higher or more interesting

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FIGURE 4

Scatter plot of NASA TLX scores and objective workload metric scores. NASA TLX indicates NASA Task Load Index.

workload and may have also contributed to outliers. A larger study in which the patients are randomly selected would make the sample more well-represented. There are some aspects of workload that are difficult to capture with an objective metric. For example, level of frustration is a very subjective and represented a sizable portion of NNP workload.

Need for Further Research Future research needs to be conducted to describe NNP workload and to further develop metrics to

quantify NNP workload. Without reliable measures of workload, it is difficult to determine appropriate staffing. Bedside neonatal nursing workload and staffing levels are known to contribute to infection rates, mortality, delayed or missed care, and amount of discharge planning education.4,6,8,9,45 Similar research on the effect of NNP workload on patient outcomes is lacking. Further research of factors affecting frustration felt by NNPs and methods to decrease this frustration is needed. Experiences such as difficult parental

FIGURE 5

NASA Task Load Index score distribution by workload factor. The figure is a bubble plot illustrating the score distribution and frequency of score on the NASA Task Load Index by individual workload factor.

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Summary of Recommendations for Practice and Research What we know:

• Level of workload has an effect on both the provider and the patient.

What needs to be studied:

• Further research to describe and quantify NNP workload. • Research studying the relationship between NNP workload and patient outcomes.

What we can do today:

• Increase awareness of the importance of NNP workload.

psychosocial interactions and complex discharge processes may contribute to frustration. Discharges in the NICU can be a complicated process as providers and nurses prepare families to care for their infants at home, and extensive communication between providers and families is required.46,47 Parental stress in the NICU has been well documented, but providers may not be well trained to communicate with families during this stressful time.48-50 This study contributes to the body of knowledge regarding NNP workload by demonstrating that the NASA TLX can be used with NNPs. Additional studies of NNP workload at academic and private institutions as well as in units of different levels are needed. Larger, validation studies with the objective workload metric need to be conducted, but this study indicates that the objective metric has the potential to capture the workload that NNPs are experiencing.

Acknowledgments The authors thank Dr Buffy Lupear, DNP, CRNA, APRN, and the Leadership Excellence in Advanced Practice program of Vanderbilt University Medical Center for their guidance in this project. They also thank Dr Kate Kemplin, DNP, RN, CCEMTP, and Dr Susan Thul, DNP, ARNP, CNM, for their assistance in the editing of the manuscript.

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