Nurses' moral distress and leadership communication in hospitals serving Black patients during COVID-19.

BACKGROUND: Poorer leadership communication during COVID-19 may have contributed to the moral distress of nurses in hospitals where Black patients predominantly access their care (BSH). PURPOSE: To compare nurse moral distress and leadership communication during the COVID-19 pandemic in hospitals that serve disproportionately many or few patients of Black race. METHODS: In a national hospital sample (n = 90), nurse survey data were collected (March 2021). Nurse moral distress was analyzed in linear regression models. The key covariates were BSH category (Medicare Black patient percentage) and leadership communication. DISCUSSION: Nurses in high-BSH had significantly greater moral distress and more difficulty accessing personal protective equipment than nurses in low-BSH. The percentage of nurses in high-BSHs with high moral distress was double that of nurses in low-BSHs. Poorer leadership communication in BSHs accounted for the nurses' greater moral distress. CONCLUSION: Policies should improve leadership communication, mitigate distress, and support nurses in under-resourced settings.

Racial and ethnic disparities in emergency department transfers to public hospitals.

OBJECTIVE: To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. DATA SOURCES AND STUDY SETTING: ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018). STUDY DESIGN: Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means. DATA COLLECTION/EXTRACTION METHODS: We examined 1,265,588 adult ED patients transferred from 187 hospitals. PRINCIPAL FINDINGS: Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. CONCLUSIONS: Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.

A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks.

Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism. CONTEXT: Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. METHODS: To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. FINDINGS: The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. CONCLUSIONS: The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.

The Association of Missed Nursing Care With Very Low Birthweight Infant Outcomes.

The health outcomes of very low birthweight (VLBW) infants in neonatal intensive care units (NICUs) may be jeopardized when required nursing care is missed. This correlational study is the first to look at the association between missed nursing care and mortality, morbidity, and length of stay (LOS) for VLBW infants in a U.S. NICU sample. We used 2016 hospital administrative discharge abstracts for VLBW newborns (n = 7,595) and NICU registered nurse survey responses (n = 6,963) from the National Database of Nursing Quality Indicators. The 190 sample hospitals were from 19 states in all regions. Missed clinical nursing care was significantly associated with higher odds of bloodstream infection and longer LOS, but not mortality or severe intraventricular hemorrhage. With further research, these results may motivate the development of interventions to reduce missed clinical nursing care in the NICU.

Discharge Age and Weight for Very Preterm Infants in Six Countries: 2012-2020.

BACKGROUND: Postmenstrual age for surviving infants without congenital anomalies born at 24-29 weeks' gestational age from 2005 to 2018 in the USA increased 8 days, discharge weight increased 316 grams, and median discharge weight z-score increased 0.19 standard units. We asked whether increases were observed in other countries. METHODS: We evaluated postmenstrual age, weight, and weight z-score at discharge of surviving infants without congenital anomalies born at 24-29 weeks' gestational age admitted to Vermont Oxford Network member hospitals in Austria, Ireland, Italy, Switzerland, the UK, and the USA from 2012 to 2020. RESULTS: After adjustment, the median postmenstrual age at discharge increased significantly in Austria (3.6 days, 99% CI [1.0, 6.3]), Italy (4.0 days [2.3, 5.6]), and the USA (5.4 days [5.0, 5.8]). Median discharge weight increased significantly in Austria (181 grams, 99% CI [95, 267]), Ireland (234 [143, 325]), Italy (133 [83, 182]), and the USA (207 [194, 220]). Median discharge weight z-score increased in Ireland (0.24 standard units, 99% CI [0.12, 0.36]) and the USA (0.15 [0.13, 0.16]). Discharge on human milk increased in Italy, Switzerland, and the UK, while going home on cardiorespiratory monitors decreased in Austria, Ireland, and USA and going home on oxygen decreased in Ireland. CONCLUSIONS: In this international cohort of neonatal intensive care units, postmenstrual discharge age and weight increased in some, but not all, countries. Processes of care at discharge did not change in conjunction with age and weight increases.

Leading Improvements in the Delivery of Nursing Care for Older Adults with Frailty in Long-Term Care Using Mitchell's Quality Health Outcome Model and Health Outcome Data.

Protecting frail older residents from adverse health outcomes associated with preventable illnesses and conditions, such as geriatric syndromes within the long-term care (LTC) health system requires attention by the health care team, led by professional nurse leaders, to all of the operant contextual factors influencing health outcomes. Mitchell's Health Outcomes Model helps to frame these operant contextual factors to help understand how the person and the situation are viewed, which then directs professional nurse leaders' interventions. Utilization of the LTC facilities Quality Metrics data can shape and inform nurses leaders as to the gaps which can be filled to meet resident care needs operant among these modifiable contextual factors.

Understanding the relative contributions of prematurity and congenital anomalies to neonatal mortality.

OBJECTIVE: To examine the relative contributions of preterm delivery and congenital anomalies to neonatal mortality. STUDY DESIGN: Retrospective analysis of 2009-2011 linked birth cohort-hospital discharge files for California, Missouri, Pennsylvania and South Carolina. Deaths were classified by gestational age and three definitions of congenital anomaly: any ICD-9 code for an anomaly, any anomaly with a significant mortality risk, and anomalies recorded on the death certificate. RESULT: In total, 59% of the deaths had an ICD-9 code for an anomaly, only 43% had a potentially fatal anomaly, and only 34% had a death certificate anomaly. Preterm infants (<37 weeks GA) accounted for 80% of deaths; those preterm infants without a potentially fatal anomaly diagnosis comprised 53% of all neonatal deaths. The share of preterm deaths with a potentially fatal anomaly decreases with GA. CONCLUSION: Congenital anomalies are responsible for about 40% of neonatal deaths while preterm without anomalies are responsible for over 50%.

Hospital nurses' moral distress and mental health during COVID-19.

AIMS: To explore factors associated with nurses' moral distress during the first COVID-19 surge and their longer-term mental health. DESIGN: Cross-sectional, correlational survey study. METHODS: Registered nurses were surveyed in September 2020 about their experiences during the first peak month of COVID-19 using the new, validated, COVID-19 Moral Distress Scale for Nurses. Nurses' mental health was measured by recently experienced symptoms. Analyses included descriptive statistics and regression analysis. Outcome variables were moral distress and mental health. Explanatory variables were frequency of COVID-19 patients, leadership communication and personal protective equipment/cleaning supplies access. The sample comprised 307 nurses (43% response rate) from two academic medical centres. RESULTS: Many respondents had difficulty accessing personal protective equipment. Most nurses reported that hospital leadership communication was transparent, effective and timely. The most distressing situations were the transmission risk to nurses' family members, caring for patients without family members present, and caring for patients dying without family or clergy present. These occurred occasionally with moderate distress. Nurses reported 2.5 days each in the past week of feeling anxiety, withdrawn and having difficulty sleeping. Moral distress decreased with effective communication and access to personal protective equipment. Moral distress was associated with longer-term mental health. CONCLUSION: Pandemic patient care situations are the greatest sources of nurses' moral distress. Effective leadership communication, fewer COVID-19 patients, and access to protective equipment decrease moral distress, which influences longer-term mental health. IMPACT: Little was known about the impact of COVID-19 on nurses' moral distress. We found that nurses' moral distress was associated with the volume of care for infected patients, access to personal protective equipment, and communication from leaders. We found that moral distress was associated with longer-term mental health. Leaders should communicate transparently to decrease nurses' moral distress and the negative effects of global crises on nurses' longer-term mental health.

Measuring Parent Satisfaction With Care in Neonatal Intensive Care Units: The EMPATHIC-NICU-USA Questionnaire.

Background: Neonatal intensive care unit (NICU) patient satisfaction is measured as parent satisfaction. Parents are critical to the family-centered care model and can evaluate care. Several EMpowerment of PArents in THe Intensive Care (EMPATHIC) instruments were developed in the Netherlands to measure parent satisfaction with neonatal and pediatric intensive care. EMPATHIC instruments comprise five domains and a total score: information, care and treatment, organization, parental participation, and professional attitude. To our knowledge, the EMPATHIC has not been adapted for USA use. Objectives: (1) To select a relevant EMPATHIC instrument for our study. (2) To expand the content reflecting the role of nurses and the cultural heterogeneity of USA NICU infants. (3) To adapt the selected EMPATHIC instrument to USA English. (4) To establish psychometric properties of the linguistically adapted instrument. (5) To evaluate instrument performance with additional items. Methods: The EMPATHIC-30 was selected based on shortest length, high overlap with neonatal EMPATHIC-N, and availability of a validated Spanish-language version. Six items from the EMPATHIC-N were added, two of which were split into separate items, resulting in the EMPATHIC-38. A neonatal nurse practitioner adapted wording to USA English. Cognitive debriefing was performed with eight NICU parents to evaluate adapted wording. Parent survey data from a study about missed nursing care and NICU parent satisfaction were utilized. Internal consistency of the five domains and overall score was measured by Cronbach's alpha. Spearman's rank correlations were computed for domains and overall score with four validity measures. Differential validity was determined using 13 parent demographic subgroups. Results: Data were from 282 parents. Parent race was predominantly White (61%) or Black (22%). One fifth were Hispanic. The adapted wording was satisfactory. Four of the five EMPATHIC-30 and EMPATHIC-38 domains had Cronbach alphas at or above 0.70, indicating acceptable reliability. Correlations between the domain, total scores, and validity indicators ranged from 0.30 to 0.57, indicating positive, moderate associations. Results were replicated in demographic subgroups. Reliability and validity of the three domains with additional items were better than or equivalent to values for the original. Conclusion: The linguistically adapted EMPATHIC-30-NICU-USA and the expanded EMPATHIC-38-NICU-USA exhibit satisfactory psychometric properties and are suitable for use in USA NICUs.

Parent Satisfaction With Care and Treatment Relates to Missed Nursing Care in Neonatal Intensive Care Units.

Background: The satisfaction of parents of infants in neonatal intensive care is important to parent-infant bonding and parents' ability to care for their baby, including after discharge. Given the principal caregiver role of nurses in this setting, parent satisfaction is influenced by high quality nursing care. Nursing care that is required but missed, such as counseling and support, might influence parent satisfaction. How missed nursing care relates to parent satisfaction is unknown. Objective: To describe the satisfaction of parents of infants in neonatal intensive care and to determine how satisfaction relates to missed nursing care in a sample of USA nursing units. Methods: The design was cross-sectional and correlational. Thirty neonatal intensive care units that participate in the National Database of Nursing Quality Indicators were recruited. To maximize sample variation in missed care, the highest and lowest quartile hospitals on missed nursing care, measured by nurse survey, were eligible. Ten parents of infants who were to be discharged were recruited from each site to complete a survey. Parent satisfaction was measured by the EMPATHIC-38 instrument, comprising five subscales: information, care and treatment, organization, parental participation, and professional attitude, and a total satisfaction score. Multivariate regression models were estimated. Results: Parent satisfaction was high (5.70 out of 6.00). The prevalence of missed care was 25 and 51% for low and high missed care units, respectively, and 40% for all units. On average, nurses missed 1.06 care activities; in the low and high missed care units the averages were 0.46 and 1.32. Over 10% of nurses missed activities that involved the parent, e.g., teaching, helping breastfeeding mothers, and preparing families for discharge. One standard deviation decrease in missed care activities at the unit level was associated with a 0.08-point increase in parent satisfaction with care and treatment (p = 0.01). Conclusion: Parents in USA neonatal intensive care units are highly satisfied. Neonatal intensive care nurses routinely miss care. Parent satisfaction with care and treatment is related to missed nursing care. Nursing care that is missed relates primarily to the care of the baby by the parents, which could have long term health and developmental consequences.

Missed care relates to nurse job enjoyment and intention to leave in neonatal intensive care.

AIM(S): To determine relationships among missed nursing care, job enjoyment and intention to leave for neonatal nurses. BACKGROUND: Being unable to provide required nursing care to infants could contribute to poorer neonatal nurse job outcomes, which may exacerbate staffing challenges. Little evidence exists about how missed nursing care relates to neonatal nurse job outcomes. METHOD(S): The design was cross-sectional. Secondary data from the 2016 National Database of Nursing Quality Indicators Registered Nurse Survey were used, which included nurse ratings of job enjoyment, intention to leave and missed nursing care. American Hospital Association data from 2016 were used to describe hospitals. Linear and logistic regressions were calculated. RESULTS: There were 5,824 neonatal nurses. Mean nurse job enjoyment was 4.26 out of 6 (SD = 0.97). On average, 15% of nurses intended to leave their position. Each one unit increase in missed nursing care was associated with a 0.26 decrease in job enjoyment and a 29% increased odds of intention to leave after controlling for nursing and hospital characteristics. CONCLUSIONS: Missed nursing care can influence nurse job enjoyment and intention to leave in neonatal care units. IMPLICATIONS FOR NURSING MANAGEMENT: Neonatal nurse managers should address missed nursing care to improve neonatal nurse job outcomes.

Association of Patient Acuity and Missed Nursing Care in U.S. Neonatal Intensive Care Units.

The health outcomes of infants in neonatal intensive care units (NICUs) may be jeopardized when required nursing care is missed. This correlational study of missed care in a U.S. NICU sample adds national scope and an important explanatory variable, patient acuity. Using 2016 NICU registered nurse survey responses (N = 5,861) from the National Database of Nursing Quality Indicators, we found that 36% of nurses missed one or more care activities on the past shift. Missed care prevalence varied widely across units. Nurses with higher workloads, higher acuity assignments, or in poor work environments were more likely to miss care. The most common activities missed involved patient comfort and counseling and parent education. Workloads have increased and work environments have deteriorated compared with 8 years ago. Nurses' assignments should account for patient acuity. NICU nurse staffing and work environments warrant attention to reduce missed care and promote optimal infant and family outcomes.

How Nurse Work Environments Relate to the Presence of Parents in Neonatal Intensive Care.

BACKGROUND: Parental presence in the neonatal intensive care unit (NICU) is essential for families to participate in infant care and prepare them to transition from hospital to home. Nurses are the principal caregivers in the NICU. The nurse work environment may influence whether parents spend time with their hospitalized infants. PURPOSE: To examine the relationship between the NICU work environment and parental presence in the NICU using a national data set. METHODS: We conducted a cross-sectional, observational study of a national sample of 104 NICUs, where 6060 nurses reported on 15,233 infants cared for. Secondary analysis was used to examine associations between the Practice Environment Scale of the Nursing Work Index (PES-NWI) (subscale items and with a composite measure) and the proportion of parents who were present during the nurses' shift. RESULTS: Parents of 60% (SD = 9.7%) of infants were present during the nurses' shift. The PES-NWI composite score and 2 domains-Nurse Participation in Hospital Affairs and Manager Leadership and Support-were significant predictors of parental presence. A 1 SD higher score in the composite or either subscale was associated with 2.5% more parents being present. IMPLICATIONS FOR PRACTICE: Parental presence in the NICU is significantly associated with better nurse work environments. NICU practices may be enhanced through enhanced leadership and professional opportunities for nurse managers and staff. IMPLICATIONS FOR RESEARCH: Future work may benefit from qualitative work with parents to illuminate their experiences with nursing leaders and nurse-led interventions in the NICU and design and testing of interventions to improve the NICU work environment.

Infants in Drug Withdrawal: A National Description of Nurse Workload, Infant Acuity, and Parental Needs.

Infants in drug withdrawal have complex physiological and behavioral states, requiring intensive nursing care. The study objectives were to describe acuity, parental needs, and nurse workload of infants in drug withdrawal compared with other infants. The design was cross-sectional and involved secondary nurse survey data from 6045 staff nurses from a national sample of 104 neonatal intensive care units. Nurses reported the care of 15 233 infants, 361 (2.4%) of whom were in drug withdrawal. Three-fourths of hospitals had at least 1 infant in drug withdrawal. In these hospitals, the mean number of infants in drug withdrawal was 4.7. Infant acuity was significantly higher among infants in drug withdrawal. Parents of infants in drug withdrawal required significantly more care to address complex social situations (51% vs 12%). The number of infants assigned to nurses with at least 1 infant in withdrawal (mean = 2.69) was significantly higher than typical (mean = 2.51). Given infant acuity and parental needs, policies legislating patient-to-nurse ratios should permit professional discretion on the number of patients to assign nurses caring for infants in drug withdrawal. Managers and charge nurses should consider the demands of caring for infants in drug withdrawal in assignment decisions and provide support and education.

Nursing Care Disparities in Neonatal Intensive Care Units.

OBJECTIVES: To describe the variation across neonatal intensive care units (NICUs) in missed nursing care in disproportionately black and non-black-serving hospitals. To analyze the nursing factors associated with missing nursing care. DATA SOURCES/STUDY SETTING: Survey of random samples of licensed nurses in four large U.S. states. STUDY DESIGN: This was a retrospective, secondary analysis of 1,037 staff nurses in 134 NICUs classified into three groups based on their percent of infants of black race. Measures included the average patient load, individual nurses' patient loads, professional nursing characteristics, nurse work environment, and nursing care missed on the last shift. DATA COLLECTION: Survey data from a Multi-State Nursing Care and Patient Safety Study were analyzed (39 percent response rate). PRINCIPAL FINDINGS: The patient-to-nurse ratio was significantly higher in high-black hospitals. Nurses in high-black NICUs missed nearly 50 percent more nursing care than in low-black NICUs. Lower nurse staffing (an additional patient per nurse) significantly increased the odds of missed care, while better practice environments decreased the odds. CONCLUSIONS: Nurses in high-black NICUs face inadequate staffing. They are more likely to miss required nursing care. Improving staffing and workloads may improve the quality of care for the infants born in high-black hospitals.

Factors associated with infant feeding of human milk at discharge from neonatal intensive care: Cross-sectional analysis of nurse survey and infant outcomes data.

CONTEXT: Nurses are principal caregivers in the neonatal intensive care unit and support mothers to establish and sustain a supply of human milk for their infants. Whether an infant receives essential nutrition and immunological protection provided in human milk at discharge is an issue of health care quality in this setting. OBJECTIVES: To examine the association of the neonatal intensive care unit work environment, staffing levels, level of nurse education, lactation consultant availability, and nurse-reported breastfeeding support with very low birth weight infant receipt of human milk at discharge. DESIGN AND SETTING: Cross sectional analysis combining nurse survey data with infant discharge data. PARTICIPANTS: A national sample of neonatal intensive care units (N=97), nurses (N=5614) and very low birth weight infants (N=6997). METHODS: Sequential multivariate linear regression models were estimated at the unit level between the dependent variable (rate of very low birth weight infants discharged on "any human milk") and the independent variables (nurse work environment, nurse staffing, nursing staff education and experience, lactation consultant availability, and nurse-reported breastfeeding support). RESULTS: The majority of very low birth weight infants (52%) were discharged on formula only. Fewer infants (42%) received human milk mixed with fortifier or formula. Only 6% of infants were discharged on exclusive human milk. A 1 SD increase (0.25) in the Practice Environment Scale of the Nursing Work Index composite score was associated with a four percentage point increase in the fraction of infants discharged on human milk (p<0.05). A 1 SD increase (0.15) in the fraction of nurses with a bachelor's degree in nursing was associated with a three percentage point increase in the fraction infants discharged on human milk (p<0.05). The acuity-adjusted staffing ratio was marginally associated with the rate of human milk at discharge (p=.056). A 1 SD increase (7%) in the fraction of infants who received breastfeeding support was associated with an eight percentage point increase in the fraction of infants discharged on human milk (p<0.001). CONCLUSIONS: Neonatal intensive care units with better work environments, better educated nurses, and more infants who receive breastfeeding support by nurses have higher rates of very low birth weight infants discharged home on human milk. Investments by nurse administrators to improve work environments and support educational preparation of nursing staff may ensure that the most vulnerable infants have the best nutrition at the point of discharge.

Nurse Staffing in Neonatal Intensive Care Units in the United States.

The neonatal intensive care unit (NICU) is a setting with high nurse-to-patient ratios. Little is known about the factors that determine nurse workload and assignment. The goals of this study were to (1) develop a measure of NICU infant acuity; (2) describe the acuity distribution of NICU infants; (3) describe the nurse/infant ratio at each acuity level, and examine the factors other than acuity, including nurse qualifications and the availability of physicians and other providers, that determined staffing ratios; and (4) explore whether nurse qualifications were related to the acuity of assigned infants. In a two-stage cohort study, data were collected in 104 NICUs in 2008 by nurse survey (6,038 nurses and 15,191 infants assigned to them) and administrators reported on unit-level staffing of non-nurse providers; in a subset of 70 NICUs in 2009-2010, census data were collected on four selected shifts (3,871 nurses and 9,276 infants assigned to them). Most NICU infants (62%) were low-acuity (Levels 1 and 2); 12% of infants were high-acuity (Levels 4 and 5). The nurse-to-infant ratio ranged from 0.33 for the lowest-acuity infants to 0.95 for the highest-acuity infants. The staffing ratio was significantly related to the acuity of assigned infants but not to nurse education, experience, certification, or availability of other providers. There was a significant but small difference in the percentage of high-acuity (Levels 4 and 5) infants assigned to nurses with specialty certification (15% vs. 12% for nurses without certification). These staffing patterns may not optimize patient outcomes in this highly intensive pediatric care setting.

Disparities in perinatal quality outcomes for very low birth weight infants in neonatal intensive care.

OBJECTIVE: To determine if hospital-level disparities in very low birth weight (VLBW) infant outcomes are explained by poorer hospital nursing characteristics. DATA SOURCES: Nurse survey and VLBW infant registry data. STUDY DESIGN: Retrospective study of 8,252 VLBW infants in 98 Vermont Oxford Network hospital neonatal intensive care units (NICUs) nationally. NICUs were classified into three groups based on their percent of infants of black race. Two nurse-sensitive perinatal quality standards were studied: nosocomial infection and breast milk. DATA COLLECTION: Primary nurse survey (N = 5,773, 77 percent response rate). PRINCIPAL FINDINGS: VLBW infants born in high-black concentration hospitals had higher rates of infection and discharge without breast milk than VLBW infants born in low-black concentration hospitals. Nurse understaffing was higher and practice environments were worse in high-black as compared to low-black hospitals. NICU nursing features accounted for one-third to one-half of the hospital-level health disparities. CONCLUSIONS: Poorer nursing characteristics contribute to disparities in VLBW infant outcomes in two nurse-sensitive perinatal quality standards. Improvements in nursing have potential to improve the quality of care for seven out of ten black VLBW infants who are born in high-black hospitals in this country.

Characteristics of the NICU work environment associated with breastfeeding support.

PURPOSE: The provision of breastfeeding support in the neonatal intensive care unit (NICU) may assist a mother to develop a milk supply for the NICU infant. Human milk offers unique benefits and its provision unique challenges in this highly vulnerable population. The provision of breastfeeding support in this setting has not been studied in a large, multihospital study. We describe the frequency of breastfeeding support provided by nurses and examined relationships between NICU nursing characteristics, the availability of a lactation consultant (LC), and breastfeeding support. SUBJECTS AND DESIGN: This was a secondary analysis of 2008 survey data from 6060 registered nurses in 104 NICUs nationally. Nurse managers provided data on LCs. These NICUs were members of the Vermont Oxford Network, a voluntary quality and safety collaborative. METHODS: Nurses reported on the infants (n = 15,233) they cared for on their last shift, including whether breastfeeding support was provided to parents. Breastfeeding support was measured as a percentage of infants on the unit. The denominator was all infants assigned to all nurse respondents on that NICU. The numerator was the number of infants that nurses reported providing breastfeeding support. Nurses also completed the Practice Environment Scale of the Nursing Work Index (PES-NWI), a nationally endorsed nursing care performance measure. The NICU nursing characteristics include the percentages of nurses with a BSN or higher degree and with 5 or more years of NICU experience, an acuity-adjusted staffing ratio, and PES-NWI subscale scores. Lactation consultant availability was measured as any/none and in full-time equivalent positions per 10 beds. RESULTS: The parents of 14% of infants received breastfeeding support from the nurse. Half of the NICUs had an LC. Multiple regression analysis showed a significant relationship between 2 measures of nurse staffing and breastfeeding support. A 1 SD higher acuity-adjusted staffing ratio was associated with a 2% increase in infants provided breastfeeding support. A 1 SD higher score on the Staffing and Resource Adequacy PES-NWI subscale was associated with a 2% increase in infants provided breastfeeding support. There was no association between other NICU nursing characteristics or LCs and nurse-provided breastfeeding support. CONCLUSIONS: Nurses provide breastfeeding support around the clock. On a typical shift, about 1 in 7 NICU infants receives breastfeeding support from a nurse. Lactation consultants are not routinely available in NICUs, and their presence does not influence whether nurses provide breastfeeding support. Better nurse staffing fosters nurse provision of breastfeeding support.

Nurse staffing and NICU infection rates.

IMPORTANCE: There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights. OBJECTIVE: To study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes. DESIGN: Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010). SETTING: Sixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs. PARTICIPANTS: All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630). All staff-registered nurses with infant assignments. EXPOSURES: We measured nurse understaffing relative to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010. MAIN OUTCOMES AND MEASURES: An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection. RESULTS: Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviation-higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.19-1.62; P < .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P < .001) in 2009. CONCLUSIONS AND RELEVANCE: Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants.