Observational sickness assessment by the NICU staff nurses
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《美国医学杂志》
1 St. Stephens Hospital, Department of Neonatology, Tis Hazari, Delhi 110054, India
2 Department of Biostatistics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110016, India
Objective. To see the level of agreement on subjectively assessed sickness by NICU staff nurse with doctor. Methods. Prospective study in NICU for three months. The nurses were asked to assess whether a baby is sick or not on the basis of observed physical variables. Both the nurses and the attending physician made their assessment on a progress sheet separately. Statistical analysis was carried out to see the agreement of the nurses with the doctors in respect to the sickness assessment, treatment, final outcome and the agreement between the symptoms picked up by the nurses and the doctors. Results. Out of 112 babies admitted, 90 were observed to be sick by the nurses out of which 85 were observed to be sick by the doctors (Kappa=0.4098). Considerable accuracy was noted on comparing symptoms picked up by the nurses and the doctors'. The Kappa value for respiratory, GI and neurological system was 0.4278,0.401 and 0.59 respectively. A significant correlation was seen between the two groups with regard to the treatment given(p value=0.0456). Conclusion. Trained NICU staff nurse can identify sick neonate on observation.
Keywords: NICU; Sickness assessment by nurses
Neonatal nursing is a challenging and a changing speciality. The experienced neonatal intensive care unit (NICU) nurse serves as a link between a newborn and sometimes hostile environment. Education and experience give the nurses the necessary tool to serve as an interpreter for the infant, using intuition and assessment of the physiological data and behavior to discern the infants response to the treatment and the environment.[1]
Neonatal Nurse Practitioner (NNP) started in USA, a registered nurse with clinical expertise in neonatal nursing who completed an educational programme of study and supervised practice beyond the level of basic nursing in the speciality with supervised clinical experience in the management of newborn and their families.[2] They are performing various works efficiently. When NNP evaluated for resuscitation it was observed that they are proficient in resuscitation,[3] they are safe and cost effective for neonatal transfer[4] and they are providing value added neonatal care by merging traditional medical and nursing roles.[5]
In India there is no curriculum like NNP for the staff nurse. The general nursing staff are looking after the nursery and NICU. They are constantly observing babies in both nursery and NICU. It is important for them to observe any abnormality early and immediately inform the doctor on duty to reduce morbidity and mortality. However, there are no studies from India showing how good or efficient they are in this role.
Aim of the study is to see whether the staff nurse who is closely observing the babies in the NICU can identify a sick neonate by observing only the physical findings and their level of agreement with the doctor on subjectively assessed sickness.
Materials and Methods
This is a prospective study for period of three months from June 2003 to August 2003 in neonatal intensive case unit at St. Stephen's Hospital, Delhi. This is intramural nursery and babies shifted to nursery from labour room, operation theatre, post natal ward or intermediate unit of nursery for treatment or observations were included in the study. Nursing staff with more than 6 months of NICU experience assigned for nursery management of the baby were asked to classify the baby into 'sick' or 'non-sick' group based on observed physical findings, behaviour; and whether they need immediate attention and treatment or only frequent observation. The sick babies were sub-classified into involved systems, based on common clinical findings like abdominal distention, GI bleed, pre-feed, lethargy, seizure, jitteriness, apnoea, tachycardia, respiratory distress, cyanosis or sick look.
On admission all the babies were attended by post graduate pediatrician working as registrar and they noted their own findings separately and classified the baby into sick or not sick and planned the further management. Management plan was subject to change based on further clinical condition of the baby and consultant's advice.
Data was analyzed to see the level of agreement of staff nurse with the doctor for sick/not sick babies. Further, data regarding system involvement by nurse's observation was analyzed to see the agreement with that of doctor's in both the groups.
Statistical Method
Kappa value was calculated to see the agreement between the nurses and the doctors observation and its significance, student T test was also applied.
Results
Out of 112 admissions 90 were observed sick and 22 not sick by the staff nurses with no death in the not sick group. Those who were observed sick (n=90)by the staff nurses 85 were observed sick by the doctors and those observed as not sick (n=22) by the nurses 13 were observed as sick by doctors.The agreement was 83.95% with an expected agreement of 72.77%(Kappa value 0.4098).
Following observations were made when we looked for agreement on system involvement (based on observed physical variables) between doctor and staff nurse [Table - 1]. Respiratory systems involvement observed as sick in 76 babies by the nurses and out of which 56 babies had respiratory system involvement as observed by doctor. Out of 36 as not sick observed by staff, 10 were observed as sick by doctor. Agreement was 73.21% and the kappa value was 0.4278.The respiratory system findings observed by the staff nurse were tachypnea, respiratory distress, apnea, grunting, irregular respiration and cyanosis.
Those with neurological symptoms like seizures, jitteriness, 44 were observed to be sick by the nurses, out of which 28 were observed as sick by the doctors. Those observed as not sick (n=68) by the nurses 16 were observed as sick by the doctors.(K value 0.401).
Babies with gastrointestinal problems like abdominal distension, GI bleeding, feed intolerance,16 were observed as sick by the nurses whereas out of that 9 were observed as sick by the doctors. Out of 96 observed as not sick by the nurses 3 were observed as sick by the doctors (K value 0.59).
The relationship between the two groups with regard to the treatment is shown in [Table - 2]. The total number of babies who received treatment was 103. Out of 90 babies observed as sick by the nurses 87 received treatment and 22 observed as not sick, 16 received treatment (P value 0.0456). Those observed as sick (n=98) by the doctors 90 received treatment, out of 14 seen as not sick by the doctors 5 received treatment later on (P Value 0.0252).
Discussion
The present study revealed that the nurses' observation on sickness at admission related well to the assessment by the doctors. Duration of stay is not necessarily a good measure of accuracy of assessment in a neonatal unit. On the other hand, intercurrent problems like NEC, develop in babies who were well on admission as a newborn and this adds up to the duration of stay.
As the NICU nurses picked up the observed abnormal physical finding which was more than one in many babies and the final diagnosis was not simply one. So each individual observed physical finding in sick newborn was not looked for agreement between staff and doctor. As the final diagnosis was sometimes more than one in individual babies, we looked for the agreement of system involved based on the time of admission abnormal physical findings.
In the west nursing practitioners are coming in vogue where nurses take on many functions traditionally the domain of the physicians.[2]
In Britain, Advanced Neonatal Nurse Practitioner (ANNP) are recently introduced to the field of neonatal care. As a part of their training, they have formalized instruction in how to perform a neonatal check, together with clear teaching on the significant pathological variable they are looking for. The study has shown that ANNP are more effective than pediatric SHOs in detecting the abnormalities during the neonatal check.[6]
They are found to function well and such a delegation of responsibilities allows costs to come down[7] and care to improve[8] as nursing care constantly at the bedside and can respond faster to the needs of the baby.
The ability to perform these functions efficiently is dependant on the training received by the nurses and her motivational level and innate abilities.[2] Studies have shown that the nurse practitioners are highly motivated.
There are no studies from India looking into the abilities of the nurses trained in the country to perform in these extended roles. Previous studies have shown that primary health workers are not skilled enough to look for severity of illness among young infants.[9]
The present study looks primarily at a neonatal unit to see how skilled they are at picking up sickness in newborns. This assessment is important if they are to refer babies to the doctors. This involved trained neonatal nurses (General Nursing and Midwifery, GNM's, with NICU experience. These nurses have diploma in nursing and on an average have six months of experience in the neonatal unit.
The study shows that diploma nurses are capable of assessment. This study needs to be extended to nurses in the labor room and postnatal wards because it is they who refer sick babies to the neonatal unit. In case their assessment is not appropriate it can be recommended for a posting in the nursery to improve their assessment skills.
Conclusion
Trained diploma staff nurse can identify sick neonate by observing abnormal physical variable and this correlate moderately with doctors observation.
References
1.Lund CH, Epstein B. Neonatal Nursing: The organization of care and quality assurance in the NICU. In Avery GB, Fletcher MA , MacDonald MG, Neonatology : 5th edn, Philadelphia; Lippincot Williams & Wilkins, 1999; 61-72.
2.Blackmon LR, Batton DG, Bell EF, Engle WA,Kanto WP. Advanced practice in neonatal nursing. Pediatrics 2003; 111 : 1453-1454.
3.Aubrey WR, Yoxall CW. Evaluation of the role of the neonatal nurse practitioner in resuscitation of the preterm infant at birth. Arch Dis Child Fetal Neonatal Ed. 2001; 85 : F 96-94.
4.Leslie A, Stephenson T. Neonatal transfer by advanced neonatal nurse practitioner and pediatric registrar. Arch Dis Child Fetal Neonatal Ed 2003; 88 : F 509-512.
5.Smith SL, Hall MA. Developing a neonatal work force : role evaluation and retention of advanced neonatal nurse practitioner. Arch Dis Child Fetal Neonatal Ed 2003; 88 : F 426-429.
6.Lee TWR, Skelton RE, Skene C. Routine neonatal examination : effectiveness of trainee pediatrician compared with advanced neonatal nurse practitioner. Arch Dis Child Fetal Neonatal Ed 2001; 85 : F 100-104.
7.Teicher S, Crawford K, William B,Nelson B,Andrews C.Emerging role of the pediatric nurse practitioner in acute care: Pediatr Nurs 2001; 27(4) : 387-390.
8.Silver HK, Murphy MA, Gitterman BA.The hospital nurse practitioner in pediatrics. A new expanded role for staff nurses: Am J Dis Child 1984 Mar; 138(3) : 237-239.
9.Bandhyopadhyay S,Kumar R,Singhi S,Aggarwal A.Are primary health workers skilled enough to assess the severity of illness among young infants Indian Pediatr 2003; 40 : 713-718.(James Jyotsna, Tiwari Lokesh, Swahney Po)
2 Department of Biostatistics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110016, India
Objective. To see the level of agreement on subjectively assessed sickness by NICU staff nurse with doctor. Methods. Prospective study in NICU for three months. The nurses were asked to assess whether a baby is sick or not on the basis of observed physical variables. Both the nurses and the attending physician made their assessment on a progress sheet separately. Statistical analysis was carried out to see the agreement of the nurses with the doctors in respect to the sickness assessment, treatment, final outcome and the agreement between the symptoms picked up by the nurses and the doctors. Results. Out of 112 babies admitted, 90 were observed to be sick by the nurses out of which 85 were observed to be sick by the doctors (Kappa=0.4098). Considerable accuracy was noted on comparing symptoms picked up by the nurses and the doctors'. The Kappa value for respiratory, GI and neurological system was 0.4278,0.401 and 0.59 respectively. A significant correlation was seen between the two groups with regard to the treatment given(p value=0.0456). Conclusion. Trained NICU staff nurse can identify sick neonate on observation.
Keywords: NICU; Sickness assessment by nurses
Neonatal nursing is a challenging and a changing speciality. The experienced neonatal intensive care unit (NICU) nurse serves as a link between a newborn and sometimes hostile environment. Education and experience give the nurses the necessary tool to serve as an interpreter for the infant, using intuition and assessment of the physiological data and behavior to discern the infants response to the treatment and the environment.[1]
Neonatal Nurse Practitioner (NNP) started in USA, a registered nurse with clinical expertise in neonatal nursing who completed an educational programme of study and supervised practice beyond the level of basic nursing in the speciality with supervised clinical experience in the management of newborn and their families.[2] They are performing various works efficiently. When NNP evaluated for resuscitation it was observed that they are proficient in resuscitation,[3] they are safe and cost effective for neonatal transfer[4] and they are providing value added neonatal care by merging traditional medical and nursing roles.[5]
In India there is no curriculum like NNP for the staff nurse. The general nursing staff are looking after the nursery and NICU. They are constantly observing babies in both nursery and NICU. It is important for them to observe any abnormality early and immediately inform the doctor on duty to reduce morbidity and mortality. However, there are no studies from India showing how good or efficient they are in this role.
Aim of the study is to see whether the staff nurse who is closely observing the babies in the NICU can identify a sick neonate by observing only the physical findings and their level of agreement with the doctor on subjectively assessed sickness.
Materials and Methods
This is a prospective study for period of three months from June 2003 to August 2003 in neonatal intensive case unit at St. Stephen's Hospital, Delhi. This is intramural nursery and babies shifted to nursery from labour room, operation theatre, post natal ward or intermediate unit of nursery for treatment or observations were included in the study. Nursing staff with more than 6 months of NICU experience assigned for nursery management of the baby were asked to classify the baby into 'sick' or 'non-sick' group based on observed physical findings, behaviour; and whether they need immediate attention and treatment or only frequent observation. The sick babies were sub-classified into involved systems, based on common clinical findings like abdominal distention, GI bleed, pre-feed, lethargy, seizure, jitteriness, apnoea, tachycardia, respiratory distress, cyanosis or sick look.
On admission all the babies were attended by post graduate pediatrician working as registrar and they noted their own findings separately and classified the baby into sick or not sick and planned the further management. Management plan was subject to change based on further clinical condition of the baby and consultant's advice.
Data was analyzed to see the level of agreement of staff nurse with the doctor for sick/not sick babies. Further, data regarding system involvement by nurse's observation was analyzed to see the agreement with that of doctor's in both the groups.
Statistical Method
Kappa value was calculated to see the agreement between the nurses and the doctors observation and its significance, student T test was also applied.
Results
Out of 112 admissions 90 were observed sick and 22 not sick by the staff nurses with no death in the not sick group. Those who were observed sick (n=90)by the staff nurses 85 were observed sick by the doctors and those observed as not sick (n=22) by the nurses 13 were observed as sick by doctors.The agreement was 83.95% with an expected agreement of 72.77%(Kappa value 0.4098).
Following observations were made when we looked for agreement on system involvement (based on observed physical variables) between doctor and staff nurse [Table - 1]. Respiratory systems involvement observed as sick in 76 babies by the nurses and out of which 56 babies had respiratory system involvement as observed by doctor. Out of 36 as not sick observed by staff, 10 were observed as sick by doctor. Agreement was 73.21% and the kappa value was 0.4278.The respiratory system findings observed by the staff nurse were tachypnea, respiratory distress, apnea, grunting, irregular respiration and cyanosis.
Those with neurological symptoms like seizures, jitteriness, 44 were observed to be sick by the nurses, out of which 28 were observed as sick by the doctors. Those observed as not sick (n=68) by the nurses 16 were observed as sick by the doctors.(K value 0.401).
Babies with gastrointestinal problems like abdominal distension, GI bleeding, feed intolerance,16 were observed as sick by the nurses whereas out of that 9 were observed as sick by the doctors. Out of 96 observed as not sick by the nurses 3 were observed as sick by the doctors (K value 0.59).
The relationship between the two groups with regard to the treatment is shown in [Table - 2]. The total number of babies who received treatment was 103. Out of 90 babies observed as sick by the nurses 87 received treatment and 22 observed as not sick, 16 received treatment (P value 0.0456). Those observed as sick (n=98) by the doctors 90 received treatment, out of 14 seen as not sick by the doctors 5 received treatment later on (P Value 0.0252).
Discussion
The present study revealed that the nurses' observation on sickness at admission related well to the assessment by the doctors. Duration of stay is not necessarily a good measure of accuracy of assessment in a neonatal unit. On the other hand, intercurrent problems like NEC, develop in babies who were well on admission as a newborn and this adds up to the duration of stay.
As the NICU nurses picked up the observed abnormal physical finding which was more than one in many babies and the final diagnosis was not simply one. So each individual observed physical finding in sick newborn was not looked for agreement between staff and doctor. As the final diagnosis was sometimes more than one in individual babies, we looked for the agreement of system involved based on the time of admission abnormal physical findings.
In the west nursing practitioners are coming in vogue where nurses take on many functions traditionally the domain of the physicians.[2]
In Britain, Advanced Neonatal Nurse Practitioner (ANNP) are recently introduced to the field of neonatal care. As a part of their training, they have formalized instruction in how to perform a neonatal check, together with clear teaching on the significant pathological variable they are looking for. The study has shown that ANNP are more effective than pediatric SHOs in detecting the abnormalities during the neonatal check.[6]
They are found to function well and such a delegation of responsibilities allows costs to come down[7] and care to improve[8] as nursing care constantly at the bedside and can respond faster to the needs of the baby.
The ability to perform these functions efficiently is dependant on the training received by the nurses and her motivational level and innate abilities.[2] Studies have shown that the nurse practitioners are highly motivated.
There are no studies from India looking into the abilities of the nurses trained in the country to perform in these extended roles. Previous studies have shown that primary health workers are not skilled enough to look for severity of illness among young infants.[9]
The present study looks primarily at a neonatal unit to see how skilled they are at picking up sickness in newborns. This assessment is important if they are to refer babies to the doctors. This involved trained neonatal nurses (General Nursing and Midwifery, GNM's, with NICU experience. These nurses have diploma in nursing and on an average have six months of experience in the neonatal unit.
The study shows that diploma nurses are capable of assessment. This study needs to be extended to nurses in the labor room and postnatal wards because it is they who refer sick babies to the neonatal unit. In case their assessment is not appropriate it can be recommended for a posting in the nursery to improve their assessment skills.
Conclusion
Trained diploma staff nurse can identify sick neonate by observing abnormal physical variable and this correlate moderately with doctors observation.
References
1.Lund CH, Epstein B. Neonatal Nursing: The organization of care and quality assurance in the NICU. In Avery GB, Fletcher MA , MacDonald MG, Neonatology : 5th edn, Philadelphia; Lippincot Williams & Wilkins, 1999; 61-72.
2.Blackmon LR, Batton DG, Bell EF, Engle WA,Kanto WP. Advanced practice in neonatal nursing. Pediatrics 2003; 111 : 1453-1454.
3.Aubrey WR, Yoxall CW. Evaluation of the role of the neonatal nurse practitioner in resuscitation of the preterm infant at birth. Arch Dis Child Fetal Neonatal Ed. 2001; 85 : F 96-94.
4.Leslie A, Stephenson T. Neonatal transfer by advanced neonatal nurse practitioner and pediatric registrar. Arch Dis Child Fetal Neonatal Ed 2003; 88 : F 509-512.
5.Smith SL, Hall MA. Developing a neonatal work force : role evaluation and retention of advanced neonatal nurse practitioner. Arch Dis Child Fetal Neonatal Ed 2003; 88 : F 426-429.
6.Lee TWR, Skelton RE, Skene C. Routine neonatal examination : effectiveness of trainee pediatrician compared with advanced neonatal nurse practitioner. Arch Dis Child Fetal Neonatal Ed 2001; 85 : F 100-104.
7.Teicher S, Crawford K, William B,Nelson B,Andrews C.Emerging role of the pediatric nurse practitioner in acute care: Pediatr Nurs 2001; 27(4) : 387-390.
8.Silver HK, Murphy MA, Gitterman BA.The hospital nurse practitioner in pediatrics. A new expanded role for staff nurses: Am J Dis Child 1984 Mar; 138(3) : 237-239.
9.Bandhyopadhyay S,Kumar R,Singhi S,Aggarwal A.Are primary health workers skilled enough to assess the severity of illness among young infants Indian Pediatr 2003; 40 : 713-718.(James Jyotsna, Tiwari Lokesh, Swahney Po)