Friday, November 14, 2014

Misfortune at Birth

This blog post originally appeared on the RWJF Human Capital Blog.


Eileen Lake, PhD, RN, FAAN, and Jeannette Rogowski, PhD, are co-principal investigators of a study, supported by the Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative, that generated evidence linking nurse staffing and work environments to infant outcomes in a national sample of neonatal intensive care units.* A new documentary, “Surviving Year One,” examines infant mortality in Rochester, N.Y. and nationwide. It is being shown on PBS and World Channel stations (check local listings). Read more about it on the RWJF Culture of Health Blog here and here.

Are some premature babies simply born in the wrong place? Premature babies are fragile at birth and most infant deaths in this country are due to prematurity.  It is well established that blacks have poorer health than whites in our country, but the origin of these disparities is still a mystery.  It’s possible that the hospital in which a child is born may tell us why certain population groups have poorer health.

A new study by University of Pennsylvania and Rutgers investigators that I led shows that seven out of ten black infants with very low birth weights (less than 3.2 lbs.) in the United States have the simple misfortune of being born in inferior hospitals. What makes these hospitals inferior?  A big component is lower nurse staffing ratios and work environments that are less supportive of excellent nursing practice than other hospitals.  Our study, which was funded by the RWJF Interdisciplinary Nursing Quality Research Initiative, indicates that the hospitals in which infants are born can affect their health all their lives. 

A Brighter Future

What can be done to make these hospitals better?  A first step would be to include nurses in decisions at all levels of the hospital, as recommended by the Institute of Medicine to position nursing to lead change and advance health. Laws in seven states require hospitals to have staff nurses participate in developing plans for safe staffing levels on all units.

Another solution would be to require hospitals to publicly report their neonatal unit staffing levels or work environment ratings (which are determined from a standard survey of nurses about features of their job, such as whether there is teamwork between nurses and doctors) so that pregnant women can make informed decisions about birth options in their communities. Five states require staffing levels to be displayed on nursing units.  Colorado already publicly reports work environment ratings on all hospitals with more than 100 beds.

It would also be a good idea to require the use of a patient acuity tool in staffing plans. We developed a five-level acuity tool for critically ill babies that is ready for use.  Our research using this acuity tool revealed substantial understaffing in neonatal intensive care nursing units was related to higher infection rates.

Previously, there was very little research evidence about the role of nurses in improving outcomes for premature babies, despite nurses being the main caregivers for infants in hospitals.  Our work filled in these gaps. We showed that in hospitals recognized for excellent nursing standards, premature infants have lower rates of death, infection, and severe brain hemorrhage. These standards include the active participation of nurses in hospital policies and decision making.

Among the premature infants who are fortunate enough to survive, the birth hospital is where they receive their first nutrition. Nurses are the principal caregivers and assist new mothers in developing supplies of breast milk, which the U.S. Surgeon General recommends for all newborns. Breast milk is particularly beneficial for premature infants because their immune systems are not completely developed, and it provides both nutrition and immunity protection. In hospitals where disproportionately more black infants are born, 47 percent more infants were discharged without receiving breast milk than in hospitals where the proportion was low. Nurses also play a great role in supporting and guiding mothers through breast-feeding. They commit a large amount of time to instructing and encouraging breast-feeding mothers, but if a neonatal intensive care unit (NICU) is understaffed, nurses have less time to devote to these activities. This in turn may affect infants’ access to breast milk.

Premature newborns often require life-saving interventions and central venous catheters.  Especially in a unit as nurse-intensive as a NICU, nurses play a significant role in preventing infection. They must remember to carefully use sterile techniques while performing procedures and be diligent about detecting early signs of infection. Although these tasks are crucial, they can also be time consuming. They may also be unintentionally overlooked in an understaffed unit. In hospitals where disproportionately more black infants are born, infections were 29 percent more frequent.

Improving Quality

These two perinatal care standards, breast milk and infection prevention, build a foundation for an infant’s lifelong health. Infections can affect neurological development and growth during childhood. In addition, the optimal nutrition provided by breast milk has a lasting impact on a person’s health. Breast-feeding is particularly important for premature infants because it reduces the chance an infant will develop a potentially fatal condition known as necrotizing enterocolitis, in which part of the bowel dies.  The study showed that one-third to one-half of the poorer health outcomes suffered by these premature infants were related to a lack of nursing resources.

Most importantly, if safe staffing helps to improve nurses’ resources in the NICU, the outcomes of those seven of ten black very low birth weight infants may be improved.  Health as a newborn builds a foundation for a healthier life.

*Lake is the Jessie M. Scott Term Chair in Nursing and Health Policy at the University of Pennsylvania School of Nursing and associate director of the Center for Health Outcomes & Policy Research. She leads a program of research on the contributions of the nurse's work environment and clinical nursing expertise to patient outcomes. She has developed an instrument to measure the work environment that is endorsed by the National Quality Forum as a nursing care performance standard that is used internationally.

Rogowski is the University Professor in Health Economics at the Rutgers School of Public Health. For more than two decades, her research has focused on access to care, quality and treatment costs for infants with very low birth weights. Rogowski has served as a member of the Institute of Medicine Committee on Understanding Premature Birth and Assuring Healthy Outcomes and is currently a member of the National Advisory Committee for the RWJF Investigator Awards in Health Policy Research.

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