Abstract
Neonatal Nurse Practitioners (NNPs) are essential in delivering complex care in Neonatal Intensive Care Units (NICUs), yet limited research has examined the work system factors shaping their workload. This qualitative study explored barriers and facilitators affecting NNP workload using direct observations and semi-structured interviews with 32 NNPs across two level-IV NICUs. Observational and interview data were analyzed using a situational workload framework through deductive and inductive coding. Key barriers included competing task demands, lack of coordination, frequent interruptions, limited ancillary support, staff shortages, and high or shifting patient acuity. Facilitators that helped mitigate workload included strong rapport with attending physicians and fellows, supportive coworkers, experienced nurses, effective task delegation, and adequate support staff (e.g., pharmacists, nutritionists). The study highlights how work system factors dynamically influence NNP workload. Findings can inform workflow redesign and system efficiency to enhance support for NNPs and improve safety and care quality in NICU environments
Introduction
The role of the neonatal nurse practitioner (NNP) in the neonatal intensive care unit (NICU) is indispensable in today’s rapidly evolving healthcare environment (Cusson et al., 2008). As defined by the National Association of Neonatal Nurse Practitioners (NANNP), NNPs manage a broad spectrum of responsibilities—including clinical care, education, research, professional development, management, coordination, and administration (NNP Workforce Position Statement, 2013). These responsibilities are further influenced by a variety of work system factors that shape clinician workload (Gurses et al., 2009).
Background
In acute care settings, increasing clinician workload leads to stress, burnout, reduced job satisfaction, and negative impacts on care quality (Chana et al., 2015; Owens, 2023; Purcell et al., 2011; Snapp & Reyna, 2019). These challenges are even more pronounced in the NICU, where the care of critically ill infants, is characterized by a unique set of complexities. Due to infant fragility, underdeveloped organs, weight-based medication needs, limited communication, and sensitivity to environmental stressors, even minor care changes can have significant consequences (Raju et al., 2011). Prior research has extensively examined the impacts of nursing workload on NICU patient safety (Doerhoff & Garrison, 2015; Tubbs-Cooley et al., 2018, 2019) and a few studies have assessed NNP workload using the subjective (i.e. NASA TLX) and objective (i.e., clinician-patient ratios and patient acuity metrics) measurement methods in the NICU (Dye & Wells, 2017; Dye et al., 2023; Jaeger et al., 2016). However, a research gap remains in the comprehensive understanding of work system-based barriers and facilitators that shape NNP workload and performance in the NICU. Our study adopts a qualitative research approach informed by the conceptual framework of the situational workload (Carayon & Gürses, 2005). By exploring the barriers and facilitators and how they contribute to NNP workload, we aim to provide a deep and contextualized insight into the work system factors that shape the clinical work environment of NNPs in the NICU.
Approach
The study was conducted in two large level-IV NICUs (116 and 49 beds, respectively) affiliated with two large academic health centers. A total of 32 NICU NNPs participated, with work experience ranging from 1 to 28 years. Data was collected using three-hour direct observations while each NNP was working as usual, followed by a 30-minute semi-structured interview conducted virtually. The interviews included semi-structured questions about workload barriers and facilitators—both during the observation period and in their overall experiences. Additionally, specific probes were used to explore insights derived from the observational data. Observations occurred on weekdays and weekends, randomly assigned within shifts. Observation data were collected using an observation tool developed, based on previous research (Gurses & Carayon, 2007), and pilot-tested. The observation tool consisted of both structured (i.e., work system-related barriers and facilitators) and unstructured sections (i.e., space for handwritten notes). Handwritten notes were transcribed post-session, and the interviews were recorded and transcribed. Data analysis employed a combination of deductive and inductive approaches: the deductive approach was guided by an established conceptual framework (Gurses & Carayon, 2007), while the inductive approach allowed for the identification of concepts not explicitly captured within the framework.
Outcome
Analysis revealed several major barriers in the NICU work system that consistently contributed to high NNP workload in the NICU including (see Table 1 for details): (1) Competing task demands, (2) Lack of proper coordination with other clinicians, (3) Interruption from other clinicians for non-emergent things, (4) Limited ancillary support during nights or weekends, (5) Unanticipated admissions/transfers and complicated discharges, (6) Limited experienced RN staff, (7) High patient acuity and/or unexpected changes in acuity, and (8) Staff shortages causing high volumes of patient assignments per NNP and limited resources in critical/unanticipated situations.
Major Barriers Contributing to NICU NNP Workload.
Several work system facilitators were identified that often reduce the workload or help deal with barriers that contribute to high NNP workload (See Table 2 for details). These facilitators include: (1) Good rapport with attendings and fellows, (2) Co-workers that are willing to help, (3) Being able to prioritize/delegate tasks, (4) Having experienced RNs on the team, and (5) Having adequate support staff e.g. flex NP, nutritionist, pharmacists, etc.
Major Facilitators to Mitigating NICU NNP Workload.
Conclusion
By identifying specific workload barriers for workload management, this study highlights key areas for potential targeted interventions to reduce NNP workload in NICUs. It also reveals the facilitators within NICU NNP teams that frequently help alleviate their workload. Future steps include collecting additional data for a thorough and detailed analysis, where we will aggregate observational and interview data and develop a comprehensive coding scheme to systematically categorize the barriers and facilitators. Overall, this systematic examination of NNP workload management aims to optimize NNP performance and well-being by providing a greater understanding of healthcare system efficiency, workload management, patient safety, and potential interventions to reduce NNP workload in the NICU.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by grant number R01HD109303 from Eunice Kennedy Shriver National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
