Role of Work System Barriers and Facilitators in NICU NNP Workload: A Multi-Site Study

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.

Table 1.

Major Barriers Contributing to NICU NNP Workload.

Barriers	Examples
Competing task demands (e.g., multiple babies destabilizing at the same time)	“The day the baby came back from the OR. . .In addition to that, we had 28-week-old twins, so we had to stabilize the twins as well as this baby, so that was a big challenge, babies acting up at the same time” (#Int1_Site2)
Lack of proper coordination with other clinicians (e.g., lack of shared decision-making approach, not forthcoming with treatment plans, making sudden changes without consulting the provider, etc.)	“NP was trying to track subspecialty consults down and figure out what the plan is as they were not forthcoming about their plan” (#Obs7_Site2)
Interruption from other clinicians (e.g., nurses) for non-emergency issues	“Constantly responding to messages on the phone, which I think just is exhausting. . .it’s like over stimulating” (#Int11_Site1)
Limited ancillary support during nights or weekends (e.g., unavailability of nutritionists and flex NP ((NP on shift with no patient assignment), higher patient assignments, difficulties in access to techs and specialty clinicians, etc.)	“Saturdays, for the most part, are a little better in general because it’s a weekend. You’re not typically having the ancillary services super involved. There aren’t extra people during rounds. That can also be a negative as well because you don’t have nutrition support over the weekend. You don’t have as much pharmacy support over the weekend.” (#Int5_Site2)
Unanticipated admissions/transfers, complicated discharges	“Due to some last-minute recommendations from subspecialty consult, discharge was delayed and got complicated, NP spending time with RN and case manager to speed things up.” (#Obs11_Site2)
Limited experienced RN staff	“Inexperienced RNs reach out NPs frequently. Lots of pages from RNs that could go to the charge nurse, resource nurse, etc.” (#Obs14_Site1)
High patient acuity and/or unexpected changes in acuity	“The acuity here exceeds a lot of hospitals around here” (#Int7_Site1)
Staff shortages causing high patient assignments and limited resources in critical/unanticipated situations	“Due to staff shortage, NPs have to take care of more babies, at the same time handle admissions, discharge, and transfers” (#Obs10_Site2)

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.

Table 2.

Major Facilitators to Mitigating NICU NNP Workload.

Facilitators	Examples
Good rapport with attendings and fellows	"Having a fellow/attending that is cooperative and collaborative and just easy to work with can make or break your day" (#Int9_Site1)
Co-workers that are willing to help	“She still has 4 babies to go on rounds for, another NP’s round is over so she offered to help with the new admission” (#Obs9_Site2)
Being able to prioritize/delegate tasks	“I started off seeing my patients early and then prioritized the sicker ones” (#Int1_Site2)
Having experienced RNs on the team	“They (Experienced RN) are able to really apply critical thinking. So, they will often, instead of just calling you with a problem, they’ll think it through and really communicate in a very different way” (#Int8_Site2)
Having adequate support staff (e.g. flex NP, nutritionist, pharmacists, etc.)	“When we have a flex NP they’re super-helpful in helping with discharges” (#Int3_Site2)

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.