OBJECTIVE This study examined the relationships among nurse fatigue, individual nurse factors, and the practice environment in the inpatient setting. BACKGROUND Nurse fatigue affects the quality of care provision on inpatient units. Scant literature exists regarding how aspects of the practice environment relate to nurse fatigue. METHODS A cross-sectional, correlational design was used in this survey study of 175 neonatal intensive care unit nurses from multiple hospitals. Data were collected using the Checklist Individual Strength questionnaire and the Practice Environment Scale of the Nursing Work Index. Hierarchical regression analysis was performed to examine the relationships. RESULTS Higher fatigue was significantly associated with more hours worked, fewer hours of sleep, a physical or mental contributor to fatigue, and a recent distressing patient event. Lower fatigue was significantly associated with better nurse manager ability, leadership, and support. CONCLUSIONS Nurse fatigue may be diminished with organizational and individual strategies. Developing tactics for nurse managers to better support staff members after a recent distressing patient event is indicated.

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.

There are limited evidence-based standards for determining workload assignments of the neonatal nurse practitioner (NNP) in the neonatal intensive care unit (NICU). The purpose of this project was to describe the assignment pattern of the NNP, based on workload. The aim was to identify the level of satisfaction reported by the NNP relative to performance, patient outcome, and safety. During the project period, the NNPs responded to an electronic survey at the end of each worked shift. The following objective measures were utilized to describe workload: (a) number of NNPs assigned to the shift, (b) caseload, (c) patient acuity, (d) experience and competence of the NNP, (e) perception of safety, and (f) level of satisfaction of the NNP in relation to assignment factors. The implication of this project for NNP practice was to design a process to monitor a baseline of activity from which change can be implemented.

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.

IMPORTANCEThere 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.OBJECTIVETo study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes.DESIGNRetrospective 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).SETTINGSixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs.PARTICIPANTSAll 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.EXPOSURESWe 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 MEASURESAn 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.RESULTSHospitals 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 RELEVANCESubstantial 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.

Background: Sleep duration, both short and long, is recognized as a potential contributor to adverse health conditions.This study evaluated whether long sleep duration in early gestation (15 weeks) was associated with increased circulating concentrations of inflammatory cytokines across pregnancy.Methods: Self-reported 24-hour sleep duration and blood samples were obtained concurrently at 15, 24 and 36 weeks gestation in 85 pregnant women with a history of preeclampsia.Plasma samples were assayed for the inflammatory cytokines IL-2, -6, -8, IFNγ, TNFα, GM-CSF and anti-inflammatory cytokines IL-4, -5, and -10 using Luminex technology.A ratio of pro-to-anti-inflammatory cytokines was calculated using multiples of the median (MOMs) for each relevant cytokine type to normalize the data for comparison.Data were analyzed using repeated measures mixed models.Results: Women with long sleep (≥ 9 hours) at 15 weeks gestation had higher IL-6 concentrations throughout gestation than women who were regular sleepers (p = .003).No other cytokine or the ratio of pro-to-inflammatory cytokines differed between groups.No interactions of group by time were significant. Conclusions:The tendency to sleep for more than 9 hours in early pregnancy may contribute to increased low-grade inflammation as evidenced by higher circulating concentrations of IL-6.This may initiate or augment pre-existing pathophysiology associated with adverse pregnancy outcomes.While, our data are preliminary, they direct further investigation to determine whether this association increases risk for adverse pregnancy outcomes.

Approximately 1 in 4 infants born at very low birth weight (VLBW) die, and most do so in the first month of life. Such VLBW infants require intensive nursing care in a neonatal intensive care unit (NICU). The American Nurses Credentialing Center has developed a program that recognizes hospitals and other health care organizations for quality patient care and nursing excellence. Only 7% of US hospitals are awarded the nursing excellence (RNE) designation; approximately 20% of hospitals with a NICU have achieved this recognition. The outcomes for VLBW infants in the United States born at RNE hospitals are unknown. This cross-sectional cohort study was designed to examine the association of hospital RNE status with VLBW infant outcomes. The study population was composed of 72,235 infants weighing between 501 and 1500 g who were born in the NICUs of 558 Vermont Oxford Network hospitals between 2007 and 2008. The primary study outcome measures included mortality within 7 or 28 days of birth; hospital stay mortality; nosocomial infection, defined as occurrence of an infection in blood or cerebrospinal fluid culture more than 3 days after birth; and severe (grade 3 or 4) intraventricular hemorrhage. Multivariable logistic regression models were used to control for potential confounders. Joint significance tests were used to summarize the overall pattern for the 5 outcome measures. The percentage of infants with each outcome was as follows: 7-day mortality, 7.3% (5258/71,955); 28-day mortality, 10.4% (7450/71,953); hospital stay mortality, 12.9% 9278/71,936); severe intraventricular hemorrhage, 7.6% (4842/63,525); and infection, 17.9% (11,915/66,496). The rates for the 5 outcomes in the RNE and non-RNE hospitals were as follows: 7-day mortality {7.0% in RNE hospitals vs 7.4% in non-RNE hospitals [adjusted odds ratio (aOR), 0.87; 95% confidence interval, 0.76Y0.99; P = 0.04]}, 28-day mortality [10.0% in RNE hospitals vs 10.5% in non-RNE hospitals (aOR, 0.90; 95% CI, 0.80Y1.01; P = 0.08)], hospital stay mortality [12.4% in RNE hospitals vs 13.1% in non-RNE hospitals (aOR, 0.90; 95% CI, 0.81Y1.01; P = 0.06)], severe intraventricular hemorrhage [7.2% in RNE hospitals vs 7.8% in nonRNE hospitals (aOR, 0.88; 95% CI, 0.77Y1.00; P = 0.045)], and infection [16.7% in RNE hospitals vs 18.3% in non-RNE hospitals (aOR, 0.86; 95% CI, 0.75Y0.99; P = 0.04)]. The adjusted absolute decrease in risk of outcomes in RNE hospitals compared with non-RNE hospitals ranged from 0.9% to 2.1%. The differences between the RNE and nonRNE hospitals for all 5 outcomes were jointly significant (P G 0.001). The mean effect across all 5 outcomes was also significant (OR, 0.88; 95% CI, 0.83Y0.94; P G 0.001). In an older-gestational-age subgroup of 68, 253 infants with gestational age of 24 weeks or longer, the ORs for RNE for all 3 mortality outcomes and infection were statistically significant, with P values ranging from 0.01 to 0.03. These findings show that hospital RNE status in VLBW infants is associated with significantly lower rates of 7-day mortality, nosocomial infection, and severe intraventricular hemorrhage compared with non-RNE hospitals. However, birth in RNE hospitals does not improve rates of 28-day mortality or hospital stay mortality.

O NE IN 4 VERY LOW-BIRTH-weight (VLBW) infants (Ͻ1500 g) dies in the first year of life; nearly all deaths (87%) occur in the first month. 1 Infant mortality in the United States is concentrated in this population. Although they account for only 1.5% of births, these infants account for more than half of infant deaths. 1 Very low-birth-weight infants who survive have higher rates of morbidity and disability , including developmental delays and cognitive impairment, than infants with normal birth weights. Neonatal intensive care unit (NICU) infants are among the most nurse-intensive patients, with recommended patient-nurse ratios of at most 2 to 1 for neonates needing intensive care. 6,7 To intervene before the onset of life-threatening problems, nurses must make complex assessments, implement highly intensive therapies, and make immediate adjustments dependent on infant response. 8 Maintaining optimal respiratory, cardiac, and feeding status may result in improved de-Context Infants born at very low birth weight (VLBW) require high levels of nursing intensity. The role of nursing in outcomes for these infants in the United States is not known. Objective To examine the relationships between hospital recognition for nursing excellence (RNE) and VLBW infant outcomes.

The aims of this study were to describe and compare the epidemiology of acute poisoning hospital discharges in women of reproductive age and during pregnancy (aged between 15 and 44) to include the incidence rate, risk factors, substances involved, rates of intentional versus unintentional poisonings, and in pregnant women, distribution over trimesters. Through a cohort study design, the California patient discharge dataset and linked vital statistics-patient discharge database were used to identify cases of acute poisoning hospital discharges from 2000 to 2004 among women of reproductive age and among pregnant women. Odds ratios (OR) were calculated to identify risk factors using logistic regression. Of 4,436,019 hospital discharges in women of reproductive age, 1% were for an acute poisoning (115.3/100,000 person-years). There were 2,285,540 deliveries and 833 hospital discharges for an acute poisoning during pregnancy (48.6/100,000 person-years). Pregnancy was associated with a lower risk of acute poisoning (OR = 0.89, P = 0.0007). Poisonings were greatest among young black women regardless of pregnancy status and among those with substance abuse or mental health problems. Analgesic and psychiatric medications were most commonly implicated. The majority of poisonings among women of reproductive age (69.6%) and among pregnant women (61.6%) were self-inflicted. Efforts to reduce acute poisonings among women of reproductive age should include education regarding the use of over-the-counter medications and interventions to reduce self-inflicted harm.

The incidence of obesity is increasing at an alarming rate. There is compelling evidence that obesity increases the risk of preeclampsia about three-fold, and in developed countries is the leading attributable risk for the disorder. In this presentation we explore this relationship and propose targets for future studies guided by the much more extensively studied relationship of obesity to cardiovascular disease. We further address the hypothesis that asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, may be one convergence point for the mechanism by which obesity increases the risk of preeclampsia. We conclude with consideration of the clinical implications of this information.

To assess the interrelation among psychological and physiologic stress and race and their relation to preterm delivery. We conducted a cross-sectional study of stress, race and preterm delivery history among 60 non-pregnant women of reproductive age. Women were enrolled using a stratified recruitment scheme based on race (black vs. white) and history of preterm delivery (0, 1, 2+) in order to achieve roughly equal numbers in each group. Enrolled women completed a one-time study visit that included the collection of blood and urine and the completion of an extensive questionnaire that included a number of psychosocial instruments (i.e., Perceived Stress Scale, State-Trait Anxiety Inventory, Center for Epidemiologic Studies Depression Scale, Everyday Discrimination Scale, Life Orientation Test-Revised, and Parenting Stress Index). Blood was assayed for: IL-6, DHEA-S, EBV, CMV, cholesterol, CRP and HA1C. Epinephrine, norepinephrine, and creatinine were measured in urine. Multivariable logistic regression was used to examine the adjusted odds of having delivered two or more preterm births as a function of psychological and physiologic stress measures and race. Among the 60 women enrolled in the study, 59 (98%) met the study's inclusion criteria and were eligible for analysis. Of the 59, 30 (51%) participants were black and 29 (49%) were white. With regard to pregnancy history, 20 (34%) had a history of 2+ PTBs, 18 (31%) with one and 21 (35%) with none. The mean age of participants was 31.6 (SD=5.6) and 23 reported smoking. While there was a suggestion of an association between increased CES-D, PSS and LOT-R scores and preterm birth history, none of the findings were statistically significant, perhaps due to our modest sample size. We found no relation between the physiologic measures of psychosocial stress and preterm delivery history. Overall, we found no statistically significant association between stress and race and preterm delivery history; although there was the suggestion of a possible association with depressive symptoms, perceived stress, and optimism.

ObjectiveTo describe birth outcomes following intentional acute poisoning during pregnancy.SettingCalifornia Linked Vital Statistics-Patient Discharge Database, 2000 to 2004.ParticipantsPregnant women age 15 to 44, who had a singleton live birth or fetal death that occurred between gestational ages 20 and 42 weeks who were discharged from the hospital for an intentional poisoning were compared to pregnant women discharged from the hospital for any nonpoisoning diagnosis. Intentional acute poisoning hospital discharges were identifed by the presence of an ICD-9-CM E-Codes E950-E952 (suicide, attempted suicide and self-inflicted injuries specified as intentional.)MethodsThrough a retrospective cohort design, birth outcomes including low birth weight; preterm birth; fetal, neonatal, and infant death; and congenital anomalies were identified by the presence of ICD-9-CM diagnosis codes or by notation in the dataset.ResultsThere were 430 hospital discharges for an intentional poisoning during pregnancy documented in the dataset (rate=25.87/100,000 person years). The rate of intentional poisoning was greatest in the first weeks of gestation and declined with increasing gestational age. Analgesics, antipyretics, and antirheumatics were most commonly implicated. Adverse birth outcomes associated with intentional poisoning included preterm birth (odds ratio [OR]=1.34; 95% Confidence Interval [CI] [1.01, 1.77]), low birth weight (OR=1.49; 95% CI [1.04, 2.12]), and circulatory system congenital anomalies (OR=2.17; 95% CI [1.02, 4.59]).ConclusionIntentional acute poisoning during pregnancy was associated with several adverse birth outcomes; however, these relationships may be confounded by concomitant maternal substance abuse.

Neonatal nurses care for one of the highest risk patient populations: very-low-birth-weight (VLBW) infants. These infants, treated in Neonatal Intensive Care Units (NICUs) are closely monitored and provided with an array of life support measures and intensive interventions. The large variation in outcomes across NICUs that currently exists cannot be explained by differences in patient or NICU characteristics, such as volume or NICU level. Because NICU cases are among the most nurse-intensive hospitalizations, nursing care may explain some of this variation and provide an opportunity for improving outcomes for these infants. In this study of large-scale nursing effects on NICU outcomes in the United States, we examined whether variation in acuity-adjusted nurse staffing and environments contribute to the variation in NICU patient outcomes.

Objective To integrate research literature that has provided insights into the cervical dilation rate that may best describe the slowest-yet-normal dilation rate among nulliparous women when beginning with criteria commonly associated with active labor onset. Data Sources A literature search from 1950 through 2008 was conducted using the Medline electronic database, reference lists from identified articles, and other key references. Study Selection Research reports written in English with a focus on the cervical dilation and/or labor duration of low-risk, nulliparous women with spontaneous labor onset. Data Extraction Classic and contemporary research literature was reviewed and organized under the following subheadings: Friedman Studies, Partograph Studies, Active Management of Labor Studies, Additional Studies. Data Synthesis An integrative review of the literature approximated the slowest-yet-normal cervical dilation rate for nulliparous women when beginning with criteria commonly associated with active labor. Conclusions The slowest-yet-normal linear dilation rate approximates 0.5 cm/hour for low-risk, nulliparous women with spontaneous labor onset when starting at dilatations traditionally associated with active labor onset. However, this linear rate must be evaluated judiciously in light of the physiological acceleration of dilation that occurs during typical labor. Given this, cervical dilation for this population is likely slower than 0.5 cm/hour in earlier active labor and faster in more advanced active labor. Faster dilation expectations (e.g., 1 cm/hour) likely contribute to an overdiagnosis of dystocia (“slow, abnormal progression of labor”) in contemporary practice and, subsequently, to an overuse of interventions aimed at accelerating labor progress.

INTRODUCTION:Laboring women are often admitted to labor units under criteria that are commonly associated with the onset of active-phase labor (i.e., cervical dilatation of 3-5 cm in the presence of regular contractions). Beginning with these criteria through complete dilatation, this systematic review describes labor duration and cervical dilation rates among low-risk, nulliparous women with spontaneous labor onset. METHODS:Studies published in English (between 1990 and 2008) were identified via MEDLINE and CINAHL searches. Data were abstracted and weighted "active labor" durations (i.e., from 3-5 cm through complete dilatation) and linear dilation rates were calculated. RESULTS:Eighteen studies (n = 7009) reported mean "active labor" duration. The weighted mean duration was 6.0 hours, and the calculated dilation rate was 1.2 cm per hour. These findings closely parallel those found at the median. At the statistical limits, the weighted "active labor" duration was 13.4 hours (mean + 2 standard deviations) and the dilation rate was 0.6 cm per hour (mean - 2 standard deviations). DISCUSSION:These findings indicate that nulliparous women with spontaneous labor onset have longer "active" labors and therefore slower dilation rates than are traditionally associated with active labor when commonly used criteria are applied as the starting point. Revision of existing active labor expectations and/or criteria used to prospectively identify active phase onset is warranted.