Joumal of Advanced Nursmg, 1994,20, 874-880

The changing role of the nurse in neonatal care: astudy of current practice in EnglandAnne Hams RNResearch Associate

and Margaret Redshaw BA PhDResearch Fellow, Neonatal Nurses Project, University of Bnstol, Institute of ChildHealth, Royal Hospital for Sick Children, Bnstol, England

Accepted for pubhcation 3 February 1994

HARRIS A & REDSHAW M (1994) Journal of Advanced Nursmg 20, 874-880The changing role of the nurse in neonatal care, a study of current practice inEnglandThe boimdanes of nursing in neonatal care, and the interface between the workof nursing and medicsJ staff m delivering care, are changing The enhanced orexpanding role of the neonatal nurse is not a universally accepted one If thisprofessional development is to be widely accepted and implemented, some keyissues will need to be addressed so that the changing role of the nurse andassociated skill base are well founded As part of a large-scale national study ofneonatal nursing m England, data were collected from nurses working in 24different units Regional centres, subregional centres and district units from sixwidely separated health regions participated, and individual data werecollected from 718 nurses (599 D-I grades and 119 A-C grades) Whileindicating that there is lnter-unit variation in nursing practice, the results alsoshow that many nurses are already in the process of changing their role in thisacute specialty Nurses doing so are more likely to have a qualification m thisspecialty, though not all of them have A small number of nursery nurses andnursing auxiliaries were undertaking tasks that could be considered part of anexpanded role The implications of the findings are discussed

T».T'T.T.#-vr«¥T/-.'T.T/-.».T and practical care, and this is now embodied in the post-INTRODUCTION . j « i .

basic courses providing specific training m special euidDuring Its evolution, the field of neonatology has seen intensive care of the newbornrapid advances m terms of the knowledge and expertise Development of the nurse's role m neonatal care hasneeded to care for increasing numbers of small, sick new- taken place in a number of countnes, commonly inbom babies (Harvey ef al 1989, Audit Commission 1993, response to medical staffing crises (Boxall 1987) In theRoberton 1993) With this developmg understanding eind Umted States, advsmcement of the role has largely takenthe adv£inces in technology, nursing and medical tech- place in a technical direction, encompassing a wide rangeniques have been refined Nurses working in this area have of practical climcal procedures (Karp 1993) In Canada,developed a skill base from which to deliver both technical although the role is clinically focused and contains a tech-

nical element, relatively greater emphasis has been placedCromi copyright reserved 1994 No part oj this paper may be reproduced on expanding the nursmg role m areas that mclude admm-without wntten permission of the secretary of state for health lstration, teaching, parental support, and research (HerbertCorrespondence AnneHams Research Associate Neonatal Nurses & Little 1983, Beresford 1991)Project, University of Bnstol Institute oJ Child Health Royal Hospital forSick Children St Michael s Hill Bnstol BS2 8BJ England

874

Changing role of neonatal care nurses

Advanced nurse practitioner

Interest m the concept of the advanced nurse practitionerin the Umted Kingdom has recently been developmg(Chiswick & Roberton 1987, Hale et al 1987) Findingsfrom a survey by the National Association of NeonatalNurses on neonatal nurse practitioners concluded that,while it was important to look to the future, there werereservations about development of the role (Boxall 1987,Hall et al 1992) Fundamental issues such as staffingadequacy, remuneration, career structure, and the goal ofdehvermg holistic family care, will need to be addressedin addition to immediate traming requirements

Recent studies in the Umted Kmgdom have focused onthe role of the nurse m high-technology areas (Youngmanet al 1988, DoH 1989, Stock & Ball 1992), lookmg at quali-fications m specialty, and the overlap between tasks car-ried out by nurses and technicians The possibility ofoverlap m other areas is evident, with increasing interestand concern on the part of professional bodies and organiz-ations about the developing role of the advanced nursepractitioner The concern and interest essentially springfrom two different pomts of view one focused on thechanging scope of the nurse's professional practice (UKCC1992), the other focused on the possibility of nurse prac-titioners taking on clinical duties normally assigned tojunior medical staff in traming (Higginson 1992, DoH1993)

The nurse practitioner role has been taken on by nursesm the community (Stilwell et al 1987, Drury et al 1988)and IS being lmtiated m a wide range of hospital special-ties, including cardiovascular surgery, urology, paedi-atrics, and accident and emergency care In the area ofneonatal nursmg, an advanced practitioner course hasbeen set up in one English health region (Hall et al1991)

THE STUDY

As part of a large-scale national study of neonatal nursing,commissioned and funded by the Department of Health,London (Redshaw et al 1993a,b), the issue of the changmgrole of the neonatal nurse was addressed In general, thestudy aimed to document many aspects of the workmgenvironment of neonatal units, focusmg on a wide rangeof organizational and individual factors The first stageinvolved the collection of general information from a largenumber of neonatal umts, the second concerned the work,perceptions and expenences of a large number of individ-ual nurses, and the third stage mvolved participation ofparents whose babies had been m neonatal care

Specifically m relation to the 'extended' and 'expanding'role of the neonatal nurse, the aim was to assess the waysm which nurses m neonatal care had already begun tochange their role, the effects of grade and qusdification m

specialty (QIS) on these aspects of practice, and nurses'attitudes to these professional developments

Methods

The results presented below arise from the data collectionthat took place during the second stage of the study Fourneonatal umts m each of six health regions in Englandwere visited (a regional centre, a subr^ional centre andtwo district units), resultii^ in a total of 24 study sitesThe definitions of the types of unit are as found in theReport of the Royal College of Physicians (1988) The umtswere selected to provide a widely distnbuted, and yet rep-resentative, sample m terms of size, location and the popu-lation served

All nursing staff involved m canng for babies or directlyresponsible for neonatal unit management were invited toparticipate Following ethical committee permission, stafflists were obtamed from senior nurses or managers Eachumt was visited, and individually addressed letters andquestionnaires were left for each nurse to complete andretum directly Nonresponders were contacted agam 4weeks later, but not subsequently

Throughout the study confidentiality was of the utmostimportance Rigorous professional guidelines were fol-lowed numbered questionnaires were used, data weremade anonymous and entered on the project computersystem and data m any form are only accessible to theresearch team At each hospital visit, during which nurseson the different shifts were seen, these pomts were stressedto the nurses being asked to participate

Sample

A total of 929 nurses were recruited to the study, of whom718 (78%) returned completed questionnaires The ques-tionnaire Itself covered a wide range of topics, includingeducation, training and expenence and health It also con-tained a large section about the current working situationSenior nurses were interviewed at the time of the visit anddata were obtamed concermng umt policy on the role ofnursing staff m neonatal care In order to address the ques-tion of how far the 'extended' or 'expanded' role was inoperation m this specialty, nurses were questioned usinga list of 30 tasks These mcluded methods of blood sam-pling, administration of drugs, and a wide range of techni-cal £ind invasive procedures Nurses were asked whetherthey had undertaken the task in the past and whether theywere doing so regularly now If they had not yet earnedout the task, they were asked whether they wished to doso This area of the task inventory was m addition to thedata collection on more traditional aspects of neonatalcare nursing

The data presented are those obtained from 599 qualifiednurses m the D-I grades, unless otherwise indicated In

875

A Hams and M Redshaw

exammmg the effects of grade, unit type and qualificationin specialty on the performance of specific tasks, theappropnate x̂ test was used

RESULTS

Policy on the expanded role of the nurse

Interviews with unit nursmg managers mdicated that fora quarter of units (six out of 24) there was a policy regard-ing the expanded role of the nurse The units with such apolicy comprised two regional centres, one subregionalcentre and three district units

When asked about specific activities, heelpnck bloodsampling was reported for all units, admmistration ofintravenous (IV) antibiotics for 88% (21 units) and removalof intravenous cannulae for 83% (20 units) Intravenousadministration of other drugs at 67% (16 units), intubationat 42% (10 units), use of a blood gas analyser at 63% (15units) and use of a bilimbmometer at 42% (10 units) wereless common No unit managers reported nursmg staffundertaking insertion of mtra-arterial (IA) cannulae,umbilical arterial catheters (UAC) or chest drains

Tasks commonly undertaken hy individual nurses

The individual data collected show that those tasks rou-tinely carried out by nurses working m neonatal care andgraded D-I include taking heelpnck blood samples (90%),removing IV cannulae (89%), and giving IV antibiotics(67%) Higher proportions of nurses had actually earnedout these tasks at some time, but were not doing soregularly 98% heelpnck samplmg, 98% removing IVcannulae, and 77% giving IV antibiotics

The distribution of tasks earned out by nurses gradedD-I IS presented m Figure 1, showing a significant effectfor the giving of FV antibiotics (P<0 001), but little differ-ence on the other tasks shown When these data are

displayed according to umt type (Figure 2), few differencesare evident

Less common activities

Other less common tasks and areas of care that some nursesworking m neonatal umts appeared to be takmg on wereexammed Intravenous adxmnistration of drugs other thanantibiotics was regularly undertaken by 50% of nurses,removal of endotracheal (ET) tubes (as an emergency orelective procedure) by 44%, setting up of artenal blood-pressure momtormg by 4 1 % , and removal of penpheralIA cannulae by 38% As with the more common tasks,greater numbers of nurses had earned these out previously,though were not doing them on a regular basis now Atsome time, 65% of nurses had given drugs other than anti-biotics intravenously, 80% had removed ET tubes, 66%had set up arterial BP monitoring, and 66% had removedperipheral IA CEumulae

Differences across the grades in carrying out these tasksare shown in Figure 3 There is a clear effect of seniority,with significantly more G grades regularly undertakingthese tasks than nurses at any of the other levels(P<0 0 1 - < 0 001)

Differences according to unit type are shown m Figure 4The proportion of nurses carrying out these tasks wasgreatest m the regional centres, followed by tbe sub-regional and then the district units (P<0 001), reflectmgboth the levels of care available and the type of babiesadmitted

Other still less common teisks that were regularly car-ried out by 20% or less of D-I grades were removal ofan umbilical arterial catheter (20%), using a blood gasanalyser (13%), using a bilirubmometer (12%), and takinga blood sample from an mdwellmg artenal catheter (9%)A frequency distribution by grade is shown m Figure 5Similar significant effects of grade to those reported formore common tasks were found (P<0 01) for all except

100

80

60

40

20

0F

Grade

H & l

Figure 1 Common tasks earned out r^ularly by neonatal nurses at different grades D heelpnck, • remove intravenous cannula,^ give mtravenous antibiotics Source Neonatal Nurses Project (DoH 1993)

876

Changing role of neonatal care nurses

Heelpnck Remove IV cannula

Task

Give IV anttMotKS

Figure 2 Gommon tasks carried out regularly by neonatal nurses in different types of unit D regional, • suhregional, ^ districtSource Neonatal Nurses Project (DoH 1993)

100

BO

40

20

0F

Grade

M & l

Figure 3 Less common tasks carried out regularly by neonatal nurses D other drugs (intravenously), • set up hlood-pressuremonitoring, ^ remove endotracheal tube, 0 remove lntra-arterial cannula Source Neonatal Nurses Project (DoH 1993)

100

80

Q 60

IO 40

20

0IV other drugs Remove ETT BP monitonng

Task

Remove lA cannula

Figure 4 Less common tasks carried out regularly by neonatal nurses in different types of umt D regional, • subregional, ̂ districtSource Neonatal Nurses Project (DoH 1993)

use of a bilmibmometer Some less obvious effects of unittype were foimd, for example, the use of a bilirubmo-meter was actually higher for nurses working in sub-regional and district umts (21% and 19% compared with2% m regional centres)

The tasks that were most infrequently reported as a rou-

tine part of the neonatal nurse's work are shown m Table 1It appears that a small proportion of nurses in neonatalcare are carrying out these euid other tasks that have moreusually been earned out by medical staff It is also clearthat some nurses have previously performed tasks thatthey are not currently undertaking

877

A Hams and M Redshaw

50

40

O 20

10

0H&l

Figure 5 Other less common tasks earned out regularly by neonatal nurses D remove UAC, • blood gas analyser, S usebilirubinometer, ^ sample lntra-atenal catheter Source Neonatal Nurses Project (DoH 1993)

Table 1 Tasks carried outinfrequently by neonatalnurses, grades D—I {n = 599) (inpercentages) Tasks

VenepunctureArtenal stabInsertion of intravenous cannulaInsertion of lntra-arterial cannulaInsertion of umbilical artenal cathetersInsertion of central venous pressure catheterIntubationInsertion of cbest dramRemoval of chest drainLumbar punctureCalculation of total parenteral nutrition requirements

Nurses carryingout taskregularly

1 170 331 670 330 170 171 670 504 840 170 50

Nurses havingcarried out taskpreviously

12 191 50

11020 670 500 17

21 54100

24 870 173 84

Nurses with a specialist qualification

In general, more nurses with a speciahst quahfication werecarrying out the tasks examined than those without a post-basic neonatal nursing quahfication However, for the twomost common activities (heelpnck sampling and removingrv cannulae), t)emg QIS made httle difference Of all thestafF carrying out heelpricks, 48% were QIS and the com-parable figure for nurses removing IV cannulae was 51%For all the other tasks examined, including the giving ofantibiotics intravenously, there was a significant relation-ship with having a post-basic neonatal qualification(P<0 001 for all but use of the blood gas anetlyser and thebilirubinometer, for which the values were P<0 01 andP<0 02 respectively) The proportion of QIS nurses under-taking the less common tasks was quite high and variedrelatively little between the tasks, rangmg fi-om 61% ofnurses using a bilmibmometer to 75% of those taking ablood sample bom an indwelling artenal catheter

Junior (A-C) grade staff

Data were also collected firom the more junior (A-C) gradestaff on the same range of tasks Of the 119 staff m the

study at these grades, all were nursery nurses or nursingauxiliaries except nine who were enrolled nursesHeelpnck blood sampling had been carried out by morethan 80% of the staff at these grades, 52% had removedan rv cannula and 15% had used a bilmibmometer Morerarely, some staff at these grades had undertaken adminis-tration of rv antibiotics, removal of an ET tube, removalof an IA cannula, and use of a blood gasanalyser Using nurses at these grades for these tasks wasnot found to be restncted to any particular t)^e ofumt

Attitudes to the changing role

Many D—I grade nurses expressed interest m expandingtheir role m neonatal care The majority of nurses who hadnot earned out the most common tasks wished to do so aspart of their current practice heelpnck blood S£mipling(eight out of the 10), removal of an FV cannula (seven outof the 11) and giving IV antibiotics (104 out of 138) Withthe less common tasks, 51% of the nurses who had notalready done so would like to be able to give drugs, otherthan Etntibiohcs intravenously, 63% would hke to site FVcannulae, 71% to mtut)ate, 40% to remove ET tubes, 63%

878

Changing role of neonatal care nurses

to use a bilmibmometer and 74% to use a blood gasanalsyer

Much smaller numbers of nurses would like to performa lumtwu- puncture (8%), insert a chest dram (9%) or insertan umbilical artenal catheter (16%)

DISCUSSION

It seems that some of the tasks exammed have already beenincorporated mto the day-to-day work of nurses m neo-natal care The data collected on policy sind practiceappear to agree in relation to the most common tasks exam-ined Thus heelpnck blood sampling, removal of an IVcannula and giving IV antibiotics are part of the skill basecommonly expected of qualified and tramed nursesworking m this specialty

Areas of skill involving more invasive procedures,the use of advanced technical equipment, or in whichdecision-making is an mtegral part, clearly have yet to beaccepted as part of the role on a broad scale In a smallnumber of units, though the stated policy was for nursesnot to take on such tasks, they were m fact doing so as aregular part of their work This, and the use of unqualifiedand untramed staff to carry out technical nursmg tasks,raises questions about the legal implications of theseaspects of practice and the extent of liability assumed bythe employing authority To argue that such untrained staffare 'supervised' while carrying out these tasks is unaccept-able, in view of the high levels of expertise demanded mpost-basic course traimng and the realities of supervisionThe use of unqualified staff as nurses working m this waym an acute specialty like neonatal care cannot be regardedas good practice

The lower levels of practice found for H and I grades,on both the common and less common tasks examined,probably reflect a reduced level of clinical involvementcind more commitment m the spheres of management orteaching for some individuals

Changes in policy and practice

Changes m policy, differences m experience and the prac-tice of different units may account for the large frequencydifferences found between the relatively low proportionof nurses regularly carrying out certain tasks (for instancevenepuncture or removal of a chest dram), and the higherproportion who have earned out these tasks at some timepreviously For the nurse who has leamt new skills,moving to another unit may mean no longer being able topractice them Local certification may be useful m theshort term to both employer and employee, but vanationsin policy and training both within and between hospitalsrender them unsatisfactory

Umt type differences m practice of the kind descnbedare protwbly a function of medical staffing and cover as

well as of nursing policy developments Thus, where thereare fewer numbers of junior doctors or where medicalcover IS generally poor, nurses may have taken on dutiesthat m other circumstances would not having been con-sidered withm their area of expertise Concerns about thequality of care given to babies have led nurses to considertakmg on additional tasks, despite staffing inadequaciesand the absence of a plarmed career structure (Redshawet al 1993c) Educational training programmes, orien-tation, assessment of competence, and updating of skillsare all required elements in preparation for major pro-fessional developments of this kind

Role developments

The findings, supported by observations made duringstudy visits, are based on a task-onented approach to nurs-mg developments m neonatal care This approach facili-tated accurate data collection and enabled a detailedprofile of current practice to be constructed However,from many perspectives the changing role of the neonatalnurse is as much a function of changing perceptions of thenursing and medical interface as of the specific activitiesemployed m the role To many neonatal nurses, the chang-ing role should include areas such as training, education,research, amd family-centred care

The evidence from the present study of nurses workingin neonatal units is that there Eire some areas of activitywhich they see as part of their job and others they wouldlike to take on, given appropriate trainmg and recogmtionHowever, there are some technically difficult and invasivetasks which relatively few nurses wish to encompass mtheir role

Findings from the study sire of direct relevance to manyof the currently proposed developments and new modelsof care in the oi^anization and provision of neonatalservices The information collected and presented couldprovide a context and point for companson against whichto view these and other future developments

Acknowledgements

The study was commissioned and funded by theDepartment of Health, London, but the opinions expressedare those of the researchers alone Thanks are due to JennyIngram, Tina Owen, and Mike Taysum for data input andcomputing, and to the project advisory group for supportand advice Most of all, we would like to acknowledge thelarge number of nurses workmg m neonatal care whowillingly participated in the study

References

Audit Gommission (1993) Children First HMSO, LondonBeresford D (1991) Neonatal nurse practitioners in Ganada and

879

A Hams and M Redshaw

Sweden. Unpublished report to Nottingham Neonatal Services,Queans Medical Centre, Nottingham, October

Boxall J (1987) The Development of Neonatal Nurse PractitionersPaper presented at the Neonatal Nurses Association AnnualConference, Nottingham

Chiswick M & Roberton N (1987) Doctors and nurses in neonatalcare towards integration Archives of Disease m Childhood62, 653-655

Department of Health (1989) Survey of Nurses m High TechnologyCare Department of Health, London

Department of Health, Working Group on Specialist MedicalTraining (1993J Hospital Doctors Training for the FutureHealth Pubhcations Unit, Oldham, Lancashire

Dniry M , Greenfield S , Stilwell B & Hull F (1988) A nursepractitioner in general practice patient perceptions and expec-tations loumal of The Royal College of General Practitioners38(316), 503-505

Hale P , Boxall ) & Hunt M (1987) The role of the neonatal nursepractitioner a viewpoint Archives of Disease m Childhood62, 760-761

Hall M, Smiths & Jackson] (1991) Neonatal Nurse PractitionersThe Way Forward Origins and Development of the WessexInitiative 'The Challenge of Carmg '91' Conference, Vickers,London, November

Hall M , Smith S , )ackson J , Perks E & Walton, P (1992) Neonatalnurse practitioners a view from Perfidious Albion' Archives ofDisease in Childhood 67, 458-462

Harvey D , Cooke R WI & Levitt G (eds) (1989) The Baby UnderlOOOg Wnght, London

Herbert F & Little C (1983) Nurse Practitioner Program,University of Alberta Canadian Medical Association Journal128(11), 1311-1312

Higginson I (1992) Descnption and Preliminary Evaluation of

Department of Health Initiatives To Reduce Junior Doctors'Hours Report for the NHS Management Executive, Departmentof Health, London

Karp T (1993) Neonatal Nursmg Pathway To Excellence or ADead End Profession'' Neonatal Nurses Association Conference,Nottingham, September

Redshaw M E , Hams A & Ingram J C (1993a) The neonatal umtas a working environment a survey of neonatal unit nursingUnpublished report to the Department of Health, London

Redshaw M E , Hams A & Ingram J C (1993b) The Neonatal Unitas a Working Environment A Survey of Neonatal Unit Nursing(Executive Summary) Department of Health, London

Redsbaw M E , Hams A & Ingram J C (1993c) Nursmg and medi-cal staffing in neonatal units Joumal of Nursing Management1(5), 221-228

Roberton N R C (1993) A Manual of Neonatal Intensive Care 3rdedn Edward Arnold, Sevenoaks, Kent

Royal College of Physicians (1988) Medical Care of the Newbomin England and Wales RCP, London

Stilwell B , Greenfield S , Drury M & Hull F (1987) A nursepractitioner in general practice Joumal of The Royal College ofGeneral Practitioners 37(297), 154-157

Stock ) & Ball ) (1992) A Study of Nurses and Technicians mHigh Technology Areas Institute of Manpower Studies,Brighton

United Kingdom Central Council on Nursing, Midwifery andHealth Visitmg (1992) The Scope of Professional PracticeUKCC Position Statement UKCC, London

Youngman M , Mockett S & Baxter C (1988) The Roles ofNurses and Technicians in High Technology Chnical AreasA Preliminary Report Department of Health and SocialSecurity, London

880