P3D187: Unique Educational Challenges Experienced in the Neonatal Intensive Care Unit While Managing Mechanically Ventilated Infants

Background: The Neonatal Intensive Care Unit (NICU) provides collaborative opportunities for various medical providers caring for the smallest and sickest of infants. A standard rounding team may include attending neonatologists, neonatal-perinatal medicine fellows, pediatric residents, neonatal nurse practitioners (NNPs), registered nurses, respiratory therapists, registered dieticians, pharmacists, and sub-specialized consultants. This variety offers unique perspectives to optimize care for hospitalized neonates but also leads to unique educational challenges. Both formal educational experiences such as didactic lectures and simulated case studies and informal experiences such as bedside rounding and clinical discussions often include participants with vastly different backgrounds in pathophysiology, pharmacology, and human development. This foundational difference can be exemplified by a typical allopathic or osteopathic medical student who may spend 12-24 months in the classroom studying physiology compared to a typical NNP student who may spend a single semester on physiology.

Methods: Qualitative analysis was performed on a series of recorded interviews and focus groups. Four attending neonatologists and two NNP supervisors were sent the following two questions, (1) What principles are most important to understand to effectively manage a mechanically ventilated infant? and (2) What principles are most commonly misunderstood or misapplied when managing a mechanically ventilated infant? Their responses were given in person and recorded. The same two questions were given to two NNP focus groups that included one NNP with less than 1 year of clinical experience, one NNP with 5-8 years of clinical experience, and one NNP with 10 or more years of clinical experience. These responses were also given in person and recorded. All responses were transcribed and inductively coded by two independent researchers. These codes were then used in a thematic analysis to identify commonalities among responses. Frequency and strength of themes were compared between NNPs and neonatologists.

Results: The attending group demonstrated a greater likelihood to consider principles of pulmonary physiology when considering management of an intubated and mechanically ventilated infant. The NNP group demonstrated a greater likelihood to consider established clinical guidelines and protocols when considering ventilator management in neonates. Both expressed the challenges of caring for this population especially when a patient experiences a clinical change. The approach to this change varied again between the two groups with NNPs often focusing on the difference between the patient versus an expected outcome while neonatologists viewed the clinical change as the expected outcome.

Conclusion: When considering the fragility of premature neonatal lungs, upmost caution must be used with mechanical ventilation to avoid the risk of injury. Collaborative teams can work together towards this common goal. Due to the foundational differences in physician training and NNP training in particular, different educational approaches should be considered when teaching these two clinical decision makers on best ventilator practice in neonates.