EDUCATION
Grover F. Powers, M.D., Contributing Editor
INSTITUTES
FOR
PHYSICIANS
AND
NURSES
IN THE
CARE
OF
PREMATURE
INFANTS
An Evaluation
of
Five
Years
Experience
By Alfred Yankauer, M.D., Ethel Tschida, R.N., Mary Allen Engle, M.D.,
and Madeleine Phaneuf, R.N.
Btsreau of Maternal and Child Health, New York State Department of Health, and
Department of Pediatrics, New York Hospital-Cornell Medical Center
These institutes were niade possible by grants from the United States Children’s Bureau, Department
of Health, Education, and Welfare.
Irving Goldberg, M.P.H., senior biostatistician, New York State Department of Health, assisted in the
preparation of statistical data.
ADDRESS: (A.Y.) 39 Columbia Street, Albany 7, New York.
95
CONTRIBUTORS’ SECTION
W
1THIN the past 20 years medicalat-tention in the developed countries of the world has been focused upon the
as-sociation of premature birtil and neonatal
mortality. In the United States, 7.4 per cent
of the live births in 1950 weighed 2500 gIn. or loss. Yet this small group accounted for two-thirds of all infant deaths within tile first 28 days after birth.’ The first nursery unit especially designed for premature
in-fants was opened by Dr. Julius Hess in Chicago in 1922, and since that time the
United States has pioneered in the develop-mont of such units. The differential in the
survival rates of infants given care in spe-cial units as compared with infants given
care justifies the continuance
of this trend.
The Committee for the Study of Child Health Services of the American Academy of Pediatrics pointed to a lack of training in
newborn care (particularly premature
in-fant care) as one of the shortcomings of both podiatric undergraduate and
post-graduate education programs.4 These
short-comings are even more pronounced in
nursing ti’6 For the most part,
nurses rendering care to premature infants
have had to learn through experience and trial and error rather than through an
or-ganized educational program.
PLANNING
AND
ORGANIZATION
OF INSTITUTES
Because of the potential values of reduc-ing neonatal mortality by increasing the number of professional personnel trained in the care of premature infants, the United
States Children’s Bureau and the New York
State Department of Health requested the Department of Pediatrics of the New York
Hospital to offer a series of institutes on premature infant care. The New York Hos-pital-Cornoll Medical Center had opened in 1932 and included a large,
well-organized premature infant nursery. Thus
facilities and teaching personnel wore
readily available for lectures and
demon-strations. In addition, graduate nurses
par-ticipating in the institute could be offered a supervised work experience in the
pro-mature nursery.
In planning for the institutes, an increase
in the number of pediatricians and nurses skilled and interested in the care of pro-mature infants was recognized as a primary
goal. It was also hoped that its “graduates”
would become leaders capable of
organiz-ing premature programs and educational
activities in other sections of the country.
Three fundamental principles guided the
institute program:
TABLE I
I’EIICENTAGE l)IMTIIIBuTION OF TEA(IIING ‘I’IME ACCORDING TO SUBJECT MATTER INSTITUTES
IN TIlE CAnE OF PREMATURE INFANTS,
1949-54
96 YANKAUER - TRAINING IN THE CARE OF PREMATURES
program would be presented with attention
to latest knowledge, techniques and no-search. The principles involved in the
nurs-ing and medical management, the public health aspects, including use of community
resources; and the significance of social and
environmental factors would be covered as veii. The faculty would be drawn from a
broad range of professional disciplines.
2. In all instances, physicians and nurses
would be selected as members of a working team. Pediatricians and nurses working in hospitals and public health physicians and
nurses would receive the same instruction,
and the team approach would be
empha-sized. In this way, it was felt that mutual interest and help with sharing of problems
would be stimulated.
3. All applicants would be carefully
screened and only those with positions of responsibility in hospitals or health agencies
accepted.
The faculty for the institute was drawn
principally from the New York Hospital-Cornell Medical Center and the Cornell University-New York Hospital School of
Nursing. Selected representatives from com-munity health and social agencies such as
the New York State Department of Health,
tile New York City Department of Health,
the Visiting Nurse Service of New York
and the American Foundation for the Blind,
likewise participated. During the first 2 weeks, physicians and nurses together at-tended lectures, seminars, clinical
confer-ences, demonstrations, and field trips. Since a maximum of 6 physician-nurse teams
could be accommodated at any one
insti-tute, informal questioning and group
dis-cussion took place at all sessions. Exclusive of time for orientation and individual con-fenences, about 62 hours of teaching time was offered. The percentage distribution
of these hours by subject matter is shown in Table I. It can be seen that although a large proportion of time was devoted to the
mcdi-cal and nursing aspects of premature infant care, significant amounts of time wore allo-cated to such subjects as parent education,
j)ublic health and field trips.
.
Subject Matter PerCent.
of Time
NlIe(lical an(l nursing theory, priiiciples and practice (premature infants)
Planning and administration of a premature
unit
Field trips (including observation of other
pre-mature units and home visit with public
health nurse)
Public health aspects (including programs,
statistics, problems)
Parent education (including coverage of
psy-chological and social factors)
Clinical conferences (pediatric, joint obstet-nc-pediatric conferences and rounds, not
necessarily (leahug with preniat ure iufatit
care)
40
15
13
10
S
14
‘I’otal teaching time, all subjects 100
The attendance of physicians at the in-stitute was limited to these first 2 weeks.
The nurse member of each team remained an additional 2 weeks, during which time
she was offered 68 hours of teaching time. About 80 per cent of this time was spent in work experience in the premature infant nursery. The remainder was equally divided between observation at prenatal clinic,
pro-mature follow-up clinic, mothers’ classes, and participation in group seminars and
demonstrations.
The remainder of this report is
con-corned with an evaluation of the first 5
years experience of the institutes. During
this period of time 23 such institutes were held and physician-nurse teams wore drawn from 24 states and the Territory of Hawaii.
In addition to these teams a number of spe-cial observers attended many of the insti-tutes, and it is of interest that 11 countries
wore represented among those visitors. For most of this period of 5 years there was a
* Based on responses of 147 of the 04 individuals attending (luring the years 1949-1953.
and nurses who ilad responsibilities relat-ing to premature infants. This in itself is an
expression of the need and value of the institutes.
There are a number of other facts which point to the same conclusion. Time was
allowed at the end of each institute for the participants and a few members of the
faculty to moot together and critically evaluate the program. A stenographer was present at these meetings and comments wore compiled into a report. Tile report was reviewed by the physician and nurse
responsible for the direction and planning of the program, and the program or faculty
was altered if the same suggestions were made after successive institutes (this
altora-tion did not appreciably affect the distribu-tion of subject matter time). The reports of the first 23 institutes have been
systemati-cally reviewed by one of us (A.Y.) The overwhelming number of spontaneously favorable comments contrasts strikingly
with the relatively small number of negative comments.
The nurse-director of the Institutes made
several field trips to various states and ro-nowed contact with participating physician-nurse teams. This follow-up contact also provided evidence of the continuing and
permanent values to the physician and
nurse of their experiences at the institute.
As a direct result of the institute, teaching programs in premature infant care wore instituted in at least 5 different states and possibly in other areas as well.
A more extensive attempt was made to
evaluate the institute experience by pre-paring a detailed questionnaire which was
sent to all 204 individual team-members who had attended the institute during its first 4 years. Replies were received from
147 or 72 per cent of these individuals. This
is an excellent response to a mail
question-nairo and in itself indicates the continuing
interest of physicians and nurses wilo
a-ticipated.
An analysis of these 147 replies is
pro-sented in Tables II to VI. Table II shows the
distribution of physicians and nurses
ac-cording to their type of practice at the time
they attended the institute. Eighty per cent
of the physicians and nurses were engaged
ill 1)nivate practice or hospital practice. Tile
vast majority of these practices were
di-nectly concerned with the care of premature
infants. Approximately 20 per cent of those
who attended were employed by public
health agencies and engaged in promoting
and administering public health programs for premature infants.
Table III describes the activities of
per-sonnel at the time they answered the
quos-tionnaire and compares it with that
do-scnibed at the time they attended the institute (1 to 4 years previously). Ninety
per cent of the physicians and 80 per cent
of the nurses were still actively associated
with premature infant care at the time the
questionnaire was answered. Although the
status of pilysicians might have been
cx-pected to remain stable, the stability of the nurses who attended the institute is rather
impressive. An analysis of the replies to the
TABLE II
PERSONNEL ATTENDING INSTITUTE AcconDINo TO TYPE OF PRAcnICE AT TIME OF ATTENDANCE*
Type of Practice
Physicians Nurses Total
Number Per Cent Number -
---Per Cent Number
-Per (‘en!
Hospital and private practice
Public health practice
Public health and hospital practice
64 14
80 .0 17.5
. 5
.54 13
-So .6
19.4
-1 -18
7 2
80 .
18.4 1 .4
.1ttitule Total
Type of Practices at Time of J,utitute
Phy.ician IIo8J)ital and Private Public Ifedth Nur.w Public Health and Hospital hospital Public Jbeal!h
Leiigtli of Iiistitute ‘I)() long
About right ‘l’oo short Not state(l
Needs were met
Iii large l)ILrt Iteasonably vell Slightly
Not stIIte(l I’III1)ha5iS of Institute
Should tint be changed Should 1)0 challge(l
Not stated 147 6 I’26 9 6 147 97 43 4 ‘3 147 78 48 ‘21 64 6 54 3 64 38 23 64 31 29 4 14 12 2 14 10 4 14 9 5 2 ‘2 ‘2 ‘5 54 47 5 ‘5 .54 38 13 .54 30 11 13 13 12 I 13 9 ‘3 I 13 8 ‘2 3
* Based oh replies of 147 of 204 in(livi(lualS attending institute, 1949-53.
TABLE III
(‘IIANo IN ‘I’YI’E OF PnAc’rmc OF PERSONNEL ATTENDING INSTITUTE* (AS ItELATEI) TO ASSOCIATION W1TII PREMATURES)
‘
Per.onne1 (iii(l Type of Practice
at Time of Jn.ititu!et
Tot(ll
Type of Practice at Time of Quextionnaire
Active
.
Inactive I nknonn
. A8soc. wit/i Prematures vot Assoc. with Prematures Physicians, totIll
hospital and private
l’uhlic health
Public health and hospital
80 li4 14 74 62 10 3 -3 -1 I -I I -Nurses, total 110s1)itlll Public health 67 54 13 52 40 IQ 7 6 1 6 6 -‘2
-* Base(l on replies of 147 of ‘204 in(livi(luals atten(ling institute, 1949-1953.
#{149}1’All individuals ere selected initially because they held or vould hold positions of responsibility iii hospitals
OI health (lel)artlnents a.ss()ciate(l wit h prelilature infant care.
questionnaire in relation to year of at-tendanco at the institute was also made,
and no consistent time trends wore found. In all probability, those findings reflect the
values of the careful screening and selection
of applicants.
Table IV summarizes the attitudes of those who attended the institute as these
attitudes relate to its length, its fulfillment
of their needs, and the subject matter covered. The vast majority of those
attend-ing felt that the length of the institute was
TABLE IV
Suggestion
Total
Num-ber*
Number5 of
Physi-. ]\urses cians
15 4
6j-19
6
4
3
3
3
4
3
* Same individual may be counted for more than
one suggestion.
aI)out right. It is interesting to note that 6
pediatricians felt that the institute was too
long while 5 of the hospital nurses and 3
pediatricians felt tilat they would have
pro-ferred a longer experience. About
two-thirds of all personnel responding felt that
the institute largely met their needs and almost all of the remaining third indicated
that their needs were reasonably well met. In response to the question: “In
rotro-spect, would different emphasis have been more helpful?” Thirty-eight per cent of the
entire group (48 per cent of the
pediatni-cians, 36 per cent of public health physi-cians, 27 per cent of the hospital nurses and 2 of the 10 public health nurses)
mdi-cated that they would have preferred a different emphasis in subject matter. Analysis of the response to this question
according to the year of attendance at the institute did not show any meaningful variation. Of the total respondents
mdi-eating a desire for change in emphasis, 60 per cent were practicing pediatricians. Most of the suggested changes in emphasis
are given in Table V. It is interesting to
note that while 6 physicians stated that
they would have liked loss emphasis on
public health and social welfare, 4
physi-TABLE V
SUGGESTED CHANGES IN EMPhASIS OF INSTITUTE
BY PhYsIcIANS AN I) NUIISES ATTEN l)ING INSTITUTE
;reater emphasis 011 techniques
or on clinical approach IASS public health or social
wel-fare
More emphasis OII problems in rural ali(l semi-urban areas, or in small hospitals
IIore public health or social welfare
More work experience with
pe-matures
More “advanced approach”
cians would have preferred more emphasis in those fields.
Although practicing physicians constitute
a large proportion of those desiring some
change in emphasis, half of the practicing
physicians indicated in their responses that
the emphasis of the institutes should not
be changed. In view of their responses to
the previous questions it seems reasonable to conclude that even those who favored a
change ill emphasis felt that on the whole
tile institute met their needs and was \vortil-while experience although more of the
clini-cal aspects of care and techniques might
have been stressed. The fact the institute
was directed towards four basically
differ-ont groups necessitated limiting the degree
of emphasis the institute could provide for
each. The inclusion in later institutes of
periods for individual conferences with
members of the faculty provided an
op-portunity for further pursuit of specific
interests.
The questionnaire contained a check list
designed to discover the nature of
subse-quont improvements in the hospitals or pub-lie health agencies whose personnel
at-tended the institute. It requested tile
opin-ion of the physician and nurse as to whether
such improvements wore related to their
own attendance at the institute. Table VI is
a tabulation of the responses to this check
list by physician-nurse teams in private and
hospital practice. There were no material
differences in response between physicians
and nurses. This tabulation points up some
significant amid positive ob senvations .
Gen-orally, and to an appreciable degree, tile
institutes seem to have had a favorable
in-fluence upon all items which respondents
were asked to check. It is evident that
wherever improvement was manifest it was
apparently influenced and presumably
‘) stimulated by attendance at the institute.
The greatest gains seem to have been in
- 1)hysician-nurSe relationships and in both
medical and nursing policies in relation to
‘2 I)remattlre infants. This would seem to
justify the original intent and design of
the institutes which called for recruitment
1(X) YANKAUER - TRAINING IN THE CARE OF PREMATURES
TABLE VI
RELATION OF ATrENI)N(E AT INSTITUTE TO SUBSEQUENT ChANGES IN POLIcIES, PRACTICE ANI) FACILITIES IN hOSPITALS
‘ . . . . .
7.i/J)e of I. iliii,, I rae/ne or I’(I(Il?!IJ.
Response to Questionnaire by 66 Physicians and 55 Nurses in Private and b!ospiial Practiee*
Status Improved Status Status or Not Stated Related to Attendance at institute Not Related to Attendance at Institute
I . Physician-nurse working relationsllips ill lu)sl)ital
2. ibIe(lical policies and practices in hospital
II. related to premature service
1). related to otherservices (obstetric, l)e(liatric, etc.)
(. cooperation between services
(1. hospital administrative policies 3. Nursing policies and practices in hospital
a. related to premature service
h. related to other services (obstetric, pe(liLtri(, etc.)
C. cooperation between services
(1. hospital a(lministrative policies
4. Facilities and equipment in hospital
5. Utilization of public health services by hospital
6. Utilization of social services by hospital 7. Standards of premature care in community
8. Public health program for premature infants
66 79 51 48 41 77 46 45 40 6() 36 ‘20 45 32 7 9 1.5 15 10 8 10 12 6 24 10 17 8 6 20 1 1 25 28 35 I 1 33 25 37 15 48 48 28 41 28 22 30 30 35 25 33 39 38 22 ‘27 36 40 42
* The numbers iii the body of the tal)le represent individual responses of )hysician and nurses iili(I (1(5mint
repre-sent the mmumber of hospitals in which changes may or may not have occurred.
selection of applicants who had responsi-1)ihity for the care of premature infants in the hos1)ital situation.
A similar tabulation was made for public health personnel who attended the
insti-tutes. They were asked questions relating to their own programs and responded in the same way. All public health teams re-corded positive gains in premature infant
programs in their own states and indicated
that those gains wore related to their own attendance at the institute.
Because of the favorable responses of
physicians and nurses, both on the final day
of their institute and from 1 to 4 years later, the institutes will continue to be hold several times each year at the New York Hospital-Cornell Medical Center.
SUMMARY
AND
CONCLUSIONS
The organization and content, of insti-tutes for physicians and nurses in the care
of premature infants at the New York Hos-pital-Cornoll Medical Center, 1949-1954,
are described. Participants and observers were drawn from 24 states and the Tern-tony of Hawaii, and 11 foreign countries.
Several indications of the need and value
of this typo of graduate training have been discussed, based on 5 years of expenionce
with the program.
Responses to a detailed questionnaire
seeking the opinion of those who attended the institutes from 1949 through 1953 has
boon analyzed. Responses were received from 72 per cent of the group. They mdi-cated that the institute had met existing needs in large part and that the experience
was worthwhile. Concrete evidence of
im-provoments in hospital and in public health practice was reported and was considered related to attendance at the institute.
In view of the favorable nature of this
do-mand for this type of training experience,
tile institutes will continue to be offered.
REFERENCES
1. Shapiro, S., and Ungor,
J.
: Weight at birthamid its effect on survival of the newborn
in the United States, early 1950.
Wash-ington, D.C., National Office of Vital
Sta-tistics, Special Reports, 39:No. 1, July 23,
1954.
2. Clifford, S. H. : Role of the pediatrician in
the prevention of needless neomiatal
deaths. J.A.M.A., 153 :473, 1953.
3. Pakter,
J.,
and Jacobzmnor, H. : A five yearreview of the premature infant program
in New York City. New York State
J.
Med., 54:3207, 1954.
4. Child Health Services and Podiatric
Educa-tion, Report of the Committee for the
Study of Child Health Service of the
American Academy of Pediatrics. New
York, Commonwealth Fund, 1949.
5. National League for Nursing Education:
More about clinical facilities. Am.
J.
Nursing, 48:50, 1948.
6. Brown, E. L. : Nursing for the Future-A
Report Prepared for the National
Nurs-ing Council. New York, Russell Sage
