Mothers in the NICU: outsider to partner

The emerging care delivery model for Neonatal Intensive Care Units (NICU) is family-focused, developmentally supportive care. The purpose of this study was to explore and describe mothers' experience of becoming a mother while their infants were receiving care in the NICU. A qualitative research design was used. Interviews with 15 mothers whose infants were in a Level III NICU were analyzed using Spradley's domain analysis approach. Mothers developed from outsider to engaged parent along four continua: (1) focus: from NICU to baby; (2) ownership: from their baby to my baby; (3) caregiving: from passive to active; and (4) voice: from silence to advocacy. Mothers entered the continua at different points and moved at different rates toward "engaged parenting." The final stage, partnering, required active participation of nurses. Mothers' development evolved in predictable patterns. The results of this study can be considered in implementation and evaluation plans for NICUs moving to family-focused developmental care.     

Who Is at Risk? High-Risk Infant Follow-up

Plans for discharge home from the neonatal intensive care unit (NICU) should begin with identification of which infants are at-risk for developing disability or early demise. As much as possible, this article serves as an evidenced-based review for identifying vulnerable infants in the NICU who are at higher risk for morbidity or early mortality. This article draws on the American Association of Pediatrics recommendations that highlight the responsibilities of the NICU team to recognize risk, plan discharge, and assist with transitioning care post discharge. Nurses, as professional team members, are ideal for identifying at-risk status, devising individualized discharge plans, and assuring referrals to high-risk infant follow-up (HRIF). HRIF programs bridge care pre and post NICU discharge to assure that infants with complex issues and special needs reach optimal health and developmental levels.     

Use of a training program to enhance NICU nurses' cognitive abilities for assessing preterm infant behaviors and offering supportive interventions

This study tested the use of a developmentally supportive care (DSC) training program in the form of videotaped and personalized instruction to increase nurses' cognitive abilities for assessing preterm infant behavioral signals and offering supportive care. The study used a two-group pre-test post-test quasi-experimental repeated measures design. The participants were 25 NICU nurses, 13 in the intervention group, and 12 in the control group. An instrument developed for the purpose of the study was a video test that measured the effectiveness of the DSC training. The video test questionnaires were administered to the participants twice with an interval of four weeks. ANCOVA controlling the baseline scores was used for data analysis. In general, the results support the hypothesis that nurses' cognitive abilities were enhanced after the DSC training. The increase in nurses' cognitive abilities is the prerequisite for behavioral change, based on the assumptions of Bandura's Social Cognitive Learning Theory (Bandura, 1986). As nurses' cognitive abilities increased, it would be possible that nurse behaviors in taking care of these preterm infants might change. Therefore, the author recommends that in order to improve NICU care quality and the outcomes of preterm infants, the concepts of developmentally supportive care be incorporated into NICU caregiving practice by educating nurses.     

Parenting the post-NICU premature infant

The birth of a premature infant is stressful for family members who must adjust to unfamiliar surroundings, learn new vocabularies, cope with the infant's uncertain survival and outcome, maintain vigilance at the neonatal intensive care unit (NICU), and eventually assume care for a recovering infant at home. Nursing research has focused on many issues related to parenting prematurely born infants, including parenting during the initial hospitalization, concerns of mothers about infant discharge, the relationship between premature infants and their mothers during the first 2 years after hospital discharge, the quality of the home environment on premature infant outcomes, parenting after the first 2 years, and interventions to improve parenting. This article focuses on research about parenting the post-NICU discharge infant to assist nurses in giving comprehensive, evidence-based care.     

Primary care of the premature infant discharged from the neonatal intensive care unit

Premature infants require varying degrees of newborn intensive care and have a wide range of physical and developmental outcomes. Subsequent ambulatory care for these infants is often complex. Although tertiary hospitals often provide multidisciplinary follow-up clinics, the pediatric nurse practitioner (PNP) responsible for primary care has a unique opportunity to influence the lives of these special babies and their families. While the basic principles of well child care and health maintenance apply to this special population, there are several inherent challenges. The transition from neonatal intensive care unit (NICU) to home can be stressful for families. Infants born prematurely often have unpredictable behavior and present with cues that are vague and unclear to caregivers. Growth must be monitored adjusting for prematurity, and nutrition must be tailored to the physical and developmental level of the infant. Assessments of development, vision, and hearing must also be adjusted for prematurity. Fortunately, the majority of premature infants discharged from the NICU thrive and develop normally. However, some will experience medical problems and developmental delay. Knowledge of complications common to premature infants will be helpful to the PNP providing primary care. These include difficulties of growth and feeding, gastroesophageal reflux, apnea and bradycardia, chronic lung disease, fine and gross motor abnormalities, and other learning problems. Providing care to the NICU graduate is one of the challenges faced by PNPs in primary care, but one that is both rewarding and enjoyable.     

Nurses' beliefs and values about doing cue-based care in an NICU in Taiwan

Although advances in medical technology have increased the survival rate of preterm infants, science is no cure-all for these high-risk patients. A growing number of studies report that caregiving interventions cause physiological and behavioral distress in such infants. The results have prompted changes in caregiving practices, attempting to reduce stress and strengthen protection for the infants, in order to promote their stability and development in the neonatal intensive care unit (NICU) . This study uses qualitative research methods to grasp the richness and diversity of nurses' beliefs and experience in the taking care of preterm infants. Ten groups of questions explore how NICU nurses take care of premature infants, nurses' perspectives on cue-based care, and the extent to which NICU nurses practice cue-based care. The results generated three themes: (1) timely and skillful management of the preterm infants; (2) compassionate and holistic care for the infants and their highly stressed families; and (3) the relationship between good nursing care and meeting the needs of preterm infants, families, physicians, units, and the environment. It is apparent that the approach to care delivery in NICU practice is still clinical-based, and that there are some obstacles to the delivery of cue-based care. The reasons for this include lack of knowledge, incomplete collaboration with team members, and insufficient support from the administrative systems. To improve the quality of nursing care and preterm infant outcomes, it will be necessary to educate NICU nurses on cue-based care, to enhance collaboration among all team members, to reduce their non-nursing workload, and to re-design NICUs for optimal cue-based care.     

Neonatal nurses’ perceptions of supportive factors and barriers to the implementation of skin-to-skin care in extremely low birth weight (ELBW) infants - A qualitative study

There is currently a lack of evidence around perceptions of implementation of skin-to-skin care (SSC) in infants weighing <1000 gms amongst neonatal nurses. Majority of published work mainly focuses on infants weighing <2500 gms.AimThis study aimed to investigate neonatal nurses’ perceptions of supportive factors and barriers to the implementation of SSC in extremely low birth weight (ELBW) infants in a tertiary level neonatal intensive care unit (NICU) in London.MethodsA broad qualitative approach that included semi-structured interviews with seven neonatal nurses was used.ResultsAll seven nurses interviewed supported SSC in ELBW infants. There was a general consensus on barriers of its implementation. Humidity was perceived as a significant barrier for SSC in ELBW infants. Other barriers included concerns for infant safety, insufficient training, increased workload, lack of clear guidelines and management support.ConclusionsThis study identified supportive factors and barriers of SSC in ELBW infants in a tertiary neonatal unit. It ascertained the facilitation of parental readiness, development of clear guidelines, provisions of continuing education as well as organisational support as supportive factors in the implementation of SSC in ELBW infants. Furthermore, humidity was perceived as an additional barrier for SSC in these infants.     

Improving neonatal caregiving through a developmentally supportive care training program

This study was performed to explore the effects of a training program in developmentally supportive care (DSC) on nurse caregiving and preterm infant behavior during bathing in a neonatal unit. The study applied a single-group pretest and posttest design to analyze behaviors. Twenty preterm infants were bathed 120 times by 13 nurses. Indirect observation was adopted to collect all behavioral data. Results showed that infants felt less stress and nurses were more supportive during posttraining baths. Caregivers should receive training in DSC, and its applications could be expanded to other nursing caregiving activities.     

Components of developmental care and the evidence for their use in the NICU

Developmental care, a philosophy of care that requires rethinking the relationships between infants, families, and healthcare providers, is in place in the majority of neonatal intensive care units in the United States. Developmental care includes a variety of activities designed to manage the environment and individualize the care of the premature infant based on behavioral observations. The goal is to promote a stable, well-organized infant who can conserve energy for growth and development. Research about the effects of developmental care has shown a trend toward improved short-term physiologic, development, and resource utilization outcomes for infants up to 24 months of age, but benefits beyond this age are unclear. Most of the research has focused on developmental care as a whole, but there is also strong scientific evidence for specific components of developmental care. The NICU care provider should use developmental care interventions that are clearly supported by evidence, and use others based on judgment and the infant's responses.     

对NICU早产儿实施发育支持护理的效果评价

目的 探讨发育支持护理对早产儿特别是极低出生体质量儿及病重儿的影响.方法 将NICU住院的120例早产儿按收住顺序分为实验组和对照组各60例,对照组予以传统常规护理,实验组在此基础上制订照顾计划、优化治疗环境、减轻疼痛、鸟巢式护理和袋鼠式护理、实施非营养性吸吮,并比较两组早产儿在体质量、进奶量、平均住院时间方面的差异....     

The impact of preterm birth on the family and society. Part 2: Transition to home

The birth of a preterm infant and the transition from the acute care of the newborn intensive care unit (NICU) to home can impose many emotional and financial stresses on the family. This article, the second in a series on the impact of preterm infants on the family, discusses the issues that must be considered by the nurse in planning for the discharge of these infants, who may have complex medical needs at home. The coordination of these home services and advocacy for preterm infants and their families is an important role for nurses.     

Nurses' expectations of using music for premature infants in neonatal intensive care unit

This study aimed to describe nurses' expectations of using music for premature infants in the neonatal intensive care unit (NICU) and to find out about the related background factors. The subjects consisted of 210 Finnish nurses who were recruited from the country's five university hospitals providing premature infant care in NICU. The data were collected by validated questionnaire, and the response rate was 82%. Most nurses preferred recorded music to live music in the NICU. They expected that music would have positive effects on premature infants, parents, and staff. Few demographic and many background factors of the respondents' music-related experiences correlated significantly with the expectations concerning their preference. In conclusion, the nurses' expectations were positive regarding the use of music in the NICU, which supports evidence regarding the efficacy of music therapy for premature infants.     

A Philosophy of Care for a Neonatal Intensive Care Unit

Crisis reactions, a stressful environment, infant care practices, and nurse behavior may cause difficulties in entering the natural parental role for parents of infants who are admitted to a neonatal intensive care unit (NICU). In connection with discussions in the Uppsala NICU on what constitutes good care, a philosophy of care, based on Callista Roy's adaptation model, was formulated for the purpose of providing developmentally supportive, family-centered care, and for defining good care and the professional nurse role. The philosophy describes the infant's needs and environment. Caring activities focus on support of the infant's and his parent's roles and self-concept in their progress towards independence from professional assistance. The philosophy is an essential component in the introductory program which integrates newly recruited personnel from different disciplines into the unit. It is presented as a suggestion of how a model-based philosophy of care can be formulated by operationalization of the theoretical concepts of a nursing model.     

Caring for critically ill infants: strategies to promote physiological stability and improve developmental outcomes

Promoting organization and delivering developmentally supportive care leads to improved outcomes for infants and their families. Critical care nurses must function as catalysts to expand the thinking of caregivers from a dimension consisting primarily of physiology to one that embraces the emotional and cognitive growth and well-being of the patient, the patient's family, and staff members. For critically ill infants, developmentally supportive care that is relationship based and that promotes the balance of organized neurobehavioral and physiological function is an avenue to achieve that end. Beneficial or adverse outcomes of nursing care used during this critical period can persist long after an infant is discharged from the intensive care setting.     

Infant suffering and nurse advocacy in neonatal intensive care

This discussion of nurse advocacy and infant suffering in neonatal intensive care was based on content analysis of interviews of 20 neonatal nurses in three NICUs over a period of 6 years. Throughout that span of time, nurses experienced significant emotional distress when they believed that therapies resulted in infant suffering without proportional benefit. In all of the nurses interviewed, infant suffering triggered a variety of acts of advocacy, ranging from changes in nursing care to decrease infant distress to formal requests that the medical plan of care be reviewed. Characteristics of infants, nurses, and the NICU organization were described as possibly influential to nurse advocacy. Finally, some thoughts about an ethic of the good were presented. Gajardo-Velasquez noted, "Nothing really great and important can be obtained without a certain amount of sacrifice; therefore, suffering is present in every human action that tends to transform and create new conditions for life." Our technology in the NICU has saved many lives and prevented much suffering and avoidable disability. It has also, for some, been a source of profound suffering. It is hoped that nurses in neonatal intensive care will use the ideas presented here as a starting point for their individual and collective examination of what constitutes an ethic of the good. Perhaps such an ethic can minimize the cost in suffering of the powerful technology of neonatal intensive care.     

Ethical issues in the neonatal intensive care unit

The case of Baby Y presented a difficult and complex ethical dilemma for the family and the staff involved. The issues of religious beliefs and law, up-holding these beliefs in the center of a religious community, financial concerns, and health care workers disagreeing about carrying out treatments made this case one that few will forget. When asked after Baby Y died how they felt, many members of the staff answered that it should not have gone on as long as it did and that they learned a lot from the family and the experience. Palliative care has been well associated with the adult cancer population in the form of hospice care. It is the hope that this well-integrated aspect of care crosses over to the NICU population. Many of the patients in the types of cases mentioned previously stay in the NICU for extended periods of time until a decision is made clear or the infant expires on his own time. The hustle and bustle of a busy, open, and not-so-private NICU is not the place for this to take place. The NICU should have a designated place where these infants can be cared for better in a more family-centered and staff-friendly environment. Pain management is another important aspect of palliative care. Comfort of the infant is of utmost importance, as it helps the family believe the suffering is under control. During the last few days or weeks of life, the family should have time that is peaceful and restful, and, eventually, the infant should have a pain-free death.Lastly, a part of the palliative care philosophy and approach includes providing treatments that may ap-pear to prolong the inevitable but in fact help the process along to resolution. In the case of Baby Y, surgery to repair some of the defects may have allowed her to go home with her family and spend her short life with them. This was the wish of the mother,especially, and it never happened. It may well be the"what if" she continues to ask for the rest of her life.