Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice

Title. Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice. Aim. This paper is a discussion of evidence‐based core measures for developmental care in neonatal intensive care units. Background. Inconsistent definition, application and evaluation of developmental care have resulted in criticism of its scientific merit. The key concept guiding data organization in this paper is the United States of America’s Joint Commission’s concept of ‘core measures’ for evaluating and accrediting healthcare organizations. This concept is applied to five disease‐ and procedure‐independent measures based on the Universe of Developmental Care model. Data sources. Electronically accessible, peer reviewed studies on developmental care published in English were culled for data supporting the selected objective core measures between 1978 and 2008. The quality of evidence was based on a structured predetermined format that included three independent reviewers. Systematic reviews and randomized control trials were considered the strongest level of evidence. When unavailable, cohort, case control, consensus statements and qualitative methods were considered the strongest level of evidence for a particular clinical issue. Discussion. Five core measure sets for evidence‐based developmental care were evaluated: (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family‐centred care, and (5) the healing environment. These five categories reflect recurring themes that emerged from the literature review regarding developmentally supportive care and quality caring practices in neonatal populations. This practice model provides clear metrics for nursing actions having an impact on the hospital experience of infant‐family dyads. Conclusion. Standardized disease‐independent core measures for developmental care establish minimum evidence‐based practice expectations and offer an objective basis for cross‐institutional comparison of developmental care programmes.     

Individualized family-centered developmental care: Reflections on implementation

Despite the growing evidence, implementation of individualized family-centered developmentally supportive care (IFDC) remains a challenge in most institutions. Cognitive acceptance has been easier to gain than actual implementation into everyday practice in the neonatal intensive care unit. Understanding the cultural dynamics of the neonatal intensive care unit necessary for shifting care delivery paradigms along with effective leadership and a reflective process that facilitates sustained change in knowledge, skills, and attitudes may foster the long-term changes fundamental to an individualized family-centered developmentally supportive care philosophy. Copyright 2002, Elsevier Science (USA). All rights reserved.     

Reducing nosocomial infection in neonatal intensive care: An intervention study

Nosocomial infection is a common cause of morbidity and mortality for hospitalized neonates. This report describes measures taken to reduce the prevalence of nosocomial infection within a 34‐bed neonatal intensive care unit in Malaysia. Interventions included a one‐to‐one education programme for nursing staff (n = 30); the education of cleaners and health‐care assistants allocated to work in the unit; and the introduction of routine (weekly) screening procedure for all infants with feedback given to staff. The education programme for nurses focused on the application of standard precautions to three common clinical procedures: hand washing, tracheobronchial suctioning and nasogastric tube feeding. These were evaluated using competency checklists. The prevalence of nosocomial blood and respiratory tract infections declined over the 7‐month study period. This study highlights the importance of education in contributing to the control of nosocomial infection in the neonatal intensive care unit.     

Mutual trust in infant care: the nurses and mothers experiences

The relationship between healthcare providers and parents of infants in neonatal intensive care unit is based on trust and constitutes a core measure of family-centred care and health. The aim of the present qualitative study was to explore mothers and nurses experiences of trust in one another around the caregiving of the hospitalised infant in intensive neonatal care unit. Focused ethnographic research study conducted through observations and in-depth interviews with 20 mothers and 16 nurses in NICU of Tabriz (Iran) in 2017. Two main themes of ‘gradual and fragile trust of mother-to-nurse’ (subthemes: Primary trust-mistrust, mother's trust to responsible nurse, mother trust Increase with skilful nurse performance, and vulnerability to trust) and ‘gradual and fragile trust of nurse-to-mother’ (subthemes: Nurse's initial assessment of trust to mother's readiness to participate, Development of trust to mother, and vulnerability of nurse's trust to mother) were obtained. The present study revealed that mutual trust between the nurse and the mother in the care of the infant was a gradual and progressive process that was achieved over time. Complexities around the care of a hospitalised infant influenced how fragile or vulnerable the trust became between nurse and mother. Findings from this research can be used in supporting increased maternal participation in infant care and improvement of family-centred care in the neonatal intensive care unit.     

Neonatal nurses' perspectives of family-centred care: a qualitative study

Aims and objectives. The aim of this study is to explore neonatal nurses' perspectives of their role in facilitating family centred care in the neonatal intensive care unit. Background. The philosophy of family centred care focuses on the health and wellbeing of the newborn and their family, through the development of a respectful partnership between the health care professional and the infant's parents. Many studies report family centred care in the context of paediatric care; however, few studies explore neonatal nurses' perspective of family centred care in the context of neonatal care. Design. Qualitative interpretative approach. Methods. Four focus groups and five individual face-to-face interviews were conducted with neonatal intensive care nurses (total n?=?33) currently practicing in a tertiary Neonatal Intensive Care Unit in Australia. Each focus group and face to face interview was audio-taped and transcribed. Data was analysed using thematic analysis. Results. Four dominant themes emerged from the data: (1) Getting to know parents and their wishes (2) Involving family in the day to day care (3) Finding a 'happy' medium (4) Transitioning support across the continuum. Conclusion. These findings revealed a general understanding of family centred care principles. Nurses reported the potential benefits and challenges of adopting a family centred care approach to deliver optimal care for neonates and their families. The study highlighted that nurses need ongoing organisation support, guidance and further education to assist them in delivering family centred care effectively. Relevance to clinical practice. Family centred care is a central tenet underpinning neonatal care. Understanding neonatal nurses' perspectives will be useful when developing strategies to strengthen family centred care in the neonatal intensive care unit, and potentially improve neonatal care and family outcomes.     

The effects of education levels of developmental care in Australia: Perceptions and challenges

BackgroundDevelopmental care consists of a range of clinical, infant-focused, and family-focused interventions designed to modify the neonatal intensive care environment and caregiving practices to reduce stressors on the developing brain. Since the inception of developmental care in the early 1980s, it has been recommended and adopted globally as a component of routine practice for neonatal care. Despite its application for almost 40 y, little is known of the attitude of neonatal nurses in Australia towards the intervention.Aims and objectivesThe objective of this study was to establish Australian neonatal nurse perceptions of developmental care and explore associations between developmental care education levels of the nurses and personal beliefs in the application of developmental care.DesignThis involves a cross-sectional survey design.MethodsAn online questionnaire was completed by 171 neonatal nurses. Participants were members of the Australian College of Neonatal Nursing (n = 783). Covariate associations between key components of developmental care and respondents' geographical location, place of employment, professional qualifications, and developmental care education level were analysed. The reporting of this study is in accordance with the Enhancing the Quality and Transparency of Health Research Checklist for Reporting Results of Internet E-Surveys.ResultsDifferences were observed between groups for geographical location, place of employment, and professional qualification level. Rural nurses were less likely to support the provision of skin-to-skin care (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.2–1.8) than nurses in a metropolitsan unit. Nurses working in a neonatal intensive care unit and nurses with postgraduate qualifications were more likely to support parental involvement in care ([OR: 2.3, 95% CI: 0.9–6.2] and [OR: 2.1, 95% CI: 0.6–7.4], respectively). Rural respondents were more likely to have attended off-site education (OR: 3.6, 95% CI: 1.3–9.9) than metropolitan respondents.ConclusionThe application of developmental care in Australia may be influenced by inadequate resources and inequitable access to educational resources, and similar challenges have been reported in other countries. Overcoming the challenges requires a focused education strategy and support within and beyond the neonatal intensive care unit.     

Clinical competence of neonatal intensive care nursing students: How do we evaluate the application of knowledge in students of postgraduate certificate in neonatal intensive care nursing?

This paper represents preliminary research into understanding the context of competence in post graduate student nurses undertaking any certificate in neonatal intensive care in Australia. The paper explores literature that discusses the evaluation of clinical competence in nursing.Two main themes emerged from this review. Firstly there is confusion regarding the terminology around competence, competent, competency and competencies which has contributed to the use of unreliable and invalid evaluation methods. Secondly, the three most common methods used to evaluate competence (direct observation, self-assessment and practice portfolios), lack reliability and validity; the processes are subjective and assessors may be making judgements on imperfect evidence.The review demonstrates there is no clear consensus on the concept of competence for nursing students undertaking postgraduate education neonatal intensive care in Australia. It is necessary to contextualise competence for neonatal intensive care nursing students, to generate evidence for valid and reliable evaluation of clinical performance.     

Developmentally supportive caregiving and technology in the NICU: isolation or merger of intervention strategies?

Providing nursing care in the highly technical environment of the neonatal intensive care unit is changing as concepts of developmentally supportive caregiving merge with conventional nursing interventions and are integrated into routine practice. Medical knowledge with the use of technology is insufficient in guiding the whole of neonatal nursing care. Integration of other patterns and concepts is essential to expert nursing practice with high risk infants and their families.     

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.     

The meaning of caring touch for healthcare professionals in an intensive care unit: A qualitative interview study

BackgroundThe way health care professionals touch patients and relatives in the intensive care unit plays a significant role. A negative feeling can be caused by being touched in the wrong way, this is why a holistic approach with respect for the patient is important for the ability to make the patient and their relatives feel secure, avoiding unnecessary suffering.AimThe aim of the study was to describe the meaning of caring touch that is given in the ICU from the health care professionals perspective.MethodQualitative interview study with health care professionals in the intensive care unit, analysed using inductive content analysis, resulting in two themes and four main categories.FindingsTwo themes emerged: Imperative touch and emotional touch and four main categories: touch as a natural tool, create a prerequisite for touch, empathetic touch and conversant touch.ConclusionCaring touch can be used as a natural tool in the daily work in order to bring comfort and calm to the patient in the intensive care unit.     

Drivers of medical errors in the neonatal intensive care unit (NICU): A qualitative analysis

Infants in the neonatal intensive care unit (NICU) are particularly susceptible to medical errors. This qualitative study sought to determine the drivers of medical errors in the NICU and suggestions for preventing medical errors among NICU registered nurses (RNs) and respiratory therapists (RTs). Qualitative analyses consisted of categorizing data based on themes. Themes that emerged from the qualitative analyses were also informed by the socio-ecological model, including themes related to organizational, interpersonal, and individual factors. The themes included organizational categories of fear, workload, staff, and pay; the interpersonal category of communication; and individual categories of natural causes, fear, and concentration. These themes can be used to inform future research studies to develop interventions in a multi-level framework to reduce medical errors in the NICU.     

Qualitative analysis of patients’ intensive care experience during mechanical ventilation

Aim. To understand patients’ intensive care experience while receiving mechanical ventilation in intensive care units. Background. The mechanically ventilated patient’s experience in the intensive care unit is unique. Notably lacking are international studies on patients’ experience, particularly those living in Asia. A better understanding of patients’ experience is needed for nurses to develop approaches to take care of these patients. Design. A phenomenological approach formed by the ideas of Heidegger was used. Methods. Eleven participants surviving from mechanical ventilation were interviewed in‐depth. Patients were asked to describe their experience by responding to the question ‘what is it like to experience mechanical ventilation treatment at an ICU?’. Giorgi’s phenomenological analysis procedure was used to analyse the data. Results. Five mutually exclusive themes emerged, which were: ‘being in an unconventional environment’, ‘physical suffering’, ‘psychological suffering’, ‘self‐encouragement’ and ‘self‐reflection’. ‘Self‐encouragement’ and ‘self‐reflection’ enhanced patients’ self‐confidence, which was beneficial to recovering. Conclusion. Patient’s experiences while receiving mechanical ventilation in the intensive unit were poignant and frightening. Relevance to clinical practice. Critical care nurses should place the highest priority on recognising and meeting the needs of ventilated patients in intensive care units. An intensive care unit should be a place for the patient to live as a human being; not just a place to survive.     

Infant mental health in intensive care: Laying a foundation for social,emotional and mental health outcomes through regulation,relationships and reflection

Infants and their families who begin their lives in intensive care often experience short and long term behavioral, socioemotional and mental health challenges that often follow them into adulthood. Utilization of evidence-based infant mental health principles, approaches and strategies in the neonatal intensive care unit can contribute to the promotion of optimal outcomes for babies and their parents. In order to integrate mental health best practices into intensive care settings, an emphasis on infant and family regulation, optimal nurturing relationships and reflective practice is offered. Using a parallel process, similar strategies in support of intensive care professionals in their provision of appropriate mental health supports to babies and families is essential.