Designing the neonatal intensive care unit for optimal family involvement

The effect of maternal multisensory stimulations on bath stress in premature infants: A randomized controlled clinical trial

Bathing in Neonatal Intensive Care Unit (NICU) is a stressful experience to preterm infants. Reducing this stress is an important challenge in bathing preterm infants. The aim of present study was to evaluate the effects of maternal supportive interventions on the stress caused by swaddled bathing in preterm infants. In this randomized clinical trial, 48 preterm infants randomly allocated into control and intervention groups. In intervention group the mothers were asked to initiate multisensory supportive interventions 5 min before and through swaddled bathing. In controls the mothers were only present during bathing. To determine the level of stress, infant responses were recorded by camera 5 min before bathing and 5 min after bathing. Then infants' stress measured by using Newborn Stress Scale (NSS). Finding was shown that the level of stress in control group was especially increased after bathing that was statistically significant (p < 0.001). Although there was an increase in stress among interventions but it was not statistically significant (p > 0.05). Considering the positive effects of multisensory interventions in decreasing the stress of preterm infants, it can be recommended as cost-free and non-pharmacological care during infants bathing.

Comparing light and noise levels before and after a NICU change of design

OBJECTIVE

To compare light and sound levels before and after a change of design and evaluate these levels considering recommended NICU standards.

STUDY DESIGN

A pre-test/post-test design. Light and sound levels were compared between the former open ward (OW) NICU of 34 beds and the current 40-bed unit composed of both pods and single-family rooms (SFR).

RESULT

Light levels were significantly higher in the pod/SFR unit for all levels of care, days of the week and time of the day. These findings could be attributed to the number and configuration of windows in the new pod/SFR unit allowing for more daylight entry compared to the OW. Sound levels were significantly lower in the current NICU (pod/SFR) compared to the former OW.

CONCLUSION

Following the change of design, the pod/SFR unit are less noisy than the OW, although light levels are higher indicating the necessity to measure light levels.

Emotional responses of parents participating for the first time in caregiving for their baby in a neonatal unit

BACKGROUND

Parents of term and preterm infants hospitalised at birth experience a stressful situation. They are considered as primary caregivers in neonatal units and are encouraged to participate in their child's care.

OBJECTIVES

The aim of our study was to analyse the feelings of parents participating for the first time in caregiving for their baby admitted at birth in a neonatal unit in France and to compare the feelings reported by parents of term and preterm infants.

METHODS

An online survey was created in 2014 for parents who had a baby hospitalised at birth. We analysed parents' responses to this open-ended question: "How did you feel when you participated in caregiving for your baby for the first time?" using a qualitative discourse analysis by two analysts. Themes were identified and coded.

RESULTS

Between February 2014 and March 2018, 1603 parents of preterm infants and 239 parents of term infants responded to this open-ended question. Twenty-five per cent of parents expressed positive feelings exclusively (confidence, ease, joy, pride, feeling supported by healthcare professionals, by their family and feeling of being a parent), 41% expressed negative feelings exclusively (stress, fear, feeling of being judged, frustration, anger, uselessness and clumsiness) and 34% expressed mixed feelings (both positive and negative). Parents of term infants expressed less frequent feelings of stress and fear than parents of preterm infants: with a relative risk (RR) of 0.69, 95% confidence interval (CI) 0.56, 0.87. Parents of term babies more frequently expressed feelings of frustration: RR 2.40 (95% CI 1.33, 4.32).

CONCLUSIONS

Infant- and Family-Centred Developmental Care supportive programmes are recommended within neonatal units in order to improve the experience of parents participating in caregiving for their baby hospitalised at birth.

Towards an architecture of flexibility

OBJECTIVE

Our objective was to explore the case for adoption of flexibility as a core value in the design process for Neonatal Intensive Care Units (NICUs).

METHODS

Guidelines for NICU design and care of NICU patients and families were examined to identify opportunities for building flexibility into NICU design to optimize function and experience.

RESULTS

Benefits of building flexibility into NICU design included the ability for units to adapt quickly and economically to unpredictable events and demographic changes. Further, by centering family presence as a design necessity, NICUs may better protect families from experiencing additional harm due to separation and interruption of restorative activities. We were able to highlight several examples of current NICUs, which have successfully adopted flexible design and operational models to provide optimal levels of clinical and family-centered care.

CONCLUSION

By intentionally incorporating flexibility into the design of an NICU, infants, families, and healthcare providers can be provided with an environment that can adapt to shifting needs to optimally support unit function and clinical outcomes.

Parents' Experiences of Support in NICU Single-Family Rooms

PURPOSE

This study aimed to explore support for mothers and fathers in single-family rooms (SFRs) of a NICU.

DESIGN

A qualitative descriptive design was employed.

SAMPLE

A convenience sample of 15 parents (nine mothers, six fathers) were recruited from a Level III NICU.

METHOD

During their infants' hospitalization, each parent recorded their thoughts and feelings regarding support whenever appropriate over a period of 48 hours using Handy Application to Promote Preterm infant happY-life (HAPPY), an android recording application.

RESULTS

Parents felt supported when staff facilitated their learning in a collaborative manner, fostered their optimism, and provided situational assistance. Continuity and consistency of care and presence were important characteristics of supportive nursing care. Though SFRs offered privacy for parents to learn and to be with their infants, the design limited parental access to nursing and medical staff, which sometimes prevented parents from receiving adequate support and partaking in decision making concerning their infants' care.

Increased parental satisfaction by unrestricted visiting hours and developmentally supportive care in NICUs - results of a German multicenter study

Purpose: This study aims to provide insights into the impact of organizational family-centered care characteristics at German neonatal intensive care units (NICUs) on the satisfaction of parents of very low birthweight (VLBW) infants.Materials and methods: Using multilevel modeling, this study analyzed whether organizational characteristics of NICUs fostering parent-infant interaction (by way of the existence of a recreation room, possibility of rooming in, existence of unrestricted visiting hours for parents, existence of parental classes, and the connection to parent associations as well as the existence of standards on developmentally supportive care) increase the satisfaction of parents after the infants' high-intensive care phase within the NICU.Results: Nine hundred and twenty-three VLBW infants from 66 NICUs in Germany born between May and October 2013 were enrolled in this multicenter study. We retrieved 1493 questionnaires completed by 1277 parents. The existence of unrestricted visiting hours (adjusted odds ratio (AOR): 1.967; 95% CI [1.118, 3.459]) and standardized procedures for developmentally supportive care (AOR: 1.775; 95% CI [1.166, 2.704]) were positively associated with parental satisfaction.Conclusions: Fostering the parent-infant interaction through the provision of developmentally supportive care and unrestricted visiting hours for parents whose infants are hospitalized within an NICU significantly contributes to the satisfaction of parents.

Recommendations on the environment for hospitalised newborn infants from the French neonatal society: rationale, methods and first recommendation on neonatal intensive care unit design

AIM

Hospitalised newborn infants may be stressed due to inappropriate sensory stimuli and early separation from their families, that can negatively impact their neurodevelopment. The French Group of Reflection and Evaluation of the Environment of Newborns (GREEN) issues guidelines based on environmental neonatology and family-centred care. The first recommendation focuses on private family rooms versus large shared rooms.

METHODS

These guidelines are based on a systematic evaluation of the literature providing different grades of evidence. Internal and external reviews by multidisciplinary experts examined the scientific evidence of all recommendations. The literature search was performed for the period January 1, 2000 to January 1, 2016 with the keywords 'single room' or 'private room' and 'neonatal intensive care unit'.

RESULTS

A total of 25 studies were retained. Most studies reported a positive impact of private rooms on the health of newborn infants and satisfaction of families. Private rooms could lead to sensory deprivation if there is low parental involvement with limited presence and to reduced interaction among caregivers.

CONCLUSION

We recommend that neonatal units should mostly have private rooms. With this architectural design, we recommend supporting the staff's needs for changes in the organisation and philosophy of care and to provide improved family support.

Effect of single family rooms for preterm infants on neurodevelopment: study protocol for a systematic review

INTRODUCTION

Preterm infants are at an increased risk for neurodevelopmental delay. They have to endure many stressors in early life, including parent-infant separation, noise and painful procedures during hospitalisation in the highly technological environment of the modern neonatal ward. Currently, a shift is being noticed in the architectural design of neonatal wards towards single family rooms instead of the common open bay units. The influence of the hospital environment on health and specifically neurodevelopment in this vulnerable patient population remains under discussion.

OBJECTIVES

To assess the effect of single family rooms during hospitalisation primarily on neurodevelopment in preterm infants. Secondary outcome measures will be neonatal (ie, breastfeeding rates, sepsis, growth during hospital stay, length of hospital stay) and parental (ie, parental stress, satisfaction, participation, presence and self-efficacy).

METHODS AND ANALYSIS

The PRISMA-P 2015 (Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015) 17 items checklist was used for the generation of the protocol for this review. The following PICO was formulated: Population: preterm infants with need of hospitalisation in the neonatal ward; Intervention: single family rooms; Comparison: standard neonatal care in open bay units; Outcome: neurodevelopmental outcome of infants from 9 months onwards. If at least two studies, with low or moderate risk of bias, suitable for inclusion are found a meta-analysis will be performed. If quantitative synthesis is not appropriate the data will be presented descriptively.

DISSEMINATION PLANS

This will be the first review, systematically assessing the effect of single family rooms on neurodevelopmental outcome in preterm infants. Clinical practice could possibly be optimised to ameliorate neurodevelopment in this vulnerable patient population based on these insights. This systematic review will be published in an international peer-reviewed journal.

REGISTRATION

We registered this systematic review protocol with the PROSPERO (International Prospective Register of Systematic Reviews) on 2 November 2016 (registration number: CRD42016050643).

ETHICS

We will use data from patients enrolled in studies and/or trials already approved by the relevant ethical committees and therefore this systematic review requires no further permissions.

Effect of Family-centered Care on Improving Parental Satisfaction and Reducing Readmission among Premature Infants: A Randomized Controlled Trial

INTRODUCTION

Healthcare quality is usually evaluated through analysing medical outcomes including neonatal readmission and patient and family satisfaction. Parental involvement in neonatal care is considered as one of the most important factors, which directly affects these outcomes. The aim of the present study was to determine the effect of family-centered care including maternal participation, presence, and information about neonatal care, on maternal satisfaction and neonatal readmission; the care services were provided by the primiparous mothers of preterm infants.

MATERIALS AND METHODS

One hundred and ten primiparous mothers with preterm infants participated in this clinical trial. All samples were randomly divided into family-centered care (FCC) and control groups, through simple random sampling. The FCC program, which consisted of information about neonatal care, maternal presence, and participation in the care process, was implemented in the FCC group, while the control group was provided with routine care. Data were obtained using demographic and satisfaction questionnaires and readmission checklist.

RESULTS

In the FCC group, the mean score of satisfaction increased after the implementation of the program (22.36 and 59.28 before and after the program, respectively) (p<0.001); however, this increase in the control group was not significant. The obtained results regarding the different aspects of satisfaction indicated that mothers in the FCC group were more satisfied with maternal presence in the neonatal intensive care unit (NICU), compared with aspects of information and participation. In addition, the number of neonatal readmission was less in the FCC group compared with the control group, and the mean duration of hospitalization was 6.96 and 12.96 days in the FCC and control groups, respectively (p<0.001).

CONCLUSION

FCC program seems to be effective in increasing maternal satisfaction and decreasing neonatal readmission. Therefore, it seems necessary that healthcare authorities of the departments of obstetrics and gynecology in Iran provide the opportunity for the implementation of such programs in clinical environments, which follow the policy of parental absence and participation in the intensive care units.

NICU parent-to-parent partnerships: a comprehensive approach

Parents of newborns in the neonatal intensive care unit (NICU) find themselves in a world of unknown medical terminology, advanced technology, and the realization that their dream of a healthy baby has been shattered. The unique partnership with trained parent-to-parent volunteers, who have had previous NICU experiences, enhances professional support and helps new NICU parents adjust to these unexpected challenges. This practice-based article describes the Helen DeVos Children's Hospital NICU Parent-to-Parent Partnership's (PPP) 40-year commitment to the parent-to-parent philosophy and its comprehensive approach to delivering trained volunteer PPP services to NICU families. A historical review of the literature, including this hospital's original research, current programming, recruiting, training, supervision, and survey feedback, is outlined.

Patient- and family-centered care and the pediatrician's role

Drawing on several decades of work with families, pediatricians, other health care professionals, and policy makers, the American Academy of Pediatrics provides a definition of patient- and family-centered care. In pediatrics, patient- and family-centered care is based on the understanding that the family is the child's primary source of strength and support. Further, this approach to care recognizes that the perspectives and information provided by families, children, and young adults are essential components of high-quality clinical decision-making, and that patients and family are integral partners with the health care team. This policy statement outlines the core principles of patient- and family-centered care, summarizes some of the recent literature linking patient- and family-centered care to improved health outcomes, and lists various other benefits to be expected when engaging in patient- and family-centered pediatric practice. The statement concludes with specific recommendations for how pediatricians can integrate patient- and family-centered care in hospitals, clinics, and community settings, and in broader systems of care, as well.

Infant neurobehavioral development

The trend toward single-room neonatal intensive care units (NICUs) is increasing; however scientific evidence is, at this point, mostly anecdotal. This is a critical time to assess the impact of the single-room NICU on improving medical and neurobehavioral outcomes of the preterm infant. We have developed a theoretical model that may be useful in studying how the change from an open-bay NICU to a single-room NICU could affect infant medical and neurobehavioral outcome. The model identifies mediating factors that are likely to accompany the change to a single-room NICU. These mediating factors include family centered care, developmental care, parenting and family factors, staff behavior and attitudes, and medical practices. Medical outcomes that plan to be measured are sepsis, length of stay, gestational age at discharge, weight gain, illness severity, gestational age at enteral feeding, and necrotizing enterocolitis (NEC). Neurobehavioral outcomes include the NICU Network Neurobehavioral Scale (NNNS) scores, sleep state organization and sleep physiology, infant mother feeding interaction scores, and pain scores. Preliminary findings on the sample of 150 patients in the open-bay NICU showed a "baseline" of effects of family centered care, developmental care, parent satisfaction, maternal depression, and parenting stress on the neurobehavioral outcomes of the newborn. The single-room NICU has the potential to improve the neurobehavioral status of the infant at discharge. Neurobehavioral assessment can assist with early detection and therefore preventative intervention to maximize developmental outcome. We also present an epigenetic model of the potential effects of maternal care on improving infant neurobehavioral status.

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.

Breast milk expression and maintenance in mothers of very low birth weight infants: supports and barriers

The study objective was to identify patterns of factors that supported or hindered initiation of breast milk expression and maintenance of breast milk production after the birth of a very low birth weight (VLBW) infant in a sample of US women with varied prenatal infant feeding intentions. In-depth interviews were conducted 1 to 6 months after delivery in 32 women who initiated breast milk expression after encouragement from hospital staff. Pregnancy complications, anxiety regarding their infant's health, and lack of privacy interfered with initiation of milk expression. After hospital discharge, using manual or small electric breast pumps, travel to the neonatal intensive care unit, return to work, and difficulty with time management interfered with maintenance of breast milk production. Family support, positive attitudes toward pumping, and anticipation of breastfeeding supported maintenance of breast milk production. From these data emerge points of intervention where additional support could improve mothers' experiences and increase duration of breast milk feeding.

Support for siblings of NICU patients: an interdisciplinary approach

Siblings of hospitalized newborns in neonatal intensive care units (NICU) experience unique thoughts and feelings in response to this situational crisis. Providing an opportunity for siblings and their parents to address both of their concerns can improve sibling adjustment to the NICU, and is also consistent with a family-centered care philosophy. This article traces the development and evolution of sibling policy and program changes at Helen DeVos Children's Hospital (HDVCH) NICU, and describes the current comprehensive model for inclusion of siblings. Particular emphasis will be given to the cornerstone program "Celebrating Siblings Pizza Party." Infection control considerations and the importance of an interdisciplinary team approach to enhance an array of sibling services are also highlighted.

The impact of individual room on rehospitalization and health service utilization in preterms after discharge

AIM

To compare individual room implemented family-centred care to classical designed neonatal intensive care unit and find out its effect on rehospitalization and application to health services in preterm infants after discharge.

METHODS

Mothers whose infants were born before 34 gestational weeks and hospitalized for at least one week in the NICU were enrolled in the study. Mothers who were hospitalized with their preterm infants in individual rooms (Group I) were compared with mothers who were not hospitalized with their preterm infants (Group II). After the third postdischarge month, groups were compared for their rates of phone consultations to physician/hospital, acute care applications, rehospitalization and parent's perception of child's vulnerability.

RESULTS

Although demographic and medical information did not indicate any differences between the groups, the mean number of acute care visits (p = 0.046), the median number of phone consultations (p = 0.001) and rehospitalization rate (12.9% vs. 34.5%, p < 0.05) were significantly higher in Group II. The anatomical problems, such as inguinal hernia and retinopathy of prematurity, were the main recorded causes in Group I whereas problems related to prematurity like feeding difficulties were dominating in Group II.

CONCLUSION

The availability of individual rooms that allows maternal presence and participation during the hospitalization of the mother's preterm infant, is correlated with lower rates of rehospitalization and healthcare applications.

Transition to an individual-room NICU design: process and outcome measures

Redesign of a neonatal intensive care unit is a major budget undertaking, demanding accountability for its equipment and feasibility of design. It must be philosophically based and driven by research supporting best practice. The NJCU at the Magee-Womens Hospital of the University of Pittsburgh Medical Center, a Level III, 74-bed unit, has made the change from a ward design to an individual-room design suitable for family-centered, developmentally supportive care. This article presents the design process as it occurred. Unique to this process are the involvement of NJCU-graduate families and the use of transition teams. Guidelines and recommendations are offered to others interested in designing and practicing in an individual-room NJCU. Outcome data demonstrate staff adjustment to the new design and practice model. A comparison of this NICU design is made with the Recommended Standards for Newborn ICU Design.

Implementation and case-study results of potentially better practices for family-centered care: the family-centered care map

OBJECTIVE

The objective of this study was to enhance the ability to coordinate and deliver care in a holistic manner, through a family-centered care map, so that the developmental, physical, and psychosocial needs of the infant and family are met.

METHODS

A Web-based map was based on 7 distinct clinical phases with 3 variations of an infant's course through a NICU. Sixty-three potentially better practices were identified and 7 potentially better practices were implemented through case studies.

RESULTS

Measures of family satisfaction revealed improvements in delivery of family-centered care. Increases in discharge growth parameters for extremely low birth weight infants were demonstrated. Length of stay for very low birth weight infants decreased from 73 to 60 days in Vermont.

CONCLUSIONS

The collaborative process enhances identification of potentially better practices and results in both qualitative and quantitative improvements in family-centered care.

Family-centered care in the NICU

Family-centered care is a philosophy of care that embraces a partnership between staff and families. Families, patients, and staff benefit in a family-centered care environment and the design of the newborn intensive care unit (NICU) must not interfere with its successful implementation. Unrestricted parental presence in the NICU, parental involvement in infant caregiving, and open communication with parents are basic tenets of family-centered care. By virtue of their continual presence and role in the NICU, nurses are in a unique position to support family-centered care.