Nurses' Descriptions of Interactions When Caring for Women With Perinatal Substance Use Disorders and Their Infants

Chapter 10: Review of parent and healthcare provider experiences based on approach to managing Neonatal Opioid Withdrawal Syndrome (NOWS)

Neonatal Opioid Withdrawal Syndrome (NOWS) is a group of clinical withdrawal signs occurring in prenatally opioid-exposed newborns and manifesting as neurobehavioral dysregulation, including extreme irritability such as excessive crying, rigid muscle tone, and difficulty feeding and sleeping. One U.S. infant experiencing NOWS is born every 25 min. Clinical management of these infants has traditionally occurred in the high-acuity environment of a neonatal intensive care unit (NICU), which contributes to separation of infants from their parents and increases the likelihood of pharmacological intervention to manage withdrawal. Over the past decade, more holistic approaches, such as the Eat, Sleep, and Console method, have focused on parents' active participation in care, rooming-in, and implementation of non-pharmacologic soothing techniques to reduce medication use, hospital length of stay, and healthcare expenditures. These distinctly different management approaches have contributed to unique experiences for parents and healthcare providers involved in infants' care; therefore, the purpose of this paper is to review the experiences of parents and healthcare providers as they relate to management approaches for infants with NOWS.

The Alberta Neonatal Abstinence Syndrome Mother-Baby Care ImprovEmeNT (NASCENT) program: protocol for a stepped wedge cluster randomized trial of a hospital-level Neonatal Abstinence Syndrome rooming-in intervention

BACKGROUND

Neonatal Abstinence Syndrome (NAS), a problem common in newborns exposed to substances in-utero, is an emerging health concern. In traditional models of care, infants with NAS are routinely separated from their mothers and admitted to the Neonatal Intensive Care Unit (NICU) with long, expensive length of stay (LOS). Research shows a rooming-in approach (keeping mothers and infants together in hospital) with referral support is a safe and effective model of care in managing NAS. The model's key components are facilitating 24-h care by mothers on post-partum or pediatric units with support for breastfeeding, transition home, and access to Opioid Dependency Programs (ODP). This study will implement the rooming-in approach at eight hospitals across one Canadian Province; support practice and culture shift; identify and test the essential elements for effective implementation; and assess the implementation's impact/outcomes.

METHODS

A stepped wedge cluster randomized trial will be used to evaluate the implementation of an evidence-based rooming-in approach in the postpartum period for infants born to mothers who report opioid use during pregnancy. Baseline data will be collected and compared to post-implementation data. Six-month assessment of maternal and child health and an economic evaluation of cost savings will be conducted. Additionally, barriers and facilitators of the rooming-in model of care within the unique context of each site and across sites will be explored pre-, during, and post-implementation using theory-informed surveys, interviews, and focus groups with care teams and parents. A formative evaluation will examine the complex contextual factors and conditions that influence readiness and sustainability and inform the design of tailored interventions to facilitate capacity building for effective implementation.

DISCUSSION

The primary expected outcome is reduced NICU LOS. Secondary expected outcomes include decreased rates of pharmacological management of NAS and child apprehension, increased maternal ODP participation, and improved 6-month outcomes for mothers and infants. Moreover, the NASCENT program will generate the detailed, multi-site evidence needed to accelerate the uptake, scale, and spread of this evidence-based intervention throughout Alberta, leading to more appropriate and effective care and use of healthcare resources.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT0522662. Registered February 4^th, 2022.

Original Research: Nurses' Self-Assessed Knowledge, Attitudes, and Educational Needs Regarding Patients with Substance Use Disorder

BACKGROUND

Substance use disorder (SUD) is a chronic illness, but it's often seen as an intentional choice rather than as a disease. People with SUD are frequently stigmatized, leading to disparate care. Findings from previous studies have indicated that nurses feel inadequately prepared to care for, and tend to have negative attitudes toward, patients with SUD. But it's unknown what kind of education would better prepare nurses caring for this patient population, or whether these negative attitudes vary across practice settings.

PURPOSE AND DESIGN

This observational, cross-sectional, mixed-methods study sought to explore nurses' self-assessed knowledge of and attitudes toward caring for patients with SUD (whether formally diagnosed or not) in hospital settings across the United States. A secondary aim was to determine nurses' educational preferences and needs in this area.

METHODS

Data were collected over a three-month period in early 2020, using the online social networking platform Facebook. All participants were nurses working in hospital settings throughout the United States. Participants were surveyed using two tools: the Drug and Drug Problems Perceptions Questionnaire, and another questionnaire that included open-ended questions regarding nurses' SUD-related education and their experiences and perceived needs in caring for patients with SUD. Quantitative data were analyzed using analysis of variance and post hoc Tukey tests. Qualitative data were analyzed using thematic analysis.

RESULTS

A total of 691 nurses participated. Nurses reported having been educated in SUD but wanted additional face-to-face education from mental health specialists. The nurses working on mental health units had significantly more positive attitudes toward caring for patients with SUD than nurses on other units. Older nurses had significantly more positive attitudes toward patients with SUD than younger nurses. Qualitative analysis uncovered four themes: unmet needs, personal experiences inform care, personal beliefs inform perceptions, and judgmental attitudes.

CONCLUSIONS

Study findings indicate that, in general, hospital nurses have negative attitudes toward patients with SUD. The results further reaffirm the need for empathy-based nursing education for nurses who care for these patients. Participants expressed a preference for face-to-face training by mental health specialists experienced in SUD. Given the increasing prevalence of SUD and the expected retirement of older nurses, it is urgent that we prioritize empathy-based nursing education, particularly for newer-to-practice nurses, in order to improve nurses' attitudes and ensure best care for patients with SUD.

Health Care Professionals' Perceptions of Caring for Patients with Substance Use Disorders during Pregnancy

PURPOSE

Pregnant patients with substance use disorders (SUDs) may experience stigma and implicit and explicit bias from health care professionals when seeking prenatal care. This study explored the perceptions of health care professionals caring for pregnant women with SUDs and examined changes in their perceptions over time following attendance at an educational conference about SUDs.

STUDY DESIGN AND METHODS

Evidence-based education was presented to health care professionals at a conference to reinforce the complex needs of pregnant women with SUDs. An adapted version of the Attitudes of Healthcare Providers Survey (AHPS) was administered at three intervals and assessed health care professionals' perceptions of pregnant women with SUDs. Data from the three time points were analyzed using repeated measures ANOVA.

RESULTS

There was a significant decrease in mean AHPS scores between T1 (38.24 ± 8.93) and T2 (32.71 ± 7.77), p < .05, and then a significant increase in mean AHPS score between T2 and T3 (37.08 ± 8.45), p < .05. High mean scores on health care professionals' knowledge and competence were noted after the educational intervention but were not sustained over time.

CLINICAL IMPLICATIONS

Education cannot change health care professional perceptions of pregnant individuals with SUD. Health care professionals need access to additional clinical and community resources. Nurse leaders must continue to advocate for institutional and community resources to meet referral, treatment, and follow-up needs during pregnancy. Reducing perceptions of stigma and acknowledging the impact of implicit bias toward pregnant women with SUD may reduce barriers and improve their care.