Measuring Parental Presence in the Neonatal Intensive Care Unit

Accuracy of Electronic Health Record Documentation of Parental Presence: A Data Validation and Quality Improvement Analysis

Parental presence in the neonatal intensive care unit (NICU) is known to improve the health outcomes of an admitted infant. The use of the electronic health record (EHR) to analyze associations between parental presence and sociodemographic factors could provide important insights to families at greatest risk for limited presence during their infant's NICU stay, but there is little evidence about the accuracy of nonvital clinical measures such as parental presence in these datasets. A data validation study was conducted comparing the percentage agreement of an observational log of parental presence to the EHR documentation. Overall, high accuracy values were found when combining two methods of documentation. Additional stratification using a more specific measure, each chart's complete accuracy, instead of overall accuracy, revealed that night shift documentation was more accurate than day shift documentation (76.3% accurate during night shifts, 55.2% accurate during day shifts) and that flowsheet (FS) recordings were more accurate than the free-text plan of care (POC) notes (82.4% accurate for FS, 75.1% accurate for POC notes). This research provides a preliminary look at the accuracy of EHR documentation of nonclinical factors and can serve as a methodological roadmap for other researchers who intend to use EHR data.

Description and evidence on the supporting and enhancing neonatal intensive care unit sensory experiences (SENSE) program

AIM

To describe the supporting and enhancing neonatal intensive care unit (NICU) sensory experiences (SENSE) program, associated research and opportunities for further study.

METHODS

A review of current materials on SENSE program implementation, publications related to SENSE development, and research on program implementation and patient outcomes was conducted to describe the SENSE program and its associated research.

RESULTS

The SENSE program combines structured, evidence-based, multisensory interventions with parent engagement in order to optimise outcomes in the complex NICU environment. Through a stepwise and scientific process, the SENSE program was developed to include specific doses and targeted timing (based on the infant's postmenstrual age, PMA) of evidence-based interventions such as massage, auditory exposure, rocking, holding and skin-to-skin care for parents to provide their infants each day of NICU hospitalisation. It is adapted in context of concurrent medical interventions, infant behavioural responses, as well as NICU culture. The program is feasible to implement, acceptable to staff, and related to infants receiving more developmentally appropriate sensory exposures. Adaptations related to NICU culture and parent involvement have been reported. Research has identified relationships of the SENSE program to improved parent confidence, neurobehaviour and feeding at term age as well as improved communication 1 year of age.

CONCLUSION

The literature related to the SENSE program is promising, but more research on efficacy and implementation is needed.

Barriers and Facilitators of Parent Presence in the Neonatal Intensive Care Unit

PURPOSE

The purpose of this study was to describe system-level and personal factors influencing parent presence in the neonatal intensive care unit (NICU) and identify differences in factors by sociodemographic characteristics.

STUDY DESIGN AND METHODS

In a cross-sectional national survey study using social media recruitment, participants rated the frequency of 13 potential barriers and 12 potential facilitators using a 5-point Likert scale. Experiences of discrimination and parent-staff engagement were also measured.

RESULTS

Valid responses were analyzed from 152 participants. Uncomfortable facilities and home responsibilities were the most highly reported system-level and personal barriers, respectively. Encouragement to participate in caregiving and social support were the most highly reported system-level and personal facilitators, respectively. Participants reported low to moderate levels of discrimination and moderate levels of parent-staff engagement. Latent class analysis revealed three sociodemographic clusters. Differences in barriers, facilitators, discrimination, and engagement were found among clusters.

CLINICAL IMPLICATIONS

NICU facilities are uncomfortable and may discourage parent presence. Allowing support persons to accompany parents, providing comfortable facilities, and engaging parents in caregiving may promote greater parent presence and improved parent and child outcomes. Studies of potential bias toward parents with lower education and income and effects on parent presence and infant outcomes are needed.

Feasibility and Impact of a Pilot Neonatal Cuddler Program on Preterm Infants in the Neonatal Intensive Care Unit

OBJECTIVE

Preterm infants experience daily stress in the neonatal intensive care unit (NICU). Positive sensory experiences mitigate stress responses, but parental participation can be limited by external pressures. This study aimed to describe the impact of a neonatal cuddler program (NCP) on preterm infants' growth.

STUDY DESIGN

A multidisciplinary program trained volunteers to interact with NICU infants when family was not at bedside. Infants were followed prospectively throughout admission. Intervention data included frequency, type, and duration of activity throughout the study period. Student t-test and chi-square test were used to analyze the impact of volunteer interaction on anthropometric measures at discharge.

RESULTS

Forty-five infants interacted with a volunteer (intervention group, n = 45) compared with the control group (n = 56) following coronavirus disease 2019 restrictions. The median (range) time of interaction with a volunteer in the intervention group was 90.0 (5.0-705.0) minutes per infant. Infants in the two groups had similar gestational ages, birth weights, lengths, and occipitofrontal circumferences (OFC). Infants in the intervention group had higher rates of spontaneous intestinal perforation, bronchopulmonary dysplasia, and reached full enteral feeds later. However, rates of severe intraventricular hemorrhage, retinopathy of prematurity, and duration of mechanical ventilation were similar. Infants in the two groups did not differ in the NICU length of stay. At discharge, infants in the intervention group weighed more (p = 0.04) and had higher OFC's (p = 0.01) and OFC z-scores (p = 0.03). The change in z-scores from birth to discharge was significant for the weight (p = 0.02) but not length or OFC. In regression analyses, only group allocation was identified as a significant factor for OFC z-scores at discharge (β= 0.279, p = 0.011) and for change in weight z-scores from birth to discharge (β = 0.226, p = 0.041).

CONCLUSION

Growth is positively impacted by an NCP despite limited interaction. Additional work is needed to demonstrate the impact on neurobehavioral and developmental outcomes.

KEY POINTS

· Establishing and implementing a neonatal cuddler program in a large, level IV NICU is feasible.. · Neonatal cuddler programs can provide positive sensory experiences when parents are not at bedside.. · Even limited exposure to these positive sensory experiences can positively impact growth parameters for preterm infants..

Parents' and neonatal healthcare professionals' views on barriers and facilitators to parental presence in the neonatal unit: a qualitative study

BACKGROUND

Parent and infant separation in the neonatal unit is associated with adverse health outcomes. Family-integrated care has several advantages and the potential to reduce these adverse outcomes but requires parental presence. This study aimed to explore the views of parents and neonatal healthcare professionals (nHCPs) on barriers and facilitators to parental presence in a Swiss neonatal unit and to identify possible differences between nHCPs and parents, and between mothers and fathers.

METHODS

Data were collected through semi-structured interviews with parents and focus group discussions with nHCPs. Inductive content analysis was used to identify barriers and facilitators to parental presence in the neonatal unit.

RESULTS

Twenty parents (10 mothers and 10 fathers) and 21 nHCPs (10 nurses and 11 physicians) participated in the study. Parents and nHCPs experienced barriers and facilitators related to: (1) Structural factors of the institution, such as infrastructure or travel and distance to the neonatal unit. (2) Organization and time management of parental presence, daily activities, and work. (3) Resources, which include factors related to the legal situation, support services, family, and friends. (4) Physical and psychological aspects, such as pain, which mainly affected mothers, and aspects of emotional distress, which affected both parents. Self-care was an important physical and psychological facilitator. (5) Parent-professional interaction. Parental presence was influenced by communication, relationship, and interaction in infant care; and (6) Cultural aspects and language. Some perspectives differed between mothers and fathers, while the overall views of parents and nHCPs provided complementary rather than conflicting insights. Using visit plans to support the organization, educating nHCPs in knowledge skills and available resources to improve encouragement and information to parents, strengthening parent self-care, and improving nHCPs' attitudes towards parental presence were seen as possible improvements.

CONCLUSIONS

Multifactorial barriers and facilitators determine parental presence and experience in the neonatal unit. Parents and nHCPs made specific recommendations to improve parental presence.

Considering the Influence of Social Determinants of Health on Parent Feeding Practices: A Case Example

BACKGROUND

Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. SDOH can be grouped into 5 domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. SDOH impact people's health and quality of life but may also contribute to disparities in access to food, education, and healthcare. SDOH uniquely influence parent feeding practices in the neonatal intensive care unit (NICU) in a variety of ways, ranging from logistical considerations for parent visitation to cultural beliefs such as family perception of human milk feeding.

EVIDENCE ACQUISITION

A hypothetical case example of a preterm infant with a feeding disorder in the NICU is used to connect SDOH that influence prenatal health, parental lived experience, and postnatal medical care to maternal and infant outcomes with implications for feeding practices. Barriers and facilitators to successful feeding practices in the NICU and at discharge are considered for each SDOH domain.

RESULTS

This case example increases awareness of SDOH and how they influence parent feeding practices in the NICU, focusing on the intersection of SDOH, parent stress, and oral feeding outcomes. Examples were provided for how to support applying findings into practice.

IMPLICATIONS FOR PRACTICE AND RESEARCH

By being creating a culture of SDOH awareness, NICU staff can assist families in overcoming barriers by putting supports in place to increase equitable participation in developmentally supportive feeding practices during the NICU stay.

Barriers to, and facilitators of, eHealth utilisation by parents of high-risk newborn infants in the NICU: a scoping review protocol

INTRODUCTION

Parental presence in the neonatal intensive care unit (NICU) has been demonstrated to enhance infant growth and development, reduce parental anxiety and stress and strengthen parent-infant bonding. Since eHealth technology emerged, research on its utilisation in NICUs has risen substantially. There is some evidence that incorporating such technologies in the NICU can reduce parental stress and enhance parent confidence in caring for their infant.Several countries, including China, restrict parental attendance in NICUs, citing infection control challenges, issues of privacy and confidentiality and perceived additional workload for healthcare professionals. Due to COVID-19 pandemic-related shortages of personal protective equipment and uncertain mode of transmission, many NICUs around the world closed to parental visiting and engagement in neonatal care.There is anecdotal evidence that, given pandemic-related restrictions, eHealth technologies, have increasingly been used in NICUs as a potential substitute for in-person parental presence.However, the constraints and enablers of technologies in these situations have not been exhaustively examined. This scoping review aims to update the literature on eHealth technology utilisation in the NICU and to explore the literature on the challenges and facilitators of eHealth technology implementation to inform future research.

METHODS AND ANALYSIS

The five-stage Arksey and O'Malley methodological framework and the Joanna Briggs Institute scoping review methodology will serve as the foundation for this scoping review. Eight databases will be searched for the relevant literature published between January 2000 and August 2022 in either English or Chinese. Grey literature will be manually searched. Data extraction and eligibility screening will be carried out by two impartial reviewers. There will be periods of both quantitative and qualitative analysis.

ETHICS AND DISSEMINATION

Since all data and information will be taken from publicly accessible literature, ethical approval would not be necessary. A peer-reviewed publication will be published with the results of this scoping review.

TRIAL REGISTRATION NUMBER

This scoping review protocol was registered in Open Science Framework and can be found here: https://osf.io/AQV5P/.

A Concept Analysis of Family Presence During COVID-19

BACKGROUND

In 2020, the COVID-19 pandemic required health care organizations throughout the United States to implement strict visitor restriction policies to mitigate the spread of the virus. These policy changes had a direct impact on family presence (FP) in hospital settings.

PURPOSE

The aim of this study was to conduct a concept analysis of FP during the COVID-19 pandemic.

METHODS

Walker and Avant's 8-step method was used.

RESULTS

Four defining attributes of FP during COVID-19 were derived based on a review of the literature: being there or with, seeing is believing, during challenging times, and subjective advocates. The COVID-19 pandemic was the main antecedent of the concept. The consequences and empirical referents were discussed. Model, borderline, and contrary cases were developed.

CONCLUSION

This concept analysis provided an understanding of the concept of FP during COVID-19, which is imperative to optimizing patient care outcomes, as literature identified a support person or system as an extension of the care team that facilitates successful care management. Whether by advocating for their patients to have a support person present during team rounds, or by stepping in as the patient's main support system in the absence of family, nurses must find a way to do what is best for their patients even during the unprecedented times of a global pandemic.

Parental Participation in Preterm Infant Feeding in the Neonatal Intensive Care Unit

PURPOSE

To identify factors associated with parental participation in the feeding care of hospitalized preterm infants and determine associations between parental participation in feeding and infant neurobehavioral outcomes.

STUDY DESIGN AND METHODS

Secondary analysis of data collected during a larger study of preterm infants. Parental participation in gavage and oral feeding was measured as a proportion of all feeding opportunities. Neurobehavioral outcomes were measured using a neurobehavioral assessment and feeding milestones. Other data were collected from the electronic health record.

RESULTS

Parental participation in feeding was low. There were associations between parental participation in gavage feeding and infant sex, insurance type, maternal race, infant gestational age at birth, and birthweight. There were associations between parental participation in oral feeding and infant sex, insurance type, maternal race, and study group. Greater parental participation in feeding was associated with earlier achievement of some feeding milestones.

CLINICAL IMPLICATIONS

Parental participation in feeding can decrease the time required for infants to achieve feeding milestones, possibly leading to decreased length of hospitalization. Nurses should encourage parents to participate in caregiving for their preterm infants. Interventions are needed to remove barriers to parental participation in caregiving.

Comparisons of Three Measures of Maternal Engagement Activities in the Neonatal Intensive Care Unit

BACKGROUND

Mothers' engagement with their hospitalized preterm infant(s) is recognized as an important aspect of treatment in neonatal intensive care units (NICUs). However, no gold standard exists for measuring maternal engagement, and the various methods used to measure mothers' time have documented limitations.

OBJECTIVES

This study sought to compare three measurement methods of maternal engagement (a five-item maternal cross-sectional survey, time use diaries, and electronic health records [EHRs]) to identify whether these methods capture consistent data and patterns in detected differences in measures of engagement.

METHODS

Maternal engagement was defined as time spent visiting the infant in the NICU (presence), holding (blanket holding in the mother's arms or by kangaroo care [KC]), and caregiving (e.g., bathing and changing diapers). The survey estimating daily maternal engagement was administered in two Level III NICUs and one Level IV NICU at study enrollment, at least 2 weeks after admission. Mothers then completed the daily time use diaries until infant discharge. Data were also collected from participants' EHRs, charted by nursing staff. Wilcoxon signed-rank tests were used for pairwise analysis of the three measures for maternal engagement activities.

RESULTS

A total of 146 participants had data across all three measurement types and were included in the analysis. In the Level III NICUs (n = 101), EHR data showed significantly more time spent with all engagement activities than the diary data. In the Level IV data, only differences in time holding were significant when comparing EHR data with survey data, with mothers reporting more time doing KC and less time blanket holding. Comparison of EHR data with diary data showed more time in all activities except KC.

DISCUSSION

In most cases, time spent in engagement activities measured in the EHR was higher than in the surveys or time use diaries. Accuracy of measurements could not be determined because of limitations in data collection, and there is no gold standard for comparison. Nevertheless, findings contribute to ongoing efforts to develop the most valuable and accurate strategies for measuring maternal engagement-a significant predictor of maternal and infant health.

The Association of Social Factors and Time Spent in the NICU for Mothers of Very Preterm Infants

OBJECTIVES

Evaluate the association between maternal social factors and maternal time spent in the NICU for very preterm infants admitted to 4 level III and IV NICUs.

METHODS

In this prospective observational cohort study, we enrolled mother-infant dyads whose infants were born <32 weeks' gestation. Enrollment occurred after 2 weeks of NICU exposure, when maternal social factors and demographic information was collected. Maternal time spent in the NICU was abstracted from the electronic medical record and was dichotomized into 0 to 6 days and ≥6 days per week. Demographic differences between the 2 groups were compared by using χ2 tests. Logistic regression was used to assess the independent association between maternal social factors and the average number of days per week spent in the NICU.

RESULTS

A total of 169 mother-infant dyads were analyzed. Maternal social factors associated with more time spent in the NICU included an annual household income of >$100 000, compared with those with an annual household income of <$50 000 (adjusted odds ratio [aOR]: 5.68; 95% confidence interval [CI] 1.77-18.19), a travel time <30 minutes to the NICU (compared with those who traveled >60 minutes [aOR: 7.85; 95% CI 2.81-21.96]), and the lack of other children in the household, compared with women with other children (aOR: 3.15; 95% CI 1.39-7.11).

CONCLUSIONS

Maternal time spent in the NICU during a prolonged birth hospitalization of a very preterm infant differed by socioeconomic status, travel time, and presence of other dependents. Strategies to better identify and reduce these disparities to optimize engagement and, subsequently, improve infant health outcomes is needed.