A Mixed-Methods Study to Investigate Barriers and Enablers to Nurses' Implementation of Nonpharmacological Interventions for Infants With Neonatal Abstinence Syndrome

BACKGROUND

The incidence of neonatal abstinence syndrome has increased significantly as a result of the opioid epidemic. A lengthy hospitalization is often required to treat the infant's withdrawal symptoms. A comprehensive understanding of factors that influence nurses' implementation of nonpharmacological interventions for infants with neonatal abstinence syndrome is needed.

PURPOSE

To investigate barriers and enablers to nurses' implementation of nonpharmacological interventions for infants with neonatal abstinence syndrome through the lens of the Theoretical Domains Framework, which provides a structure to examine factors that influence healthcare providers' behavior related to the implementation of evidence-based practice and interventions in clinical practice.

METHODS

A convergent parallel mixed-methods study was conducted. Qualitative data were collected using semistructured interviews and quantitative data were collected using a tailored Determinants of Implementation Behavior Questionnaire with neonatal nurses. Findings from the interviews and surveys were merged through joint review to compare and contrast themes.

RESULTS

Enablers and barriers to nurses' implementation of nonpharmacological interventions included education, experience, ability to implement nonpharmacological interventions, parental participation, stigmatization, lack of managerial/organizational support, staffing ratios, internal and external resources, and stress. Knowledge, Skills, Beliefs About Capabilities, Social/Professional Role and Identity, Organization, and Emotion of the Theoretical Domains Framework aligned with these themes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Findings from this study will inform the development of programs to improve nurses' implementation of nonpharmacological interventions and health and utilization outcomes in infants with neonatal abstinence syndrome. Furthermore, future work should focus on the development of programs to improve nurses' implementation of nonpharmacological interventions, with specific strategies aimed to mitigate marginalization of vulnerable patient populations.

Outcome reporting in neonates experiencing withdrawal following opioid exposure in pregnancy: a systematic review

Background

Neonatal withdrawal secondary to in utero opioid exposure is a growing global concern stressing the psychosocial well-being of affected families and scarce hospital resources. In the ongoing search for the most effective treatment, randomized controlled trials are indispensable. Consistent outcome selection and measurement across randomized controlled trials enables synthesis of results, fostering the translation of research into practice. Currently, there is no core outcome set to standardize outcome selection, definition and reporting. This study identifies the outcomes currently reported in the literature for neonates experiencing withdrawal following opioid exposure during pregnancy.

Methods

A comprehensive literature search of MEDLINE, EMBASE and Cochrane Central was conducted to identify all primary research studies (randomized controlled trials, clinical trials, case-controlled studies, uncontrolled trials, observational cohort studies, clinical practice guidelines and case reports) reporting outcomes for interventions used to manage neonatal abstinence syndrome between July 2007 and July 2017. All “primary” and “secondary” neonatal outcomes were extracted by two independent reviewers and were assigned to one of OMERACT’s core areas of “pathophysiological manifestation”, “life impact”, “resource use”, “adverse events”, or “death”.

Results

Forty-seven primary research articles reporting 107 “primary” and 127 “secondary” outcomes were included. The most frequently reported outcomes were “duration of pharmacotherapy” (68% of studies, N = 32), “duration of hospital stay” (66% of studies, N = 31) and “withdrawal symptoms” (51% of studies, N = 24). The discrepancy between the number of times an outcome was reported and the number of articles was secondary to the use of composite outcomes. Frequently reported outcomes had heterogeneous definitions or were not defined by the study and were measured at different times. Outcomes reported in the literature to date were mainly assigned to the core areas “pathophysiologic manifestations” or “resource use”. No articles reported included parent or former patient involvement in outcome selections.

Conclusions

Inconsistent selection and definition of primary and secondary outcomes exists in the present literature of pharmacologic and nonpharmacologic interventions for managing opioid withdrawal in neonates. No studies involved parents in the process of outcome selection. These findings hinder evidence synthesis to generate clinically meaningful practice guidelines. The development of a specific core outcome set is imperative.

Neonatal Abstinence Syndrome: An Uncontrollable Epidemic

There is an uncontrollable epidemic of drug abuse, with the misuse of opioids the most alarming. Along with the increase in opioid abuse, there exists a concomitant upsurge in the number of neonates experiencing neonatal abstinence syndrome (NAS) due to the effects of the mother's withdrawal from the drug. Neonates experiencing NAS exhibit various nervous system, gastrointestinal, and respiratory untoward symptoms. Diagnosis is determined by taking an accurate maternal history and assessment of clinical signs and symptoms. Clinical management strategies include pharmacologic and nonpharmacologic therapies. Nursing care is evidence based, includes nonpharmacologic therapies, and focuses on prevention and support.

Shining a Light: Integrating Protocols Into Clinical Practice for Treatment of Neonatal Abstinence Syndrome

BACKGROUND AND PURPOSE

The epidemic use of opioids is negatively influencing the health of the American people. Pregnant women and their unborn babies have not escaped the ravages of substance use. A dramatic increase in maternal opioid use has led to an increasing number of infants experiencing withdrawal symptoms known as neonatal abstinence syndrome (NAS). The purpose of this article is to highlight best practice for the management of infants with opioid withdrawal.

REVIEW OF PROTOCOLS AND TREATMENTS

Review of available protocols and treatments revealed wide variation in the treatment of NAS and little use of standardized guidelines or protocols, despite current recommendations of the American Academy of Pediatrics. There is supporting evidence showing that the use of standardized protocols reduces the length of treatment and enhances outcomes in the neonatal population.

EVIDENCE-BASED RECOMMENDATIONS

Evidence-based strategies to address gaps in practice include developing strong protocols to identify infants at risk and implementing standardized plans when treating NAS. Consistent assessment, initial treatment with nonpharmacologic measures, and conservative use of pharmacologic agents are important elements to an NAS treatment protocol.

CONCLUSIONS AND IMPLICATIONS

In evaluating the current literature for best practice in the management of the newborn with opioid withdrawal, it is clear that evidence-based standardized protocols need to be in place for the best treatment of the mother-infant dyad, caring for both the infants with NAS as well as the mothers with opioid use disorder.

NICU Culture of Care for Infants with Neonatal Abstinence Syndrome: A Focused Ethnography

PURPOSE

The purpose of this focused ethnography was to describe the culture of care and nonpharmacologic nursing interventions performed by NICU nurses for infants with neonatal abstinence syndrome (NAS).

METHOD

Roper and Shapira's framework for the analysis included participant observation, individual interviews, and examination of existing documents.

SAMPLE

Twelve full-time nurses were observed and interviewed.

RESULTS

Results described the culture of care provided to infants with NAS by NICU nurses as evidenced by six themes: learn the baby (routine care, comfort care, environment, adequate rest and sleep, feeding), core team relationships (support, interpersonal relationships), role satisfaction (nurturer/comforter, becoming an expert), grief, making a difference (wonderful insanity, critical to them), and education and care of the mother.

Neonatal Abstinence Syndrome:The Experience of Infant Massage

Babies born to women who have used opioids during pregnancy frequently develop withdrawal symptoms following birth. Although a consistently used protocol is not available to treat these infants, interventions commonly used include a pharmacological regimen and supportive care such as swaddling, frequent feedings, decreased sensory stimulation, and protection from skin breakdown (Murphy-Oikonen, Montelpare, Bertoldo, Southon, & Persichino, 2012). A qualitative study was designed to better understand how infant massage might impact these babies’ behavior and the mothers’ relationship with their babies. Themes derived from the data include empowerment, enjoyment and bonding, and calm and comfort. The themes suggest that infant massage helps alleviate withdrawal symptoms in infants while fostering a connection between mother and child.

Evidence-based nurse-driven interventions for the care of newborns with neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is a growing problem in the United States, related to increased maternal substance use and abuse, and a set of drug withdrawal symptoms that can affect the central nervous system and gastrointestinal and respiratory systems in the newborn when separated from the placenta at birth. Infants with NAS often require a significant length of stay in the neonatal intensive care unit (NICU). Pharmacologic treatments and physician-directed interventions are well researched, but nursing-specific interventions and recommendations are lacking. A thorough review and analysis of the literature and interviews with neonatal experts guided the development of a nursing clinical practice guideline for infants with NAS in a level IV NICU. Recommended nursing-specific interventions include methods for maternal drug-use identification, initiation and timing of the Finnegan Scoring System to monitor withdrawal symptoms, and bedside interventions to lessen the drug-withdrawal symptoms in the newborn with NAS.