NANN Membership Recommendations: Opportunities to Advance Racial Equity Within the Organization.

BACKGROUND: Neonatal care has advanced significantly in recent years, yet racial health inequities persist in the neonatal intensive care unit (NICU), with infants from racial and ethnic minority groups less likely to receive recommended treatment. Healthcare providers acknowledge that there are steps that can be taken to increase knowledge and awareness regarding health inequities. PURPOSE: To better understand current health equity-related initiatives in the neonatal community and solicit feedback from National Association of Neonatal Nurses (NANN) membership about advancing racial equity within the organization. METHODS: A cross-sectional survey was conducted in January 2021. The anonymous, onetime survey was distributed to active NANN members via SurveyMonkey and included questions related to racial equity initiatives, recommendations, and demographics. Data analysis was conducted using an exploratory approach using descriptive statistics, and thematic analysis was used to summarize responses to open-ended questions. RESULTS: There were 325 members who completed the full survey, of whom were White (83%), female (96%), staff nurses (42%), and those with more than 16 years of experience (69%), and most (69%) were familiar with NANN's racial equity position statement. Recommendations were summarized into the following themes: (1) research, (2) education, (3) workforce diversity, (4) communication, (5) scholarships, (6) resources, and (7) community outreach. IMPLICATIONS FOR PRACTICE AND RESEARCH: NANN members offered clear and actionable recommendations to advance health equity within the neonatal community and organization, which included offering more diversity, inclusion, and equity education at the annual conferences, in ANC articles, and newsletters, and the creation of scholarships or reduced membership fees to encourage diverse enrollment in the organization.

Application of the Adverse Childhood Experiences Framework to the NICU.

BACKGROUND: Infants and families requiring neonatal intensive care unit (NICU) care often experience significant stress and trauma during the earliest period of the infant's life, leading to increased risks for poorer infant and family outcomes. There is a need for frameworks to guide clinical care and research that account for the complex interactions of generational stress, pain, toxic stress, parental separation, and lifelong health and developmental outcomes for infants and families. PURPOSE: Apply the Adverse Childhood Experiences (ACEs) framework in the context of the NICU as a usable structure to guide clinical practice and research focused on infant neurodevelopment outcomes and parental attachment. METHODS: An overview of ACEs is provided along with a detailed discussion of risk at each level of the ACEs pyramid in the context of the NICU. Supportive and protective factors to help mitigate the risk of the ACEs in the NICU are detailed. RESULTS: NICU hospitalization may be considered the first ACE, or potentially an additional ACE, resulting in an increased risk for poorer health outcomes. The promotion of safe, stable, and nurturing relationships and implementation of trauma-informed care and individualized developmental care potentially counter the negative impacts of stress in the NICU. IMPLICATIONS FOR PRACTICE AND RESEARCH: Nurses can help balance the negative and positive stimulation of the NICU through activities such as facilitated tucking, skin-to-skin care, mother's milk, and active participation of parents in infant care. Future research can consider using the ACEs framework to explain cumulative risk for adverse health and well-being in the context of NICU care.

Reimagining Supportive Approaches at the Intersection of Mandatory Reporting Policies for the Mother-Infant Dyad Affected by Substance Use.

BACKGROUND: As rates of substance use during pregnancy persist, the health and optimal development of infants with prenatal substance exposure remain a key priority. Nurses are tasked with identifying and reporting suspected cases of child maltreatment, including abuse and neglect, which is often assumed to be synonymous with substance use during pregnancy. While policies aimed at protecting infants from child abuse and neglect are well intentioned, literature regarding the short- and long-term social and legal implications of mandatory reporting policies is emerging. PURPOSE: In this article, we explore the intersections between the condition of substance use in pregnancy and policies related to mandatory reporting. METHODS: We provide an overview of historical and current trends in mandatory reporting policies for nurses related to substance use in pregnancy and related ethical and social implications for mother-infant dyads. RESULTS: Nurses often function at the intersection of healthcare and social services, underscoring the important role they play in advocating for ethical and equitable care for both members of the mother-infant dyad affected by substance use. IMPLICATIONS FOR PRACTICE AND RESEARCH: We offer recommendations for practice including the integration of respectful care and family-centered support for the mother-infant dyad affected by substance use. Cross-sectoral collaborations, inclusive of the family, are important to the advancement of evidence-based and equity-focused research, advocacy, and policy initiatives to support familial preservation and reduce mother-infant separation.

Exploring Environmental Factors Contributing to Fluid Loss in Diapers Placed in Neonatal Incubators.

PURPOSE: Assessing fluid output for infants in the neonatal intensive care unit is essential to understanding fluid and electrolyte balance. Wet diaper weights are used as standard practice to quantify fluid output; yet, diaper changes are intrusive and physiologically distressing. Less frequent diaper changes may have physiologic benefits but could alter diaper weights following extended intervals. METHODS: This pilot study examined the impact of initial diaper fluid volume, incubator air temperature and humidity, and diaper brand on wet diaper weight over time. Baseline fluid volume was instilled, and then diapers were placed in a neonatal incubator. Wet diaper weight was assessed longitudinally to determine changes in fluid volume over time. A factorial design with repeated measures (baseline, 3 hours, and 6 hours) was used to explore the effects of diaper brand (brand 1 vs brand 2), baseline fluid volume (3 mL vs 5 mL), and incubator temperature (28°C vs 36°C) and humidity (40% vs 80%) on the trajectory of weight in 80 diapers. RESULTS: Wet diaper weight was significantly reduced over 6 hours ( P < .005). However, wet diaper weight increased in 80% humidity, but decreased in the 40% humidity over time ( P < .0001). Baseline fluid volume, incubator temperature, and diaper brand did not influence wet diaper weight over time (all P > .05). IMPLICATIONS: Understanding environmental factors that influence the trajectory of wet diaper weight may support clinicians in optimizing the interval for neonatal diaper changes to balance the impact of intrusive care with need to understand fluid volume loss.

Integrating Neonatal Intensive Care Into a Family Birth Center: Describing the Integrated NICU (I-NIC).

BACKGROUND: Parent-infant separation resulting from admission to a neonatal intensive care unit (NICU) is often reported as the most challenging and distressing experience for parents. Aiming to mitigate the stress of parent-infant separation, a new neonatal care model was designed to integrate NIC with delivery and postpartum care. Yet, little is known about the model and its implementation. METHODS: Using a qualitative descriptive design with field observations, we describe the characteristics of an integrated-neonatal intensive care (I-NIC) model and examined perceptions of clinical staff (n = 8) and parents (n = 3). RESULTS: The physical layout of the I-NIC rooms required additional oxygen and suction columns and new signage to specify them as NICU-equipped. Other NICU-related equipment was mobile, thus moved into rooms when necessary. Nurses were cross-trained in labor/delivery, postpartum, neonatal care; however, nurses primarily worked within their specific area of expertise. Clinician and parent perceptions of the model were notably positive, reporting decreased anxiety related to separation, increased ability for chest feeding and skin-to-skin care, and improved interdisciplinary care. CONCLUSION: Future work is needed to understand implementation of the model in other settings, with specific attention to unit architecture, level of NICU care services, patient census, and staff and patient outcomes.

Cognitive behavioural therapy and medication for treatment of adolescent depression: a network meta-analysis.

BACKGROUND: Cognitive behavioural therapy (CBT) and medication are widely accepted and useful interventions for individuals with depression. However, a gap remains in our current understanding of how CBT directly benefits adolescents with depression. AIMS: The purpose of this study was to examine the short- and long-term effectiveness of CBT only, CBT+Medication, or Medication alone in reducing the duration of major depressive episodes, lessening internalizing and externalizing symptoms and improving global functioning. METHODS: Data were extracted from 14 unique studies with a total of 35 comparisons. Network meta-analysis was conducted and p-scores, a measure of the extent of certainty that one treatment is better than another, were used to rank treatments. RESULTS: There was no significant difference between any two treatments for depression, nor internalizing or externalizing symptoms. For global functioning, CBT had significantly greater effect at the longest follow-up than CBT+Medication. CBT+Medication had the highest p-score for depression, short- and long-term effects, and internalizing and externalizing symptoms long-term effects. No indication of publication bias was found. CONCLUSIONS: Neither modality, CBT nor medication, is superior for treating adolescent depression. However, CBT was superior in improving global functioning, which is essential for meeting developmental goals.

Developing a Family Resource: Considerations for Family Member Research Participation.

When individuals participate in health care research, the choice often affects the entire family. Researchers are responsible for protecting participants and minimizing any burdens the research may place on them. Resources to educate potential study participants about these issues from a family perspective are lacking. A family-focused, evidence-based resource was created for individuals and families to prompt discussion prior to their consenting to enrollment in research. The resource includes key relevant questions to consider related to their study participation and was revised based on input from family nurse scientists and a hospital-based family advisory group. This resource raises awareness of the importance of employing a family lens when designing research and during the recruitment and enrollment of participants. Adopting a family lens in health care research will support the participant's ability to make an informed choice regarding participation and may ultimately enhance the experience of participants and their families and study outcomes.

Parents' pandemic NICU experience in the United States: a qualitative study.

BACKGROUND: Prior to the COVID-19 pandemic, parents of infants in the Neonatal Intensive Care Unit (NICU) frequently reported high levels of stress, uncertainty, and decreased parenting confidence. Early research has demonstrated that parents have had less access to their infants in the hospital due to restrictions on parental presence secondary to the pandemic. It is unknown how parents have perceived their experiences in the NICU since the beginning of the COVID-19 pandemic. The purpose of this study was to describe the lived experience of parents who had an infant in the NICU in the context of the COVID-19 pandemic to inform healthcare providers and policy makers for future development of policies and care planning. METHODS: The study design was a qualitative description of the impact of the COVID-19 pandemic on parents' experiences of having an infant in the NICU. Free-text responses to open-ended questions were collected as part of a multi-method study of parents' experiences of the NICU during the first six months of the pandemic. Participants from the United States were recruited using social media platforms between the months of May and July of 2020. Data were analyzed using a reflexive thematic approach. FINDINGS: Free-text responses came from 169 parents from 38 different states in the United States. Three broad themes emerged from the analysis: (1) parents' NICU experiences during the COVID-19 pandemic were emotionally isolating and overwhelming, (2) policy changes restricting parental presence created disruptions to the family unit and limited family-centered care, and (3) interactions with NICU providers intensified or alleviated emotional distress felt by parents. A unifying theme of experiences of emotional distress attributed to COVID-19 circumstances ran through all three themes. CONCLUSIONS: Parents of infants in the NICU during the first six months of the COVID-19 pandemic experienced emotional struggles, feelings of isolation, lack of family-centered care, and deep disappointment with system-level decisions. Moving forward, parents need to be considered essential partners in the development of policies concerning care of and access to their infants.

Impacts of Neonatal Hospitalization on Families during the 2019 Coronavirus Pandemic.

OBJECTIVE: Limited data are available regarding family and financial well-being among parents whose infants were hospitalized during the 2019 coronavirus (COVID-19) pandemic. The study objective was to evaluate the family and financial well-being of parents whose infants were hospitalized in the neonatal intensive care unit (NICU) during COVID-19. STUDY DESIGN: Parents were recruited for this online, cross-sectional survey via support groups on social media. Data collection was completed between May 18, 2020 and July 31, 2020. The final sample consisted of 178 parents, who had an infant hospitalized in an NICU between February 1, 2020 and July 31, 2020. The primary outcomes were impact on family life and financial stability, as measured by the Impact on Family scale, an instrument that evaluates changes to family life as a result of infant or childhood illness. RESULTS: Of the 178 parent respondents, 173 (97%) were mothers, 107 (59.4%) were non-Hispanic White, and 127 (69.5%) of the infants were born prematurely. Parents reported significant family impact and greater financial difficulty. Extremely premature infants, lower household income, parent mental health, and lower parental confidence were predictive of greater impacts on family life. CONCLUSION: Parents reported significant family and financial impacts during their infant's hospitalization amid COVID-19. Further studies are needed to guide clinical practice and inform family-supportive resources that can mitigate consequences to family well-being. KEY POINTS: · Impact of infant hospitalization in the context of COVID-19 is largely unknown.. · In a cohort of NICU parents during COVID-19, they reported changes to family life and finances.. · Greater impacts were reported by parents with lower income, confidence, and very premature infants..

Becoming an Antiracist Neonatal Community.

BACKGROUND: There are pervasive and documented disparities in maternal and infant outcomes related to race and ethnicity. Critical awareness is growing in our current cultural environment about strategies to improve health equity, the need to challenge implicit bias, and dismantle racism in healthcare to decrease racial health inequities. METHODS: In this article, we provide a summary of health inequities that exist within the perinatal/neonatal population and offer strategies for initiating conversations and improving health equity by challenging bias and increasing diversity. RESULTS: Transformative leaders must understand the evidence related to health disparities, understand social drivers of inequity issues, and identify solutions to influence change. IMPLICATIONS FOR PRACTICE: With heightened awareness and examination of implicit bias, we can improve care for all infants and their families. IMPLICATIONS FOR RESEARCH: We need to continue research and quality improvement efforts to improve health equity. Furthermore, research is needed that focus on social determinants of health as drivers of preterm delivery and birth complications, rather than biological (eg, racialized) factors.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=42.

Inpatient Unit Leaders' Perspectives on Parent Engagement in Neonatal and Pediatric Intensive Care: A Secondary, Qualitative Analysis.

BACKGROUND: Hospital unit leaders help set the unit's priorities and are responsible for guiding the unit mission and philosophy of care; however, the perspective of leaders in facilitating parent engagement within intensive care units is limited. PURPOSE: The purpose of this study was to explore how medical and nursing unit leaders facilitate parent engagement in intensive care settings. METHODS: Qualitative secondary analysis of 16 semistructured interviews of unit leadership (medical directors and nurse managers). Directed content analysis explored themes within the interviews using systematic strategies to ensure rigor. FINDINGS: Unit leadership described 3 main features of care delivery necessary for supporting parent engagement: (1) culture of care, (2) relationships in care, and (3) environment of care. Communication among providers and parents and timing of decision-making were key areas addressed, along with concerns about physical space limiting parent engagement. Unit leaders discussed how the 3 main features (unit culture, relationships, and physical space) of care delivery were interconnected to optimize parent engagement. IMPLICATIONS FOR PRACTICE: Overall, unit leaders recognized the importance of each feature of care delivery in facilitating engagement. Parent engagement is ultimately influenced by the optimization of delivering inclusive care: the physical space, the policies surrounding medical and nursing care, and the overall culture of the unit. IMPLICATIONS FOR RESEARCH: Future research needs to explore best practices around relationship building and managing space limitations. Further clarification of the needs and expectations of both parents and providers surrounding parent engagement in intensive care settings is needed.

Patterns of Parenting Confidence Among Infants With Medical Complexity: A Mixed-Methods Analysis.

BACKGROUND: Parenting confidence is an important factor in fostering optimal health and development of infants with medical complexity. However, our understanding of how parents of medically complex infants describe development of confidence is limited. The purpose of this mixed-methods study was to describe the nature and development of parenting confidence. METHODS: A mixed-method design was used to examine how parents described their level of confidence. Ten parents of infants with medical complexity. Quantitative measures provided patterns of confidence and qualitative data focused on parent descriptions of confidence. Parents completed online surveys at 3 time points: (1) study enrollment, (2) infant discharge from hospital, and (3) 3 months after discharge. Parents were purposively sampled, using their confidence patterns, for qualitative phone interviews. RESULTS: Our analysis of quantitative findings revealed 3 confidence patterns: (1) increasing, (2) stable, and (3) varying. Parents described their confidence as either (1) a state of being confident or (2) how they behaved in the parenting role. Parents felt both certain and uncertain in their level of confidence and described confidence as being situationally dependent. IMPLICATIONS FOR PRACTICE: Parenting confidence needs to be cultivated through encouragement and repeated exposure to parenting behaviors. Nurses are well-suited to help identify parents with low confidence to support parents so that they can develop confidence. IMPLICATIONS FOR RESEARCH: Because there is variability in parent confidence during this critical early period of life, future research should consider a larger cohort of parents that compares confidence in diverse parent groups (ie, married vs living together couples, same-sex couples, and single parents). Research should also examine effective strategies to promote confidence and associated long-term health and developmental outcomes.

A systematic review of human papillomavirus vaccination among US adolescents.

The human papillomavirus (HPV) causes many anogenital and oral cancers affecting young adults in the United States. Vaccination during adolescence can prevent HPV-associated cancers, but vaccine uptake among adolescents is low and influenced by factors serving as barriers and facilitators to HPV vaccination. In this systematic review, we synthesized research using the socioecological framework model to examine individual-level, relationship-level, community-level, and societal-level factors that influence HPV vaccine initiation and completion among US adolescents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to guide the methodology for this review. An electronic search was conducted in January 2020 using PubMed, Cumulative Index of Nursing and Allied Health Literature, ProQuest Central, Scopus, and American Psychological Association PsycInfo databases. The Joanna Briggs Institute tools were used to assess the quality for the 57 studies included in this review. The most consistent influences of HPV vaccination included age at vaccination, awareness, and knowledge about HPV vaccination, socioeconomic status, insurance status, race/ethnicity, and preventative care behaviors at the individual level. Provider recommendation, familial/peer support of vaccination, and parental health behaviors were influences at the relationship level. Although fewer findings elucidated community-level and societal-level influences, high-poverty areas, high-risk communities with large proportions of racial/ethnic minority groups, healthcare facilities servicing children, and combined health policies appear to serve as facilitators of HPV initiation and completion. Findings from this review can inform culturally relevant and age-specific interventions and multi-level policies aiming to improve HPV vaccination coverage in the United States.

Parenting Self-Efficacy in Fathers of Medically Complex Infants: A Longitudinal Study.

INTRODUCTION: Infants with medical complexity are have multiple chronic conditions and require specialized intensive care. One important factor in optimizing infant health and development is parenting self-efficacy (PSE). The purpose of this study was to examine parental self-efficacy in fathers over time. METHODS: A longitudinal survey study was conducted with fathers of medically complex infants. We used the validated Karitane Parent Confidence Scale to assess PSE and multivariable linear regression examined the associations between father and infant characteristics on PSE. RESULTS: Fathers (n=27) were white (74%), married (85%), high school educated (37%), with incomes ≥ $US50,000 (66%). Father's mean PSE score was 39.28 (±3.9). Hispanic ethnicity and total number of chronic conditions were significant predictors of lower PSE in fathers (p < .03). CONCLUSIONS: Fathers of medically complex infants reported low PSE. More strategic interventions need to focus on self-efficacy and creating opportunities for connection between fathers and infants.

Psychosocial Correlates of Jordanian Adolescents' Help-Seeking Intentions for Depression: Findings From a Nationally Representative School Survey.

Little is known about help-seeking for depression among Jordanian adolescents who are a vulnerable population with high rates of depressive symptoms and few mental health services. The purpose of this study was to (1) explore Jordanian adolescents' helpseeking intentions for depression and (2) examine whether depression stigma, depression severity, or their interaction are associated with Jordanian adolescents' willingness to seek help for depression and the type of treatment they would seek. In collaboration with the Jordanian Ministry of Education, we conducted a nationally representative, school-based survey of adolescents aged 12-17 years ( N = 2,349). One fourth of the adolescents reported they would not seek professional help for depression, and those respondents had higher average depression scores. Among those adolescents willing to seek help, the most likely sources included family member (57%), school counselor (46%), psychiatrist (43%), religious leader (39%), and general health practitioner (28%). Lower stigma scores were associated with greater likelihood to seek psychotherapy or visit a psychiatrist, while higher stigma scores were associated with increased likelihood to seek help from a school counselor or a family member. Jordanian adolescents experience significant barriers to seeking professional help for depression. However, even among adolescents with greater depression severity and depression stigma, school counselors were identified as a key resource for help. These findings suggest that school-based interventions may fill a critical service need for adolescents with depression and other mental health problems. School nurses should be leveraged along with counselors to address mental health issues in this vulnerable population.

Associations between sociodemographic characteristics and neonatal length of the stay.

BACKGROUND: Infants with past NICU admission have a significantly higher risk of developing neurodevelopmental disorders. Studies have demonstrated an iatrogenic effect of the NICU environment on neurodevelopmental outcomes, even while accounting for physical factors. It is, therefore, critical that an infant's LOS is driven by physical needs versus sociodemographic barriers. METHODS: We leveraged electronic health records and a backward selection regression model to explore physical and sociodemographic predictors of infant LOS. RESULTS: Our results demonstrated that physical predictors (birthweight and ventilator use) accounted for the majority of variance in our model but that a sociodemographic predictor, mean visits per day, was also significant. CONCLUSIONS: Infants who were visited more frequently experienced a shorter LOS, possibly due to increased parental involvement resulting in more individualized care and directly impacting infant stability and morbidity. By supporting visitation, we can reduce the costs of lengthy NICU hospitalizations while improving infant and parent health and well-being.

Diagnosed behavioral health conditions during the perinatal period among a commercially insured population by race/ethnicity, 2008-2020.

Objective: We sought to examine trends in diagnosed behavioral health (BH) conditions [mental health (MH) disorders or substance use disorders (SUD)] among pregnant and postpartum individuals between 2008-2020. We then explored the relationship between BH conditions and race/ethnicity, acknowledging race/ethnicity as a social construct that influences health disparities. Methods: This study included delivering individuals, aged 15-44 years, and continuously enrolled in a single commercial health insurance plan for 1 year before and 1 year following delivery between 2008-2020. We used BH conditions as our outcome based on relevant ICD 9/10 codes documented during pregnancy or the postpartum year. Results: In adjusted analyses, white individuals experienced the highest rates of BH conditions, followed by Black, Hispanic, and Asian individuals, respectively. Asian individuals had the largest increase in BH rates, increasing 292%. White individuals had the smallest increase of 192%. The trend remained unchanged even after adjusting for age and Bateman comorbidity score, the trend remained unchanged. Conclusions: The prevalence of diagnosed BH conditions among individuals in the perinatal and postpartum periods increased over time. As national efforts continue to work toward improving perinatal BH, solutions must incorporate the needs of diverse populations to avert preventable morbidity and mortality.