Effect of Routine Nurse Caregiving on the Stress Responses and Behavior State in Preterm Infants: A Systematic Review.

BACKGROUND: Although routine nurse caregiving is vital for the overall health of preterm infants, variations in approaches may exert distinct effects on preterm infants' stress responses and behavior state. PURPOSE: The purpose of this systematic review was to examine routine nurse caregiving in the neonatal intensive care unit and its effect on stress responses and behavior state in preterm infants. DATA SOURCES: A systematic search was conducted using PubMed, Embase, and CINAHL for studies published between 2013 and 2023. STUDY SELECTION: Included studies enrolled preterm infants born <37 weeks gestational age and investigated nurse caregiving practices and effects on stress responses and/or behavior state. DATA EXTRACTION: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, data about study design, methods, findings, and limitations were extracted and summarized. Included studies were evaluated for bias using the National Health, Lung, and Blood Institute quality assessment tools. RESULTS: All 13 studies included in the review received a fair quality rating. Nurse caregiving activities, including suctioning, diaper changes, bathing, and weighing, were associated with increases in heart and respiratory rates, blood pressure, energy expenditure, and motor responses, lower oxygen saturations, and fewer sleep states. IMPLICATIONS FOR PRACTICE AND RESEARCH: Adapting nurse caregiving frequency and duration, aligning caregiving with infant state, and integrating developmental care strategies may reduce infant stress responses and support behavioral rest. Further research is needed to understand how caregiving activities affect stress responses and behavior state in preterm infants, aiding in identifying modifiable caregiving stressors to promote optimal development.

Parent Perspectives on Communication Quality in the Neonatal Intensive Care Unit.

BACKGROUND: Though prior literature has demonstrated that communication in the Neonatal Intensive Care Unit (NICU) needs to be improved, in-depth descriptions of parents' views of NICU communication are lacking. PURPOSE: We sought (1) to explore parent perceptions of communication in the NICU and (2) to understand parents' communication needs and preferences. METHODS: We conducted in-depth semi-structured cognitive interviews utilizing concurrent probes with parents of 10 patients in our urban level IV Neonatal Intensive Care Unit over a period of 4 months (July 2021-October 2021). Interview questions were derived from the Quality of Communication scale. We conducted thematic analysis of interview transcripts modeled after work by Braun and Clarke. RESULTS: Four overarching themes were identified: Strengths, Challenges, People, and Coping Strategies. Parents reported a range of communication quality in the NICU. Results revealed that the first 48 hours of NICU hospitalization represent a period of vulnerability and uncertainty for parents. Parents value clear yet hopeful communication about a baby's clinical status and expected course. IMPLICATIONS FOR PRACTICE AND RESEARCH: We hope that the concrete findings from this study can both inform practice in the NICU now and influence practice guidelines to include such components as emphasis on the first 48 hours, desire for proactive information sharing, and the importance of including hope.

Pilot Testing Transcreated Spanish-Language Study Materials for Symptom Research With Infants and Parents in the Neonatal Intensive Care Unit.

BACKGROUND: Rising admission rates of Hispanic/Latinx families to the neonatal intensive care unit (NICU) have increased the number of non-English-speaking individuals who may wish to participate in research studies. However, a lack of appropriately translated research study materials may limit the opportunity for these families to be involved in research that could impact the care that infants and families receive in the NICU. PURPOSE: The primary purpose was to pilot test study materials that were transcreated from English to Spanish with the assistance of a bilingual community advisory board with Spanish-speaking parents of NICU infants. METHODS: A total of 19 Spanish-speaking parents (15 mothers and 4 fathers) who were representative of the population of interest completed paper-and-pencil surveys, along with a cognitive interview. Preliminary data related to decision-making and goals of care, infant symptoms, and their experiences in the NICU were also collected. RESULTS: The internal reliability of the transcreated study instruments ranged from good to excellent (α= 0.82-0.99). Participants reported that study materials were not offensive and did not make them feel uncomfortable; however, they found some words/phrases to be confusing. Parents had the opportunity to provide suggested wording changes. IMPLICATIONS FOR PRACTICE AND RESEARCH: Language barriers and a lack of cultural responsiveness can affect the care that infants and their families receive. More accurate and culturally appropriate transcreation of study materials can remove barriers to research participation and facilitate better communication with non-English-speaking families, which may lead to the development of better-informed evidence-based interventions and clinical practices in the NICU.

Improving Self-Reported Person-centered Care Competency in Nursing Students: A Pilot Study Using Interactive Case Studies.

BACKGROUND: To prepare nursing students to deliver high-quality care, educators need strategies to foster person-centered care (PCC). PURPOSE: This pilot study evaluated an intervention with interactive case studies on undergraduate nursing students' PCC competency. METHODS: We conducted a pilot study with sophomore undergraduate nursing students (n = 39) from a Midwestern US university. We developed a 90-minute class seminar with interactive case studies highlighting how patient preferences, values, and circumstances could influence fall risk. We assessed PCC using the Patient-Centered Care Competency Scale. RESULTS: Although there was no statistically significant change in overall PCC competency before and after the intervention, we noted a small to medium effect size on PCC competency per Cohen's d standards (d = 0.35). Content analysis of students' open-ended responses reflected PCC and clustered into 5 themes. CONCLUSIONS: Findings suggest that educators may use interactive case studies to foster nursing student PCC competency.

Using the life course health development model to address pediatric mental health disparities.

TOPIC: Early-life experiences, the transmission of health and disease within families, and the influence of cumulative risks as well as protective factors throughout life shape the trajectory of health, including mental health. Long-term health trajectories established early in life are influenced by biologic, social, and environmental factors. Negative trajectories may be more salient if exposures to adversity occur during critical developmental periods. PURPOSE: The purpose of this brief is to (a) review pediatric health disparities related to depression and the intergenerational transmission of pediatric depression using a Life Course Health Development (LCHD) model and (b) provide recommendations for pediatric mental health research. SOURCES: Peer-reviewed papers available for PubMed, CINAL, and Medline. Other sources include published books, papers, and gray materials. CONCLUSIONS: The LCHD model is a perspective to guide and foster new scientific inquiry about the development of mental health outcomes over the life course. The model enables synthesis of mental health, nursing, and public health, linking mental health prevention, risk reduction, and treatment in children.

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.

Parent Perspectives on Defining Neonatal Serious Illness.

Objectives: We hoped to understand (1) how parents of seriously ill neonatal intensive care unit patients conceptualize neonatal serious illness, and (2) how parent and physician perspectives on neonatal serious illness might differ. Design: This was a prospective survey study. Setting/Subjects: Parent members of the Courageous Parents Network. Measurements: We circulated a modified version of a previously developed survey. Participants were presented with a list of potential definition components and asked to rank components by importance and suggest modifications to the definition as needed. Thematic analysis of free-text responses was conducted to identify key themes in parent responses Results: Eighty-eight percent of parent participants agreed or strongly agreed with our working definition of neonatal serious illness. Parents agreed with the content of the definition but suggested using different language (especially less jargon) when using the definition to inform conversations with parents. Conclusions: The majority of parents surveyed for this study supported our definition of neonatal serious illness, which suggests that it may be useful for clinical and research applications. At the same time, parent responses revealed important differences in perceptions about serious illness between parents and physicians. In addition, parents will likely use any definition of neonatal serious illness differently than clinicians. We therefore propose that our definition be used to identify neonates with serious illness for the purposes of research and clinical care, but should not be used verbatim for communication with parents.

Defining Neonatal Serious Illness: Perspectives of Nurses and Social Workers.

Objectives: To explore (1) how neonatal nurses (NN) and social workers (SW) define serious illness and (2) how physician, nurse, and SW perceptions of serious illness differ. Design: Prospective survey study. Setting/Subjects: Members of the National Association of Neonatal Nurses or the National Association of Perinatal Social Workers. Measurements: We circulated a modified version of a previously developed survey. Participants were given a list of definition components and asked to rank components by importance and to suggest modifications. Results: Eighty-eight percent of participants agreed with our definition of neonatal serious illness. NN and SW differ in important ways in their views of neonatal serious illness when compared with physicians and parents. Conclusions: Our definition of neonatal serious illness has broad acceptability and may be useful for clinical care and research. Future work should prospectively identify patients with neonatal serious illness and establish the usefulness of our definition in real time.

Inclusion of Spanish-Speaking Families in NICU Symptom Research Using a Community Advisory Board.

BACKGROUND: Admission rates of Hispanic/Latinx families to the neonatal intensive care unit (NICU) are rising, yet knowledge regarding their experiences is limited. Non-English-speaking families are often excluded from research because study measures are not available in their language. The inclusion of these families in NICU research is crucial to understand the impact of cultural and language barriers in infant and family care, and the translation of study measures into Spanish could better ensure that these families' perspectives are included. However, previous research has utilized the standard translation-backtranslation method with which problems have been noted. PURPOSE: This article describes the planning, preparation, and action phases that were completed with the use of a community advisory board (CAB) to prepare and transcreate research study materials from English to Spanish for pilot testing. METHODS: Community members of interest were invited to form the CAB, and 2 meetings were held to review study materials in the English and Spanish versions. Prior to the second meeting, a professional translation company translated study materials from English to Spanish. RESULTS: Feedback from the CAB ensured consistent content and reading levels, and culturally appropriate language usage. The CAB also provided suggestions to the research protocol and advised sensitive methods of recruitment and measure administration. IMPLICATIONS FOR PRACTICE AND RESEARCH: More accurate and culturally appropriate transcreation of study measures can reduce barriers to research participation and facilitate better communication with non-English-speaking families in health equity research to better inform evidence-based interventions and clinical practices across diverse groups.

Preliminary Validation of the Psychosocial Assessment Tool in the Neonatal Intensive Care Unit.

OBJECTIVE: Research suggests families whose infants are admitted to the Neonatal Intensive Care Unit (NICU) experience elevated distress and may have pre-existing risk factors for maladjustment. This study sought to validate the newly developed Psychosocial Assessment Tool (PAT-NICU/Cardiac Intensive Care Unit [CICU]), a comprehensive screening measure for family psychosocial risk in the NICU. METHODS: The sample included 171 mothers, who completed the PAT-NICU/CICU and other related measures within 2 weeks of their infant's NICU admission at a level 4 unit within a large pediatric hospital. PAT-NICU/CICU scores were compared to a companion risk survey completed by NICU social workers. Test-retest reliability was assessed through repeated measures at 2-month follow-up. RESULTS: Analyses suggest the PAT-NICU/CICU is effective in classifying psychosocial risk. This is supported by statistically significant correlations between the PAT-NICU/CICU and validated measures, in addition to elevated scores on concurrent measures by risk classification. Internal consistency, test-retest reliability, and acceptability for the PAT-NICU/CICU were satisfactory. CONCLUSIONS: This preliminary study demonstrates the validity, reliability, and acceptability of the PAT-NICU/CICU as a psychosocial screening tool to aid identification of families who may benefit from supportive services during NICU admission. This new measure is a more comprehensive tool that assesses a wide variety of risk factors and stress responses. However, future studies of this measure are needed with more diverse samples. Prompt screening of NICU parents may facilitate earlier linkage with appropriate levels of resources or intervention. This research is crucial in improving risk assessment and psychosocial care for families in the NICU.

Characteristics of Critically Ill Infants at the End of Life in the Neonatal Intensive Care Unit.

Objectives: About 16,000 infants die in the neonatal intensive care unit (NICU) each year with many experiencing invasive medical treatments and high number of symptoms.1 To inform better management, we characterized diagnoses, symptoms, and patterns of care among infants who died in the NICU. Method: Retrospective electronic medical record (EMR) review of 476 infants who died following admission to a large regional level IV NICU in the United States over a 10-year period. Demographic, symptom, diagnosis, treatment, and end-of-life characteristics were extracted. Results: About half of infants were male (55.9%, n = 266), average gestational age was 31.3 weeks (standard deviation [SD] = 6.5), and average age at death was 40.1 days (SD = 84.5; median = 12; range: 0-835). Race was documented for 65% of infants, and most were White (67.0%). One-third of infants (n = 138) were seen by fetal medicine. Most infants experienced pain through both the month and week before death (79.6%), however, infants with necrotizing enterocolitis had more symptoms in the week before death. Based on EMR, infants had more symptoms, and received more medical interventions and comfort measures during the week before death compared with the month prior. Only 35% (n = 166) received a palliative care referral. Conclusions: Although the medical profiles of infants who die in the NICU are complex, the overall number of symptoms was less than in older pediatric populations. For infants at high risk of mortality rate, providers should assess for common symptoms over time. To manage symptoms as effectively as possible, both timely and continuous communication with parents and early referral to palliative care are recommended.

Building Strong Clinician-Researcher Collaborations for Successful Hospice and Palliative Care Research.

Hospice and palliative care research aim to build a knowledge base to guide high-quality care for people with serious illness and improve their quality of life. Considering its focus on patient and family caregiver's experiences, hospice and palliative care research activities primarily take place in real-world clinical settings where seriously ill patients and their family caregivers receive care (eg, nursing homes, clinics, inpatient units). Conducting research in these settings poses many challenges because researchers, clinicians, and administrators may have different priorities-and scientific control is difficult. Therefore, clinician-researcher-administrator collaboration in planning and conducting studies is critical for successful hospice and palliative care research. For an effective collaboration, clinicians, researchers, and site administrators must be considered equal partners. Each collaborator brings their unique expertise, knowledge, and skills that when combined can strengthen scientific rigor, feasibility, and success of the project, as well as have study outcomes that are more translatable to real-world practice. However, little guidance exists to give actionable steps to build collaborative partnerships for hospice and palliative care researchers. The purpose of this article is to describe the process of forming successful clinician-researcher-administrator collaborations through five phases of the research life cycle: idea generation, partnership, proposal writing, research process, and dissemination. Exemplars are drawn from the authors' experiences conducting collaborative research and highlight strategies and resources for successful hospice and palliative care collaborations.

Systematic review of family engagement interventions in neonatal, paediatric, and adult ICUs.

AIMS AND OBJECTIVES: The purpose of this systematic review was to evaluate interventions that have been used to engage families in direct care activities (active family engagement) in adult, paediatric, and neonatal intensive care unit (ICU) settings. BACKGROUND: Family engagement is universally advocated across ICU populations and practice settings; however, appraisal of the active family engagement intervention literature remains limited. SEARCH STRATEGY: Ovid Medline, PsycArticles & PsycInfo, Scopus, and CINAHL were searched for family interventions that involved direct care of the patient to enhance the psychological, physical, or emotional well-being of the patient or family in neonatal, paediatric, or adult ICUs. INCLUSION/EXCLUSION CRITERIA: Studies were included if an active family engagement intervention was evaluated. Studies were excluded if they were not published in English or reported non-interventional research. RESULTS: A total of 6210 abstracts were screened and 19 studies were included. Most studies were of low to moderate quality and were conducted in neonatal ICUs within the United States. Intervention dosage and frequency varied widely across studies. The interventions focused on developmental care (neonatal ICU) and involved families in basic patient care. Family member outcomes measured included satisfaction, stress, family-centred care, confidence, anxiety, and depression. Most studies found improvements in one or more outcomes. CONCLUSIONS: There is a paucity of literature about active family engagement interventions, especially in adult and paediatric populations. The optimal dosage and frequency of family engagement interventions remains unknown. Our systematic review found that data are limited on the relationship between family engagement and patient outcomes, and provides a timely appraisal to guide future research. RELEVANCE TO CLINICAL PRACTICE: Further research on the efficacy of family engagement interventions is warranted. The translation of active family engagement interventions into clinical practice should also be supported.

End-of-Life Healthcare Service Needs Among Children With Neurological Conditions: A Latent Class Analysis.

ABSTRACT: BACKGROUND: At the end of life, children with neurological conditions have complex healthcare needs that can be met by providing care of their life-limiting conditions concurrently with hospice care (ie, concurrent care). Given the limited literature on concurrent care for children with neurologic conditions, this investigation aimed to identify patterns of nonhospice, healthcare service needs and to assess characteristics of children within each group. METHODS: A nationally representative sample children with neurological conditions enrolled in concurrent hospice care was used. Latent class analysis and descriptive statistics were calculated to identify patterns of healthcare needs and characteristics of children within the groups. A subgroup analysis of infants was conducted. RESULTS: Among the 1601 children, the most common types of services were inpatient hospitals, durable medical equipment, and home health. Two classes of service needs were identified: moderate intensity (58%) and high intensity (42%). Children in the moderate-intensity group were predominantly between 1 and 5 years old, male, White, and non-Hispanic. The most common neurological condition was central nervous system degeneration. They also had significant comorbidities, mental/behavioral health conditions, and technology dependence. They commonly resided in urban areas in the South. Children in the high-intensity group had a wide range of neurological conditions and high acuity. The subgroup analysis of infants indicated a different neurological profile. CONCLUSIONS: Two distinct classes of nonhospice, healthcare service needs emerged among children with neurological conditions at the end of life. The groups had unique demographic profiles.

Predictive Ability of an Illness Severity Measure: Implications for Nursing Research.

BACKGROUND AND PURPOSE: Illness severity among children with life-limiting illnesses is measured with the pediatric complex chronic conditions (CCC) measure. Developed in 2000/2001, it was revised in 2014 to include infant-specific categories. METHODS: Discrimination, calibration, accuracy, and validation tests were used to examine the predictive performance of the measures. RESULTS: Among the 10,175 infants in the analysis, both measures poorly discriminated-palliative care consultation (C-statistics 0.6396 vs. C-statistics 0.5905) and any inpatient procedure (C-statistics 0.6101 vs. C-statistics 0.5160). The Hosmer-Lemeshow goodness-of-fit tests revealed good calibration for both measures. The original measure was more accurate in predicting end-of-life outcomes-palliative care consultation (Brier Score 0.3892 vs. 0.7787) and any inpatient procedures (Brier Score 0.3115 vs. 0.4738). CONCLUSIONS: The revised measure did not perform any better than the original in predicting end-of-life outcomes among infants.

Parent Perceptions of Infant Symptoms and Suffering and Associations With Distress Among Bereaved Parents in the NICU.

CONTEXT: Healthcare providers and parents face many challenges caring for infants at the end of life (EOL). Symptom assessment and management in critically ill infants can be especially difficult. However, the impact of the infant's EOL experience on bereaved parents is largely unknown. OBJECTIVE: Explore associations between parental perceptions of infant symptoms and suffering at EOL in the neonatal intensive care unit (NICU) and parent adjustment following the death. METHODS: Retrospective, cross-sectional pilot study involving parents of infants who died within the previous five years in a large, Midwestern, level IV NICU. Parents were recruited through mailed invitations, and 40 mothers and 27 fathers participated from 40 families. Parents retrospectively reported on infant symptom burden and suffering during the last week of life and the Impact of Events Scale-Revised (IES-R), and Prolonged Grief-13 (PG-13). Hierarchical regressions examined demographic/medical factors and parent perceptions at EOL in relation to post-traumatic stress symptoms (PTSS) and prolonged grief (PG). RESULTS: Clinical levels of PTSS (Mothers = 18%; Fathers = 11%) and PG (Mothers and Fathers = 3%) were low. Maternal perception of higher symptom burden was associated with greater PTSS, R2 = 0.46, P= 0.001, and PG, R2 = 0.47, P < 0.01. Paternal perception of greater infant suffering was associated with greater PTSS, R2 = 0.48, P= 0.001, and PG, R2 = .38, P < 0.01. CONCLUSION: Perceptions of symptoms and suffering were associated differently with mother and father adjustment after bereavement. While not necessarily causal, better symptom management at EOL could minimize distress for both infants and their parents.

Use of an Electronic Reporting Tool and Clinical Surveillance Process in the Neonatal Intensive Care Unit to Decrease Risk for Central Venous Catheter Complications Associated With Tip Migration.

This quality improvement project formalized central venous catheter tip surveillance augmented by the use of electronic patient reporting tool. The project setting was a large level IV academic neonatal intensive care unit with a representative convenience sample of patients with central venous catheters and quality improvement reports of complications from tip migration. Providers received education before implementation of a central venous catheter tip surveillance program using a revised electronic reporting tool was initiated. Provider evaluations of the electronic reporting tool included compliance with the guidelines and use of the tool in multidisciplinary patient rounds, and were entered into a database for analysis. Nine evaluations of the electronic reporting tool were completed, with an average of 97% compliance with guidelines. Seven evaluations during multidisciplinary patient rounds using the reporting tool data demonstrated use by both resident physicians and advanced practice nurses. Central venous catheter patient data were reviewed after process implementation. Overall, infant central venous catheter complications related to tip migration decreased following implementation. Therefore, the use of an electronic reporting tool improved compliance with evidence-based clinical practice guidelines and resulted in a decrease in the risk for central venous line complications related to tip migration in this setting.