The knowledge, attitude and behavior on the palliative care among neonatal nurses: what can we do.

BACKGROUND: Neonatal nurses should provide timely and high-quality palliative care whenever necessary. It's necessary to investigate the knowledge, attitude and behavior of palliative care among neonatal nurses, to provide references and evidences for clinical palliative care. METHODS: Neonatal intensive care unit (NICU) nurses in a tertiary hospital of China were selected from December 1 to 16, 2022. The palliative care knowledge, attitude and behavior questionnaire was used to evaluate the current situation of palliative nursing knowledge, attitude and behavior of NICU nurses. Univariate analysis and multivariate logistic regression analysis were used to analyze the influencing factors. RESULTS: 122 nurses were finally included. The average score of knowledge in neonatal nurses was 7.68 ± 2.93, the average score of attitude was 26.24 ± 7.11, the score of behavior was 40.55 ± 8.98, the average total score was 74.03 ± 10.17. Spearman correlation indicated that score of knowledge, attitude and behavior of palliative care in neonatal nurses were correlated with the age(r = 0.541), year of work experience(r = 0.622) and professional ranks and titles(r = 0.576) (all P < 0.05). Age (OR = 1.515, 95%CI: 1.204 ~ 1.796), year of work experience (OR = 2.488, 95%CI: 2.003 ~ 2.865) and professional ranks and titles (OR = 2.801, 95%CI: 2.434 ~ 3.155) were the influencing factors of score of knowledge, attitude and behavior of palliative care (all P < 0.05). PUBLIC CONTRIBUTION: NICU nurses have a positive attitude towards palliative care, but the practical behavior of palliative care is less and lack of relevant knowledge. Targeted training should be carried out combined with the current situation of knowledge, attitude and practice of NICU nurses to improve the palliative care ability and quality of NICU nurses.

Barriers to the Implementation of Infant- and Family-Centered Developmental Care From Focus Groups With Neonatal Care Providers.

AIM: Although infant- and family-centered developmental care (IFCDC) is scientifically grounded and offered in many hospitals to some extent, it has not yet been universally implemented as the standard of care. In this article, we aim to identify barriers to the implementation of IFCDC in Belgian neonatal care from the perspective of neonatal care providers. METHODS: We conducted 8 online focus groups with 40 healthcare providers working in neonatal care services. An inductive thematic analysis was carried out by means of Nvivo. RESULTS: The focus groups revealed barriers related to contextual, hospital, and neonatal unit characteristics. Barriers found in the hospital and neonatal unit were related to financing, staffing, infrastructure, access to knowledge/information and learning climate, leadership engagement, and relative priority of IFCDC. Contextual barriers were related to peer pressure and partnerships, newborn/parent needs and resources, external policy, and budgetary incentives. CONCLUSION: Three main barriers to IFCDC implementation have been identified. Resources (staffing, financing, and infrastructure) must be available and aligned with IFCDC standards, knowledge and information have to be accessible and continuously updated, and hospital management should support IFCDC implementation to create an enabling climate, including compatibility with the existing workflow, learning opportunities, and priority setting.

Iatrogenic skin injuries in infants admitted to neonatal intensive care units: An investigation in 22 Chinese units.

OBJECTIVE: To investigate the incidence of iatrogenic skin injuries in neonates across 22 neonatal intensive care units (NICUs) in China. DESIGN: Prospective study. SETTING: 22 NICUs in China. PATIENTS: Infants admitted to NICU. INTERVENTIONS: None. MEASUREMENTS: The "Iatrogenic Skin Injuries Data Collection Form of infants" were used to collect the data during hospitalization. MAIN RESULTS: A total of 8126 neonates who were hospitalized in 22 tertiary hospitals across 15 provinces, cities, and autonomous regions of China between December 1, 2019 and January 31, 2020 were analyzed. Five hundred and twenty-one infants had iatrogenic skin injuries, including 250 with diaper dermatitis (47.98%), 70 with physicochemical factor-related skin lesions (PCFRSIs) (13.44%), 81 with medical device-related pressure injuries (MDRPIs) (15.55%), and 69 with medical adhesive-related skin injuries (MARSIs) (13.24%), accounting for 91% of the total number of iatrogenic injuries. Among these, diaper dermatitis was closely related to the skin and feeding status. Furthermore, the risk was higher among neonates who had skin damage upon admission or were already fully fed orally. The influencing factors of MDRPIs and MARSIs were similar. They were negatively associated with gestational age and birth weight, and were closely related to the presence of various tubes. CONCLUSIONS: Diaper dermatitis, PCFRSIs, MDRPIs, and MARSIs were the four common types of iatrogenic skin injuries in newborns. The various types of iatrogenic skin injuries were influenced by varying factors. Specialized nursing measurements can reduce the likelihood of these injuries.

Assessment of Neonatal Intensive Care Unit Sound Exposure Using a Smartphone Application.

OBJECTIVE: This study aimed to determine the impact of neonatal intensive care unit (NICU) design and environmental factors on neonatal sound exposures. We hypothesized that monitoring with a smartphone application would identify modifiable environmental factors in different NICU design formats. STUDY DESIGN: Minimum, maximum, and peak decibel (dB) recordings were obtained using the Decibel X phone app, and the presence of noise sources was recorded in each patient space at three NICUs over a 6-month period (December 2017 to May 2018). Data were analyzed by Student's t-test and ANOVA with Bonferroni correction. Data were collected at the University of Maryland Medical Center single family room (SFR) level IV and St. Agnes Healthcare hybrid pod/single family room level III NICU, Baltimore, MD and at Prince George's Hospital Center open-pod design Level III NICU, Cheverly, MD. RESULTS: All recordings in the three NICUs exceeded the American Academy of Pediatrics (AAP) recommended <45 dB level. The maximum and peak dB were highest in the open pod format level III NICU. Conversations/music alone and combined with other factors contributed to increased sound exposure. Sound exposure varied by day/night shift, with higher day exposures at the level III hybrid and open pod NICUs and higher night exposures at the level IV SFR NICU. CONCLUSION: Although sound exposure varied by NICU design, all recordings exceeded the AAP recommendation due, in part, to potentially modifiable environmental factors. A smartphone application may be useful for auditing NICU sound exposure in quality improvements efforts to minimize environmental sound exposure. KEY POINTS: · Smartphone application was used to assess NICU sound exposure.. · All cases of sound exposure exceed recommendations.. · A smartphone application was used to identify modifiable factors..

Actual and Potential Impact of a Home Nasogastric Tube Feeding Program for Infants Whose Neonatal Intensive Care Unit Discharge Is Affected by Delayed Oral Feedings.

OBJECTIVE: To compare healthcare use and parent health-related quality of life (HRQL) in 3 groups of infants whose neonatal intensive care unit (NICU) discharge was delayed by oral feedings. STUDY DESIGN: This was a prospective, single-center cohort of infants in the NICU from September 2018 to March 2020. After enrollment, weekly chart review determined eligibility for home nasogastric (NG) feeds based on predetermined criteria. Actual discharge feeding decisions were at clinical discretion. At 3 months' postdischarge, we compared acute healthcare use and parental HRQL, measured by the PedsQL Family Impact Module, among infants who were NG eligible but discharged with all oral feeds, discharged with NG feeds, and discharged with gastrostomy (G) tubes. We calculated NICU days saved by home NG discharges. RESULTS: Among 180 infants, 80 were orally fed, 35 used NG, and 65 used G tubes. Compared with infants who had NG-tube feedings, infants who had G-tube feedings had more gastrointestinal or tube-related readmissions and emergency encounters (unadjusted OR 3.97, 95% CI 1.3-12.7, P = .02), and orally-fed infants showed no difference in use (unadjusted OR 0.41, 95% CI 0.1-1.7, P = .225). Multivariable adjustment did not change these comparisons. Parent HRQL at 3 months did not differ between groups. Infants discharged home with NG tubes saved 1574 NICU days. CONCLUSIONS: NICU discharge with NG feeds is associated with reduced NICU stay without increased postdischarge healthcare use or decreased parent HRQL, whereas G-tube feeding was associated with increased postdischarge healthcare use.

Status of Multidisciplinary Collaboration in Neonatal Cardiac Care in the United States.

While outcomes for neonates with congenital heart disease have improved, it is apparent that substantial variability exists among centers with regard to the multidisciplinary approach to care for this medically fragile patient population. We endeavored to understand the landscape of neonatal cardiac care in the United States. A survey was distributed to physicians who provide neonatal cardiac care in the United States regarding (1) collaborative efforts in care of neonates with congenital heart disease (CHD); (2) access to neonatal cardiac training; and (3) barriers to the implementation of protocols for neonatal cardiac care. Responses were collected from 10/2018 to 6/2019. We received responses from 172 of 608 physicians (28% response rate) from 89 centers. When compared to responses received from physicians at low-volume centers (< 300 annual bypass cases), those at high-volume centers reported more involvement from the neurodevelopmental teams (58% vs. 29%; P = 0.012) and a standardized transition to outpatient care (68% vs. 52%; P = 0.038). While a majority of cardiothoracic surgery and anesthesiology respondents reported multidisciplinary involvement, less than half of cardiology and neonatology supported this statement. The most commonly reported obstacles to multidisciplinary engagement were culture (61.6%) and logistics (47.1%). Having a standardized neonatal cardiac curriculum for neonatal fellows was positively associated with the perception that multidisciplinary collaboration was "always" in place (53% vs. 40%; P = 0.09). There is considerable variation among centers in regard to personnel involved in neonatal cardiac care, related education, and perceived multidisciplinary collaboration among team members. The survey findings suggest the need to establish concrete standards for neonatal cardiac surgical programs, with ongoing quality improvement processes.

Discharging Medically Complex Infants with Supplemental Nasogastric Tube Feeds: Impact on Neonatal Intensive Care Unit Length of Stay and Prevention of Gastrostomy Tubes.

OBJECTIVE: The aim of this study is to evaluate the feasibility, safety, and efficacy of discharge with supplemental nasogastric tube (NGT) feeds in medically complex infants. STUDY DESIGN: Cohort study of 400 infants enrolled in the Transitional Medical Home (TMH) program at Duke University Level IV neonatal intensive care unit from January 2013 to 2017. RESULTS: Among 400 infants enrolled in the TMH, 57 infants were discharged with an NGT. A total of 45 infants with a variety of diagnoses and comorbidities were included in final analysis. Among 45 infants, 5 obtained a gastrostomy tube (GT) postdischarge. Median (25-75th percentile) length of use of NGT in 40 infants was 12 days (4-37). Excluding four outliers who used NGT for ≥140 days, the median length of use was 8 days (3-24). This extrapolates to a median of 288 hospital days saved for the remaining 36 infants. There were only three emergency room visits related to parental concern for incorrect NGT placement. There was no statistically significant difference in percent oral feeding predischarge or growth in first month postdischarge between infants who orally fed versus those who obtained GTs. CONCLUSION: Discharge with supplemental NGT feeds is safe and feasible utilizing a standardized protocol and close postdischarge follow-up. This practice can decrease length of stay and prevent need for GT. KEY POINTS: · Discharge with nasogastric tube (NGT) supplementation is safe.. · Discharge with NGT supplementation decreases cost.. · Discharge with NGT can decrease neonatal intensive care unit length of stay.. · Medical home model facilitates safe discharge..

Protective Dressings, Injury, and Device Failure in Preterm Infants Receiving Nasal Continuous Positive Airway Pressure: A Randomized Controlled Trial.

OBJECTIVE: To investigate the protective effect of a hydrocolloid nasal dressing on the incidence and severity of nasal injury and continuous positive airway pressure (CPAP) failure in preterm infants receiving nasal CPAP (N-CPAP). METHODS: A randomized controlled trial was conducted over 4 months in 2019 at level 3 neonatal ICUs in two hospitals affiliated with Isfahan University of Medical Sciences, Iran. Eighty eligible infants were born at 32 weeks of gestation or younger and/or with a birth weight of 1,500 g or less and had received between 4 and 72 hours of CPAP. Infants were randomly assigned to two groups; the intervention group used a protective dressing, and the control group received routine care. Data collection tools included a demographic questionnaire and nasal injury assessment score chart. MAIN OUTCOME MEASURES: The incidence and severity of nasal injury in preterm infants undergoing N-CPAP. RESULTS: Infants in the intervention group had a significantly lower incidence and severity of nasal injury compared with the control group: 15 of 40 (37.5%) versus 37 of 40 (92.5%; P < .001). Overall, the injuries identified in this study were mostly mild and moderate, with only three severe injuries in the intervention group and five in the control group. No significant differences were detected in CPAP failure (P > .05). CONCLUSIONS: The studied nasal barrier dressing is a safe and convenient solution to reduce nasal injury in preterm infants receiving N-CPAP.

Reducing Peripheral Intravenous Catheter Extravasation in Neonates: A Quality Improvement Project.

PURPOSE: Our objective was to reduce total and severe peripheral intravenous extravasation (PIVE) incidence by 40% in our neonatal intensive care unit. SETTING/APPROACH: This quality improvement initiative was performed at an academic, free-standing suburban children's hospital, in a level 4 neonatal intensive care unit from June 2017 to April 2018. Baseline extravasation data for a period of 6 months prior to the initiative were reviewed, along with a nursing knowledge questionnaire and random audits of catheter stabilization techniques. A Pareto chart and a key driver diagram were created to identify the most common causes of extravasations and lead to a series of process changes. We implemented 4 Plan-Do-Study-Act (PDSA) cycles: (1) dressing protocol for peripheral intravenous vascular (PIV) catheter securement that instituted standardized securement and safer equipment; (2) education on PIV assessment and maintenance, concentrating on hourly evaluation and documentation; (3) guidance algorithm for PIVE identification and treatment; and (4) escalation policy, limiting the number of placement attempts and increased use of a "superuser" team. OUTCOMES: The overall prevalence of extravasations decreased by 54%, from 73 preintervention to 40 at postintervention. At baseline, 52% (38/73) extravasations were severe; however, those in the severe category decreased by 35% (14/40) postintervention. The overall rate of adherence to the PIV catheter management algorithm approached 95%; whereas adherence to the securement guideline fluctuated between 80% and 98%. IMPLICATION FOR PRACTICE: The implementation of these new practice recommendations along with the education has resulted in a decreased rate and severity of extravasation. Frequent audits and reinforcements are integral to sustainment and to ensure accountability for the implemented procedures.

A Collaborative Learning Assessment of Developmental Care Practices for Infants in the Cardiac Intensive Care Unit.

OBJECTIVE: Assess differences in approaches to and provision of developmental care for infants undergoing surgery for congenital heart disease. STUDY DESIGN: A collaborative learning approach was used to stratify, assess, and compare individualized developmental care practices among multidisciplinary teams at 6 pediatric heart centers. Round robin site visits were completed with structured site visit goals and postvisit reporting. Practices of the hosting site were assessed by the visiting team and reviewed along with center self-assessments across specific domains including pain management, environment, cue-based care, and family based care coordination. RESULTS: Developmental care for infants in the cardiac intensive care unit (CICU) varies at both a center and individual level. Differences in care are primarily driven by variations in infrastructure and resources, composition of multidisciplinary teams, education of team members, and use of developmental care champions. Management of pain follows a protocol in most cardiac intensive care units, but the environment varies across centers, and the provision of cue-based infant care and family-based care coordination varies widely both within and across centers. The project led to proposed changes in clinical care and center infrastructure at each participating site. CONCLUSIONS: A collaborative learning design fostered rapid dissemination, comparison, and sharing of strategies to approach a complex multidisciplinary care paradigm. Our assessment of experiences revealed marked variability across and within centers. The collaborative findings were a first step toward strategies to quantify and measure developmental care practices in the cardiac intensive care unit to assess the association of complex inpatient practices with long-term neurodevelopmental outcomes.

Family Rooms in Neonatal Intensive Care Units and Neonatal Outcomes: An International Survey and Linked Cohort Study.

OBJECTIVES: To evaluate the proportion of neonatal intensive care units with facilities supporting parental presence in their infants' rooms throughout the 24-hour day (ie, infant-parent rooms) in high-income countries and to analyze the association of this with outcomes of extremely preterm infants. STUDY DESIGN: In this survey and linked cohort study, we analyzed unit design and facilities for parents in 10 neonatal networks of 11 countries. We compared the composite outcome of mortality or major morbidity, length of stay, and individual morbidities between neonates admitted to units with and without infant-parent rooms by linking survey responses to patient data from 2015 for neonates of less than 29 weeks of gestation. RESULTS: Of 331 units, 13.3% (44/331) provided infant-parent rooms. Patient-level data were available for 4662 infants admitted to 159 units in 7 networks; 28% of the infants were cared for in units with infant-parent rooms. Neonates from units with infant-parent rooms had lower odds of mortality or major morbidity (aOR, 0.76; 95% CI, 0.64-0.89), including lower odds of sepsis and bronchopulmonary dysplasia, than those from units without infant-parent rooms. The adjusted mean length of stay was 3.4 days shorter (95%, CI -4.7 to -3.1) in the units with infant-parent rooms. CONCLUSIONS: The majority of units in high-income countries lack facilities to support parents' presence in their infants' rooms 24 hours per day. The availability vs absence of infant-parent rooms was associated with lower odds of composite outcome of mortality or major morbidity and a shorter length of stay.

Patient and provider factors impacting referral for neonatal organ donation.

BACKGROUND: As determination of brain death is infrequent in neonates, the AAP endorses donation after circulatory determination of death as an acceptable alternative. Despite this recommendation, neonatal organ donation is infrequent. Timely referral to OPOs is a vital first step in the organ donation process. The aim of this study was to identify patient and provider factors impacting timely referral for neonatal organ donation. METHODS: Medical records were reviewed for deaths occurring in a Level IV NICU from 2007 to 2017. Clinical and demographic factors, provider type, timing of OPO referral (before or after death), and outcome were assessed. Bivariate and multivariable logistic regression models were utilized to identify predictors of OPO referral characteristics. RESULTS: Between 2007 and 2017, 329 deaths occurred in the NICU or delivery room. Of the 265 infants meeting inclusion criteria, 96% had late referrals (after death) and were declined for organ donation. Frequency of timely referrals (before death) improved when OPO contact was by an attending neonatologist, when withdrawal of life support was planned, and with increasing birthweight, gestational age, and PMA. Factors associated with decreased OPO referral included male sex, lower weight at death, earlier PMA, and deaths occurring while receiving maximal intensive care support. No organs or tissues were donated. CONCLUSIONS: This study is the first to report NICU referral patterns for organ donation. We found that timely provider referral of neonates to the OPO was rare. Exploration of provider knowledge will guide future educational interventions aimed to improve the referral process.

Barriers and facilitators of kangaroo mother care adoption in five Chinese hospitals: a qualitative study.

BACKGROUND: Kangaroo mother care (KMC) has been proved to be a safe and cost-effective standard of care for preterm babies. China hasn't adopted the KMC practice widely until recently. We aim to assess barriers and facilitators of KMC adoption in neonatal intensive care units (NICUs) and postnatal wards in China. METHODS: We conducted clinical observations and semi-structured interviews with nurses, physicians, and parents who performed KMC in seven NICUs and postnatal wards housed in five hospitals in different provinces of China between August and September 2018. The interviews provided first-hand stakeholder perspectives on barriers and facilitators of KMC implementation and sustainability. We further explored health system's readiness and families' willingness to sustain KMC practice following its pilot introduction. We coded data for emerging themes related to financial barriers, parent- and hospital-level perceived barriers, and facilitators of KMC adoption, specifically those unique in the Chinese context. RESULTS: Five hospitals with KMC pilot programs were selected for clinical observations and 38 semi-structured interviews were conducted. Common cultural barriers included concerns with the conflict with traditional postpartum confinement (Zuo-yue-zi) practice and grandparents' resistance, while a strong family support is a facilitator for KMC adoption. Some parents reported anxiety and guilt associated with having a preterm baby, which can be a parental-level barrier to KMC. Hospital-level factors such as fear of nosocomial infection and shortage of staff and spaces impeded the KMC implementation, and supportive community and peer group organized by the hospital contributed to KMC uptake. Financial barriers included lodging costs for caregivers and supply costs for hospitals. CONCLUSIONS: We provided a comprehensive in-depth report on the multi-level KMC barriers and facilitators in China. We recommend policy interventions specifically addressing these barriers and facilitators and increase family and peer support to improve KMC adoption in China. We also recommend that well-designed local cultural and economic feasibility and acceptability studies should be conducted before the KMC uptake.

A comparative study of mothers of infants hospitalized in an open ward neonatal intensive care unit and a combined pod and single-family room design.

BACKGROUND: The well-being of mothers of infants requiring Neonatal Intensive Care Unit (NICU) hospitalization may be affected by the architectural design of the unit. A few recent studies suggest there may be some drawbacks of single-family rooms (SFRs) for infants and their mothers, such as isolation of mothers and reduced exposure to auditory stimulation for infants. PURPOSE: To compare NICU-stress, symptoms of depression, perceptions of nurse-parent support and family-centered care, sleep disturbances, breastfeeding self-efficacy and readiness for discharge in mothers of infants cared for in an open ward (OW) to those cared for in a unit that includes both pods and SFRs. METHODS: A pre-post quasi-experimental study was conducted in a Canadian level 3 unit before and after transitioning to a new unit of 6-bed pods and SFRs. OW data were collected in 2014 and pod/SFR data 1 year after the transition in 2017 to 2018. Mothers of infants hospitalized for at least 2 weeks completed questionnaires about stress, depressive symptoms, support, family-centered care, and sleep disturbances. In the week prior to discharge, they responded to breastfeeding self-efficacy and readiness for discharge questionnaires. They described their presence in the NICU at enrollment and again prior to discharge. RESULTS: Pod/SFR mothers reported significantly less NICU-stress compared to OW mothers. OW mothers had greater sights and sounds stress and felt more restricted in their parental role. Pod/SFR mothers reported greater respect from staff. Controlling for maternal education, pod/SFR mothers perceived their infant's readiness for discharge to be greater than OW mothers. There were no significant differences between groups in depressive symptoms, nurse-parent support, sleep disturbances, and breastfeeding self-efficacy. At enrollment and again in the weeks preceding discharge, pod/SFR mothers were present significantly more hours per week than OW mothers, controlling for maternal education. CONCLUSIONS: Further study of small pods is indicated as these units may be less stressful for parents, and enhance family-centered care, as well as maternal presence, compared to OWs.

Feasibility Case Series of Environment and Sleep in Infants With Congenital Heart Disease.

BACKGROUND: Developmental delay is a significant concern for infants born with complex congenital heart disease (CCHD). Environmental exposures (e.g., excessive light and sound exposure, sleep disruption) in neonatal intensive care are associated with poor developmental outcomes. However, the environmental experience of newborn infants in cardiac care is unknown. OBJECTIVES: The aim of the study was to examine the feasibility of continuous environmental data collection (i.e., light and sound exposure, sleep pattern) in pediatric cardiac care units and describe the environmental experience of three hospitalized infants with CCHD. METHODS: A case series of three infants undergoing cardiac surgery for CCHD within the first month of life was performed. Measures of light, sound, and sleep were collected in 24-hour periods on three to four separate hospital days. For each day, light and sound meters were attached to the hospital bed, and an actigraphy band was placed on the infant's lower leg to measure sleep/wake states. Feasibility of continuous environmental data collection was assessed through acceptability of data collection for families and clinical staff, usability of data collection equipment for research staff, and study protocol adherence. Descriptive statistics were used to calculate the count and duration of episodes of excessive light and sound exposure, hourly levels of light and sound exposure, total sleep time, duration of individual sleep episodes, and number of arousals from sleep. RESULTS: Although continuous environmental data collection was generally acceptable to families and clinical staff, multiple usability issues were identified by research staff, and study protocol adherence was variable. Missing data were a major limitation. User error during equipment setup was a main contributor to missing data. Infants experienced frequent episodes of sound exposure above recommended maximum levels, whereas light exposure generally remained below recommended maximum levels. Infant sleep patterns were highly fragmented, with frequent arousals and short duration of individual sleep episodes. DISCUSSION: Lessons learned during preliminary data collection with the infants in this case series will inform methods and prevent missing data in future, large-scale studies of this vulnerable, hard-to-recruit population. Data reflect a cardiac care environment characterized by excessive sound exposure and highly disrupted sleep. These environmental stressors may affect developmental outcomes in infants with CCHD.

Behavioral Observation of Infants With Life-Threatening or Life-Limiting Illness in the Neonatal Intensive Care Unit.

BACKGROUND: Infants in the neonatal intensive care unit experience aversive stimuli that cause pain and distress. Maintaining adequate relief from pain and distress is challenging because of infants' varying ages and stages of development and their nonverbal status. Thus, pain and distress must be interpreted by a healthcare provider or other proxy from their own observations or perceptions. There is no standard research or clinical measure for pain and distress in infants. OBJECTIVE: The purpose of this analysis was to evaluate the use of the COMFORT Behavior (COMFORT-B) Scale as a measure of pain and distress in infants diagnosed with life-threatening or life-limiting illnesses in the neonatal intensive care unit in comparison with the nurse-documented Neonatal Pain, Agitation and Sedation Scale; the infants' Technology Dependence Scale; and the mothers' report of total perceived symptom scores. METHODS: Infants diagnosed with life-threatening or life-limiting illnesses and hospitalized in a Level IV neonatal intensive care unit in the Midwestern United States and their parents were included. Measurement of pain and distress in infants was collected weekly from enrollment through 12 weeks or until discharge, whichever occurred first. Observations for the COMFORT-B Scale were conducted before and after standard caregiving activities. Pearson r correlations were used to compare means between pain and distress, technology dependence, and mothers' total perceived symptom scores over time. RESULTS: Data from 78 infants (46 male and 32 female infants) of ages 23-41 weeks of gestation at birth were analyzed. No correlations were found among the COMFORT-B Scale; the Neonatal Pain, Agitation and Sedation Scale; and mothers' total perceived symptom scores. Moderate correlations were found among the Technology Dependence Scale; mothers' total perceived symptom scores; and the Neonatal Pain, Agitation and Sedation Scale. DISCUSSION: Performing COMFORT-B observations can be challenging, and it is unclear whether the information obtained from the COMFORT-B Scale added to the assessment of the infant's pain and distress that is typically recorded in the health record or from parents. Further evaluation is needed to determine if it is more reliable to collect the Neonatal Pain, Agitation and Sedation Scale scores rather than conduct observations using the COMFORT-B Scale in studies of infants with life-threatening and life-limiting illnesses in the neonatal intensive care unit.

Measures of Stress Exposure for Hospitalized Preterm Infants.

BACKGROUND: Extended hospitalization in neonatal intensive care units subjects preterm infants to multiple stress exposures that affect long-term cognitive functioning, motor development, and stress reactivity. Measurement of stress exposure is challenging with multiple measures of stress exposure in use, including counts of skin-breaking or invasive procedures or counts of noxious sensory exposures. OBJECTIVES: The purpose of this analysis was to compare measures of stress exposure commonly used by researchers and to determine the predictive validity of these measures for early neurobehavior. We accomplished this objective through the following specific aims: (a) describe the stress exposures of preterm infants in the first 2 weeks of life, (b) determine the correlations among measures of stress exposure, and (c) compare the predictive validity of measures of stress exposure for early neurobehavior. METHODS: Very preterm infants born between 28 and 31 weeks postmenstrual age were enrolled from four neonatal intensive care units in a large Midwest city. We measured stress exposure over the first 14 days of life for each infant as a count of skin-breaking procedures, a count of invasive procedures, and cumulative scores derived from the Neonatal Infant Stressor Scale. Neurobehavior was assessed at 35 weeks postmenstrual age using the motor development and vigor and alertness/orientation subscales from the Neurobehavioral Assessment of the Preterm Infant. We used Spearman's rho to determine correlations among the measures of stress exposure and multiple linear regression to determine the predictive validity of each stress exposure measure for neurobehavioral outcomes. RESULTS: Seventy-one preterm infants were included in the analysis. We found marked variance across individuals in all measures of stress exposure. There were moderate-high correlations among the measures of stress exposure. No measure of stress exposure was associated with early neurobehavior. DISCUSSION: The stress experiences of hospitalized preterm infants vary. This variance is reflected in all measures of stress exposure. Because measures of stress exposure are highly correlated, the most objective measure requiring the least interpretation should be used. However, the currently available measures of stress exposure used in this analysis may not reflect the infant's physiological stress responses and fail to associate with early neurobehavior.

Managerial features and outcome in neonatal intensive care units: results from a cluster analysis.

BACKGROUND: Healthcare organisations differ in performance even if they are located in the same country or region. Suitable managerial practices and organisational processes can lead to better health outcomes. As a result, hospitals are constantly looking for managerial arrangements that can improve outcomes and keep costs down. This study aims to identify different managerial models in neonatal intensive care units (NICUs) and their impact on a large number of outcomes. METHODS: The research was conducted in Italy, within the SONAR project. SONAR's aim was to identify the characteristics of NICUs, monitor outcomes and promote best practices. This study includes 51 of the 63 NICUs that took part in the SONAR project. Questionnaires on the activities and managerial features were administered to doctors and nurses working in NICUs. A total of 643 questionnaires were analysed from doctors and a total of 1601 from nurses. A cluster analysis was performed to identify managerial models of NICUs. RESULTS: Three managerial models emerged from cluster analysis: traditional, collaborative and individualistic. In the "traditional" model the doctor is above the nurse in the hierarchy, and the nurse therefore has exclusively operational autonomy. The "collaborative" model has as key elements professional specialisation and functional coordination. The "individualistic" model considers only individual professional skills and does not concern the organisational conditions necessary to generate organisational effectiveness. The results also showed that there is an association between managerial model and neonatal outcomes. The collaborative model shows best results in almost all outcomes considered, and the traditional model has the worst. The individualistic model is in the middle, although its values are very close to those of traditional model. CONCLUSIONS: Health management needs to assess NICU strategically in order to develop models to improve outcomes. This study provides insights for management useful for designing managerial characteristics of NICUs in order to achieve better results. NICUs characterised by a collaborative model in fact show better neonatal outcomes.

Preparing Nurses for Palliative Care in the NICU.

BACKGROUND: Neonatal intensive care unit (NICU) nurses require knowledge and skill to meet the unique needs of infants and families. Increasingly, principles of palliative care are being integrated into the NICU setting to improve the quality of care. PURPOSE: The purpose of this article is to describe the efforts of the End-of-Life Nursing Education Consortium (ELNEC) project and its Pediatric Curriculum, which began in 2003 to provide this education, and to also describe efforts by nurses to implement the training into their practice settings. METHODS: The ELNEC Pediatric Palliative Care (ELNEC-PPC) project is a train-the-trainer educational program and evidence-based curriculum. FINDINGS/RESULTS: Participants attend a course or receive online training and then apply the education to implement improved practices in areas such as symptom management, care at the time of death, and bereavement support for families. IMPLICATIONS FOR RESEARCH: Experiences with ELNEC-PPC have demonstrated that nurses can implement the curriculum to improve care. IMPLICATIONS FOR PRACTICE: Continued attention to palliative care in this setting is needed, and future research is needed to evaluate the outcomes of this education and practice change.

Predictors of Parental Presence in the Neonatal Intensive Care Unit.

BACKGROUND: Parental presence in the neonatal intensive care unit (NICU) may affect preterm infants' developmental outcomes. However, few studies have described predictors of parental presence in the NICU. PURPOSE: To identify sociodemographic, clinical, environmental, and maternal psychological factors that predict parent presence in the NICU. METHODS: Using a prospective cohort design, 66 preterm infants between 32 and 40 weeks' corrected gestational age were recruited at 2 level III NICUs in the United States. Data for length of parental presence were collected for 48 consecutive hours from daily visitation logs and medical records. A general linear model was estimated to identify significant predictors of parental presence. RESULTS: Parental presence varied considerably, with a mean percentage of visitation time of 32.40%. The number of children at home (P = .003), presence of neurological comorbidity (P < .001), room type (P < .001), surgical history (P < .001), and perceived stressfulness of the NICU (P = .03) each had large main effects on parental presence, and room type and surgical history (P = .004) had a large interaction effect on parental presence. These predictors accounted for 65.8% of the variance in parental presence. IMPLICATIONS FOR RESEARCH: Future research aimed at understanding predictors of parent presence is essential for developing interventions and designing NICUs that support parental presence. IMPLICATIONS FOR PRACTICE: Understanding factors that contribute to parental presence may help healthcare providers identify infants at risk for low parental presence and thus be able to provide greater support to these infants and their families. As a result, this may help improve outcomes and attachment.