Exploring Parental and Staff Perceptions of the Family-Integrated Care Model: A Qualitative Focus Group Study.

BACKGROUND: Family-integrated care (FICare) is an innovative model of care developed at Mount Sinai Hospital, Canada, to better integrate parents into the team caring for their infant in the neonatal intensive care unit (NICU). The effects of FICare on neonatal outcomes and parental anxiety were assessed in an international multicenter randomized trial. As an Australian regional level 3 NICU that was randomized to the intervention group, we aimed to explore parent and staff perceptions of the FICare program in our dual occupancy NICU. SUBJECTS AND DESIGN: This qualitative study took place in a level 3 NICU with 5 parent participants and 8 staff participants, using a post implementation review design. METHODS: Parents and staff perceptions of FICare were explored through focus group methodology. Thematic content analysis was done on focus group transcripts. RESULTS: Parents and staff perceived the FICare program to have had a positive impact on parental confidence and role attainment and thought that FICare improved parent-to-parent and parent-to-staff communication. Staff reported that nurses working with families in the program performed less hands-on care and spent more time educating and supporting parents. IMPLICATIONS FOR PRACTICE: FICare may change current NICU practice through integrating and accepting parents as active members of the infant's care team. In addition, nurse's roles may transition from bedside carer to care coordinator, educating and supporting parents during their journey through the NICU. IMPLICATIONS FOR RESEARCH: Further research is needed to assess the long-term impact of FICare on neonates, parents, and staff.

Fathers' Needs and Masculinity Dilemmas in a Neonatal Intensive Care Unit in Denmark.

BACKGROUND: Most healthcare professionals in neonatal intensive care units typically focus on the infants and mothers; fathers often feel powerless and find it difficult to establish a father-child relationship. In family-centered healthcare settings, exploring fathers' experiences and needs is important because men's roles in society, especially as fathers, are changing. PURPOSE: To describe fathers' needs when their infants are admitted to a neonatal intensive care unit and to discuss these needs within a theoretical framework of masculinity to advance understanding and generate meaningful knowledge for clinical practices. METHODS: This qualitative study used participant observation, interviews, multiple sequential interviews, and a focus group discussion. Data were analyzed using grounded theory principles. RESULTS: Analysis of the fathers' needs generated 2 primary themes: (1) Fathers as caregivers and breadwinners and (2) fathers and emotions. Fathers wished to be involved and to take care of their infants but have to balance cultural and social norms and expectations of being breadwinners with their wishes to be equal coparents. IMPLICATIONS FOR PRACTICE/RESEARCH: Health professionals in neonatal intensive care units must be aware of fathers' need and desire to be equal coparents. Nurses should play a key role by, for example, showing that fathers are as important to their infants as are the mothers, helping them become involved in childcare, and ensuring that they are directly informed about their children's progress. Further research in other cultural settings would contribute to knowledge regarding fatherhood and the role of fathers in childcare.

Maternal experiences with and sources of information on galactagogues to support lactation: a cross-sectional study.

An increase in the marketing and use of herbal galactagogues among breastfeeding mothers in the US has raised the issue of how best to provide support and information on the use of these products, particularly in light of limited availability of certified lactation counselors and continued suboptimal rates of breastfeeding globally. Currently, no cross-sectional data are available on the experiences and attitudes of mothers regarding the use of herbal and pharmaceutical galactagogues for lactation in the US. The findings of an online survey of 188 breastfeeding mothers on experiences with and sources of information on galactagogues are presented. Most mothers (76%) reported that while breastfeeding, they felt as though they were not making enough milk to meet the needs of their child, and yet 54% also indicated that they had not supplemented with formula. A large proportion of respondents reported utilizing galactagogues to increase lactation and finding them useful. The results indicated that most women learned about galactagogues from the Internet or by word of mouth through friends. Lactation consultants were the third-most reported sources of information on these products. While many respondents reported perceiving galactagogues as innocuous, more evidence on safety and efficacy is needed to support women properly who seek out and use them. Large-scale studies of the prevalence of galactagogue use in the US and rigorous evaluation of use globally are needed to ensure that mothers who choose to breastfeed may safely avail themselves of all options when counseling support is insufficient.

Parental Perception of Risk Associated With Their Premature Infant.

BACKGROUND: Preterm birth has been linked to increased parental stress, depression, and anxiety. Although the rate of neonatal morbidity and mortality decreases with increasing gestational age, recent research has revealed that there is no threshold age for risk or parental concern. PURPOSE: This study examines parental concern about medical and developmental outcomes of their premature infant. METHODS: Parents of 60 premature infants were surveyed in a follow-up clinic regarding their level of concern about 11 morbidities and their child's gestation-adjusted age; these were compared with the infant's inpatient chart. "Concern scores" were tallied and compared across gestational age groups and knowledge of gestation-adjusted age using Chi-square tests of independence. FINDINGS: Many parents reported concerns about morbidities that were unsupported by their child's diagnoses. Across parents of extremely, very, and moderate-late preterm children, the mean concern scores were 13.9, 15.7, and 19.7, respectively. Overall, 62% of parents incorrectly reported the gestation-adjusted age of their child. Parents who were correct were significantly more likely to correctly anticipate abnormal developmental patterns (70%) and growth patterns (65%) than those who were incorrect (33% and 31%, respectively). IMPLICATIONS FOR RESEARCH: Future research should focus on whether NICU graduate parental stress levels are directly linked to the severity of their child's condition, and how physicians can help decrease NICU graduate parental stress. IMPLICATIONS FOR PRACTICE: Parental anxiety regarding all gestational age neonatal intensive care unit infant outcomes can be decreased by a thorough explanation of gestation-adjusted age and a discussion of expected prematurity-related issues.

A Review of Herbal and Pharmaceutical Galactagogues for Breast-Feeding.

BACKGROUND: Therapeutic approaches to addressing insufficient lactation are available but remain poorly understood. Current trends in maternal health, such as increasing rates of obesity, delayed age at childbearing, and high rates of cesarean section, may be associated with physiological challenges for lactation that cannot be managed by counseling alone. Women who have not had success with counseling alone, including adoptive mothers seeking to induce lactation, may use galactagogues (pharmaceutical and herbal compounds used to increase lactation). We present a review of selected studies of galactagogues and data indicating popular demand for such products. METHODS: A systematic search was conducted for published studies on the use of galactagogues for breast-feeding. The following databases were searched: MEDLINE (PubMed), EBSCO (Academic Search Complete), and EMBASE. The search was conducted between July 15, 2015, and August 18, 2015; only English language articles were included, and we imposed no restrictions on publication date. Two authors independently reviewed the studies and extracted data. RESULTS: Blinded, placebo-controlled clinical trials of 2 pharmaceutical galactagogues (domperidone and metoclopramide) and 5 popular herbal galactagogues (shatavari, fenugreek, silymarin, garlic, and malunggay) were identified. All of the studies identified for domperidone showed a significant difference in milk production between the treatment and placebo groups. Of the 6 trials of metoclopramide, only 1 study showed a significant difference in milk production compared to placebo. Results of the clinical trials on herbal galactagogues were mixed. Our review of the evidence for the efficacy of popular pharmaceutical and herbal galactagogues revealed a dearth of high-quality clinical trials and mixed results. CONCLUSION: Health providers face the challenge of prescribing or recommending galactagogues without the benefit of robust evidence. Given the suboptimal rates of exclusive breast-feeding worldwide and the availability and demand for medical and herbal lactation therapies, controlled trials and analyses investigating these medicines are urgently warranted.

Health provider experiences with galactagogues to support breastfeeding: a cross-sectional survey.

BACKGROUND: Exclusive breastfeeding for infants up to 6 months is widely recommended, yet breastfeeding rates are relatively low in the US. The most common reason women stop breastfeeding early is a perceived insufficiency of milk. Galactagogues are herbal and pharmaceutical products that can help increase milk supply; however, data on their efficacy and safety is limited. Lactation consultants, obstetricians, and other health providers are an important point of contact for breastfeeding women experiencing challenges with lactation. This study explored providers' perceptions, experiences, and practices in relation to galactagogue recommendation. METHOD: A cross-sectional survey was conducted among a convenience sample of English-speaking health providers in the US who counsel breastfeeding women and their infants. RESULTS: More than 70% of respondents reported to recommend galactagogues. The most frequently recommended galactagogue was fenugreek with respondents indicating that they recommend it either 'always' (8.5%) or 'most of the time' (14.9%) and 'sometimes' (46.8%). More than 80% of the respondents indicated that galactagogues were useful for their clients and only one-third reported side effects. Reasons for refraining from recommending galactagogues were insufficient evidence of its efficacy and safety. Respondents reported a wide variety of sources of information used for their own education about galactagogues. DISCUSSION: Despite little evidence regarding safety and efficacy, some galactagogues are widely recommended and often perceived to be useful. However, concerns about their efficacy and safety remain. In order to assure both providers and users about safety and efficacy, more robust studies as well as better pharmacovigilance systems are needed.

Relationships of Maternal Stress with Milk Immune Components in African American Mothers of Healthy Term Infants.

BACKGROUND: In the United States, African American infants experience the highest mortality, and their mothers report the lowest breastfeeding rates. Science reports decreased infant mortality among breastfed infants and suggests that milk immune component (MIC) levels are associated with maternal stressors. Little is known about these relationships among African Americans; therefore the aim was to explore the relationships of African American mothers' stressors and MICs 1-14 days postdelivery. MATERIALS AND METHODS: Mothers meeting eligibility requirements were approached for consent 48-72 hours postdelivery of a healthy term infant and given instructions to collect milk (Days 3, 9, and 14) and saliva (Day 9), as well as complete three Perceived Stress Scale questionnaires (Days 3, 9, and 14) and a survey of pregnancy stressors experiences. Pearson correlations and linear regressions were performed to assess the relationships of maternal stressors with MICs. RESULTS: There was at least one statistically significant correlation of a maternal stressor with nine of the 10 MICs (effect sizes ranging from r = 0.22 to 0.38) on Days 3 and 9. Of all MICs, epidermal growth factor had the most associations with maternal stress indicators. No mediational relationship of cortisol with MICs was observed. CONCLUSIONS: Many of the MIC changes observed could potentially impact the health of term and preterm infants. Further research is warranted.

The very low birth weight infant microbiome and childhood health.

This review describes current understandings about the nature of the very low birth weight infant (VLBW) gut microbiome. VLBW infants often experience disruptive pregnancies and births, and prenatal factors can influence the maturity of the gut and immune system, and disturb microbial balance and succession. Many VLBWs experience rapid vaginal or Caesarean births. After birth these infants often have delays in enteral feeding, and many receive little or no mother's own milk. Furthermore the stressors of neonatal life in the hospital environment, common use of antibiotics, invasive procedures and maternal separation can contribute to dysbiosis. These infants experience gastrointestinal dysfunction, sepsis, transfusions, necrotizing enterocolitis, oxygen toxicity, and other pathophysiological conditions that affect the normal microbiota. The skin is susceptible to dysbiosis, due to its fragility and contact with NICU organisms. Dysbiosis in early life may resolve but little is known about the timing of the development of the signature gut microbiome in VLBWs. Dysbiosis has been associated with a number of physical and behavioral problems, including autism spectrum disorders, allergy and asthma, gastrointestinal disease, obesity, depression, and anxiety. Dysbiosis may be prevented or ameliorated in part by prenatal care, breast milk feeding, skin to skin contact, use of antibiotics only when necessary, and vigilance during infancy and early childhood.

Using quality improvement principles to improve the care of patients with severe sepsis and septic shock.

BACKGROUND: Sepsis, an inflammatory response to an infection that may lead to severe organ dysfunction and death, is the leading cause of death in medical intensive care units. The Society of Critical Care Medicine has issued guidelines and promoted protocols to improve the management of patients with severe sepsis and septic shock. Generally, the medical community has been slow to adopt these guidelines because of the system challenges associated with protocol implementation. We describe an interdisciplinary team approach to the development and implementation of management protocols for treating patients with severe sepsis and septic shock. METHODS: To determine the effectiveness of the bundled emergency department and critical care order sets developed by the Sepsis Steering Committee, we performed a case review of 1,105 sequential patients admitted to a large academic tertiary referral hospital with a diagnosis of severe sepsis or septic shock between July 2008 and January 2012. RESULTS: Implementation of the protocol led to improved order set use over time, a significant decrease in the median time to antibiotics of 140 (range 1-820) minutes in 2008 to 72 (range 1-1,020) minutes in 2011 (P≤0.001), and a decrease in median length of stay from 8 days (range 1-54) in 2008 to 7 days (range 1-33) in 2011 (P=0.036). CONCLUSION: A multidisciplinary team approach to sepsis management using protocols and early goal-directed therapy is feasible in a large academic medical center to improve the process of care and outcomes.

Revising oxygen targeting for very low birth weight infants.

Translating new knowledge into practice requires sufficient time, administrative support, and access to current information. A regional level III neonatal intensive care unit was tasked with updating a best practice that challenged the history of its well-recognized success in this field. Using strategies that can be applied in any setting, this interprofessional team drove the successful adoption of the updated best practice using a multidimensional implementation plan to promote patient safety.

Exploring the use of mothers' own milk as oral care for mechanically ventilated very low-birth-weight preterm infants.

PURPOSE: The purpose of this study was to explore the use of mothers' own milk (colostrums, transitional milk, and mature milk) as oral care in the ventilator-associated pneumonia (VAP)-prevention bundle of mechanically ventilated preterm infants weighing 1500 g or less. SUBJECTS: Mechanically ventilated preterm infants weighing 1500 g or less admitted to a regional level III NICU in the Gulf South between January 1, 2006, and December 31, 2009. DESIGN: Retrospective descriptive. METHODS: Oral care with mothers' own milk was implemented as part of the VAP-prevention bundle in the neonatal intensive care unit in the fourth quarter of 2007. Using retrospective deidentified data retrieved from the electronic medical record, the primary and secondary outcome variables were collected among eligible infants (≤1500 g) admitted January 1, 2006, to December 31, 2007 (before implementation) and January 1, 2008, to December 31, 2009 (after implementation). Sample characteristics, including infant gestational age, birth weight, and gender, as well as maternal age, type of delivery, and incidence of maternal chorioamnionitis, were also collected. Data analysis included frequencies and distributions to summarize sample characteristics and variables of interest. Appropriate tests for differences were conducted on outcome variables between the before and after groups of the human milk oral care intervention. MAIN OUTCOME MEASURES: The feasibility outcome variable included nursing compliance with the oral care procedure. The safety outcome variable included record of any adverse events associated with the oral care procedure. The efficacy health outcomes included the rate of positive tracheal aspirates, positive blood cultures, the number of ventilator days, and length of stay. RESULTS: Infant age (26.1-26.6 weeks) and weight (840-863 g) were similar in the before (n = 70) and after (n = 68) sample subjects. There were no statistically significant differences in ventilator days, χ² (46, n = 115) = 46.22, P = .46, and length of stay, χ (75, n = 115) = 78.78, P = .36, between groups. Although the rate of positive tracheal aspirates and positive blood cultures reduced after implementation of oral care with mothers' own milk, these differences were not statistically significant (U(47) = 250, z = -7.1, P = .48; U(47) = 217.5, z = -1.44, P = .15). CONCLUSIONS: There were no statistically significant differences in the rates of positive tracheal aspirates and blood cultures after implementation of oral care with mothers' own milk. The findings of this study suggest that using mothers' own milk as part of the VAP-prevention bundle is a feasible and safe practice; however, further research is needed to determine the immunological benefits of this practice.

Using a multiuser virtual environment to facilitate nursing journal clubs: a mixed-methods study.

PURPOSE: The purpose of this mixed-methods pilot study was to explore the feasibility of using Second Life to conduct research and to describe nurses' experiences in using Second Life to facilitate nursing journal clubs. METHODS: A QUAN→qual sequential design using survey and qualitative methods was used to guide scientific inquiry. Survey data were analyzed using descriptive statistics, and t, Mann-Whitney U, and χ tests were used to test for presurvey and postsurvey group differences. Journal club screencast recordings were thematically analyzed. SETTING: This study was conducted in an Internet-accessible, 3-dimensional multiuser virtual environment. SAMPLE: A convenience sample of registered nurses from 7 facilities consented to participate. Completed data from 29 presurveys and 20 postsurveys were included in data analyses. FINDINGS: Overall, nurses reported a benefit in using Second Life to facilitate journal clubs. The Mann-Whitney U test identified (P < .05) improvement in 7 of 8 critical appraisal competencies after journal club activities: determining design, determining population, interpreting statistics, linking findings/conclusions, identifying limitations, identifying implications, and interpreting qualitative findings. Qualitative analyses of screencastings validated reports of improved critical appraisal competencies and identified 3 inworld themes: presence, learning strategies, and learning outcomes. CONCLUSIONS: Registered nurse study participants reported a benefit of using Second Life for nursing journal clubs. Participants perceived and demonstrated improvement in critical appraisal competencies. IMPLICATIONS: Further research is warranted on outcomes associated with nurses' appraisal of evidence for application to practice using a multiuser virtual environment.

Innovative technology offers virtual visitation for families.

Parents of preterm infants and infants with congenital anomalies requiring treatment must begin their relationship with their infant in the unfamiliar and often stressful neonatal intensive care unit, full of strange sights and sounds. Innovative technology such as webcams offers virtual visitation, which holds potential to improve parent-infant bonding and reduce parents' self-perceived stress.

NICU perspectives on palliative care.

Few health care professionals have received palliative care training to comfort dying infants and their families. One institution's development of a palliative care program in the neonatal intensive care unit setting is discussed in this column.

Review of the relationships between maternal characteristics and preterm breastmilk immune components.

The immune properties of breastmilk are the most effective preventative means of reducing infant mortality through both passive and active immunity. Breastmilk for term infants has been linked to decreased incidence of respiratory and ear infections and gastrointestinal distress. This protection is even more important for the preterm infant. Prematurity is one of the leading causes of infant death in the United States. Hospitalized infant outcomes associated with consumption of breastmilk are shorter length of stay and decreased incidence of nosocomial infections and necrotizing enterocolitis (NEC). The presence of nosocomial infections and necrotizing enterocolitis increases risk of preterm mortality and morbidity as well as healthcare expenditures. However, breastmilk immunological components such as secretory immunoglobulin A, lactoferrin (LFT), and cytokines provide a framework of immunity that, in conjunction with nutritional support, significantly improves neonatal health. The relationship between maternal characteristics and breastmilk immune properties is central to further the understanding of the impact of breastmilk on preterm infant morbidity and mortality. The purpose of this article is to review the numerous immune components in breastmilk, the moderators of the immune components, and the relevance of these components to preterm/infant health. Exploration of the complexity of breastmilk immune components may direct future development of interventions to improve and sustain the immunological benefits of preterm breastmilk.

Creating a tool to evaluate patient performance.

Patient education is a nursing responsibility that is often impromptu, spontaneous, and poorly documented. In many cases the patient's ability to perform a skill or task in the management of an illness or disease process affects the patient's outcome. A tool designed to evaluate patient performance guides the teaching process, promotes communication between the patient and nurse, and promotes communication among health care providers as it relates to patient performance. Nurses are in key positions to develop patient performance tools to ensure that the patient, or a patient's family member, can manage the health care requisites.