Nurses' Descriptions of Interactions When Caring for Women With Perinatal Substance Use Disorders and Their Infants.

The purpose of this review is to describe health care interactions between nurses and women with perinatal substance use disorders, including interactions with their infants from the perspective of the nurses. Findings from 11 qualitative inclusion articles were synthesized using a metasummary approach. The majority of articles showed that nurses experience problematic interactions when providing care to women with perinatal substance use disorders and their infants, although some results indicated that some nurses engage in interactions that are assuring. Six types of conflictual interactions were identified: inadequate care, distressing, condemning, deficient knowledge, rejecting, and dissatisfying. Two types of therapeutic interactions were identified: compassionate and supportive. The findings underscore the importance of managing stigma, enhancing knowledge of the science of addiction processes, and promoting best practices when caring for this population.

Implementing Trauma-Informed Strategies for Mothers of Infants with Neonatal Abstinence Syndrome.

PURPOSE: To improve outcomes of infants with neonatal abstinence syndrome (NAS) by implementing an evidence-based approach to care. METHODS: An interdisciplinary team developed and implemented an educational module about the elements and principles of trauma-informed care (TIC) and standardized education on NAS for mothers with substance use disorder (SUD). The team collaborated with community behavioral health professionals to secure the services of a certified recovery specialist. Primary outcome measures of average length of stay (LOS) and admissions to special care nursery (SCN) for NAS infants were analyzed. RESULTS: Following health care team education on TIC and implementation of the standardized NAS brochure, average LOS decreased significantly from 6.5 to 5.1 days from baseline period (January-December 2019) to the implementation period (February-June 2020; p = 0.03). There was no difference in SCN admission from the baseline period (February-June 2019) to the implementation period (February-June 2020). Referrals to certified recovery specialists did not change. CLINICAL IMPLICATIONS: Education on the impact of trauma on new mothers with SUD can promote collaboration between them and the neonatal team. Standardizing education for new mothers of infants with NAS can help to engage families of infants with NAS and improve clinical outcomes.

Knowledge of and Perceived Competence in Trauma-Informed Care and Attitudes of NICU Nurses Toward Mothers of Newborns With Neonatal Abstinence Syndrome.

OBJECTIVE: To explore how knowledge of and perceived competence in trauma-informed care inform the attitudes of NICU nurses toward mothers of newborns with neonatal abstinence syndrome (NAS). DESIGN: A cross-sectional survey study. SETTING: A southern U.S. metropolitan children's hospital with 145 NICU beds. PARTICIPANTS: Convenience sample of 150 NICU nurses. METHODS: Participants completed an online survey questionnaire adapted from the Attitudes About Drug Abuse in Pregnancy questionnaire and the Trauma-Informed Pediatric Care survey. Participants also responded to one open-ended question about their experiences in working with mothers of newborns with NAS. We used descriptive and inferential statistics and content analysis to analyze the survey data. RESULTS: Participants demonstrated low to moderate knowledge about and perceived competence in trauma-informed care and showed more judgmental attitudes toward mothers of newborns with NAS. Level of knowledge about mothers with substance use disorder and perceived competence in trauma-informed care were associated with participants' attitudes toward mothers of newborns with NAS. Emergent themes from qualitative data included the following: Mother-Newborn Dyads Shape Nurses' Judgmental Attitudes, Caring for Mothers of Newborns With NAS Is a Challenging Experience, and Need to Refine Care for Mothers Through Intra- and Interdisciplinary Collaboration. CONCLUSION: NICU nurses need further education about mothers of newborns with NAS. Improved knowledge about these women and adaptation of the principles of trauma-informed care may influence NICU nurses' judgmental attitudes toward mothers of newborns with NAS.

Nurses' Finnegan Scoring of Newborns with Neonatal Abstinence Syndrome Not Affected by Time or Day of the Week.

OBJECTIVE: Newborns exposed to drugs in utero are at risk of developing neonatal abstinence syndrome (NAS), characterized by behavioral changes and physiologic instability. Finnegan scoring tool quantifies severity of symptoms and guides treatment. This article evaluates whether time of day and the number of shift hours affects modified Finnegan scores, and the subjective component of these scores. STUDY DESIGN: Institutional review board-approved, retrospective chart review of newborns admitted to neonatal intensive care or transitional nursery from 2011 to 2014. INCLUSION CRITERIA: > 35 weeks' gestation, known maternal substance use, positive maternal or newborn urine, or meconium drug screen, NAS treatment. RESULTS: A total of 101 charts were evaluated. Mean treatment duration was 31.8 days (standard deviation ±18.3). There was no significant relationship between observer shift hour and high scores (> 8) (p = 0.83). Highest scores occurred in the afternoon, decreased at night (p = 0.03), and throughout admission (p < 0.0001). Weekend and weekday scores were similar (p = 0.4). The objective component of the scores remained similar throughout the day (p = 0.91) and week (p = 0.52). CONCLUSION: Finnegan scores given by nurses were not influenced by shift hour. Time of day did not influence overall high scores or the proportion of objective to total Finnegan score. Inter-rater reliability was maintained regardless of time of day or day of the week.

Effect of a Neonatal Abstinence Syndrome Training Program on Nurses' Confidence and Ability to Use the Finnegan Scoring Tool.

OBJECTIVE: To study the impact of an educational training program about neonatal abstinence syndrome (NAS) on the accuracy and reliability of NAS scoring by neonatal nurses when using the Finnegan Scoring Tool (FST), as well as the impact of training on nurses' confidence when using the FST. DESIGN: Pilot project based on the Plan-Do-Study-Act framework with a pretest-posttest design. SETTING/LOCAL PROBLEM: Although nurses at this agency receive training on the FST as part of their unit orientation education, there is not currently a program for assessing their confidence and accuracy when using this tool over time. PARTICIPANTS: A convenience sample of registered nurses from the mother-baby (n = 11), NICU (n = 5), and pediatrics (n = 1) units. INTERVENTION/MEASUREMENTS: Nurses watched a video of a neonate, used the FST to score the neonate's withdrawal symptoms, and completed a rating of their self-confidence when using the tool before and after an educational training session and at a 2- to 4-week follow-up session. RESULTS: Participants improved to at least 90% interobserver reliability from the pretraining (64.7%) to posttraining (94.1%) assessments. No participants maintained 90% at follow-up. There appears to be a correlation between years of neonatal experience with tool confidence at pretraining (r = 0.52, N = 17, p < .04), posttraining (r = 0.52, N = 17, p < .03), and follow-up (r = 0.56, N = 17, p < .02) assessments. Pretraining reliability had a positive correlation to follow-up reliability (r = 0.51, p < .04). There was a statistically significant increase in confidence from before the training (mean = 2.06, standard deviation = 0.56) to after (mean = 2.47, standard deviation = .51; t[16] = -3.3, p < .004 [two-tailed]). Although participants reported feeling confident when using the scoring tool, they did not always accurately score symptoms. Participants reported positive buy-in and the need for additional training. CONCLUSION: Advanced training in NAS and the FST may help nurses improve NAS symptom detection and contribute to better neonatal health outcomes.

Neonatal Opioid Withdrawal Syndrome: A Developmental Care Approach.

Tens of thousands of infants are impacted yearly by prenatal opioid exposure. The term neonatal opioid withdrawal syndrome (NOWS) is now replacing the more familiar term neonatal abstinence syndrome (NAS). Ongoing debate continues related to standard regimens for treatment of this oftentimes perplexing condition. Historically, treatment has focused on pharmacologic interventions. However, there is limited research that points to nonpharmacologic methods of treatment as viable options, whether alone or in addition to pharmacologic interventions. This article, utilizing a review of pertinent literature, outlines the physical aspects of NOWS, including its pathophysiology and the resulting physical clinical signs. In addition, we present an overview of how age-appropriate, nonpharmacologic interventions, centered on developmental care, may be a valuable approach to organize and prioritize routine care for these infants, their families, and the health care team facing the challenges of NOWS. Finally, the need for further research to better define evidence-based standards of care for these infants and their families is discussed.

Substance Abuse Disorder: Prenatal, Intrapartum and Postpartum Care.

The growing opioid crisis in the United States affects childbearing women and their infants at an alarming rate. Substance use disorders in pregnancy have transitioned from a topic barely addressed to one that has become mainstream in the issue of pregnancy management. Opioid use can include appropriate use of a prescribed medication, the misuse of street drugs, and maintenance on an opioid agonist treatment such as methadone. Identifying this population of childbearing women is critical to be able to organize the appropriate resources and to provide a comprehensive multidisciplinary evidence-based plan of care. All clinicians need to be educated in identifying and caring for the growing population of women with substance use disorders. Each component of the continuum from prenatal care, labor and birth, and postpartum has challenges and issues that can have a positive or negative impact on the outcome of the pregnancy and the mother-infant relationship. Risk assessment, medication-assisted treatment, pain management, and fostering maternal-infant bonding are important considerations in the care of the woman with substance use disorder. Unbiased empathetic nurses are well positioned to strongly advocate and intervene on behalf of women with substance use disorder, which in turn will help to create positive outcomes for the mother and her baby.

Evaluation of a Nurse-Led Program for Rural Pregnant Women With Opioid Use Disorder to Improve Maternal-Neonatal Outcomes.

OBJECTIVES: To generate effect sizes of preliminary program outcomes and identify areas for program improvement related to a nurse-led, community-based screening, referral, and advocacy program for women with perinatal opioid use disorder (OUD): the Engaging Mothers for Positive Outcomes with Early Referrals (EMPOWER) program. DESIGN: We extracted outcomes retrospectively from medical records for the first 19 mother-newborn dyads who participated in the program (postintervention group). We compared these outcomes with those of 19 randomly selected mother-newborn dyads in which mothers had perinatal OUD and received care before the program launch (preintervention group). SETTING/LOCAL PROBLEM: A maternity care practice and community hospital in a rural Massachusetts county with high rates of perinatal OUD. PATIENTS: Women with perinatal OUD and their neonates. INTERVENTION/MEASUREMENTS: As part of the EMPOWER program, women with perinatal OUD developed individualized pregnancy plans; were referred to community resources in the prenatal period; and received education about neonatal abstinence syndrome, nonpharmacologic newborn care, and breastfeeding. We compared the pre- and postintervention groups for maternal and neonatal outcomes and prenatal community referrals and generated effect sizes using Cohen's d and Cramer's phi (Φ). RESULTS: Rates of breastfeeding initiation (Φ = 0.289) and continuation (Φ = 0.318), mean neonatal birth weight (d = 0.675), and length of hospital stay (d = 0.541) were greater in the postintervention group with medium effect sizes. Diagnosis of neonatal abstinence syndrome and admission to the NICU were also greater in the postintervention group, with small effect sizes (Φ = 0.246 and Φ = -0.144, respectively.) Significantly more women in the postintervention group received prenatal referrals for peer/family support services. We identified areas for program improvement as prenatal education on smoking and postpartum contraceptive use. CONCLUSION: Preliminary findings suggest that the EMPOWER program may contribute to improved outcomes for mothers and newborns affected by OUD; however, further data collection after instituting program improvements is needed.

Postpartum Nurses' Experience Caring for Infants With Neonatal Abstinence Syndrome.

OBJECTIVES: In previous years, otherwise healthy infants with neonatal abstinence syndrome (NAS) in our hospital were transferred to the NICU and frequently treated with medication. Currently, infants with NAS room-in with their mothers and rarely require medication. We sought to understand the lived experience of nurses on maternity and well-newborn units caring for infants with NAS. METHODS: We conducted focus groups of registered nurses on postpartum units at 2 hospitals using qualitative methodology. Themes were identified through consensus, and the focus groups were stopped when no new themes were identified. RESULTS: Seventeen postpartum nurses participated in 5 focus groups. The following major themes emerged: (1) managing the expectations of parents of newborns with NAS, (2) current NAS protocol (positive aspects of rooming-in and challenges with withdrawal scoring tool), (3) inconsistencies in care and communication, (4) perceived increase in nursing workload on the postpartum unit, and (5) nurses' emotional response to the care of infants with NAS. CONCLUSIONS: We highlight the perspectives of nursing staff on the well-newborn unit who were previously unaccustomed to caring for infants with NAS. With increasing numbers of infants with NAS and longer stays on the well-newborn unit, hospitals must prepare to better support staff and implement protocols that offer consistency in practice.

Eat, Sleep, Console Approach: A Family-Centered Model for the Treatment of Neonatal Abstinence Syndrome.

BACKGROUND: The opioid epidemic in the United States has resulted in an increased number of drug-exposed infants who are at risk for developing neonatal abstinence syndrome (NAS). Historically, these infants have been treated with the introduction and slow weaning of pharmaceuticals. Recently, a new model called Eat, Sleep, Console (ESC) has been developed that focuses on the comfort and care of these infants by maximizing nonpharmacologic methods, increasing family involvement in the treatment of their infant, and prn or "as needed" use of morphine. PURPOSE: The purpose of this evidenced-based practice brief was to summarize and critically review emerging research on the ESC method of managing NAS and develop a recommendation for implementing an ESC model. METHODS: A literature review was conducted using PubMed, Cochrane, and Google Scholar with a focus on ESC programs developed for treating infants with NAS. FINDING/RESULTS: Several studies were found with successful development and implementation of the ESC model. Studies supported the use of ESC to decrease length of stay, exposure to pharmacologic agents, and overall cost of treatment.Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=32&autoPlay=true.

Survey of Neonatal Intensive Care Unit Nurses' Use of a Motion/Sound Infant Seat.

BACKGROUND: Perinatal substance exposure is an increasing concern in infants being cared for in neonatal intensive care units. Current recommendations support nonpharmacologic treatments for this population of infants. Multimodal (motion, sound) seats are often employed to soothe infants. PURPOSE: The purpose of this study was to survey neonatal intensive care unit nurses on their practices regarding the use of a motion/sound infant seat. METHODS: Sixty-six nurses (52% of 126 total nurses) completed the survey about their self-disclosed practices that included (1) reasons for use; (2) rationale for choice of settings of motion and sound; (3) duration of time infants spent in seat in one session; (4) perception of positive infant response; (5) who places infants in the seat; and (6) nursing instructions dispensed prior to use. RESULTS: Chief reasons for use were infant state, lack of persons to hold infants, and a diagnosis of neonatal abstinence syndrome. Rationale for choice of motion and sound settings included trial and error, prior settings, personal preferences/patterns, assumptions, and random selection. Nurse responses regarding the amount of time the infant was placed in the seat in a single session ranged from 10 to 360 minutes, with determining factors of infant cues, sleeping, feeding, and someone else to hold the infant. IMPLICATIONS FOR PRACTICE: As nonpharmacologic treatments evolve, nurses need guidelines for safe, effective interventions to care for infants. IMPLICATIONS FOR RESEARCH: Further research is necessary to ascertain the responses of withdrawing infants and to establish guidelines and education for use of the motion/sound infant seat.

Changing Neonatal Nurses' Perceptions of Caring for Infants Experiencing Neonatal Abstinence Syndrome and Their Mothers: An Evidenced-Based Practice Opportunity.

BACKGROUND: Neonatal intensive care units (NICUs) are caring for an increasing number of infants born with neonatal abstinence syndrome (NAS). The literature identifies the need for education for NICU nurses on NAS including skills for interacting with the mother with substance use disorder. PURPOSE: An evidence-based practice project was developed to offer an educational presentation targeting these topics to 206 NICU participants (93% registered nurses, 1% licensed vocational nurses, and 6% nursing assistants) at a level IV NICU. METHODS: A pretest/posttest was developed to assess knowledge of the participants prior to and after completion of the educational presentation. A posteducational questionnaire was developed to evaluate the skills learned for interacting with the mother with substance use disorder and the participant's professional readiness. RESULTS: The posttest demonstrated a statistically significant (P < .001) increase in knowledge of NAS. On the post-educational questionnaire, 96% of participants correctly identified 3 skills they would use clinically with mothers with substance use disorder and 84% of participants identified 2 personal strengths and 2 weaknesses that influence their care of infants with NAS and their families (professional readiness). IMPLICATIONS FOR PRACTICE: These results demonstrate that this educational presentation was effective and should be replicated at other facilities to improve the knowledge and skills of NICU nurses to promote improved care for infants with NAS. IMPLICATIONS FOR RESEARCH: Future studies should examine the impact on patient outcomes by preforming post-discharge interviews with the mothers of infants with NAS in the NICU pre- and post-educational intervention. Expanding the presentation into an interprofessional educational opportunity would promote increased knowledge and care by the entire multidisciplinary team.

Infants in Drug Withdrawal: A National Description of Nurse Workload, Infant Acuity, and Parental Needs.

Infants in drug withdrawal have complex physiological and behavioral states, requiring intensive nursing care. The study objectives were to describe acuity, parental needs, and nurse workload of infants in drug withdrawal compared with other infants. The design was cross-sectional and involved secondary nurse survey data from 6045 staff nurses from a national sample of 104 neonatal intensive care units. Nurses reported the care of 15 233 infants, 361 (2.4%) of whom were in drug withdrawal. Three-fourths of hospitals had at least 1 infant in drug withdrawal. In these hospitals, the mean number of infants in drug withdrawal was 4.7. Infant acuity was significantly higher among infants in drug withdrawal. Parents of infants in drug withdrawal required significantly more care to address complex social situations (51% vs 12%). The number of infants assigned to nurses with at least 1 infant in withdrawal (mean = 2.69) was significantly higher than typical (mean = 2.51). Given infant acuity and parental needs, policies legislating patient-to-nurse ratios should permit professional discretion on the number of patients to assign nurses caring for infants in drug withdrawal. Managers and charge nurses should consider the demands of caring for infants in drug withdrawal in assignment decisions and provide support and education.

Neonatal Abstinence Syndrome: Exploring Nurses' Attitudes, Knowledge, and Practice.

BACKGROUND: As opioid abuse increases in the United States, the rate of neonatal abstinence syndrome (NAS) rises dramatically. Caring for infants with NAS and their families is a significant challenge to neonatal nurses. PURPOSE: The purpose of this survey study was to explore attitudes and practice trends among nurses caring for infants with NAS. The study also aimed to identify any gaps in knowledge about NAS. METHOD: An anonymous, cross-sectional survey study was conducted using a researcher-developed questionnaire. The survey questionnaire included 20 Likert-scale questions regarding nurses' attitudes, knowledge, and practice in care of infants with NAS, 1 case study with 3 questions, and 2 open-ended questions. Nurses, including advanced practice nurses and nurse leaders, were invited to participate at a regional neonatal nursing conference in the New England area. RESULTS: A total of 54 participants responded, the majority being white, female, non-Hispanic, and bachelor's prepared. Many nurses shared concerns regarding the setting in which infants with NAS are cared for. Nurses expressed varying attitudes regarding interacting with the mothers but generally wanted to build a partnership with them. Nurses also reported a lack of standardized and consistent practice in care for infants with NAS. Three major themes were identified from open-ended questions, including environmental issues, relationship with the mother, and inconsistency in care. IMPLICATIONS FOR PRACTICE: Further research is needed for nurses providing care to infants with NAS. Specific education programs are needed for nurses who are caring for infants with NAS. IMPLICATIONS FOR RESEARCH: Further research is needed regarding the effects of NAS on nurses and other healthcare providers.

Simplification of the Finnegan Neonatal Abstinence Scoring System: retrospective study of two institutions in the USA.

OBJECTIVE: To develop a simplified Finnegan Neonatal Abstinence Scoring System (sFNAS) that will highly correlate with scores ≥8 and ≥12 in infants being assessed with the FNAS. DESIGN, SETTING AND PARTICIPANTS: This is a retrospective analysis involving 367 patients admitted to two level IV neonatal intensive care units with a total of 40 294 observations. Inclusion criteria included neonates with gestational age ≥37 0/7 weeks, who are being assessed for neonatal abstinence syndrome (NAS) using the FNAS. Infants with a gestational age <37 weeks were excluded. METHODS: A linear regression model based on the original FNAS data from one institution was developed to determine optimal values for each item in the sFNAS. A backward elimination approach was used, removing the items that contributed least to the Pearson's correlation. The sFNAS was then cross-validated with data from a second institution. RESULTS: Pearson's correlation between the proposed sFNAS and the FNAS was 0.914. The optimal treatment cut-off values for the sFNAS were 6 and 10 to predict FNAS scores ≥8 and ≥12, respectively. The sensitivity and specificity of these cut-off values to detect FNAS scores ≥8 and ≥12 were 0.888 and 0.883 for a cut-off of 6, and 0.637 and 0.992 for a cut-off of 10, respectively. The sFNAS cross-validation resulted in a Pearson's correlation of 0.908, sensitivity and specificity of 0.860 and 0.873 for a cut-off of 6, and 0.525 and 0.986 for a cut-off of 10, respectively. CONCLUSION: The sFNAS has a high statistical correlation with the FNAS, and it is cross-validated for the assessment of infants with NAS. It has excellent specificity and negative predictive value for identifying infants with FNAS scores ≥8 and ≥12.

Analysis of the factors that influence the Finnegan Neonatal Abstinence Scoring System.

OBJECTIVE: To evaluate factors that can influence the Finnegan Neonatal Abstinence Score (FNAS). STUDY DESIGN: Retrospective analysis of 367 patients admitted to two level IV neonatal intensive care units. Linear mixed effects models were developed to evaluate daily census, time of the day, and day of the week as fixed effect predictors. The degree of influence that nurses had on FNAS variability was also estimated. RESULTS: Bivariate analyses showed that daily census and the time of day have significant influence on the FNAS in institution 1, with minimal clinical significance. The proportion of variation in the FNAS attributable to differences in nurses was of 9.8% and 5.1% for institutions 1 and 2, respectively (P<0.0001). CONCLUSIONS: The minimal influences of extraneous factors on the FNAS support the clinical utility of the scoring system in the assessment and management of infants with Neonatal Abstinence Score.

Enhancing Care for Infants With Neonatal Abstinence Syndrome: An Evidence-Based Practice Approach in a Rural Midwestern Region.

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning and implementation of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.