Are families attending a neonatal intensive care unit engaged and satisfied with video education? A scoping review

The birth of a child is an exciting and challenging time for parents. The first few years following birth involve an adjustment period as parents work together to balance work, family, infant care, and self-care. Approximately 7 - 15% of parents will have an infant who will spend some amount of time in a Neonatal Intensive Care Unit (NICU). These parents experience the typical stressors associated with parenthood plus the additional stress of worrying about their infant's survival, development, and/or long-term health. After NICU discharge, parents are sent home to care for an ill and/or preterm infant and often continue to worry about rehospitalizations, ongoing health issues, and the long-term consequences of the experience. The impact of the NICU experience and subsequent infant health issues on parental and family outcomes is an understudied area that merits research attention. The current study examined how the NICU experience and subsequent infant health problems that may follow during the first three years after discharge affects parental stress, couple functioning, and family dynamics. A variable known to attenuate stress and family outcomes (i.e., family resources) was included to study the contribution of this factor. Parents with infants who had been discharged from the NICU six months to three years ago were recruited via the Internet and posted flyers (N = 199). Parents reported objective indicators of their infants' health during the NICU admission and at the present time, parenting stress, family burden, couple functioning, and access to family resources. Both parents were invited to participate to gain a more comprehensive picture of perspectives and experiences, and to compare responses of mothers and fathers. However, women (n = 182; 91.5%) greatly outnumbered men (n = 17; 8.5%) almost eleven to one in the sample making comparisons of mothers and fathers statistically underpowered. Multivariate regression analyses revealed that a shorter length of stay in the NICU, less infant rehospitalizations, and additional infant diagnoses following discharge were significant positive predictors of increased parental stress. Moreover, a higher number of medical devices used by the infant at discharge and fewer infant rehospitalizations were associated with poorer couple functioning. Infant use of extracorporeal membrane oxygenation (ECMO) during the NICU stay, a greater number of medical devices used by the infant during the NICU stay, the more specialists seen in the first year post-discharge, and the more medications currently prescribed, were all associated with greater family burden. Family resources did not significantly moderate (i.e., change or strengthen) the relationships between infant health and each outcome; however, fewer family resources was associated with increased parental stress, poorer couple functioning, and greater family burden. Analysis of covariance (ANCOVA) was used to examine sex differences and although no differences were found, analyses were greatly underpowered and should be interpreted with caution. Results suggest that infant health severity, the associated burden of care, and family resources are important contributors for parental and family adjustment. Family-focused interventions that incorporate information and skills on managing their child's health issues, communication between medical providers and parents, transitioning home from the NICU, ways to adaptively coping strategies, and ways to overcome barriers to resources and treatment may be effective mechanisms to prevent negative psychosocial sequelae among NICU parents and families following discharge. Additional implications and future directions are discussed.

Background: NICU parents are at risk for poor emotional functioning, including mood disorders, anxiety, and parental distress. Identifying factors associated with poor emotional functioning can help identify at-risk parents who may benefit from mental health support. Objective: To determine the prevalence of depressive symptoms among parents at NICU discharge, risk factors associated with elevated depression scores, and the relationship between depressive symptoms, anxiety, and NICU parental stress. Methods: Data were collected from parents (n=300) and infants (n=300) enrolled in a randomized trial of peer-to-peer support after NICU discharge. Baseline parent and infant characteristics were collected by pre-discharge survey and chart review. Depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale (CES-D) short form (10 items). Parental NICU stress was assessed using measure 1 (stress occurrence) of the Parental Stressor Scale:NICU (PSS:NICU) (46 items), containing four subscales: infant appearance/behavior, parental role alteration, NICU environment, and parental relationship with staff. Regression and partial correlation methods were used to test for relationships between depressive symptoms, stress, and parent and infant factors. Parent factors included age, sex, race, education, work, relationship status, and number of other children at home. Infant factors included sex, gestational age (GA), birth weight, and length of stay (LOS). Results: Approximately 45% of parents had elevated CES-D scores ≥10 points (Table 1). The mean(SD) age of parents was 30(7) years, 89% were mothers, and 44% self-identified as African American, with 45% reporting a college degree or higher. Most parents were married/partnered (53%), employed pre-NICU (71%), and first-time parents (43%). Infants were predominantly male (58%), with birth weights ≥2500 g (58%) and GAs ≥37 weeks (57%) (Table 2). The majority of infants had a LOS >2 weeks (54%). In adjusted models, female baby gender (p=0.014), GA (p=0.006), and LOS (p=0.045) were all associated with increased odds of having an elevated CES-D score. Parents of infants with GAs ≥37 weeks had a 6.6-fold (95%CI: 2.2-19.7) increased odds of having an elevated CES-D score compared to those with GAs < 28 weeks GA. Parental NICU stress was lower in parents older in age (p=0.009), but higher in mothers vs. fathers (p=0.002). CES-D scores were positively correlated with total PSS:NICU scores (partial r2=0.14) and subscale scores (all p≤0.001). In adjusted models, each 1-point increase in total PSS:NICU score was associated with a 2.4-point (95% CI: 1.6-3.10, p < 0.001) increase in total CES-D score. Conclusion: Almost half of surveyed parents experienced depressive symptoms at NICU discharge. Infant GA was a strong predictor of elevated CES-D scores, and NICU parental stress was positively correlated with depressive symptoms. Further investigation of risk factors associated with depression is planned, as is the examination of peer-to-peer support on depressive symptoms after NICU discharge.

Background Central lines are a vital component of ongoing care in the neonatal intensive care unit (NICU). Central line associated bloodstream infection (CLABSI) is a leading source of sepsis in the NICU setting, with up to 20% mortality. Aim We aimed to achieve significant reduction in the number of positive blood culture and CLABSI events in a tertiary NICU setting by implementation of an education strategy to teach correct skin cleansing and line access technique for 100% of patient encounters. Method Positive blood culture and CLABSI events were recorded at baseline and monthly throughout the study period. We established optimal cleansing technique using chlorhexidine gluconate 2% solution allowed to dry for 30 s prior to any skin break or line access procedure in the NICU. An audit to establish baseline compliance was performed. Subsequently, an educational bundle was introduced for all NICU staff involving face-to-face teaching on the importance of the technique, placement of reminder posters with the slogan ‘Wipe and Wait’ in key clinical areas and audits of compliance were commenced. Results At baseline correct cleansing procedure was recorded as 100% for central line access/insertion events but 0% for peripheral line access or skin break events. Data recorded 6 months prior to introduction of the educational bundle showed positive blood culture and CLASBI rates ranging from 6–14/month and 2–4/month respectively. Data for 3 months post introduction of the education bundle showed a decrease in blood culture and CLABSI rates ranging from 0–3/month (difference in medians, p=0.03) and 0–2/month (difference in medians, p=0.06) respectively. Conclusion We demonstrated that good cleansing for peripheral line access/skin break events as well as central line access events resulted in a rapid and significant reduction in positive blood culture rates and reduced CLABSI rates within our NICU setting. This work highlights the importance of correct cleansing technique in performing all procedures within the NICU. It also demonstrates the substantial benefit of this simple educative intervention in improving quality of patient care and reducing infection in NICU patients.

A nurse led a team of providers in a quality improvement (QI) project to positively impact inpatient care and outcomes for infants with neonatal abstinence syndrome (NAS). The Eat Sleep Console (ESC) model was implemented to promote rooming-in and family-centered care as part of a nonpharmacological treatment approach. To compare the ESC model with the traditional Finnegan treatment approach to describe differences in infants' pharmacotherapy use (morphine), length of stay (LOS), weight loss, consumption of mother's own milk by any feeding method within 24 hours of discharge, Neonatal Intensive Care Unit (NICU) use, and Pediatric Unit utilization. The QI project was conducted at a single hospital site with more than 1700 deliveries per year in the Midwestern United States. A comparative effectiveness study design was used to evaluate the ESC model. The ESC model impacted care and outcomes for infants with NAS, contributing to a significant reduction in morphine treatment, decrease in LOS among morphine-treated infants, increase in weight loss in infants who did not require morphine treatment, less NICU use, and greater Pediatric Unit utilization. A nonsignificant increase was found in the number of infants who consumed their mother's own milk by any feeding method in the 24-hour period prior to discharge. Results may be helpful for hospitals striving to optimize care for infants exposed to opioids, using assessments of eating, sleeping, and consoling to guide individualized treatment decisions and to reduce morphine use.

To explore the use of Indigenous philosophies and ways of knowing as a means to critique, understand and improve the care of Indigenous infants and families in the neonatal intensive care unit (NICU). The ability of health professionals to provide culturally safe and equitable care to Indigenous infants and their families can affect infant development and long-term health outcomes. Research suggests that family involvement in care benefits both the infant and their family, but there is limited research that addresses the experience of Indigenous families in the NICU and advances understanding of how nurses involve Indigenous families in their infants' care. A discursive, critical review will be presented to outline the assumptions of Indigenous philosophies and to explore how the consideration and implementation of Indigenous ways of knowing can improve the nursing care of Indigenous infants and their families in the NICU. First, our subjective positioning as Indigenous nurses and as health researchers is described. Second, our understanding of Indigenous philosophical frameworks and how these approaches fit in the context of the philosophy of science is defined. Third, the key elements of an Indigenous philosophical paradigm are described. Fourth, an application of Indigenous paradigms to supporting the care of Indigenous infants and families in the NICU context is made. An Indigenous philosophical approach to nursing is ideal for understanding and improving the experiences of Indigenous infants and families in the NICU. This approach allows nurses to critically analyse the history and legacy of colonialism and its impact on the health and wellbeing of Indigenous peoples. By prioritising the voices and concerns of Indigenous families in the clinical setting and in nursing research, nurses can better understand the experiences of these families in the NICU and use strengths-based approaches to facilitate family involvement in care. The application of Indigenous philosophies in the nursing context can be used to inform the care of Indigenous infants and families in the NICU. Potential benefits include improved therapeutic relationships between nurses and Indigenous families, and increased uptake of parent-led interventions in nursing practice, which may lead to improved health outcomes for Indigenous infants in the NICU and throughout their subsequent development.

Neonatal intensive care unit (NICU) admission increases parents' stress levels and it might be even higher in the crisis of coronavirus disease 2019 (COVID-19) pandemic and lockdown. This study was done to identify the stress levels of parents of admitted neonates and the difficulties encountered in neonatal care and follow-up during the COVID-19 pandemic and lockdown. The Parental Stressor Scale (PSS:NICU) and Perceived Stress Scale (PeSS) were used to identify the stress levels of parents of admitted neonates. Online survey form with a structured questionnaire comprising PeSS and NICU:PSS was sent through messaging app (Google form) after informed consent. PSS score of <14 was considered low stress, 14-26 moderate and >26 as high. A total of 118 parental responses (mother /father in 26, both in 46) for 72 admitted neonates, were obtained. The mean (SD) PeSS score was 19.7 (5.8%) and 92 (78%) had moderate stress while 11 (9%) had high stress. In NICU:PSS, sights-sounds and parental role had more median scores: 2.25 (1-3.75) and 2.21 (1-3.57), respectively. Maternal and paternal NICU:PSS (p-0.67) and PeSS (p-0.056) scores were not statistically different. Keeping nil per oral, invasive ventilation, culture-positive sepsis, fathers' transport difficulty and longer duration of mothers' and neonates' hospital stay was associated with increased NICU: PSS scores. Twenty (29%) parents could not bring their child for follow-up and there was a delay in immunisation in 21 (30%). The pandemic and the lockdown might have disrupted antenatal and postnatal follow-ups further adding to the parental stress.

Exploring parental stress and spiritual needs in the neonatal intensive care unit (NICU).

Family-provider relationships and well-being in families with preterm infants in the NICU

The article examines the evolution of models for providing family-centered services in neonatal intensive care settings. Child-focused, parent-infant interaction, and ecological models are presented and discussed. One specific ecological model, the family-centered care model, is examined in detail. While most current programs endorsed family-centered care (FCC) as a "best practice" for developmental intervention with infants, few were found that implemented these practices. Most utilized only limited components of FCC. Instead, programs operating in NICU settings had features directed toward child care, staff training, family support and transition to the community, rather than impacting the philosophy of care and/or service delivery system in the NICU. Suggestions for working toward FCC in NICU settings are given and barriers are discussed.

BackgroundAdmission of a preterm infant to the Neonatal Intensive Care Unit (NICU) is highly stressful for parents. NICU nurses play a crucial role in providing support, positively impacting health and aiding effective stress management during this challenging period. This study assesses stress and nurse-parent support for parents with preterm infants in the NICU, exploring connections between stress, support, and various parental and infant variables.MethodsThis descriptive cross-sectional study was conducted between January and July 2019 on a total of 150 parents (75 mothers and 75 fathers) with preterm infants in a private hospital’s NICU in Ankara, Turkey. Data were collected using the Parent and Infant Information Form, Parental Stressor Scale: NICU (PSS: NICU), and Nurse-Parent Support Tool (NPST).ResultsThere was no significant correlation between PSS: NICU and NPST scores (p > 0.05). However, a significant difference was observed in the overall NPST score (p = 0.036) and its emotional support subscale (p = 0.013). Mothers’ PSS: NICU was influenced by infant information (p = 0.027) and marital duration ((p = 0.002), while fathers’ was influenced by number of children (p = 0.040) and infant care participation (p = 0.001). NPST was affected by number of children (p = 0.004) and infant respiratory status (p = 0.011) for mothers and number of children for fathers (p = 0.038). Since parents require informational, emotional, and care-related support, nurses should continuously enhance their professional and communication skills to establish effective communication with parents and provide targeted support.ConclusionThis study found mothers received greater nurse support than fathers. Mothers with one child had higher nurse support, while mechanical ventilation for mothers and having more than one child for fathers were linked to reduced support. Lower stress levels were noted in mothers married for 6–10 years, those informed about the infant, and fathers actively participating in infant care with more than one child.

Desde comienzo de ano y hasta mediados de marzo, el segoviano Torreon de Lozoya acoge una exposicion de esas que no se ven todos los dias: Marc Chagall: El mensaje biblico (1931-1983). Financiada por Caja Segovia, que ha querido conmemorar con magnificencia los ciento veinticinco anos de su fundacion, la exposicion reune oleos, grabados, dibujos y un gran tapiz del artista judio, la mayoria de ellos nunca expuestos en nuestro pais, y cuya tematica comun es la Biblia.

The experience of hospitalization of a newborn in the Neonatal Intensive Care Unit (NICU) may become distressing both for the baby and parent. The study aimed to assess the degree of parental stress and coping strategies in parents giving KMC to their babies hospitalized in NICU compared to the control group parents not giving KMC. The prospective observational study enrolled a cohort of 337 parents of premature babies hospitalized in NICU in 2016 in Eastern Poland. The Parental Stressor Scale: Neonatal Intensive Care Unit, Coping Inventory for Stressful Situations were used. The level of stress in parents giving KMC was defined as low or moderate. Analysis confirmed its greater presence in the group of parents initiating KMC late (2–3 weeks) compared to those starting this initiative in week 1 of a child’s life. An additional predictor of a higher level of stress in parents initiating KMC “late” was the hospital environment of a premature baby. Task oriented coping was the most common coping strategy in the study group. KMC and direct skin-to-skin contact of the parent with the baby was associated with a higher level of parental stress only initially and decreased with time and KMC frequency.

Flexible approaches to parenting training interventions in the neonatal intensive care unit (NICU), including family integrated care (FICare) models, are urgently needed across the globe. Many FICare trials inadvertently exclude parents with low resources who cannot commit to daily infant care (eg, 4-8 hours/day). Preemie Progress (PP) is a fully automated, video-based training program that allows parents to choose when and where they learn, without requiring parent bedside presence. This study aims to examine the feasibility of recruitment, retention, fidelity, and changes in outcomes during a pilot randomized controlled trial of PP, a video-based intervention aimed at training mothers of very preterm infants in evidence-based family management skills in the NICU. Mothers of infants born between 25 weeks and 0 days to 31 weeks and 6 days of gestation were enrolled in an NICU in the Midwestern United States. Electronic surveys were sent to collect maternal outcomes (Patient-Reported Outcomes Measurement Information System [PROMIS] 8a depression and anxiety scales) at baseline (T1), 14 days (T2) and 28 days (T3) after T1, and 30 days after NICU discharge (T4). Infant electronic health records were extracted to collect infant (ie, weight gain velocity at 36 weeks and receipt of mother's milk) and health care outcomes (ie, NICU length of stay as well as readmissions and emergency department visits within 30 days of discharge). Of 123 eligible mothers, 64 (52%) were randomly assigned to 1 of 2 arms (PP: n=33, 52%; attention control [AC]: n=31, 48%). Loss to follow-up was 30% (10/33) in the PP arm and 13% (4/31) in the AC arm. PP mothers watched a mean 17.8 (SD 18.9) of 49 videos. PP retention was linked to higher fidelity. PP mothers showed trends toward greater reductions in anxiety 30 days after discharge (mean -7.54, SD 1.93; 95% CI -11.32 to -3.76) compared to AC mothers (mean -4.67, SD 1.59; 95% CI -7.80 to -1.55). PP infants trended toward greater receipt of exclusively mother's milk 28 days after baseline (PP: 14/26, 54%; AC: 10/28, 36%) and decreased NICU stay (PP: 57.2 days; AC: 68.3 days) but higher readmissions (PP: 4/33, 12%; AC: 2/31, 6%). We were able to recruit a diverse sample of mothers from a range of socioeconomic backgrounds, including mothers experiencing barriers to bedside presence. Recruitment goals were met. PP showed promising trends in improving maternal, infant, and health care outcomes. Additional studies are needed to optimize PP and study procedures to improve retention and fidelity. PP has the potential to support parent training outside of traditional FICare models or serve as a complement to structure the parent education pillar of adapted FICare models. ClinicalTrials.gov NCT04638127; https://www.clinicaltrials.gov/study/NCT04638127.

BACKGROUND Flexible approaches to parenting training interventions in the neonatal intensive care unit (NICU), including family integrated care (FICare) models, are urgently needed across the globe. Many FICare trials inadvertently exclude parents with low resources who cannot commit to daily infant care (eg, 4-8 hours/day). Preemie Progress (PP) is a fully automated, video-based training program that allows parents to choose when and where they learn, without requiring parent bedside presence. OBJECTIVE This study aims to examine the feasibility of recruitment, retention, fidelity, and changes in outcomes during a pilot randomized controlled trial of PP, a video-based intervention aimed at training mothers of very preterm infants in evidence-based family management skills in the NICU. METHODS Mothers of infants born between 25 weeks and 0 days to 31 weeks and 6 days of gestation were enrolled in an NICU in the Midwestern United States. Electronic surveys were sent to collect maternal outcomes (Patient-Reported Outcomes Measurement Information System [PROMIS] 8a depression and anxiety scales) at baseline (T1), 14 days (T2) and 28 days (T3) after T1, and 30 days after NICU discharge (T4). Infant electronic health records were extracted to collect infant (ie, weight gain velocity at 36 weeks and receipt of mother’s milk) and health care outcomes (ie, NICU length of stay as well as readmissions and emergency department visits within 30 days of discharge). RESULTS Of 123 eligible mothers, 64 (52%) were randomly assigned to 1 of 2 arms (PP: n=33, 52%; attention control [AC]: n=31, 48%). Loss to follow-up was 30% (10/33) in the PP arm and 13% (4/31) in the AC arm. PP mothers watched a mean 17.8 (SD 18.9) of 49 videos. PP retention was linked to higher fidelity. PP mothers showed trends toward greater reductions in anxiety 30 days after discharge (mean −7.54, SD 1.93; 95% CI −11.32 to −3.76) compared to AC mothers (mean −4.67, SD 1.59; 95% CI −7.80 to −1.55). PP infants trended toward greater receipt of exclusively mother’s milk 28 days after baseline (PP: 14/26, 54%; AC: 10/28, 36%) and decreased NICU stay (PP: 57.2 days; AC: 68.3 days) but higher readmissions (PP: 4/33, 12%; AC: 2/31, 6%). CONCLUSIONS We were able to recruit a diverse sample of mothers from a range of socioeconomic backgrounds, including mothers experiencing barriers to bedside presence. Recruitment goals were met. PP showed promising trends in improving maternal, infant, and health care outcomes. Additional studies are needed to optimize PP and study procedures to improve retention and fidelity. PP has the potential to support parent training outside of traditional FICare models or serve as a complement to structure the parent education pillar of adapted FICare models. CLINICALTRIAL ClinicalTrials.gov NCT04638127; https://www.clinicaltrials.gov/study/NCT04638127

Identifying Depression in Neonatal Intensive Care Unit Parents: Then What?