Denise Maguire

Clinician perceptions of a changing hospital environment.

OBJECTIVE: The purposes of this study were to describe how a move into a new hospital influenced the work environment, how long it takes clinicians to adjust to such a significant change, and how much a new hospital work environment helps the practice shift toward patient- and family-centered care (PFCC). BACKGROUND: Creating a healthy work environment to keep patients safe and staff engaged in the mission of the organization is perhaps one of the most important roles of hospital administrators and nursing leaders. METHODS: A descriptive and comparative design was used to investigate how clinicians perceive, evaluate, and adjust to a new hospital environment, and how much a healthy work environment helps the practice shift toward patient- and family-centered care. RESULTS: Perceived stress was significantly higher than baseline 15 months after the move into the new hospital (p < 0.0000), and employees with 3 or more years of service had significantly higher stress than others (p < 0.000). Nurses had the second lowest mean stress score (x = 12.5). The PFCC score increased significantly (p < 0.007). CONCLUSIONS: The single-patient room model increased the workload of many clinicians, and their stress increased after 15 months. There were additional burdens not measured that also may have added to the stress of the participants. The new hospital enabled a significant practice shift toward PFCC.

Long-Term Outcomes of Infants with Neonatal Abstinence Syndrome

Abstract Parents of infants with neonatal abstinence syndrome (NAS) in the NICU may have questions about the long-term consequences of prenatal exposure to methadone, both asked and unasked. Although the signs of withdrawal will abate relatively quickly, parents should be aware of potential vision, motor, and behavioral/cognitive problems, as well as sleeping disturbances and ear infections so their infants can be followed closely and monitored by their pediatrician with appropriate referrals made. Furthermore, this knowledge may inspire parents to enroll their infants in an early intervention program to help optimize their outcomes. There are still many unanswered questions about epigenetic consequences, risk for child abuse/neglect, and risk of future substance abuse in this population.

Creating a successful environment for neonatal nurse practitioners.

Factors that contribute to the neonatal nurse practitioner (NNP) practice environment have emerged from research grounded in the results of a nonexperimental, descriptive, and correlational study that described the role and nursing identity of 258 NNPs. These factors may be used as prescriptions for developing successful NNP environments or to strengthen a current practice. Nursing management has a responsibility to identify factors that enhance nursing identity of NNPs and to plan strategies to operationalize those factors to provide an optimal environment in which NNPs can practice to their fullest potential. Implications are raised for nursing administration and education to address the issues of role differentiation, socialization, and identity of advanced practice nurses in tertiary care.

Care of the infant with neonatal abstinence syndrome: strength of the evidence.

There is little empirical evidence that guides management of infants with neonatal abstinence syndrome. The standard of care first described in the 1970s is still prevalent today, although it has never been tested in this population. Standard of care interventions include decreasing external stimulation, holding, nonnutritive sucking, swaddling, pressure/rubbing, and rocking. These interventions meet the goals of nonpharmacologic interventions, which are to facilitate parental attachment and decrease external stimuli. Many nursing interventions used in infants with neonatal abstinence syndrome have been tested in low-birth-weight infants, whose treatment often includes the same goals. Those interventions include music therapy, kangaroo care, massage, and use of nonoscillating water beds. Nursing attitude has also been shown to be impactful on parental attachment. The American Academy of Pediatrics recommends breast-feeding in infants whose mothers are on methadone who do not have any other contraindication. It also provides guidelines for pharmacologic management but cannot provide specific recommendations about a standard first dose, escalation, or weaning schedule. Buprenorphine has some evidence about its safety in newborns with neonatal abstinence syndrome, but high-powered studies on its efficacy are currently lacking. There are many opportunities for both evidence-based projects and nursing research projects in this population.

Patterns of Disruptive Feeding Behaviors in Infants With Neonatal Abstinence Syndrome.

Background:Severe irritability in infants with neonatal abstinence syndrome often impacts their ability to feed successfully, which challenges a mothers ability to demonstrate this most basic parenting skill. There is little empiric evidence to guide recommendations for practice in this population. Purpose:Describe the infant behaviors that disrupt feeding in infants with neonatal abstinence syndrome. Methods:A mixed-method approach was used to describe digitally recorded infant feeding behaviors. Qualitative methodology was first used to identify categories of behaviors during the feeding. The categories were used as a coding scheme to identify the temporal sequence, duration, and frequency of behaviors observed during a feeding. Results:The behavior categories that disrupted feeding were identified as fussing, resting, crying, and sleeping/sedated. Infants spent almost twice as much time in fussing as in feeding. The majority of the infants were fussing between 1 and 11 minutes during the feeding, and fussing disrupted feeding in every subject at least once. Feeding behavior occurred only 24% of the time, while fussing and crying occurred 51%. Fussing was the primary transitional behavior from one category to another. Infants who did not complete their feeding had nearly twice the mean number of fussing episodes as those who completed their feeding. Implications for Practice:Fussing is a transitional state and appears to provide an opportunity to test interventions that help the mothers reengage their infants in feeding. The frequency of the behavioral transitions provides a measure of irritability that has not been previously described in this population. Implications for Research:Additional study is needed to evaluate the impact and contributions of maternal behaviors and external variables on infant behavioral transition.

Using a clinical collaborative model for nursing education: application for clinical teaching.

The promise of a Clinical Collaborative Model (CCM) is that it engages hospital partners in a mutually beneficial partnership by providing the entire student clinical experience in one institution. The CCM prepares students for the day-to-day reality of patient care through the use of individual staff nurse preceptors, enhancing the relationship between the student and hospital upon graduation. The authors describe a successful paradigm for student nurse clinical education across the baccalaureate program.

A Systematic Review: The Utility of the Revised Version of the Score for Neonatal Acute Physiology Among Critically Ill Neonates.

The revised version of the Score for Neonatal Acute Physiology (SNAP-II) has been used across all birth weights and gestational ages to measure the concept of severity of illness in critically ill neonates. The SNAP-II has been operationalized in various ways across research studies. This systematic review seeks to synthesize the available research regarding the utility of this instrument, specifically on the utility of measuring severity of illness sequentially and at later time points. A systematic review was performed and identified 35 research articles that met inclusion and exclusion criteria. The majority of the studies used the SNAP-II instrument as a measure of initial severity of illness on the first day of life. Six studies utilized the SNAP-II instrument to measure severity of illness at later time points and only 2 studies utilized the instrument to prospectively measure severity of illness. Evidence to support the use of the SNAP-II at later time points and prospectively is lacking and more evidence is needed.

Ethical issues related to caring for low birth weight infants

Background: Currently preterm births are the leading causes of newborn deaths and newborn mortality in developed countries. Infants born prematurely remain vulnerable to many acute complications and long-term disabilities. There is a growing concern surrounding the moral and ethical implications of the complex and technological care being provided to extremely low birth weight infants in neonatal intensive care units in the developed nations. Research purpose: The purpose of this study was to describe the ethical and moral issues that neonatal intensive care nurses experience when caring for low birth weight preterm infants and their families. Research design: A phenomenological method design was used to describe the lived experiences of nurses with ethical and moral issues encountered in the neonatal intensive care unit. One-on-one, semi-structured interviews using open-ended questions were used to gather data from the participants. Research participants: The setting for this study was a 97-bed neonatal intensive care. A total of 16 female nurses were interviewed. Ethical considerations: Approval to conduct the research study was obtained from the institutional review board of the hospital where the study was conducted. Formal signed consent was obtained from each participant. To ensure confidentiality, each participant was asked to choose a confederate name to be used in the interview and the transcriptions. Findings: The thematic analysis identified five recurring themes: (a) at the edge of viability, (b) infant pain and discomfort, (c) crucial decisions, (d) communicating with parents, and (e) letting go. Conclusion: Neonatal intensive care unit nurses indicated that they often had challenges to their own sense of morality as they struggled to protect the infant from pain and unnecessary discomfort, provide care to an infant and their family whom they thought was faced with a lifetime of challenges and poor health, accepting decisions made by parents, and feeling as if parents were not adequately informed about outcomes.

Mothers on methadone: care in the NICU.

When women addicted to opioids seek prenatal care, the treatment of choice is methadone.1,2 Methadone mediates the addiction by reducing fluctuations in maternal serum opioid levels and protecting the fetus from repeated withdrawal episodes.3 Methadone maintenance is associated with increased maternal weight gain, decreased illegal drug use, and improved compliance with prenatal care.4 Although the risks are less when compared with street drugs, the risk to the fetus is physical dependence. Despite the magnitude of this national problem, there is a dearth of literature to guide NICU nurses on how to best support mothers of infants with neonatal abstinence syndrome (NAS) in the care of their infants. The purposes of this article are to review what is known about women in methadone treatment who have a history of opioid addiction and apply that evidence to guide neonatal nurses to support mothers of infants with NAS in the NICU.

Characteristics of Maternal-Infant Interaction During Treatment for Opioid Withdrawal.

Abstract Purpose: The purpose of this study was to describe the interactions between mothers in a methadone treatment program and their infants during a bottle feeding and compare the findings with normed data. Design: A comparative-descriptive design was used. Sample: Data from 12 opiate-exposed mother–infant dyads were compared with normed data. Main outcome variable: Nursing Child Assessment Satellite-Training Scale scores. Results: The opiate-exposed dyads scored significantly lower than the normed dyads in the infant subscales of clarity of cues (p < .001, 95% confidence interval [CI], 1.56–4.08) and responsiveness to caregiver (p < .01, 95% CI, 0.27–2.5), as well as the total score (p < .001, 95% CI, 2.42–6.15). Parent sensitivity to infant cues subscale (p < .01, 95% CI, 0.42–2.37) and parent contingency score (p < .01, 95% CI, 0.55–3.81) were also significantly lower. The cognitive growth fostering subscale scores were significantly higher in the neonatal abstinence syndrome (NAS) group (p < .01, 95% CI, −2.94 to −0.7).