Research on Developmental Care Helping Both Preemies and Parents

Transcription

1 Research on Helping Both Preemies and Parents RAYMOND J. BINGHAM, RNC, MSN m My first exposure to the value of research came when I was a new registered nurse, straight out of school. I was orienting in a busy neonatal intensive care unit (NICU) at a major university medical center, and struggling to adapt to the rapid-fire, life-or-death a tmosphere. Tiny premature babies, some weighing barely more than a pound and not much longer than my open hand, depended on my nursing skill and knowledge. Everything associated with them was fraught with peril. Changing a diaper a basic chore required deft and delicate handling to avoid dislodging intravenous lines or bruising translucent skin, yet I was nervous, clumsy and unsure. Then one morning Jill, my orientation preceptor, handed me a flier and said, Look, there s a neonatal lecture today! I sighed, Abstract Developmental care for premature infants was introduced by Dr. Heidi Als more than 20 years ago, and has become an accepted standard of care. Research into developmental care has shown some benefits in neonatal outcomes, but there is no standard definition of developmental care, and its practice can vary widely across different neonatal units. Dr. Bernadette Melnyk developed a program entitled Creating Opportunities for Parent Empowerment (COPE) to help parents of premature infants learn about the common appearance and behaviors of these infants, and about developmentally appropriate parenting skills. COPE has helped to reduce parental anxiety and stress and to improve outcomes for premature infants. DOI: /j X x Keywords developmental care prematurity neonatal care COPE , AWHONN 45

2 Raymond J. Bingham, RNC, MSN, is a science writer and editor living in Montgomery Village, MD. The author reports no conflicts of interest or relevant financial relationships. This article was written by the author in his private capacity; no official support or endorsement by the U.S. National Institutes of Health is intended or should be inferred. Address correspondence to: rjbrnc@ comcast.net. Premature infants display distinct stages of neurologic development, and they face particular challenges by having to progress through these stages outside of the natural and protective environment of the maternal womb already overwhelmed with new information. But Jill made sure to drag me along. The lecturer was Dr. Heidi Als, a psychologist. Her research had found that premature infants displayed distinct stages of neurologic development, and they faced particular challenges by having to progress through these stages outside of the natural and protective environment of the maternal womb. At the conclusion of her lecture, she described some nursing care techniques for these infants keeping them in a flexed posture, keeping their arms and hands midline for security and comfort and providing nesting boundaries with blanket rolls that mimicked some aspects of the womb and seemed to help to decrease stress and improve growth. She referred to these steps as developmental care. I was skeptical at first. The techniques described by Dr. Als seemed to require a lot of e x- tra manipulation of the infant, when I had been taught to minimize stimulation as much as possible. Babies squirm and move about, making it hard to maintain them in a perfect alignment. Plus, I was a busy nurse, with little time to make blanket rolls. However, Jill seemed excited. Soon, she and the other more experienced nurses began practicing developmental care. Even the attending medical staff joined in, noting, for instance, that keeping infants in a neutral, flexed posture reduced struggling on the ventilator. I started applying the precepts, and soon I observed that appropriate positioning and nesting seemed to allow the infants under my care to rest more quietly. They expended less energy in crying and agitation, and I expended less energy trying to soothe them. Their vital signs generally remained more stable. And they just looked calmer and happier. Even their parents seemed happier. Box 1. Benefits of Decreasing chronic lung disease and necrotizing enterocolitis Easing the transition to nipple feedings Shortening the length of NICU stays Promoting long-term neurodevelopmental, behavioral and motor outcomes Improving family interactions Source: Sy mington and Pinelli (2006). Basic Tenets of That was about 20 years ago. Since then, developmental care has gained wide acceptance in NICUs across the country and around the world, and has been put into practice in many forms. Still, the basic tenets remain. An infant born prematurely and taken to a NICU suddenly encounters unfamiliar and unpredictable surroundings. The primary goal of developmental care is to try to modify the NICU environment and care practices to create a more natural and less stressful setting for the infant, one that is more conducive to promoting optimal growth and development (A ita & Snider, 2003). In the model originally conceived by Als (1998), all infants are actively engaged in their own functioning and development, interacting with others and their surroundings through five interrelated systems: (1) autonomic, regulating physiologic parameters such as heart rate and respiratory rate; (2) motor, involving posture, tone and muscle movement; (3) state organization, representing different states from alertness to drowsiness to quiet sleep; (4) attentional/interactive, referring to interactions with parents, caregivers and their environment and (5) self-regulation, involving expressive behaviors and responses to outside stimuli such as noise and touch (Als). Other theorists have also emphasized the importance of emotional and social factors in the maturation of the infant (Aita & Snider, 2003). 46 Nursing for Women s Health Volume 16 Issue 1

3 and Nursing The perspective of neonatal nursing stresses ongoing assessment of the growth and developmental needs infants in individualizing care. By incorporating developmental care practices throughout the NICU, nursing promotes an interdisciplinary, collaborative approach involving physicians, physical and occupational therapists, lactation consultants and others. To improve patient care, all care providers need to have clear and accurate knowledge of premature infant physiology and characteristics, as well as to share their observations on each infant s individual behavioral cues and responses (Aita & Snider, 2003). In addition, the nursing concept of developmental care incorporates a family-centered approach, recognizing the central and ongoing role that parental involvement plays in infants lives. Nurses and other clinicians can share information with parents, help them recognize their infant s unique responses and developmental milestones and involve them in making decisions and establishing the plan of care (Aita & Snider, 2003). In this way, parents become more comfortable discussing their observations, asking questions and raising concerns. The parents know their infant s entire history and often are the first to note day-to-day changes in their infant s condition. I know that on more than one occasion, I was able to avert a potential crisis by listening to the concerns of a parent who felt something just wasn t right. Along with direct patient care, neonatal nurses also play a central role in managing the many peripheral aspects of the NICU environment. They can take steps such as lowering ambient light and noise to reduce stimuli, clustering care procedures to minimize disruptions to sleep, modifying regimens to improve feeding tolerance and creating opportunities for nurturing bonding experiences between the infant and parents (Aita & Snider, 2003). Research on Despite the common-sense appeal and widespread acceptance of developmental care, research on its outcomes has been mixed. In a Cochrane review conducted in 2006 of 36 studies on developmental care, the reviewers noted that the term developmental care has grown to encompass a wide range of practices and interventions designed to minimize the stress on the infant from the NICU environment. Most of the reviewed studies tended to focus on one aspect or intervention, making it difficult to combine their results and determine overall effectiveness. Still, the review found evidence of the beneficial outcomes of developmental care interventions in several areas (see Box 1). However, the reviewers also noted that few large clinical trials had evaluated developmental care (Symington & Pinelli, 2006). In response to this review, a randomized controlled study involving 164 infants born at less than 32 weeks was conducted in the Netherlands to compare those who received an extensive individualized developmental care program with those who received basic developmental care (decreased light, nesting and positioning). At follow-up assessments done when the infants were 1 and 2 years of age, no differences were noted between the groups in physical growth or in scores on a range of cognitive, psychomotor and neuromotor tests. To explain The primary goal of developmental care is to try to modify the NICU environment and care practices to create a more natural and less stressful setting for infants February March 2012 Nursing for Women s Health 47

4 The nursing concept of developmental care this finding, the researchers suggested that both the intervention and control infants were cared for on the same unit, so there may have been some crossover of developmental care techniques. In addition, the length of time infants received the individualized developmental care varied widely, as hospitals in the Dutch health care system transfer infants back to regional hospitals once they are stabilized (Maguire et al., 2009). Creating Opportunities for Parent Empowerment (COPE) Another research study carried out in two NICUs in upstate New York, under the direction of nurse scientist Bernadette Melnyk, took a different approach. Melnyk and her team evaluated the effectiveness of a program to educate parents about premature birth, the characteristics of preterm infants and the basic tenets of developmental care. Most expectant parents envision having a healthy, well-developed baby. The experience of a h igh-risk pregnancy can be very traumatic for them. incorporates a family-centered approach, recognizing the central and ongoing role that parental involvement plays in infants lives In the event of a preterm delivery, they will have immediate fears about their infant s survival. The appearance of a premature infant small body, scrawny torso and limbs, thin and shiny skin, underdeveloped head and facial features can be unfamiliar and frightening to them. They must deal with the highly foreign and technical environment of the NICU. And they worry about the long-term consequences of prematurity on the health and growth of their child. A ccording to Melnyk (2011), when suddenly confronted with the birth of a premature infant, parents often can no longer really assimilate what parenting behaviors they should engage in. Many experience very high levels of stress, depression and anxiety. Early on, some parents may respond by becoming reluctant to be with, touch or hold their infant, while others may try to o verstimulate their infant in hopes of eliciting a reassuring response. Such parental behaviors can impede the development of the infant. Melnyk and her associates developed a program, called Creating Opportunities for Parent Empowerment (COPE), aimed at helping these parents adjust. The program provided the parents with a series of audiotapes and workbooks while their infants were in the NICU. The tapes provided information about the different stages of premature infant development, and taught appropriate ways to interact with infants and participate in their care to best meet their developmental needs. Meanwhile, the program sought to build skills to help the parents use what they had learned, such as differentiating sleep and wake states and understanding signs of exhaustion or stress. Nurses worked with parents to help them understand this information and how it related to their own infants, such as by reading certain behavioral cues. For example, open eyes and an attentive gaze would indicate that the infant is alert and ready to interact, while blinking, sneezing, closing the eyes or turning away often means the infant is tired or overstimulated, and needs to rest. The COPE program was delivered in four phases (see Box 2). A clinical trial involving more than 200 parents of premature infants evaluated the effectiveness of COPE. Compared to a control group of parents and infants who received usual NICU care, COPE parents reported higher beliefs in their parenting role and better understanding of the characteristics of their infants and the behaviors to expect, and they displayed more positive Box 2. Four Phases of the COPE Program Phase I - Occurs 2 to 4 days after NICU admission and teaches parents about typical premature infant behaviors; parents are assisted to identify special characteristics of their infants and begin keeping a record of developmental milestones. Phase II - Occurs 2 to 4 days after Ph ase I and offers parents suggestions on how to participate in their infant s hospital care to promote interaction and bonding and reduce the infant s stress. Phase III - Occurs prior to discharge and presents parental roles and appropriate pa rent-infant interactions, and discusses ways to decrease stress for the infant, in preparation for the transition home. Phase IV - Occurs 1 week after discharge and provides activities in the home to promote the infant s cognitive development. 48 Nursing for Women s Health Volume 16 Issue 1

5 interactions with their infants. In addition, the mothers reported lower anxiety, depression and overall parenting stress, and fathers were more involved in care and more sensitive to the needs of their infant. As a significant added benefit, the infants of COPE parents averaged almost 4 fewer days in the NICU than the infants in the control group (Melnyk et al., 2006). Discussions with the NICU staff indicated that the shorter stays were a function of both the improved growth and development of the infant, and the preparedness of the parents to care for the infant at home (Arizona State University, 2006). The shortened NICU stays translated into a savings in hospitalization costs of almost $5,000 per infant. Infants with a birth w eight of less than 1,500 grams achieved even greater results, being discharged home an average of 8 days sooner than infants in the control group, for an average savings of almost $10,000 per infant (Melnyk & Feinstein, 2009). Melnyk has estimated that COPE, if implemented nationwide, could save the health care system roughly $2 billion per year. After these results were published, Melnyk s office received calls about COPE from neonatal units across the country. Her vision is to improve the clinical care and the health outcomes for all premature infants and their parents, while also lowering the costs of care (Bingham, 2009). Melnyk and her team are continuing to follow these infants, to examine the long-term impact of COPE. Implementing COPE as Evidence-Based Practice In addition, a new study by Melnyk looked at the response of 81 staff nurses to the implementation of COPE in the NICU of a large children s hospital (Melnyk et al., 2010). All of the nurses, who ranged in age from 23 to 69 years, were surveyed about their beliefs related to evidence-based practice (EBP). Forty-eight of the nurses worked in one of two unit pods selected to implement COPE. They participated in a 1-day workshop focused on the evaluation and implementation EBP, common EBP barriers and facilitators, a description of COPE and the research base that supported it and details of how to administer the program. The other 33 nurses, serving as a comparison group, did not receive this training, and COPE was not implemented in their pods. There were no differences in EBP beliefs or implementation between the two groups before February March 2012 Nursing for Women s Health 49

6 the workshop. At a 6-month follow-up, however, nurses in the COPE pods reported higher belief in EBP than nurses in the non-cope pods. They also reported higher EBP implementation, although this difference was not statistically significant (Melnyk et al., 2010). Still, over the first 3 months of COPE implementation, the researchers found that few parents had received all phases of the program. The most common barrier reported by the nurses was the acute condition of the infant and the complexity of care, complicating efforts to work with the parents. Given this feedback, the research team introduced a COPE mentor, who worked with the nurses to remind them about using COPE, track the number of COPE sessions delivered to the parents, place triggers and reminders in the patient chart, and administer certain phases of COPE when the staff nurses were unable to do so. The nurses reported that the mentor s reminders and assistance were very helpful in more fully implementing the program (Melnyk et al., 2010). Conclusion The technology of neonatal care has advanced greatly in the 20 years since I started as a neonatal nurse, and survival of premature infants has improved. But there are still almost half a million infants born preterm in the United States each year, and they face a number of both acute and chronic challenges. Developmental care seems to make sense, and as a NICU nurse I observed what I saw as positive effects on the infants and families in my care. Research into this mode of care can help NICU clinicians determine what developmental methods are most effective, both for shortterm stability and l ong-term improvements in growth and development. Meanwhile, an evidence-based family-centered program such as COPE holds great promise to improve the developmental outcomes for premature infants and decrease stress and improve caretaking among parents, while in turn decreasing the financial impact of prematurity on our health care system. NWH References Als, H. (1998). Developmental care in the newborn intensive care unit. Current Opinion in Pediatrics, 10, Aita, M., & Snider L. (2003). The art of developmental care in the NICU: A concept analysis. Journal of Advanced Nursing, 41, Arizona State University. (2006). COPE program reduces premature infants length of NICU stay and improves parents mental health outcomes. Ret rieved August 3, 2009, from asu.edu/news/magazine/archives/nursing mag_fall06.pdf Bingham, R. (2009). Workshop examines costeffectiveness research in health care. Retrieved August 6, 2009, from gov/newsletters/2009/02_06_2009/story6.htm Maguire, C. M., Walther, F. J., van Zwieten, P. H., Le Cessie, S., Wit, J. M., & Veen, S. (2009). Follow-up outcomes at 1 and 2 years of infants born less than 32 weeks after Newborn Individualized and Assessment Program. Pediatrics, 123, Melnyk, B. (2011). COPE: Improving outcomes for premature infants and parents [videocast]. Retrieved from summary.asp?live=9907 Melnyk, B. M., Bullock, T., McGrath, J., Jacobson, D., Kelly, S., & Baba, L. (2010). Translating the evidence-based NICU COPE program for parents of premature infants into clinical practice: Impact on nurses evidence-based practice and lessons learned. Journal of Perinatal and Neonatal Nursing, 24(1), Melnyk, B. M., & Feinstein, N. F. (2009). Reducing hospital expenditures with the COPE (Creating Opportunities for Parent Empowerment) program for parents and premature infants: An analysis of direct healthcare neonatal intensive care unit costs and savings. Nursing Administration Quarterly, 33 (1), Melnyk, B. M., Feinstein N. F., Alpert-Gillis, L. Fairbanks, E. Crean, H. F. Sinkin, R. A.,...Gross, S. J. (2006). Reducing premature infant s length of stay and improving parents mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial. Pediatrics, 118, e1414 e1427. Symington, A. J., & Pinelli, J. (2006). Dev elopmental care for promoting development and preventing morbidity in preterm infants. Cochrane Dat abase of Systematic Reviews, 2006 (2), Art. No.: CD doi: / CD pub2 50 Nursing for Women s Health Volume 16 Issue 1