Date of Award

Winter 2024

Project Type

Clinical Doctorate

College or School

CHHS

Department

Nursing

Program or Major

DNP

Degree Name

Other

First Advisor

Cathleen Colleran

Second Advisor

Courtney Coffey

Abstract

Background: Medical breakthroughs including antenatal corticosteroids and exogenous surfactants have improved survival in extremely premature and extremely low birth weight (EP-ELBW) infants. Currently, babies as young as 22 weeks’ gestation are being actively resuscitated and provided with intensive care in neonatal intensive care units (NICUs) around the world. As a consequence of premature delivery, fragile and immature newborns are at risk for significant morbidities affecting their multiple organ systems. Additionally, such infants encounter neurodevelopmental trauma induced by recurrent stressful experiences ubiquitous to the NICU. Postnatal stress contributes to alterations in the hypothalamic-pituitary-adrenal (HPA) axis and is associated with alterations in brain volume and neuronal connectivity. Neurodevelopmental differences, including cognitive, motor, and sensory impairments, correlate with extreme prematurity. Researchers have identified opportunities within the NICU that boost resilience, contribute to restorative sleep, and enhance autonomic stability. The objectives of this quality improvement project included enhanced clustered care practices, reducing non-nurturing interventions, and partnering with families to provide environmental enrichment aimed at stress attenuation. The clinical site was a 60-bed, Level IV NICU, and the initiative focused on EP-ELBW neonates born at less than 29 weeks’ gestation.

Methods: A multidisciplinary workgroup of interested NICU employees was established. The team utilized the quality improvement process to induce clinical practice change through education and simulation training. Pre- and post-education surveys were administered to assess individual developmental care practices. These surveys aimed to evaluate change in knowledge, attitudes, and implementation of developmental care strategies following the educational interventions. Bedside logging tools were utilized to document nurturing and non-nurturing encounters experienced by EP-ELBW infants during the first 14 days of life. The key outcomes included shifts in the frequency of nurturing and non-nurturing interactions following the education of staff and parents. The day of life when the first nurturing occurred was also recorded.

Interventions: A simulation video depicting a developmentally supportive method of transferring premature infants into skin-to-skin care with a parent or caregiver was created and disseminated to NICU staff. In addition, educational reviews were offered on various topics, including a comprehensive overview of the autonomic nervous system and factors that induce cerebral blood flow fluctuations in the preterm baby. Opportunities for therapeutic interventions were included in each learning activity. A series of journal clubs were also offered, focusing on moderating postnatal stress and fostering resilience in EP-ELBW infants. Finally, the author met with families of qualifying newborns to discuss the many benefits of frequent nurturing encounters, including skin-to-skin care.

Results: Raw p-values were calculated using Pearson’s chi-squared test. Using a significance level of 0.05, pre- and post-intervention surveys supported the null hypothesis. Thus, there is insufficient evidence that the intervention affected NICU care practices according to Qualtrics self-report practice surveys. The infants admitted during or after the educational interventions received an 18% increase in daily nurturing encounters and a 19% decrease in non-nurturing encounters. In addition, this group of babies received their initial nurturing encounter 43% sooner than the pre-intervention group of patients.

Conclusions: The implementation of mindful hands-on care and increased family involvement is known to mitigate stress and promote neurodevelopment. This QI initiative was successful in helping premature babies access earlier and more frequent nurturing experiences while decreasing non-nurturing encounters.

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