Caring, chaos and the vulnerable family: experiences in caring for newborns of drug-dependent parents

Neonatal intensive care nurses' accounts of care for mothers/families with substance-exposed pregnancies: A critical discourse analysis

AIMS

To explore the effects of power dynamics and hospital organizational structure upon neonatal intensive care nurses' experiences caring for infants and families from a substance-exposed pregnancy (SEP).

DESIGN

This secondary data analysis further investigated the results of a primary study after the original analysis suggested differences in work environments may impact relationship-building opportunities between nurses and mothers/families. Critical discourse analysis served as both the theoretical lens and analytic technique.

METHOD

Nine (9) nurses from the southeast region of the United States (U.S.) were interviewed in 2019. Fifty-one (51) stories of caregiving experiences were analysed with a focus on narratives related to organizational structure and care delivery.

RESULTS

Study findings revealed nurses experienced challenges providing high-quality, family-centered care for patients in the neonatal intensive care unit (NICU) affected by substances during pregnancy. Nurses described the central challenge of workload, exacerbated by power imbalances and structural constraints within the hospital's organizational structure. Findings suggest workload issues may endorse stigma by inhibiting opportunities to build relationships. Nurses report manageable workloads can support healthcare teams and recipients of care.

CONCLUSION

The study suggests power imbalances between nurses, families and adjacent healthcare professionals can inhibit the delivery of high-quality care. Supporting healthcare teams and recipients of care while centering the role of organizational structure is critical. Questions emerged about workload demands impacting the potential production of stigma in clinical environments.

IMPACT

This study examines the intersection of nurses' care experiences and hospital organizational structure. It identifies how the unique needs of caring for infants and families from a SEP increase the complexity of power imbalances and organizational constraints to further increase workload demands. Findings have implications for global healthcare organization leaders who build and maintain the structural integrity of clinical environments and nurse leaders who advocate and guide clinical teams to provide high-quality care in stressful healthcare environments.

REPORTING METHOD

EQUATOR guidelines were followed, using the COREQ checklist.

PATIENT OR PUBLIC CONTRIBUTION

NICU nurses were interviewed about their care-provision experiences. Interviews were analysed in the primary study and the current analysis of secondary data.

Neurodevelopmental, Mental Health, and Parenting Issues in Preterm Infants

The World Health Organization in its recommendations for the care of preterm infants has drawn attention to the need to address issues related to family involvement and support, including education, counseling, discharge preparation, and peer support. A failure to address these issues may translate into poor outcomes that extend across the lifespan. In this paper, we review the often far-reaching impact of preterm birth on the health and wellbeing of the parents and highlight the ways in which psychological stress may have a negative long-term impact on the parent-child interaction, attachment, and the styles of parenting. This paper addresses the following topics: (1) neurodevelopmental outcomes in preterm infants, including cognitive, sensory, and motor difficulties, (2) long-term mental health issues in premature infants that include elevated rates of anxiety and depressive disorders, autism, and somatization, which may affect social relationships and quality of life, (3) adverse mental health outcomes for parents that include elevated rates of depression, anxiety, and symptoms of post-traumatic stress, as well as increased rates of substance abuse, and relationship strain, (4) negative impacts on the parent-infant relationship, potentially mediated by maternal sensitivity, parent child-interactions, and attachment, and (5) impact on the parenting behaviors, including patterns of overprotective parenting, and development of Vulnerable Child Syndrome. Greater awareness of these issues has led to the development of programs in neonatal mental health and developmental care with some data suggesting benefits in terms of shorter lengths of stay and decreased health care costs.

Exploration of the Care Giving Dynamic Between NICU Nurses and Mothers with a Substance-Exposed Pregnancy

PURPOSE

To explore the caregiving dynamic between NICU nurses and mothers with a substance-exposed pregnancy (SEP) by examining how nurses view these mothers compared to mothers without an SEP.

DESIGN

A qualitative design using interviews with NICU nurses who care for infants and families with an SEP.

SAMPLE

The sample (n = 9) was all female, with an average of approximately 10 years of nursing experience in the NICU, with two-thirds having achieved a Bachelor of Science in Nursing (BSN) or higher.

MAIN OUTCOME VARIABLE

Perceptions of nurses working with families affected by an SEP.

RESULTS

Stigmatized views and trust issues shaped nurses' views of mothers with an SEP as different from other mothers. Empathy levels toward mothers differed related to nurses' views of substance use as either a moral decision or chronic disease. These viewpoints shaped the nurse's judgment of the mother's potential to provide a safe environment and independently care for the infant at home. Nurses described personal distress when caring for these families.

The Complexities Associated with Caring for Hospitalised Infants with Neonatal Abstinence Syndrome: The Perspectives of Nurses and Midwives

The global incidence of Neonatal Abstinence Syndrome (NAS) has increased significantly in the last decade. Symptoms of NAS manifest from the central and autonomic nervous systems as well as the gastrointestinal system and vary in severity and duration. The clinical management of infants experiencing NAS is dependent on symptoms and may include both pharmacological and non-pharmacological measures. In cases where symptoms are severe, infants may be admitted to special care nurseries or neonatal intensive care units. Existing research on nurses' involvement in caring for infants with NAS focuses on pharmacological and non-pharmacological interventions to treat physical symptoms associated with NAS. This research sought to add to the body of knowledge around NAS and conveys nurses' and midwives' experiences of delivering care for infants with NAS. Semi-structured interviews were held with nine nurses/midwives. Interviews were audio-recorded, transcribed verbatim and thematically analysed. Five themes emerged from the data. These themes are: Complex care needs; Prioritising physiological care; Experiencing compassion fatigue; Lacking continuity of care; and Stigma. The findings demonstrated the complex nature of care provision for infants with NAS. Competing priorities and the stigmatising nature of NAS threaten optimal care being delivered to these vulnerable infants and their parents.

Recovering Together: Mothers' Experiences Providing Skin-to-Skin Care for Their Infants With NAS

BACKGROUND

Over the past 2 decades, the prevalence of neonatal abstinence syndrome (NAS) has increased almost 5-fold. Skin-to-skin care (SSC), a method of parent-infant holding, is a recommended nonpharmacologic intervention for managing NAS symptoms. SSC has the potential to reduce withdrawal symptoms while positively influencing parent-infant attachment. Yet, little is known about the SSC experiences of mothers of infants with NAS.

PURPOSE

The purpose of this study was to explore the SSC experiences of mothers of infants with NAS, including perceived barriers to SSC in the hospital and following discharge home.

METHODS

A qualitative descriptive design was used to obtain new knowledge regarding the experience of SSC of mothers of infants with NAS. Purposive sampling was used to recruit participants eligible for the study. We conducted semistructured individual interviews with postpartum mothers of infants with NAS. Data were analyzed using thematic analysis.

FINDINGS/RESULTS

Thirteen mothers participated in the study. Four themes emerged from the data analysis: "a little nerve racking"; "she needed me, and I needed her"; dealing with the "hard times"; and "a piece of my puzzle is missing." SSC was described as a conduit for healing and bonding; in addition, several barriers to SSC were reported.

IMPLICATIONS FOR PRACTICE AND RESEARCH

These findings highlight the inherent benefits of SSC for infants with NAS and demonstrate the unique challenges of these mother-infant dyads. Critical changes in hospital practices are needed to create an environment supportive of SSC for this patient population. In addition, research regarding implementation of interventions to increase SSC usage in this population is warranted.

Experiences of Nursing Professionals Working With Women Diagnosed With Opioid Use Disorder and Their Newborns: Burnout and the Need for Support

BACKGROUND

As the rate of opioid use in pregnancy escalates, there are a growing number of women diagnosed with opioid use disorder (OUD) and their newborns being cared for in inpatient settings.

PURPOSE

In this study, we sought to better understand the experiences of nurses and nursing assistants working with women diagnosed with OUD and their newborns. By identifying the needs of nurses and nursing assistants, the findings from this study may contribute to reductions in stigma and improved patient care.

METHODS

Nurses and nursing assistants were recruited from a postpartum unit at a large urban hospital in Utah. Participants (n = 30) attended up to 4 semistructured focus groups. We utilized Braun and Clarke's 6-phase approach to thematic analysis to analyze transcribed interviews.

FINDINGS/RESULTS

Themes identified during the data analysis process included negative feelings and reactions toward patients; preferential concern for the newborn over maternal well-being; and identification of organizational and training needs to overcome these challenges.

IMPLICATIONS FOR PRACTICE

These findings identify strategies for addressing challenges faced by nurses and nursing assistants in caring for women diagnosed with OUD and their newborns.

IMPLICATIONS FOR RESEARCH

Future research should examine the effectiveness of approaches to reduce behaviors influenced by stigma among nurses and nursing assistants working with women diagnosed with OUD and their newborns, as well as employee and patient satisfaction, and long-term health outcomes.

Factors Associated With a Trusting Relationship Between Pregnant and Postpartum Women With Substance Use Disorders and Maternity Nurses

Trusting relationships between pregnant and postpartum women with substance use disorders (SUDs) and maternity nurses can improve health outcomes for women and their infants. This study was conducted to identify factors associated with the formation of trust in these nurse–patient relationships. Using a qualitative description approach, semi-structured interviews were conducted with 10 women who used substances during pregnancy and 15 maternity nurses. The narratives were analyzed with standard content analytic techniques. Findings revealed that six characteristics of nurses and five characteristics of women fostered or hindered the formation of trusting relationships. The characteristics of the maternity nurses were (a) interpersonal connections, (b) demeanor toward women, (c) ways of providing care, (d) approaches to providing information, (e) attitudes toward substance use, and (f) addiction expertise. The characteristics of the women were (a) engagement with nurses, (b) demeanor toward nurses, (c) attitudes toward care, (d) investment in recovery, and (e) ways of interacting with infant. The characteristics provide a framework by which maternity nurses can examine their attitudes and behaviors toward women with SUDs and inform the development of strategies to enhance their practice with this population.

The Infant Cuddler Study: Evaluating the effectiveness of volunteer cuddling in infants with neonatal abstinence syndrome

Objectives

St. Michael's Hospital launched a volunteer cuddling program for all infants admitted into the neonatal intensive care unit in October 2015. The program utilizes trained volunteers to cuddle infants when caregivers are not available. This was a pilot study to assess the impact of a volunteer cuddle program on length of stay (LOS) and feasibility of implementation of the program.

Methods

A mixed methods approach was utilized to measure both quantitative and qualitative impact. A pilot cohort study with a retrospective control group assessed the feasibility of implementing a volunteer cuddling program for infants with neonatal abstinence syndrome (NAS). Length of stay was used as a surrogate marker to measure the impact of cuddling on infants being treated for Neonatal Abstinence Syndrome. Focus groups using semi-structured interviews were conducted with volunteers and nurses at the end of the pilot study.

Results

LOS was reduced by 6.36 days (U=34, P=0.072) for infants with NAS in the volunteer cuddling program. Focus groups with both bedside nurses and program volunteers described a positive impact of cuddling programs on infants, families, staff, and volunteers alike.

Conclusions

The study results suggest that the volunteer cuddling program may reduce LOS in infants with NAS and have potential economic savings on hospital resources. However, larger prospective cohort studies are needed to confirm these results.

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.

Moral distress of nurses surrounding neonatal abstinence syndrome: Application of a theoretical framework

TOPIC

Neonatal nurses who care for infants with symptoms of neonatal abstinence syndrome (NAS) may experience moral distress through conflicting professional ethics. The nurse may find it difficult to simultaneously exemplify beneficence and nonmaleficence.

OBJECTIVE

The purpose of this paper is to explore the moral distress of nurses in the context of infants experiencing symptoms of NAS and apply a new conceptual model to this phenomenon. Understanding how nurses navigate moral dilemmas may provide insight into strategies to better support them to address moral conflict.

METHODS

Moral distress was explored in the context of nurses who care for infants with symptoms of NAS. A literature review was completed, followed by the application of the model onto the derived themes.

RESULTS

The theoretical application resulted in a framework that exemplifies the experience of caring for infants with symptoms of NAS and their families described by many nurses within the literature. If moral distress is not resolved, negative outcomes may be experienced by the nurse, with additional negative outcomes experienced by the family.

CONCLUSION

This theoretical model provided insight into the experience of moral distress surrounding nursing care for infants with symptoms of NAS. Additional research is needed to investigate moral residue and moral resilience in this particular caregiving dynamic.

Trying to Do What Is Best: A Qualitative Study of Maternal-Infant Bonding and Neonatal Abstinence Syndrome

BACKGROUND

The maternal experience of caring for and bonding with infants affected by neonatal abstinence syndrome (NAS) has not been adequately characterized.

PURPOSE

This study was designed to describe mothers' experiences of, supports for, and barriers to bonding with infants with NAS.

METHODS

Semistructured interviews were coded using computer-assisted thematic content analysis. A code co-occurrence model was used to visualize the relationships between themes.

RESULTS

Thirteen mothers of infants with NAS participated. Trying to Do What Is Best emerged as the overarching theme with which several subthemes co-occurred. Subthemes that captured mothers loving their infants and bonding, feeling supported by the infants' fathers, feeling supported in the community, and receiving information from hospital staff were associated with mothers' trying to do what is best. Barriers to trying to do what is best included feeling unsupported in the community, guilt about taking medications or substances during pregnancy, feeling judged, and infant withdrawal.

IMPLICATIONS FOR PRACTICE

Specific implications for practice may be derived from the mothers' criticisms of NAS assessment tools. Mothers highlighted the value of reassurance and education from providers and the uniquely nonjudgmental support received from peers and male coparents.

IMPLICATIONS FOR RESEARCH

There is a lack of information about maternal-infant bonding in dyads affected by NAS and factors that contribute to parental loss of custody. Qualitative, quantitative, and mixed-methods studies in diverse populations might help researchers better understand the long-term outcomes of NAS and develop interventions that decrease family separation.

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.

Neonatal abstinence syndrome

Neonates exposed prenatally to opioids will often develop a collection of withdrawal signs known as neonatal abstinence syndrome (NAS). The incidence of NAS has substantially increased in recent years placing an increasing burden on the healthcare system. Traditional approaches to assessment and management have relied on symptom-based scoring tools and utilization of slowly decreasing doses of medication, though newer models of care focused on non-pharmacologic interventions and rooming-in have demonstrated promise in reducing length of hospital stay and medication usage. Data on long-term outcomes for both traditional and newer approaches to care of infants with NAS is limited and an important area of future research. This review will examine the history, incidence and pathophysiology of NAS. We will also review diagnostic screening approaches, scoring tools, differing management approaches and conclude with recommendations for continued work to improve the care of infants with NAS.

Neonatal abstinence syndrome

Neonatal abstinence syndrome refers to the signs and symptoms attributed to the cessation of prenatal exposure (via placental transfer) to various substances. This Primer focuses on neonatal abstinence syndrome caused by opioid use during pregnancy - neonatal opioid withdrawal syndrome (NOWS). As the global prevalence of opioid use has alarmingly increased, so has the incidence of NOWS. NOWS can manifest with varying severity or not at all, for unknown reasons, but is likely to be associated with multiple factors, both maternal (for example, smoking and additional substance exposures) and neonatal (gestational age, sex and genetics). Care for the infant with NOWS begins with addressing the issues experienced by pregnant women with opioid use disorder. Co-occurring mental illness, economic hardship, intimate partner violence, infectious diseases and limited access to care are common in these women and can result in poor maternal and neonatal outcomes. Although there is no consensus regarding optimal NOWS management, non-pharmacological interventions (such as breastfeeding and rooming-in of the mother and the baby) have become a priority, as they can ameliorate symptoms without the need for further opioid exposure. Untreated NOWS can be associated with morbidity in early infancy, and the long-term consequences of fetal opioid exposure are only beginning to be understood.

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.

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.

Compassion Fatigue, Burnout, and Neonatal Abstinence Syndrome

NICU nurses have seen a dramatic increase in cases of neonatal abstinence syndrome (NAS). The care needs of infants with NAS are highly demanding and can lead to feelings of frustration and emotional exhaustion among NICU nurses. Although studies have examined the experiences of nurses caring for NAS patients, none have specifically addressed the risk for compassion fatigue and burnout. Nurses need practical strategies to reduce their risk for compassion fatigue and burnout when caring for these patients. Improved education and implementation of self-care measures can help nurses more effectively manage stress and positively impact care of these infants and their families.

NICU Culture of Care for Infants with Neonatal Abstinence Syndrome: A Focused Ethnography

PURPOSE

The purpose of this focused ethnography was to describe the culture of care and nonpharmacologic nursing interventions performed by NICU nurses for infants with neonatal abstinence syndrome (NAS).

METHOD

Roper and Shapira's framework for the analysis included participant observation, individual interviews, and examination of existing documents.

SAMPLE

Twelve full-time nurses were observed and interviewed.

RESULTS

Results described the culture of care provided to infants with NAS by NICU nurses as evidenced by six themes: learn the baby (routine care, comfort care, environment, adequate rest and sleep, feeding), core team relationships (support, interpersonal relationships), role satisfaction (nurturer/comforter, becoming an expert), grief, making a difference (wonderful insanity, critical to them), and education and care of the mother.

Development, Implementation, and Evaluation of a Pilot Parenting Educational Intervention in a Pregnancy Buprenorphine Clinic

We developed a pilot evidence-based prenatal educational intervention to increase knowledge of neonatal abstinence syndrome (NAS) and early parenting skills for women with opiate dependency who enrolled in a pregnancy buprenorphine clinic. We developed, implemented, and tested modules regarding expectations during newborn hospitalization for observation or treatment of NAS and regarding evidence-based parenting skills in response to NAS behaviors. Testing evaluated baseline knowledge of early parenting skills with newborns at risk for NAS and change from baseline after the educational intervention. No statistically significant difference in composite knowledge scores was observed. A brief survey completed by the participants postpartum affirmed the perception of women that the educational intervention effectively prepared them for the early postpartum period while their newborns were hospitalized.

Soutien social et expérience paternelle des pères de nouveau-nés prématurés

Cadre de la recherche : Plusieurs études ont montré que le vécu parental lors d’une naissance prématurée peut être de nature traumatique avec un impact sur la qualité de la relation parent-enfant (Lindberg, Axelsson et Ohrling, 2008). Cependant, force est de constater que les processus en jeu chez le père restent relativement inexplorés.

Objectifs : L’objectif de cette étude exploratoire est de développer un modèle de compréhension de l’expérience paternelle de nouveau-nés prématurés. Celle-ci est appréhendée par la relation avec le nourrisson (Blomqvist et al., 2012 ; Helth et Jarden, 2013) et l’expérience du devenir père (Zaouche Gaudron et al., 2003 ; Zaouche Gaudron et al., 2005) mais également par la relation avec l’équipe soignante (Fegran et Helseth, 2009). La gravité de la prématurité est également examinée (Ibanez et al., 2006).

Méthodologie : L’échantillon se compose de 48 pères de bébés prématurés. Un entretien semi-directif basé sur le Clinical Interview for Parents of High Risk Infants (Meyer et al., 1993) a été adapté et utilisé pour le recueil de données. Les axes réfèrent à la grossesse de la conjointe, à l’accouchement, à la relation avec le nourrisson et au soutien social.

Résultats : Nos principaux résultats indiquent que les pères construisent un premier lien avec leur bébé par le contact du peau-à-peau et par l’accordage du regard. Ils témoignent, par ailleurs, d’un vécu traumatique lié à la prématurité décrit par des sentiments ambivalents, comme la peur, le stress mais également le bonheur. La source la plus importante de soutien social, hormis la famille, est l’équipe soignante et les autres parents dans le service.

Conclusions : Les principales conclusions permettent d’amener des propositions quant aux pratiques professionnelles afin de soutenir le processus de paternalisation dans ce contexte particulier de prématurité.

Contribution : Dans une approche qualitative, cette étude apporte un éclairage concernant l’expérience paternelle dans le contexte particulier qu'est la prématurité du nouveau-né.

A Qualitative Study of Family Experience With Hospitalization for Neonatal Abstinence Syndrome

BACKGROUND AND OBJECTIVES

Although the incidence of neonatal abstinence syndrome (NAS) in the United States quintupled between 2000 and 2012, little is known about the family perspective of the hospital stay. We interviewed families to understand their experiences during the newborn hospitalization for NAS and to improve family-centered care.

METHODS

A multidisciplinary team from 3 hospital units composed open-ended interview questions based on a literature review, clinical experience, and an internal iterative process. Trained investigators conducted semi-structured interviews with 20 families of newborns with NAS at hospital discharge. Interviews were recorded and transcribed verbatim. Two investigators independently analyzed each transcript, identified themes via an inductive qualitative approach, and reached a consensus on each code. The research team sorted the themes into broader domains through an iterative process that required consensus of 4 team members.

RESULTS

Five domains of family experience were identified: parents' desire for education about the course and treatment of NAS; parents valuing their role in the care team; quality of interactions with staff (supportive versus judgmental) and communication regarding clinical course; transfers between units and inconsistencies among providers; and external factors such as addiction recovery and economic limitations.

CONCLUSIONS

Families face many challenges during newborn hospitalization for NAS. Addressing parental needs through improved perinatal education, increased involvement in the care team, consistent care and communication, and minimized transitions in care could improve the NAS hospital experience. The results of this qualitative study may allow for improvements in family-centered care of infants with NAS.

Integrative review: nurses' roles and experiences in keeping children safe

AIM

To identify nurses' role and experiences of keeping children safe.

BACKGROUND

Approaches to preventing, identifying and responding to child abuse and neglect have moved towards a multidisciplinary approach where all professionals are expected to contribute to the goal of keeping children safe. Frequently in contact with children and families, nurses well positioned to contribute to keeping children safe from abuse and neglect. Much has been published around nurses' experiences of their role in keeping children safe, but this literature has not yet been synthesized to determine the challenges and potential scope of this role.

DESIGN

Integrative review following an Integrative Review framework.

DATA SOURCES

Studies were identified through a search of the electronic databases CINAHL, Medline, Web of Science, Scopus and Informit to identify literature published between 2005-2015.

REVIEW METHODS

All the studies were critically appraised for methodological quality using the Critical Skills Appraisal Programme. Data from each study were extracted and categorized according to the review aims and the study's major findings.

RESULTS

Inclusion criteria were met in 60 studies. Three main findings were identified including nurses' insufficient knowledge, need for validation and improved communication and balancing surveillance and support for vulnerable families.

CONCLUSIONS

Nurses have many roles and experiences in keeping children safe but often felt they did not have the knowledge, skills and support to take action in this area. Further research is needed to understand why nurses feel inadequate and disempowered to advocate and intervene on the behalf of children at risk of abuse or neglect.

A National Survey of the Nursing Care of Infants With Prenatal Substance Exposure in Canadian NICUs

BACKGROUND

Many communities are reporting increases in the number of infants requiring NICU care. Practices continue to vary and there is limited available evidence about nursing care.

PURPOSE

The purpose of this study was to describe current nursing care practices for infants with prenatal substance exposure in the NICU setting and during transition to the community. Findings from this study were compared with an earlier Canadian survey (by Marcellus in 2002) to identify shifts in clinical nursing practice for this population.

METHODS

This was a cross-sectional descriptive survey design. A 68-item survey composed of multiple-choice and open-ended questions was administered through FluidSurveys online software. A convenience sample of 62 clinical managers or clinical educators in hospitals with active maternal-infant clinical units with 500 deliveries or more annually and/or pediatric hospitals with a separate designated neonatal service (ie, Level 2 and 3 units) was chosen.

RESULTS

A greater number of NICUs are using clinical guidelines to support the standardization of quality care. Improvements in nursing practice were identified and these included the consistent use of a withdrawal scoring tool and provision of education for team members in orientation. A decline in routine discharge planning meetings and routine parent teaching plans was discovered.

IMPLICATIONS FOR PRACTICE

This survey has improved understanding of the current state of nursing care for infants with prenatal substance exposure and their families during this critical time of transition. The purpose of the survey was to compare findings with the 2002 study by Marcellus to identify any improved practices and describe current state nursing care practices in the NICU. Practice changes over the last decade have included keeping mothers and infants together, expanding concepts of the team, integrating programs and services across hospital and community settings, and creating opportunities for NICU teams to learn more about substance use, mental health, violence, and trauma.

IMPLICATIONS FOR RESEARCH

Focus on discharge planning, parent teaching, and creation and implementation of national/hospital guidelines is essential for consistent evidence-based quality patient care.

Supporting women with substance use issues: trauma-informed care as a foundation for practice in the NICU

Infants with neonatal abstinence syndrome and their mothers require extended support through health and social service systems. Practitioners are interested in exploring innovative approaches to caring for infants and mothers. There is now compelling evidence linking women's substance use to experiences of trauma and violence. A significant shift in the fields of addiction and mental health has been awareness of the impact of trauma and violence on infants and children, women, their families, and communities. In this article, the current state of knowledge of trauma-informed care is reviewed, in particular for application to practice within the NICU. Trauma survivors are at risk of being retraumatized because of health care providers' limited understanding of how to work effectively with them. Recognizing the impact of trauma and implementing evidence-based trauma-informed practices in the NICU holds promise for improving outcomes for women and their infants.

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.

Experiences of mothers of infants with neonatal abstinence syndrome in the neonatal intensive care unit

OBJECTIVE

To describe the experiences of mothers of infants with neonatal abstinence syndrome (NAS) in the neonatal intensive care unit (NICU).

DESIGN

Qualitative description.

SETTING

We recruited participants from community-based, out-patient, addiction treatment facilities in a large urban city in the southwestern region of the United States.

PARTICIPANTS

A convenience sample of 15 Hispanic, substance addicted mothers of infants with NAS participated.

METHODS

We conducted semistructured, individual, interviews and analyzed the data using qualitative content analysis. First, we analyzed the data independently and then discussed the themes until a consensus was reached.

RESULTS

We identified four themes: (a) understanding addiction, (b) watching the infant withdraw, (c) judging, and (d) trusting the nurses. The participants felt there was a lack of understanding concerning addiction that was particularly noted when interacting with the nurses. They shared their feelings of guilt and shame when observing their infants withdrawing. The participants felt judged by the nurses for having used illicit drugs during pregnancy. Feeling judged interfered with the participants' ability to trust the nurses.

CONCLUSION

These findings provide nurses with a better understanding of the experiences of mothers who have addiction problems and may lead to more customized nursing care for this high-risk population of mothers and their infants.

Drug addiction in pregnancy: disease not moral failure

Nurses have demonstrated concern for years about their interactions with pregnant women who abuse drugs. Reports of nurses' concern with substance abuse have been reported in the literature since the 1980s. As with any chronic disease, drug addiction causes physiologic changes, and the pathology that occurs in the brain drives characteristic behaviors. Research suggests that choices that addicts make are driven by pathology rather than by failure of a moral compass. This article reviews the theoretical explanations for addictive behaviors, describes the pathophysiology of drug addiction that is responsible for the predictable symptoms and behaviors exhibited by women who abuse prescription drugs and other opioids, and identifies nursing interventions to impact positive outcomes. Nurses who have a working knowledge of this disease will provide more effective nursing care to the women they encounter and are better prepared to make a difference in the lives of both women and their children.

Mothers on methadone: care in the NICU

When women addicted to opioids seek prenatal care, the treatment of choice is methadone. Methadone mediates the addiction by reducing fluctuations in maternal serum opioid levels and protecting the fetus from repeated withdrawal episodes. Methadone maintenance is associated with increased maternal weight gain, decreased illegal drug use, and improved compliance with prenatal care. 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.

An ethnomethodological approach to examine exploitation in the context of capacity, trust and experience of commercial surrogacy in India

The socio-ethical concerns regarding exploitation in commercial surrogacy are premised on asymmetric vulnerability and the commercialization of women's reproductive capacity to suit individualistic motives. In examining the exploitation argument, this article reviews the social contract theory that describes an individual as an 'economic man' with moral and/or political motivations to satisfy individual desires. This study considers the critique by feminists, who argue that patriarchal and medical control prevails in the surrogacy contracts. It also explores the exploitative dynamics amongst actors in the light of Baier's conceptualization of trust and human relationship, within which both justice and exploitation thrive, and Foucault's concept of bio-power. Drawing on these concepts, this paper aims to investigate the manifestations of exploitation in commercial surrogacy in the context of trust, power and experiences of actors, using a case study of one clinic in India. The actors' experiences are evaluated at different stages of the surrogacy process: recruitment, medical procedures, living in the surrogate home, bonding with the child and amongst actors, financial dealings, relinquishment and post-relinquishment.This study applies ethnomethodology to identify phenomena as perceived by the actors in a situation, giving importance to their interpretations of the rules that make collective activity possible. The methods include semi-structured interviews, discussions, participant observation and explanation of the phenomena from the actors' perspectives. Between August 2009 and April 2010, 13 surrogate mothers (SMs), 4 intended parents (IPs) and 2 medical practitioners (MPs) from one clinic in Western India were interviewed.This study reveals that asymmetries of capacity amongst the MPs, SMs, IPs and surrogate agents (SAs) lead to a network of trust and designation of powers through rules, bringing out the relevance of Baier's conceptualization of asymmetric vulnerability, trust and potential exploitation in human relationships. The IPs are exploited, especially in monetary terms. The SMs are relatively the most exploited, given their vulnerability. Their remuneration through surrogacy is significant for them, and their acquired knowledge as ex-surrogates is used for their own benefit and for exploiting others. Foucault's conceptualization of power is hence relevant, since the ex-SMs re-invest the power of their exploitative experience in exploiting others.

NICU nurses' lived experience: caring for infants with neonatal abstinence syndrome

PURPOSE

The primary aim of this qualitative methods study was to describe the lived experiences of neonatal intensive care unit (NICU) nurses with ethical and morally challenging issues.

SUBJECTS

The target population for the study was registered nurses working in the NICU. Interviews were completed with 16 nurses from 1 hospital.

DESIGN

A phenomenological method design was used to describe NICU nurses' lived experiences with ethical and moral issues encountered in the NICU.

METHODS

After obtaining signed consent, the principal investigator interviewed all participants, using a semistructured interview guide consisting of open-ended questions.

MAIN OUTCOMES

Ethical and moral distress related to neonatal abstinence syndrome was the predominant outcome.

PRINCIPAL RESULTS

Caring for infants, coping with families, and discharging infants home were the major concerns voiced by nurses in this study.

CONCLUSIONS

Nurses in this study struggled with issues of beneficence and nonmaleficence and were not aware of scientific evidence that guides methadone management of pregnant women.

Re-examining authoritative knowledge in the design and content of a TBA training in India

Since the 1990s, the TBA training strategy in developing countries has been increasingly seen as ineffective and hence its funding was subsequently reallocated to providing skilled attendants during delivery. The ineffectiveness of training programmes is blamed on TBAs lower literacy, their inability to adapt knowledge from training and certain practices that may cause maternal and infant health problems. However most training impact assessments evaluate post-training TBA practices and do not assess the training strategy. There are serious deficiencies noted in information on TBA training strategy in developing countries. The design and content of the training is vital to the effectiveness of TBA training programmes. We draw on Jordan's concept of 'authoritative knowledge' to assess the extent to which there is a synthesis of both biomedical and locally practiced knowledge in the content and community involvement in the design of TBA a training programme in India.

FINDINGS

The implementation of the TBA training programme at the local level overlooks the significance of and need for a baseline study and needs assessment at the local community level from which to build a training programme that is apposite to the local mother's needs and that fits within their 'comfort zone' during an act that, for most, requires a forum in which issues of modesty can be addressed. There was also little scope for the training to be a two way process of learning between the health professionals and the TBAs with hands-on experience and knowledge. The evidence from this study shows that there is an overall 'authority' of biomedical over traditional knowledge in the planning and implementation process of the TBA training programme. Certain vital information was not covered in the training content including advice to delay bathing babies for at least six hours after birth, to refrain from applying oil on the infant, and to wash hands again before directly handling mother or infant. Information on complication management and hypothermia was not adequately covered in the local TBA training programme.

KEY CONCLUSIONS

The suggested improvements include the need to include a baseline study, appropriate selection criteria, improve information in the training manual to increase clarity of meaning, and to encourage beneficial traditional practices through training.

Drugs and having babies: an exploration of how a specialist clinic meets the needs of chemically dependent pregnant women

OBJECTIVES

to explore the extent to which a specialist clinic meets the needs of chemically dependent women.

DESIGN

a critical ethnography informed by theorists such as Habermas and feminists' interpretation of Foucault.

SETTING

a specialist antenatal clinic for chemically dependent pregnant women at a major metropolitan women's hospital in Melbourne, Australia.

PARTICIPANTS

a purposive sample of twenty (20) chemically dependent pregnant women who attended the clinic. Data collection and analysis included three taped interviews (two preceding the birth and one post birth), observation of the interactions between the women and the clinic staff over a 25-month period and chart audits.

FINDINGS

similar to other studies there were multiple factors influencing development and maintenance of chemical dependency in this group of women, including family instability, family history of drug and alcohol abuse, childhood sexual abuse, having a chemically dependent partner and having a dual diagnosis of both drug addiction and mental illness. Initially there was considerable variation between the women and the clinic staff's expectations with regard to attending for antenatal care and conforming to a set regime as the women struggled with the contradictions inherent in their lifestyle and that of the 'normal' expectant mother. Aspects of that struggle included their belief that their opinions and knowledge of their lives was largely ignored, leading to episodes of resistance. Several women alleged the clinics staff's relationship with them was influenced by a belief that the women were 'hopeless addicts in need of expert medical and midwifery care' and that the clinic staff exercised control in an authoritarian manner. However, as they explored possibilities for collaboration, they realised they could exercise power and work towards a more equal relationship with staff. The quality of relationships in most instances improved over time, and if not always strictly collaborative, was situated at various points along a continuum from minimal to full co-operation, with concomitant varying levels of success in terms of outcomes. It was often the attitude of individual staff members, particularly midwives, that was the key to the way in which the women responded to care.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

comprehensive history-taking and engaging women as early as possible in pregnancy; providing continuity of care - particularly midwife care - to assist in developing a collaborative approach to care; provision of an extended period of postnatal support to at least six months for those women able to parent their children was a key recommendation.

The experiences of NICU nurses in caring for infants with neonatal abstinence syndrome

PURPOSE

This study explored the experiences of NICU nurses in caring for infants with neonatal abstinence syndrome (NAS).

DESIGN

A qualitative research approach was used with open-ended questions employing computer-assisted personal interviews.

SAMPLE

Fourteen NICU nurses employed in a regional hospital provided responses.

RESULTS

The nurses reflected a personal struggle between a desire to employ their technical and critical nursing skills and the need to provide expected maternal care to NAS infants. Other themes included frustration and burnout, challenges to values about parenting, and increased awareness of drug use in the community and at home.

DISCUSSION

The results suggest that nurses underrate the skill required to care for infants with NAS. The level of knowledge, patience, and commitment to these newborns should be reframed to increase job satisfaction, and education should be offered to nurses about women struggling with addictions.

Introducing a caring/relational framework for building relationships with addicted mothers

Health care practice with addicted mothers requires health professionals to both desire and acquire knowledge, skills, and attitudes geared toward developing relationships that foster trust. In this article, nursing and social work theories are used to offer an integrated and interdisciplinary framework for building relationships with addicted mothers in health care settings. Embracing and utilizing caring/relational concepts serve as an impetus to the development of effective relationships with this vulnerable population.