"All these people saved her life, but she needs me too": Understanding and responding to parental mental health in the NICU

Skin-to-skin contact at birth for very preterm infants and symptoms of depression and anxiety in parents during the first year - A secondary outcome of a randomized clinical trial

BACKGROUND

Mental health issues are common in parents to preterm infants. In the neonatal intensive care unit (NICU), skin-to-skin contact (SSC) as an avenue for parent-infant closeness may improve parental mental health. Few studies exist regarding its benefits when initiated immediately postbirth. The aim was to determine the effect of SSC for very preterm infants at birth on parents' mental health, by assessing symptoms of depression and anxiety within the first year.

METHODS

The Immediate Parent-Infant Skin-to-Skin Study was a randomized clinical trial conducted 2018-2021 at three NICUs in Sweden and Norway. Very preterm infants (28-33 weeks of gestation) were allocated to standard incubator care or SSC with either parent, initiated at birth and continued throughout the first 6 h. Symptoms of depression and anxiety in parents were assessed with the Edinburgh Postnatal Depression Scale and Spielberger State-Trait Anxiety Inventory.

RESULTS

The study included 91 infants (36 twins [40 %]) and 73 mothers and 73 fathers. Infants had a mean gestational age of 31 + 1 weeks and birthweight of 1534 g. Immediate SSC was found to significantly reduce depression symptoms in mothers and anxiety symptoms in fathers at one week after birth and depression and anxiety symptoms in fathers at term-equivalent age of infant.

LIMITATIONS

Limitations include a small sample size and limited background data on prenatal depression and anxiety.

CONCLUSIONS

Immediate parent-infant SSC following a very preterm birth may provide a protective effect on parents' mental health and should be supported in the clinical setting, alongside necessary nursing, and medical care.

The Family Snapshot-Innovation to integrate family context into daily interactions in the NICU

AIM

Current literature favours individualised decision making, an approach that requires understanding patients within their context and tailoring treatment and recommendations to their unique needs. In neonatology, family context becomes synonymous with patient context. In the neonatal intensive care unit (NICU), the team may be challenged to understand the intricacies of the family context, paramount for both families and clinicians. However, a significant gap exists between the intent to share information about the family context and the process of doing so. The transformational goal of this project was to embed an understanding of the family context into all interactions that occur in the NICU between clinicians and families, and between clinicians when discussing patients.

METHODS

We designed and implemented the Family Snapshot (FS), an innovation to bridge the gap between the intent and the process to share the family context.

RESULTS

Two groups of process measures have been collected to understand workflow integration: (1) whether the forms are being used and (2) how the forms are being used. Overall, completion of at least some part of the FS was >90%.

CONCLUSION

This manuscript describes our process, its feasibility and impact and presents two tools, the FS antenatal consultations and the FS tab.

NICU Parent and Staff Advocacy to Address Parental Mental Health

Parents of infants requiring neonatal intensive care unit (NICU) hospitalization often experience increased rates of distress, trauma, and perinatal mood disorders. Untreated parental mental health conditions have short- and long-term effects for infants and families. While some NICUs provide varying degrees of mental health supports for NICU families, these services are not universally or systematically integrated in US NICUs. Multiple factors contribute to this gap in care, including mental health stigma, funding constraints, and lack of staff training and capacity. In an effort to address this gap, we used a participatory action research approach, guided by a Patient and Stakeholder Engagement model, to partner with graduate NICU parents and patient-facing NICU staff to identify parental mental health needs and ideas to address them. Through efforts to mitigate power differentials and engage parents as research and program development partners, our work shaped NICU practices, programming, and subsequent research.

Understanding and addressing mental health challenges of families admitted to the neonatal intensive care unit

This article reviews the psychological distress experienced by NICU families, including anxiety, postpartum depression (PPD), and post-traumatic stress disorder (PTSD), in addition to providing recommendations for clinicians at the individual, institutional, and national level. Currently, mental health screenings, specialized evaluations, and treatment options are not routinely offered to NICU families and are frequently under-utilized when offered. Here we provide expert opinion recommendations to address challenges in supporting universal screening, offering bedside interventions, including trained mental health professionals in care plans, updating neonatology training competencies, and advocating for policies that support the mental health of NICU families. We advocate that mental health of NICU families be incorporated into the standard of care.

Application of the Adverse Childhood Experiences Framework to the NICU

BACKGROUND

Infants and families requiring neonatal intensive care unit (NICU) care often experience significant stress and trauma during the earliest period of the infant's life, leading to increased risks for poorer infant and family outcomes. There is a need for frameworks to guide clinical care and research that account for the complex interactions of generational stress, pain, toxic stress, parental separation, and lifelong health and developmental outcomes for infants and families.

PURPOSE

Apply the Adverse Childhood Experiences (ACEs) framework in the context of the NICU as a usable structure to guide clinical practice and research focused on infant neurodevelopment outcomes and parental attachment.

METHODS

An overview of ACEs is provided along with a detailed discussion of risk at each level of the ACEs pyramid in the context of the NICU. Supportive and protective factors to help mitigate the risk of the ACEs in the NICU are detailed.

RESULTS

NICU hospitalization may be considered the first ACE, or potentially an additional ACE, resulting in an increased risk for poorer health outcomes. The promotion of safe, stable, and nurturing relationships and implementation of trauma-informed care and individualized developmental care potentially counter the negative impacts of stress in the NICU.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Nurses can help balance the negative and positive stimulation of the NICU through activities such as facilitated tucking, skin-to-skin care, mother's milk, and active participation of parents in infant care. Future research can consider using the ACEs framework to explain cumulative risk for adverse health and well-being in the context of NICU care.

Enhancing team success in the neonatal intensive care unit: challenges and opportunities for fluid teams

Fluid teams, characterized by frequent changes in team membership, are vital in the neonatal intensive care unit (NICU) due to high patient acuity and the need for a wide range of specialized providers. However, many challenges can hinder effective teamwork in this setting. This article reviews the challenges related to fluid teamwork in the NICU and discusses recommendations from team science to address each challenge. Drawing from the current literature, this paper outlines three challenges that can hinder fluid teamwork in the NICU: incorporating patient families, managing hierarchy among team members, and facilitating effective patient handoffs. The review concludes with recommendations for managing NICU teamwork differently using strategies from team science.

A Qualitative Study of Nurses' Perspectives on Neonatologist Continuity of Care

BACKGROUND

Families and staff in neonatal intensive care units (NICUs) value continuity of care (COC), though definitions, delivery, and impacts of COC are incompletely described. Previously, we used parental perspectives to define and build a conceptual model of COC provided by neonatologists. Nursing perspectives about COC remain unclear.

PURPOSE

To describe nursing perspectives on neonatologist COC and revise our conceptual model with neonatal nurse input.

METHODS

This was a qualitative study interviewing NICU nurses. The investigators analyzed transcripts with directed content analysis guided by an existing framework of neonatologist COC. Codes were categorized according to previously described COC components, impact on infants and families, and improvements for neonatologist COC. New codes were identified, including impact on nurses, and codes were classified into themes.

RESULTS

From 15 nurses, 5 themes emerged: (1) nurses validated parental definitions and benefits of COC; (2) communication is nurses' most valued component of COC; (3) neonatologist COC impact on nurses; (4) factors that modulate the delivery of and need for COC; (5) conflict between the need for COC and the need for change. Suggested improvement strategies included optimizing staffing and transition processes, utilizing clinical guidelines, and enhancing communication at all levels. Our adapted conceptual model describes variables associated with COC.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Interdisciplinary NICU teams need to develop systematic strategies tailored to their unit's and patients' needs that promote COC, focused to improve parent-clinician communication and among clinicians. Our conceptual model can help future investigators develop targeted interventions to improve COC.

Addressing caregiver mental health in the neonatal ICU

PURPOSE OF REVIEW

The neonatal ICU (NICU) setting is a unique opportunity to not only detect major changes in caregiver mental health through universal perinatal mood and anxiety disorder (PMAD) screening but also intervene with specialized support. We review evidence for addressing caregiver mental health in the NICU, explore current guidelines and models for integrated behavioural health programmes, and describe challenges specific to NICUs, particularly in standalone paediatric hospitals.

RECENT FINDINGS

Parents of infants admitted to the NICU are at an increased risk for developing PMADs at rates well above the general postpartum community. Select NICUs within the United States and internationally have recognized the importance of having an embedded psychologist to address caregiver PMADs. However, organizational structures within paediatric healthcare systems are not equipped to manage the logistical, ethical, legal and practical needs of comprehensive caregiver mental health programmes.

SUMMARY

To properly address caregiver mental health in NICU settings, clinical and administrative teams must work together to ensure seamless service provision. Systems that facilitate the development of unique parent medical records at the onset of paediatric care are likely to significantly reduce potential liability risks and solve several challenges related to caregiver-focused mental health support in the NICU.

VIDEO ABSTRACT

http://links.lww.com/MOP/A70.

Understanding the Family Context: A Qualitative Descriptive Study of Parent and NICU Clinician Experiences and Perspectives

Enabling individualized decision-making for patients requires an understanding of the family context (FC) by healthcare providers. The FC is everything that makes the family unique, from their names, preferred pronouns, family structure, cultural or religious beliefs, and family values. While there is an array of approaches for individual clinicians to incorporate the FC into practice, there is a paucity of literature guiding the process of collecting and integrating the FC into clinical care by multidisciplinary interprofessional teams. The purpose of this qualitative study is to explore the experience of families and Neonatal Intensive Care Unit (NICU) clinicians with information sharing around the FC. Our findings illustrate that there are parallel and overlapping experiences of sharing the FC for families and clinicians. Both groups describe the positive impact of sharing the FC on building and sustaining relationships and on personalization of care and personhood. The experience by families of revolving clinicians and the risks of miscommunication about the FC were noted as challenges to sharing the FC. Parents described the desire to control the narrative about their FC, while clinicians described seeking equal access to the FC to support the family in the best way possible related to their clinical role. Our study highlights how the quality of care is positively impacted by clinicians' appreciation of the FC and the complex relationship between a large multidisciplinary interprofessional team and the family in an intensive care unit, while also highlighting the difficulties in its practical application. Knowledge learned can be utilized to inform the development of processes to improve communication between families and clinicians.