Introduction to Family Integrated Care in the Neonatal
- Slides: 45
Introduction to Family Integrated Care in the Neonatal Intensive Care Unit
The Beginnings
The Beginnings
Results from Estonia Compared 84 care by parent with 72 care by nurses babies in the NICU Anecdotal = 30% reduction in NI 20% reduction in LOS 50% reduction in nurse utilization improved parent/staff satisfaction
Fi. Care Pilot Study • Pilot – March 2011 -March 2012 – 4 bed spaces in Mount Sinai level 2 NICU – 40 patients < 35 weeks gestation, low resp support (CPAP included) – Excluded palliative care, anomalies, those likely to transfer out, parents unable to be present – Parents spent minimum of 8 hrs/day – Key outcomes: improved weight gain, less nosocomial infection, increased breastfeeding, less ROP, fewer patient safety reports
Fi. Care Pilot Study Results
Fi. Care Randomized Controlled. Trial • 2 year project – 19 Canadian, 6 Australian, 1 New Zealand NICU • Infants <33 weeks, parents spent minimum 6 hrs/day • Veteran parent program • Parent classes and education • Results in early analysis similar to the pilot study
Fi. Care Study Protocol
Response to Fi. Care Study • Conference in Banff in February 2016 • Intervention units taught the control units about Fi. Care • Control units started to make plans and commitments to implement in their centres
4 Pillars of Fi. Care Staff Education & Support Parent Education NICU Environment Psychosocial Support / Veteran Parents
Myths About Fi. Care Myth: • Parents will look after micro-preemies and take on advanced nursing skills Truth: • Professional accountability and responsibility remains the same • Nurses help parent learn what is appropriate to do and teach, coach and support them
Myths About Fi. Care Myth: • Parents will be at the bedside 24/7 and have to sign a contract Truth: • Parents are encouraged to be at the bedside as much as possible • Nurses encourage parents to be present during rounds, attend parent group and be present for their baby • No contracts
Myths About Fi. Care Myth: • Fi. Care decreases the need for nurses Truth: • Nursing patient assignments remain the same • Early on, the nurse may spend more time teaching the parent • Close to discharge the parent should be doing most of the care
Myths About Fi. Care Myth: • Fi. Care is a top-down initiative coming from management Truth: • Nurses have been doing this already for many years • The Fi. Care project had nurses involved right from the start, including traveling to Tallin, Estonia • Nursing runs the steering committee
Staff Education and Support • Philosophy: All staff develop the knowledge and skills to fully partner with families and integrate them into the care team • Support staff with information and practice • Provide the tools necessary to help staff support families • A new philosophical approach to interactions with families evolves
Parent Education • Providing parents with information to learn how to become integrated into their baby’s care team • Learning about their own baby’s condition • Learning how to become an effective parent of a vulnerable child
Parent Education Sessions • Held weekly or monthly – may vary over time • An element of parent support at each session from professionals but also from each other • Veteran parent present at sessions
Potential Parent Education Topics • • Orientation to the hospital Coping with hospitalization Comforting your baby / pain management Handling your baby / Infant development Feeding (breastfeeding, post-discharge etc) Preparing for discharge Immunizations Baby care in the 1 st 6 months
Implications for Staff • Parents will learn things like: – Every child every time – no needles sticks without pain control – It’s okay to wake a baby to put them in KC • Parents may challenge staff at the bedside on: – Positioning – Gentle diaper changes (no turkey hold!) – Feeding more slowly (tube feeds) – More KC
Key Components of Parent Group • Casual, open, inviting environment • Responsive to the needs of participants • Supportive for those who want to share, and those who prefer to just listen • Safe environment to speak – “what happens in group, stays in group” • Recognize issues that are beyond the scope of the group – refer to social work and spiritual care
Staff Role in Parent Groups • Inform and encourage parents to attend • Facilitate their attendance by helping them plan skin to skin and feeding around group times • Be a guest and/or a presenter
Key Points about Parent Education • Go over materials when you provide them • Do not assume literacy • Inform parents of the Family Information Library at Children’s Hospital, which they can access in person, or call on the phone – the library will send materials to parents wherever they are
Partnering with Parents • Communication boards or other tools at the bedside • Go over checklists with them • Offer patient education materials and info on where to find more specific information
Why Include Parents in Rounds • • They become more engaged and involved Understand what is important Feel part of the team Investment up front pays dividends later – Less questions after rounds and in the night as they know what is going on – Also know what to look for – Less stress • May improve outcome for the infants
Engaging Parents During Rounds • Should be inclusive of everyone • Must commit and demonstrate attendance in rounds • What are we expecting from them? – progressive with identification first then after couple days do PCA and then other things on sheet.
Stages of Parents in Rounds Integrating parents as true partners in rounds is a process that goes in stages: 1. 2. 3. 4. Attend – be introduced by the nurse or neo Ask questions at the end Introduce the baby and give information about the previous 24 hours (using a guide)
Why Include Parents in Rounds • • They become more engaged and involved Understand what is important Feel part of the team Investment up front pays dividends later – Less questions after rounds and in the night as they know what is going on – Also know what to look for – Less stress • May improve outcome for the infants
Reality… • Not everyone will want to participate • Some will want to but can’t – Other children outside hospital – Single parents with other children – Rural families – Lack of confidence – but we can help this with peer pressure! • But…. – If we change the culture and manage the change slowly things will improve with time!
Impact on Nursing • Needs to be collaborative not competitive • What it is not? ! – Not going to impact on their job safety or allow a reduction in nursing staff – Invasive procedures such as IV insertion, catheterization, resuscitation remain domain of nursing • Acknowledge stress from nursing at change but its a partnership. Avoid repetition.
NICU Environment The NICU is a terrible and wonderful place: • Babies struggling • Worried parents • Unfamiliar words and machines • Noise • Staff busy, tense • Babies growing • Parents learning • Staff kindness We interpret the world in terms of how it makes us feel!
Being a Patient in NICU is Stressful! From: Harvard University Centre on the Developing Child (http: //developingchild. harvard. edu/science/key-concepts/toxic-stress/)
“Trauma Informed Care” Becoming “trauma-informed” means recognizing that people often have many different types of trauma in their lives. People who have been traumatized need support and understanding from those around them. Understanding the impact of trauma is an important first step in becoming a compassionate and supportive community. From: The Trauma Informed Care Project. org
Impact of Trauma • Alters biology – stress hormones negatively impact development • Immune system compromise • Behavior – unpredictable, less reasoning • Mental health – can babies get depressed? – Ability to develop trust
How the NICU Environment is Traumatizing To Babies: • Painful procedures • Sleep interruption • Constant noise • Unwelcome handling • Discomfort from feeding, medications, indwelling devices, respiratory failure etc To Parents: • Lack of control over events • Conflict with staff • Guilt • Difficult place to recover from delivery • Rules! • Inconsistency in communication
Transition from Rule Based to Fi. Care Standard Care Fi. Care • Visiting hours • Parent/family led visiting – what works • Rules about what they for them can do and when they can do it • Seeking what we can do to help meet their needs • Focus on helping them integrate into the team
Fi. Care Environment • • • Welcoming to whoever comes Supportive of family's needs Accessible and comfortable Inclusive rounding policies Visiting hours? – partnership based instead of rules based • Make the best use of the space you have
Making the Environment Be present with the person (baby) during care: • Watch facial expressions • Watch for signs of stress • Respond to them – slow down, remove stress, support – until stress signs diminish Be present with parents: • Active listening • Ask for their story and be patient – don’t look too busy to listen • Talk about what they want, how they can be partners • Find common goals
Parents as Partners • Gradual process incorporating them into bedside care • Gradual process incorporating them into rounds – starts by being there, then introducing their baby, progresses to presenting more details about their baby’s condition as they feel comfortable • More time spent early on pays off with parents taking over much of the care
Sharing Bedside Care • • Nurse Responsibilities Provide orientation Prepare and check feedings Administer gavage feed Record vital signs Ensure probes and leads in place Adjust oxygen support Help parent learn to weigh, bath, change diaper Document in chart • • Parent Responsibilities Learn and follow Be double check on milk Hold the syringe during gavage feeding Breast or bottle feed Learn to reposition probes and leads Adjust oxygen prongs when they come out Bath & weigh baby when off vent. Complete checklists
Psychosocial Support • Social workers – already a big part of what they do • Mental health workers – if possible – Psychological support • Nurses/Physicians/Allied Health/Support Staff encourage parents to attend group – determine what support needs parents have
Veteran Parent / Peer Psychosocial Support • • Family Program Coordinator Veteran parent “buddies” Veteran parents at parent group meetings Veteran parent volunteers in the unit providing informal peer support
Challenges for Staff • Promoting family participation in care when families are facing multiple other issues • Partnering with families who are difficult to partner with • Not giving the message to parents that we are “too busy” for them – even when we are busy – time invested early pays off in the end!
Put yourself in their shoes! • Imagine yourself in an incubator • Hear the sounds • Feel the environment
Kangaroo Care • The cornerstone of family integration in care • Key points: – Must be direct skin contact – Can be any amount of time, but needs 1 hour to trigger all positive effects – It’s okay to “wake” a baby to put them in KC – KC is the best place to recover from a hard day for the baby
Parent Perspective NICU Parent Story
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