Neonatal Intensive Care What is the NICU The

Neonatal Intensive Care

What is the NICU? • The NICU is a unit that specializes the care of ill or premature newborn infants. • Each nurse is assigned to 1 -3 patients a shift. • All nurses hired are licensed registered nurses.

Information on St. Johns NICU • “When babies are very sick, the treatments they receive immediately after birth are critical. St. John Hospital’s 35 -bed Neonatal Intensive Care Unit (NICU) (one of the first in the state) has been a leader in caring for critically ill and premature babies for over 40 years. ” (http: //www. stjohnprovidence. org/services/ob stetrics/nicu/

Information cont’d • “Dedicated to keeping pace with changing technology and treatments, St. John Hospital currently provides the only Level III Neonatal Intensive Care Unit on Detroit’s east side, which means only we are qualified to care for the sickest babies. In fact, as a regional referral center, many community hospitals on Detroit’s east side and extending into the Thumb area transfer their critically ill babies to St. John for care. ”

Types of Neonatal Care • Level III neonatal intensive care is provided by board-certified neonatologists and a multidisciplinary team who are experienced in caring for sick newborns. • “This unit offers family-centered care and latest in treatment and technology to provide life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illnesses”

Types of care cont’d • Electronic equipment is used to take over bodily functions that are not yet matured or properly working. For example, incubators used have the ability to closely reproduce the intrauterine environment and special ventilators are used to breathe for the babies.

What is a Discourse Community? • According to John Swales, discourse communities are “groups that have goals or purposes, and use communication to achieve these goals. ” • A discourse community aims to achieve unspecific agreed upon set of common public goals.

What is a Discourse Community? • According to Johns, discourse communities, “enable members throughout the world to maintain their goals, regulate membership, and communicate efficiently with one another. ”

Characteristics of a discourse community • 1. A discourse community has a broadly agreed upon set of public goals • 2. A discourse community has mechanisms of intercommunication among their members • 3. A discourse community uses its participatory mechanisms primarily to provide information and feedback • 4. A discourse community utilizes and possesses one or more genres in “the communicative furtherance of its aims”

• 5. A discourse community owns genres • 6. A discourse community has a number of members with suitable degree of relevant content and expertise.

Purpose of the study • The purpose of the study conducted was to explain how the NICU nurses communicate with one another as well as other healthcare professionals to care for the patient, and the consequences if communication is altered.

Why is it important? • Proper communication when caring for a patient is imperative in order to prevent mistakes as errors. • An error or misunderstanding in communication between caretakers could be life threatening. • Newborns lack verbal communication skills, thereby making effective communication between staff even more important

Why is it important? • If information is left out of report it can potentially lead to life threatening consequences to the patient and negligence. • Nurse must communicate with the parents due to the high emotions they may be experiencing

Methods • In order to conduct this research project two registered nurses, both with a minimum of 2 years of experience in the NICU were interviewed. • The nurses answered numerous questions related to the ways and effects of proper communication and methods they use to ensure proper communication (example SBAR) • Three documents were analyzed and evaluated to determine how the unit communicates in ways other than verbally.

Interviewees • The first individual interviewed is Michele Harding. She has worked in the neonatal intensive care unit for over ten years. She is currently working the midnights shift (7 pm-7 am) however is in the process of switching to working the day shift (7 am-7 pm). • The second individual interviewed is Linda Debaja. She has worked in the neonatal intensive care unit for over four years. She too is currently working the midnight shift. • Both of the individuals interviewed are licensed registered nurses.

The Interview • According to Merriam, asking good questions is crucial when conducting an interview because the questions are what fuel the interview and provide the information. The wording of the question is important and if further clarification is needed, the interviewer must ask a follow-up question. After this, the interviewer may ask how the interviewee feels. “Using words that make sense to the interview, words that reflect the respondent’s world view, will improve the quality of data obtained during the interview. ” Good questions include asking experience and behavior questions, opinion and values questions, feeling questions and knowledge and sensory questions. However, questions that one should avoid include asking “why” questions because they lead to speculation.

What was asked? • 1. Please explain to me what occurs the moment you walk onto the unit to begin your shift 1 • 2. Communication methods between nurses who are beginning and ending their shift is vital, name at least one thing that can be done to improve communication? • 3. How do you use SBAR( situation, background, assessment, recommendation) when reporting off your patients?

• 4. When specific tests are ordered and vital medical information is omitted by the previous shift nurse, who is held responsible? What precautions are taken to prevent reoccurrences? • 5. What is involved in caring for newborns, (i. e. ) special handling?

• 6. The care of patients involves the collaborative effort of several professionals, who are those members? • 7. In your opinion, are there members in a specific field that do not get the deserved recognition? • 8. What occurs when one of those fields needed daily are unavailable?

• 9. How does communication between professionals change from day shift to night shift? • 10. Does the communication within the neonatal intensive care unit differ from communication on another unit, If so how? • 11. Besides the patients, what is the big difference between this unit compared to others? What sets this unit apart from another unit?

• 12. In what ways do you feel this unit could improve? Please list some examples on how to make that change • 13. Now that this unit has been remodeled, how has communication among the hospital staff changed?

Transcribing the Interview • Merriam describes three ways to record and transcribe interviewing data. • The first method described is to tape or video record. While this method is the most accurate it is very intrusive and has drawbacks such as bringing feelings of uneasiness and discomfort to the individual being interviewed. However, this way enables the interviewer to capture all the information and not miss an answer.

• The second way described is to write down during the interview after each question is asked. While this method is less intrusive, it leads to breaks in the interview. When writing everything down during the interview, the individual who is being interviewed is repeatedly paused and the thought process is broken.

• The last method Merriam describes is to listen intently during the interview and then as soon as the interview is over go back and write down the answers. While this method is least intrusive, information can easily be left out especially if the answers are long or there are numerous amount of questions asked. This last method would not be the best because according to Merriam, “Verbatim transcription of recorded interviews provides the best database for analysis. ”

• When observing participants during the interview, Merriam suggests to pay attention, take great notes and separate what is data and what is trivia. What the observer chooses to observe depends on how structured that observer wants the interview to be. There is not a specific amount of time one must observe and there is also not a preferred pattern to observing.

Interview Findings • 1. The act of Effective Communication • Since the patients cannot verbally communicate, the nurse must be able to read the cues of the baby to determine how the patient is feeling, , “Obviously babies unlike adults cannot tell us what they are feeling (Dabaja, 2015). Similarly, Harding states, “Our patients can't communicate with us, good assessment skills are key to a successful future”

Interview Findings • Proper communication within the unit is crucial because the particular patients that make up this unit are helpless and completely dependent. This being said, if there is a break in the communication standards in the NICU, a medical error may occur. While this does not happen often, it is still a possibility that must be strongly prevented, “In the NICU, premature newborns require less stimulation, handling, and a very tiny window for mistakes” (Dabaja, 2015). Dabaja further explained the best way to communicate information about your patients at shift change is to give report at the baby’s bedside.

Interview Findings • Effective communication must also exist between the nurses and the parents. This is a very scary time for the parents and many have questions they would like answered. The nurses must acknowledge those emotions and answer those questions. Effective communication is what keeps the unit running smoothly day after day.

Interview Findings • 2. The act of efficiency • The nurses in the NICU can care for anywhere from 1 -4 patients at a time depending on the acuity of the patient and the current staffing. • The nurse must be able to plan out ahead of time how to get all the required tasks done for each patient and still have time to chart.

Interview Findings • When time is limited or staffing is short, the nurses must prioritize and communicate with other staff members they need help. • According to Harding the unit can be, “very stressful when missing a team member; we must remember to try to pull together and be team players” (2015).

Interview Findings • 3. The act of vigilance • The nurses in the NICU are trained to always expect the unexpected • Majority of the patients in the NICU are in critical condition when first being admitted.

Interview Findings • “…unlike adults, they [newborns] will not decompensate gradually, it will happen immediately. Critical thinking is critical with these babies and being precise with all interventions performed and especially medications given is what will help them improve” (Debaja, 2015).

Interview Findings • 4. The act of calmness • The act of calmness goes hand in hand with the act of vigilance. Like stated earlier, the nurse must always be watching for signs of danger and act in a way to prevent it. • When a situation cannot be prevented, the nurse must remain calm.

Interview Findings • The nurses are all trained for various situations that may occur. They know when recognize that they need to call for help and they know the importance of staying calm. The act of calmness is especially important when the parents are at the bedside.

Interview Findings • “Obviously babies unlike adults cannot tell us what they are feeling (Dabaja, 2015).

Genre Analysis • In order for a unit in a hospital to function successfully and safely, proper and clear communication is crucial. While majority of the documentation that occurs within a hospital on a particular patient is now computer based, many important forms are still hard copies in the patient’s charts. Clarity of these forms is needed in order for numerous healthcare workers to provide proper treatment to the patients.

• While many of the forms contained in the bedside chart are reviewed daily, some documents are used more than others. Three specific documents that are seen in the patient’s chart and that are used daily by the nursing staff in the neonatal intensive care unity include: a safety contract, a patient kardex, and a visitor identification form. I have chosen to analyze these genres because they each provide important information and allow the newborn to be provided safe and effective care.

NICU Safety Contract • A neonatal intensive care unit/special care nursery safety contract is a yellow sheet of paper and begins by welcoming the parents or legal guardian to the unit. The safety contract continues on by listing important steps the parent or legal guardian is asked to follow in order to keep their baby safe. The list consists of 13 bullet points that focus mainly on providing a safe and secure environment for the newborn.

NICU Safety Contract • This document then describes 8 practices that according to the Academy of Pediatrics may decrease the risk of Sudden Infant Death Syndrome (SIDS). • Examples of the listed practices include: “baby is always placed on his or her back to sleep, baby sleeps on a firm mattress with a tightly fitted sheet, no waterbeds, couches, or anything soft, and baby’s face should remain uncovered during sleep for easy breathing. ”

NICU Safety Contract • Logos is seen specifically in the safety contract because the concept behind the document is to provide a secured environment for their newborn. The article appeals to logos again as well as ethos by referring to the Academy of Pediatrics. By referencing to a prestige and known academy when describing 8 practices that prevent SIDS, the contract is providing credibility, proof and logic.

NICU Safety Contract • The Safety contract uses pathos appeal by emphasizing the importance of the newborn’s safety. Every parent feels many emotions when having to have their newborn admitted into the NICU. Many are anxious, nervous, scared and worried to be apart from their newborn. This document acknowledges those emotion by describing 13 ways the NICU and SCN work to provide a secure and safe environment. Rather than use the term ‘patient’ the document uses the term ‘baby, ’ acknowledging that this baby indeed belongs to the parents.

NICU Safety Contract • The safety contract uses ethos appeal by having the St John Providence logo in the upper right hand corner. This personal branding clarifies that St John Providence supports what this document is saying, provides confidence to the recipient of the document. Since St. John is a large corporation that has been around for years, the seal on the document demonstrates ethos or credibility.

NICU Patient Kardex • The function of the Kardex is to provide integral information pertaining to the newborn to the assigned nurse. This Kardex lists information for the nurse to refer to while caring for this patient.

NICU Patient Kardex • The patient Kardex is also on a yellow sheet of paper. The Kardex is one of the most important if not the most important document used hourly by the nursing staff. The document provides information on the newborn that aids in the patient’s care. By looking at this one sheet of paper, the nurse is able to see the patient’s name, whether it is a resident or neonatal nurse practitioner baby, and if the newborn is currently in phase I, phase II, or special care.

NICU Patient Kardex • The document is then divided into 13 boxes and headings that allow the nurse to fill in the blanks with pencil. While some of the data on the sheet is permanent, some of the data changes daily. By writing in pencil, the nurses are able to erase and edit the document to fit the newborn’s current status. Like stated above, this one sheet of paper is able to efficiently and rapidly tell the nurse a great amount of information about the patient.

NICU Patient Kardex • The Kardex appeals to logos by allowing the nurse to see and note the improvement and progress of the newborn. For example, the nurse is able to reference and compare the newborn’s birth measurements to current measurements.

NICU Patient Kardex • The kardex appeals to ethos appeal by having the St John Providence logo in the upper right hand corner. This personal branding clarifies that St John Providence supports what this document is saying, provides confidence to the recipient of the document. Since St. John is a large corporation that has been around for years, the seal on the document demonstrates ethos or credibility.

NICU Patient Kardex • The Kardex is kept simple because while it has a lot of vital information on it, it needs to be clear and to the point. The nurses have approximately 24 patients at a time. They need to be able to obtain the information they are looking for quickly. Like stated above, the nurses write on this form. While this allows the nurses to edit the form every day, it has its drawbacks. For example, some nurses write very neatly while others do not. Sometimes it may be unclear and hard to read the handwriting on the form. Another issue with constant erasing is over time the form becomes harder to read due to the erased pencil marks.

NICU ID Form • The third document is the Neonatal and Pediatric Identification Form; Parent/Primary Care Provider/Alternate. Usually when a baby is born the hospital gives two adult armbands to the parents with the baby’s identification information on it. These armbands are to be worn at all times by the parents in order to allow them to visit with their baby. Over time the ink on the armbands fade and since newborns may stay in the NICU for many weeks, an alternate way of identifying the visitors is needed.

NICU ID Form • This form is used to properly identify the patient’s parents and guardian. Since the unit is an intensive care and since the patients are newborns, security is a high priority. This form is kept in the bedside chart for the nurse to refer to when there is a visitor. Each patient is allowed two visitors at a time, and one of the two visitors must be a guardian at all times.

All three Genres: • The sentences and word choices use within the patient safety document and the patient visitation documents once again are simple. The sentences are short and to the point and the words chosen are simple enough for a layperson to understand. Because the hospital has patients, visitors, and guardians from all education and economical backgrounds, having simple and concise wording and sentences is needed. These documents are read by individuals of all backgrounds and since they ensure the safety of the newborn, it is important that the individual signing them is able to read and understand the terms.

All three Genres: • The patient Kardex is not written in a layperson’s terms. While the structure of the document is simple, the words chosen are medical terms. Since the nurses are the ones who read these Kardex, medical terminology is understood by the reader.

Purpose of Genres • Like stated above, the safety contract and the patient identification form are to provide a safe and secure environment to the newborn. Newborns are extremely vulnerable. The hospital staff and nurses must act as their advocates and prevent harm. The function of the Kardex is to provide integral information pertaining to the newborn to the assigned nurse. This Kardex lists information for the nurse to refer to while caring for this patient.

Genre Analysis Findings • The NICU and SCN value safety, efficiency, effective communication and understanding. The described documents allow the unit to portray these values. The values have been achieved each time the parents and the medical staff follows the guidelines listed on the documents. The documents list steps in providing safe care for the individuals. When these steps are followed particularly in the safety contract and parent identification form, the hospital has achieved safety.

Genre Analysis Findings • The clarity of all the documents enables effective communication and understanding between the medical staff and the parents The clarity of the kardex helps the hospital to achieve the value of effective communication and efficiency between the medical staff themselves.

Conclusion • When coding the interviews themes were established: The act of Effective Communication, the act of efficiency, the act of vigilance, and the act of calmness • When analyzing the documents, it was found that the genres are written in lay men terms and are easy to read. The Kardex aids in effective communication while the Identification and the Safety Contract aid in patient safety.

Conclusion • The research concludes effective and efficient communication between nurses is one of the most important skills a nurse must obtain. • Due to the vast number of patients as well as the number of staff members caring for each patient, NICU nurses must communicate efficiently and hourly to other staff members like the neonatologist, neonatal nurse practitioner and others in order to provide safe and effective care to the patients.