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Close Collaboration with Parents Training Program

– Improving Quality of Care

MIĘDZYNARODOWA KONFERENCJA NAUKOWO-SZKOLENIOWA "NEONATUS 2015"

24-25 września 2015r. / 24-25 September, 2015

Liisa Lehtonen, MDHead of the Division of Neonatology,Turku University Hospital

Professor in Pediatrics, Turku University, Finland

Close Collaboration with ParentsTraining Program

• Motivation: Why integrate parenting in neonatal care?

• Challenges in implementation

• Solution: Close Collaboration with Parents Training Program

Structure and content

Key features facilitating implementation of family centered care

Expansion of the program nationally and internationally

The first results of the evaluation studies

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A model of single family room unit: The step-down unit at Rainbow Babies’ and Children’s Hospital,

Cleveland, Ohio in 1997

The Close Collaboration with Parents Training Program

Turku University Hospital, Finland

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Initial motivation

To prepare the unit for the transition to single-family room unit.

New architecture brings new challenges.

Care culture needs to be updated for the benefit of both parents and staff.

Research shows that

• separation is harmful for the development of a child

• there is a strong predisposition for bonding between the caregiver and the offspring immediately after birth

• the quality of care affects brain development (shown e.g. by comparing the children in Romanian orphanages to those in foster homes)

Sullivan R et al: Infant Bonding and Attachment to the Caregiver: Insights from Basic and Clinical Science. Clinics in Perinatology 2011;38(4):643-655.Braun K: The Prefrontal-limbic system development, neuroanatomy, function, and implications for socioemotional development. Clinics in Perinatology 2011;38(4):685-702.

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Preterm infants are born with vulnerable brain

under rapid growth and development. Environment matters.

Latva R, Lehtonen L, Salmelin RK, Tamminen T: Visiting less than every day. A marker for later behavioral problems in Finnish preterm infants. Arch Pediatr Adolesc Med 2004; 158:1153-

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Latva R, Korja R, Salmelin RK, Lehtonen L, Tamminen T: How is maternal recollection of the birth experience related to the behavioral and emotional outcome of preterm

CBCL total score

Median (Q1, Q3)

p

Physical contact after birth

before NICU admission (36%)24 (17,32)

0.024

No physical contact before admission 35 (29, 41)

Even a short physical mother-infant contact after birth associated with fewer behavioral

problems at 5 to 6 years of age

Early physical mother-infant contact in NICU infants

• In 2008-2009, 43% and 67% of NICU infants (depending on the hospital) had a physical contact with their mothers in the delivery room before NICU admission

• None of the infants below 32 weeks of gestation had physical contact with their mothers before admission

Niela-Vilén H, Axelin A, Salanterä S, Lehtonen L, Tammela O, Salmelin R, Latva R: Early physical contact between a mother and her NICU-infant in two university hospitals in Finland. Midwifery 2013; 29:1321-1330.

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In randomized controlled trials, interventionssupporting parenting in neonatal care

• improved cognitive (5 yr) and language (2 yr) development

• improved behavioral outcomes (CBCL)

• decreased autistic features (M-CHAT scores)

• decreased parenting stress.

Early support to parenting can be seen in later emotional, social, and cognitive development.

COPE Trial, Melnyk et al 2006; Tromso Intervention, Nordhov et al 2010; Family Nurture Intervention , Welch M et al: 2015.

Single family room unit model in neonatal care associates with better

Örtenstrand et al Stockholm Study 2010; Lester B et al: Single Family Room Care and Neurobehavioral and Medical Outcome in Preterm Infants. Pediatrics 2014; Flacking R et al: Closeness and Separation in Neonatal Intensive Care Unit. Acta Paediatr 2013;101:1032-37.

• growth of the child

• neurobehavioral and cognitive development of the child

• psychological well-being of the parent by decreasing stress and depression

• work satisfaction of the staff

• (shorter length of stay in a hospital)

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• Positive outcomes mediated by maternal involvement and OT

visits offering developmental support.

Lester et al: Single-family room care and neurobehavioral and medical outcomes in preterminfants. Pediatrics 2014;134:754-760.

AttitudeArchitectureArchitecture

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18 month CA Outcomes

N( Follow-up rate)

Open Bay

N=263

Single Family Room

N=153

p value

Bayley Cognitive Composite 87.4 ±±±± 13 90.9 ±±±± 13 (n = 153) 0.0103

Bayley Language Composite 83.8 ±±±± 16 88.0 ±±±± 17 (n = 150) 0.0133

Bayley Receptive Communication 7.1 ±±±± 5 7.7 ±±±± 3 (n = 150) 0.0749

Bayley Expressive

Communication

7.7 ±±±± 3 8.3 ±±±± 3 (n = 149) 0.0496

Bayley Motor Composite 88.2 ±±±± 14 91.7 ±±±± 14 (n = 151) 0.0248

Bayley Fine Motor 8.9 ±±±± 3 9.7 ±±±± 3 (n = 151) 0.0024

Bayley Gross Motor 7.4 ±±±± 2 7.8 ±±±± 2 0.1710

Vohr BR et al. Presented in the PAS Meeting, 2015.

Vohr BR et al: Single Family Room NICU Associated

with Improved 18-Month Outcomes for Infants < 1250g

• Positive outcomes mediated by breast milk provision.

Vohr BR et al: Single Family Room NICU Associated with Improved 18 Month OutcomesFor Infants < 1250g

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Pineda et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants

hospitalized in different neonatal intensive care unit environments. J Pediatr 2014;164:52-60

One non-randomized, exploratory study found that care in private rooms associated with lack of MRI asymmetry in temporal lobes and lower language scores at 2 years.

Pineda et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants

hospitalized in different neonatal intensive care unit environments. J Pediatr 2014;164:52-60

One non-randomized, exploratory study found that care in private rooms associated with lack of MRI asymmetry in temporal lobes and lower language scores at 2 years.

136 preterm infants born <30 weeks gestation from an urban, 75-bed level III NICU from 2007-2010. 86 infants tested at 2 years of age.

Bayley-III Language (n = 84) open bay 91.9 (11.4) SFR 84.9 (10.5) p = .005

No difference in Bayley III cognitive scores.

No difference when visitation and holding controlled.

But: No parent’s bed in the room.

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Importance of parent talk

• parents’ presence increased infants’ vocalizations already at 32 weeks of gestation

• exposure to adult talk at 32 weeks of gestation correlated to expressive communication scores at 18 months of corrected age

Caskey M, Stephens B, Tucker R, Vohr B. Adult talk in the NICU with preterm infants and developmental outcomes. Pediatrics. 2014;133:e578-84.Caskey M, Stephens B, Tucker R, Vohr B. Importance of parent talk on the development of preterm infant vocalizations. Pediatrics. 2011;128:910-6.

Even if family centered care is an accepted standard,

…its implementation is a problem

Interventions may remain limited, difficult to generalize and their implementation can face resistance if targeted to a part of the staff.

Guidelines alone may not change everyday practice if the content and knowledge are not internalized by the staff.

Without a facilitator (a mentor) a training does not proceed and the change does not happen and sustain.

There are few studies about effective interventions implementing family centered care culture in a NICU.

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Close Collaboration with Parents Training Program for NICU staff

Sari Ahlqvist-Björkroth, MSc,

Psychologist

Zack Boukydis, PhD,

Professor in Psychology

Liisa Lehtonen, MD, PhD,

Professor in Pediatrics

Anna Axelin, RN, PhD,

University Research Fellow

Simo Raiskila, Medical Student

Sanna Pick, RN, and other mentor nurses

Multiprofessional staff of two Finnish NICUs and

Close Collaboration Team

The main goal is

to change care culture to support parenting during the hospital stay of the infant.

to change staff attitudes, rather than single care practices, thereby allowing innovations (by the staff) to create the best way to deliver FCC in their own unit context.

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Care culture,

attitudes

Care practices

Parent’’’’s experience of their

parental role in the unit

Updating care culture

Turku University NICU in 2010

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Turku University NICU in 2014

Content of the training

1. To recognize the individual needs of the infant

2. To share the observations with parents

3. To understand the individual characteristics and context of each family

4. To integrate this knowledge to work in close collaboration with parents regarding infant care and the transition to home

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1. To recognize the individual needs of the infant

• to notice when the infant is either available for contact or turning away from environmental stimulation

• to recognize signs of stress and self soothing• to recognize the behavioral and personal uniqueness of each baby

To learn to communicate about infant neurobehavior (the framework from the infant neurobehavioral assessment methods such as NBAS, APIB, NNNS)

2. To share the observations with parents

To practice attentive listening and ‘wondering’ about infant behavior together with the parents

To learn to give space for the parents

To appreciate parents’ capacity for intuitive parenting

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3. To understand the individual characteristics and context of each family

To build understanding for parents’ experiences during pregnancy, delivery and neonatal care (Clinical Interview for Parents of High-Risk Infants. Meyer EC, Zeanah CH, Boukydis CFZ, Lester BM, 1993)

To understand parents without making negative judgments.

4. To work in close collaboration with parents regarding infant care and the transition to home

Transition process begins early by integrating the parents in the infant care.

Parents give information about their own observations about their baby.

The staff supports the transition to home as a team.

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Individual mentoring in the Close Collaboration with Parents Training Program

The mentor, who is a NICU nurse from the unit, is trained about the content of each phase

and the role of the mentor in supporting staff to explore new practices .

Individual mentoring facilitates bedside practices and enables staff to consolidate their learning from their experiences.

Train the trainer -method

Reflective supervision in the Close Collaboration with Parents Training Program

Frequent supervisions

Reflection of the thoughts and the feelings awaken by the practice sessions

Reflection of concerns

To help the individual staff to internalize and to integrate the new ideas into their everyday practice

Individual differences in adaptation to new care practices and culture is allowed and respected.

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Expansion of the CC Training program in Finland

• Nine Finnish hospitals are/have been in training

the first ones were funded by the Association of Friends of the

University Children's Hospitals

• Content of the training is the same for all

modifications in the structure and schedule according to the local

context.

• The CC Training has been successful in different contextsLevel II and III NICUs.

One region with very long distances.

One bilingual region.

One unit with neonatal and pediatric patients.

• International expansion in the planning phase

Bliss Baby Charter Audit Tool for mapping unit context

to evaluate family centered care practices in the unit

7 principals of FCC are evaluated with 140 criteria

http://www.bliss.org.uk/improving-care/babycharter/audit/

In two-day audit, 15 persons were interviewed in each unit

• parents, head neonatologist, head nurse, and nurses working at the bedside

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The Evaluation Study of The

Close Collaboration with Parents

Training Program

On-going

Coming soon:

Parent participation and parent-infant closeness pre- and post-

training on 4 hospitals

Axelin A, Ahlqvist-Björkroth S, Kauppila W, Boukydis Z, Lehtonen L: MCN Am J Matern Child Nurs 2014;39:260-8. Raiskila S, Axelin A, Rapeli S, Vasko I, Lehtonen L: Trends in care practices reflecting parental involvement in neonatal care. Early Hum Dev 2014;90(12):863-7.

United Nations’ Convention on the Rights of the Child, Article 9

““““--- a child shall not be separated from his or her parents against their will- --””””