Perkins, Emmi BScPT; Ginn, Lesley BScPT; Fanning, Jamie Kneale MClSc; Bartlett, Doreen J. PhD
The neonatal intensive care unit (NICU) provides the medical care required to survive by infants who are at high risk of developmental dysfunction. The inherent nature of the NICU, with increased sound, activity, handling, and light levels, places stress on infants as they struggle to survive. 1 Care in the NICU should be targeted at managing the infants’ medical and physiological requirements while at the same time supporting their neurodevelopment. 2 Developmentally supportive care is purported to minimize the detrimental effects of the NICU by supporting the infant’s development as it occurs synactively through autonomic, motor, state, and attentional subsystems. 3 Developmentally supportive care includes modifying the infants’ physical environment (eg, light and noise) and care-giving interventions (eg, handling, organization of care, and positioning). 3,4 Infants who received developmentally supportive care have been observed to have better medical outcomes with respect to shorter duration of mechanical ventilation and supplemental oxygen support, earlier oral feeding, and shorter hospital stays than those who did not. 5,6 In terms of neurodevelopmental outcomes, infants who received developmentally supportive care have obtained higher Bayley cognitive and motor scores at nine months 5 and better motor, state, attention, and regularity scores as measured by the Assessment of Preterm Infants’ Behaviour at nine and one-half months than infants who had not received developmentally supportive care. 6
As a collaborator in an interactive workshop that was prepared and conducted for NICU nurses at St. Joseph’s Health Care in London, Ontario, Canada, one of us (J.F.) identified the goals and outcomes of developmentally supportive positioning, which is only one aspect of developmentally supportive care, by incorporating research evidence that has recently been summarized in two systematic reviews. 7,8 Despite the evidence supporting the benefits of developmentally supportive care, which includes developmentally supportive positioning, 5,6 the concepts have been slow to be incorporated into clinical nursing practice.
The Canadian Physiotherapy Association 9 describes “education of the profession, other health professionals, the public and clients with the intent of transferring knowledge and skills and developing understanding, independence and competence” as one of the 10 primary functions of physical therapists in Canada. The American Physical Therapy Association, 10 in describing the scope of practice of physical therapy, states that physical therapists provide consultative services and education to staff in health facilities, colleagues, businesses, community organizations, and other agencies. Sweeney et al 11 describe the physical therapist’s consultative role in the NICU as including collaborative participation in the identification and analysis of problems and in the subsequent development of action plans, consideration of individual learning styles, rates of change in the analysis and interpretation of the change process, and outcome evaluation and recommendation of revisions to action plans. Included in the authors’ description of physical therapists’ clinical education and self-learning/professional development role for NICU practice is identification of learner knowledge and skill needs, preparation of clinical training that reflects both the baseline and expected achievement levels, establishment of training objectives and priorities, selection of teaching format and methods, communication of information, demonstration of procedures, arrangement of practice sessions and repeat demonstrations, and provision of feedback to learners regarding their performance. Given physical therapists’ knowledge of the importance of neurobehavioral development in the long-term outcome of the infant, ongoing physical therapy consultation in the NICU is warranted.
Strategies that might facilitate the incorporation of developmentally supportive positioning in routine care provided by NICU nurses include (1) offering technical and analytical expertise, (2) encouraging the use of reflective practice, (3) improving outcome measurement as a means of providing feedback, and (4) providing ongoing formal and informal educational support. To successfully implement developmentally supportive positioning in the NICU, a variety of strategies and expertise in education and consultation is likely needed.
Some pediatric physical therapists have acquired postgraduate training and experience in providing neonatal care. These therapists possess specialized knowledge of neurobehavioral development and are able to work in the practice setting of the NICU with infants who are physiologically or behaviorally unstable based on their advanced clinical competencies. 11 With advanced knowledge and skills, physical therapists have the technical and analytical skills to provide education to other healthcare team members in the NICU environment. An example of technical support provided by the physical therapist in the NICU is the education of nurses regarding effective positioning with and without the use of specialized equipment. The therapist in the NICU can collaborate with nurses to facilitate the development of their problem-solving skills with respect to positioning of neonates.
Nurses have a history of being encouraged to use reflection as a means to improve practice and increase competency. 12 Schon 13 describes reflective practice as consisting of reflection-in-action and reflection-on-action. Reflection-in-action is described as a process of feeling, seeing, or noticing what is being done, learning from the experience, and then adjusting one’s practice accordingly. 13,14 Whereas reflection-in-action allows the practitioner to redesign what is being done while doing it, reflection-on-action allows the practitioner to explore the assumptions used during the experience and justify or alter those assumptions. 13,15 Novice nurses are frequently preoccupied with technical concerns and experienced nurses can develop routines that may not include consideration of the neurobehavioral development of their clients. Reflective practice is a method to access, make sense of, and learn from clinical experiences 16 and can facilitate the linkage of technical knowledge attained from training with the dynamic, contextual knowledge gained through clinical experience. Reflective practice has been found to result in improved patient care by providing nurses with the tools needed to bridge the gap between theory and practice. 17 All disciplines working in the NICU setting, including but not limited to nurses, could engage in reflective practice to benefit these vulnerable infants by optimizing the use of developmentally supportive positioning into regular practice.
As a consultant, the physical therapist must be aware that adults are self-directed learners and use many different learning styles. 18 Thus, it is imperative that preferred learning styles of nurses are identified and a variety of learning options are provided. According to Whitehouse and Lloyd, 19 research has shown that trainees value feedback, and it is important for the feedback to be specific. Trainees value the opportunity to discuss their progress and plans. A lack of feedback or feedback that implies that current practices are inappropriate will hamper the learning process and dissuade change. Without feedback, nurses will have difficulty assimilating their technical knowledge regarding positioning with their clinical positioning skills. In the form of feedback, the physical therapist can provide nurses with both tangible and self-evaluative tools to measure the outcomes of their developmentally supportive care practices.
Although these strategies have been suggested to support the change to developmentally supportive positioning in the NICU, the effect of formal and informal education on nurses’ level of awareness and performance of positioning of neonates is not known. In this study, we investigated positioning of neonates in the NICU over a five-year period. The first purpose of the study was to determine the effect of a physical therapist’s education approaches on nurses’ abilities to position neonates in the NICU at St. Joseph’s Health Care in London, Ontario, by repeatedly measuring nurses’ positioning effectiveness over this time. A second purpose was to survey nurses in the NICU to (1) describe and compare full-time and part-time nurses’ methods of knowledge aquisition, perceived usefulness of educational methods, and satisfaction with abilities to position infants and to describe changes in nurses’ positioning practice patterns as a result of newly acquired knowledge and (2) describe NICU nurses positioning goals, identify perceived barriers to successful positioning, and identify nurses’ perceptions of support needed to enhance and maintain developmentally supportive positioning of neonates.
The research reported here was initiated by the senior author (J.F.), the physical therapist working in the NICU at St. Joseph’s Health Care in London, Ontario, Canada. At the time that this study was conducted through the University of Western Ontario and St. Joseph’s Health Care, institutional approval was not required for program evaluations and therefore was not sought. Overall, the design can be considered to be a one-group, repeated-measures, alternating-treatment design that we describe in the text and summarize in a table. The “treatment” involves a variety of informal and formal awareness and education sessions employed over time in an attempt to improve nurses’ positioning of neonates. This longitudinal work began in 1997, when J.F. started collecting data systematically on nurses’ application of knowledge of positioning infants in the NICU. For all but the last data collection point, data collection was conducted solely by J.F.
Evaluation of Positioning Effectiveness: Data Collection Tool
Nurses’ application of knowledge of positioning was measured repeatedly over time using scoring criteria adapted from The Profile of the Nursery Environment and of Care Components20 (Table 1). Specifically, the outcome of interest is positioning effectiveness, which we define as an optimal developmental position in the context of each infant’s acuity and developmental stage, based on the judgment of the rater. Because of the variation in potential positions, we have not provided figures to illustrate the various levels of scoring. A score of 1 was assigned for those infants who, as a result of no supportive positioning, demonstrated prolonged fussiness, motor disorganization, or stress behavior; appeared uncomfortable; and had moved into a position such that medical equipment was causing them discomfort. A score of 2 was given when an effort had been made to support the infant but was ineffective such that the above indicators were present to some extent. A score of 3 was given when the infant appeared comfortable and was supported in a mostly flexed posture, the medical needs had been taken into consideration, and the infant was able to initiate some self-regulatory behavior, although motor stress signs might have been present at times. A score of 4 was given if the infant appeared comfortable, was supported in an ideally flexed posture (without compromising medical needs), and demonstrated age-appropriate self-regulatory motor control.
We assume an infant’s position is, at least in part, due to positioning efforts of the nurses in the NICU, who are the primary caretakers. The aim of optimal positioning was to support the infant in a manner that promoted organized movements of the infant, optimizing the infant’s motor self-regulatory abilities, state stability, comfort, and physiological flexion while not interfering with medical equipment and inviting parent interaction with their infant. Ratings of position were conducted throughout the 24-hour period. Nurses routinely changed infants’ positions on a two-, three-, or four-hour schedule, depending on the infants’ care needs. Nurses may have intervened at any time, however, to reestablish support positioning should the infant require assistance.
Evaluation of Positioning Effectiveness: Data Collection Procedures
A summary of the following data collection procedures is contained in Table 2. At the study outset in July 1997, a baseline data collection phase was conducted by J.F. An informal survey was subsequently distributed in September 1997 to ascertain the level of nurses’ awareness of principles of positioning and their comfort in positioning infants. A second data collection phase was held in October 1997 to measure the impact of the survey on developmentally supportive positioning in the NICU.
In the survey, the nurses identified a need for new equipment to aid them in proper positioning. As a result, a trial of new equipment took place and it was subsequently purchased during the period between October 1997 and February 1998. A formal in-service to introduce the nurses to the positioning equipment was conducted in March 1998. In April 1998, another point of data collection was performed to investigate whether the formal in-service had had an impact on the nurses’ positioning practices.
A one-day in-service conducted by Katherine M. Jorgensen (RNC, MSN/MBA, Hon D), a Newborn Individualized Developmental Care and Assessment Program (NIDCAP) consultant, was held in September 1998. This in-service was attended by 70% of the NICU nursing staff. This was the nurses’ first formal introduction to all aspects of developmentally supportive care, which included positioning, through St. Joseph’s Health Care. A NIDCAP self-study guide was available on a sign-out basis to each nurse employed in the NICU. A data collection phase followed in March 1999 to identify differences in nurses’ positioning practices as a result of the NIDCAP presentation and availability of the self-study guide.
In January 2000, an optional “refresher day” was held to reinforce nurses’ positioning knowledge. In October 2000 and March 2001, J.F. collected data regarding NICU neonatal positioning to monitor nurses’ positioning practices in the absence of formal education but with nursing requested bedside consultation provided by the physical therapist.
In early 2001, J.F., in collaboration with other NICU service providers, developed an interactive, computer-based educational workshop including information regarding developmental care, emphasizing positioning and handling. This one-day workshop, held in March 2001 after the sixth data collection point, was offered on four different days to facilitate all nurses attending and was viewed by 82% of the nurses. The morning session focused on progression of feeding of infants born preterm. The afternoon comprised four concurrent 50-minute sessions in which groups of four to eight nurses engaged in the following topics: transition from isolette to cot, exploring the visual and auditory environments, developmentally supportive swaddled bathing, and positioning and handling from admission to discharge.
In the latter session, a review of the maturation of the tactile system and the associated maladaptive responses of the neonate to the NICU environment with respect to handling and positioning was completed. Goals and positioning outcomes of developmentally supportive positioning were reviewed. The goals included enhancing development of flexor tone, facilitating and supporting self-regulatory behaviors, ensuring energy conservation, promoting state stability and transition, enhancing infant-parent interactions, and avoiding interference with necessary medical interventions, thus supporting the infants’ developing perceptual and sensorimotor abilities. A series of pictures and/or videotapes of handling and positioning were then presented for discussion by the small group; this discussion was facilitated by the physical therapist (J.F.). Participants were asked to comment on the effectiveness of the positioning, using the scaling system presented in Table 1. Through group discussion, participants identified strategies to improve the positioning of the infants based on the identified outcomes. Data collection was subsequently conducted in June and October 2001 to monitor the immediate and longer term effects of the workshop.
For the final data collection point in October 2001, three raters (J.F., E.P., and L.G.) visited the NICU unannounced at three different times to cover the morning, afternoon, and night shifts. The three raters independently and simultaneously assigned a score (see Table 1) to each infant’s position. Scores were then discussed, and consensus was used to assign a final score to each infant’s position based on individualized needs and judgment of positioning effectiveness in the context of current health status and developmental stage.
Analysis of the quantitative data of positioning effectiveness was conducted descriptively in the form of box plots.
Evaluation of Nurses’ Perceptions of Positioning Abilities: Development and Implementation of a Survey
A survey was developed by the investigation team in November 2001 with the intention of identifying nurses’ perceptions of their abilities to position infants and related issues (see Appendix). The survey that had been distributed by J.F. in September 1997 was used as a template. The payroll department provided a list of all nurses employed in the NICU (n = 94). The surveys were addressed to and placed in the mailboxes of each of the 94 nurses. Envelopes and a box were provided for anonymous return of completed surveys. Fifty responses were received corresponding to a response rate of 53%. A description of the participants is contained in Table 3.
Quantitative data collected via the survey were analyzed by obtaining frequency counts for the nominal level variables and by calculating means and standard deviations for the questions about perceived usefulness of the educational methods and reported satisfaction with their abilities. For the perceived usefulness of the educational methods, the order of the ranks was converted to a scale in which 6 was most useful, and 1 was least useful; therefore, higher mean scores represented greater perceived usefulness. For the satisfaction data, scores were coded from 1, for never satisfied, to 5, always satisfied. The χ2 statistic was used to determine differences in the proportion of part-time and full-time nurses reporting different methods of knowledge acquisition. The Mann-Whitney U test was used to compare the perceived usefulness of various educational methods and satisfaction with their abilities between part-time and full-time nurses. Qualitative analysis of the open-ended questions was conducted using the induction of categories using content analysis. 21 The induction of categories using content analysis involved the organization of the qualitative feedback from each open-ended question on the survey into like categories from which trends were identified. This was conducted using consensus among the three primary investigators.
The first purpose of the current research study was to determine the effect of formal and informal education on nurses’ abilities to position neonates in the NICU over a five-year period. Figure 1 contains a graphic representation of the distribution of the nurses’ positioning scores over the course of the study (from July 1997 to October 2001) in the form of box plots. Visual analysis suggests that implementation of formal educational guidelines for the use of positioning devices provided in the equipment in-service, the NIDCAP in-service, and the interactive computer-based workshop contributed to almost uniform ideal effects with respect to developmentally effective positioning. Visual analysis also highlights the decline in nurses’ positioning practice effectiveness at the October 2000, March 2001, and October 2001 data collection phases. The first two intervals did not have formal education sessions; however, bedside consultation was provided on request. The final data collection point highlights a decline in positioning performance after more than six months since a formal education session.
Nurses’ Perceptions of Positioning Abilities: Quantitative Results
A summary of the methods of positioning knowledge acquisition reported by part-time and full-time nurses is presented in Table 4. There were no significant differences between part-time and full-time nurses with respect to their methods of knowledge acquisition. The majority of nurses reported obtaining knowledge about positioning through workshops, in-services, and bedside consultations. In contrast, relatively few nurses reported gaining knowledge through independent reading or audiovisual resources.
Nurses’ perceptions of the usefulness of various educational methods are contained in Table 5. Full-time nurses were more likely to rank bedside consultation as a more useful means of acquiring new knowledge than part-time nurses (Mann-Whitney U test = 142.0; p = 0.01). Overall, nurses reported workshops, physical therapy in-services, and bedside consultation to be more useful than audiovisual resources, independent reading, or general hospital in-services.
The majority of nurses reported that they were “mostly satisfied” with both their abilities to identify client needs and position their clients (Table 6). No significant differences were found between part-time and full-time nurses in their satisfaction with their abilities to position neonates in developmentally supportive positions.
Nurses also provided data describing changes in their positioning practice patterns as a result of newly acquired knowledge. Thirty-nine of 50 nurses reported that they had gained new knowledge about developmentally supportive care in the past year. Of the 11 who reported that they had not gained any new knowledge, two said that this was because they had had no opportunities to learn. Two nurses reported they knew all there is to know about positioning, two stated that there had been insufficient time to acquire new knowledge, and two reported that they were focusing on other areas of their practice. Four nurses reported that the developmentally supportive information that had been provided had been previously learned. One nurse reported she had not gained any new knowledge because she had been unable to attend the workshops. Eighty-nine percent of the nurses who completed the survey reported that they had changed their care plans based on their new knowledge.
Nurses’ Perceptions of Positioning Abilities: Qualitative Results
Another purpose was to identify nursing positioning goals. These were obtained through content analysis of the qualitative data/survey and included (1) enhancing development of positioning in flexion, (2) encouraging infant self-regulation/infant comfort, (3) not interfering with medical interventions, and (4) enhancing infant-parent interactions. Perceived barriers to successful positioning as identified by the NICU nurses included (1) acuity of infant, (2) lack of appropriate positioning aids, (3) active infants, and (4) lack of skill application for effective outcomes of good positioning. Finally, nurses’ suggestions for future supportive directives included (1) in-services, (2) new positioning aids, and (3) bedside physical therapy consultation.
Formal education was found to have had a significant effect on the short-term quality of neonatal positioning. However, the box plots in Figure 1 illustrate that the effectiveness of positioning declines following intervals with no formal education. Nurses ranked the interactive educational workshop and formal physical therapy in-services as the most useful methods of learning about optimal neonatal positioning. Nurses also stated a preference for bedside consultation to discuss and evaluate their positioning practices. In this section, we discuss the relevance of the study results in relation to the existing literature and the previously identified strategies (offering technical and analytical expertise, using reflective practice, improving outcome measurement, and providing formal and informal education) to facilitate improved positioning in the NICU.
A decline in positioning effectiveness was observed over the intervals of March 1999 to October 2000 and March 2001, as well as June 2001 to October 2001. In an article by Gilkerson and Als, 14 it was recommended that the developmental team get together at a minimum of six-month intervals to reflect on their work in the implementation of developmental care practices. Without ongoing reflection and action, the advances in the practice of developmental care quickly diminish, given the many pressures and competing priorities in an NICU. In the current research, the role of the physical therapist in introducing developmentally supportive positioning was a small component of her responsibilities in the NICU. Intervals of time between educational opportunities or bedside consultation were not frequent enough to ensure optimal positioning of the infants over time. We speculate that more regular follow-ups with nursing staff using formal in-services and bedside consultation, case reviews, and relevant research presentations could prevent the observed declines in positioning.
By offering technical and analytical information and skills, the therapist can continue to facilitate nurses’ positioning abilities. Posel 22 contends that demonstration and practice are essential when psychomotor learning is necessary. Campbell 23 proposes that adult learners retain information best when they can put the information to immediate use. This is consistent with the finding of the current study in which the full-time nurses ranked bedside consultation as a useful means of acquiring and applying new knowledge. They might have had greater access to the physical therapist than the part-time nurses and thus potentially had greater opportunities for individual support. The physical therapists’ role as a consultant needs to go beyond the provision of information to facilitate positioning abilities. Nonetheless, the results of this study suggest that informal bedside consultation alone is insufficient in promoting nurses’ positioning abilities. The data highlight that formal education through workshops and physical therapy in-services is more effective than the form of bedside consultation used in this study. Implementing a formal program of bedside consultation to widen exposure to facilitating reflection and action should be considered.
The current results also suggest that nurses might be insufficiently reflective of their positioning practices. Although most nurses were highly satisfied with their positioning abilities and reported that they had gained knowledge that they had integrated into their positioning practices, the final data collection point suggests that nurses might be prompted to use the principles of reflective practice. The physical therapist could suggest strategies of reflection-in-action and reflection-on-action to assist in consolidating the integration of theory and practice.
Our results support the previous finding that small group practice and discussion enhance adult learning. 23 Nurses ranked the interactive educational workshop as the most useful method of learning, followed by the physical therapy in-service. In contrast, audiovisual resources, independent reading, and hospital in-services not provided by the physical therapist were ranked lower. This latter finding suggested that these methods alone are unlikely to be effective in changing practice of a large group of service providers. Nurses also stated a preference for bedside consultation to discuss and evaluate their positioning practices, supporting the importance of the role of a physical therapist as a consultant in the NICU.
Physical therapists have an opportunity to provide specific, one-on-one feedback to nurses in the NICU to provide them with the opportunity to reflect on the outcome of their positioning efforts. The scoring criteria used to assign scores to the neonates’ positions could be shared with the nurses as a means for them to monitor the effectiveness of their positioning. Also, documentation of positioning outcomes for each neonate would increase the consistency of care and emphasize the need for nurses to constantly evaluate the outcome of their positioning practices.
Als and Gilkerson 24 recommend that continuing education, regularly scheduled supervision, self-assessment, and opportunities for reflection must be available. Lawhon 4 states that the team should have access to specific training and consultation opportunities. Indeed, opportunities have been provided to nurses at St. Joseph’s Health Care to increase and reinforce their knowledge and abilities to optimally position neonates. Despite these opportunities, 22% of the nurses reported that they had not gained new knowledge in the past 12 months. Factors such as receptiveness to learning opportunities, maternity leave, the shift worked, and the hiring trend (ie, recently hired nurses who had not had exposure to formal education) could be influences. However, we hypothesize that with increased formal, planned physical therapy consultation, knowledge and skill acquisition regarding positioning abilities would increase.
Recommendations to further the progress made in developmental positioning in the NICU at St. Joseph’s Health Care, and possibly other NICUs, include (1) providing regularly scheduled formal in-services, (2) scheduling bedside consultation sessions regularly to provide feedback and to encourage nurses to reflect on their positioning practices, (3) focusing bedside consultation on positioning of neonates who have higher levels of acuity, (4) assisting the nursing staff to develop a means of communicating the positioning outcomes as part of the infants’ care plans, and (5) developing a system to ensure positioning resources are available consistently at the bedside.
A clear limitation of the current research study is the subjective nature of the scoring system used during data collection. Given the unique health condition of each infant in the NICU, some subjective consideration of each infant’s medical situation contributed to the final assigned score of the nurse’s positioning of the infant. This limitation was minimized through the use of consensus among the investigators; however, consensus was only used during the last data collection phase.
A second limitation of the research study is the fact that although this design is considered to be a one-group, repeated-measures study, the participants are not the same nurses over the whole time period. This simply reflects the reality of the pool of nurses who work in the NICU over time. The variation in staff complement highlights the need to regularly schedule formal in-services about positioning.
Finally, a low number of surveys were completed by NICU nurses and returned to the investigation team. The response rate was 53%, which is modest. Some surveys were not picked up due to the part-time/casual status of the nurses as well as by those that were on maternity leave, leave of absence, or sick leave.
Future research directions include, but are not limited to, the following areas: reliability and validity testing of the measure of positioning effectiveness, exploration of a greater range of educational strategies for adult learning (such as greater incorporation of reflective practice), use of stronger methodologic designs such as a randomized, controlled trial comparing different educational approaches with evaluation of the outcome by a rater masked to intervention, greater frequency of outcome measurement to more closely monitor patterns of decline in performance to clarify the optimal frequency of formal education approaches, and replication of this and other studies in different settings.
Formal education provided by the physical therapist at St. Joseph’s Health Care has had the greatest positive effect on positioning practices of NICU nurses when compared with other methods of knowledge aquisition available. Positioning effectiveness declined when there was no formal provision of positioning education. Based on the nurses’ reported preference for bedside consultation as one means to increase the knowledge of neonatal positioning, the role of the NICU physical therapist as a consultant could be expanded. By formalizing this role to include bedside consultation and formal education, the observed reduction in positioning effectiveness might be avoided. Given that nurses identified a lack of knowledge as a barrier to positioning, further education, consultation, and facilitation of reflective practice are required to assimilate the newly acquired positioning knowledge into practical skills.
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