A 5-fold increase in the United States from 2000 to 2012 of infants exposed to opioids in utero and diagnosed with neonatal abstinence syndrome (NAS) has created a need to standardize interventions for care.1 Withdrawal symptoms of infants exposed to opioids in utero may include jitteriness, feeding issues, gastrointestinal upset, extreme irritability, sleep disturbances, and seizures.2 Infants diagnosed with NAS may require medications to manage their symptoms, but nonpharmacologic options should also be included in the standard of care. A dual-treatment regimen has the potential to ameliorate length of inpatient hospitalization, decrease severity of symptoms, and lessen the need for pharmacologic agents.3–5 Nonpharmacologic interventions include a low-stimulating environment with rooming-in that encourages involvement of the mother/caregiver as well as breastfeeding, skin-to skin care, positioning, acupuncture, nonnutritive sucking, swaddling, and the use of specialty beds.3,5–7
For over 15 years, the Institute of Medicine (IOM) has challenged healthcare systems to provide evidence-based, standardized care in efforts to deliver safe, high-quality care to consumers.8
Standardized approaches to nonpharmacologic and pharmacologic care for infants with NAS were associated with both decreased length of hospitalization and length of treatment with opioids.8–13 The motion/sound infant seat is used by nurses, families, and other healthcare personnel as a nonpharmacologic comfort measure. However, little is known concerning how nurses make decisions encompassing the use of motion/sound seats for infants with NAS.
The purpose of this study was to identify the current practices of a sample of neonatal intensive care unit (NICU) nurses in the utilization of a motion/sound infant seat. The study is a preliminary study to address the standardization of this intervention as a nonpharmacologic technique in the care of infants with in utero exposure to substances that cause withdrawal symptoms. Understanding the current use provides a baseline for how this intervention could be better integrated into this standard of care.
Simulation of an intrauterine environment (gentle rocking, muffled noises) has been hypothesized to soothe agitated infants. Infants with in utero substance exposure are often disorganized, struggle with sensory integration and regulation, and are prone to overstimulation, which may elicit a “shut-down” response that mimics a quiet infant state.7,14 The use of music therapy on behavioral state, physiological metrics, and feeding behaviors in the premature infant population has been studied, but not specifically in the population of infants with substance withdrawal.15–18
Past studies have examined the use of rocker beds, waterbeds, and vibrotactile stimulation mattresses. In a small sample study (n = 14) in 1999, D'Apolito19 found that the use of a rocker bed versus a standard bed did not alleviate withdrawal symptoms, and the type and amount of motion could provoke overstimulation in this high-risk population. Oro and Dixon20 in 1998 conducted a study (n = 30) in which they compared the use of nonoscillating waterbeds versus traditional bassinets in the treatment of narcotic-exposed infants. Results indicated that use of the nonoscillating waterbed in conjunction with a pharmacologic regimen could diminish central nervous system withdrawal symptoms and medication dose, and improve weight gain.19 Recently, Zuzarte et al21 studied the use of a mattress delivering stochastic vibrotactile stimulation in opioid-exposed, pharmacologically treated, term infants (n = 26), and its therapeutic potential in improving autonomic function among infants with NAS, and found that the use of the mattress reduced activity and physiologic instability.
While not a bed, the motion/sound infant seat is a seat with multiple motion and sound settings, which was designed to mimic natural caregiver motions, such as bouncing and swaying.22 The manufacturer guidelines for use include operation of the seat, placement of the seat to prevent falls, and risk of suffocation when using padding or other materials not supplied specifically for the seat.22 Preliminary data from a study by Synan and Milford, using the 4moms mamaRoo infant seat as a nonpharmacologic intervention with 72 infants with NAS identified a significant difference in physiologic stability and calmer behavioral states before placement in mamaRoo and 30 minutes after being placed in the mamaRoo.23 However, this work conducted by the National Perinatal Association and 4moms remains unpublished. Moreover, guidelines for use of the seat as a nursing intervention are scarce and are predominantly found in lay materials.24–26
The research questions for this descriptive, exploratory study include:
- What are the reasons given by NICU nurses for the use of the motion/sound infant seat?
- What are the rationales for choice of the motion and sound settings on the infant seat?
- What is the duration of time the infant spends in the motion/sound infant seat?
- What is the perception of a positive infant response after implementing the use of the motion/sound infant seat?
- What are the nursing instructions for use given to parents and others using the motion/sound infant seat?
What This Study Adds
- Describes the variability of the nurses' use of the motion/sound infant seat in the neonatal intensive care unit.
- Emphasizes the need for further development of best practices to guide the use by nurses of the motion/sound infant seat.
- Identifies the need for educational material for the parent/caregiver or other personnel using the motion/sound infant seat.
- Identifies areas of future research on the use of the motion/sound infant seat including population-based studies, measures of positive/negative outcomes, and predictive criteria for use and outcome-based research.
The setting was a level III NICU in an urban county that has approximately 900 annual admissions and serves as a regional referral center for 22 rural counties. The study received approval from the institutional review board at the study site.
The 10-question survey was designed by the study's site Women's and Children's nurse researcher and research assistant, who is also a NICU registered nurse (RN). A statement at the beginning of the survey explained the purpose, and consent was implied by survey completion. Demographic information was not collected in efforts to deidentify participants. Two questions were multiple-choice format and focused on the most often selected noise and motion settings. The remaining 8 questions allowed for free-text responses to appraise nurse use of the motion/sound infant seat. They addressed (a) reasons for use, (b) duration of time infants spent in seat, (c) rationale for choice of noise settings, (d) rationale for choice of motion settings, (e) perception of a positive infant response, (f) who places infants in the seat, and (g) nursing instructions dispensed prior to use by others. The final question permitted any additional comments on use of the seat. The survey was constructed to prompt NICU nurses' perceptions, opinions, and practices in using the multimodal infant seat as a nonpharmacologic nursing intervention in the management of irritable, difficult-to-console infants.
Demographic data were not collected from the sample, due to nurses' requests during the survey approval processes. The reason the nurses gave was that the demographic questions could be used to identify an individual nurse, and they wished to remain anonymous. Institutional data at the time of the survey indicated that approximately 58% of the nurses offered the survey had attained a bachelor's degree or higher degree, and there is an equal division of day and night nurses.
All NICU RNs who worked in the study setting were sent an anonymous, secure link to a tailored survey powered by SurveyMonkey. Participation was voluntary. The survey was open for 2 weeks and staff were encouraged during daily huddle sessions to complete the survey and voice their opinions. A second e-mail with the link was sent out at the halfway point of the study to remind nurses about the survey. Nurses who completed the survey were invited to self-enter their names into a drawing for a $20.00 gift card.
Frequency statistics were performed to analyze responses to survey questions. The free-text responses were collated and reviewed by the researcher and NICU nurse research assistant. The comments were divided into the dichotomous categories of positive and negative comments.
Surveys were sent to 126 NICU RNs, and 66 completed the survey (52%).
The motion/sound infant seat used most often in this setting has 5 settings for motion (car ride, kangaroo, tree swing, rock a bye, and ocean wave), and nurses were asked to choose the settings they may use when placing an infant in the seat. The survey allowed for multiple settings to be chosen by the same respondent. Car ride motion (n = 50; 76%) was the most frequent type of motion setting reported to be used by the nurses. Tree swing (n = 31; 47%) and kangaroo (n = 29; 45%) were the next most frequent motion settings reported followed by ocean wave (n = 19; 30%) and rock a bye (n = 15; 24%). The seat also has 5 noise settings (crickets, rain, white noise, ocean, and babbling stream). The nurses were asked to choose all settings they may use when placing an infant in the seat. Sixty-three of 66 nurses responded. Sixty-three percent chose white noise, followed by ocean (60%), rain (33%), crickets (32%), and babbling stream (24%).
Eight of the 10 questions allowed free-text responses to questions focused on nurse utilization of the motion/sound infant seat. In the first question, nurses were asked to list the reasons they placed an infant in the multimodal seat. All survey respondents answered the question and listed multiple reasons. The 3 most frequent responses to the reason the infant was placed in the motion/sound seat in order of frequency were (1) a fussy or inconsolable infant, n = 54 (83%); (2) unable to hold the infant due to other nursing obligations and family or staff members were also not available, n = 33 (50%); and (3) the infant had a diagnosis of NAS, n = 21 (33%).
Nurses were queried about the length of time in minutes the infant is in the motion/sound seat per individual session. Times ranged from 10 to 360 minutes. Nurses could respond with 1 number or give a range of time. For those who indicated 1 number, the time ranged from 10 to 180 minutes (mean = 70.3). For those who indicated a range of times, the shortest time frame was 20 to 180 minutes and the longest time frame was 60 to 360 minutes. Nurse respondents stated their reasons for leaving the infant in the motion/noise seat for designated times in free-text comments. Twelve nurses clarified that time was dependent on infant “reputation” for fussiness. If the infant was sleeping, whether the infant was receiving oral feeding, or the timing of the last or next feeding also was identified by the respondents as factors they considered in deciding how long to leave the infant in the seat. Five nurses specifically responded that they “never wake up a sleeping infant.”
Nurses were then asked, “How do you determine which motion setting to use?” Multiple responses were allowed. Six common themes were extracted from the responses (Figure 1). The 6 themes include (1) trial and error; (2) prior setting; (3) random selection; (4) assumption of what the infant might find soothing; (5) personal patterns; and (6) no use of the motion setting. The most common response was “trial and error,” in which nurses reported they observed infant cues and responses to the motion and might then adapt their choice. Personal pattern and personal preference were reported least frequently by the nurse respondents. Personal patterns included phrases such as “I always use one setting” or “I start with tree swing and change to car ride if still fussy.” Personal preference included responses such as “I watch the motion and see if it's soothing to me” or I use “whichever causes the infant motion seat to squeak the least.”
The next survey question asked, “How do you determine which noise setting to use?” Many of these answers mirrored the rationale used in the prior question regarding motion selection (Figure 2). The majority of respondents identified the selection of noise setting was based on the following: which noise would be most soothing to the infant; least irritating to nearby infants; most likely to drown out ambient NICU noise; and sound mimicking in utero noises. Personal preference is defined as the nurse played the noise which was most soothing or less irritating to them as they worked. A handful of nurses responded they never used the noise function on the motion/sound infant seat.
Nurses were then asked how they recognize a positive response from an infant in the seat. Overwhelmingly, 88% (n = 58) of free-text comments perceived a quiet alert state or a sleeping infant as a positive response. The remaining 12% (n = 6) cited “normal” vital signs, nonnutritive sucking, lower Finnegan scores, or a decrease in reflux/emesis events as a positive reaction.
The nurse respondents were also asked who, besides a nurse, might place an infant in the seat (Figure 3). Certified nursing assistants, parents, and fellow nurses were the most frequent responses in the survey. NICU volunteers, physical therapists, and child life specialists were also identified by survey respondents as personnel who place infants in the seat. Four nurses in the study responded that they do not allow anyone else to place the infant in the seat.
Nurses were then questioned about any instructions they dispensed to other staff members or parents who may use the infant seat (Figure 4). The majority of nurses' responses (72%) focused on safety, including instructions on buckling of straps, infant securement and position, and awareness of medication/fluid lines and surrounding equipment. Other instructions centered on appropriate motion and sound settings, and appropriate dress of the infant for temperature stability. One nurse gave specific guidance to parents about not allowing the infant to sleep in the infant motion seat and another encouraged parents to return the infant to the crib as soon as possible to promote safe sleep practices. One nurse reported she does not give parents instructions stating, “If parents are visiting, I expect them to hold their child, not use the seat.” The final question asked nurses to free-text any further comments they would like to make about the use of the motion/sound infant seat. These comments were categorized as either positive or negative feedback (Table 1).
Motion/sound infant seats are often used in NICUs to calm irritable infants, which includes infants withdrawing from in utero substance exposure. The study found much variability in the nurses' choices as to timing and duration of the use of the seat, settings, and assessment of positive cues of the infant before, during, and after use of the seat. While the majority of responses indicated that the nurses' decisions were based on the individual infant's responses, an essential component of developmental care, nurses reported they rely on their own response to the seat's motion or sound in guiding their assessment and management of the infant. The study also revealed that nurses are not the only caregivers of the infant who may be placing the infant in the seat. Instructions to others on safety and placement of the infant in the seat by nurses in the study were also variable and nonstandardized.
The inconsistency in practice requires attention, as the past 15 years in healthcare has seen a surge in initiatives focused on patient quality and safety. The IOM 2001 report, “Crossing the Quality Chasm” urged healthcare systems to delineate specific practice guidelines to foster safe, consistent, high-quality care.9 Variability in care, including the underuse of care, overuse of care, and potential misuse of care, due to a lack of evidence-based recommendations or poor adherence or implementation of recommendations, can jeopardize patient safety and quality of care.27 Marcellus et al28,29 championed the need for nurses to support standardization in practice, to ensure consistent delivery of evidence-based care for families and infants impacted by perinatal substance exposure. Implementation of disease-specific NICU care standards combined with advocating for the adoption of evidence-based practices is identified strategies to mitigate practice deviations and improve outcomes in infants with neonatal illness.30 With the widespread use of the motion/sound seat in NICUs as an intervention for infants with NAS, identification of inconsistent practice is a critical step in developing best practice standards for supporting this vulnerable population.31
The length of time the infant remains in the motion/sound seat is inconsistent as reported by the nurse participants in the study and the exceptionally long period of time that was reported, up to 360 minutes, suggests the nurses were using the seat to promote sleep. This underlines the need for safe sleep best practices to be considered. There is a gap between nursing beliefs and knowledge of safe sleep recommendations and what is practiced in the hospital setting.32–34 The variation in practice presents an opportunity and obligation for nurses to consistently model safe sleep practices and champion sudden infant death syndrome prevention education, as evidence has shown that following infant hospitalization, parents will often copy observed nurse behavior and practice.35
IMPLICATIONS FOR PRACTICE
Patient assessment in response to nursing interventions is essential to guide practice. The study found, that for some nurses, the determination of the time the infant remained in the seat and the selection of settings were based on personal preferences rather than infant responses to the intervention. Nursing practice requires standardized approaches based on evidence for best practices. The results of this study point to the variability of practices used by nurses implementing the motion/sound infant seat. There is a scarcity of evidence and policy for the use of the motion/sound infant seat as a nursing intervention. As nonpharmacologic treatments for NAS evolve, nurses will need standardized, evidence-based guidelines as to safe and effective methods and strategies.
Nursing communication has been shown to be highly valued by NICU parents, and studies on the role of nurses in educating parents on topics such as sudden infant death syndrome and unit equipment have demonstrated the impact of nurse recommendations on increased parental adherence and knowledge.36–38 As the primary providers of education on infant care, nurses have a responsibility to educate and consistently demonstrate best practices to families and other caregivers. Yet, the paucity of evidence on best practices for the use of the motion/sound infant seat creates a void in the best information to be given to families and caregivers by nurses. To advocate for safe sleep practices and to cultivate consistent role-modeling of best practices, nurse may need ongoing education and competencies.35
IMPLICATIONS FOR RESEARCH
One of the 3 components of the IOM's definition of quality healthcare is consistency with current knowledge, which necessitates research to produce “the most reliable knowledge about the likelihood that a given strategy will change a patient's current health status into desired outcomes.”39 Patient assessment of the response to nursing interventions is essential to nursing practice. Prior research has shown that even healthy newborns are highly individualized in how they regulate behavior, and process and adapt to environmental stimuli, such as lights, sounds, and motion.40,41 Only 1 unpublished study was found that examined infants' physiological and behavioral response to motion/sound seats.23 It is essential to conduct well-controlled studies including the use of biomarkers, infant stress cues, and other forms of assessment of the positive or negative impacts of the motion/sound infant seat to determine the safety of the seat and to determine changes over time. Research in the areas of criteria of use, monitoring of the infant before, during, and after use, timing, duration, and setting choices for the best and safest outcomes for the use of the motion/sound infant seat is needed to guide practice. In addition, research comparing outcomes of infants needing soothing from a variety of factors (ie, colic) needs to be conducted to determine the best practices for those populations when using the seat. Best practices based on outcome research will then be the foundation for the development of specific nursing guidelines and educational materials for all users of motion/sound infant seats.
Several limitations existed in this study. The study was conducted in a single hospital NICU, which limited generalizability of the results. Staff use of the seat might vary from one NICU to another due to a multitude of variables, such as staffing levels, existing policy and education on use of the seat, number of seats available for use, and average number of infants with NAS in the daily census. No demographic data were collected to encourage participation due to the lack of identifiers, and because the researchers were not trying to correlate demographics with survey results. Despite this, the response rate was low (52%), and this also impacts the generalizability of the findings. In hindsight, it would have been noteworthy to study the correlation of demographic variables such as day-shift nurses versus night-shift nurses, highest education level of the nurses, and years of nursing experience. The survey did not ask about negative responses of the infant while in the motion/sound seat, which is a missed opportunity for assessment. In addition, the phrasing of the survey question to determine the length of time the infant spent in the seat allowed for both a single number or a range of time, which made it challenging to ascertain a specific number of minutes. The validity and reliability of the survey requires further testing, as it was self-developed by the nurse researcher and research assistant.
NAS is a rapidly escalating problem that will challenge nurses to incorporate existing knowledge and interventions with novel treatments, as strategies evolve to assure optimal care for this vulnerable population. While it is agreed upon that there is a place for nonpharmacologic treatment for all infants with NAS, the use of the motion/sound infant seat is currently being employed widely and inconsistently for this intent, without specific nursing guidelines. Further research is necessary to analyze the seat as an efficacious nonpharmacologic intervention, with outcome data stimulating the drafting and incorporation of appropriate usage guidelines into the NAS management arsenal.
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Keywords:© 2019 by The National Association of Neonatal Nurses
infant seat; neonatal abstinence syndrome; NICU; nonpharmacologic intervention; variation in care