In the neonatal intensive care unit (NICU), a parent's positive perception of discharge readiness is an essential component of a successful discharge experience. According to the American Academy of Pediatrics (2015), proper preparation for discharge and well-planned follow-up care reduces morbidity, mortality, and readmission of infants discharged from a NICU. In a study comparing parents' perceptions of discharge readiness and readmissions, Berry et al. (2013) found that the parents' decreased perceptions of discharge readiness often resulted in hospital readmissions of less than 30 days after discharge. Nurse-driven, family-centered discharge preparation increases parental confidence, knowledge, and empowerment and promotes a positive parental perception of discharge readiness (Burnham, Feeley, & Sherrard, 2013). According to Griffin (2013), family-centered care (FCC) principles include nurses partnering with parents or guardians by treating them with respect and dignity, sharing pertinent information, encouraging them to participate in their infant's care, and collaborating in policy and program development to improve care delivery and patient outcomes.
Given that FCC practices employed during the infant's hospitalization promote parental readiness, NICU registered nurses (RNs) should employ family-centered approaches as appropriate to efficiently educate and empower parents to care for their infant independently at home (Bastani, Abadi, & Haghani, 2015). This article presents the findings of an educational initiative that was implemented to increase NICU RNs’ knowledge of FCC practices and to empower them to integrate FCC principles into their daily patient care. Implications for nursing professional development (NPD) practitioners are also offered.
When parents or guardians are not well prepared for their baby's discharge from the hospital, they often lack confidence and experience increased levels of anxiety, which can result in unnecessary pediatrician and emergency department visits and/or infant rehospitalization (Amin, Ford, Ghazarian, Love, & Cheng, 2016). Parental perception of discharge readiness influences infant safety, parent satisfaction, and “physical, emotional, psychological, and social well-being of the family” (Chen, Zhang, & Bai, 2015, p. 136). Wu et al. (2016) demonstrated a significant increase (6%) in family perception of discharge readiness after the discharge process and family teaching were improved.
Positive parental perception of discharge readiness can be fostered through family-centered discharge education and preparation (Bastani et al., 2015; Chen et al., 2015; Ingram et al., 2016). When used in tandem, these two components improve parental confidence and discharge readiness through bonding and hands-on skills acquisition (Knier, Stichler, Ferber, & Catterall, 2015; O'Brien et al., 2015). FCC tenets posit that RNs should partner with parents in providing care for the infant during the hospital stay by encouraging parents to provide independent care for their baby with tasks like diapering, bathing, feeding, and temperature taking to build caregiver confidence and promote a positive perception of discharge readiness (Adama, Bayes, & Sundin, 2016; Griffin, 2013). Confident and empowered parents are usually more successful at transitioning from the NICU to caring for the infant in their home (Purdy, Craig, & Zeanah, 2015).
Educating RNs is key to enabling them to provide adequate parental education and support based on FCC principles (Chen et al., 2015; Hall et al., 2017). A study regarding RNs’ perceptions of working with families of critically ill infants and children indicated educating RNs about FCC could improve practice and patient outcomes (Butler, Willetts, & Copnell, 2015). Another study demonstrated that both NICU RNs and parents value FCC practices; however, there is a need for education, policy, and executive or organizational support for effective implementation thereof (Trajkovski, Schmied, Vickers, & Jackson, 2016). Facilitating education is an important competency for NPD generalists and specialists, and education is key to promoting FCC practices (Halstead, 2007).
Inadequate parental and family discharge readiness was identified at a 55-bed Level IV NICU in the southwest region of Pennsylvania. At this facility, postdischarge surveys conducted by Press Ganey reflected an inadequate parental perception of discharge readiness as indicated by declining top box scores which were not meeting the benchmark. Specific low-rated questions indicated that inadequate discharge education and preparation could be contributing factors. Two survey questions of concern fell under the “Preparing for Discharge” category, including “how prepared you felt for your baby's discharge” and “opportunity you had to care for your baby on your own before discharge” (Press Ganey Associates, Inc., 2016, p. 48). The low ratings on these two questions indicated that parents did not consistently care independently for their infant during hospitalization and did not feel prepared for discharge. In addition to the Press Ganey scores indicating parents were not well prepared for discharge, the NICU unit directors and other members of the interprofessional healthcare team observed inadequate FCC practices on the unit. Hospital administrators felt the NICU RNs had learning gaps related to this area of their practice because FCC education was not included in new hire or yearly competency training. NPD educators sought evidence to support a plan to address this identified need.
Educating RNs about FCC enables them to appropriately integrate the principles and form partnerships with parents by encouraging hands-on infant care as soon as possible after admission. Galarza-Winton, Dicky, O'Leary, Lee, and O'Brien (2013) used an educational intervention to address a problem of inefficient integration of FCC principles into bedside practices in a NICU. They developed a 4-hour workshop for staff RNs (n = 35) intended to increase the RNs’ knowledge base and improve skills to promote parental involvement in the infant's care, which could increase parental confidence and improve the perception of discharge readiness. The clinical significance of the study was evident in the NICU culture shift after the workshop, which showed improved compliance with the family-integrated model of care (Galarza-Winton et al., 2013).
Kornburger, Gibson, Sadowski, Maletta, and Klingbeil (2013) also demonstrated how an educational intervention could improve the RNs’ abilities to provide appropriate discharge teaching to parents using the teach-back method. The study was based on evidence that higher quality discharge teaching by RNs can improve discharge readiness and promote a safe transition from hospital to home. The participating RNs (n = 58) were surveyed before the 20-minute educational session and 1 month after. Postsurvey results indicated there was a 36.2% increase in nurses' understanding of the “teach-back” method. In addition, usage of the teach-back method increased by 41.7%, indicating a positive change in practice after the education intervention. Clinical significance was established by the RNs’ increased knowledge and practice with the teach-back method after the education session. Similarly, in a pre–post cohort intervention study, Kwah, Whiteman, Grunfeld, Niccolls, and Wood (2017) demonstrated how an educational intervention increased RNs’ knowledge and confidence regarding support for breastfeeding, kangaroo care (parents holding baby skin to skin), and positive touch in the NICU. These activities are key components of the second tenet of FCC—participation. They increase bonding, which is difficult but critical to establish in the NICU.
In another study, Kwah et al. (2017) addressed NICU RNs’ poor understanding and implementation of evidence-based practices that support breastfeeding, kangaroo care, and positive touch through a workshop to increase knowledge and confidence in the NICU RNs. They used the Neonatal Unit Assessment Tool before and after the educational intervention to assess the effectiveness of the intervention. Forty-seven clinicians from two different NICUs completed the Neonatal Unit Assessment Tool. Knowledge gain was assessed using this 36-question multiple-choice test preintervention and postintervention, and results showed an increase in nurses' clinical knowledge and confidence after the intervention. Knowledge regarding breastfeeding, kangaroo care, and positive touch increased from the preintervention scores (M = 26.60, SD = 3.2) to the postintervention (M = 28.66, SD = 0.03), t(46) = 4.61, p = .05. Clinical significance surfaced in subsequent interviews, as 18 of the RNs attributed “individual and unit-wide change in practice to an increase in knowledge and confidence” as an outcome of the intervention (Kwah et al., 2017, p. 1). This study demonstrated the relevance of increasing nursing knowledge, which builds confidence and enables nurses to support parents' involvement in their infant's care.
Another study regarding kangaroo care demonstrated the positive effects education had on NICU RNs' knowledge and confidence. Kangaroo care supports bonding and is one aspect of FCC that promotes discharge readiness. Almutairi and Ludington-Hoe (2016) addressed the diminished nursing practice of kangaroo care in the NICU due to inadequate formal training and a knowledge deficit. They conducted a pretest–posttest quasi-experiment to determine the effects of a 2.5-day course on kangaroo care on the RNs’ knowledge and skills confidence. The two-tailed paired samples t test demonstrated that the change in mean score for knowledge was statistically significant, t(54) = −9.1, p = .00, in 18 of the 20 knowledge questions following the course. This improvement demonstrated that “continuing education is needed for nurses to remain current with the evidence and that experienced nurses can gain many knowledge benefits when able to attend a concentrated course” (Almutairi & Ludington-Hoe, 2016, p. 521).
Overall, the reviewed literature yielded information on how an identified evidence-based practice intervention could be used to address clinical deficiencies in practice settings. Evidence supported an educational intervention to address nurse knowledge gaps regarding specific clinical practices related to FCC and discharge preparation. A well-planned educational intervention to address nurse knowledge deficit regarding integration of FCC into practice could increase nurses' knowledge and positively affect patient outcomes.
A quality improvement (QI) project was implemented to address the identified problem of inadequate family discharge readiness at the facility. The intended outcomes of the QI project were to increase NICU RNs’ knowledge of FCC practices and to empower them to integrate FCC principles into their daily patient care practices. The facility's institutional review board granted approval for this project.
The QI project was conducted over 8 weeks and was designed for RNs who worked in the NICU. The project manager developed a self-designed knowledge test based on FCC concepts for the purposes of the QI project. Content validity of the knowledge test was established through expert opinion from various healthcare providers who had experience with FCC and the NICU discharge process. External experts included a clinical nurse specialist and FCC book author from a large medical center and a patient resource nurse who managed the Family Integrated Care program at a large hospital in Canada. Internally, experts from the NICU included the chief medical director, the unit managers, the programmatic nurse educator, and the manager of training and education. Data collection followed a pretest/posttest/retention test design to allow for evaluation of changes in the mean scores of RNs’ knowledge. Data analysis was completed using the Data Analysis Tool in Microsoft Excel 2016. To determine clinical significance related to knowledge increase, a benchmark of at least a 10% gain in aggregate mean scores from the pretest to posttest was selected. A one-tailed paired samples t test was used to determine statistical significance in the change of mean scores from the pretest to the posttest using p < .05. A single-factor analysis of variance was performed to determine statistical significance in the change of mean scores from the posttest to the retention test also using p < .05. A benchmark of no greater than a 10% reduction in aggregate mean scores from the posttest was set to demonstrate clinical significance related to knowledge retained.
The intervention for the QI project consisted of a 30-minute educational session. Facility leadership mandated attendance at the educational sessions for all NICU RNs (n = 180) and offered 0.5 continuing education contact hours for the session. Completion of the knowledge test (at the three time points) was considered voluntary for participants. Various pedagogical methods were incorporated into the delivery of the educational sessions, led by the project manager and supported by NPD educators. A brief PowerPoint presentation was included to support lecture bursts that addressed the central tenets of FCC, methods of integrating FCC into daily practice, barriers and means of overcoming barriers, and the impact of FCC on parental perception of discharge readiness. Narrative pedagogy was used at the beginning of the presentation to elicit emotional interest in the presentation information and to encourage reflection on professional practice regarding the impact FCC can have on patient outcomes. The presentation content included a differentiation between understanding the principles of FCC and integrating them and the effect the integration has on discharge readiness for parents and families. Barriers to FCC integration were addressed, and the nurses were encouraged to discuss obstacles with the project manager during mentoring on the unit. The presentation concluded with case exemplars that the RNs could encounter when implementing FCC. The exemplars led to open discussion about specific concerns the nurses anticipated and allowed for clarification and addressing of concerns.
QI PROJECT IMPLEMENTATION
Throughout the first 4 weeks, the project team offered multiple educational sessions to meet the needs of the NICU RNs. The NICU RNs voluntarily completed the pretests before the session (n = 159) and the posttest immediately following the education (n = 61). The educational content was converted to an online version with access through the facility's learning management system for RNs unable to attend an education session during the QI project implementation phase. The second 4 weeks were used for mentoring nurses (by the project manager) on the unit to reinforce FCC information from the education sessions. The retention test was e-mailed to all NICU RNs 4 weeks after the education session.
Posters were displayed on the unit to reinforce knowledge gained from the presentation. During mentoring on the unit, the project manager offered RNs an infographic card and a small charm with infant footprints to put on their identification badge as a reminder of the importance of implementing FCC. The information on the card was a reference for the RNs as they incorporated FCC principles into their practice. These mentoring activities promoted discussion regarding issues encountered while practicing the FCC principles learned in the education session. Practical application of FCC often resulted in situation-specific questions and concerns, which the RN could discuss with the project manager. This also afforded an opportunity to provide evidence-based practice literature specific to the RNs’ individual questions and concerns.
A total of 159 NICU RNs voluntarily completed both the pre- and post-knowledge test (88% response rate). The RNs ranged in age from 21 to 61 years (M = 31.33). Years of nursing experience ranged from 0.5 to 30 years (M = 7.28; 41% < 3 years). The average number of years of NICU experience was 5.7, and 52.8% of the RNs had been there for less than 3 years. Most of the participating RNs (n = 120, 77.3%) worked in the NICU their entire nursing careers. The participants' educational background ranged widely; associate degree was 23.9% (n = 38), bachelor of science in nursing degree was 65.4% (n = 104), 10% (n = 16) had a master of science in nursing degree, and 0.01% (n = 1) had a doctor of nursing practice degree.
To determine knowledge gained, pretest and posttest aggregate scores were compared. The pretest mean score was 8.15 (n = 159, range: 0–10, SD = 1.23). The posttest mean score was 9.97 (n = 61, range: 8–10, SD = 0.21). A one-tailed paired samples t test determined the change in means was statistically significant (t = −18.5, df = 158, p = .00). Furthermore, the data were compared to the benchmark of at least a 10% increase in scores from the pretest to the posttest to determine clinical significance. Findings revealed a 21.7% increase; thus, the benchmark was exceeded. The findings suggested the 30-minute educational session helped to increase the NICU RNs’ knowledge of FCC practices in this project.
A total of 65 NICU RNs (41% response rate) completed the retention test. The aggregate mean from the retention test (M = 9.62, SD = 0.82) was compared to the aggregate mean from the posttest (M = 9.97, SD = 0.21). A single-factor analysis of variance determined the change in means was statistically significant, F(1, 222) = 25.44, F crit = 3.88, p < .00. Furthermore, the data were compared to the benchmark of no greater than a 10% reduction in aggregate mean scores from the posttest. The benchmark was met, as the percentage change in mean scores from the posttest to the retention test was −3.5%. The findings suggested knowledge retention was supported by the educational session and 4 weeks of mentoring. Both approaches may have empowered the RNs to integrate FCC principles into their daily patient care practices, which resulted in continued reflection on practice that allowed for knowledge to be retained.
IMPLICATIONS FOR NPD PRACTITIONERS
NICU RNs need to understand FCC principles like partnering with parents to encourage participation in the infant's care. Evidence demonstrates FCC should be a standard practice in the NICU, but RNs must be knowledgeable about and supported in the application of the principles in order to promote parental perception of discharge readiness effectively (Aagaard, Uhrenfeldt, Ludvigsen, & Fergran, 2015; Adama et al., 2016; American Academy of Pediatrics, 2012; Trajkovski et al., 2016). The findings from the QI project demonstrated an increase in NICU RN knowledge after an educational session and 4 weeks of mentoring regarding FCC. The knowledge was retained as evidenced by a minimal decline in survey scores 4 weeks after the intervention. Based on these findings, NPD specialists should consider implementing FCC education and mentoring in orientation programs and yearly competency training for all NICU RNs. Incorporating the strategies may lead to a unit culture change and improved patient and family outcomes.
The pedagogical approaches used in this QI project (lecture bursts, narrative pedagogy, and case exemplars) could serve as a useful framework that can be mirrored by NPD practitioners. In addition, the need to be flexible with educational delivery methods is an important consideration. As modeled in this QI project, although faculty attended the session during work hours, the offering of an online version helped meet the professional role demands of the NICU RNs and lessened the burden of pulling staff away from the units.
Mentoring was an additional strategy used for this QI project and one that NPD practitioners may consider incorporating when facilitating a change in practice. Findings from this QI project suggest having access to a resource person following education allowed for the reinforcement of knowledge. It is plausible that NICU RNs become empowered to integrate FCC into their daily practices by applying knowledge gained in a supportive learning environment. The cyclical pattern of reflecting on professional practice and implementing new knowledge learned in a supportive environment led to retention and a sustainable change in professional practice.
A limitation of this QI project was the time constraint. The implementation timeline of 8 weeks did not afford the opportunity to assess knowledge retention later than 4 weeks postintervention. Also, a longer time frame would have provided the opportunity to compare Press Ganey scores to assess the effectiveness of FCC practices on parents' perception of discharge readiness.
Family-centered discharge preparation improves parental confidence through bonding and hands-on skills acquisition, which empowers parents to transition to home successfully. Findings from this QI project reflect that education and mentoring supported NICU RNs’ knowledge gain and retention in FCC practices. Having a supportive environment to apply knowledge gained may empower NICU RNs to reflect on professional practice and make sustainable changes in practices. Armed with the knowledge and understanding of FCC principles, NICU RNs are in a prime position to promote parental perception of discharge readiness.
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