Prevention of neurodevelopmental sequelae is a high priority in the care of infants with congenital heart defects. Individualized family-centered developmental care has been identified as a promising approach to promote infant neurodevelopment during hospitalization.
To educate nurses on the concept of individualized family-centered developmental care and its application to nursing practice and to reduce perceived barriers to its implementation.
Two evidence-based visual educational tools called “developmental care flowers” were created and implemented in the inpatient and procedural units of a cardiac center. Each flower petal represented a core component of individualized family-centered developmental care: cue-based care, patient positioning, supportive environment, and parent engagement. Surveys were administered before and after the educational intervention to assess changes in nurses’ knowledge and perceptions of individualized family-centered developmental care.
Nurses reported that the developmental care flowers improved their understanding of individualized family-centered developmental care. The educational tools reduced some perceived barriers to implementation of this care model and increased nurse-reported inclusion of parents in care. Qualitative feedback from staff members regarding the tools was positive and acknowledged that individualized family-centered developmental care should be an ongoing priority.
The inpatient and procedural developmental care flowers are useful tools for educating nurses about individualized family-centered developmental care. They could be revised into more interactive tools that might be used to educate parents and further support the integration of this care concept into nursing practice.
Infants born with congenital heart disease (CHD) are living longer owing to medical and surgical advances that have dramatically reduced mortality rates.1 As infant survival has increased, so too has the recognition of neurodevelopmental sequelae of CHD. One possible factor in adverse neurological outcomes is the stressful hospital environment.2-4 Exposure to repeated stressful and noxious stimuli in early life may alter brain development, resulting in abnormal neurological changes and behavior.5-8
Individualized family-centered developmental care (IFDC) is well established as the standard of care for infants in neonatal intensive care to reduce early life exposure to stress and improve neurodevelopmental outcomes.9-12 Some of the outcomes that have been reported as a result of developmental care in premature infants include decreased hospital length of stay, improved weight gain, enhanced cognitive performance, and better psychomotor functioning.13 The IFDC model of care consists of a broad category of interventions intended to decrease stressors associated with hospitalization, ultimately promoting behavioral organization of the infant. Lisanti and colleagues4 recently proposed use of the model for infants with CHD.
The IFDC model has 3 core components: cue-based care, parent engagement, and the provision of a supportive environment.
Despite recognition of the importance of IFDC, specific methods used to implement the care framework into practice in the pediatric cardiac population remain variable.14 This lack of consistency demonstrates a need for further education and culture change throughout pediatric cardiac nursing. One factor contributing to the variability may be the multifactorial nature of IFDC. The model is described as having 3 core components: cue-based care, parent engagement, and the provision of a supportive environment.4 Teaching nurses about these specific components of IFDC may help them understand the framework and its applicability to everyday nursing practice.
To promote education on IFDC and its implementation in our cardiac center, a committee of nurses was formed across the center’s departments and units, including members from the inpatient units (cardiac intensive care unit, cardiac step-down unit, and short procedure unit) and procedural units (cardiac catheterization laboratory and cardiac operating room). Evaluation of current staff education at the time revealed that nurses did not receive formal education specific to IFDC during onboarding or as part of continuing education. Education did occur informally through “teaching moments” between nurse peers and nursing leaders but was limited to the inpatient units. The aim of this clinical education project was to use a visual educational tool to (1) increase nurses’ self-reported knowledge of IFDC and (2) decrease nurses’ perception of barriers to IFDC.
Creation of Educational Tools
The committee of interdepartmental nurses from the inpatient and procedural units created 2 visual educational tools on IFDC for the inpatient and procedural units in the cardiac center, calling them the “developmental care flowers” (DCFs; Figures 1 and 2). Development of content for these evidence-based tools was based on synthesis of the literature and consultation with an interdisciplinary team of developmental care specialists at our institution, including those in the areas of rehabilitation therapy, speech-language pathology, pediatric psychology, lactation, and child life therapy. The tools were designed in the shape of flowers, with each petal representing a core component of IFDC. “Patient positioning” was included as a separate petal to specify developmentally appropriate positions for infants requiring cardiac surgery. The visual tool was a laminated page with the front side displaying the flower and the back side displaying a table with more detailed guidelines and resources regarding the components listed on the flower petals.
Different teaching methods were used across the various units (inpatient versus procedural) based on the unit structure and staff size. Procedural areas were inherently smaller; therefore, education on the DCFs was provided primarily through one-on-one teaching and nursing staff huddles, with 100% of staff receiving education. Given the larger nursing staffs in the inpatient units and the rotating nature of flex or float pool staff in inpatient units but not in the procedural areas, it was challenging to ensure that all inpatient nursing staff received one-on-one education. To address this problem, education was provided during before-shift staff huddles with all oncoming inpatient nursing staff members, as well as bedside rounding with members of the DCF committee, and the DCFs were widely displayed throughout the unit and at infants’ bedsides. The DCFs were designed so that nurses could read the contents and learn independently. All education, whether one-on-one or staff huddles, directed nurses to review the content displayed on both the inpatient and procedural DCFs.
Preintervention and Postintervention Surveys
Surveys were administered before and after the educational intervention to assess nurses’ self-reported knowledge and perceptions of IFDC. The surveys were adapted from a questionnaire used to assess current practice of developmental care in North American institutions15 and were created through Google Surveys, with a link to the survey emailed to the entire nursing staff. Procedural area nurses were given a shortened version of the survey because some of the specific developmental care practices were not applicable to that care setting (eg, parent participation in care, holding, and other nonpharmacological comfort interventions). Because this clinical education project evaluated a local education initiative without generating generalizable knowledge, our institution did not require institutional review board oversight. Responding inpatient nurses and procedural area nurses who completed the survey before the intervention provided the baseline data. The educational intervention was performed for 5 months before distribution of the second survey to allow for adequate capture of data from both procedural and inpatient nursing staff. The educational intervention took longer than expected owing to periods of increased acuity in the inpatient units. Because surveys were administered anonymously and not linked before and after the intervention, it is not known whether individual nurses completed both preintervention and postintervention surveys. Two email reminders were sent out for both surveys to maximize nurse participation.
Survey responses were totaled by frequencies and percentages, stratified by inpatient and procedural nurse respondents. For survey questions with a 5-item Likert scale, responses of “disagree” and “strongly disagree,” as well as “agree” and “strongly agree,” were collapsed into a single category. Data were analyzed using χ2 and Fisher exact tests, as appropriate, to compare responses between the surveys administered before and after the educational intervention. The level of statistical significance was set at P < .05.
A sample of 44 inpatient and 9 procedural area nurses completed the preintervention survey, with response rates of 15% (of 290 total inpatient nurses) and 22% (of 40 total procedural area nurses), respectively. A total of 64 inpatient nurses and 16 procedural area nurses completed the postintervention survey, with response rates of 22% and 40%, respectively. Approximately half of the inpatient nurses had 5 years of experience or less, and the vast majority (>90%) were female and younger than 50 years of age. Over three-quarters of the procedural nurses were female, had more than 5 years of experience, and were over 40 years of age. In both inpatient and procedural areas, respondents did not differ significantly between the 2 surveys on the basis of sex, age, or years of experience.
Qualitative feedback about the developmental care flowers from nurses in both inpatient and procedural settings was overwhelmingly positive.
Postintervention survey results demonstrated that 41% of inpatient nurses and 81% of procedural nurses reported that implementation of the DCFs improved their understanding of appropriate infant developmental care. In addition, 39% of inpatient nurses and 87% of procedural nurses reported that the DCFs helped them integrate specific developmental care interventions into the care of infants in the cardiac center.
Many self-reported perceptions and beliefs about IFDC practices by inpatient and procedural nurses, such as the value of developmental care rounds or offering skin-to-skin holding, did not change significantly from before to after the intervention (Table 1). After implementation of the DCFs, inpatient nurses did report a decrease in the perception of barriers related to concerns about catheter or tube dislodgment (P = .02; Table 2). The procedural area nurses reported a significant decrease in barriers, including the need for more education on IFDC (P < .003) and the lack of IFDC experts to mentor staff (P < .04). More than two-thirds of inpatient nurses consistently reported often or always supporting clustering care, proper positioning, nonnutritive sucking, holding, and regulating light and sound; however, regulated screen time, skin-to-skin holding, and incubator use for premature infants were reported by less than half of respondents in both preintervention and postintervention surveys (Table 3). Significant improvements were found in the following nurse-reported practices: allowing parents to be present for procedures (P < .01) and allowing parents to both read and respond to infant behavioral and feeding cues (P = .03; Table 4).
Qualitative feedback about the DCFs from nurses in both inpatient (94% of respondents) and procedural (75% of respondents) settings was overwhelmingly positive, and some respondents offered suggestions for next steps in education and implementation of IFDC (Table 5). Themes that emerged from feedback included the use of repetition to support learning IFDC concepts, individualizing the DCFs for interactive use at the bedside, and continuing to make IFDC an educational priority.
The inpatient and procedural DCFs were helpful in providing nursing education on IFDC in a cardiac center. The results indicated a stronger influence of the DCFs on nursing understanding and integration of IFDC into practice in the procedural units than in the inpatient units. Differences in responses between the inpatient and procedural units may be due in part to the novelty of bringing IFDC practice to procedural areas. Our critical care and step-down units have previously been educated about developmental care,2,16 whereas the procedural units have historically not been the focus of any such education. The new initiative for the procedural areas may have created more overall interest and positive response to the educational tools. Additionally, in our cardiac center the procedural areas have a much smaller staff, giving them greater opportunities for one-on-one education and allowing the core group of staff to focus on the initiative together. Other centers have reported increased effectiveness of staff nurse education when using smaller target groups.17,18 Finally, the interdepartmental collaboration demonstrated in this project among nurses from critical care, step-down, operating room, catheterization laboratory, and recovery units provided an important example of the teamwork that is needed to promote change across a cardiac center.
Implementation of the DCFs successfully decreased some nurse-reported perceived barriers to IFDC. Nurses working in procedural areas perceived fewer barriers to IFDC specific to lack of education and lack of mentors. Inpatient unit nurses reported less perceived concern about catheter or tube dislodgment. One perceived barrier that was noted by staff to consistently inhibit IFDC was high patient acuity. Although this factor may limit nurses’ ability to implement some developmental care practices, further education may illuminate other aspects of IFDC that are still feasible despite patient acuity and increase nurses’ comfort with such practices.15
Although the DCFs were successful in increasing knowledge of IFDC, they were not sufficiently interactive to result in significant changes to nurse-reported developmental care practices. Variation in such practices was found for many aspects of IFDC, as has been described previously.15 Future outreach may use in-service training modalities to improve competency and teamwork among nursing staff in order to practice and review IFDC concepts before implementation at the bedside.19 Other methods should include addressing determinants of successful implementation of IFDC, such as linking specific educational strategies to nurses’ attitudes, knowledge, routines, and current resources.20
Implications for Practice
Individualized family-centered developmental care should continue to be a high priority in the pediatric cardiac population. Hospitalized infants with CHD can benefit from this model of care, which may be introduced by nurses and disseminated to the entire interdisciplinary team. The DCFs may be particularly helpful in introducing the concepts of IFDC to cardiac centers that have not begun formal education or practice initiatives to incorporate IFDC into standard care. Although the DCFs helped improve nurse-reported knowledge of some IFDC practices, future work should focus on improving the consistency of integrating IFDC interventions into daily nursing practice. To facilitate adoption of IFDC practices, nurses can elect unit-based developmental care champions or experts who can promote the use of the DCFs and encourage interaction with the tool through bedside rounding. Future work can also include making the DCFs more interactive and individualized for specific patients, allowing parents as well as nurses to identify individualized developmental care needs. Although the DCFs did not target parent education, tailoring them to support parental understanding of IFDC should be considered as well.
This clinical educational project relied on self-report of nurses to determine the acceptance of a visual educational tool and did not measure actual nursing knowledge or bedside practice of IFDC. Additionally, both surveys had relatively low response rates, but the rate was higher for the postintervention survey, possibly indicating survey respondent bias that could have affected the results. Because the procedural areas have a much smaller staff, the sample size for the procedural areas was small. Therefore, results should be interpreted with caution. The surveys were administered anonymously, making individual linking of preintervention and postintervention responses impossible. Potential overlap and nonindependence between the 2 samples may have affected the results. Finally, the results are limited by the lack of information on the number of nurses in the inpatient units who received education using the DCFs. Despite our best attempts to use multiple methods to inform inpatient nurses about the DCFs, some nurses might have missed the education, affecting the postintervention survey results.
To facilitate adoption of IFDC practices, nurses can elect unit-based developmental care champions who can promote the use of the DCFs and encourage interaction with the tool through bedside rounding.
Individualized family-centered developmental care is a promising model of care to improve neurodevelopmental outcomes of infants with CHD. Nurses are well positioned to lead the education and practice of IFDC, guiding the interdisciplinary team and parents of hospitalized infants with CHD. The inpatient and procedural DCFs are useful tools to provide education on nurse-driven, family-centered, and developmentally supportive interventions for infants in a pediatric cardiac center. Future work is needed to promote optimal implementation of IFDC, including ensuring that the entire interdisciplinary care team is educated on IFDC practices, reducing barriers to these practices, and educating parents on the benefits of this framework of developmental care.
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This work was supported by the Cardiac Center Research Core at Children’s Hospital of Philadelphia. Dr Lisanti was also supported by National Institute of Nursing Research grant T32NR007100.
To learn more about family-centered care, read “Implementing Intensive Care Unit Family-Centered Care: Resources to Identify and Address Gaps” by Hwang et al in AACN Advanced Critical Care, 2017;28(2):148-154. Available at www.aacnacconline.org.