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Newborn & Infant Nursing Reviews xxx (2015) xxx–xxx

YNBIN-50627; No of Pages 5

Contents lists available at ScienceDirect

Newborn & Infant Nursing Reviews

j ourna l homepage: www.na in r .com

The Sobreviver (Survive) Project

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Mary Coughlin, RN, MS, NNP⁎Caring Essentials Collaborative, LLC, 391 Ashmont Street, Boston, MA 02124, USA

a b s t r a c ta r t i c l e i n f o

⁎ Tel.: +1 617 532 0794, +1 617 291 4623 (mobile).E-mail address: mec@caringessentials.org.

http://dx.doi.org/10.1053/j.nainr.2015.09.0101527-3369/© 2015 Published by Elsevier Inc.

Please cite this article as: Coughlin M. The Sj.nainr.2015.09.010

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Keywords: 12

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Parental stressNICUNeonatal researchInternational

OA neonatal intensive care unit (NICU) stay can be stressful for parents and their infants. The Sobreviver Projectdescribed in this paperwas a project funded by the EuropeanUnion to attempt to ease parental stress. This articlewill describe the interventions used in three NICUs in Portugal and the outcomes of this project.

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obreviver (Survive) Project. Newborn & Infant

© 2015 Published by Elsevier Inc.

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Background and Purpose

In March, 2014 XXS – Associação Portuguesa de Apoio ao BebéPrematuro – (Portuguese Parents of Premature Babies Organization)launched C.A.R.E. (Cuidados de Apoio a Recém-nascidos Em Risco), aEuropean Union funded project whose main objective was to improvethe experience of care for premature infants and their parents in theneonatal intensive care unit (NICU) in Portugal. This national, multi-pronged project included prematurity prevention and awareness cam-paigns, NICU parent training and parenting skills building workshops,NICU parent–clinician partnerships as well as the development and im-plementation of specialized pilot projects focused on integrating, stan-dardizing, and sustaining developmentally supportive care principlesand practices in neonatal intensive care units across the country. TheSobreviver (translated: survive) pilot project focused on standardizingthe practice of kangaroo mother care (KMC) in three NICUs in Portugal.

The 2014 Cochrane Review on KMC concluded that when comparedto conventional neonatal care, KMCwas found to reduce overallmortality,decrease the incidence of severe infections as well as nosocomial infec-tion, decrease hypothermia, severe illness, lower respiratory tract disease,and the length of hospital stay.1 In addition, kangaroo carewas associatedwith increasedweight gain, head circumference and length.1 A 2015 ran-domized controlled trial by Filho et al.2 suggests that skin-to-skin caremight be an effective and safe method for promoting decolonization ofsmall for gestational age newborns nostrils colonized bymethicillin resis-tant Staphylococcus aureus (MRSA)/methicillin resistant Staphylococcusepidermis (MRSE) (p=0.007). Korraa et al.3 demonstrated that kangaroomother care improves cerebral blood flow in preterm infants (p b 0.05)and Johnston et al.4 concluded that skin-to-skin care is safe and effectivein managing procedural pain in neonates.

Despite the ever growing body of evidence highlighting the benefitsand safety of kangaroo care in the neonatal intensive care unit there re-mains a high degree of variability and inconsistency in practice, not only

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between NICUs but also within the same NICU. Several factors havebeen implicated in this inconsistency to include: (1) a lack of clear prac-tice guidelines to include eligibility criteria, (2) insufficient competencybased education and performance expectations of staff and parents,(4) a paucity of consistent documentation criteria, and (5) a dearth ofindividual and systems accountability for the provision of evidence-based practice.

Facilitating practice change for quality improvement requires athoughtful and systematic approach. In most instances, clinicians arenot opposed to the adoption of evidence-based best practice but strugglewith how to integrate the practice consistently, reliably and safely into analready busy workflow. That being said, nurses' attitudes about skin-to-skin care play an intangible but key role in promoting and facilitating kan-garoo care experiences in the NICU.5 A meta-ethnography from Vittneret al.6 looking at skin-to-skin holding from the clinician's perspectivehighlights the clinician's real-time challenges in the provision of kangaroomother care. The varying thresholds for initiation of skin-to-skin carecombined with the availability of adequate or appropriate resources andfurther complicated by workflow challenges, patient acuity and parentalreadiness converge to create this chaos and inconsistency.

The primary aimof this pilot projectwas to increase the frequency ofkangaroo care experiences in three tertiary care neonatal intensive careunits in Portugal (Centro Materno-Infantil do Norte do CentroHospitalar do Porto [CMIN-CHP], Hospital de Sao Francisco Xavier[HSFX], Lisbon and Maternidade Dr. Alfredo da Costa [MAC], Lisbon).

Budget/Resources

Funds from the C.A.R.E. project supported the education, training,coaching and project management for the Sobreviver pilot evaluation.Nurtured by Design™ (a U.S. based company who manufactures posi-tioning supports for the NICU patient population) donated 50 KangarooZaks™, an innovative device ergonomically designed to facilitate safe,prolonged, and effective kangaroo mother care sessions in the NICUand the post-partum ward. These devices were distributed betweenthe three NICUs to standardize the practice and process for kangaroo

Nursing Reviews (2015), http://dx.doi.org/10.1053/

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t1:1 Table 1t1:2 Sample failure modes and effects analysis (FMEA) table.

t1:3 Processt1:4 step

Potentialfailuremode

Potentialfailureeffect

Severity (1–10) Potentialcauses

Occurrence(1–10)

Current processcontrols

Detection(1–10)

Risk priorityscore

Action plan

t1:5 What ist1:6 the step?

In whatway canthe stepgo wrong

What is theimpact to thepatient iffailure modeis notcorrected?

How severe isthe effect to thepatient (higher# = highereffect)

Whatcausesthe stepto gowrong?

How frequentlydoes thishappen? (higher# = higherfrequency)

What are theexisting controlsto prevent/detect thefailure mode?

How probable isthe detection?(higher# = higherdetection rate)

Calculated asseverity × occurrence× detection (higher# = higher priority)

What actions stepswill be taken toresolve failures?

t1:7 Identifyingt1:8 whicht1:9 infants cant1:10 safelyt1:11 participatet1:12 in SSC

Noguidelines

Infants whomay beeligible aredenied accessto this EBP

10 Noguidelines

10 None 10 1000 Develop a practiceguideline with eligibilitycriteria. Review eligibilitycriteria daily with eachinfant–parent dyad andhealthcare team

Fig. 1. Evidence based practice model.

2 M. Coughlin / Newborn & Infant Nursing Reviews xxx (2015) xxx–xxx

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mother careduring thepilot project. The availability of safe andcomfortableseating to facilitate the kangaroo mother care experiences was variablewithin and between each unit and was identified as a limiting factorin promoting kangaroo mother care, however the safety features ofthe Kangaroo Zak™ appeared to mitigate some of these concerns.

Methodology

An initial failure modes and effects analysis (FMEA) was performed(Table 1).7 The selected process for evaluationwas the current kangaroomother care practice at each site. Amultidisciplinary teamwas recruitedat each site to review their current practice and identify failure modesthat undermined the standardization of kangaroo mother care practicein their unit and prioritize each failure mode. Once completed, eachteam then outlined an improvement action plan in collaboration withthe consultant and, using the Plan-Do-Study-Act (P-D-S-A)methodology,began the practice improvement work.

Benchmark data were collected regarding staff and parent's knowl-edge, perceptions, and experience with kangaroo mother care. Staffand parents were re-surveyed at three and six months following theproject start date. In addition, documentation frequency and qualitywere benchmarked and trended over the project period.

Intervention

The identified failure modes included a lack of knowledge, skill andconfidence for both staff and parents in the provision of safe and reliableskin-to-skin or KMC care as well as poorly defined practice guidelinesand documentation criteria. The initial intervention focused on address-ing the perceived knowledge gap. All direct caregivers attended a 4-hourinteractive learning session presenting the neurobiological and psycho-socio-emotional needs of the developing human framed by the currentresearch on the effects of traumatic stress and early life adversity. Kanga-roo mother care represented the comprehensive evidence-basedbest practice in meeting the needs of the hospitalized infant andoperationalizing a trauma-informed approach to care in the NICU.8

Following the education intervention, the consultant met with eachunit's project champion team. Each unit was given the autonomy to se-lect champion teammembers and consequently team composition var-ied between the three units. The overarching objectives for each unitwere established: (a) develop a kangaroo mother care or skin-to-skinpractice guideline with clear eligibility criteria, (b) establish a cliniciancompetency for the seated and standing infant transfer for kangaroomother care (emphasizing the benefits of the standing transfer overthe seated transfer for the infants physiologic stability), (c) establishand implement a process for educating NICU parents on the benefitsof kangaroo mother care as well as including a return demonstrationcompetency for each parent with the infant transfer, and finally,(d) standardize the documentation for kangaroo mother care

Please cite this article as: Coughlin M. The Sobreviver (Survive) Project. Nj.nainr.2015.09.010

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Oexperiences to include a start and stop time for each kangaroo mothercare session.

Practice Guideline Development

Each champion teamand unit leadershipwere given samples of kan-garoo mother care practice guidelines, policies, and protocols (for bothintubated and non-intubated infants) as well as several key review arti-cles to support and guide each team's development of a kangaroomoth-er care practice guideline with eligibility criteria that reflected anevidence-based framework (Fig. 1).9–11

The implementation of the new practice guideline coincided witheach unit's successful completion of staff and parent competencybased training with the infant transfer as well as drafting a documenta-tion strategy. All staff at each facility were educated on the practiceguideline as part of the competency based education.

Competency Based Education

A competency checklistwas developed for both staff and parents (allteachingmaterials were translated into Portuguese and all teaching ses-sions for parents were taught in Portuguese; staff education was a com-bination of English and Portuguesewith translations as necessary). Bothstaff and parents were required to do a return demonstration of amockup infant transfer using both the seated and standing transfer

ewborn & Infant Nursing Reviews (2015), http://dx.doi.org/10.1053/

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Fig. 2. Infant transfer method (sentada = seated; pe = standing).

3M. Coughlin / Newborn & Infant Nursing Reviews xxx (2015) xxx–xxx

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methods. The Kangaroo Zak™ device was part of the competency andfacilitated an overwhelming acknowledgment and general adoption ofthe standing transfer as the preferred transfer method following thecompetency training (p = 0.0001) (Figs. 2–4).

Documentation Criteria

The staff education sessions emphasized a dose-dependent effect ofkangaroomother care on the infant–parent dyad. This information faci-litated a better understanding of the documentation criteria for kanga-roo mother care. Each unit transitioned from a simple check markstyle of documentation to a more complete record of the kangaroomother care session. Two of the units utilize electronic documentationwhich integrates the International Classification for Nursing Practice(ICNP®) while the other unit uses a paper documentation system(with a plan to transition to electronic documentation within the next12 months). All three units were able to integrate the minimum docu-mentation requirements (start and stop times for each kangaroomothercare session). In addition to recording each kangaroo care session, eachunit integrated a ‘standing order’ for convalescing infants to participatein kangaroo mother care and for infants who continued to require

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Fig. 3.Mockup for the infant transfer.

Please cite this article as: Coughlin M. The Sobreviver (Survive) Project.j.nainr.2015.09.010

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ROintensive care, their eligibility was discussed daily on rounds and a kan-

garoo sticker was affixed to the incubator as an infantwas deemed eligi-ble to experience kangaroo mother care.

Results

Staff and parent surveys regarding kangaroo mother care knowl-edge, practice, and experience were collected at three distinct timepoints: at baseline (September 2014), three months (February 2015)and six months (May 2015) following the education and process inter-ventions. Statistical analysis was completed at the unit and project levelfor both staff and parent surveys. Survey results demonstrated a statis-tically significant improvement in practice, knowledge, and competenceover the pilot project period (Fig. 5).

The statistical significance of the staff survey outcomes reflects the im-portance of integrating a systematic approach to practice improvement.The staff survey responses revealed a solid baseline staff knowledge onthe benefits of kangaroo mother care however, this knowledge did notseem to impact practice (which was quantified by the frequency inwhich kangaroo mother care sessions were documented in the medicalrecord at baseline). However, when reviewing staff responses regarding

Fig. 4. Parent participating in the kangaroo care competency based training session.

Newborn & Infant Nursing Reviews (2015), http://dx.doi.org/10.1053/

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Fig. 5. Kangaroo care.

4 M. Coughlin / Newborn & Infant Nursing Reviews xxx (2015) xxx–xxx

obstacles to providing kangaroo mother care, it becomes clear that prac-tice was significantly impacted when each unit developed a protocol forkangaroo mother care with clear eligibility criteria (Fig. 6).

In addition, integrating a competency for the infant transfer also con-tributed to the increase frequency of kangaroo mother care experiences.As staff gained confidence and competence in the infant transfer therewas a significant increase in the frequency of kangaroo mother care

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Fig. 6. Obstacles to providing kangaroo care (the lo

Fig. 7. Staff co

Please cite this article as: Coughlin M. The Sobreviver (Survive) Project. Nj.nainr.2015.09.010

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sessions documented and also parent perceptions of an increase frequen-cy in their experience of kangaroo mother care (Figs. 7 and 8).

An interesting and exciting improvementwas the increase in kanga-roomother care experienceswith the infant's father. Sharing this crucialparenting activity with bothmothers and fathers validates parental roleidentity and increases confidence and competence in parenting (Fig. 9).

Parent survey results indicate that the staff at each facility had signif-icantly improved their practices and processes to educate parents aboutkangaroo mother care. This was achieved in partnership with the XXSorganization (the national neonatal parent organization of Portugal)who provided local former NICU parents to partner with the NICUstaff in designing and presenting the parent education sessions. In addi-tion, XXS provided parent education pamphlets that highlight thebenefits of kangaroo mother care in the NICU. Ensuring that all parentsare well informed about the evidence-based benefits of kangaroomother care empowers the parent to advocate for these experienceswith their infants during their NICU stay (Fig. 10).

Documentation has improved significantly at each site and two ofthe three units are now utilizing kangaroo mother care as a non-pharmacologic intervention for certain medical procedures and aremonitoring andmeasuring the impact of this evidence-based intervention.

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RImplications for Practice

Education and knowledge about evidence-based practice is notenough to ensure adoption— process is critical, but so is buy-in and en-gagement. There were varying degrees of active support and willingparticipation in this pilot project from physicians and nursing leader-ship. This is of significant concernwhen setting expectations for sustain-ability of the practice improvements made during the pilot period. In

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wer the number = major barrier to practice).

nfidence.

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Fig. 8. How many times parents were provided kangaroo care experiences (Nunca = never; todos os dias = always).

Fig. 9. Frequency that kangaroo mother care was facilitated.

5M. Coughlin / Newborn & Infant Nursing Reviews xxx (2015) xxx–xxx

RRaddition, staff must be engaged and empowered to express concerns

around safety and competence and explore solutions that will bringconsensus for the practice improvement initiative.

Change is requisite for improvement and requires an ongoing com-mitment to excellence, a commitment to caring consistently and reliably!

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231232Q4233234235Q5236237238239240241242243244245246247248249250251252253254255256Fig. 10. Parent and clinician partners.

Please cite this article as: Coughlin M. The Sobreviver (Survive) Project.j.nainr.2015.09.010

“Unless someone like you cares awhole awful lot, nothing is going toget better. It's not.” – Dr. Seuss

References

1. Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce morbidity andmortality in low birthweight infants. Cochrane Database Syst Rev. 2014, CD002771,http://dx.doi.org/10.1002/14651858.CD002771.pub3.

2. Filho FL, de Sousa SHC, Freitas IJS, et al. Effect of maternal skin-to-skin contact on de-colonization of methicillin-oxacillin-resistant staphylococcus in neonatal intensivecare units: a randomized controlled trial. BMC Pregnancy Childbirth. 2015;15:63.

3. Korraa AA, El Nagger AI, Mohamed RAE0S, Helmy NM. Impact of kangaroo mothercare on cerebral blood flow of preterm infants. Ital J Pediatr. 2014;40:83, http://dx.doi.org/10.1186/s13052-014-0083-5.

4. Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Skin-to-skincare for procedural pain in neonates. Cochrane Database Syst Rev. 2014, CD008435,http://dx.doi.org/10.1002/14651858.CD008435.pub2.

5. Kymre IG. NICU nurses' ambivalent attitudes in skin-to-skin care practice. Int J QualStud Health Well-being. 2014;9, http://dx.doi.org/10.3402/qhw.v9.23297.

6. Vittner D, Casavant S, McGrath JM. A meta-ethnography: skin-to-skin holding fromthe caregiver's perspective. Adv Neonatal Care. 2015;15:91-200.

7. Institute for Healthcare Improvement (IHI). Failure Modes and EffectsAnalysis (FMEA) Tool. Retrieved fromhttp://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx2014.

8. Coughlin M. Transformative nursing in the NICU: trauma-informed, age-appropriatecare. New York, NY: Springer Publishing Company, LLC. 2012.

9. Ludington-Hoe SM, Morgan K, Abouelfettoh A. A clinical guideline for implementa-tion of kangaroo care with premature infants of 30 or more weeks' postmenstrualage. Adv Neonatal Care. 2008;8:S3-S23.

10. NyqvistKH,AndersonGC,BergmanN,et al. Stateof theart andrecommendationskangaroomother care: application in a high-tech environment. Acta Paediatr. 2010;99:812-9.

11. Davanzo R, Brovedani P, Travan L, et al. Intermittent kangaroo mother care: a NICUprotocol. J Hum Lact. 2013;29:332-8.

Newborn & Infant Nursing Reviews (2015), http://dx.doi.org/10.1053/

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