Date of Award
Projects: SPU Access Only
Doctor of Nursing Practice (DNP)
Dr. Lorie Wild
Dr. Christine Hoyle
Background and significance
The discharge (DC) readiness of premature infants from the Neonatal Intensive Care Unit (NICU) often focuses on their hemodynamic stability and may neglect parents’ preparedness to care for their high-risk premature infant at home. About 16% of coping difficulties post-discharge are associated with parents' unreadiness at discharge from the NICU (Smith et al., 2013). Parents’ participation in the DC process may be limited (Shillington & McNeil, 2021). Because parents’ readiness is not well known, it is important to assess their readiness for the DC of their premature infants which may help parents emerge from the NICU experience with increased competence.
Problem and purpose statement
Evaluating parents’ readiness for DC from the NICU with their premature infant can help reduce adverse effects once they have fully transitioned home. The purpose of this project was to identify the factors that could help improve parents’ readiness to the DC of their premature infants. The results from this project were used to highlight potential changes needed in the NICU DC process at the project’s hospital.
This quality improvement project employed a descriptive design using a survey methodology. The project lead worked with NICU providers, nurses, and parent council members to evaluate the readiness of parents to discharge with their premature infants the day prior to or the day of DC using the web-based application REDCap. The survey included the Quality of Discharge Teaching Scale (QDTS) (Weiss, 2017), 19-items using an 11-point Likert scale about parents’ technical and psychological readiness, and open-ended questions adapted from Larsson et al., (2016). The NICU discharge coordinator distributed an invitation letter granting access to the online intake survey. The data collection lasted two months. Participants needed to be ≥18 years of age, a NICU stay ≥ one week, and have a valid email and internet access. Participants had to opt-in or -out of a similar post-discharge survey. The Kenner Model for Transition (KMT) served as a theoretical framework for analysis (Boykova et al., 2019): informational needs, stress and coping, parent-child development, social interaction, and grief.
A total of 18 parents were invited to complete the pre-discharge survey with 4 participants completing (22% response rate). No participant completed the post-discharge survey. The participants had infants born between 28 and 32 weeks of gestation and were age 8-11 weeks at time of survey completion. The survey questions were regrouped using four of the five KMT categories (no items addressed grief) plus other items addressing the DC teaching process.
Informational Needs included parents’ perceptions of caring for a premature infant, the infant’s medical needs or treatments, practical skills, and parents’ understanding of who and when to call in an emergency. While there were small to moderate gaps overall, two parents received either enough or more than enough information than what they needed (i.e., -9 to 0) while other two parents had gaps between 3 and 5. Of note, when asked about the practice they needed vs. received with their infant’s medication and treatments, two parents had unmet needs (gaps =3 and 4) thus, suggesting an intervention in this area may be beneficial.
Stress and Coping gauged the uncertainties of parenting a premature infant at home after a stay in the NICU, e.g., parents’ emotions, confidence, what to do in case of an emergency, and the care of their premature infant. Parents were asked whether the nurses listened to and addressed their specific questions or concerns and were sensitive to their personal beliefs. While gaps between the emotional support needed vs. received were small, parents’ overall need for information about their emotions after DC was high (mean=8 out of 10). Parents reported that nurses setting up their premature infants’ appointments was helpful but worried about their infant being off monitors, their risk of rehospitalization, and the driving distance to the hospital.
Parent-Child Development involved parents’ perception of their relationship with the infant after DC. Parents’ confidence to care for their infant at home ranged between 5 and 10 (mean 7.75). Two parents were very confident (i.e., 10 out of 10) while the other two were less so, reporting 5 and 6 (out of 10).
Social interaction refers to parents’ ability to interact with family, friends, and medical professionals and was measured as the amount of information family members needed vs. received about their infant’s care after going home, the amount of support parents would have at home, and whether they would be a part of a “Birth to Three” program. Gaps between what families needed vs. received were small. While only half reported they would have support at home, 3 of 4 parents had “Birth to Three” resources. These findings suggest that help from NICU staff to identify additional support resources may be needed.
Process measures addressed parents’ perception of how nurses conducted DC teaching such as whether information was given in a way they could understand and if the nurses checked to make sure they understood. Parent ratings were low for the former with no score >5 of 10. Two parents reported that nurses checked to make sure they understood (i.e., 10 out of 10), the other two each reported 6 (out of 10). These results point to opportunities for improvement.
Recommendations & Sustainability Plan:
The NICU team will act on the recommendations from this project to improve parents’ discharge readiness. These recommendations include identifying parents that might need more support at DC throughout the premature infant’s stay, starting DC teaching the day of the admission, and using “teach-back” methods. A parent-designed stimulation room to help practice on medications and other hospital supplies could also be helpful. Lastly, using a DC checklist highlighting outpatient resources such as support groups could help parents deal with stress and coping.
Implications for Nursing
Premature infants require frequent follow-up and are at high risk of rehospitalization. Parents’ readiness at discharge can help improve the infant outcomes and the continuity of care from inpatient to primary care. To ensure premature infants thrive at home, it is important that nurses, researchers, and policymakers continue to evaluate the needs of parents throughout their premature infants’ discharge from the NICU.
Boykova, M. V., Kenner, C., Walker, K., & Discenza, D. A. (2019). Post discharge care of the newborn, infant, and families. Comprehensive Neonatal Nursing Care, 5, 783 -808). https://doi.org/10.1891/9780826139146.0037
Larsson, C., Wågström, U., Normann, E., & Thernström Blomqvist, Y. (2016). Parents experiences of discharge readiness from a Swedish neonatal intensive care unit. Nursing Open, 4(2), 90-95. https://doi.org/10.1002/nop2.71
Shillington, J., & McNeil, D. (2021). Transition from the neonatal intensive care unit to home. Advances in Neonatal Care, Publish Ahead of Print. https://doi.org/10.1097/anc.0000000000000835
Smith, V. C., Hwang, S. S., Dukhovny, D., Young, S., & Pursley, D. M. (2013). Neonatal intensive care unit discharge preparation, family readiness and infant outcomes: Connecting the dots. Journal of Perinatology, 33(6), 415-421. https://doi.org/10.1038/jp.2013.23
Weiss, M., Johnson, N. L., Malin, S., Jerofke, T., Lang, C., & Sherburne, E. (2008). Readiness for discharge in parents of hospitalized children. Journal of Pediatric Nursing, 23(4), 282-29
Houendjou Badjio, Annie Lynda, "Evaluating Parents’ Readiness for the Discharge of their Premature Infant from the Neonatal Intensive Care Unit (NICU)" (2022). Doctor of Nursing Practice (DNP) Scholarly Projects. 42.