An Ethnography of Parents' Perceptions of Patient Safety in the Neonatal Intensive Care Unit Background: Parents of neonates are integral components of patient safety in the neonatal intensive care unit (NICU), yet their views are often not considered. By understanding how parents perceive patient safety in the NICU, clinicians can identify appropriate parent-centered strategies to involve them in promoting safe care for their infants. Purpose: To determine how parents of neonates conceptualize patient safety in the NICU. Methods: We conducted qualitative interviews with 22 English-speaking parents of neonates from the NICU and observations of various parent interactions within the NICU over several months. Data were analyzed using thematic content analysis. Findings were critically reviewed through peer debriefing. Findings: Parents perceived safe care through their observations of clinicians being present, intentional, and respectful when adhering to safety practices, interacting with their infant, and communicating with parents in the NICU. They described partnering with clinicians to promote safe care for their infants and factors impacting that partnership. We cultivated a conceptual model highlighting how parent-clinician partnerships can be a core element to promoting NICU patient safety. Implications for Practice: Parents' observations of clinician behavior affect their perceptions of safe care for their infants. Assessing what parents observe can be essential to building a partnership of trust between clinicians and parents and promoting safer care in the NICU. Implications for Research: Uncertainty remains about how to measure parent perceptions of safe care, the level at which the clinician-parent partnership affects patient safety, and whether parents' presence and involvement with their infants in the NICU improve patient safety. Correspondence: Madelene J. Ottosen, PhD, MSN, RN, Cizik School of Nursing, The University of Texas Health Science Center at Houston, 6901 Bertner Ave, Ste #567E, Houston, TX 77030 (Madelene.j.ottosen@uth.tmc.edu). This research was supported in part through a grant from the Agency for Healthcare Research and Quality, R03HS022944, Parent perceptions in NICU safety culture: Parent-Centered Safety Culture Tool, and a grant from the Agency for Healthcare Research and Quality, 1P30HS024459-01, caregiver innovations to reduce harm in neonatal intensive care. No conflicts of interest exist for any of the coauthors. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2019 by The National Association of Neonatal Nurses

Mothers' Experiences in the NICU Before Family-Centered Care and in NICUs Where It Is the Standard of Care Background: Family-centered care (FCC) in neonatal intensive care units (NICUs) was initiated in 1992 to promote a respectful response to individual family needs and support parental participation in care and decision-making for their infants. Although benefits of FCC have been reported, changes in the maternal experience in the NICU are unknown. Purpose: The purpose of this study was to compare mothers' experiences in NICUs where FCC is the standard of care and to compare these with the experiences of mothers 2 decades ago. Methods: In this qualitative descriptive design, mothers of infants born under 32 weeks postconceptional age were asked to describe their experiences with their infant's birth and hospitalization. Open-ended probing questions clarified maternal responses. Saturation was reached after 14 interviews. Iterative coding and thematic grouping was used for analysis. Results: Common themes that emerged were: (1) visiting; (2) general caregiving; (3) holding; (4) feeding; and (5) maternal ideas for improvement. Findings indicated important improvements in privacy, mother–nurse relationship, ease of visiting, and maternal knowledge and participation in infant caregiving. Implications for Practice: Mothers suggested improvements such as additional comforts in private rooms, areas in the NICU where they can meet other mothers, and early information on back-transport. Better recognition and response for mothers without adequate social support would provide much needed emotional assistance. Implications for Research: Future research addressing benefits of webcams, wireless monitors, back-transport, maternity leave, and accommodations for extended visiting for siblings would address other needs mentioned by mothers. Correspondence: Madalynn Neu, PhD, RN, FAAN, College of Nursing, University of Colorado, 13120 E. 19th Ave, Aurora, CO 80045 (madalynn.neu@ucdenver.edu). This work was supported in part by grants from the University of Denver Center for Community Engagement to Advance Scholarship and Learning, the PROF Fund at the University of Denver, and Sigma Theta Tau, Alpha Kappa Chapter-at-Large. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

The Beneficence of Cuddle Therapy in Hyperekplexia: A Case Report Background: Benevolent injustice occurs when well-intentioned treatment efforts produce an outcome that limits the potential of a patient. The unintended harm can result in significant moral distress for the family and the healthcare team. Clinical Findings: We discussed an ethical dilemma regarding a neonate who had suspected seizure and hypoxic–ischemic encephalopathy after home birth delivery. The healthcare team experienced moral distress about the mother's desire to not use anti-seizure medications and instead trial other interventions such as cuddling. Subsequently, clinical analysis ruled out a seizure disorder. Genetic studies on this neonate confirmed hereditary hyperekplexia, which presented as exaggerated Moro reflex and apnea that mimicked seizure. Intervention: We discussed how applying any one of the 4 basic ethical principles of autonomy, beneficence, nonmaleficence, or justice could counteract benevolent injustice and moral distress. Outcomes: Discussions with the patient's mother and nurse allowed the team to overcome their reluctance to try the mother's treatment recommendations. This resulted in adopting the seemingly counterintuitive intervention of cuddling that turned out to be effective for this neonate with hereditary hyperekplexia. Practice Recommendations: The moral distress associated with benevolent injustice should be identified early to minimize long-term consequences to the patient, family, and healthcare team. Healthcare teams should learn to apply ethical principles when discussing patient care concerns in an unbiased manner. Guided ethical discussions allow us to be more efficient in providing family-centered care that aligns with the patient's best interest. Correspondence: Belinda Chan, MD, Division of Neonatology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108 (Belinda.chan@hsc.utah.edu). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

The Role of the NICU in Father Involvement, Beliefs, and Confidence: A Follow-up Qualitative Study Background: Fathers are important to infant outcomes. Infants of involved fathers have improved weight gain, sleep, and psychosocial behaviors. Father involvement with neonatal intensive care unit (NICU) infants reduces the length of stay. Purpose: The purpose of this study was to explore and describe involvement, confidence, and beliefs of fathers of infants who were hospitalized in the NICU and discharged home in order to begin to investigate NICU father involvement from a longitudinal perspective. Methods: This exploratory qualitative study was conducted 4 to 5 years after the initial NICU stay using telephone interviews. Fathers who participated in this study were selected from participants of a previous NICU study. Qualitative analysis was conducted using standard procedures for grounded theory. Results: Nineteen fathers participated in the study. The major themes were “It was scary,” “Just be there,” “It was rough,” “It's not about yourself,” “A special bond,” and “Almost a treat.” The fathers reported that the NICU providers, nurses, and staff helped them to overcome uncertainty and lack of knowledge, which helped them improve their confidence and involvement during the NICU stay. Implications for Practice: Fathers see nurses as a source of support. Nurses can encourage fathers to visit regularly and participate in infant care activities. NICU presence aids fathers in developing confidence and knowledge in parenting during their child's infancy, which can set the stage for ongoing involvement. Implications for Research: Future work should continue to focus on longitudinal studies of fathering and the role of the NICU in encouraging involvement and parenting readiness. Correspondence: Gina Clarkson, PhD, APRN, NNP-BC, College of Nursing, Idaho State University, 921 S, 8th Ave, Stop 8101, Pocatello, ID 83209 (clargina@isu.edu). Supported by ISU Seed Grant (internally funded) in the amount of $12,771 from May 1, 2018, to June 30, 2019. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Giving Voice to Parents in the Development of the Preemie Prep for Parents (P3) Mobile App Background: Parents at risk for preterm birth frequently receive prematurity education when the mother is hospitalized for premature labor. Parental ability to learn and consider the information is limited because of the stress of the hospitalization. A promising approach is dissemination of information to at-risk parents before the birth hospitalization. Purpose: This article describes formative research used to develop smartphone-based prematurity education app for parents at-risk for preterm birth. Methods: Stakeholders were parents with a prior preterm birth. Using stakeholder meeting transcripts, constant comparative analysis was used to reflect upon the parental voice. Results: The parents named the app, Preemie Prep for Parents (P3). Parent perspectives revealed desire for information in the following 5 categories. (1) Power in knowledge and control: parents want autonomy when learning information that may influence medical decision-making. (2) Content and framing of information: they desire information from a trusted resource that helps promote prenatal health and provides neonatal intensive care information. (3) Displaying content: parents want personalization, push notifications, photographs displaying fetal development, and easy-to-understand statistics. (4) Providing information without causing harm: they desire non–value-laden information, and they do not support “gamifying” the app to enhance utilization. (5) Decision making: parents want information that would benefit their decision making without assuming that parents have a certain outlook on life or particular values. Implications for Practice: These findings support the need for the P3 App to aid in decision making when parents experience preterm birth. Implications for Research: The findings highlight the need to study the effects of smartphone-based prematurity education on medical decision-making. Correspondence: Mir A. Basir, MD, MS, Department of Pediatrics, Medical College of Wisconsin, Ste CCC-410, 8701 Watertown Plank Rd, Milwaukee, WI 53226 (mbasir@mcw.edu). This project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH) (grant no. UL1TR001436). Its content is solely the responsibility of the authors and do not necessarily represent the official views of NIH. The authors have no conflict of interest relevant to this article to disclose. © 2019 by The National Association of Neonatal Nurses

Kangaroo Mother Care in Hospitalized Low Birth-Weight Infants on Respiratory Support: A Feasibility and Safety Study Background: Low birth-weight (LBW) infants on respiratory support are often deprived of kangaroo mother care (KMC) due to fear of instability. Data on safety of KMC in these infants are lacking. Primary Objective: To determine the feasibility of KMC in LBW infants on continuous positive airway pressure or synchronized intermittent mandatory ventilation. Secondary Objectives: To compare vital signs (heart rate [HR], respiration, temperature, and SpO2) and ventilatory parameters (FIO2, peak inspiratory pressure [PIP], and positive end-expiratory pressure [PEEP]) before, during, and after KMC, and assess the mother's perception of the KMC intervention. Methods: LBW infants stable on respiratory support were given KMC for 1 hour. Vital signs and ventilator parameters were recorded before, every 15 minutes during and after KMC. Feasibility was defined as continuation of KMC for 1 hour without interruption, with stable vital signs (HR > 100/min, SpO2 > 90%, and temperature 36.5°C-37.5°C) and ventilator parameters (no change in PIP, PEEP, or increase in FIO2 not more than 0.1) without tube dislodgement. Results: Twenty LBW infants with a mean birth weight of 1390 ± 484 g were included. All infants completed 1-hour duration of KMC without interruption. No significant changes in temperature, respiratory rates, or saturations were noted. The HR and FIO2 were marginally higher during KMC than before or after (HR before 147.3 ± 11.5, during 150.8 ± 11, and after 147.3 ± 11.1, P = .04; FIO2 before 30.6 ± 8.1, during 31.8 ± 8.1, and after 30.7 ± 8.0, P = .034). No accidental extubation or dislodgement of lines occurred. Most mothers were happy. Implications for Practice: The vital signs were stable during KMC. KMC is feasible in infants receiving respiratory support. Implications for Research: Effectiveness of early initiation and prolonged duration of KMC. Correspondence: Suman PN Rao, MD, DM, Department of Neonatology, St John's Medical College Hospital, Sarjapur Rd, Koramangala, Bangalore 560034, India (raosumanv@gmail.com). Dr Bisanalli conceived, designed, collected, and drafted the manuscript; Dr Rao conceived, supervised the research, and edited the manuscript and act as a guarantor for this article; Ms Nesargi analyzed and edited the manuscript; and Dr Govindu helped with analysis and edited the manuscript. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2019 by The National Association of Neonatal Nurses

Chlorhexidine Gluconate Utilization for Infection Prevention in the NICU: A Survey of Current Practice Background: Central-line-associated bloodstream infection (CLABSI) contributes to significant morbidity and mortality in the neonatal intensive care unit (NICU). Disinfection of skin is part of bundled cares aimed at prevention of CLABSI. While considered an essential component of insertion and maintenance bundles, the optimal solution to disinfect neonatal skin remains controversial. Purpose: The purpose of this project was to survey neonatal nurse practitioners and nursing leaders across NICUs regarding the current use of chlorhexidine gluconate (CHG) in term and preterm infants. Methods: This descriptive study involved the collection of survey data to determine NICU practices related to the use of CHG in their infant population. The sample was composed of nursing directors of NICUs and neonatal nurse practitioners who completed an electronic survey via a provided link. Findings/Results: Chlorhexidine was reported to be used in 53 (82.81%) of the NICUs and was the primary agent used to prepare the skin for central vascular catheter insertion (53.23%) followed by povidone-iodine (45.16%), and 70% isopropyl alcohol (1.61%). Gestational age or birth weight restrictions for CHG use were reported in 43 (82.69%) NICUs. Trends in the data demonstrated nursing's role in using CHG in the NICU. Adverse events reported from CHG included burns, redness, dermatitis, and other irritations. Concerns included risk of absorption, burns, skin irritation, lack of evidence, and overall safety. Implications for Practice: Systematic monitoring by nurse leaders is needed to identify evidence related to skin disinfection and CHG in neonates. Targeted education for nursing staff related to directed to developmental maturation of the skin, safe use of CHG, review of best evidence, rationale for usage of CHG, and potential iatrogenic effects is recommended. Implications for Research: Research is needed to evaluate the impact of educational offerings and surveillance for adverse events on CLABSI rates. Correspondence: Karen Beekman, MS, RNC-NIC, NNP-BC, ACCNS-N, Dayton Children's Hospital, One Children's Plaza, Dayton, OH 45404 (beekmankk@childrensdayton.org). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Acute Kidney Injury Guidelines Are Associated With Improved Recognition and Follow-up for Neonatal Patients Background: Studies demonstrate that neonatal acute kidney injury (AKI) is associated with increased morbidity and mortality. Acute kidney injury survivors are at risk for renal dysfunction and chronic kidney disease and require long-term follow-up. Purpose: To maximize identification of AKI and ensure referral, we created guidelines for diagnosis, evaluation, and management of AKI. Methods/Search Strategy: Retrospective cohort study of neonatal intensive care unit patients treated before guideline implementation (cohort 1; n = 175) and after (cohort 2; n = 52). Outcome measures included AKI incidence, documented diagnosis, and pediatric nephrology consultation. Statistical methods included t tests, Fisher exact tests, and Wilcoxon rank sum tests. Findings/Results: We found 68 AKI episodes in 52 patients in cohort 1 and 15 episodes in 12 patients in cohort 2. Diagnosis and documentation of AKI improved after guideline implementation (C1:24/68 [35%], C2: 12/15 [80%]; P= .003) as did pediatric nephrology consultation (C1:12/68 [18%]; C2: 12/15 [80%]; P< .001) and outpatient referral (C1: 3/47 [6%], C2:5/8 [63%]; P< .01). Implications for Practice: Neonatal AKI guideline implementation was associated with improvements in recognition, diagnosis, and inpatient and outpatient nephrology consultation. Early recognition and diagnosis along with specialist referral may improve outcomes among neonatal AKI survivors, ensuring appropriate future monitoring and long-term follow-up. Implications for Research: Future research should continue to determine the long-term implications of early diagnosis of AKI and appropriate subspecialty care with follow-up. Correspondence: Katherine Vincent, NNP, Department of Pediatrics, Division of Neonatology, Medical University of South Carolina, 165 Ashley Ave, Charleston, SC 29425 (vincentk@musc.edu). All work for this study was performed at the Medical University of South Carolina in Charleston, Charleston, South Carolina. The data were presented as poster presentation at the Southern Society Pediatric Research 2018 Regional Meeting and at the 2018 3rd International Symposium on Acute Kidney Injury in Children and were presented as an oral presentation at the 2018 Darby Children's Research Institute and Pediatric Research Day and at the 2019 National Association of Neonatal Nurses Research Summit. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2019 by The National Association of Neonatal Nurses

Malassezia furfur Emergence and Candidemia Trends in a Neonatal Intensive Care Unit During 10 Years: The Experience of Fluconazole Prophylaxis in a Single Hospital Background: Because Candida spp is a major cause of mortality and morbidity in preterm infants, fluconazole prophylaxis has been suggested by some experts and hospital policy. In our hospital, fluconazole prophylaxis was used in eligible preterm infants and set as the neonatal intensive care unit (NICU) practice in 2014. Purpose: This study focused on fungal bloodstream infections and aimed to evaluate the benefit and harm of fluconazole prophylaxis. Methods/Search Strategy: This retrospective, descriptive study involved medical record reviews in our hospital from April 2005 to October 2016. NICU patients were included if Candida species, yeast-like organisms, or Malassezia species were cultured from their venous catheter tips or blood cultures. Findings/Results: After fluconazole prophylaxis, cases of Candida spp decreased and those of Malassezia furfur emerged. We reviewed 19 cases of catheter-related M furfur colonization and 1 case of M furfur fungemia. The gestational age was 27.3 ± 2.0 weeks and birth weight was 959.2 ± 229.8 g. Hyperalimentation with lipid infusion was used in all cases. All of the neonates survived with antifungal agent use. Implications for Practice: This study highlights that prophylactic fluconazole may be an associated factor of Malassezia colonization; M furfur remains a potential concern for fungemia in the care of premature infants and thus requires our attention. Implications for Research: Future studies should further investigate the incidence and impact of noncandidal fungal infections with fluconazole prophylaxis use in premature infants. Correspondence: Kuang-Che Kuo, MD, Division of Infectious Disease, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd, Niaosong District, Kaohsiung City 833, Taiwan, ROC (light@cgmh.org.tw). The authors declare no conflicts of interest. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by The National Association of Neonatal Nurses

Improving Staff Knowledge and Attitudes Toward Providing Psychosocial Support to NICU Parents Through an Online Education Course Background: Provider–parent communication is a critical determinant of how neonatal intensive care unit (NICU) parents cope, yet staff feel inadequately trained in communication techniques; many parents are not satisfied with the support they receive from hospital providers. Purpose: This study evaluated whether NICU staff would demonstrate improved knowledge and attitudes about providing psychosocial support to parents after taking an online course. Methods: After providing demographic information, staff at 2 NICUs took a 33-item survey both before and after taking a 7-module online course “Caring for Babies and Their Families,” and again at 6-month follow-up. Scores (means ± standard deviation) from all time periods were compared and effect sizes calculated for each of the course modules. Results: NICU staff participants (n = 114) included nurses (88%), social workers (7%), physicians (4%), and occupational therapists (1%). NICU staff showed significant improvement in both knowledge and attitudes in all modules after taking the course, and improvements in all module subscores remained significant at the 6-month follow-up mark. Night staff and staff with less experience had lower pretest scores on several items, which improved on posttest. Implications for Practice: This course, developed by an interprofessional group that included graduate NICU parents, was highly effective in improving staff knowledge and attitudes regarding the provision of psychosocial support to NICU parents, and in eliminating differences related to shift worked and duration of work experience in the NICU. Implications for Research: Future research should evaluate course efficacy across NICU disciplines beyond nursing, impact on staff performance, and whether parent satisfaction with care is improved. Correspondence: Sue L. Hall, MD, 145 N. Crimea Street, Ventura, CA 93001 (suehallmd@gmail.com). This work was supported in part by unrestricted support from Medela, The Wellness Network, and Prolacta Bioscience. Dr. Hall is a consultant for The Wellness Network. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by The National Association of Neonatal Nurses