Evaluation of NICU Nurses' Competence in Pain Assessment 5 Years After Implementation of the COMFORTneo Scale Background: Adequate pain management of preterm and sick newborn infants is a critical issue in the neonatal intensive care unit, as the infants are small and vulnerable with limited resources to deal with pain and stressful experiences. The use of pain assessment instruments, however, must be applied correctly to achieve consistency and improve continuity in care and treatment among clinicians. Purpose: To assess the development of neonatal intensive care unit nurses' interrater agreement in using the COMFORTneo pain assessment tool 5 years after initial implementation, and to identify items needing further development through analysis of discrepancies among nurses' COMFORTneo scores. Methods: An evaluation study with a pre- and postdesign comparing nurses' interrater reliability in assessing infant pain using the COMFORTneo pain assessment tool at baseline and 5-year follow-up. Results: Eighty-five percent of the nurses in the follow-up group (n = 26) had improved their skills 5 years after the implementation, and the improvement was significant (P < .000). We also found that interrater reliability was satisfactory (κ scores ≥0.65) for all the items of the COMFORTneo tool. However, to obtain “very good” interrater reliability (κ scores ≥0.80) 3 items were identified needing increased focus. Implications for Practice: A thorough implementation of a national clinical guideline has been partially effective in ensuring that nurses used the COMFORTneo in their daily practice, which increased their competence in pain assessment. Implications for Research: Further research into the education of nurses on the efficacy of pain scales, nonpharmacologic and pharmacologic therapies, and individualized pain assessment is needed to better address pain management. Correspondence: Rikke Louise Stenkjaer, CCRN, MVO, Department of Neonatology, Rigshospitalet University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark (rikke.louise.stenkjaer@regionh.dk). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Factors Affecting Time NICU Nurses Spend With Fathers: Results From a Larger Study Background: Father involvement in the neonatal intensive care unit (NICU) is important for outcomes of children and should be encouraged. Neonatal nurses have been identified as a major source of support for fathers; yet, nurses have identified obstacles to family-centered care of the father. Purpose: The purpose of this article is to present results that broaden the knowledge of factors that affect time NICU nurses spend with fathers. The information presented here is a portion of results from a larger survey that examined factors affecting NICU nurse caring beliefs of fathers. Methods: This survey study included NICU nurses and was administered anonymously online. Content analysis was completed on responses to open-ended questions. Results: Questions asked nurses about the time they spend with fathers. Nurses described problems with workflow and encouraged family bonding. Some nurses described spending equal amounts of time with both parents, whereas others focused on either the mother or the father. Paternal attributes that affected time nurses spent with fathers included confidence, motivation, level of competence, beliefs, attitudes, and availability. Maternal factors included culture and gatekeeping. Infant factors were level of illness and tolerance to activity. Implications for Practice: Unmotivated fathers may benefit from encouragement from nurses to participate in the care of their infants. Nurses can encourage parental partnerships in caring for their infants. Implications for Research: Factors identified in this study can help guide future studies. Understanding the relationship between NICU fathers and nurses can help improve interactions and communication. 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). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Role of the Neonatal Nurse Practitioner in the Community Hospital Background: The role of the neonatal nurse practitioner (NNP) is well established in the neonatal intensive care unit. The level IV NNP is traditionally supported by large multidisciplinary teams while the level I to III NNP may be the sole in-house provider with limited resources. Purpose: The purpose of this research project is to identify the NNP role, responsibilities, and barriers to practice in the level I, II, and III newborn care settings. Methods: This study used a descriptive, exploratory design to examine NNP roles and responsibilities in level I, II, and III care centers via an online survey. Results: Of the respondents (171), the majority (71.3%) work 24-hour shifts, 51.5% being the single NNP during the day with 67.8% being alone at night. Nearly 27% have limited or are without ancillary support while 29.8% cannot meet some standards of care due to inadequate resources. Almost 22% lack written protocols and procedural opportunities are limited or a concern for 15.8% of the NNPs. Implications for Practice: A better understanding of the responsibilities of the level I to III NNP will assist with developing staffing guidelines, influence practice models, and guide recruitment and retention of the NNP. Implications for Research: A systematic literature review yielded articles on the value of nurse practitioners and their ability to deliver safe, effective and cost-conscience care but not on what the role entails on a daily basis. Further studies are needed to specifically compare the role of the level IV NNP to the level I, II, and III NNP to further delineate NNP functionality according to level of care. Correspondence: Barbara Snapp, DNP, NNP-BC, Mary Washington Hospital, Neonatal Intensive Care, 3rd Floor, 1001 Sam Perry Blvd, Fredericksburg, VA 22401 (bsnapp@childrensnational.org). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Maternal Distress in the Neonatal Intensive Care Unit: A Concept Analysis Background: The neonatal intensive care unit (NICU) can cause significant psychological distress in a mother. There is no common definition of maternal distress in the NICU currently in use. Purpose: To develop a clear conceptual understanding of maternal distress in the NICU using conceptual definitions and empirical findings. Methods/Search Strategy: A literature search was conducted using EBSCOhost, MEDLINE, CINAHL, PsychINFO, and Google Scholar. The concept analysis was guided by Walker and Avant's (2011) guide. Findings/Results: Maternal distress in the NICU consists of a combination of depressive, anxiety, trauma, and posttraumatic stress symptoms. The symptoms occur together on a spectrum and present differently in each mother. The antecedents to maternal distress are a NICU hospitalization and a perceived interruption to the transition to motherhood. Consequences of maternal distress in the NICU are issues with developing a healthy maternal–infant bond, adverse infant development, and decreased maternal quality of life. Implications for Practice: A complete understanding of maternal distress in the NICU will lead to increased awareness of adverse mental health states in this population. Implications for Research: Identification of mothers at risk for maternal distress in the NICU, as well as the identification of antecedents and consequences related to the mother and the infant from maternal distress in the NICU. Using a single, clear definition of maternal distress in the NICU population will lead to a more cohesive body of literature. Correspondence: Morgan A. Staver, BSN, RN, College of Nursing, University of Nebraska Medical Center, 4101 Dewey Ave, Omaha, NE 68131 (morgan.staver@unmc.edu). The authors declare no conflicts of interest. © 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

Pharmacologic Management of Neonatal Abstinence Syndrome Using a Protocol Background: The opioid epidemic in the United States has reached unprecedented proportions with far-reaching impacts on the most vulnerable population. The number of neonates born addicted to opioids has grown exponentially over the last several decades, leading to increased neonatal intensive care unit admissions and rising healthcare costs. Recent studies have yielded mixed results regarding which medication is most effective at relieving the symptoms of opioid withdrawal and reducing the weaning timeframe for babies with neonatal abstinence syndrome (NAS). Purpose: To explore and compare the effectiveness of morphine versus methadone in the treatment for NAS using a standardized protocol. Method: A literature search of PubMed and CINAHL was performed. The search yielded 10 quantitative studies that were analyzed for potential practice changes. Conclusion: Based on current literature, following a standardized, stringent weaning protocol is more beneficial than the pharmacologic agent used. Studies reveal shorter weaning times and hospital stays in almost every group that followed rigid guidelines. Implication for Research: Although current studies are promising for the desired outcome, more research is needed to develop appropriate protocol-based weaning regimens for management of NAS. Implication for Practice: As the occurrence of NAS continues to rise, its management must vigorously meet the challenges of the diagnosis. Institutions should reevaluate their current protocols based on reassuring data showing that stringent guidelines using morphine or methadone can improve clinical outcomes, reduce hospital length, and lower healthcare costs. Correspondence: Lieutenant Brandi L. Gibson, MSN, RN, RNC-NIC, Nurse Corps, US Navy, Duke University School of Nursing, Box 3322, Durham, NC 27710 (Brandi.gibson@duke.edu). All the authors have read and approved this article for publication and have all contributed equal substance to this work. This manuscript has not been submitted for consideration by another journal. The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government. LT Gibson is a military service member. This work was prepared as part of her official duties Title 17, USC, §105 provides that “Copyright protection under this title is not available for any work of the U.S. Government.” Title 17, USC, §101 defines a “U.S. Government work as a work prepared by a military service member or employees of the U.S. Government as part of that person's official duties.” Written work prepared by employees of the Federal Government as part of their official duties is, under the US Copyright Act, a “work of the United States Government” for which copyright is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Use of Potassium Hydroxide (KOH) Test Reduces Antifungal Medication Prescription for Suspected Monilial Diaper Dermatitis in the Neonatal Intensive Care Unit: A Quality Improvement Project Background: Despite availability of rapid fungal potassium hydroxide (KOH) tests, many care providers rely on visual assessment to determine the diagnosis of monilial diaper dermatitis (MDD). Purpose: To determine whether a KOH test, when MDD is suspected, would result in more accurate diagnoses, with decreased antifungal medication prescription and exposure. Methods: Quality improvement project from 2016 through 2017 with protocol implemented in 2017 for treatment of MDD after positive KOH testing. If monilial rash suspected, after 2 negative KOH tests, then antifungal ordered (considered false negative). χ2 testing and cost determination were performed. Sample: Neonates in 2 level III neonatal intensive care units. Outcome Variables: KOH test results, use of antifungal medication, and cost. Results: The patient census included 1051 and 1015 patients in the year before and after the protocol initiation. The medical orders for antifungal medication decreased from 143 to 36 (P < .001; 95% odds ratio confidence interval, 2.24-4.38). There was a 75% reduction in both use and cost, as charged, of antifungal agents. Overall charges, including KOH test costs, decreased by 12%. Three infants received multiple negative KOH tests, then a positive one. These met the definition of false-negative tests, per protocol. There were no cases of fungal sepsis. Implications for Practice: Use of a quality improvement protocol, in which the use of KOH testing is required, before antifungal agents are prescribed, results in decreased exposure and costs. Implications for Research: To test the feasibility of bedside “point-of-care” KOH testing, and whether KOH testing and reduced antifungal medication use affects antimicrobial resistance or invasive fungal sepsis. Correspondence: Elena Bosque, PhD, ARNP, NNP-BC, Department of Neonatology, Seattle Children's Hospital, PO Box 5371/M1-12, Seattle, WA 98145 (elena.bosque@seattlechildrens.org). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Improving the Efficiency and Effectiveness of Parent Education in the Neonatal Intensive Care Unit Background: March of Dimes partners with hospitals across the country to implement NICU Family Support (NFS) Core Curriculum, a program providing education to parents in neonatal intensive care units (NICUs) across the country. Purpose: This NFS project's goal was to increase the efficiency and effectiveness of NICU parent education by establishing consistency, improving quality, and identifying best practices. Methods/Search Strategy: A 5 topic curriculum was developed and implemented across NFS program sites. The project studied 4 main outcomes of interest related to efficiency and effectiveness: increase in parenting confidence, parent learning, knowledge change, and satisfaction. Data were collected from speakers and attendees immediately following educational sessions. Analytical approaches included descriptive statistics such as frequency, percentage, and response rate, and inferential approaches such as t test, χ2, and analysis of variance. Findings/Results: Findings suggest that the NFS Core Curriculum improved both program efficiency and effectiveness. Sessions fully implemented according to recommended strategies had better outcomes than sessions not fully implemented according to recommended strategies (P < .0001). Across the 3648 attendees at 41 sites, 77% of parents reported learning “a lot” at the session they attended and 85% of attendees reported increased confidence. Attendees also reported positive knowledge change and high satisfaction. Implications for Practice: Parent education best practices identified through this initiative can be utilized for future NFS Core Curriculum topics and potentially generalized to all NICU parent education and family education in other hospital intensive care units. Implications for Research: Content and best practices identified through this project will require regular review to ensure medical accuracy and appropriateness of best practices as the physical design of NICUs evolves. Correspondence: Lori G. Gunther, MS, March of Dimes, 1550 Crystal Dr, Ste 1300, Arlington, VA 22202 (loriggunther@gmail.com). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Trying to Do What Is Best: A Qualitative Study of Maternal–Infant Bonding and Neonatal Abstinence Syndrome Background: The maternal experience of caring for and bonding with infants affected by neonatal abstinence syndrome (NAS) has not been adequately characterized. Purpose: This study was designed to describe mothers’ experiences of, supports for, and barriers to bonding with infants with NAS. Methods: Semistructured interviews were coded using computer-assisted thematic content analysis. A code co-occurrence model was used to visualize the relationships between themes. Results: Thirteen mothers of infants with NAS participated. Trying to Do What Is Best emerged as the overarching theme with which several subthemes co-occurred. Subthemes that captured mothers loving their infants and bonding, feeling supported by the infants’ fathers, feeling supported in the community, and receiving information from hospital staff were associated with mothers’ trying to do what is best. Barriers to trying to do what is best included feeling unsupported in the community, guilt about taking medications or substances during pregnancy, feeling judged, and infant withdrawal. Implications for Practice: Specific implications for practice may be derived from the mothers’ criticisms of NAS assessment tools. Mothers highlighted the value of reassurance and education from providers and the uniquely nonjudgmental support received from peers and male coparents. Implications for Research: There is a lack of information about maternal–infant bonding in dyads affected by NAS and factors that contribute to parental loss of custody. Qualitative, quantitative, and mixed-methods studies in diverse populations might help researchers better understand the long-term outcomes of NAS and develop interventions that decrease family separation. Correspondence: Katherin Rockefeller, MD, Department of Psychiatry, Center for Autism and Developmental Disorders, Maine Behavioral Healthcare, 236 Gannett Dr, South Portland, ME 04106 (krockefell@mainebehavioralhealthcare.org). This research was supported by funding for transcription costs from the Department of Pediatrics and the Neurosciences Service Line at Maine Medical Center. Dr Craig was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, grant number KL2TR001063. 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