A Randomized Trial of Continuous Versus Intermittent Skin-to-Skin Contact After Premature Birth and the Effects on Mother–Infant Interaction Background: Premature birth affects opportunities for interaction between infants and mothers. Skin-to-skin contact (SSC) is standard care in neonatal care but has not been sufficiently studied regarding the effects on interaction between preterm infant and mothers. Purpose: The purpose of this study was to compare interaction between preterm infants and their mothers after continuous versus intermittent SSC from birth to discharge. A secondary aim was to study a potential dose–response effect between time in SSC and quality of interaction. Methods: Families were randomly assigned to either continuous (n = 17) or intermittent (n = 14) SSC before delivery. Interaction was measured from videotapes of a Still-Face Paradigm collected at 4 months' corrected age. Face-to-face interaction was coded according to Ainsworth's Maternal Sensitivity Scales and the Maternal Sensitivity and Responsivity Scales-R. Dose–response correlations were calculated between mean time spent in SSC and each of the interaction scales. Results: There were no statistically significant differences between groups in maternal interactive behavior toward their infants regarding sensitivity, interference, availability, acceptance, withdrawal, or intrusivity. There was no correlation between mean time in SSC and quality of interaction. Implications for Practice: Continuous SSC from birth to discharge was not superior to intermittent SSC concerning mother–infant interaction between preterm infants and their mothers at 4 months' corrected age. However, compared with other studies, mean time in SSC was also high in the intermittent group. Implications for Research: Further studies are needed to find out how interaction between parents and preterm infants can be improved, supported, and facilitated in the neonatal intensive care unit (NICU) and whether there is an optimal dose for SSC. Correspondence: Charlotte Sahlén Helmer, RN, Division of Nursing Science, Department of Social and Welfare Studies, Linköping University, 601 74 Norrköping, Sweden (charlotte.sahlen.helmer@liu.se). This work was supported by the County Council of Östergötland (LiO-12134, LiO-17711, LiO-278801), South Sweden Nursing Society (SSSH-2008), Hälsofonden (LiU 2009), and Linköping University. The authors gratefully acknowledge participating families, Lisbet de Jounge, Birgitta Lundin, and staff members at the neonatal intensive care units at Linköping University Hospital and at Sachs' Children's Hospital in Stockholm. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

A Kangaroo Care Pathway for NICU Staff and Families: The Proof Is in the Pouch Background: Kangaroo care (KC) improves bonding and neonatal health outcomes worldwide. However, concerns for patient safety, interrupted workflow, and parent readiness continued to impede KC in a level IV neonatal intensive care unit (NICU). Its current policy did not recommend using more than 1 staff member during patient transfer. In addition, NICU staff and parents lacked skills training and education regarding the feasibility of routine KC. Purpose: A KC pathway was developed and integrated within a multifaceted, champion-based, simulated educational training program for NICU staff and families to promote earlier and more frequent KC by increasing their knowledge and comfort with this practice. Methods: Patient data collected before and after the study determined the frequency, timing, and mode of respiratory support during KC. Pre- and posttest surveys evaluated nurses' knowledge and comfort level with KC. Results: The frequency of KC occurred 2.4 times more after the intervention. The percentage of KC episodes for intubated patients nearly doubled. The posttest survey scores for nursing knowledge and comfort level also markedly improved. Implications for Practice: The KC pathway ameliorated feelings of discomfort by depicting criteria and instructions for safe practice. Multidisciplinary champions were invaluable in assisting the nursing staff with patient transfer during KC. Implications for Research: More dose–response studies are needed to maximize the clinical benefits of KC in developed countries. Correspondence: Karen Stadd, DNP, CRNP-BC, MSN, Johns Hopkins Hospital, 4404 Prancing Deer Dr, Ellicott City, MD 21043 (kstadd@yahoo.com). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

An Observational Study on Early Dyadic Interactive Behaviors of Mothers With Early-Preterm, Late-Preterm, and Full-Term Infants in Malawi Background: Mother–infant interactions are necessary for infant growth and development. However, preterm birth is associated with less positive mother–infant interactions than full-term birth. Malawi has the highest preterm birth rate in the world, but studies of the mother–infant relationship in Malawi are limited and studies that observed mother–infant interactions could not be located. Purpose: This study explored mother–infant interactions among Malawian mothers of early-preterm, late-preterm, and full-term infants. Methods: This observational study explored maternal and infant interactive behaviors. We recruited 83 mother–infant dyads (27 early-preterm, 29 late-preterm, and 27 full-term dyads). Findings: Mothers of early-preterm infants looked at and rocked their infants less, and their infants looked at their mothers less, than mothers of either late-preterm infants or full-term infants. The infants in all groups were asleep most of the time, which contributed to low levels of interactive behaviors. Factors that were related to infant behaviors included marital status, maternal occupation, maternal education, infant medical complications, infant gender, history of neonatal deaths, and multiple births. Implications for Practice: Our findings provide evidence about the need to encourage mothers to engage interactive behaviors with their infants. Implications for Research: Future studies of factors that contribute to positive interactions in Malawi are needed. Correspondence: Kaboni Whitney Gondwe, PhD, GH, UCM, RN, MRM, College of Nursing, University of Wisconsin-Milwaukee, 1921 E Hartford Ave, Milwaukee, WI 53211 (kabonigondwe@gmail.com; gondwe@uwm.edu). Research funded by Duke University Graduate School, Duke Global Health Institute, and Duke University School of Nursing PhD Fellowship for the first author. The authors acknowledge out study participants; Professor Ellen Chirwa, PhD, RN, MRM; Matron Phoebe Jamieson, BSN, RN, RM; and nurses, nurse in-charge, other matrons, and doctors at Queen Elizabeth Central Hospital. Dr Brandon, who is a Co-Editor for Advances in Neonatal Care and the coauthor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal. The other 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

Development of an Innovative Nonanimal Training Model for Infant Pleural Effusion Drainage via Pigtail Catheter Placement Background: Chest tube placement is an important skill for providers and bedside nurses caring for critically ill infants, allowing for the evacuation of pleural fluid and pneumothoraces. No realistic simulation models are commercially available for trainees to practice and learn this skill on infants. Purpose: Our objective was to develop an inexpensive and reproducible model for percutaneous pleural pigtail placement for pleural fluid removal via the Seldinger technique. Methods: The model was developed using hardware material and a discarded infant resuscitation manikin. The rib cage was constructed using electrical cable wires. Discarded and expired 250-mL bags of intravenous fluids were placed inside the chest cavity to simulate pleural fluid. Shelf liner was wrapped around the chest and abdomen of the infant model to simulate the skin layer. Pediatric critical care faculty performed the procedure on the final model and scored it for realism and utility for teaching. Without including the discarded manikin and fluid bags, the cost of the materials for the model was less than $20. Results: Eight pediatric critical care faculty tested the pleural pigtail placement model. All faculty agreed the model provides a realistic simulated reproduction of placing a pleural pigtail, felt the model was simple to use, and indicated they would use it as a teaching tool in the future. Implications for Practice: An effective model for pleural pigtail placement can be inexpensively constructed using discarded bags of intravenous fluid and easy-to-find hardware materials. Implications for Research: Future studies are needed to assess whether this model helps providers and nurses develop and maintain the clinical skills for successful percutaneous pleural pigtail catheter placement. Video Abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=35&autoPlay=true Correspondence: Adrian D. Zurca, MD, Penn State Hershey Children's Hospital, 500 University Dr, Mail Code H085, PO Box 850, Hershey, PA 17033 (azurca@pennstatehealth.psu.edu). 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

Promoting Parent Partnership in Developmentally Supportive Care for Infants in the Pediatric Cardiac Intensive Care Unit Background: Limited opportunities for parents to care for their critically ill infant after cardiac surgery can lead to parental unpreparedness and distress. Purpose: This project aimed to create and test a bedside visual tool to increase parent partnership in developmentally supportive infant care after cardiac surgery. Methods: The Care Partnership Pyramid was created by a multidisciplinary team and incorporated feedback from nurses and parents. Three Plan-Do-Study-Act (PDSA) cycles tested its impact on parent partnership in care. Information about developmentally supportive care provided by parents during each 12-hour shift was extracted from nursing documentation. A staff survey evaluated perceptions of the tool and informed modifications. Results: Changes in parent partnership during PDSA 1 did not reach statistical significance. Staff perceived that the tool was generally useful for the patient/family but was sometimes overlooked, prompting its inclusion in the daily goals checklist. For PDSA 2 and 3, parents were more often observed participating in rounds, asking appropriate questions, providing environmental comfort, assisting with the daily care routine, and changing diapers. Implications for Practice: Use of a bedside visual tool may lead to increased parent partnership in care for infants after cardiac surgery. Implications for Research: Future projects are needed to examine the impact of bedside care partnership interventions on parent preparedness, family well-being, and infant outcomes. Correspondence: Erica Sood, PhD, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803 (esood@nemours.org). The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Noteworthy Professional News No abstract available

Healthcare Satisfaction and Unmet Needs Among Bereaved Parents in the NICU Background: Learning directly from bereaved parents about their experiences in the neonatal intensive care unit (NICU) can improve services at end-of-life (EOL) care. Parents who perceive that their infant suffered may report less satisfaction with care and may be at greater risk for distress after the death. Despite calls to improve EOL care for children, limited research has examined the EOL experiences of families in the NICU. Purpose: We examined parent perceptions of their infant's EOL experience (eg, symptom burden and suffering) and satisfaction with care in the NICU. Methods/Search Strategy: Forty-two mothers and 27 fathers (representing 42 infants) participated in a mixed-methods study between 3 months and 5 years after their infant's death (mean = 39.45 months, SD = 17.19). Parents reported on healthcare satisfaction, unmet needs, and infant symptoms and suffering in the final week of life. Findings/Results: Parents reported high levels of healthcare satisfaction, with relative strengths in providers' technical skills and inclusion of the family. Greater perceived infant suffering was associated with lower healthcare satisfaction and fewer well-met needs at EOL. Parents' understanding of their infant's condition, emotional support, communication, symptom management, and bereavement care were identified as areas for improvement. Implications for Practice: Parents value comprehensive, family-centered care in the NICU. Additionally, monitoring and alleviating infant symptoms contribute to greater parental satisfaction with care. Improving staff knowledge about EOL care and developing structured bereavement follow-up programs may enhance healthcare satisfaction and family outcomes. Implications for Research: Prospective studies are needed to better understand parental perceptions of EOL care and the influence on later parental adjustment. Correspondence: Amy E. Baughcum, PhD, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205 (Amy.Baughcum@nationwidechildrens.org). This research was supported by a grant from the Research Institute at Nationwide Children's Hospital (grant number 20051014). The study was conducted through Nationwide Children's Hospital in Columbus, Ohio. A portion of this work was presented at the Society of Pediatric Psychology Annual Meeting, Portland, Oregon, March 2017. The authors would like to thank the families who generously participated in this work. Dr. Fortney, who is a Guest Editor for Advances in Neonatal Care and the coauthor and mentor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal. The authors declare no conflicts of interest. © 2019 by The National Association of Neonatal Nurses

Implementation of the Neonatal Sepsis Calculator in Early-Onset Sepsis and Maternal Chorioamnionitis Background: Utilization of the neonatal sepsis calculator published by Kaiser Permanente is rapidly increasing. This freely available online tool can be used in assessment of early-onset sepsis (EOS) in newborns 34 weeks' gestation or more based on maternal risk factors and neonatal examination. However, many hospitals lack standard guidelines for its use, leading to provider discomfort with practice change. Purpose: The goal of this project was to study the antibiotic use rate for EOS at a level III neonatal intensive care unit and create standardized guidelines and staff education for using the sepsis calculator. Our ultimate goal was to decrease antibiotic use for EOS in newborns 34 weeks' gestation or more. Methods: A standard quality improvement Plan-Do-Study-Act (PDSA) model was utilized with a plan to study the problem, implement the intervention, and test again for improvement. The primary outcome of interest was a decrease in the use of antibiotics for EOS in neonates 34 weeks' gestation or more. Results: Over a 4-month period, prior to sepsis calculator implementation, antibiotic use for suspected EOS was 11% and blood culture was done on 14.8% of live births. After implementation of the sepsis calculator and completion of the PDSA cycle, sepsis calculator use was greater than 95%, antibiotic use dropped significantly to 5% (P = .00069), and blood culture use dropped to 7.6% (P = .00046). Implications for Practice: Staff education and systematic intervention using a PDSA model can significantly impact patient care, decreasing the administration of antibiotics to infants at risk for sepsis. Implications for Research: Future research is needed to decrease antibiotic use in premature infants less than 34 weeks' gestation with similar risk factors and clinical features. Video Abstract available athttps://journals.na.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=34&autoPlay=true Correspondence: Gangaram Akangire, MD, MS, FAAP, Section of Neonatology, Children's Mercy Kansas City, University of Missouri–Kansas City, 2401 Gillham Rd, Kansas City, MO 64108 (gakangire@cmh.edu). The authors thank pediatric nurse practitioners Kristie Hobbs, APRN, and Heather Williams, APRN, and neonatal nurse practitioners Jean Bohning, APRN, and Pamala Moor, APRN, for their help with data abstraction. The authors also thank Medical Writing Center at Children's Mercy for their help in editing and proof reading 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

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