Bedside Education and a

Standardized Positioning Tool

to Improve Developmental Positioning of NICU Nurses

Arlene Spilker DNP, RN, CNE

Outcomes

The participants will describe the fundamental principles of developmental positioning.

The participants will discuss the current evidence regarding the actual and potential benefits of developmental positioning.

The participants will analyze the barriers to developmental positioning and propose potential solutions.

Preterm infants do

not have the typical

fetal position

because of their

decreased amount of

time in utero – “a lack

of physiologic flexion”

Fetal PositioningIntrauterine environment – free

floating & self-contained

NICU Positioning

Extrauterine environment -gravitational pull & no

boundaries

Long Term Outcomes In the U.S., preterm birth impacts about 500,000

infants every year, and it is the leading cause of long-term neurodevelopmental disability, with an estimated cost of $26 billion dollars per year ("Preterm Birth," n.d.).

How Do We Practice?

Evidence Based Practice Questions

What do we know?

What remains unknown?

What resources are available?

What is feasible for our unit?

What Do We Know?

Developmental positioning:

promotes normal postural &

musculoskeletal development (Coughlin et al., 2010;

Jeanson, 2013; Madlinger-Lewis et al., 2014; Zarem et al., 2013)

maintains a patent airway (Gibbins, Hoath, Coughlin,

Gibbins, & Franck, 2008)

promotes thermal regulation (Gibbins, Hoath,

Coughlin, Gibbins, & Franck, 2008)

What Do We Know?

Infants who are developmentally

positioned:

cry less, have less flailing of their extremities,

and fewer behavioral indicators of pain (Gibbins,

Hoath, Coughlin, Gibbins, & Franck, 2008).

have improved physiologic outcomes and

sleep states (Picheansathian, Woragidpoonpol, & Baosoung,

2009).

What Remains Unknown?

The definition and standardization of developmental positioning has not been fully researched or implemented into practice (Coughlin, Lohman, & Gibbins, 2010).

Developmental positioning is inconsistently implemented (Gibbins,

Coughlin, & Hoath, 2010).

Poor Positioning Negatively Impacts:

Cerebral Blood Flow

Blood pressure

FiO2 needs

Pain scores

Sleep and rest

Need for PT

Motor development

Parental anxiety and satisfaction

Nursing satisfaction

Hip Abduction & Scapular Retraction

Hip Abduction & Scapular Retraction

Torticollis and Dolicocephaly

Torticollis

Flattened Posture

What’s Wrong w/this Picture?

Knees, Ankles, Feet

Knees extended, ankles and feet externally rotated

Knees, ankles, feet extended

Knees, ankles feet are alignedand softly flexed

NeckNeck hyperextended

Neck neutral

Neck neutral, head slightly flexed forward 10°

Hips

Hips abducted, externally rotated

Hips extended

Hips aligned and softly flexed

HeadRotated laterally (L or R) greater than 45° from midline

Rotated laterally (L or R) 45°from midline

Positioned midline to less than 45° from midline (L or R)

Shoulders

Shoulders retracted

Shoulders flat/in neutral

Shoulders softly rounded

Hands

Hands away from body

Hands touching torso

Hands touching face

Proper Positioning Components

Neutral head position

Rounded shoulders

Hips and knees flexed

Toes pointed straight

Hands to mouth

Boundaries provided appropriately

Mimic the fetal position

EYES, NIPPLES, KNEES & TOES ALL IN SAME DIRECTION = PROPER ALIGNMENT

Trying…

Still Trying

Principles of Building SupportsMaterials Concepts

Placement of Linen SupportSupine or Side lying Prone

Making a Nest - ProneEQUIPMENT PROCEDURE

Appropriate Size Bunting

Cloth diapers and/or T-shirts

Boundary rolls

Make an appropriate size linen support for the baby’s trunk

Place the linen support in the middle third of the bunting vertically!

Place the baby deep into the “pocket” of the bunting

Allow the shoulders to fall forward and the arms to “hang” somewhat

Place straps and use boundaries inside or outside the bunting

Prone PositioningSupport for Torso

Width – NIPPLE to NIPPLE Length – Ends at Groin

Making a Nest –Supine or Side Lying

Equipment Procedure

Appropriate size bunting

Cloth diapers and/or t-shirts to make supports for the shoulders

Boundary rolls/bumber

Position baby deep in the bunting pocket with the hips and knees flexed

Position the linen rolls to provide support behind the shoulders

Strap the baby in and use boundary rolls/bumpers as needed

Side-lying

Pretty Good

Better

Common Concerns IV site assessments

Skin temperature probe placement

Catheter toes monitoring

Temperature regulation

Phototherapy

“Safety” issues with hands to mouth positioning on ventilated patients

Current State of Our NICU Pros

Some developmental care products available

Incubators that facilitate developmental care

Developmental care committee and “experts” on staff

Interdisciplinary support

Cons

Not enough developmental care products

Wrong size products used on patients

Products used incorrectly much of the time

Lack of education/knowledge

Fear of the unknown

Hip abduction

Lack of circuit support

Practice Problem No standardization or exact definition for

developmental positioning in the literature

Minimal education on use of developmental positioning equipment at this facility

Musculoskeletal outcomes are adversely affected (preferential head turning, eversion of ankles, flattened skulls, scapular retractions, hip abduction)

Research Purpose Improve the developmental positioning

proficiency of neonatal intensive care unit (NICU) nurses

Determine the effectiveness of a standardized positioning assessment tool as a teaching and evaluation resource

Determine barriers to providing optimal developmental positioning

Standardized Positioning Tools Infant Position Assessment Tool (IPAT)

– developed 2007-2010

Validity and reliability established –2010

IPAT used in 2013 study

Two other standardized tools (China and Italy) – validity and reliability undetermined

MethodsA 46 bed Level 3 NICU Developmental positioning team recruitedPre-Post IPAT Score Collection – 54 and 55NICU Nurse Survey – 50% response rateEducation –IPAT at each bedside, voice

over slides on bedside computers, hard copy of materials in each room, bedside consultations with positioning team members available

Pre/Post IPAT Scores Total

Pre/Post IPAT Scores Individual

LimitationsShort intervention time

Informal education – not all nurses participated

No post intervention nurses survey

Positioning equipment availability lacking

Acuity of infants may have differed

Unknown if improvement will be long term

Conclusions and Recommendations IPAT and bedside education was useful in

improving developmental positioning practice -increase in IPAT scores was statistically significant

Informal (bedside) education may be a viable alternative to formal (skills lab or other) education needs

IPAT measurements in the future at this facility would indicate whether change in practice continued and/or improved further

References• Chen, C. M., Lin, K. H., Su, H. Y., Lin, M. H., Hsu, C. L. Improving the

positioning and nesting for premature infants by nurses in neonatal intensive care units. Hu Li Za Zhi 2014: Supplement 61.

• Coughlin, M., Lohman, M. B., Gibbins, S. Reliability and effectiveness of an infant positioning assessment tool to standardize developmentally supportive positioning practices in the neonatal intensive care unit. Newborn and Infant Nursing Reviews 2010: 10(2): 104-06.

• Gibbins, S., Coughlin, M., Hoath, S. B. Quality indicators: Using the universe ofdevelopmental care model as an exemplar for change. In Kenner C, McGrath J,editors. Developmental care of newborns and infants: a guide for health professionals. Missouri, United States :Mosby Publishers; 2010. P. 43-59.

• Giometti, E., Baroni, L., Artese, C., Davidson, A. Postural care of newborns in the NICU: A study of nurses’ educational needs. ChildrensNurses: Italian Journal of Pediatric Nursing Science 2009: 1(3): 95-100.

References Hunter, J. Therapeutic positioning; Neuromotor, physiologic, and sleep

implications. In Kenner C, McGrath J,editors. Developmental care of newborns and infants: a guide for health professionals. Missouri, United States:Mosby Publishers; 2010.

Jeanson, E. One-to-one bedside nurse education as a means to improve positioning consistency. Newborn and Infant Nursing Reviews 2013: 13(1): 27-30.

Louw, R., & Maree, C. The effect of formal exposure to developmental care principles on the implementation of developmental care positioning and handling of preterm infants by neonatal nurses. Health SA Gesondheid 2005: 10(2): 24-32.

References Madlinger-Lewis, L., Reynolds, L., Zarem, C., Crapnell, T., Inder, T., &

Pineda, R. The effects of alternative positioning on preterm infants in the neonatal intensive care unit: A randomized control trial. Research in Developmental Disabilities 2014: 35: 490-97.

Picheansathian, W., Woragidpoonpol, P., & Baosoung, C. Positioning of preterm infants for optimal physiologic development: A systematic review. Joanna Briggs Institute Library of Systematic Reviews 2009: 7(7): 224-59.

Preterm birth. (2013). Retrieved May 4, 2014, from http://www.who.int/mediacentre/factsheets/fs363/en/

Preterm birth. (n.d.). Retrieved May 1, 2014, from http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PretermBirth.htm

References Symington, A. J., & Pinelli, J. Developmental care for promoting

development and preventing morbidity in preterm infants. Cochrane Database of Systematic Reviews 2006: 2

VandenBerg, K. A. Individualized developmental care for high risk newborns in the NICU: A practice guideline. Early Human Development 2007: 83(7): 443-42.

Zarem, C., Crapnell, T., Tiltges, L., Madlinger, L., Reynolds, L., Lukas, K., et al. Neonatal nurses’ and therapists’perceptions of positioning for preterm infants in the neonatal intensive care unit. Neonatal Network 2013: 32: 110-16.