Digital Repository Doctoral Projects Spring 2022 Development of a Neonatal Nursing Training Program for Nurses Working in Community Hospitals Constance Hymas Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Hymas, C. (2022) Development of a Neonatal Nursing Training Program for Nurses Working in Community Hopsitals Weber State University Doctoral Projects. https;//dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Development of a Neonatal Nursing Training Program for Nurses Working in Community Hospitals by Constance Elaine Hymas A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE or MASTER’S OF SCIENCE IN NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 18, 2022 _____ ___4/18/2022_______________ Student Signature (electronic) Date _______________________________ __________________________ Faculty Lead Signature (electronic) Date _______________________________ __________________________ Date Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: This form and paper must be submitted by the program director. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 1 Development of a Neonatal Nursing Training Program for Nurses Working in Community Hospitals Constance Hymas Weber State University Annie Taylor Dee School of Nursing Doctorate of Nursing Practice Project Faculty Project Lead: Dr. Melissa Norton Project Consultant: Kristyn Steedly Date of Submission: April 7, 2021 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 2 Abstract Nurses working in maternal and neonatal units must be prepared to resuscitate and stabilize newborn infants who are ill or premature. Nurses working in small community hospitals without Neonatal Intensive Care Units lacked standardized education and training for frontline nurses caring for unexpected high-risk deliveries. This project aimed to develop an educational program to increase the competence of nurses working at these facilities in caring for this patient population. Evaluation results demonstrated that the nurses found the class informational and felt it would change their practice. Continued education on the care of ill or premature infants due to this project will be further disseminated systems-wide to increase nurses' competence in caring for these patients and their families. Keywords: competence, rural, premature, infant, nurse DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 3 Table of Contents Introduction ....................................................................................................................................6 Background and Problem Statement ............................................................................................7 Diversity of Population and Project Site .....................................................................................8 Significance for Practice Reflective of Role-Specific Leadership…………………………....10 Literature Review ........................................................................................................................10 Search Methods ..........................................................................................................................11 Synthesis of Literature...............................................................................................................11 Newborn Stabilization…………………………………………….……...……………...11 Levels of Care………………………………………………………………...………….12 Nursing Competence…………………………………………………………….……….14 Community Hospitals and Newborn Health Outcomes………………………………….14 Barriers to Competence…………………………………………………………………..16 Solutions……………………………………………………………...………………….17 Educational Modalities…………………………………………………………..17 Staff Involvement…………………………………………………………….…..18 Discussion…………………………………………………………………………….….18 Implications for Practice……………………………………………………………...….19 Framework……………………………………………………………………………………...19 Project Plan………………………………………………………………………..……………21 Project Design ……………………………………………………………….………….21 Needs Assessment of Project Site and Population………………………………………21 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 4 Cost Analysis and Sustainability of Project…………………………………..…..……22 Project Outcomes……………………………………………………………………….23 Consent Procedures and Ethical Considerations…………………………………..……23 Instruments to Measure the Effectiveness of Interventions…………………………….24 Project Implementation…………………………………………………………………..…..25 Interventions……………………………………………………………….…..……….25 Challenges………………………………………………………………………..…..…27 Impact…………………………………………………………………………..…...…..28 Project Evaluation…………………………………………………………………………….29 Data Maintenance/Security……………………………………..……………...………29 Data Collection and Analysis……………………………………………………….…..29 Strengths………………………………………………………………………..38 Weaknesses……………………………………………………………………..39 Quality Improvement Discussion…………………………………………………………….39 Translation of Evidence into Practice…………………………………………………..40 Implications for Practice and Future Scholarship……………...……………………….41 Sustainability…………………………..……………………………………………….41 Dissemination………………………………….……………………………………….42 Conclusion………………………………………………………………………………….….43 Reference List…………………………………………………………………………………44 Appendix A Care of the Ill and Premature Infant Class Outline…………………...……..51 Appendix B Case Studies………………………………………………………………..……54 Appendix C Gaming…………………………………………………………………………..58 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 5 Appendix D Cost Analysis……………………………………………………...……………..67 Appendix E Surveys…………………………………………………………………….……..70 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 6 Development of a Neonatal Nurse Training Program for Nurses Working in Community Hospitals. Regionalization of perinatal care in the United States has created a system in which high-risk pregnancies can be identified early and managed in facilities equipped with Neonatal Intensive Care Units (NICU) (Staebler, 2011). This system identifies hospitals equipped to provide high-level maternal and neonatal care while supporting small community hospitals through education and patient transport (Staebler, 2011). Regionalization has improved neonatal mortality and morbidity (Lasswell et al., 2010). The classification of pregnancies as low or high-risk aids in determining the best location in which pregnant women should receive care. High-risk risk pregnancies are those in which there is a likelihood the mother or infant will experience adverse health events. Low-risk pregnancies are those in which no complications or need for medical intervention have been identified (Kilpatrick et al., 2019). Most pregnancies in this community are classified as low-risk, making it possible for newborns to be delivered safely at community-based hospitals (Bellini, 2015). Although most pregnancies are uncomplicated, obstetrical and neonatal complications can occur and cannot always be predicted (Bellini, 2015). Up to ten percent of infants require some interventions at birth, and one percent require extensive resuscitation (Aziz et al., 2020). Nurses working in maternal and neonatal units must always be prepared for the need to resuscitate and stabilize patients (Bellini, 2015). This project aims to develop and implement a quality improvement neonatal nursing training program to increase the competency and confidence of nurses in managing obstetrical and neonatal complications working at community-based hospitals. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 7 Background and Problem Statement Nurses working in the Women and Children's units at Cache Valley Hospital and Brigham City Community Hospital have demonstrated that they have the training and skills needed for ensuring positive health outcomes for uncomplicated labor and delivery patients (D. Balls, personal communication, May 12, 2020, and K Griffin, personal communication, July 9, 2020). However, these nurses lack experience and skill in caring for unexpected preterm or critically ill newborns. During educational need surveys in 2020, nurses working on these units expressed a need for more education on the care of infants requiring more than primary newborn care (D. Balls, personal communication September 24, 2020, and K Griffin, personal communication, September 24, 2020). The absence of nurses trained to care for preterm or ill infants is a significant cause of poor neonatal outcomes (Lawn et al., 2013). Implementation of training programs, and continued practice of skills, is imperative to increasing nurse competence and neonatal outcomes (Ibrani & Molacavage, 2018). The Neonatal Resuscitation Program (NRP) is the benchmark for training nurses in the initial care of newborns (Ibrani & Molacavage, 2018). The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) (2021) assert that every delivery must be attended by at least one individual certified in NRP. While NRP provides concrete education and skill in the initial resuscitation and stabilization, it does not provide guidance for ongoing care (AAP and AHA, 2016). The STABLE program provides education on preterm and ill newborns' post-resuscitation/pre-transport stabilization care (Bellini, 2015). It is becoming standard for hospitals to require all staff caring for newborns to participate in STABLE (Kendall et al., (2012). In addition to education on resuscitation and stabilization, staff need training on those infants who may not be ill enough to require transport but require more than basic newborn DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 8 care (Hatch, 2012). Many facilities utilize The Perinatal Orientation and Education Program (POEP). This program consists of 15 online modules covering the care of mothers and infants (Association of Women's Health, Obstetric and Neonatal Nurses, n.d). Some facilities rely solely on a homegrown orientation program (MacKinnon, 2010). Both Cache Valley Hospital and Brigham City Community Hospital Women's Services Units require all nurses to take NRP every two years. STABLE and PEOP are required upon hire. Orientation beyond these courses consists of unit-developed orientation programs. There is no formalized ongoing education on caring for preterm or ill newborns (D. Balls, personal communication, February 10, 2021; K Griffin, personal communication, February 9, 2021). In 2018 there were 3,791,712 births registered in the United States; of those, 10% were born prematurely, prior to 34 weeks gestation (Martin et al., 2019). These infants often require more complex care because of their unique and critical care needs. Once stabilized, they are transferred to level II or III NICUs, which are prepared to deliver more critical care. However, newborns classified as late preterm, 34-36 weeks gestation, are often cared for in level I nurseries. In 2018 late preterm births accounted for 7.28% of all births in the United States (Martin et al., 2019). In 2019 there were 46,832 live births in Utah (Utah Department of Health, 2020a); 9.72% were preterm (Utah Department of Health, 2020b). It is estimated that almost half of Utah's preterm births are related to pregnancy complications, with the remaining preterm births related to unknown causes (Utah Department of Health, 2020b). Diversity of Population and Project Site Ogden Regional Medical Center (ORMC) supports several community-based hospitals that provide low-risk maternity and newborn services. These facilities provide standard delivery care by utilizing a labor, delivery, recovery, postpartum (LDRP) model in which women labor, DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 9 deliver their infants, and receive postpartum care in the same room (Ali et al., 2020). The goal is to keep mom and infant together in the same room. Despite screening during pregnancy and upon arrival to the facility, unseen complications may arise, necessitating the separation of mom and infant to provide care. Each facility has a Level 1 nursery available for such situations. Neither facility provides Neonatal Intensive Care services (MountainStar Healthcare, n.d.a; MountainStar Healthcare, n.d.b) Despite prenatal screenings and assessment upon arrival to the facility to identify mothers who are high risk, complications cannot always be anticipated (Hatch, 2012). The twenty-five registered nurses who work in these units are adept at providing care to laboring and postpartum mothers and their healthy infants. However, many of them lack training in caring for ill and preterm infants, and when called up to do so, they feel inadequate. Those nurses who have received training often lack confidence in their ability due to the low volume of preterm and ill infants. The development and implementation of a neonatal nursing training program will establish a means for the initial education of staff new to neonatal nursing and the continued education of nurses already trained to care for this patient population. This education will provide the staff with the skills and knowledge to stabilize and prepare preterm and ill newborns for transport. Increased training in caring for the neonatal population will provide staff with a better ability to recognize subtle signs of distress in newborns and allow for faster initiation of care, and potentially prevent severe illness (Hatch, 2012). Prevention of severe illness and the increased ability to care for infants with minor illnesses may also decrease the need to transfer newborns to a higher level of care (Rajan, 2018). The reduced need for transport will decrease family separation, stress, and healthcare costs (Rajan, 2018). There will also be benefits to the DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 10 organizations. Fewer transports will allow the facilities to capture revenue that would have been lost to receiving facilities (Rajan, 2018). Also, decreased family separation will increase patient satisfaction and encourage other families in the communities to receive maternal and infant care at these facilities (Rajan, 2018). Significance for Practice Reflective of Role-Specific Leadership The essentials of doctoral education for advanced nursing practice establish the competencies held by Doctor of Nursing Practice (DNP) graduates (Chism, 2019). The third essential focuses on clinical scholarship and analytical methods for evidence-based practice. This involves the ability to evaluate research, evaluate its applicability to the clinical setting, and utilize this information to guide practice and lead others in the provision of evidence-based practice (Chism, 2019). DNP leaders will find themselves involved in various roles throughout healthcare organizations, one of which may be the role of educator (Chism, 2019). This project will provide the DNP candidate with many opportunities to build leadership and educator skills. Working with facility and unit leaders and educators will strengthen collaboration skills and professional relationships. The utilization of current evidence on caring for premature and ill newborns and the development and delivery of education will require the use of analytic skills to ensure that course content is evidence-based. This project will allow the DNP candidate to lead nurses caring for ill and preterm newborns to attain and practice new knowledge and skills. This will enable them to deliver higher quality and safer patient care. Literature Review A literature review was conducted to gather current evidence on newborn infants' care requiring stabilization, care delivered in varying levels of nurseries, and educational challenges faced by nurses working in small community-based hospitals. This review illustrates the need for DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 11 nurses working in community hospital nurseries to receive education in caring for infants born preterm or ill. This review also demonstrates challenges faced by nurses in accessing this education. Search Methods Searches were conducted in PubMed, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), OVID Medline, Google Scholar, and the Weber State Stewart Library. Two searches were completed. The first focused on the care of newborns born preterm or ill and requiring stabilization. Search terms included "newborn", "neonatal", "stabilization", "resuscitation", “nurseries", and "levels of care". The second search was focused on the education and competence of nurses working in community or rural hospitals. Search terms included "nursing", "competence", "education", "orientation", “community”, and “rural”. Seventeen articles and one textbook were selected for use in this literature review. Synthesis of Literature This section aims to summarize findings from the previously mentioned searches to improve understanding of current evidence and best-practice regarding newborn care and nursing education. This summary will be utilized to plan, develop, and execute a neonatal nursing training program for small community hospitals. Newborn Stabilization Events surrounding the birth of an infant and care delivered during the first few minutes of life can have long-term implications. Identification of maternal and newborn risk factors assists with anticipation and planning for anticipated interventions. Marshall et al. (2020) conducted a review of maternal and fetal risk factors, which often lead to the need for newborn resuscitation and stabilization at birth. They presented a summary of current evidence-based DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 12 recommendations. These findings support the importance of actions taken within the first few minutes of birth and their impact on long-term neonatal outcomes (Marshall et al., 2020). They also reinforce findings and recommendations from the American Academy of Pediatrics (AAP) (2016) and the American Heart Association (AHA) (2016). At birth, the newborn infant goes through significant changes as they transition from the intrauterine to the extrauterine environment. The most critical of these changes involves the cardiorespiratory system and the infant's need to begin spontaneous respirations (Hilman et al., 2012). Most newborns make these transitions without difficulty. However, evidence shows that 4% - 10% of infants, whether born at term or preterm, will require assistance with respiratory support in the form of positive-pressure ventilation, and 1 in 3 will require chest compressions or emergency medications such as epinephrine or fluid boluses (AAP and AHA, 2016). The need for interventions at birth cannot always be anticipated. It is imperative for good patient outcomes that all nurses involved in delivering and stabilizing newborns are prepared for resuscitative and stabilization care. (AAP and AHA, 2016; Bellini, 2015; Marshall et al., 2020). These findings validate the need for nurses to be trained in the assessment, resuscitation, and stabilization of newborns utilizing standardized processes. Levels of Care When pregnancies are determined to be high-risk, attempts are made for delivery to occur at facilities equipped to provide the appropriate level of care (Bockli et al., 2013). This practice is considered one of the primary interventions responsible for the decline in maternal and infant mortality rates since the early 1980s (World Health Organization, 2014). To further improve neonatal outcomes and ensure newborns are cared for in facilities with the proper resources, The American Academy of Pediatrics published guidance on classifications of nursery care. These DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 13 classifications describe the type of care available, from basic to subspecialty care (Committee on Fetus and Newborn, 2012). These classifications assist families and medical providers in selecting the best location for care based on the infant's unique needs. In this system, nurseries are classified as level 1-4 based on available equipment and staff (Committee on Fetus and Newborn, 2012). Level I, Well Newborn Nurseries have trained personnel and equipment available to provide routine neonatal care and resuscitate and stabilize preterm and ill newborns when necessary. They can also care for newborns born at or after 35 weeks gestation who are physiologically stable. These nurseries are generally found in community and rural hospitals (Committee on Fetus and Newborn, 2012). Level II, or Special Care Nurseries, care for newborns > 32 weeks gestation with birth weights > 1500 grams who are not severely ill and are not likely to need subspecialty care while hospitalized. They also care for newborns who require mechanical ventilation or continuous positive airway pressure for < 24 hours (Committee on Fetus and Newborn, 2012). Level III nurseries, often referred to as NICUs, care for newborns of all gestational ages and weights. NICUs are equipped to provide advanced respiratory care, including high-frequency ventilation and inhaled nitric oxide, and offer a range of advanced imaging and subspecialty care. Basic surgical services may also be available (Committee on Fetus and Newborn, 2012). Level IV nurseries are equipped to offer more advanced care, such as surgical repair of complex conditions and extracorporeal membrane oxygenation (ECMO). They are also often the hub for neonatal transport and community outreach education (Committee on Fetus and Newborn, 2012). This classification system outlines the capabilities of facilities providing neonatal care. Knowledge of the levels of nurseries can be used to identify educational needs and improve the competence of nursing staff. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 14 Nursing Competence Competence is the ability to utilize knowledge and skills to analyze a situation, anticipate necessary actions, and develop a plan to attain desired outcomes (Smith, 2012). Nurses practicing in small community and rural settings experience different challenges than their counterparts in urban settings (Hurme, 2009). Often, they must be cross-trained and prepared to work in more than one clinical area (Hurme, 2009. When practicing in these hospitals, the flexibility required is compounded by the challenge of maintaining competency and confidence in low-volume, high-risk aspects of care (Banks et al., 2010; Hurme, 2009). Competencies should be specific to the patient population served and the needs of the nursing staff. The target facilities for this project follow the Donna Wright Competency Assessment Model (Wright, 2005). This model focuses on competency assessment to evaluate individual and group performance, meet regulatory standards, address problematic issues and enhance performance reviews (Wright, 2005). A key component of the Donna Wright Competency Assessment Model is the involvement of nurses in selecting needed competencies (Wright, 2005). This supports Knowles' Adult Learning Theory concept that adults are driven to learn by a need to problem solve in a timely and practical manner (Knowles et al., 2005). Community Hospitals and Newborn Health Outcomes Skilled and knowledgeable staff are as critical as equipment and supplies (Lawn et al., 2013). Providing staff with the education to care for newborn infants requiring more than basic care allows the community hospitals to continue to provide care for infants who would otherwise require transfer to facilities equipped to deliver a higher level of care (Rajan, 2018). Community hospitals are non-teaching facilities that provide acute care services to small geographical areas (Gallagher Healthcare, 2018). Community hospitals contain Level I nurseries and are primarily DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 15 focused on caring for healthy newborns or late preterm infants born between 35 and 37 weeks gestation (Committee on Fetus and Newborn, 2012). Complications during labor and delivery cannot always be anticipated. These small facilities may occasionally be required to care for infants born earlier than 35 weeks gestation or term infants who experience complications (Hatch, 2012). Nurses working in community hospitals must also be prepared to resuscitate, stabilize, and prepare for the transport of newborns born ill or preterm (Bellini, 2015). Nurses also often care for newborns referred to as "tweeners," those newborns who require more than routine care but do not require level II or level III NICU care (Hatch, 2012). Examples of tweeners include late preterm infants born at 35-37 weeks gestation and full-term newborns with health complications such as transient tachypnea of the newborn, hyperbilirubinemia, rule-out sepsis, and neonatal abstinence syndrome (Hatch, 2012). Nursing skills required to care for infants with these health conditions often go beyond the primary education, training, and skills often provided in community hospitals (Hatch, 2012). Nurses working in community hospitals must be prepared to care for infants in high-risk, low-occurrence circumstances (Ibrani & Molacavage, 2018). These nurses also need opportunities to practice these skills through continuing education and simulation (Hsu et al., 2015). The necessary additional skill set to care for these infants includes knowledge, recognition, and management of neonatal jaundice, sepsis, respiratory distress, nutritional support (including breastfeeding and formula feeding), thermoregulation, and support of the family (Lawn et al., 2013). The ability to care for newborns with these health complications promptly and without the physical stress associated with transport can positively affect long-term outcomes (Marshall et al., 2020). In addition, being prepared to care for these infants decreases family separation and healthcare costs, thereby increasing family satisfaction (Rajan, 2018). Decreased family separation increases family DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 16 bonding and improves exclusive breastfeeding. Exclusive breastfeeding has been shown to improve infant weight gain and decrease hospital length of stay (Couto et al., 2020). Barriers to Competence Nurses who desire to increase their knowledge, skills, and competence often feel that their endeavors are not supported. Studies in recent years have looked at what barriers nurses experience when pursuing continuing education. MacKinnon (2010) utilized an institutional ethnographic approach to recognize themes in nurses' social context working in rural healthcare facilities and identify possible change areas. In this ethnographic study, eighty-eight nurses working in five rural communities were interviewed. One emerging theme was nurses' experiences in learning to provide maternal child care in rural settings (MacKinnon, 2010). Nurses interviewed indicated that they had difficulty learning how to provide safe and reassuring care to maternity patients. They did not believe that attending one birth during orientation was sufficient to prepare them to care for laboring patients independently (MacKinnon, 2010). They also found it challenging to participate in formal education programs, such as the Neonatal Resuscitation Program (NRP) (MacKinnon, 2010). The AAP and AHA recommend that one NRP certified individual be present at every delivery. One nurse felt that she should decline to care for newborn patients due to a lack of training in NRP (MacKinnon, 2010). Nurses felt that decisions about nursing education were often based on staffing levels and cost of education rather than nurses' actual learning needs (Mackinnon, 2010). Penz et al. (2019) utilized data from a cross-sectional pan-Canadian Nursing Practice in Rural and Remote Canada II Survey to assess confidence and competence among 2065 registered nurses and nurse practitioners working in rural settings. Their findings were similar to MacKinnon's. Nurses felt that they were not provided with opportunities to participate in DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 17 continuing education. Nurses often felt there was a lack of support to attend continuing education programs due to critical staffing and lack of financial support from employers, including paid time away from work. Coventry et al. (2015) utilized an integrative review method to look at registered nurses' perspectives on their ability to participate in continuing education opportunities. They found that nurses are often unable or unwilling to participate in continuing education due to a lack of staff to cover their absence, lack of organizational financial support, and a reluctance to use personal time for professional education (Coventry et al., 2015). These studies demonstrate common barriers to competence. Recurring themes are lack of opportunity or funding to attend formal education, lack of adequate staffing to cover nurses' absences while attending classes, and lack of organizational support for ongoing education (Coventry et al., 2015; MacKinnon, 2010; Penz et al., 2019;). These themes present an opportunity for leaders to work with nurses to increase access to educational offerings and support to attend. Solutions Providing education to nurses in community hospitals can be challenging. Financial barriers are the cost of training, time away from work, and travel. Staffing is also a frequent challenge as small facilities have a smaller pool of nurses to draw from. These challenges require creativity in the development of educational programs. Traditional classroom education may not be feasible. Leaders and educators must take it upon themselves to develop creative yet effective education methods (Banks et al., 2012; Coventry et al., 2015; MacKinnon, 2010). Educational Modalities. Many educational modalities can be utilized for increasing nurse competence. In a pretest-posttest quasi-experimental design with 146 participants (Banks et al. (2010) found that nurses preferred hands-on, skills-based training, followed by just-in-time DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 18 training resources such as pocket cards. These findings support the need for interactive, hands-on nursing education. A qualitative study of fourteen nurses working in a rural hospital found that nurses appreciated online learning flexibility yet experienced challenges such as dedicated time and access to computers (Riley et al., 2015). A before and after educational intervention study by Mduma et al. (2015) found that frequent simulation drills improved knowledge retention. Staff Involvement. The development of any educational offerings must take into account adult learning theory. Adult learners want to be involved in assessing educational needs and developing and evaluating their own learning (Kaufman, 2003). By involving nurses in creating education plans and modalities, leaders and educators can ensure that they meet the staff's actual needs rather than perceptions of their needs. Discussion This literature search supports the concept that nurses working in community hospitals want and need education focused on caring for infants born preterm or ill. Nurses working in these settings often feel unprepared for caring for patients in low-volume, high-risk situations. Providing education that is easily accessible will improve nurse competence, patient outcomes, and family satisfaction. Nurses working in community hospitals face unique challenges in accessing education. Frequently there is an absence of education on low-volume patient care topics. Nurses also often feel that they are not supported by their supervisors to attend educational offerings due to cost or inadequate staffing. Providing education that is low-cost and available at their place of work can help overcome these barriers. Various learning methods should be utilized when developing educational programs for adult learners. Adults have different learning styles and preferences. The development of a robust educational program should involve staff in determining content and delivery methods. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 19 Implications for Practice Staff working in the maternal-child areas at Brigham City Community Hospital and Cache Valley Hospital do not regularly care for preterm or ill infants (D. Balls, personal communication, September 23, 2020; K. Griffin, personal communication, September 24, 2020). The need for these skills is infrequent, yet being able to perform the associated skills when needed can significantly impact long-term outcomes. Cache Valley Hospital and Brigham City Community Hospital utilize the Donna Wright method of competency assessment (Wright, 2005). One component of this method is to involve staff in determining what ongoing competencies are needed (Wright, 2005). Cache Valley Hospital and Brigham City Community Hospital utilize an annual Competency Assessment Tool to assess new or changing procedures, policies, equipment, or initiatives, high-risk aspects of their jobs, and problematic areas that require education. Staff expressed a need for increased education in caring for preterm and ill newborns during both the 2019 and 2020 Competency Assessment Tool process (Christie Gaz, personal communication, December 16. 2019; Kari Griffin, personal communication, September 24, 2020). Establishing a formal education program geared to this patient population will increase nurses' competence and confidence in caring for this patient population. The development of an effective program will require the involvement of nurses working on the maternal-child units and the use of multiple educational modalities. Framework Malcolm Knowles' Adult Learning Theory focuses on guiding adults through the learning process, based on the knowledge that most adults are self-directed and assume responsibility for their learning (Knowles et al., 2005). The Adult Learning Theory involves six assumptions about adult learners (Knowles et al., 2005): DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 20 1. Adults need to understand why they need to learn. 2. As individuals mature, their self-concept moves from dependence on others to lead their learning to being self-directed. 3. As individuals mature, their life experiences provide a strong foundation for learning. 4. When adults are involved in real-life situations, their readiness to learn is increased. 5. As individuals mature, they begin to appreciate the ability to apply new knowledge immediately. 6. Adults are driven to learn by a need to solve problems immediately and in a practical manner. Knowles and colleagues (2005) also stressed the importance of creating an environment of physical comfort, shared trust, respect, and acceptance to increase adults' ability to learn, hypothesize, and plan implementation in practice. Involving students in multiple interactive learning modalities helps the learner internalize new knowledge and organize it into a helpful pattern (Knowles et al., 2005). Nguyen et al. (2016) determined that applying these adult learning concepts helped undergraduate students understand how their patients responded to healthcare situations. Utilizing this framework requires that the intended participants of any educational endeavor be involved in content development and delivery planning. Framework Application to Project Knowles' Adult Learning Theory will be used to develop and deliver a training program focused on the educational needs of nurses working at the target sites. Adult learners need to understand the why behind education and be active participants in their learning (Knowles et al., 2005). Surveys will be used to query staff on specific topics they feel they need more education on regarding caring for preterm or ill newborns. Survey findings will be pooled with data from DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 21 educational planning staff meetings held in 2019 and 2020 (Christie Gaz, personal communication, December 16. 2019; Kari Griffin, personal communication, September 24, 2020) to develop a course outline. Volunteers will then be solicited from the target unit to assist with content development and planning of delivery methods. Adult learners also value the ability to apply new knowledge in problem-solving (Knowles et al., 2005). A variety of educational methods will be utilized, including case studies and simulation, to allow participants to apply new knowledge in a variety of situations. Project Plan Project Design The quality improvement design for this project is the development of a curriculum to increase the competency and confidence of nurses who work in level I nurseries and care for preterm or ill newborns. The educational program will be a four-hour face-to-face class that will involve didactic education, case scenarios, gaming, and simulation. The didactic instruction will consist of a PowerPoint presentation and group discussion. An outline of the class content is included in Appendix A. Case scenarios, presented in Appendix B, will be utilized for individual and group review. Gaming will consist of a Kahoots! review, medication relay game, and spinning wheel game. More details on these games can be found in Appendix C. Needs Assessment of Project Site and Population The primary stakeholders for this project are nurses working in level I nurseries at Brigham City Community Hospital and Cache Valley Hospital, which are part of the HCA Mountain Division. Additional stakeholders are nursing leaders, including the unit director and chief nursing officer. Indirect stakeholders are infants born preterm or ill and receiving care at these facilities and their families. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 22 Health disparities are well documented in the neonatal population (Reichman et al., 2021). For example, preterm birth is one of the primary causes of infant mortality in the United States (Enciso, 2020) and is often related to social determinants of health (Mauhck, 2017). Enciso (2020) identifies improved cultural competency through education as one of the first steps in overcoming health disparities. The National Association of Neonatal Nurses (NANN) also recognizes the role of education in the improvement of health disparities (2020). Nurses working in these facilities have frequently asked for increased education on caring for this unique patient population. Therefore, in the spring of 2021, an anonymous gap assessment survey was conducted electronically to determine specific areas where staff felt education was needed. The survey results were analyzed and utilized to develop the course outline and instructional content. The top three areas identified were: care of the infant with respiratory distress, assisting with UVC placement, and assisting with intubation. Unit leaders felt that these findings were consistent with their day-to-day observations. Additional areas included in the curriculum as a result of the gap assessment and discussion with leaders were therapeutic hypothermia, care of the infant experiencing neonatal abstinence syndrome, care of the infant with sepsis, and preparing infants for transport. Cost Analysis and Sustainability of Project The estimated cost for this project is $2,415.85. A cost analysis breaking down specific budget items is provided in Appendix D. This estimate includes person-hours for the students who will be missing a nursing shift to attend the class. Additional costs will consist of supplies required for class activities and a Survey Monkey account for pre-and post-course surveys. There will be no cost for simulation, as the instructor, or facilities, have the necessary equipment and DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 23 supplies. The cost-effectiveness of this course makes it easily sustainable, and plans are in place to incorporate it into courses regularly offered by the HCA Mountain Division. Project Outcomes The short-term objective of the project is to increase the competence and confidence of nurses working in level I nurseries when they are called upon to care for preterm or ill newborns. The birth of an infant who requires specialized nursing care cannot always be anticipated. Therefore, increasing the skills level of nurses who work on maternal-child units with NICU support is imperative in improving outcomes for these infants (Bellini, 2015; American Academy of Pediatrics (AAP) and American Heart Association (AHA), 2021). Furthermore, when nurses are unprepared to care for preterm or ill infants, there may be delays in resuscitation and stabilization, resulting in poorer long-term outcomes for the infant (Rajan, 2018). Increasing the skills levels of nurses working in these facilities will result in smoother resuscitation and preparation transport to a higher echelon of care (Rajan, 2018). Caring for newborn infants allows nurses to influence short-term outcomes and outcomes that will affect the infant throughout the lifespan (Rajan, 2018). The long-term outcome of this project is to prevent the progression of illness and decrease morbidity in preterm and ill newborns, decrease family separation, and decrease healthcare costs. Consent Procedures and Ethical Considerations IRB approval from Weber State University has been obtained for this project. HCA Mountain Division does not require IRB approval for this quality improvement project. All nursing staff working at level 1 hospitals at the designated sites will have equal opportunity to attend the class and will be informed that the class is part of a DNP project. Consent will be provided on survey instruments and implied when staff participate in surveys and register for the DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 24 class. Participants will be informed that the surveys are part of a DNP project when asked to complete them. Instruments to Measure the Effectiveness of Intervention Instrumentation will be utilized to measure the impact of the project on participants' competence and confidence. Four instruments will be used in this project to assess impact. The first is the pre-assessment, completed prior to the project implementation to determine knowledge gaps and develop course content. The second assessment is a course evaluation completed by students immediately upon completion of the class. These will follow-up surveys with students and their Directors at three-month intervals. These surveys were created in Survey Monkey and will take approximately two to five minutes to complete. During the pre-assessment, participants will report their level of competence on various topics as novice, advanced beginner, competent, proficient, or expert. Survey Monkey will analyze the results and provide a report detailing the percentage of responses for each level of competence on each topic. Immediately upon completion of the class, participants will be provided a post-course evaluation via QR code. The evaluation will take approximately five minutes to complete. In addition to knowledge and skills-based questions, nursing staff will evaluate the instructor, audiovisuals, course activities, and course content and suggest topics for future education. Staff will also be asked how well the course met the designated objectives and how they perceive attendance in the course will change their practice. The third tool will be follow-up surveys to assess how participation in the class has impacted daily practice. These surveys will be offered electronically and take approximately five minutes to complete. Questions will focus on changes in practice related to stabilizing ill or premature infants, preparing them for transport, and providing emotional support to their families. The fourth tool will query unit directors on their DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 25 perception of changes in practice for those staff who participate in the course. Appendix E contains all surveys included in the project. Project Implementation Interventions This project provides initial education for staff new to neonatal nursing and continued education of nurses already trained to care for ill and preterm infants. As a result, participants will be better able to recognize subtle signs of distress in newborns, allow for faster initiation of care, and potentially prevent severe illness. In addition, an increased ability to care for infants with minor illnesses may also decrease the need to transfer newborns to a higher level of care, thereby decreasing health care costs. The reduced need for transfer will also decrease family separation and increase patient satisfaction. Participant feedback provided immediately after the classes demonstrates a positive impact on nurses' competence and confidence. Further analysis over the next year will assess the project's continued impact as perceived by participants and their direct supervisors. The project began in June 2021 and was implemented at Cache Valley Hospital and Brigham City Community Hospital. The course content was developed based on a gap assessment conducted via an anonymous online survey sent to all nursing staff in the Women's Services units at the project sites. Nursing staff was able to access and complete the survey anonymously via a hyperlink or a QR code. Twenty-five surveys were distributed, and fifteen were completed. The gap analysis is an integral part of any quality improvement project. Gap analysis in the development of educational initiatives allows the project team to understand better the difference between learners' current understanding, skills, and practice and the preferred best DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 26 practice (Finkelman, 2022). This gap analysis focused on determining areas where the nursing staff felt they needed additional knowledge and skill. The gap analysis results were reviewed by the DNP candidate and one frontline nurse from each unit. These nurses were selected by the unit directors. Based on the gap analysis, course content focused on (a) respiratory distress, (b) assisting with umbilical venous catheter placement, (c) assisting with intubation, (d) therapeutic hypothermia, (e) Neonatal Abstinence Syndrome, (f) sepsis, and (g) preparing infants for transport. Additional content included updates from the Neonatal Resuscitation Program 8th edition, resuscitation and stabilization of preterm infants, and care of infants with conditions requiring special consideration during stabilization and resuscitation. Medications commonly used in the care of ill or preterm infants were also covered. The class was four hours in length and involved didactic lectures, case studies, and simulation. Gaming was used as a method for reviewing information presented during the class. The goals of this project were to increase nurses' knowledge, skills, and practice competency in caring for ill and preterm infants. The American Nurses Association (2015) defines competency as the expected level of nursing performance that incorporates knowledge, skills, abilities, and judgment centered around evidence-based standards. Competence assessment for this project is completed through self-reporting of staff and reports from unit directors. Measurement will be accomplished via follow-up surveys of class participants and their directors at three-month intervals for one year after the intervention. These surveys will assess competence, confidence, and change in practice as a result of participating in the class. All facilities within HCA Mountain Division are expected to engage in quality improvement activities to improve nurse competence and promote quality patient outcomes. The class developed for this project was offered twice, once at Cache Valley Hospital and once at DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 27 Brigham City Community Hospital. These hospitals often combine educational offerings due to their location and similar organizational setup. Five nurses were present at the beginning of the first class offered at Cache Valley Hospital; three were called away for patient care needs, resulting in two nurses completing the educational class. Feedback from the two participants reflected an increase in knowledge and an eagerness to incorporate this knowledge into practice. They reported that they felt more comfortable caring for ill or preterm infants after attending the class. One participant also expressed a desire to have similar training regularly to maintain and increase knowledge and skill. Evaluation of nursing education often focuses solely on the experience of the learner. However, educator self-evaluation is also essential (Parkinson, 2016). The instructor felt that the content was rushed at times and that adjustments were needed. Therefore, the content was amended based on student feedback and instructor evaluation to include fewer anecdotal stories to allow more time to focus on evidence-based content. Four students completed the class offered at Brigham City Community Hospital. Students reported increased confidence and a desire for continued education on caring for this patient population. In addition, students in both classes shared that they enjoyed the combination of didactic lectures, case studies, group discussion, and the use of gaming as a review rather than traditional paper and pencil post-test. These educational techniques will continue to be utilized in future educational programs. Challenges Challenges are expected during any quality improvement initiative, and successful change requires recognizing and acting upon these challenges. Two challenges were identified during this project. The primary challenge was staffing and the ability to schedule staff to attend the classes. The Women's Services units at Cache Valley Hospital and Brigham City Community DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 28 Hospital are small units with a combined total of twenty-five nurses. The small number of staff and the need to ensure uninterrupted patient care resulted in a small number of class participants. Staffing is a challenge inherent to any small community hospital and was accepted as part of the operational culture. The second challenge was the amount of content developed for the class. There was more information than could be adequately covered in four hours. Recommendations for sustainability are to divide the content into two three-hour classes. This adjustment will allow ample time to cover all of the needs identified during the gap assessment and ensure that learners' needs are met. Impact Most newborns transition to extrauterine life with any intervention beyond basic newborn care (American Academy of Pediatrics (AAP) and American Heart Association (AHA), 2021). Five percent of newborns require positive pressure ventilation, two percent need intubation, and one to three babies per 1,000 births will need chest compressions or emergency medications (AAP, 2021). Because these complications cannot always be anticipated, nurses working in small community hospitals must be prepared to resuscitate and stabilize infants born ill or preterm. Unfortunately, due to neonatal complications' low occurrence, these nurses often lack the knowledge, skills, and confidence to care for these infants. Increasing nursing staff competence and confidence in caring for and stabilizing preterm or ill newborns can positively affect long-term outcomes and decrease the need for transport to a higher level of care (Couto et al., 2020; Rajan, 2018). This class will continue to be supported by the HCA Mountain Division Center for Clinical Advancement (CCA). The cost per student is approximately $150.00, based on 16 students per year, and will be supported by work hours specified for annual nursing education. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 29 Based on initial findings, the course positively impacts the ability of nurses to care for ill and preterm infants. Continued assessment will determine the long-term impact on nurses, patients, and families. Project Evaluation Evaluation measures and determines the impact of an initiative by assessing current practice and improvement resulting from a quality improvement project (Finkelman, 2022). This section will look at project results based on follow-up surveys completed by participants and unit directors. Data maintenance, evaluation findings, and project strengths and weaknesses will be discussed. Data Maintenance/Security The privacy and anonymity of participants were maintained throughout the data collection and evaluation process. Data was gathered through SurveyMonkey utilizing a secure, single sign-on process. Data was also stored in SurveyMonkey, in a SOC 2 accredited data center (SurveyMonkey, n.d.). SOC 2 is a compliance system that securely holds and protects customer data. It is based on five principles of trust: security, availability, processing integrity, confidentiality, and privacy (Imperva, 2021). This system ensured that the author was the only individual with access to survey results. No personally identifiable information was collected, thereby maintaining anonymity. Data collected was utilized solely for the purpose of this project. Data Collection and Analysis Initial data collection focused on completing an organizational gap assessment of the learning needs of registered nurses working in the maternal-infant units at Brigham City Community Hospital and Cache Valley Hospital. Nurses working on these units were asked to complete the survey via an anonymous email link or a QR code. Education is often offered to DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 30 both facilities simultaneously to accommodate participant schedules and increase accessibility by staff. Therefore, data from both sites was gathered and analyzed together. Demographic data was gathered on how long the participant had been a registered nurse and how long they had worked on their current unit (Table 1). This data demonstrates a wide range of experience among the respondents. However, the majority (40%) of participants reported being a registered nurse for less than five years. There was a similarly wide range in how long the respondents had been employed on their current unit; most respondents (46.67%) reported working on their current unit for four to six years. Table 1 Work Experience Years 0-5 6-10 10-15 >15 n % % % % As a Registered Nurse 15 40 13.33 13.33 33.33 Years 0-2 2-4 4-6 6-8 >8 n % % % % % Employed on current unit 15 20 13.33 46.67 6.67 13.33 Participants were asked to report their level of competence in fifteen areas related to neonatal nursing (Table 2). Levels of competence were categorized as:  novice = minimal or textbook knowledge  advanced beginner = working knowledge of the key aspects  competent = good working and background knowledge  proficient = strong working and background knowledge  expert = authoritative knowledge with the ability to teach others. Participants were also asked about other topics on which they would like to receive education. Comments included "when to intubate vs. continue nasal cannula," "re-enforcement of NG or DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 31 OG tube insertion for high flow O2", "congenital anomalies," "lumbar punctures," and "Necrotizing Enterocolitis." Finally, results from the gap assessment were utilized to develop course content. Table 2 Gap Assessment Findings Question Novice Advanced Beginner Competent Proficient Expert N % % % % % Initial stabilization of ill or premature newborns 15 6.67 40 33.33 13.33 6.67 Providing positive-pressure ventilation 15 6.67 20 26.67 33.33 13.33 Providing chest compressions 15 0 20 46.67 20 13.33 Assisting with intubation 15 33.33 40 13.33 6.67 6.67 Assisting with insertion of an umbilical vessel catheter (UVC) 15 40 20 26.67 13.33 0 Preparing the newborn for transport 15 13.33 6.67 53.33 13.33 13.33 Care of the Late Preterm Infant 15 0 13.33 46.67 33.33 6.67 Care of the infant with hyperbilirubinemia 15 0 0 40 40 20 Care of the infant with sepsis 15 13.33 13.33 53.33 13.33 6.67 Care of the infant with respiratory distress 15 0 33.33 46.67 13.33 6.67 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 32 Care of the infant with hypothermia 15 0 40 33.33 20 6.67 Care of the infant with hypoglycemia 15 0 6.67 40 46.67 6.67 Care of the infant experiencing Neonatal Abstinence Syndrome 15 13.33 26.67 46.67 13.33 0 Infant feeding (breast, nasogastric tube (NG), bottle, cue-based) 15 0 6.67 33.33 26.67 33.33 Providing emotional support to families of ill or premature newborns 15 6.67 13.33 33.33 40 6.67 The initial gap assessment survey was analyzed and discussed the findings with a team of one staff nurse from each unit, selected by the unit director. These results were utilized to develop course content. The course was offered once at each facility. Nurses selected which class they would attend based on their work and personal schedules. Six staff nurses (n=6) participated in the class. Five participants completed the immediate post-course evaluation. Attendance was lower than anticipated due to staffing and patient acuity. Participants were asked to complete an immediate post-course evaluation to assess course delivery and changes in knowledge. Demographic data showed that most class participants had less than five years of experience as a registered nurse and had been employed on their current unit for less than two years (Table 3). Table 3 Work Experience Years 0-5 6-10 10-15 >15 n % % % % As a Registered Nurse 5 80 0 0 20 Years 0-2 2-4 4-6 6-8 >8 n % % % % % Employed on current unit 5 80 20 0 0 0 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 33 Course participants found the instructor knowledgeable and organized, that audiovisuals and course activities enhanced the course and that the content was relevant to their practice (Table 4). Knowledge-related changes varied amongst the topics covered and are reported in Table 5. Subjects with the most significant reported change in knowledge were maintenance of thermoregulation and recognition of pneumothorax and congenital diaphragmatic hernia. Topics with the lowest reported change in knowledge were assisting with securing an endotracheal tube, the 3x3 method for insertion of an Umbilical Venous Catheter, and the ability to communicate with parents after the transfer of an infant. All participants reported that they would change their practice as a result of attending the class. When asked what they liked most about the course, responses included, "The in-depth knowledge and details about each subject instead of just skimming by each subject," "I liked the interactive activities and how the slides were printed out to take notes," "Identification of possible birth defects and how to manage and care for them," "Knowledge of instructor, instructor was easy to ask questions," and "I learned so much that was targeted to what I will sue and how to be prepared." Suggestions for changes to the course included, "I wish there was a course like this quarterly to learn more, it was great" and "Perhaps incentive for others coming to course to get more people here, increasing attendance." Participants were also asked what topics they would like to receive education on in the future. Responses included "TPN and lipids, nec" and "Practice UVC insertion after watching the video." A follow-up survey was conducted three months after completion of the course to evaluate self-reported changes in practice. Three class participants completed this survey, resulting in a 50% return rate. Demographic data from the three-month follow-up showed that two respondents had less than five years of experience as a registered nurse, while one had DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 34 greater than fifteen years of experience. In addition, all of the respondents had been employed on their current unit for less than four years (Table 6). All participants agreed or strongly agreed that their practice had changed as a result of attending the class (Table 7). Table 4 Course Effectiveness Question: Strongly agree Agree Neither agree nor disagree Disagree Strongly Agree n % % % % % The instructor was knowledgeable and held my interest. 5 100 0 0 0 0 The instructor was organized. 5 100 0 0 0 0 Audiovisuals contributed to the course. 5 100 0 0 0 0 Content was relevant to my practice. 5 100 0 0 0 0 Table 5 Post Course Evaluation Question: As a result of attending this class, I am able to: Strongly agree Agree Neither agree nor disagree Disagree Strongly agree n % % % % % Provide positive-pressure ventilation. 5 60 20 20 0 0 Identify changes in the Neonatal Resuscitation Program (NRP) 8th edition. 5 80 2 0 0 0 Identify proper methods for maintaining thermoregulation in a preterm infant. 5 100 0 0 0 0 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 35 Recognize the signs and symptoms of pneumothorax. 5 100 0 0 0 0 Recognize signs and symptoms of a congenital diaphragmatic hernia. 5 100 0 0 0 0 Safely prepare Epinephrine for administration to an ill newborn. 5 60 20 20 0 0 Assist with securing an Endotracheal Tube. 5 40 60 0 0 0 Describe the 3x3 method for emergent insertion of an Umbilical Venous Catheter (UVC). 5 40 60 0 0 0 Recognize infants who are candidates for Therapeutic Hypothermia. 5 60 40 0 0 0 Communicate with the parents of an infant who has been transferred to another facility. 5 40 60 0 0 0 I will change my practice. 5 100 0 0 0 0 Table 6 Work Experience Years 0-5 6-10 10-15 >15 n % % % % As a Registered Nurse 3 66.67 0 33.33 0 Years 0-2 2-4 4-6 6-8 >8 n % % % % % Employed on current unit 3 33.33 66.67 0 0 0 Open-ended questions were also included in the follow-up survey to assess changes in practice further. These questions provided participants an opportunity to share, in their own DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 36 words, how participation in the class impacted their daily practice. Participants were asked to share three practices they changed as a result of the class. Responses included, "Positioning and handling of premature infants. Changes in NRP steps. How to handle infants with cord hernias", "I now have a better understanding of some of the disease processes and my responsibility with them," and "I haven't had many ill or preterm infants since taking this class, but I feel much more prepared for when I am put in these circumstances." Table 7 Participant Three-month Follow-up Question: I have made changes in: Strongly agree Agree Neither agree nor disagree Disagree Strongly Agree n % % % % % My daily practice. 3 33.33 66.67 20 0 0 My practice when stabilizing ill or premature newborns. 3 33.33 66.67 0 0 0 Preparing infants for transport. 3 0 100 0 0 0 How I support families of ill or premature infants. 5 0 100 0 0 0 Unit directors were also surveyed three months after the class to assess the observed change in practice of the class participants. All unit directors responded to the survey. Demographic data of the unit directors (Table 8) showed that one had been a registered nurse for 6-10 years and one for greater than fifteen years. One was a relatively new unit director, having been in that position for less than four years; the other had been in her position for greater than eight years. Both unit directors indicated they had observed a change in practice among those nurses who participated in the class (Table 9). When asked what information they would like to see in future classes., one director stated, "Being a level 1 SCN, I think just the content you have DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 37 been doing and repeat as needed since there are many times we go weeks or even months without a sick baby." A success story in stabilizing an ill newborn was also shared: "We had a 6 day old baby present to our ER last week with kernicterus, posturing, seizure-like movements, lethargic, cold temp 95.3 rectal, bilirubin level 33. We were able to start infant on oxygen for O2 sat 70%, start IV fluids, warm infant, start antibiotics and initiate Bili lights and finally transport the infant all within 90 minutes of arrival, baby was sent to PCMC on 1/19, and discharged to home 1/22. What we thought would be an infant that would pass away turned the corner and was able to go home. We won't know long term damage at this time, but the fact that the infant survived, miracles! Strong work and quick thinking and response from our L&D and Nursery staff!!!" This story demonstrates the need for nurses in small community hospitals to recognize and promptly treat ill newborns and the success that can be achieved with the necessary skills and knowledge. Table 8 Unit Director Work Experience Years 0-5 6-10 10-15 >15 n % % % % As a Registered Nurse 2 0 50 0 50 Years 0-2 2-4 4-6 6-8 >8 n % % % % % Employed on current unit 2 0 60 0 0 60 Table 9 Unit Director Three-month Follow-up Question: Strongly agree Agree Neither agree nor disagree Disagree Strongly agree n % % % % % DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 38 I have seen improvements in the daily practice of staff who attended the class. 2 50 50 20 0 0 I have seen changes in the practice of staff who attended the class when stabilizing ill or premature newborns. 2 50 50 0 0 0 I have seen changes in preparing infants for transport after staff attended the class. 2 50 0 50 0 0 I have seen changes in how staff who attended the class support families of ill or premature infants. 2 50 50 0 0 0 Strengths A strength of this project was the utilization of a gap assessment survey to determine class content. This ensured that the information taught was relevant to the nurse's self-reported needs rather than the perceptions of the instructor or unit directors. In addition, the post-course evaluation demonstrated that all class participants gained knowledge that they felt would result in a change in their practice. Finally, three-month follow-up surveys of both the class participants and unit directors demonstrated a change in practice as a result of attending the class. Program participants and unit directors will be surveyed again at six, nine, and twelve months after the classes to assess sustained change in practice. Based on current findings, the course will be offered when leadership, or staff, identifies a need. It is recommended that the course become a regular part of orientation for new nurses or added to future competency education plans. Information on topics desired for future education was included in planning 2022 Competency Education for both facilities. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 39 Weaknesses A weakness of this project was the small sample size. Staffing challenges made it difficult for many nurses to attend. However, this is a pilot project, and the findings are relevant to the sustainability of the class. In addition, more content was created than could be covered during the allotted class time. Future classes will be expanded to six hours, taught in two increments of three hours. The post-course evaluation was made available immediately upon the conclusion of the class via a QR code. One participant did not complete the post-course evaluation. The three-month follow-up survey had a fifty percent response rate. Participation in both the post-course evaluation and the follow-up survey may have been increased by offering an incentive for completion. However, it is difficult to remain anonymous when offering incentives. Finally, the questions in the gap assessment, post-course evaluation, and three-month follow-up surveys were not written in a manner that allows close cross-comparison of results. However, the six, nine, and twelve-month surveys will mimic the three-month survey and allow for cross-comparison of sustained change in practice due to attending the class. Quality Improvement Discussion This quality improvement project demonstrates that a focused education program can increase the competence and confidence of registered nurses working in small community hospitals. The self-report of improved knowledge and skills, as demonstrated during education training observations, will improve the overall quality of care at the Brigham Community Hospital and Cache Valley Hospital. These improvements in nursing practice will prepare nurses to provide a higher level of care, leading to improved patient outcomes, decreased need for family separation, and increased family satisfaction (Rajan, 2018). DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 40 Translation of Evidence Into Practice The translation of knowledge into practice is how research findings are communicated and implemented into clinical care (Curtis et al., 2017). The transparent delivery of patient care that is safe and effective requires the application of evidence derived from sound research into daily practice to improve patient outcomes (Curtis et al., 2017). In 2003, the Institute of Medicine (IOM) published five core competencies for healthcare professionals; these include: 1) The provision of patient-centered care. 2) Collaboration of interdisciplinary teams. 3) Utilization of evidence-based practice. 4) Implementation of quality improvement initiatives. 5) The use of informatics (Finkelman, 2022). The use of research findings in quality improvement projects ensures that nursing care is based on the most current evidence. Quality improvement initiatives based on education and training require an assessment of the instruction provided, including the inclusion of learner needs in curriculum development and the effectiveness of the teaching in meeting the desired outcomes (Oermann & Gaberson, 2019). Nurses working at Brigham City Community Hospital and Cache Valley Hospital have repeatedly expressed their apprehension when caring for ill or premature infants. Much of this apprehension is based on a lack of understanding of current practice standards and how to apply evidence in daily practice. Providing evidence-based educational training for nurses caring for this patient population has increased the nursing staff's knowledge, skills, and comfort level. An immediate increase in knowledge and comfort was evident in participants' immediate post-course evaluations. The implementation of this new knowledge and comfort into daily practice was DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 41 demonstrated through self-reported changes in practice during a three-month class participant follow-up survey and a survey of unit directors' observations during the same time period. The positive outcomes of this pilot program demonstrate a positive return on investment for community hospitals that support the continued education of nursing staff working with newborn infants. This investment in nursing education will improve patient outcomes through the participants' increased ability to deliver quality, evidence-based, and safe patient care to ill and premature infants. Implications for Practice and Future Scholarship Frontline nurses working in community hospitals without in-house neonatal intensive care unit support must be prepared to stabilize and care for ill or premature infants. This preparation requires education, training, and simulation to acquire and maintain the necessary knowledge and skills (Lawn et al., 2013). Limited access to education and situations to practice and utilize the knowledge and skills required when caring for this patient population makes it difficult for nurses to develop competence and confidence. The implementation and dissemination of this quality improvement project created an accessible and standardized education program for nurses in small community hospitals. This DNP project provides a foundation for the continued development of similar educational programs, which can be repeated regularly to maintain skills and knowledge. As nurse competence and confidence increase, additional content can be developed to build upon this foundation and continue to increase the depth of knowledge of these nurses Sustainability Sustainability is the aptitude to maintain a course of action without depleting available resources. The Royal College of Physicians (RCP) identified sustainability in healthcare as the DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 42 ability to deliver care to a specific individual today and the population as a whole, and future patients (Atkinson et al., 2010). Sustainability is significant in quality improvement to ensure that positive outcomes are continued beyond the conclusion of an initiative (Atkinson et al., 2010). For example, the need to stabilize and care for ill or premature infants at small community hospitals is uncommon, yet staff must continually be prepared to care for these infants. The sustainability of this project will ensure that nurses have continued opportunities to receive education and training to prepare them to care for this patient population. Brigham City Community Hospital and Cache Valley Hospital are part of the HCA Mountain Division and receive educational support through the HCA Mountain Division Center for Clinical Advancement (CCA). This standardized educational program has been officially incorporated into the HCA Mountain Division CCA education library and is readily available to the eleven hospitals within the HCA Mountain Division. The content may be delivered as a whole, or specific topics within the curriculum may be used based on learning needs. This will ensure continuity of standardized education and patient care delivery throughout the division. Dissemination Quality improvement initiatives often result in positive outcomes for patients and healthcare staff. Unfortunately, these results are not consistently shared with others. This lack of dissemination results in a delay in, or lack of, implementation of initiatives shown to improve outcomes (Melnyk & Fineout-Overholt, 2019). Dissemination of results from this project will assist other facilities, and educators, in providing education to nurses caring for ill or premature infants. Several means will be used to disseminate this pilot project's findings. Initial dissemination will be through a formal presentation to the DNP cohort and Weber State Faculty in April 2022 and publication of results in the Weber State Doctor of Nursing Practice DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 43 Repository database. Outcomes will also be shared with key stakeholders at Brigham City Community Hospital, Cache Valley Hospital, and HCA Mountain Division CCA in May 2022. In addition, sustained practice changes will be assessed through follow-up surveys with class participants and unit directors at six, nine, and twelve months post-class participation. Results of the continued surveys will be shared with the key stakeholders quarterly. The results of this project can easily be extrapolated for use in other hospital systems. Efforts will be made to share the information at a national level by submitting abstracts to present findings at the Fall 2022 Academy of Neonatal Nursing conference and the 2023 Annual Convention of the Association for Nursing Professional Development. Presenting at these events will allow information to be shared with staff nurses, managers, and educators, hopefully inspiring them to develop similar programs aimed at improving patient outcomes through increased nursing competence and confidence. Conclusion This quality improvement project demonstrated the positive impact of formal education on the competence and confidence of frontline nurses working in community hospitals. Immediately upon completion of the class, participants reported an increase in the knowledge and skills required to care for infants born ill or premature. They also reported a change in their nursing practice three months later. Similarly, unit directors reported that they had observed a change in practice among those nurses who attended the class. It is anticipated that these positive findings will also be observed during continued follow-up surveys. This class can be utilized as a foundation upon which to build further education in various nursing specialties. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 44 References Ali, E., Norris, J.M., Hall, M., & White, D.E. (2020). Single-room maternity care: Systematic review and narrative. NursingOpen, 7, 1661-1670. http://doi.org/10.1002/nop2.586 American Academy of Pediatrics (AAP) and American Heart Association (AHA). (2021). Textbook of Neonatal Resuscitation (8th ed.). The American Academy of Pediatrics. American Nurses Association (2015). Nursing scope and standards of practice (3rd ed.). American Nurses Association. Association of Women's Health, Obstetric and Neonatal Nurses (n.d.). Perinatal Orientation and Education Program (POEP). https://www.awhonn.org/education/perinatal-orientation-and-education-program-fourth-edition-poep4/ Atkinson, S., Ingham, J., Cheshire, M., Went, S. (2010). Defining quality and quality improvement. Clinical Medicine, 10, 537-539. https://doi/org/10.7861/clinmedicine.10-6-537. Aziz, K., Lee, C. C., Escobedo, M. B., Hoover, A. V., Kamath-Rayne, B. D., Kapadia, V. S., Magid, D. J., Niermeyer, S., Schmölzer, G. M., Szyld, E., Weiner, G. M., Wyckoff, M. H., Yamada, N. K., & Zaichkin, J. (2020). Part 5: Neonatal resuscitation 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics, 147(Supplement 1), e2020038505E. https://doi.org/10.1542/peds.2020-038505e Banks, C. M., Gilmartin, H., & Fink, R. M. (2010). Education methods for maintaining nursing competency in low-volume, high-risk procedures in the rural setting. Journal for Nurses in Staff Development (JNSD), 26(3), E1-E7. https://doi.org/10.1097/nnd.0b013e3181aa2f54 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 45 Bellini, S. (2015). Postresuscitation care and pre-transport stabilization of newborns using the principles of stable transport. Nursing for Women's Health, 19(6), 533-536. https://doi.org/10.1111/j.1751-486x.12248 Bockli, Kl, Andrews, B., Pellerite, M., & Meadow, W. (2013). Trends and challenges in united states neonatal intensive care units follow-up clinics. Journal of Perinatology, 34 (1), 71-74, https://doi.org/10.1038/jp.2013.136 Chism, L. A. (2019). The doctor of nursing practice: A guidebook for role development and professional issues (4th ed.). Jones & Bartlett Learning. Committee on Fetus and Newborn (20120. Levels of neonatal care. Pediatrics, 130(3), 587-597. https://doi.org/10.1542/peds.2012-1999 Couto G. R., Dias, V., & de Jesus Oliveira, I. (2020). Benefits of exclusive breastfeeding: An integrative review. Nursing Practice Today, 7(4), 245-254. https://doi.org/10.18502/npt.v7i4.4034 Coventry, T. H., Maslin-Prothero, S. E., & Smith, G (2015). Organizational impact of nurse supply and workload on nurses continuing professional development opportunities: An integrative review. Journal of Advanced Nursing, 71(12), 2715-2727. https://doi.org/10.1111/jan.12724 Curtis, K., Fry, M., Shaban, R.Z., & Considine, J. (2017). Translating research findings into clinical practice. Journal of Clinical Nursing, 25(5-6), 862-872, https://doi.org/10.1111/jocn.13586. Enciso, J. M. (2020). Teaching culturally competent healthcare in neonatal-perinatal medicine. Seminars in Perinatology, 44(4), 151239-151245. https://hal.weber.edu/login?url=https://dx.doi.org/10.1016/j.semperi.2020.151239 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 46 Finkelman, A. (2022). Quality improvement. A guide for integration in nursing. Jones & Bartlett Learning. Gallagher Healthcare. (2018, March 22). What are the different types of hospitals? Gallagher Healthcare: Industry Insights Blog. https://www.gallaghermalpractice.com/blog/post/what-are-the-different-types-of-hospitals Hatch, J. (2012). The role of the neonatal nurse practitioner in the community hospital level 1 nursery. Neonatal Network, 31(3), 141-147. https://doi.org/10.1891/0730-0832.31.3.141 Hsu L., Chang, W., & Hsieh, S. (2015). The effects of scenario-based simulation course training on nurses' communication competence and self-efficacy: A randomized controlled trial. Journal of Professional Nursing, 31(1), 37-49. https://doi-org.hal.weber.edu/10.1016/j.profnurs.2014.05.007 Hurme, E. (2009). Competencies for nursing practice in a rural critical care access hospital. Online Journal of Rural Nursing and Health Care, 71(12), 2715-2727. https://doi.org/10.14574.ojrnhc.v9i2.88 Ibrani, D. & Molacavage, S. (2018). The six-hour window: How the community hospital nursery can optimize outcomes of the infant with suspected hypoxic-ischemic encephalopathy. Neonatal Network, 37(3), 155-163. http://dx.doi.org/10.1891/0730-0832.37.3.155 Imperva. (2021). SOC 2 compliance. https://www.imperva.com/learn/data-security/soc-2-compliance/ Kaufman, D. M. (2003). Abc of learning and teaching in medicine: Applying educational theory in practice. BMJ, 326 (7382), 213-216. https://doi.org/10.1136/bmj.326.7382.213 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 47 Kendall, A.B., Scott, P.A., & Karsen, K.A. (2012). The S.T.A.B.L.E. program. The evidence behind the 2012 update. The Journal of Perinatal & Neonatal Nursing, 26(2), 147-157. http://doi.org/10.1097/JPN.0b013e31825277d4 Kilpatrick, S.J., Menard, M.K., Zahn, C.M., & Callaghan, W. M. (2019). Obstetric care consensus #9: Levels of maternal care. American Journal of Obstetrics and Gynecology, 221(6), B19-B30. https://doi-org.hal.weber.edu/10.1016/j.ajog.2019.05.046 Knowles, M., Holton, E.F., & Swanson, R. A. (2005). The adult learner. The definitive classic in adult education and human resource development (6th ed.). Burlington, MA: Elsevier. Lasswell, S., Barfield, W., Rochat, R., & Blackmon, L. (2010). Perinatal regionalization for very-low-birth-weight and very preterm infants. JAMA, 304(9), 992. https://doi.org/10.1001/jama.2010.1226 Lawn, J. E., Davidge, R., Paul, V.K., Xylander, S., deGraft Johnson, J., Costello A., Kinney, M. V., Serge, J., & Molyneux, L. (2013). Born to soon: Care for the preterm baby. Reproductive Health, 10(S1). https://doi.org/10.1186/1742-4755-10-s1-s5 MacKinnon, K. (2010). Learning maternity: The experience of rural nurses. Canadian Journal of Nursing Research, 42(1), 39-54. https://cjnr.archive.mcgill.ca/article/view/2234 Marshall, S., Lang, A. M., Perez, M., & Saugstad, O. A. (2020). Delivery room handling of the newborn. Journal of Perinatal Medicine, 48(1), 1-10. https://doi.org/10.1515/jpm-2019-0304 Martin, J. A., Hamilton, B. E., Osterman, M. J. K., & Driscoll, A. K. (2019). Births: Final Data for 2018 (National Vital Statistics Reports Volume 68, Number 13). Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13-508.pdf DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 48 Mduma, E., Ersdal, H., Svensen, E., Kidanto, H., Auestad, B., & Perlman, J. (2015). Frequent brief on-site simulation training and reduction in 24-h neonatal mortality—an educational intervention study. Resuscitation, 93, 1-7. https://doi.org/10.1016/j.resuscitation.2015.04.019 MountainStar Healthcare (n.d.a). Brigham City Community Hospital. Retrieved March 1, 2021, from https://mountainstar.com/specialties/labor-and-delivery/?location=brigham-city-community-hospital MountainStar Healthcare (n.d.b). Cache Valley Hospital. Retrieved March 1, 2021, from https://mountainstar.com/specialties/labor-and-delivery?location=cache-valley-hospital National Association of Neonatal Nurses. (2020). Racial disparity in the NICU – Position statement #3070. National Association of Neonatal Nurses. http://nann.org/uploads/About/PositionPDFS/Racial_Dispariy_in_the_NICU_-_FINAL_6.12.20.pdf Parkinson, B. (2016). Using evaluation to improve teaching and revalidation. Nursing Times, 7, 8-10. https://www.nursingtimes.net/roles/nurse-educators/using-evaluation-to-improve-teaching-22-08-2016/ Penz, K. L., Stewart, N.J., Karunanayake, C. P., Kosteniuk, J.G. & MacLeod, M.P. (2019). Competence and confidence in rural and remote nursing practice: A structural equation modeling analysis of national data. Journal of Clinical Nursing, 28(9-10), 1664-1679. https://doi.org/10.1111/jocn.14772 Rajan, S. (Ed). (2018). Neonatal care and the neonatal intensive care unit; Challenges & Opportunities. [White Paper]. MCG Health. https://doi.org/https://www.ahip.org/wp-content/uploads/2018/11/MCG-White-Paper-Neonatal-Care-and-the-NICU-AHIP.pdf DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 49 Reavy, K. (2016). Inquiry and Leadership. F.A. Davis Company. Reichman, V., Brachio, S. S., Madu, C. R., Montoya-Williams, D., & Pena- M. (2021). Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities. Seminars in Fetal and Neonatal Medicine, 26(1), 101198-101205. https://doi.org/10.1016/j.siny.2021.101198 Riley, K. & Schmidt, D. (2015). Does online learning click with rural nurses? A qualitative study. Australian Journal of Rural Health, 24(4), 265-270. https://doi.org/10.1111/ajr.12263 Smith, S. A. (2012). Nurse competence: A concept analysis. International Journal of Nursing Knowledge, 23(3), 172-182. https://doi.org/10.1111/j.2047-3095.2012.01225.x Staebler, S. (2011). Regionalized systems of perinatal care. Advances in Neonatal Care, 11(1), 37–42. https://doi.org/10.1097/anc.0b013e318206fd5a SurveyMonkey. (n.d.). Ensuring your data is secure and compliant is our top priority. https://www.surveymonkey.com/mp/data-security-and-compliance/ Utah Department of Health. (2020a). Complete Health Indicator Report of Birth Rates. https://ibis.health.utah.gov/ibisph-view/indicator/complete_profile/BrthRat.html Utah Department of Health. (2020b) Important Facts for Preterm Birth. https://ibis.health.utah.gov/ibisph-view/indicator/important_facts/PreBir.html World Health Organization (2014). Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, INFPA, the World Bank and the United Nations Population Division. http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 50 Wright, D. (2005). The Ultimate Guide to Competency Assessment in Health Care (3rd ed.). Creative Health Care Management. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 51 Appendix A Care of the Ill and Premature Infant Class Outline Time Objectives Learner/Activity Goals Content Evaluation/Outcomes 5 minutes Introduction Instructor and students introduce themselves and participate in an ice breaker activity. Icebreaker—each participant will share one thing about themselves that makes them unique. Increase familiarity and comfort among instructor and students. 20 minutes Identify changes in the Neonatal Resuscitation Program (NRP) 8th Edition Update PowerPoint (PPT) Presentation and discussion. PPT presentation List three changes in the NRP 8th edition update. 20 minutes Understand NRP considerations specific to premature infants. PPT presentation and participation in case study. PPT presentation Case study as a group Verbalize the difference in the resuscitation of preterm infants compared to term infants. 20 minutes Recognize newborn conditions requiring special consideration. PPT presentation and participation in case studies. PPT presentation Small group discussion of specific conditions (pneumothorax, airway obstruction, maternal opiate or anesthetic exposure, myelomeningocele, and abdominal wall defects) with a report out to large group. Appropriate determination of care required by infants with specific considerations. 10 minutes Demonstrate understanding of NRP topics. Participate in Kahoot! review Kahoot! game Participation in Kahoot! review. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 52 20 minutes Identify common medications used in the care of ill or premature infants. PPT presentation PPT presentation Participate in group discussion. 10 minutes Demonstrate understanding of common medications and proper administration. Medication Relay Game Medication Relay Game. The class will be divided into 2-3 teams. Relay will include matching of information related to medications discussed, demonstration of how to draw up appropriate doses of Epinephrine, and how to appropriately administer glucose gel. Active participation in relay game. 70 minutes Content determined by gap analysis --Care of the Infant with Respiratory Distress --Assisting with UVC Placement --Assisting with Intubation --Hypothermia (Cooling) --Care of the Infant experiencing Neonatal Abstinence Syndrome --Care of the Infant with Sepsis --Preparing Infants for Transport PPT presentation PPT and group discussion Participate in discussion. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 53 15 minutes Demonstrate understanding of topics determined by gap analysis Spin the Wheel Game The class will be divided into 2-3 teams. They will spin a game wheel and answer questions related to the topics discussed. Participate in review game. 45 minutes Exhibit appropriate actions for caring for a premature infant. Simulation and small group discussions. Simulation activity will be based on stabilization and preparation for transport of an infant born with Gastroschisis. At the completion of simulation, the class will break into groups of 2-3 to discuss topics support of the family after transport. They will then share discussion with the larger group. Successfully stabilize premature infants and prepare for transport. Discuss support of family after transport. 5 minutes Question & Answer and course evaluation. Students will ask the instructor for clarification on topics and complete course evaluation. Survey via QR code Completion of course evaluation. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 54 Appendix B Resuscitation and Stabilization of a Premature Infant Case Study Mary has presented to your facility at 30 weeks gestation. She reports her membranes ruptured 45 minutes ago, and the fluid was clear. She is actively contracting. After examining her, the provider reports that she is 8cm dilated and unstable for transport. A vaginal delivery is anticipated. Question 1: What steps would you take to prepare for delivery? Question 2: What supplies would you gather? Mary quickly progresses to complete and delivers a female infant. At delivery, the infant has flexed extremities but is not crying. The provider gently suctions the mouth and nose and provides gentle stimulation. At 15 seconds, the infant begins to take some spontaneous breaths. By 30 seconds, the infant is consistently taking spontaneous breaths. The umbilical cord is clamped at 60 seconds, and the baby is handed to your resuscitation team. Question 3: Was delayed cord clamping appropriate in this scenario? The infant is carried to the radiant warmer, placed on a blanket-covered thermal mattress, and wrapped in plastic wrap. A servo-controlled temperature sensor is applied to the infant's skin, and a hat is placed on the infant's head. The baby is breathing and has a heart rate of 110. However, the breathing is labored and breath sounds are decreased. Question 4: What are your next steps? The infant's breath sounds and work of breathing improve, but the oxygen saturation remains lower than target. Question 5: What is your next step? DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 55 The infant's oxygen saturation rises to an appropriate level. Question 6: What are your next steps? DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 56 Special Considerations Case Studies Case 1 (Pneumothorax) A term infant is born via emergency cesarean section. After birth, the umbilical cord is clamped, and the infant is handed to the resuscitation team. The infant is warmed, dried, and stimulated. The infant is assessed and found to be floppy with no respiratory effort, and the heart rate is 40 bpm. Positive Pressure Ventilation (PPV) is initiated, and a pulse oximeter is placed on the right hand. After 60 seconds of effective PPV, the heart rate remains less than 60 bpm. Chest compressions are initiated, the infant is intubated, and the oxygen concentration is increased to 100%. After 60 seconds of chest compressions and ventilations, the heart rate remains less than 60 bpm. A UVC is placed, and a dose of Epinephrine is administered, followed by a normal saline flush. The infant's condition does not improve. During an assessment of ventilation, it is noted that the breath sounds are absent on the right side. What do you suspect is the cause of the infant's condition? How would you treat it? Case 2 (Robin Sequence) A female infant is born at 38 weeks gestation. Upon delivery, she is placed prone on her mother's abdomen, and the umbilical cord is clamped at 30 seconds of life. After the umbilical cord is clamped, the infant is quickly assessed and found to be vigorous, crying, and centrally pink. It is noted that her hands and feet are blue, and she has a small jaw. She is moved to her mother's arms. The mother holds the infant supine so that she and the father can look at her closely and count her fingers and toes. The infant begins to have difficulty breathing, and her color becomes dusky. What do you suspect is causing her breathing difficulties? How would you treat this infant? DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 57 Case 3 (Congenital Diaphragmatic Hernia) A male infant is born at 37 weeks gestation. Upon delivery, he is floppy with no respiratory effort. The umbilical cord is clamped and cut, and he is placed under the radiant warmer. He is warmed, dried, and stimulated yet remains floppy and apneic. You note he has a barrel chest and a flat abdomen. What do you suspect is causing his respiratory distress? How would you treat this infant? Case 4 (Gastroschisis) A 16-year-old female presents in labor. She has had no prenatal care. Membranes rupture as you get her into a bed. The fluid is clear. Upon exam, she is found to be completely dilated and effaced. She begins pushing and 30 minutes later delivers a female infant who appears to be full term. It is noted that the infant's intestines are protruding from the abdominal wall. What are special considerations to be taken during this infant's initial resuscitation and stabilization? DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 58 Appendix C NRP Kahoot Game DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 59 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 60 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 61 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 62 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 63 Medication Relay Game Students will be divided into 2-3 teams. They will: 1. Be given laminated game pieces to match. 2. Upon successfully matching all game pieces, they will then be instructed to draw up an appropriate dose of Epinephrine for a 3,000-gram infant. 3. After drawing up the appropriate dose of Epinephrine they will demonstrate how to administer glucose gel to a 3500-gram infant. Game Pieces EPINEPHRINE Administered for a heart rate less 60 bpm after 30 seconds of PPV and 60 seconds chest compressions OXYGEN The dose for this medication may vary depending on gestational age VOLUME This medication is indicated if the baby not responding to resuscitation efforts and there are signs of shock or a history acute blood loss. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 64 GLUCOSE May be given IV or PO This antibiotic breaks down the cell wall and should be given first. Levels of this antibiotic must be monitored due to potential cause hearing loss. NARCAN There is insufficient evidence on the safety and efficacy of this medication to recommend it’s use in the neonatal population. DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 65 Spinning Wheel Game Students will be divided into 2-3 teams. They will spin a wheel with numbers written in each spot. Each number will correspond to a question. If they fail to answer the question appropriately, the other team gets a chance to respond. Each question is worth 100 points. When a question has been asked, the number will be erased from the wheel. Questions: 1. The purpose of Surfactant is: Prevent alveolar collapse by decreasing surface tension. 2. What should be evaluated during a respiratory assessment? Respiratory rate, work of breathing, and color. 3. What is the appropriate size Endotracheal Tube for a 3 Kg infant? 3.5 4. What landmarks are used to measure placement for an NG tube? DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 66 Nare, to ear lobe, to halfway between the xiphoid process and the umbilicus. 5. What are the primary differences between an emergent and non-emergent UVC? Depth of insertion, emergent is not placed under sterile conditions. 6. What are important safety considerations for a non-emergent UVC? Sterile technique during placement, suture/secure the catheter in place, document centimeter marking at the umbilicus, monitor for accidental catheter migration. 7. Criteria for Therapeutic Hypothermia include: > 36 weeks gestation, > 1800 grams, pH < 7.0, base deficit > 16 or an abnormal neurologic exam 8. An I:T ratio greater than what raises the suspicion for infection? 0.2 9. What does the acronym ISBAR stand for? Identification, Situation, Background, Assessment, Recommendation. 10. Infants born to mothers who took this substance during pregnancy generally do not exhibit withdrawal symptoms but may experience long-acting dysregulation. Marijuana, Cocaine 11. What actions should take place when a transport team arrives to pick up a newborn? Give the team a detailed report, provide copies of medical records and tests, accompany them to the parent's room 12. What can you do to support the parents of a newborn who has been transferred to another facility? Clarify information, assist mother with pumping if she wants to breastfeed, offer to call support persons, refer to the infant by name DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 67 Appendix D Cost Analysis DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 68 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 69 Appendix E Pre-Assessment Survey CARING FOR THE ILL OR PREMATURE NEWBORN The following is an online survey that takes approximately five minutes. The survey questions will be about your level of competence in caring for ill and premature newborns. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of the survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact constance.hymas@mail.weber.edu. Please rate your level of competence utilizing the following scale: Novice = minimal or textbook knowledge Advanced Beginner = working knowledge of the key aspects Competent = good working and background knowledge Proficient = strong working and background knowledge Expert = authoritative knowledge with ability to teach others Novice Advanced Beginner Competent Proficient Expert Initial stabilization Providing positive-pressure Ventilation Providing chest compressions Assisting with intubation Assisting with insertion of an umbilical vessel catheter (UVC) Preparing the newborn for transport Care of the Late Preterm Infant DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 70 Care of the infant with hyperbilirubinemia Care of the infant with sepsis Care of the infant with respiratory distress Care of the infant with hypothermia Care of the infant with hypoglycemia Care of the infant experiencing Neonatal Abstinence Syndrome Infant Feeding (breast, naso-gastric tube [NG], bottle, cue-based) Providing support to families of ill or premature newborns This survey has been built in survey monkey and may be completed via the link or QR code. https://www.surveymonkey.com/r/C7RL6G5 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 71 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 72 Post-Course Evaluation CARING FOR THE ILL OR PREMATURE NEWBORN COURSE EVALUATION The following is an online survey that takes approximately three minutes. The survey questions will be about your level of competence in caring for ill and premature newborns. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of the survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact constance.hymas@mail.weber.edu. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree The instructor was knowledgeable and held my interest. The instructor was organized. Audiovisuals contributed to the course. Course activities enhanced learning. Content was relevant to my practice. As a result of completing this course, I am able to provide positive-pressure ventilation. As a result of completing this course, I will change my practice. The following questions will be open-ended: What did you like most about this course? What suggestions do you have for changing this course? What topics would you like to receive education on in the future? This survey has been built in Survey Monkey. The associated link and QR code are: DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 73 https://www.surveymonkey.com/r/CDHV9FP DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 74 Change in Practice Evaluation CARING FOR THE ILL OR PREMATURE NEWBORN CHANGE IN PRACTICE EVALUATION The following is an online survey that takes approximately two minutes. The survey questions will be about your level of competence in caring for ill and premature newborns. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of the survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact constance.hymas@mail.weber.edu. As a result of attending the Caring for the Ill and Premature Newborn Course: Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree N/A I have made changes in my daily practice. I have made changes in my practice when stabilizing ill or premature newborns. I have made changes in preparing infants for transport. I have made changes in how I support families of ill or premature infants. The following questions will be open-ended: List three practices you have changed as a result of attending the course. This survey has been built in Survey Monkey. The associated link and QR code are: https://www.surveymonkey.com/r/C2VFJ5H DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 75 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 76 Director Change in Practice Evaluation CARING FOR THE ILL OR PREMATURE NEWBORN CHANGE IN PRACTICE EVALUATION The following is an online survey that takes approximately two minutes. The survey questions will be about changes in the practice of your staff since attending the Caring for the Ill or Premature Newborn class. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of the survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact constance.hymas@mail.weber.edu. As a result of attending the Caring for the Ill or Premature Newborn Course: Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree N/A I have seen improvements in the daily practice of staff who attended the class. I have seen changes in the practice of staff who attended the class when stabilizing ill or premature newborns. I have seen changes in preparing infants for transport after staff attended the class I have seen changes in how staff support families of ill or premature infants. The following questions will be open-ended: What content would you lie to see added to future classes?. This survey has been built in Survey Monkey. The associated link and QR code are: https://www.surveymonkey.com/r/VGPW7L3 DEVELOPMENT OF A NEONATAL NURSING TRAINING PROGRAM 77