Digital Repository Doctoral Projects Fall 2022 Secure Family Attachment Amber J. Barrus Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Barrus, A. J. (2022) Secure Family Attatchment. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/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. 1 Secure Family Attachment by Amber J. Barrus A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah 10/24/2022 _______________________________ ______________________________ Student Name, Credentials (Electronic Signature) Date Diane Leggett-Fife, PhD, RN _____________________________ __October 24, 2022_________________ DNP Project Faculty (Electronic Signature) Date _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Note: The program director must submit this form and paper. Amber J. Barrus, DNP-FNP Student, RN October 24, 2022 2 Secure Family Attachment Amber J. Barrus, DNP-FNP Student, RN Weber State University Annie Taylor Dee School of Nursing Doctorate of Nursing Practice Project Faculty Project Lead: Dr. Diane Leggett-Fife, Ph.D., RN Project Consultant: Dr. Jennifer Mitchell, Ph. D., BCBA-D Date of Submission: 10/24/2022 3 Abstract Childhood secure attachment profoundly contributes to developing coping mechanisms, confidence, resilience, executive functioning, and overall health. Educational opportunities for parents on tools that promote secure attachment will increase parental confidence and enhance bonds between parent and child. Purpose: This project addresses a preventative measure for improving mental and physical health outcomes by targeting relational interactions between child and parent. Methodology: Infant massage is a nonpharmacologic therapy introduced in a time of substantial brain neuroplasticity (Alto & Petrenko, 2017; Wright & Edginton, 2016). Parents receiving family dyadic relationship therapy at a nonprofit mental health agency attended a five-week infant massage course. They received instruction on infant behavior states, neurological reflexes, cue-reading, and massage strokes. The Karitane Parenting Confidence Scale (KPCS) served as pre- and post-evaluation. Parents filled out the KPCS prior to the start of the course and after its completion. Results: Post-evaluation results revealed an increased standard deviation in the following categories: parental knowledge of how to deal with their crying infant, understanding of infant cues, decision-making skills in the care of the infant, and confidence in the ability to parent the infant. Implications for Practice: Educational modalities such as infant massage enhances parental knowledge and confidence, promoting secure attachment in infants. The implications of secure attachment are supportive of improved, lifelong outcomes in overall mental and physical health (Kaya & Aydin, 2021; Rasmussen & Storebo, 2019; Stefano & Atkins, 2017). 4 Keywords: secure attachment, therapeutic touch, infant massage, early intervention, dyadic relationships, preventative car 5 Table of Contents Promoting Secure Family Relationship Through Parental Infant Massage 8 Background and Problem Statement 9 Diversity of Population and Project Site 9 Significance for Practice Reflective for Role-Specific Leadership 10 Literature Review and Framework 11 Attachment 11 Implications for Parent and Child 11 Barriers 13 Treatment 14 Therapeutic Touch 15 Efficiency 16 Parent and Child 17 Barriers 17 Solution 18 Early Intervention 18 Infant Massage 19 Other Solutions 20 Framework 21 Discussion 21 Implications for Practice 22 6 Project Plan 23 Project Design 23 Needs Assessment/Gap Analysis of Project Site and Population 23 Cost Analysis and Sustainability of Project 26 Project Outcomes 26 Consent Procedures and Ethical Considerations 27 Instrument(s) to Measure Intervention Effectiveness 28 Project Implementation 29 Project Intervention 29 Final Deliverables 29 Outline of Presentation 29 Information Brochure 30 Teaching Materials 30 Project Timeline 31 Project Evaluation 32 Data Maintenance/Security 32 Findings 35 Strengths 35 Weaknesses 35 Discussion 36 7 Translation of Evidence Into Practice 37 Implications for Practice and Future Scholarship 38 Sustainability 38 Dissemination 38 Conclusion 40 Appendix A 51 Appendix B 52 Appendix C 53 Appendix D 556 Appendix E 56 8 Promoting Secure Family Relationship Through Parental Infant Massage Research shows that childhood adversity can profoundly impact individuals' future welfare, mainly when traumatic events have accumulated over time. Early stress can negatively impact developmental health while sabotaging connectedness in caregiver ministration (Masten & Barnes, 2018). Productivity and decreased health disparities are achieved more quickly in children who demonstrate an aptitude for resilience or a tendency for adaptability in the face of distressful or potentially threatening conditions (Pourkord et al., 2020). Dependable, safe family environments are highly influential in developing resilience in children. The most profound factors associated with resilience are nurturing familial bonds, parental skills, and close connections that foster affective tolerance (Masten & Barnes, 2018). John Bowlby (1973), a well-known psychoanalyst who focused his work on children, theorized that a secure attachment between a child and a stable adult figure extensively impacts that child's future resilience and behavioral health. Secure attachment in childhood facilitates the development of affect-regulation and productive coping skills throughout adulthood, thus having far-reaching implications for long-term outcomes (Fraley, 2018). Interventions addressing attachment security are best delivered in early childhood when neuroplasticity can provide greater accessibility to enhanced development (Leblanc et al., 2017). Therapeutic touch is an effective modality for enhancing bonds and building relational safety between caregiver and child. Research shows the strengthening of attachment security when mothers consistently massage their infants (Field, 2019; Shoghi et al., 2018). Conceptually, there is a lack of understanding of the significance of therapeutic touch as a tool for attachment enhancement (Midtsund et al., 2019). The primary aim of this project is to recommend, implement, and evaluate an evidence-based practice change that promotes secure attachment in 9 families through the administration of an infant massage course for parents and guardians of children ages zero to seven in a community setting. Background and Problem Statement Secure attachments lead to healthier emotional and physical outcomes, while insecure attachments are associated with mental illness and dysfunction (Rasmussen & Storebo, 2019). Infant massage provides therapeutic touch, caregiver awareness, cue-reading, and consistent connection as an effective early intervention for building secure attachment (Leblanc et al., 2017; Wright & Edginton, 2016). Abdallah et al. (2020) described facilitating factors of parental engagement in infant massage practice as positive motivation, adequate preparation, thoughtful presentation, consistency, and establishing protocols. There is currently a deficiency of educational training for parents on the benefits, implications, and therapeutic touch methods. Parents of infants and young children need to understand the impact of therapeutic touch on forming secure family attachments (Midtsund et al., 2019). The lack of parental support for building secure attachment and its future implications has led to the aim of this project: to establish parental education supportive of using tools to enhance secure attachment for children. Diversity of Population and Project Site The setting for this DNP project will be a local, nonprofit organization that provides family therapy and a therapeutic preschool for preschool-aged children. The Children’s Center (TCC) offers comprehensive behavioral health care to children and strives to educate and support family systems with children throughout the community (The Children's Center, 2020). Spanning across northern Utah's socioeconomic populations, this project's target population will be the families who attend TCC. The Children’s Center's clinicians focus on early intervention, thereby treating children as young as infancy, and seek to recommend and recruit families to receive the 10 additional support of an infant massage training course (J. Mitchell, personal communication, March 25, 2021). Significance for Practice Reflective for Role-Specific Leadership In the Essentials of Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nursing, 2006), the first essential addresses the scientific foundation for DNP practice which relates to the aim of this project for promoting secure attachment through a method of therapeutic touch. DNP practice incorporates a holistic approach to wellness by acknowledging the dynamic interaction of behavior with an individual's environment. The DNP graduate is qualified to amalgamate a full scope of nursing science, including “ethics, the biophysical, psychosocial, analytical, and organizational sciences," (American Association of Colleges of Nursing, 2006, p. 9) to promote whole-person wellness customized for specific populations. 11 Literature Review and Framework This literature review investigates evidence-based practices that promote and support secure family attachment through a therapeutic touch methodology. Specific overarching themes emanate from the literature review to govern the development of an infant massage course designed for parents in a community setting. These themes include the implications of attachment, family involvement as exemplified in the Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU, early intervention, and therapeutic touch as a means for bond enhancement (Davidson et al., 2016; Field, 2019; Rasmussen & Storebo, 2019; Wright & Edginton, 2016). The six-step Rosswurm and Larrabee Model were utilized as a framework to direct this project (Reavy, 2016). Search Methods Search terms for this paper include secure attachment, therapeutic touch, early intervention, touch therapy, family engagement, primary care, provider, assessment, behavioral, infant massage, preterm, state anxiety, attachment theory, coping, resilience, clinical practice guidelines, and family, modeling, family involvement, parental empowerment, bonding, physical touch, Bowlby, and Ainsworth. The databases used for this literature review were CINAHL, PubMed, Google Scholar, and EBSCO. Database search exclusion criteria included journal articles older than five years, lacking peer review, and without online access to the full text. Attachment Implications for Parent and Child Enduring emotional connections between people defines attachment (Bowlby, 1973). The most influential attachment relationships occur early in childhood and provide the framework for a child to approach life's vicissitudes. Secure attachments lead to healthier emotional and 12 physical outcomes, while insecure attachments are associated with mental illness and dysfunction (Kaya & Aydin, 2021; Rasmussen & Storebo, 2019; Stefano & Atkins, 2017). A secure attachment framework allows a child to experience change and risk vulnerability because they operate from a consistent, secure base in their caregiver. Children gradually develop expectations of recurrences in these relational patterns throughout their infancy and early childhood and then learn to respond accordingly to the emotions elicited from these events. The child’s confidence is derived from their experience with caregivers (Ainsworth, 1985; Bowlby, 1973). Through early attachments, children form a view about themselves and the relational aspects of others around them while expanding the areas of the brain that mediate social and emotional regulation (Leblanc et al., 2017; Naveed et al., 2020). Secure attachments with adults provide children with a stable underpinning for coping mechanisms from which confidence can grow, while a tendency for resilience is fostered even at the cellular level (Caputo et al., 2020; Connors, 2011). Yu et al. (2017) supports the influence of early bonding in a multi-center, single-blind, randomized control trial study in Taiwan. This study showed an association between a family-centered intervention program (FCIP) and short-term outcomes for preterm neonates with birth weights under 1,500 grams in neurobehavioral development and weight gain (p <.05). Furthermore, secure attachment leads to enhanced executive functioning skills, serving the child's ability for self-discipline, goal-oriented thinking, and emotional regulation throughout their life (De Cock et al., 2017; Regueiro et al., 2020). In a descriptive correlational study with a cluster sample of 354 college-aged students, Pourkord et al. (2020) found that resilience is strongly linked to attitudes of religiousness, happiness, and secure attachment (p<0.01). 13 Caregivers hold central roles in attachment development, from which the child learns about the self and the interactions with the world around them. The caregiver’s consistent response to the child's cues determines the pattern from which the child learns to perceive threats and self-regulate (Ainsworth, 1985; Bowlby, 1973). Consistency of empathetic, patient responses from a caregiver perpetuates a secure attachment in the child. A caregiver who shows insensitivity and rejects the child tends to perpetuate an insecure-avoidant attachment in the child who is organized in dealing with distress by avoiding emotional expression around the caregiver (Benoit, 2004; Naveed et al., 2020; Wright et al., 2018). A caregiver who inconsistently responds to the child’s cues potentiates an insecure-resistant attachment in a child who resists the caregiver when the caregiver tries to connect with the child. Finally, the atypical caregiver responds to the child through terrorized, dissociated, or sexualized behavior, eliciting a disorganized method of dealing with stress with an insecure-disorganized attachment style. The child’s level of sensitivity is associated with the example of their caregivers’ behavior (Benoit, 2004; Murphy et al., 2015; Wright et al., 2018). Barriers Several barriers to secure attachment in childhood include a lack of resources, skilled clinical personnel, and culturally sensitive programs. Mental illness and other parental burdens also negatively affect the child's development (Alto & Petrenko, 2017; De Cock et al., 2017). Many children have suffered trauma and losses, disrupting secure attachments to stable adult figures (Berardi & Morton, 2017). Traumas that impede the development of secure family attachments have a wide range and can include environmental disasters, foster care, and a parent imprisoned for a crime. A child's perception of mental illness, such as depression in their parents, impedes their ability to develop a secure attachment (Kerley et al., 2021; Pleines, 2019). Some 14 issues affect the parent's emotional availability and stability, such as divorce, low income, violence, opioid use disorder, and other dependencies. Addictions prove detrimental to the establishment of secure attachment for children and impede parental mindfulness in reading their child’s cues (Kerley et al., 2021; Letourneau et al., 2020; Mirick & Steenrod, 2016). Treatment Attachments develop from birth and have a lasting effect until death. Therefore, early treatment carries implications for lifelong outcomes (Bowlby, 1973; Leblanc et al., 2017). Ainsworth (1985) hypothesizes that infants demonstrate the instinct towards forming attachments as a means of survival and security by exhibiting reflex behaviors that encourage caregivers' closeness, such as crying and, in later infancy, discrimination of the caregiver. These instinctual attachments of infancy form relational and emotional behavior in later years, thereby revealing a critical time to facilitate healthy bonding in early life (Connors, 2011; Leblanc et al., 2017). In a systematic review and meta-analysis of four randomized control trials, Mountain et al. (2017) found that secure attachment and mothers' mindfulness of their child's cues improve with treatment focusing on relational connectedness between infant and mother. Therapeutic measures are more effective for the patient and benefit the family when there is a focus on empowering parents and enhancing parental sensitivity, family involvement, presence, and connectedness (Wright & Edginton, 2016; Yu et al., 2017). In the Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU, evidence-based recommendations make optimized family engagement a means for enhancing patient wellness. The recommendations demonstrate the high priority of family involvement as a catalyst for healing and well-being. The recommended standards are inclusive of family presence, participation in care, education, and communication and specifically highlight the need for 15 parents to receive instruction on how to help in the care of their baby as a means for improving parental proficiency, confidence, and emotional health (Afand et al., 2017; Davidson et al., 2016). Parental engagement in care leads to an enhanced connection with their child while heightening their awareness of their cues. Parental education involving therapeutic awareness and intervention enables parents to advocate, instilling confidence and enabling them to participate more fully in the care of their child (Midtsund et al., 2019; Shoghi et al., 2018). Treatment involving parent mindfulness can profoundly affect the outcomes of parent-child attachment and the child's emotional regulation. In a cross-sectional qualitative study conducted by Zhang et al. (2019), 472 parents of children ages 4 to 6 were given the Mindful Attention Awareness Scale, a take-home questionnaire examining the effects of parental mindfulness on the children’s emotional regulation and attachment. Results showed that parental mindfulness was positively associated with parent-child attachment (p<0.001), lending to lower negative emotional reactivity in preschool-aged children (p=0.005) and increased emotional regulation (p<0.001). Therapeutic Touch The use of touch as a therapy has been widely studied and utilized as an evidence-based practice to combine deliberate, empathetic use of physical contact to promote health (Therapeutic Touch International Association, 2019). Intentional, nurturing touch is a powerful constituent of healthy relationships between caregiver and child and a fundamental development component across the lifespan (Field, 2019; Weaver, 2017). Various therapeutic touch methods, including infant massage, are commonly used in successful programs designed to improve the connection and attachment between caregiver and child (Wright & Edginton, 2016). Kimberli Berrett (personal communication, February 5, 2021), a clinical mental health counselor TCC in 16 Salt Lake City, Utah, suggests that a consistent nurturing touch is a profound tool. Nurturing touch can impact caregivers and children, building connectivity and enhancing secure attachment. Efficiency Intentional touch with a therapeutic emphasis is a natural, cost-effective, simple intervention free of the adverse effects often seen in other therapies involving pharmacologic treatment or other medical procedures (Midtsund et al., 2019; Yucel et al., 2020). Deliberate, nurturing touch as a treatment modality is widely applicable across many medical and psychosocial issues (Hanley et al., 2017; Weaver, 2017). Purposeful, therapeutic touch to enhance well-being improves patient outcomes in a wide variety of care populations, including cancer care, chronic pain, anxiety, nausea, depression, sleep, weight gain in neonates, agitation in Alzheimer's disease, students, and many others (Hanley et al., 2017; Therapeutic Touch International Association, 2019; Weaver, 2017). In addition, as an efficient intervention with little risk for adverse events, therapeutic touch can be a practical component of numerous successful programs designed for family involvement (Rodrigues et al., 2021; Wright & Edginton, 2016). Midtsund et al. (2019) conducted a qualitative study to closely examine the perspective of 12 mothers under stress as they took time in a community group setting to learn the skill of therapeutic touch on their babies. Researchers discovered that the mothers appreciated the opportunity to be educated on infant massage and described feelings of enhanced closeness to their babies. The findings of this study are essential in that they demonstrate simple, easily implemented, low-cost interventions that yield positive results for caregivers of infants (Midtsund et al., 2019). 17 Parent and Child Intentionally nurturing touch is linked to many benefits for both parent and child. Therapeutic touch leads to a favorable response in parasympathetic processes, a drop in cortisol levels, improved immunity, and increased serotonin, all of which reduce pain (Butruille et al., 2017; Field, 2019). This touch type is known to increase bone strength, promote rest, and instigate healthy weight gain in infants while prompting secure attachment with the caregiver (Charurvedi et al., 2020; Jakubiak & Feeney, 2016). Additionally, infant massage can relieve the mother's anxiety while enhancing the mother and baby's relational aspects and promoting well-being for both (Afand et al., 2017; Slade et al., 2020). Educating caregivers in therapeutic touch methods empowers them to feel they can contribute positively to the child's life, console their distress, and help bring about their well-being, giving back a sense of well-being to the caregiver (Midtsund et al., 2019; Weaver, 2017). Barriers Therapeutic touch is underutilized as a treatment method and a means for building connectivity between caregivers and children. Educational programs and training on therapeutic touch are lacking, and resistance to an unfamiliar idea persists amongst providers and caregivers (Midtsund et al., 2019; Weaver, 2017). A deficiency of standardization on protocols for restorative touch programs also results in a lack of awareness and hesitation in adapting such methods as a consistent practice for inpatient or outpatient settings (Abdallah et al., 2020; Parashar & Samuel, 2018). Cultural practices may also influence perceptions of physical contact and surrounding circumstances. For example, some cultures may accept infant massage, and others may view it as inappropriate or untimely (Charurvedi et al., 2020). Timing constraints and concern for adverse effects may also hinder caregivers' education (Alenchery et al., 2018). 18 Solution Early Intervention Insecure attachment in families often presents maladaptive behaviors within the home and school (Sirois & Bernier, 2018; Zhang et al., 2019). Maternal sensitivity is a crucial antecedent of secure attachment between mother and child and is fostered while the child is young (Sirois & Bernier, 2018). Primary care providers (PCP) tend to see mothers with infants and young children at well-child checkups and sick visits multiple times throughout the first years of life. These checkups provide prime opportunities for providers to assess the developmental needs of infants and their families (Bethell et al., 2017; Edmond et al., 2019). As a common touchpoint location, the appointments with the PCP are essential to assessing behavioral health issues, enhancing family engagement in self-care, and providing evidence-based resources and interventions (Bethell et al., 2017; Cole et al., 2019). The role of the primary care provider extends beyond the office. It includes community outreach in various settings where larger-scale education can comfortably occur in groups of related interest (Hartley, 2017). Early intervention is a robust approach for improving future outcomes. An infant exposed to appropriate external regulation from their caregiver consistently will build a stronger foundation off these repeated successes for affect regulation in future behavioral interactions (Leblanc et al., 2017; Slade et al., 2020). Modalities that include parent engagement in the areas of observation, responsiveness to baby’s cues, nurturing touch, and other various interventions of this design are more successful at improving outcomes when administered in early childhood, a time of greater neuroplasticity (Alto & Petrenko, 2017; Wright & Edginton, 2016). Early intervention magnifies sensitivity in mothers of infants, which can ameliorate the adverse effects of impaired attachment often seen later in life (Mountain et al., 2017; Perlman et al., 2016). 19 Attachment association is evident in the early stages of executive functioning in children's organization and cognition, affecting brain growth, development, and resiliency in later years (Kaya & Aydin, 2021; Leblanc et al., 2017; Regueiro et al., 2020). Infant Massage Infant massage is one method of building secure family attachment by involving parents and caregivers in caring for their infant. This early intervention focuses on therapeutic touch and cue observation while building connectivity between parent and child (Afand et al., 2017; Field, 2019; Shoghi et al., 2018). Massage techniques benefit the caregiver, providing them with a plan for facilitating their child's well-being and giving them some sense of power to console the child (Afand et al., 2017; Weaver, 2017). The positive conduit that infant massage provides for connection between parent and child enhances the health of both and the relational behavior between the two while facilitating the development of secure attachment (Weaver, 2017; Underdown & Barlow, 2011). Infant massage cultivates attachment security by promoting successful adaptation to caregiving and a strategic approach for caregivers (Pados & McGlothen-Bell, 2019; Porreca et al., 2017). Furthermore, as parents learn to observe and respond to their baby's cues, the interaction between caregiver and child is based on mindful interaction that evokes sensitivity and empathy in the parent (Weaver, 2017; Zhang et al., 2019). Infant Massage USA (2020) states that infant massage's benefits fall into four classifications: interaction, relaxation, stimulation, and relief. Sleep is more organized in infants receiving massage, and several other beneficial physical aspects are improved growth, neurodevelopment, immunity, and decreased septic events (Butruille et al., 2017; Field, 2019). The release of oxytocin from nurturing touch can ease postpartum depression and enhance relational behavior. Infant massage induces natural opioids within the brain, stimulating what 20 becomes a conditioned response in the infant to the parent's intentional, therapeutic touch (Palmer, 2002; Parashar & Samuel, 2018). Research supports the improved outcomes associated with infant massage. In a quasi-experimental clinical trial, Afand et al. (2017) examined the impact of therapeutic touch on anxiety levels in mothers of premature infants’ post-discharge from the neonatal intensive care unit (NICU). Anxiety was measured via the State-Trait Anxiety Inventory scale in a pre and post-test format. The experimental group included 35 mothers taught basic infant massage skills and instructed to implement them on their preterm infants at predesignated times, including just before discharge. The control group included 35 mothers who did not engage in infant massage. The study demonstrated a significant contrast between the experimental and control groups, with the mother having performed infant massage expressing more minor symptoms of anxiety overall (p<0.001) (Afand et al., 2017). In another controlled trial, 40 mothers and 40 NICU inpatient infants were divided randomly into an intervention and control group. The mothers in the intervention group were educated on infant massage techniques and provided massage to their newborns in the NICU. Results demonstrated a strong association between infant massage and maternal attachment behavior (p<0.001) (Shoghi et al., 2018), Other Solutions Several forms of psychotherapy are designed to address attachment issues across a broad expanse of cultural diversity (Alto & Petrenko, 2017). Attachment therapy modalities are often behavioral therapy sessions that facilitate the parent's more profound understanding of the child's experience and needs. In addition, emphasis is placed on developing the parent's ability to respond consistently in nurturing ways that reassure and empower the child (K. Berrett, personal communication, April 15, 2021). Child-Parent Psychotherapy (CPP), Attachment and 21 Biobehavioral Catch-up (ABC), and Parent-Child Interaction Therapy (PCIT) are three therapy modalities that have established success in enhancing secure attachments in families (Alto & Petrenko, 2017). Attachment-Based Family Therapy (ABFT) is another example of family-centered therapy to address the relational working between members (Diamond et al., 2016). Framework The framework for this project is the Rosswurm and Larrabee Model, which emphasizes moving the culture from stagnant modalities to the use of evidence-based practice, just as infant massage parent classes are a new, verified intervention to be offered at TCC (The Children's Center, 2020; Reavy, 2016). The model's five steps include assessment, linking, synthesizing, design, and implementation (Reavy, 2016). It has been determined at TCC that an additional, parent-driven tool is needed for improving attachment security in children. Compromised attachment security can be addressed with an infant massage course for parents to promote connectedness and improved family relationships. The literature supports the effectiveness of therapeutic touch modalities as early intervention, such as infant massage. A certified infant massage educator will teach a five-week infant massage course to parents and caregivers of children attending TCC, with the candidacy for attendance as deemed by TCC clinicians. This practice change will be evaluated for effectiveness, and classes will be recorded for sustainability. Discussion The literature regarding the implications of infant massage commonly reveals one or more limitations: small sample size, settings limited to the NICU or other inpatient environment, involvement of only one parent, and risk of method bias. The most common limitation was the consistency of the setting being in either the NICU or another acute-care inpatient environment, 22 producing accompanying noise and other distracting factors while not accurately assessing the intervention in the home setting. The strengths of the literature include the amount of evidence through diverse study designs and reputable resources available to support infant massage as an effective tool for enhancing attachment between parent and child. The literature underpins infant massage as a tool for promoting overall health. The literature also provides convincing evidence of improved outcomes associated with infant massage in randomized control trials. According to the literature review, the causality of secure attachment is aligned with concepts emphasized in infant massage training. The consistency of evidence allowed for hypotheses regarding the association of infant massage and enhanced parent-child relationships to be formed and shows an apparent positive relationship between these two factors. Implications for Practice Infant massage training for parents demonstrates benefits for both caregiver and child and improves parent-child attachment, caregiver stress, and future mental and physical health outcomes for children. In addition, implementing infant massage training for parents expands the nurse practitioner's options for providing a nonpharmacological, cost-effective, family-powered intervention easily and liberally administered in any setting, including the home. 23 Project Plan Successful project implementation requires a thorough and detailed plan that addresses aspects from early development through implementation, completion, and outcomes. This section addresses components of the project plan, including the project's overall design, a needs assessment of the project site and population, cost analysis, sustainability, outcomes, ethical considerations, and the instrument used to measure intervention effectiveness. Project Design As an underpinning for future scholarly application, this project addressed quality improvement by implementing a practice intervention. Practice interventions require that an evidence-based process be utilized to enhance an organization's provision of available services in a manner that does not result in an end project but incorporates an ongoing enhancement cycle (Reavy, 2016). As a widely researched intervention, infant massage is backed as an evidence-based modality for improving many aspects of health and well-being (Field, 2019; Weaver, 2017). Research has also demonstrated that parent training in infant massage is associated with secure attachment between parent and child, enhanced developmental progress, and decreased stress in parents (Butruille et al., 2017; Midtsund et al., 2019; Porreca et al., 2017). As an organization that can provide this type of high-yield tool to parents early in their baby's development, TCC has broadened its organizational capabilities to encourage positive health outcomes for children and families. Needs Assessment/Gap Analysis of Project Site and Population A needs assessment provides an understanding that narrows the project’s focus in an area of care specific to the targeted population. A scholarly approach to understanding the site and 24 population capacities produces more meaningful outcomes from the project implementation (Reavy, 2016). Social determinants of health (SDOH) hold profound implications for children, the target population for this project. This population aggregate is considered vulnerable due to dependence on others and a lack of autonomous capability. According to research, many overarching health disparities are based in early childhood, a problem that costs the US an annual fee ranging in the billions to cover resulting physical and mental health issues (Centers for Disease Control and Prevention, 2018). As a vulnerable population, children are subject to various health disparities, such as inadequate nutrition, substance abuse, and social and behavioral issues (Shivayogi, 2013). SDOHs commonly result in health disparities for children, including poverty, environmental threats, low accessibility to healthcare, individual behavioral issues, and education inequality (Centers for Disease Control and Prevention, 2020). Children of families with low socioeconomic status are even more likely to suffer from health disparities such as exposure to environmental hazards, asthma, learning disabilities, and social and mental health disorders (Children's Environmental Health Network, 2018). Mental health disorders are rising in children under 17, with ADHD, behavioral disorders, and anxiety amongst the most prevalent (Centers for Disease Control and Prevention, 2021). The health inequality evidenced by the vulnerability of children to health disparities results partly from the underdeveloped state of their physical and mental health (McCance & Huether, 2014). However, social justice concerns are pertinent to consider when addressing these disparities (Centers for Disease Control and Prevention, 2018). Children are particularly subject to poverty, with 19% of all children in the US living below the poverty line in 2016 (Children's Environmental Health Network, 2018). The low socioeconomic status of these children is linked 25 to decreased access to healthcare, supportive resources for mental health, and quality of education while increasing exposure to environmental hazards (Centers for Disease Control and Prevention, 2020; Children's Environmental Health Network, 2018). As the project site, TCC serves children and their families with emotional and behavioral issues that compromise development (The Children’s Center, 2020). The stakeholders of this project included the caregivers of the children who attend TCC and the clinicians who serve them. The clinicians of TCC use multiple modalities to support caregivers as they are faced with the daily responsibilities of rearing and nurturing young children who experience varied barriers to overall health and well-being. While TCC serves a broad, diverse expanse of ethnic and socioeconomic populations, many caregivers come from lower socioeconomic brackets and lack resources and education. They have experienced generational trauma (K. Berrett, personal communication, March 2021). The needs assessment for the population and setting of this project revealed several concepts for consideration. These concepts lay the foundation for project implementation and include the following: ● Whether secure or insecure, attachment has long-term implications for infants and children. ● Adult caregivers set the tone for attachment in children. ● Consistency and proximity are essential aspects of attachment (Mountain et al., 2017). ● Many barriers to secure attachments in families include trauma, addiction, loss, resource limitations, and access to skilled clinical personnel. 26 ● Early intervention is a critical component of effective treatment for attachment disorder (Naveed et al., 2020). ● Therapeutic touch is an effective tool for enhancing secure family attachment. ● Therapeutic touch is an underused treatment modality. ● Infant massage is an effective form of therapeutic touch (Midtsund et al., 2019). Cost Analysis and Sustainability of Project A three-year budget for this project is estimated to be $1108.49 and is potentially sustainable through generated revenue and support. The breakdown of the three-year budget includes $28.49 for a demo doll, $900.00 for massage oils, and $180.00 for informational pamphlets (See Appendix A). Under this cost analysis, the infant massage class for parents is prioritized to continue at TCC at $6.47 per person annually (see Appendix B). A three-year funding plan consists of a donated demo doll, a one-time purchase by the DNP student for class instruction. Massage oils and informational pamphlets for parent attendees come from the organizational budget for parent education and community programs (see Appendix C). Project sustainability will be achieved by developing infant massage champions amongst TCC clinicians who can continue to provide infant massage training for parents as a regular program offering for the organization. TCC clinicians are offered incentives on an organizational basis to expand and diversify their role responsibilities, which include involvement in community-based programs such as infant massage classes for caregivers (K. Berrett, personal communication, March 2021). Project Outcomes The short-term project outcome consisted of appropriate scheduling, outlining that infant massage classes for parents of infants were organized, scheduled, and filled in collaboration with 27 TCC by early January of 2022 as an added opportunity for parents to set goals for the new year in family health and wellness. The project’s long-term outcome was that parent attendees would demonstrate conceptual awareness of infant massage by the end of the five-week infant massage course. In addition, the timeliness and organization of the class structure laid the groundwork for the class design that allowed parents to receive all class content mindfully, ask pertinent questions, share concerns, and have concepts reaffirmed as needed. These efforts contributed to the success of the overarching goal for the project, which was to assist parents in developing a toolset for responding to their child’s cues in a way that builds connection for the child while in the stage of infancy (Underdown & Barlow, 2011; Weaver, 2017). Consent Procedures and Ethical Considerations IRB approval was achieved for this project with the stipulation of specific steps in implementation that served to protect the vulnerable population, protect the identity and other identifying information, and maintain the project's status as quality improvement. As the project's vulnerable and direct population, the infants involved in the infant massage class were not touched by the DNP-FNP student who instructed the class. Maintaining distance between the infants and the instructor follows The International Association of Infant Massage mandates that instructors not touch infants but support the parents as they learn to read their infants' cues further and respond accordingly (Infant Massage USA, 2020). Parent participants were recruited and enrolled by the clinicians of TCC, who were familiar with their client's individual needs and circumstances. No identifying information was shared with the DNP-FNP student regarding enrollment or participation in the course. Evaluation forms were filled out anonymously by parent participants. Confidentiality was maintained throughout the project implementation process per IRB guidelines. 28 Instrument(s) to Measure Intervention Effectiveness Evaluation of the project was obtained using the Karitane Parenting Confidence Scale (KPCS), which was developed to reinforce parenting skills for guardians of children ages 0-12 months (Crncec et al., 2008). The KPCS evaluation tool is provided free of charge with permission granted for use in clinical and research contexts (see Appendix D). 29 Project Implementation The project implementation was developed to demonstrate the association of measures, resources, and results. Leadership is integral to implementation as the DNP seeks to explicate new notions and system enhancements that improve patient outcomes (Reavy, 2016). Included in the implementation is the specification of interventions and the timeline for the project. Project Intervention The intervention of this DNP project assumed the trial of utilizing a parent-infant massage course as a tool for building secure attachment between infant and parent, as grounded by evidence-based research. The project's intervention involved using several necessary deliverables to facilitate and execute implementation steps. This section contains an account of the purpose and use of the final deliverables. Final Deliverables Deliverables were organized according to the Plan, Do, Study, Act (PDSA) cycle. The PDSA cycle serves as a means for analysis in planning that incorporates continual development. The model allows for efficiency as minor alterations to resources and materials quickly evaluate changes. Necessary adjustments are addressed with follow-up reevaluation (Zaccagnini & Pechaceck, 2021). Outline of Presentation A PowerPoint exhibition was developed for presentation to the Weber State University DNP project faculty committee as a primary step in obtaining Weber State University IRB Board approval. This same presentation was used to educate the clinicians of TCC as an introduction to the new infant massage program for parents and caregivers. Weber State faculty and TCC clinicians were informed regarding the current research on the implications of secure attachment 30 between child and caregiver. Outcomes associated with attachment were presented as evidence-based effects on mental and physical health. Infant massage was presented as a tool for enhancing secure attachment between caregiver and child. The benefits of this methodology were identified with evidence-based research. The discussion included potential ethical dilemmas and an outline of specific methods to address these issues. Information Brochure The Children’s Center clinicians recruited caregiver attendees for the infant massage course according to their expert knowledge of each participant’s needs and readiness for education. Before recruitment, clinicians were presented with informational brochures provided by the International Association of Infant Massage (Infant Massage USA, 2020). The clinicians utilized the brochures as teaching points for recruitment and shared them with potential class participants. Teaching Materials Teaching materials for project implementation included a life-sized demonstration doll, an International Association of Infant Massage instructor manual (Infant Massage USA, 2020), and photocopies of all infant massage strokes for each caregiver participant of the infant massage course. The International Association of Infant Massage requires that infant massage instructors use only a demonstration doll for teaching strokes to parents and caregivers. This method is a foundation-building step in empowering caregivers to read their infant's cues (Infant Massage USA, 2020). This stipulation involving using a demonstration doll also provided a method of instruction that involved no physical contact between the DNP student as an infant massage instructor and the infants attending with their caregivers. 31 An updated copy of the International Association of Infant Massage instructor manual was used to ensure accurate information and stroke demonstrations were shared with class attendees. This manual contains illustrations of each infant massage stroke with permission for photocopy and dispersal to class attendees. In addition, five copies of the pages with stroke demonstrations were made in preparation for an entire five-week infant massage course. Project Timeline The DNP project timeline began with completing the project proposal in June 2021. Between June and July of 2021, the DNP was certified as an International Association of Infant Massage instructor, accounting for four full training days. The introduction and literature review of the project paper was also developed within this same span of months. In September of 2021, the project proposal was presented to the Weber State University DNP project committee of faculty members, and IRB approval was obtained in October of this same year. Specific course planning took place in November and December of 2021, including the course timeline, location, and assessment of final deliverables. The PowerPoint presentation was given to the clinicians and administration of TCC in early December of 2021, with the clinicians' advertisement and recruitment of class attendees spanning the months of December 2021 and half of January 2022. The infant massage course was conducted over five consecutive Thursdays beginning in late January and ending in February 2022. Clinician feedback regarding the course was obtained in February of 2022. Sections III, IV, V, and VI were completed from March through May 2022, with the project evaluation completed in June. The fully-executed project dissemination occurred in July of 2022 (see Appendix E). 32 Project Evaluation A fundamental component of a process improvement project is evaluating methods and outcomes. Evaluation includes both formative and summative outcomes and can demonstrate the potential for the project’s impact. This project addressing secure attachment in families was evaluated using the KPCS, obtained with paper and pencil. The confidentiality of participants was strictly maintained. An unpredictable and uncontrollable factor influenced the implementation and outcome of this project. Before the implementation, the cases of the Omicron variant of the Covid-19 virus in the local community surged upward. As a result, the administration department of TCC felt it necessary to move all possible in-person sessions to an online platform. The infant massage course for this project was one of the programs that moved online. Ultimately, this factor likely decreased the number of participants and affected the project’s dissemination and outcome. Data Maintenance/Security Confidential data of this project included the identifying factors of participants and their infants. There were two total participants for this course, which was designed for a maximum of five participants. Initial outreach to potential participants was directed through the clinicians of TCC. As mental health clinicians are more intimately aware of their client’s needs and learning capacity, they were tasked with advertising the infant massage course to select potential participants according to their professional clinical judgment. Interested participants were then directed to the clinical assistant, who kept track of potential participants and managed the flow of information regarding class details, online platform information, and evaluation forms. Participants were asked not to share their names, their infant’s names, or any other identifying 33 factors during the online course. As infant massage course participants completed the pre and post-evaluation forms, the clinical assistant ensured that all identifying information was removed from the forms before presenting them to the DNP student. Data Collection and Analysis Data collection and analysis took place with the use of descriptive statistics in determining the means and standard deviations of participant answers to critical questions on the KPCS, as follows: Means and Standard Deviation of Scores on Pre-Post Measures Variable Pre-Assessment Post- Assessment M SD M SD 2. I can settle my baby. 4 0 4 0 4. I know what to do when my baby cries. 3 0 3.5 0.70710678 5. I understand what my baby is trying to tell me. 3 0 3.5 0.70710678 6. I can soothe my baby when 3.5 0.70710678 3.5 0.70710678 34 he/she is distressed. 11. I can make decisions about the care of my baby. 3 0 3.5 0.70710678 13. I feel I am doing a good job as a mother/father. 3 0 3.5 0.70710678 Note: Key question responses are presented from the Karitane Parenting Confidence Scale. The demographics of the two participants were sorted into percentages as follows: Participant Characteristics N % Gender ● Female 2 100% Age ● 31-45 2 100% Ethnicity ● White ● Latino/Hispanic 1 50% 35 1 50% Note: N = 2 36 Findings In all but two of the key question from the KPCS, post-evaluation results revealed an increased standard deviation in responses demonstrating positive outcomes from the infant massage program. Participants felt an enhanced knowledge of how to deal with their crying babies, a better understanding of their infant’s cues, an enhanced set of decision-making skills regarding the care of their infant, and more confidence in their ability to be a parent to their infant. Strengths The KPCS is a valid and reliable tool that can accurately predict positive parental practices and child outcomes. The tool assesses adaptation in parenthood by assessing the parent’s perceived aplomb for caregiving and nurturing (Usui et al., 2019; Wright et al., 2022). The critical questions utilized for the evaluation of the project focus on factors that are highly correlated to secure family attachments, including parental empowerment, nurturance, cue-reading, and stewardship (Bowlby, 1973). Weaknesses The evaluation of this project included data collection from two participants of an infant massage course typically designed for five. The change of platform from in-person to online likely decreased the number of participants for this project. Furthermore, each of the five sessions for the infant massage course was designed to facilitate interaction and sharing between class participants and provide a space of ease for dialogue between participants and the instructor. The online platform hindered this intended interplay between class participants and the instructor. 37 Discussion This DNP project regarding the security of family relationships has not brought about a finite product. However, it opens the possibilities for continual improvement cycles in empowering parents to care for their children in a profound and far-reaching manner. It addresses vital underpinnings central to the DNP-prepared nurse's role. The project demonstrates scholarship through the discovery of evidence-based practice in infant massage and the integration of effective dissemination of this therapy to parents in a setting conducive to further dialogue, networking, and shared experience between participants. This quality improvement project uses a practice that focuses on infants' immediate and long-term health and their connection with their caregivers, thereby exhibiting a framework of patient-centered care. As individual infant and family health is promoted through gentle, reassuring, therapeutic touch that enhances awareness and acceptance of cues, residual effects of strengthened family relationships are reflected in the buoying of societal systems, ultimately strengthening populational health. TCC provides a setting for the project that affords an environment accessible to a broad social population, bringing social justice to the nucleus of the project. Collaboration with TCC team imparts constant reassessment and customization of the application. The project requires leadership as data such as attendance and parent feedback are continually assimilated into tangible practice that assures effective dissemination of infant massage principles, promoting a perpetual therapy for patient-centered care. As part of the remaining discussion, the translation of evidence from this project into practice is examined for outcomes, new knowledge, and transferability. Finally, the project's sustainability and dissemination help define the implications of practice and future scholarship. 38 Translation of Evidence Into Practice Evidence-based principles of infant massage, such as parent attentiveness, cue reading, therapeutic touch, consistency, and reassurance, were translated into practice through the development, implementation, and evaluation of the DNP project on secure family relationships (Infant Massage USA, 2020). Outcomes of this translation into practice involved enhanced parental knowledge and, according to evidence-based research, the strong potential for the improved overall development of infants. Parental knowledge of their infant’s customized needs was increased through infant massage techniques. The expansion of parental confidence in addressing their infant's needs and their ability to read their infant's cues resulted from concepts taught in the infant massage course. Parents also developed decision-making skills that facilitate effective, reassuring responses to their infants during periods of crying. These skills are vital components that foster secure attachment between infant and caregiver, consequentially promoting the resilience of infants into adulthood (Fraley, 2018; Rasmussen & Storebo, 2019). The translation of evidence into practice brought about new knowledge, including the need for individualization in teaching methods and the possibility for online dissemination for inclusion and to account for unique situations. Parent attendees demonstrated varying levels of understanding, recognition, and recall of infant massage concepts and strokes. It was also noted that parents need encouragement in perceiving the individual needs of their infant with customization in timing and application of infant massage strokes. The limitation of online dispersion due to Covid provided a unique opportunity for addressing this possibility to extend the outreach of this program. This new knowledge is transferable through continued reassessment and readjustment of program application, which will take place in the adoption of the program by TCC. 39 Implications for Practice and Future Scholarship The findings of the DNP project can influence the practice of providers working with pediatric and family health populations. Those findings reinforce the need for family-specific, patient-customized care that focuses on family bonding and empowers parents to profoundly influence their children’s growth, development, and security. The DNP project regarding secure family attachment provides a foundation for future practice through the example of infant massage training for parents in a community-based center. Ensuing scholarship can continue by incorporating equal emphasis on innovation, the amalgamation of ideas, instruction, and the application of methodologies for enhancing parent-child bonds. As demonstrated through the necessity of switching to an online platform with this DNP project, adjustments can be made to ensure dissemination, customize delivery, and reinforce sustainability. Sustainability The DNP project has resulted in adopting of a parental infant massage training program at TCC. Since completing the project, two clinicians have been trained to teach parents infant massage. A regular infant massage program is under development and will follow the DNP project's pattern, allowing in-person or online classes according to parent and organizational needs. In addition, the DNP student designed a PowerPoint presentation for each of the five classes in the overall course to provide additional visual reinforcement to concepts and stroke reinforcement for parents. The presentation will be a fundamental basis for future course delivery, supporting project sustainability. Dissemination Dissemination of the project for secure family attachment enables new partnerships within the healthcare setting. It begins with introducing findings to clinicians at TCC, the Weber 40 State University DNP faculty, and the Weber State University DNP-FNP student cohort. Reported findings will be presented to TCC clinicians at a monthly staff meeting before the launch of the new infant massage program. A presentation of findings will be given to DNP faculty and students of Weber State University as directed by the course leader. In time, the staff can provide a means for further disseminating findings and promoting infant massage methodology to other healthcare professionals through the organization’s website and currently established free webinar series for pediatric providers. 41 Conclusion The implications and specific therapeutic touch methods, such as infant massage, are currently taught to parents with training challenging to access. A community setting like TCC is ideal for promoting and offering infant massage to parents with young children. This organization can also promote infant massage to other healthcare professionals who can refer qualified patients for this instruction. Parents and children benefit from the understanding and application of infant massage because it is an evidence-based method that facilitates secure attachment through consistency of reassuring touch, dependable quality time between parent and infant, enhanced parental cue reading of the infant, and parental empowerment (Midtsund et al., 2019). The DNP project outcomes demonstrate self-reported improved confidence from parents in their role as a parent, increased knowledge in dealing with their crying infant, a better understanding of their infant's cues, and more efficient decision-making skills regarding the care of their infant. As infant massage is adopted into the therapeutic toolbox, a clinician can model respect and awareness of the parent's proficiency in caring for their child by providing parent-lead therapy that can be accomplished in any setting. This capacity-building experience broadens the parent's awareness of their infant. In addition, it strengthens the infant's ability to securely explore their world with implications for improved health outcomes across the lifespan. 42 References Abdallah, B., Whitford, H., Bradbury-Jones, C., & Jones, M. (2020). Perceptions and attitudes of parents and healthcare professionals about the option of using infant massage in neonatal intensive care units. Journal of Clinical Nursing, 20(3), 499-507. https://doi.org/10.111/jocn.15564 Afand, N., Keshavarz, M., Fatemi, N. S., & Montazeri, A. (2017). Effects of infant massage on state anxiety in mothers of preterm infants prior to hospital discharge. 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Mindfulness, 10(1), 2481-2491. https://doi.org/10.1007/s12671-019-01120-y 52 Appendix A Cost Analysis Per Year Activity: Infant Massage Classes Year 1 Year 2 Year 3 Total Demo Doll $28.49 0 0 $28.49 Massage Oils $300.00 $300.00 $300.00 $900.00 Pamphlets $60.00 $60.00 $60.00 $180.00 Total $388.49 $360.00 $360.00 $1108.49 53 Appendix B Cost Analysis Per Individual Total Cost $388.49 Numbers Served 60 Cost Per Individual $6.47 Evaluation Findings TBA after implementation Return on Investment NA 54 Appendix C Cost Analysis with Funding Strategies Activity: Infant Massage Classes Three-Year Budget Funding Strategy Demo Doll $28.49 Donated by DNP Student Massage Oils $900.00 TCC Budget for Community Programs Pamphlets $180.00 TCC Budget for Community Programs Total $1108.49 55 Appendix D Karitane Parenting Confidence Scale 56 Appendix D continued 57 Appendix E DNP Project Timeline Prep Complete Project Proposal 6/1/21 Certify as IAIM educator 7/20/21 Complete Section I: Intro of DNP paper 6/28/21 Complete Section II: Lit Review 7/12/21 Fall Semester 2021 Present Project Proposal for approval 9/13/21 Obtain IRB approval 10/1/21 Determine specific timeline for course 11/1/21 Schedule dates, room, and meet w/TCC clinicians 12/1/21 Review course/design evaluation tool 12/20/2 1 Fall Semester 2021 to Spring Semester 2022 Recruitment by TCC clinicians 12/2/21- 1/20/22 58 Hold IAIM didactic course for parents 1/20/22- 2/17/22 Gather class evaluation data 2/17/22 Gather clinician feedback 2/17/22 Complete Section III DNP paper 3/1/22- 4/1/22 Complete Section IV DNP paper 4/1/22- 5/1/22 Summer Semester 2022 Complete Section V 5/1/22- 5/15/22 Complete Section VI 5/15/22- 6/1/22 Complete Project Evaluation 6/1/22- 7/1/22 Complete project Dissemination 7/1/22- 8/30/22