Joy V. Browne, Ph.D., PCNS, IMH-E

Background:

The consensus panel for Standards, Competencies, and Best Practices for Infant and Family-Centered Developmental Care (IFCDC) in intensive care began meeting about six years ago. We gathered, recognizing that we, as inter-professionals have similar goals and passion that drive our work. However, we also recognized that we come from different educational perspectives, professional cultures, and practice guidelines. We agreed that all professions should implement the practice of IFCDC based on the most robust evidence available, so we began establishing our principles, deciding on areas where there is evidence, and evaluating that evidence. The IFCDC standards are readily available at https://nicudesign.nd.edu/nicu-care-standards/.

Evidence-based standards, competencies, and best practices are foundational to optimal intensive care for babies and families but do not assure that they are implemented, especially in busy, high-intensity hospital units. Often the standards are not recognized as essential components of care when the “rubber meets the road.” Additionally, implementation is often unsuccessful if standards are implemented piecemeal and not woven into the fabric of the unit’s values and goals, policies and expected practice.

This realization has resulted in developing the Fragile Infant Forums for Implementation of the IFCDC Standards (FIFI-S). FIFI-S has been designed to provide participants with a guidebook for successful systems implementation and to assure that they have a practical tool kit on which to rely to ensure that evidence-based IFCDC practice becomes “the way we do things around here.”

The consensus panel has consistently acknowledged the importance of interprofessional work. A goal of the Forums, then, is to create a collaborative culture of practice that includes interprofessionals concerned with supporting the development of babies and families in intensive care. From the beginning, the consensus panel has developed and successfully employed a collaborative culture among the professionals and families who work in and experience intensive care. Our next steps, emphasized in the initial and subsequent Forums, are to develop strategies for implementing the evidence-based IFCDC standards collectively. These forums will collectively develop and apply interprofessional guidelines for implementing IFCDC in intensive care.

Each person and organization represented at the first Forum (virtual or in person) had the opportunity to contribute to developing implementation guidelines for Feeding, Eating, and Nutrition Delivery to be used productively by all. The outcomes of this and subsequent Forums will include materials and strategies that draw on all wisdom but are not “owned” by any profession or organization. By creating a culture of collaboration, we benefit from each other’s wisdom and respect that each contributor has a shared responsibility to protect the group’s efforts and contributions.

A brief synopsis of the Forum on Feeding, Eating, and Nutrition Delivery: 

The first of the proposed hybrid Forums focused on the standards of “Feeding, Eating and Nutrition Delivery,” held July 13-15, 2022. In the first hybrid meeting, there were on-site participants and a large audience that joined virtually. 

Sharon Cox was our keynote speaker, a nationally known expert in hospital management and strategies for clinical change. Sharon provided an inspirational talk and challenge to the participants, including strategies to make change happen. Many of her quotes and challenges reverberated through the entire Forum. 

After an overview of the Feeding, Eating, and Nutrition delivery standards and an emphasis on why they are important for the long-term outcomes of babies and families by Dr. Erin Ross, we had presentations by scientists who provided state-of-the-art research that support the standards and competencies. Drs. Pamela Dodrill, Kelly McGlothen-Bell, Britt Pados, and Erin Ross addressed clear evidence for oral feeding strategies, breastfeeding and most importantly the role of parents in successfully feeding their infant. These provided a foundation for attendees to document the significance of the next day and a half. 

Drs. Carol Jaeger and Carole Kenner, experts in systems implementation, provided several evidence-based models to identify how units can choose one to develop an implementation plan systematically (See the recommended references of the models they recommended) demonstrated). They provided several clinical examples of how units have strategized their approach to implementation and supported the work groups to use a “hands-on experience” in understanding how systems implementation can apply in their unit. A great deal of the work during the Forum was in workgroups, both in person and virtual, each group addressing individual feeding, eating, and nutrition delivery standards. 

Ms. Debra Paul provides an example of an ongoing process used in her unit to implement standardized feeding approaches. She included how barriers could be recognized, understood, and worked around, particularly as the pandemic impeded implementation. Drs. Jaeger and Kenner then provided insights into how barriers could be addressed so that progress is not impeded. They provided essential information on measuring success in an ongoing and long-term manner and emphasized how metrics are essential to successfully implementing standards. 

The process for the first FIFI-S Forum is not complete; it will be ongoing in each of the participating professionals’ work and their respective intensive care units. As FIFI-S participants attempt to apply the models of change toward implementing the standards, ongoing support from the faculty will be provided. 

Our Forum goals were for nationally known research scientists in Feeding, Eating, and Nutrition Delivery to address the evidence for some of the standards. They were followed by examples of professionals who attempted to implement the standards in their units. Each speaker effectively demonstrated why the standards are appropriate for clinical implementation. The Forum participants detailed essential systems supports that were instrumental in guaranteeing the implementation of the standards. As a collective group, the participants and leaders in the field determined the best strategies for practice implementation. They began producing a “white paper “on the system supports necessary to implement the IFCDC feeding, eating, and nutrition delivery standards. 

Ongoing efforts: 

The initial and ongoing Forums aim to develop implementation strategies so that the IFCDC standards are recognized, implemented widely, and in a sense “cemented” into the expectations for practice in intensive care. We look to all intensive care professionals invested in caring for babies and families to help us develop strategies for getting them accepted, disseminated, and implemented, and invite participation in subsequent Forums. 

The next Forum is scheduled for January 18-20, 2023, at Loma Linda University in Loma Linda, California. The Forum focus will be on “Implementing Strategies to Alleviate Stress for Babies and Families in Intensive Care,” which is addressed in one of the IFCDC standards https://nicudesign.nd.edu/nicu-care-standards/ifcdc–recommendations-for-best-practice-reducing-managing-pain-stress-in-newborns-families/ 

Please plan to join us as we revolutionize IFCDC in intensive care. It will take a systems approach which is why we start with each of the standards’ implementation guidelines. The focus on how systems can change using evidence-based and clinically meaningful strategies will assure a change toward implementing IFCDC standards of care. 

We are continually reminded of Sharon Cox’s entreaty that “very great change starts from small conversations held by people who care.” The goal of the Forums, now and in the future, is to start a conversation! 

References: 

Systematic Approach to Evidence-based Practice Improvement 

Evidence-based Practice Improvement – 

1. Alexandrov AW, Brewer TL, Brewer BB. The role of outcomes and evidence-based quality improvement in enhancing and evaluating practice changes. In: Melnyk BM & Fineout-Overholt E. Evidence-based Practice in Nursing and Healthcare: A guide to best practice. 4th edition. Philadelphia, PA: Wolters Kluwer; 2019. p. 293-312. 
2. Langley GL, Moen R, Nolen TW, Norman CL, Provost LP. The improvement guide: A practical approach to enhancing organizational performance. 2nd edition. San Francisco, CA: Jossey-Bass Publishers; 2009. 
3. Mills T, Lawton R, Sheard L. Advancing complexity science in healthcare research: The logic of logic models. BMC Medical Research Methodology. 2019; 19(1):55. 

Logic Model – 

1. Petersen D, Taylor EF, Peikes D. Logic Models: The Foundation to Implement, Study, and Refine Patient-centered Medical Home Models. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2013. AHRQ Publication No. 13-0029-EF. www.ahrq.gov 

Plan – Do – Study – Act (PDSA) Approach – 

1. Levin RF, Keefer JM, Marren J, Vetter MJ, Lauder B & Sobolewski S. Evidence-based improvement: Merging 2 paradigms. Journal of Nursing Care Quality. 2010; 25(2), 117-126. 

Fishbone Diagram, Key Driver Diagram, P-D-S-A Cycle – 

1. Institute of Healthcare Improvement. Quality Improvment Essentials: Tools. Retrieved from http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx 

Complexity Science – 

1. Fraser SW, Greenhalgh T. Coping with complexity: educating for capability. BMJ. 2001; 323(7316): 799-803. 
2. Greenhalgh T, Patoutsi C. Studying complexity in health services research: desperately seeking an overdue paradigm shift. BMC Medicine. 2018; 16(1):95. 
3. Plsek P, Greenhalgh T. The challenge of complexity in healthcare. Complexity Science BMJ. 2001; 323:625- 628. 
4. Plsek PE, Wilson T. Complexity, leadership, and management in healthcare organizations. BMJ. 2001; 323(7315):746-749. 
5. Wilson T, Holt T, Greenhalgh T. Complexity and clinical care. Complexity Science BMJ. 2001; 323:685-688. 

Disclosure: The author has no conflicts of interest