Implementing the Infant Positioning Assessment Tool in a Neonatal Intensive Care Unit PDF

Implementing the Infant Positioning Assessment Tool in a Neonatal Intensive Care Unit Item Type DNP Project Authors Buchynsky, Ivanna Publication Date 2022-05 Abstract Problem: Infants in the neonatal intensive care unit (NICU)...

Implementing the Infant Positioning Assessment Tool in a Neonatal Intensive Care Unit Item Type DNP Project Authors Buchynsky, Ivanna Publication Date 2022-05 Abstract Problem: Infants in the neonatal intensive care unit (NICU) are at increased risk for long-term complications and disability. Developmentally supportive positioning improves neurodevelopmental outcomes in this patient population. Infants hospitalized... Keywords Infant Positioning Assessment Tool (IPAT); Intensive Care Units, Neonatal; Patient Positioning--standards; Quality Improvement Download date 13/09/2024 07:14:42 Link to Item http://hdl.handle.net/10713/18885 IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 1 Implementing the Infant Positioning Assessment Tool in a Neonatal Intensive Care Unit by Ivanna Buchynsky Under Supervision of Mary Connolly, DNP, CRNP Second Reader Shari Simone, DNP, CRNP, FCCM, FAANP A DNP Project Manuscript Submitted in Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree University of Maryland School of Nursing May 2022 IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 2 Abstract Problem: Infants in the neonatal intensive care unit (NICU) are at increased risk for long-term complications and disability. Developmentally supportive positioning improves neurodevelopmental outcomes in this patient population. Infants hospitalized in NICUs with standardized positioning practices benefit from enhanced developmental outcomes. The valid and reliable Infant Positioning Assessment Tool (IPAT) promotes appropriate infant positioning and encourages caregiver accountability in developmentally supportive positioning practices when used with bedside education. In an academic community medical center NICU, there was no standardized positioning practice in place. Baseline data indicated that 75.1% of infants were being positioned in a developmentally supportive manner. Purpose: The purpose of this quality improvement project was to implement the IPAT to improve consistency in developmentally supportive positioning by promoting appropriate positioning and encouraging accountability in positioning practices. The goal was for 100% of eligible patients to have an acceptable IPAT score of ≥9 by completion of the implementation period. Methods: The project took place in a 26 bed, Level III NICU from November 2021 to January 2022. All infants over 32 weeks gestation, 1,500 grams, past the first 72 hours of life, and admitted to the unit for more than one twelve-hour shift were eligible. Implementation involved a bedside IPAT reference, an online educational training module, informational reference posters, and ongoing bedside education. Data was collected semiweekly on IPAT scores of eligible patients once per shift. A percentage of IPAT scores ≥9 was calculated for weekly averages. IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 3 Results: The results demonstrated an increase in the average percentage of eligible patients having an acceptable IPAT score of ≥9 when compared to baseline data (82.8% versus 75.1%), with the median percentage being 83.9%. Conclusions: Implementation of the standardized IPAT positively impacted consistency in developmentally supportive positioning practices at the project site. Recommendations to strengthen practice change include integrating IPAT documentation into the electronic health record (EHR), increasing the completion rate of the educational training module, and incorporating developmentally supportive positioning as part of annual competencies and new staff orientation. IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 4 Implementing the Infant Positioning Assessment Tool in a Neonatal Intensive Care Unit In the United States, one of every ten infants is born prematurely and 10 to 15% of all infants require care in the neonatal intensive care unit (NICU) (Centers for Disease Control and Prevention [CDC], 2020). Premature infants and infants requiring critical care in the NICU are at increased risk for long-term complications and disability. Developmentally supportive positioning is an intervention used to improve neurodevelopmental outcomes in this patient population. NICUs which have standardized positioning protocols demonstrate enhanced developmental outcomes in their patient population (Coughlin, Lohman, Gibbins, 2010). In an academic community medical center NICU, there is no standardized developmentally supportive positioning guideline in place. Baseline data indicates that infants are positioned in a developmentally supportive manner 75.1% of the time. The Infant Positioning Assessment Tool (IPAT) is a valid and reliable pictorial tool for evaluating infant positioning in the NICU (Coughlin, Lohman, & Gibbins, 2018). Evidence demonstrates that use of the IPAT promotes appropriate infant positioning and encourages caregiver accountability in developmentally supportive positioning practices when used in conjunction with bedside education (Coughlin, Lohman, Gibbins, 2010). The purpose of this quality improvement (QI) project is to implement the standardized IPAT to improve consistency in developmentally supportive positioning by promoting appropriate positioning and encouraging accountability in positioning practices in the NICU project site. Evidence Review Neurodevelopment follows a cephalocaudal and proximodistal pattern. The fetus begins to develop active muscle tone at 36 weeks gestation. The third trimester in utero provides the ideal environment for development of physiological flexion (Madlinger-Lewis et al., 2014). IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 5 Infants born prematurely do not have adequate physiological flexion as they lack sufficient neurological and musculoskeletal maturity. The extrauterine environment is characterized by an absence of appropriate boundaries, presence of increased gravitational pull, and abundance of neurosensory input. As a result, premature infants in the NICU often have an unfavorable alignment with a natural extended positioning for postural stability, placing them at risk for developing misalignment, skeletal deformation, and gross motor delay (Sweeney & Gutierrez, 2002). Inadequate containment and flexion in the extrauterine environment are associated with hindered development of sensory information processing in this patient population. Developmentally supportive positioning of infants in the NICU promotes skeletal integrity, postural control, and sensorimotor organization, reduces positional deformities and pain responses, improves muscle tone, postural alignment, and movement patterns, which collectively support proper neurodevelopment (Hunter, Lee & Altimier, 2010; Jeanson, 2013; Liu et al., 2007; Sweeney & Gutierrez, 2002). Developmentally supportive positioning practices of premature infants in the NICU ultimately lead to enhanced neurodevelopmental outcomes. While developmentally supportive positioning is associated with improved neurodevelopmental outcomes for premature infants, inconsistency in best positioning practices is a common problem in NICUs (Coughlin, Lohman, Gibbins, 2010). An evidence-based recommendation to improve consistency in developmentally supportive positioning is implementation of a standardized tool along with bedside education on developmentally supportive positioning. The Infant Positioning and Assessment Tool (IPAT) is a pictorial tool developed in 2010 by Coughlin, Lohman, and Gibbins, and is copyright (2018) of Koninklijke Philips Electronics N.V., specifically developed to be used as an educational reference and IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 6 evaluation instrument to standardize best positioning practices of premature infants in the NICU (Coughlin, Lohman, & Gibbins, 2010). This tool provides an objective and measurable assessment of body alignment in supine, prone, and side-lying to improve consistency in positioning practices. Several studies evaluate the validity and reliability of the IPAT. Coughlin, Lohman, and Gibbins (2010) assessed the efficacy of the IPAT in teaching consistency in positioning practices through a system-wide quality improvement initiative focusing on implementing the IPAT in conjunction with a developmentally supportive care educational program (Coughlin, Lohman, & Gibbins, 2010). Following the intervention, IPAT scores were statistically significantly higher in six urban tertiary care centers when comparing fifty-five patients during the implementation pretest phase and fifty patients during the posttest phase. Spilker, Hill, and Rosenblum (2016) also implemented the IPAT along with informal bedside education to determine the effectiveness of the implementation tactic in improving developmental supportive positioning proficiency in the NICU, yielding similar results. They found a statistically significant increase in the mean IPAT scores of the pre-intervention compared to the post-intervention groups (Spilker, Hill, & Rosenblum, 2016). Similarly, Jeanson (2013) found that application of the IPAT tool with one- to-one bedside education improves positioning consistency in their study engaging an interdisciplinary team of nurses, practitioners, and physical therapists to compromise an IPAT team scoring infants’ positioning and providing bedside education. 98% of staff indicated competency in developmentally sportive positioning following the protocol (Jeanson, 2013). Finally, Painter and colleagues (2019) examined the impact of appropriate developmental positioning on length of stay, infant weight gain, tone, and flexion by implementing an educational in-service on developmentally supportive positioning and using the IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 7 IPAT as a visual guide for evaluating infant positioning. Infants who were consistently positioned in a developmentally supportive manner had a statistically significantly increased rate of weight gain, improved tone and flexion, and higher mean scores on the Hammersmith Infant Neurological Exam (Painter et al., 2019). The evidence demonstrates that use of the IPAT along with bedside training in the NICU setting improves consistency in developmentally supportive positioning practices. See Tables 1 and 2. Theoretical Frameworks The Synactive Theory of Infant Development was developed by Heidelise Als in 1982 to understand how infants organize their behavior as a response to environmental influences, such as the hospitalized neonate in the NICU setting (Figure 1). This middle range theory describes the nervous system through behavioral observation. The presumption the theory is based on is that all living organisms are in constant communication and interaction with their environment (Als, 1982). The Synactive theory identifies infant development as an interactive and hierarchical process of five subsystems, including the autonomic, motor, behavioral, attention to interaction, and self-regulation. Als (1982) suggests that each individual subsystem is in continual interaction with these four subsystems, the environment, and the caregiver. The caregiver in the NICU setting is any individual providing hands-on care for the infant. The Synactive Theory determines that developmentally supportive positioning of infants by caregivers in the NICU aids in normalization of infant neurobehavioral organization. Thus, developmentally supportive positioning practices is a fundamental intervention for this patient population in the NICU. Complex Innovation Implementation is the implementation framework applied for this QI initiative. Helfrich, Weiner, McKinney, and Minasian (2007) theorize that effective innovation is a function of managerial support and resource availability and is mediated by an organization’s IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 8 policies, practices, and climate (Figure 2). The assumption of the Implementation Process Framework is that the climate of implementation is influenced by innovative champions and the fit between the values of the organization and the QI initiative (Helfrich et. al., 2007). In this QI practice setting, the innovation of improving consistency in developmentally supportive positioning is a shared mission among organizational stakeholders. Factors which aided the initiative include the culture of the organization placing high value in evidence-based practice, quality improvement, and professional development. These commitments facilitated achievement of the goal of the QI initiative by supporting clinical practice change with the aim to improve patient outcomes in the NICU in this academic community medical center. Methods This QI project took place in the 26-bed, Level III NICU in an academic community medical center over the course of ten weeks from November 2021 through January 2022. Infants over 32 weeks gestation, 1,500 grams, past the first 72 hours of life, and admitted to the unit for more than one twelve-hour shift were eligible for the QI initiative. The standardized instrument used in the QI project was the IPAT (Figure 3) (Coughlin, Lohman, & Gibbins, 2018). In detail, this tool uses a two-point scoring system for six areas of the body, including the head, neck, shoulders, hands, hips/pelvis, and knees/ankles/feet. A score of zero to two is allocated to each body area, zero indicating misaligned positioning to two indicating idea alignment. A total cumulative IPAT score ranges from zero to twelve, with a total score greater than or equal to nine as indicative of acceptable developmentally supportive positioning of the infant to account for technological interfaces necessary in the NICU. In the months preceding implementation, the Project Lead (PL) engaged and mobilized an interdisciplinary team of stakeholders in the NICU at the project site, including the unit IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 9 manager, clinical educator, medical director, medical core team, registered nurses (RNs), nursing support technicians (NSTs), Education Committee, Director of Maternal Child Health Services, Informatics Nurse Specialist, the academic community medical center’s Director of Professional Practice, Chief Nursing Officer, and Director of Research Review to gain support to implement this QI initiative. This process included obtaining multilevel approval for QI implementation within the academic community medical center, developing a draft developmentally supportive positioning guideline using the IPAT for the unit, preparing a draft of the IPAT for the electronic health record (EHR), placing the IPAT reference at each bedside, creating and assigning an online educational training module through NetLearning to NICU caregiver staff outlining developmentally supportive positioning and use of the IPAT (Figure 4). In addition, the PL developed an informational resource poster to act as a resource for staff (Figure 5). This poster was displayed throughout the unit for staff to review. Prior to implementation, baseline assessment was obtained by the PL using the IPAT once per shift semiweekly to calculate an averaged percentage of eligible infants with an IPAT total cumulative score of greater than or equal to 9 resulting in the baseline data of 75.1% of infants being positioned in a developmentally supportive manner on the unit pre-implementation. During implementation, the PL continued to score infant positioning using the IPAT once per shift semiweekly for ten weeks from November 2021 through January 2022. The deidentified patient IPAT total cumulative scores were then averaged to record a weekly percentage of eligible infants with an IPAT total cumulative score of greater than or equal to 9 (Appendix A & Appendix B). The stated goal for this project was for 100% of eligible patients to have an IPAT score of greater than or equal to 9 by completion of the implementation period. Data was stored on a secure data management spreadsheet by the PL to monitor progress to goal achievement. IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 10 No infant identification was recorded during any stage of data collection. Patient privacy and data confidentiality were ensured throughout the QI initiative. This QI project was intended for internal purposes for the Level III-B NICU at the project site academic community medical center. These interventions were uniquely tailored to meet the practice problem identified by the stakeholders of the site. While implementation of this QI project involved interventions designed for and data collected from humans, the intent of the implementation was to improve consistency in developmentally supportive positioning practices in the Level III-B NICU rather than contribute to generalizable knowledge on developmental positing in this patient population. This project received Human Research Protections Office (HRPO) Non-Human Subject Research designation as well as the project site’s Institutional Review Board (IRB) Quality Improvement and Not Human Subjects Research determination. Results At the conclusion of the implementation period, the results indicated an increase in the average and median percentage of infants positioned according to developmentally supportive positioning practice on the unit. Pre-implementation, the baseline data for infants being positioned according to developmentally supportive positioning practice was 75.1%, indicating that at any given time, 75.1% of infants have an IPAT score of 9 or greater on the unit. Following the initiative, the average percentage of infants with an IPAT total cumulative score of greater than or equal to nine was 82.8% and the median percentage was 83.9 (Figure 6). Both values demonstrate an increase in infants being positioned according to developmentally supportive manner post-implementation at the project site. Several factors led to the unfulfilled QI project goal, including the short data collection period and a low educational training module completion rate. The data collection period IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 11 spanned ten weeks, which is too short to detect true trends in the data. A project timeline of greater than ten weeks is needed to document continual improvement in infants being positioned in a developmentally supportive manner at the project site. In addition, the NICU caregiver educational training module completion rate by the second week of January was only 23.2%. Anticipating a low completion rate for an online training module, the abridged informational reference poster was created and displayed on the unit. Despite the information being readily available, the completion rate for the educational training module is the only way to keep an accurate record of what percentage of staff accessed the training on developmentally supportive positioning and use of the IPAT. Further barriers to the success of the initiative also included high acuity on the unit accompanied with abnormally inadequate staffing due to the novel COVID-19 pandemic. Finally, there were no costs associated with this intervention outside of the PL printing the physical IPATs and informational reference posters. Discussion To improve consistency in developmentally supportive positioning on the unit, the standardized IPAT was implemented to promote developmentally supportive positioning and accountability in positioning practices in the NICU. The goal of this QI project was for 100% of eligible patients to have an IPAT score of greater than or equal to 9 by completion of the implementation period. While the goal of the project was not achieved, an increase was seen in the percentage of infants with IPAT scores when comparing the pre-implementation, baseline percentage and the post-implementation, average and median percentages. On bedside education by the occupational therapy staff, training additional unit champions on use of the IPAT to reinforce bedside education by NICU caregiver staff, and an IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 12 increase in completion rate of the educational training module will strengthen this practice change. An increase in developmentally supportive positioning was documented in the research on other units implementing use of the IPAT. Jeanson (2013) found that application of the IPAT tool with one-to-one bedside education improves positioning consistency when engaging with an interdisciplinary team. Spilker, Hill, and Rosenblum (2016) also implemented the IPAT along with informal bedside education, yielding similar results in an increase of infants being positioned in developmentally supportively. Continuing education at the bedside on the unit in conjunction with the ongoing training will improve the rate of practice change and establish permanent practice change. Furthermore, integrating the IPAT into the EHR will increase caregiver accountability during routine cares. Once NICU caregiver staff begin to document an IPAT score at least once per shift, a chart audit can support the use of the IPAT by tracking scores. Finally, NICU caregiver staff were assigned the educational training module outside of the normal time for annual competencies when staff are constantly reminded to complete assigned modules. Expanded access of the educational training module to the NICU interprofessional team during annual competencies will increase completion of the training. Conclusion This QI initiative resulted in a positive change in infants being positioned in a developmentally supportive manner on the unit. The conclusion of this QI initiative is that implementation of the standardized IPAT positively impacts consistency in developmentally supportive positioning practices at the project site. Developmentally supportive positioning practices lead to improved neurodevelopmental outcomes in this patient population. A patient population with improved developmental outcomes ultimately lowers the cost of health care expenditure at the macrosystem level. Therefore, the no-cost, valid and reliable IPAT use in the IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 13 NICU is an invaluable intervention for infants hospitalized in the NICU. IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 14 References Als, H. (1982). Toward a syntactive theory of development: Promise for the assessment and support of infant individuality. Infant Mental Health Journal, 3(4), 229–243. https://doi- org.proxy-hs.researchport.umd.edu/10.1002/1097-0355(198224)3:43.0.CO;2-H Centers for Disease Control and Prevention [CDC]. (2020). Preterm birth. U.S. Department of Health and Human Services. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm Coughlin, M., Lohman, M. B., & Gibbins, S. (2010). Reliability and effectiveness of an infant positioning assessment tool to standardize developmentally supportive positioning practices in the neonatal intensive care unit. Newborn and Infant Nursing Reviews, 10(2), 104–106. https://doi-org.proxy-hs.researchport.umd.edu/10.1053/j.nainr.2010.03.003 Coughlin, M., Lohman, M. B., & Gibbins, S. (2018). Infant Positioning Assessment Tool (IPAT). Koninklijke Philips N.V. http://images.philips.com/is/content/PhilipsConsumer/Campaigns/HC20140401_DG/Doc uments/ipat_sheet.pdf Helfrich CD, Weiner BJ, McKinney MM, & Minasian L. (2007). Determinants of implementation effectiveness: adapting a framework for complex innovations. Medical Care Research & Review, 64(3), 279–303. https://doi-org.proxy- hs.researchport.umd.edu/10.1177/1077558707299887 Hunter, J., Lee, A., & Altimier, L. (2015). Neonatal intensive care unit. Occupational Therapy for Children and Adolescents. St. Louis: Elsevier; 2015. p. 595-635.7 IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 15 Jeanson, E. (2013). One-to-one bedside nurse education as a means to improve positioning consistency. Newborn and Infant Nursing Reviews, 13(1), 27–30. https://doi-org.proxy- hs.researchport.umd.edu/10.1053/j.nainr.2012.12.004 Liu, W. F., Laudert, S., Perkins, B., Macmillan-York, E., Martin, S., & Graven, S. (2007). The development of potentially better practices to support the neurodevelopment of infants in the NICU. Journal of Perinatology : Official Journal of the California Perinatal Association, 27 Suppl 2, S48–S74. https://doi-org.proxy- hs.researchport.umd.edu/10.1038/sj.jp.7211844 Madlinger-Lewis, L., Reynolds, L., Zarem, C., Crapnell, T., Inder, T., & Pineda, R. (2014). The effects of alternative positioning on preterm infants in the neonatal intensive care unit: a randomized clinical trial. Research in developmental disabilities, 35(2), 490–497. https://doi.org/10.1016/j.ridd.2013.11.019 Newhouse RP. (2006). Evidence and the executive. Examining the support for evidence-based nursing practice. Journal of Nursing Administration, 36(7/8), 337–340. https://doi- org.proxy-hs.researchport.umd.edu/10.1097/00005110-200607000-00001. Painter, L., Lewis, S., Hamilton, B. K., Dowling, D., & Thibeau, S. (2019). Improving Neurodevelopmental Outcomes in NICU Patients. Advances in Neonatal Care (Lippincott Williams & Wilkins), 19(3), 236–243. https://doi-org.proxy- hs.researchport.umd.edu/10.1097/ANC.0000000000000583 Spilker, A., Hill, C., & Rosenblum, R. (2016). The effectiveness of a standardised positioning tool and bedside education on the developmental positioning proficiency of NICU nurses. Intensive & Critical Care Nursing, 35, 10–15. https://doi-org.proxy- hs.researchport.umd.edu/10.1016/j.iccn.2016.01.004 IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 16 Sweeney JK, & Gutierrez T. (2002). Musculoskeletal implications of preterm infant positioning in the NICU. Journal of Perinatal & Neonatal Nursing, 16(1), 58–70. https://doi- org.proxy-hs.researchport.umd.edu/10.1097/00005237-200206000-00007 IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 17 Table 1 Evidence Review Table for Improving Consistency in Developmentally Supportive Positioning Practices in the NICU Citation: Coughlin, M., Lohman, M. B., & Gibbins, S. (2010). Reliability and effectiveness of an infant positioning assessment tool to standardize developmentally supportive positioning practices in the neonatal intensive care unit. Newborn and Infant Nursing Level III Reviews, 10(2), 104–106. https://doi-org.proxy-hs.researchport.umd.edu/10.1053/j.nainr.2010.03.003 Purpose Design Sample Intervention Outcomes Results “The aim of this study Quasi-experimental, Sampling Technique: Control: Baseline IPAT Dependent Variable: The system wide was twofold: (1) to pretest-posttest design Convenience scores on NICU IPAT scores quality improvement develop an infant Eligible: All NICU patients not receiving initiative implementing position assessment patients not receiving direct care at the time Measure: Reliability the IPAT in conjunction tool to standardize best direct care at the time of observation was established by with an educational practices in of observation Intervention: NICU having four program focusing on neonatal positioning Control: No control due staff at six urban developmentally and (2) evaluate its to quasi-experimental tertiary care centers independent reviewers supportive care yielded effectiveness in design underwent the Wee compute IPAT scores statistically higher teaching consistent Intervention: Fifty-five Care program, a system for five infants. IPAT scores at T2 (P < positioning practice.” NICU patients during wide educational Interrater reliability.0001) at each of the six the pretest phase and 50 program focused on scores were above 90% sites NICU patients during developmentally using Fleiss's κ the posttest phase supportive care as a Statistical analysis: quality improvement Not applicable initiative Intervention fidelity: Three research assistants collected baseline IPAT scores (T1). Thirteen months later (T2), the same research assistants collected post- intervention IPAT scores. Neonatal care providers were blinded to the timing of the data collection IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 18 Citation: Jeanson, E. (2013). One-to-one bedside nurse education as a means to improve positioning consistency. Newborn and Level III Infant Nursing Reviews, 13(1), 27–30. https://doi-org.proxy-hs.researchport.umd.edu/10.1053/j.nainr.2012.12.004 Purpose Design Sample Intervention Outcomes Results “The purpose of this Quasi-experimental, Sampling Technique: Control: Baseline IPAT Dependent Variable: In phase one, baseline article is to describe pre-, intra-, and posttest Convenience was performed IPAT scores score distribution how using the design Eligible: All infants less on all infants younger ranged from 3 to 11. In Infant Positioning than 34 weeks gestation than 34 weeks gestation Measure: Reliability phase two, the Assessment Tool paired regardless of by 4- to 5-person IPAT was established using education phase, scores with one-to-one bedside technology interface or reliable teams analysis of individual ranged from 6 to 11. In education can improve gestational age during Intervention: Scripted IPAT administrations phase three, the post- positioning randomly assigned education paired with with 96% to 100% education phase, the consistency across shifts IPAT training in a 52- agreement of scores scores ranged from 6 to shifts and experience.” Control: No control due bed level IIIb midwest 12. Mean IPAT scores to quasi-experimental medical center nursery across teams with were 8.3, 8.7 and 9.2 design Intervention fidelity: modification of scoring respectively. Hand Intervention: Thirty Three NICU wide to account for positioning has the infants in phase one, 21 positioning asymmetry improving greatest change, infants in phase two, assessments were IPAT scoring reliability increasing from 1.2 to and 37 infants in phase completed, including to 98% 1.5. Head position three initial baseline IPAT increased from 0.6 to Statistical analysis: evaluation, scripted 0.8. The frequency of Not applicable education paired with acceptable scores IPAT evaluation one increased and the month after baseline, frequency of subpar and four months after scores decreased. A initial bedside modified t-test education with infants determined that assessed during changes in mean scores randomly assigned were not large enough shifts without staff to reach statistical forewarning significance IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 19 Citation: Spilker, A., Hill, C., & Rosenblum, R. (2016). The effectiveness of a standardized positioning tool and bedside education on the developmental positioning proficiency of NICU nurses. Intensive & Critical Care Nursing, 35, 10–15. https://doi-org.proxy- Level III hs.researchport.umd.edu/10.1016/j.iccn.2016.01.004 Purpose Design Sample Intervention Outcomes Results “The objective of this Quasi-experimental, Sampling Technique: Control: Baseline IPAT Dependent Variable: An independent study was to determine pretest-posttest design Convenience scores on infants who IPAT scores samples t-test indicated if the use of a Eligible: Infants who were less than 34 weeks a statistically standardised infant were less than 34 weeks gestation, in incubators, Measure: Reliability significant (p = 0.027) positioning assessment gestation, in incubators, using developmental was established through increase in the mean tool (the IPAT) and using developmental positioning supplies a developmental IPAT scores of the pre- informal bedside positioning supplies Intervention: positioning team by intervention and post- education is an Control: No control due Introduction of the having each member intervention groups. effective way to to quasi-experimental IPAT tool and several The mean for the improve the design types of educational independently score for preintervention group developmental Intervention: Fifty-four materials in multiple five sample infants, was 8.39 (SD = 2.498) positioning proficiency infants pre-intervention formats, individualized with the inter-rater and the for the post- of NICU nurses.” and 55 infants post- for this 46 bed, level III reliability intraclass intervention group was intervention NICU in the western correlation for 9.42 (SD = 2.283) Statistical analysis: United States, over the consistency of single Levene’s test indicated course of one month measures was 0.797 that the assumption of Intervention fidelity: and for consistency or equal variances was Pre-intervention IPAT average measures was met (F = 1.546, p = scores were collected 0.972, and for 0.217) for the 54 pre- over a period of 12 days intervention scores and and post-intervention absolute agreement of 55 postintervention IPAT scores were single measures and scores collected for two collected over a period absolute agreement of different samples of of eight days average measures was infants 0.712 and 0.957 respectively. Cronbach’s alpha was 0.972, indicating that the IPAT had internal consistency  IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 20 Table 2 Synthesis Table for Implementing the Infant Positioning Assessment Tool in a Neonatal Intensive Care Unit Evidence Based Practice Question (PICO): Does implementing the Infant Positioning Assessment Tool (IPAT) as a reference and evaluation instrument improve consistency of developmentally supportive positioning practices in the NICU? Level of # of Summary of Findings Overall Quality Evidence Studies Coughlin, Lohman, & Gibbins (2010) found that the IPAT B: Randomization was not possible with this study design. This study is a reliable resource for providing a standardized reference had an adequate sample size with statistically significant results. The for developmentally supportive positioning practices in the findings were consistent across clinicians within and between multiple NICU. sites. Consistent recommendations based on a comprehensive literature Coughlin, Lohman, & Gibbins (2010) also found that the review with reference to scientific evidence. IPAT in conjunction with education is effective in III 2 improving developmentally supportive positioning B: Randomization was not possible with this study design. An adequate practices in the NICU. sample size was used with statistically significant results. While sample Spilker, Hill, & Rosenblum (2016) also found that the size was sufficient, IPAT scores were obtained on different infants cared IPAT is highly reliable and consistent instrument and too for by different nurses at a single clinical site. This study had consistent determined that a protocol of IPAT implementation along recommendations based on a comprehensive literature review with with bedside education yields significant increase in reference to scientific evidence. developmentally supportive positioning practices in the NICU. Jeanson (2013) found that staff reported being competent at C: No randomization was possible for this study design. Power analysis positioning according to the protocol of using the IPAT and was unreported to determine whether same size was sufficient for one-to-one bedside education. The IPAT served as an statistical analysis. Small sample size, fluctuations in census, and an effective tool for assessing positioning and helps to bridge inability to match staff caring for infants evaluated in the pre-, intra-, and III 1 the difference between staff perception and actual post-intervention phases were limitation to the study. Finally, while positioning practices. Immediate feedback and correction mean IPAT scores did increase, the results were statistically of positioning allowed nurses to see the difference proper insignificant, possibly due to the limited sample size. infant positioning has on physiological markers of stress in real time. IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 21 Level of Evidence Type of Evidence Evidence from systematic review, meta-analysis of randomized controlled trails (RCTs), or practice-guidelines based on systematic I (1) review of RCTs. II (2) Evidence obtained from well-designed RCT and/or reports of expert committees. III (3) Evidence obtained from well-designed controlled trials without randomization. IV (4) Evidence from well-designed case-control and cohort studies V (5) Evidence from systematic reviews of descriptive and qualitative study VI (6) Evidence from a single descriptive or qualitative study VII (7) Evidence from the opinion of authorities Rating Scale for Quality of Evidence (Newhouse) Consistent results with sufficient sample size, adequate control, and definitive conclusions; consistent Scientific recommendations based on extensive literature review that includes thoughtful reference to scientific evidence High (A) Well-defined, reproducible search strategies; consistent results with sufficient numbers of well- Summative Review defined studies; criteria-based evaluation of overall scientific strength and quality of included studies; definitive conclusions Experiential Expertise is clearly evident Reasonably consistent results, sufficient sample size, some control, with fairly definitive conclusions; Scientific reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence Good (B) Reasonably thorough and appropriate search; reasonably consistent results with sufficient numbers of Summative Review well-defined studies; evaluation of strengths and limitations of included studies; fairly definitive conclusions. Experiential Expertise seems to be credible. Scientific Little evidence with inconsistent results, insufficient sample size, conclusions cannot be drawn Undefined, poorly defined, or limited search strategies; insufficient evidence with inconsistent Low Quality (C) Summative Review results; conclusions cannot be drawn Experiential Expertise is not discernable or is dubious Note. Adapted from Newhouse RP. (2006). Evidence and the executive. Examining the support for evidence-based nursing practice. Journal of Nursing Administration, 36(7/8), 337–340. IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 22 Figure 1 The Synactive Theory of Infant Development (Als, 1982) IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 23 Figure 2 Complex Innovation Implementation (Helfrich et. al., 2007) IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 24 Figure 3 Infant Positioning Assessment Tool (IPAT) (Coughlin, Lohman, & Gibbins, 2018) IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 25 Figure 4 NICU Caregiver Educational Training Module on Developmentally Supportive Positioning and Utilization of the IPAT IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 26 Figure 5 Developmentally Supportive Positioning Educational Poster IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 27 Figure 6 Run chart of the percentage of IPAT total cumulative scores of ≥9 per week IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 28 Appendix A Collection Tool for Infant IPAT Scores Date Infant IPAT Score 1 2 3..... 20 IMPLEMENTING THE INFANT POSITIONING ASSESSMENT TOOL 29 Appendix B Collection Tool for Percentage of IPAT Scores ≥9 Date Percentage