Elucidating the context for implementing nonpharmacologic care for neonatal opioid withdrawal syndrome: a qualitative study of perinatal nurses

Nurses described a lack of comprehensive unit- or organization-provided NOWS and opioid use disorder (OUD) education to effectively care for this patient population. Several nurses recalled NOWS education received during new-hire orientation, but noted it was exclusive to NOWS scoring assessment skills (e.g., Finnegan scoring) without attention to maternal OUD and evidence-based NOWS treatment approaches. Experienced nurses feared new hires did not receive adequate education on how to care for neonates with NOWS, especially concerning the trajectory of maternal OUD and treatment, and the numerous, interacting complex social and family dynamics (e.g., marital status; family proximity; societal stigma). Since hospital provided education was considered lacking, nurses relied on various internet resources (e.g., Google) to learn more about how to care for families affected by NOWS but noted internet resources could be unreliable. Many nurses vocalized experience working with families affected by NOWS; however, they felt their previous experiences were not sufficient to prepare them to care for these maternal-infant dyads. They stated more formalized education from the hospital surrounding maternal OUD (e.g., pathophysiology of addiction; psychology of addiction; trajectory of recovery), NOWS (e.g., long-term infant health and social outcomes; evidence-based treatment approaches), and engaging mothers in treatment of NOWS (e.g., therapeutic communication with mothers with OUD; understanding adverse childhood experiences and trauma) would supplement their experiences and increase their ability to provide quality care to neonates and families affected by NOWS. One nurse summarized, “I just think we [perinatal nurses] need the whole opioid addiction education…we just don’t get any of it really.”

In addition to nursing education, participants stressed the need for hospitals and communities to enhance the education mothers receive regarding NOWS. A lack in maternal knowledge about NOWS was thought to negatively affect a mother’s willingness to engage in neonatal care and implement nonpharmacologic interventions. Several nurses proposed increasing prenatal education about NOWS in community and primary care settings to better prepare mothers for what to expect after delivery. This education could be delivered during prenatal care visits, addiction treatment clinic visits, or through community outreach initiatives. However, nurses acknowledged that many mothers do not receive prenatal care and suggested education provided by labor nurses could help set the stage for the entire admission. At discharge, nurses felt mothers were not adequately prepared for a successful transition to home. Specifically, nurses reported mothers were not provided adequate opioid cessation resources at discharge and/or unit and organizational collaboration with community resources and treatment centers were unknown or not well-articulated. Nurses wanted to help mothers and neonates with transition from the hospital to home, but they did not fully understand the trajectory of these patients during and following transitions back to the community.

Nurses in the NICU and pediatric unit emphasized a lack unit and hospital-provided nursing education about challenges faced by mothers with OUD and what resources may be available to help them (e.g., transportation, housing, home visits). Since mothers are not admitted to pediatric or neonatal units, some of these nurses considered the family as “the patient” but felt a strong sense of protection for the neonate who is vulnerable as the “primary patient”. In addition, they felt a sense of vulnerability in trying to engage the mother while documenting her actions. This was particularly challenging because nurses understood their charting and interactions could impact findings of Child Protection Services (CPS), yet they had little-to-no interaction with CPS to explain or discuss their concerns.

Many nurses relied on social workers and case managers to connect mothers with community resources (e.g., breastfeeding support, local and state resources, case management, residential treatment, childcare). However, nurses working night or weekend shifts felt less knowledgeable about the availability of hospital and community resources because social workers and case managers were less accessible. Nurses recommended increasing hospital-provided education and collaboration with social work and case management across shifts and in the continuum of care. This would involve considering innovative solutions to utilize social work and case management staff and resources on nights and weekends, when most mothers visited the NICU or pediatric units or when some were discharged.

Nurses identified increased hospital-provided education on addiction, recovery, and post discharge support is needed to improve their practice in interacting with the parents during the neonate’s stay and in planning for transition to the community and post discharge care. Without hospital-provided education, nurses described feeling incompetent and unconfident in communicating with mothers with OUD. They felt additional on-the-job training and education could significantly improve their understanding of the mothers’ addiction and recovery experiences, leading to increased confidence in engaging these mothers in neonatal care. On the conceptual model, this theme mapped to structural context factors both internal (e.g., hospital-provided education) and external (e.g., community resources for pregnant women with OUD) to the hospital.

Care coordination was identified as a significant factor contributing to maternal engagement in implementation of nonpharmacologic care and relied on communication across settings (e.g., prenatal, hospital, home/community), interdisciplinary communication, or communication between different providers (e.g., nurses, physicians, social workers), and intradisciplinary communication, or communication within one set of providers (e.g., nurses). Interdisciplinary communication, as described by the nurses from all types of shifts, was compromised between members of the care team (e.g., physician, social work, case manager, lactation consultant, nurse). For example, one nurse stated, “I think that a lot of times the problem with the congruency isn’t congruency of nurses to nurses. It’s more like well the doctor said this, but that’s so-and-so doctor, and now this one’s on call, and the social worker, but she’s not here on the weekend...a lot of times where the problem lies is within different disciplines.”

Nurses explained a lack of opportunity to comprehensively discuss care among disciplines contributed to inconsistent care coordination and transition planning (e.g., labor unit to NICU; discharge). One nurse said, “I don’t know what social work does once they’re out of our hands.” Although interdisciplinary care rounds facilitated discussion across disciplines, nurses accentuated a lack of communication regarding NOWS treatment which ultimately led to incongruencies in care and poorer outcomes. Further, mothers were often not involved in planning: “I think that there’s just a lot of discussion not in front of the patient [mother] as that transition [to community] and to make that work and when it’s appropriate and when it’s not.”

While describing intradisciplinary communication and care coordination, nurses cited handoff report, nursing notes, bedside report, electronic medical record charting, and nursing care plans as communication modalities contributing to congruent patient care. However, they elaborated and stated the quality of handoff varies considerably across units and between nurses. The variation in the quality of handoff report or communication between units and nurses was described as a leading cause of decreased care quality and continuity. This was thought to adversely affect implementation of maternally provided nonpharmacologic care. For example, nurses suggested handoff reports should include discussion of effective and ineffective strategies used by the previous nurse to engage the mother.

Lack of interaction or connectedness between nurses from different units (e.g., labor and NICU) and care settings (e.g., hospital to community), was considered a critical barrier to care coordination, especially to continuation of breastfeeding and skin-to-skin care initiated at delivery. For example, breastfeeding support in a postpartum unit may not have been continued in the NICU when mothers were visiting neonates. In addition to inconsistencies in maternal engagement, nurses reported significant variation in how each unit scored neonates exhibiting symptoms of NOWS. As one nurse explained, labor nurses often scored neonates with suspected NOWS higher than the NICU nurses. Thus, nurses suggested implementing NOWS care practices across all units simultaneously to improve continuity and include community partners in interdisciplinary discharge planning. Standardized care across units and coordination across settings were described as effective strategies to improve engagement of mothers in neonatal care. These strategies were thought to improve maternal engagement by decreasing the level of care disruption mothers and neonates experience as they transition across shifts, units, and hospital and community settings. On the conceptual model, the theme of interdisciplinary and intradisciplinary care coordination mapped to social dynamic context factors, including communication among team members within the hospital (internal) and outside the hospital in the community (external).

Nurses described staffing as a major unit and organizational factor contributing to the overall care of neonates with NOWS. Nurses, especially those practicing in the NICU, emphasized primary care nursing, a nursing model that assigns one nurse as a patient’s primary care provider for the duration of their hospitalization. Nurses noted primary care nursing, specifically with infants affected by NOWS, can improve care continuity and outcomes by affording increased opportunities for nurses to develop relationships the neonate’s family.

Similarly, FBC nurses also emphasized the importance of nursing consistency considering that a mother might labor with one nurse and postpartum with another. Nurses advocated for a more comprehensive approach to NOWS care – an approach that includes all hospital units (e.g., FBC, pediatrics, NICU) and community partners (e.g., treatment clinics, pediatricians, public health nurses) involved in the care of substance-exposed maternal-infant dyads. Episodic care, or unit-based care, can be overly distinct and specific to each unit. This could interfere with continuity of care, especially as nurses prepare mothers and neonates for transition from hospital into the community.

Nurses described neonates with NOWS and their families as having increased needs, both physical and educational, and these needs are often not prominent in determining nurse-patient assignments. As one participant stated, “If they [nurse] have a really heavy assignment and they have a baby who’s needing extra care or a mom who needs extra education regarding NAS [neonatal abstinence syndrome] scoring and they’re not able to be in there doing that…that is a barrier.” Because families affected by NOWS require increased education and social work resources and referrals, nurses felt these patients were of much higher acuity, not accounted for in current acuity indices or patient assignments. When discussing acuity levels and staffing, one nurse said, “[we don’t] factor in mom’s view and mom’s education needs.” Accounting for the heightened psychosocial and educational needs of mothers with OUD while making staffing decisions was thought to provide more time for nurses to effectively educate and engage mothers in neonatal care. This theme mapped to internal structural (staffing models) and social dynamic (nurse-mother relationship) context factors in the conceptual model.

The nurses felt the structural layout of the unit may facilitate or hinder maternal visitation and engagement. Many nurses described the ability for mothers to room-in with their neonate as a facilitator towards maternal involvement. Nurses recognized rooming-in contributed to increased maternal engagement in implementation of nonpharmacologic neonatal care such as breastfeeding and skin-to-skin care and provided numerous opportunities to educate the mother and connect her with community resources. Specifically, nurses described 24-h visitation policies and private rooms as two synergistic factors increasing a mother’s intention and ability to room-in with her neonate. However, other factors led to mothers having to leave the room including to go to the restroom, acquiring food, attending individual or group treatment sessions, obtaining methadone. Thus, nurses suggested utilizing rooms with bathrooms, delivering in-room meals for mothers, and providing OUD treatment, including methadone, using in-hospital resources until neonatal discharge.

Nurses from the labor and postpartum units emphasized the importance of the special care nursery in increasing maternal involvement. Nurses described a special care nursery as a virtual unit (not physical unit) which admits neonates with minor NOWS symptoms for monitoring. In the special care nursery, even after maternal discharge the mother had access to a full size bed and private bathroom in the neonate’s room. Nurses felt this model allowed for increased maternal engagement in neonatal care because the mother and neonate could remain in the same room while the mother recovers from delivery. Further, if required, the neonate would remain in the FBC as a “virtual special care” admission after the mother’s discharge. In addition, nurses described the pediatric unit as a prime location for neonatal treatment and they “encouraged moms to go with their babies to pediatrics” if the mother was discharged. Nurses felt that engagement of mothers in neonatal care was impacted by the type of unit where neonates received NOWS treatment, including the ability to room-in. On the conceptual model, this theme mapped to internal structural (e.g., unit architecture) and social dynamic (e.g., improved maternal presence at neonates’ bedsides) context factors.