INCOT: Irish Neonatal Care in Occupational Therapy Study: The Development of an Occupational Therapy Intervention for Neonatal Units in Ireland

Abstract

Background: Occupational therapists (OTs) play an important role in neonatal units internationally. This is a growing area of practice in Ireland, but it is not yet part of the standard of care in all neonatal units. Additionally, while there is evidence to support some individual interventions used within OT practice in neonatal units, no studies were identified that have examined OT as an intervention in an Irish context. The aim of this research was to explore the current developmental care practices in neonatal units in Ireland, and to pilot an occupational therapy intervention in this setting. Methods: This study followed the first two stages of the Medical Research Council (MRC) Framework for Complex Interventions. Stage One – Development – had three distinct phases. Phase I involved an exploration of the current practices of developmentally supportive and family-centred care in neonatal units in Ireland. A qualitative description design was used, involving semi-structured interviews with 10 staff members from 3 neonatal units. Phase II was informed by the previous phase and employed a survey methodology. This gathered perceptions of developmental and family-centred practice nationally. Participants included 22 neonatal unit staff and 90 veteran neonatal parents. Phase III involved a review of the literature relevant to the practice of occupational therapy in the neonatal unit, including the effectiveness of interventions used by occupational therapists in this setting, and the barriers and enablers to parental participation in co-occupations. Guided by the findings of Stage One, Stage Two (Phase IV) – Feasibility/Piloting – sought to explore the impact of the delivery and implementation of a pilot occupational therapy intervention in an Irish neonatal unit. A quasi-experimental, mixed methods design was utilised. Data collection took place over a 6-month period of time, during which an OT intervention was provided to 34 infants and their families. Infants were between 23.5- and 35-weeks’ gestation at enrolment to the study and were seen for a mean of 8 sessions (range 3–35). Self-report measures from parents pre- and post-OT intervention (n = 42 parents) completed were the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU), Perceived Maternal Parenting Self-Efficacy (PMP S- E), the Karitane Parenting Confidence Scale (KPCS), the Edinburgh Postnatal Depression Scale (EPDS) and the Hospital Anxiety and Depression Rating Scale (HADS). Clinical assessments of the infants were completed using chart review, the Neonatal Behavioural Assessment Scale (NBAS) and the Goal Attainment Scale (GAS) created for the project, as well as infant pre- and post-intervention data, including oxygen saturation and heart rate. Post-intervention surveys were used with both staff (n = 24) and parents (n = 22) to gather qualitative data regarding their experiences with neonatal OT. Results Findings from the thematic analysis of the qualitative interviews in Phase I indicated themes related to participants’ attitudes and perceptions of developmental care for infants and families, including a discrepancy between what was perceived to be ideal practice and what was carried out in neonatal units on a day-to-day basis. The sources of developmental care education and the value placed on it were also identified, as was the impact of the environment on developmental care practice. Phase II identified strengths and areas for improvement in developmental care practice in Ireland. Barriers to the delivery of developmental care identified by staff included a need for further training, a lack of staffing on the unit to support developmental care and a lack of dedicated space for parents within neonatal units. Veteran parent survey analysis also identified variations in developmental care practice and challenges with the physical space of the neonatal unit. Parents described feeling close and connected to their infants in the neonatal unit through the participation in co-occupation or shared purposeful activities with their infant. Results from the pilot study in Stage Two (Phase IV) identified a statistically significant improvement in all parental measures post-intervention, apart from the PSS: NICU infant appearance subscale and the HADS depression subscale. GAS scores showed statistically significant changes across all domains. Infant autonomic stability, as measured by heart rate and blood oxygen, demonstrated statistically significant change between pre- and immediately post-OT sessions. Staff and parent surveys indicate that the pilot intervention was feasible and deliverable. Parents perceived the occupational therapy intervention to be empowering to their participation in co-occupations with their infants and beneficial to their infants. Staff reported that the OT pilot intervention enhanced their ability to deliver developmentally supportive care in the neonatal unit. Conclusion This project has provided a profile of current developmental care practices in Ireland from the perspectives neonatal staff and parents. It has also provided strong groundwork for the development of neonatal occupational therapy as a complex intervention, and the potential benefits to infants and their families that this can provide. Infants spending time on neonatal units have complex and multifactorial needs, and parenting in this environment has identified challenges. The neonatal unit itself is a complex environment, with multiple professionals involved with the infants’ care. Thus, the findings of the pilot study need to be considered within the context of this. The findings from all phases of the project can inform the development of practice in the neonatal unit environment, and further research by occupational therapists in this area is warranted.