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Journal of Neonatal Nursing xxx (xxxx) xxx–xxx Contents lists available at ScienceDirect Journal of Neonatal Nursing journal homepage: www.elsevier.com/locate/jnn Neonatal nursing in the COVID-19 pandemic: can we improve the future? Maria Teresa Montesa,b,c,d, Nuria Herranz-Rubiae,f,d,∗, on behalf of the NeNe Nursing Group ( Alicia Ferrerog, Ana Flóreze, Ana Quirogah, Aranzazu Gómezi, Bibiana Chineaa, Cristina Gómezj, Carmen Montanerk, Noelia Sánchezj, Cristina M. Ricol, Cristina Segoviaa, Dolores Eirizm, Elena Carrillon, Eva M. Cañizareso, Guillermina Chattash, IIham Mimónk, Inés M. Guerrap, Lourdes Del Ríoo, M. Jesús Martíng, M. Olga Elenal, María Garcíaq, Mireia Alcázarn, Patricia Martínezi, Patricia Sánchezm, Raquel De Miguelr, Rocío Cortéss, Silvia Massipr, Susana Tatoq, Toñi Jiménezp) a RN, PNN, Department of Neonatology, Hospital Universitario La Paz, Paseo de La Castellana, 261, 28046, Madrid, Spain b Universidad Autónoma, Madrid, Spain c Consejera del Capítulo de Enfermería, SIBEN, Latino America, Spain d NeNe Foundation, Madrid, Spain e RN. PNN. Department of Neonatology, Hospital Sant Joan de Déu, Passeig de Sant Joan de Déu, 2, 08950, Esplugues de Llobregat, Barcelona, Spain f University of Barcelona, Barcelona, Spain a RN, PNN, Unidad de Neonatología, Hospital Universitario La Paz, Paseo de La Castellana, 261, 28046, Madrid, Spain e RN. PNN. Department of Neonatology, Hospital Sant Joan de Déu, Passeig de Sant Joan de Déu, 2, 08950, Esplugues de Llobregat, Barcelona, Spain g Department of Neonatology, H.U. Río Hortega, Valladolid, Spain h Universidad Austral, Argentina i Department of Neo H.U. 12 de Octubre, Madrid, Spain j Department of Neonatology, H.U. Puerta del Mar, Cádiz, Spain k Department of Neonatology, H.U. La Fe, Valencia, Spain l Department of Neonatology, H.U. de Burgos, Burgos, Spain m Department of Neonatology, H.U. Juan Canalejo, A Coruña, Spain n Department of Neonatology, H.U. Vall d′Hebron, Barcelona, Spain o Department of Neonatology, H.U. Reina Sofia, Córdoba, Spain p Department of Neonatology, H.U. S. Pedro de Alcántara, Cáceres, Spain q Department of Neonatology, H.U. de Cruces, Bilbao, Spain r Department of Neonatology, H.U. Gregorio Marañón, Madrid, Spain s Department of Neonatology, H.U. Clinic Maternitat, Barcelona, Spain A R T I C LE I N FO A B S T R A C T Keywords: The current 2019 coronavirus disease (COVID-19) is the world's largest and most pervasive public health SARS-CoV-2 emergency in more than one hundred years. Although neonatal units have not been at the epicentre of the Covid-19 current health crisis, they have also been forced to adopt contingency plans with the aim of protecting hospi- Pandemic talised neonates, their families, and professionals. Neonatal units have been forced to alter the neonatal care Family-centred care framework based on promoting neurodevelopment and family-centred care. Moral distress Perinatal care The peak of the pandemic is falling in most countries, but COVID-19 infection is not eradicated and there is Nurse uncertainty about new outbreaks. It is time to reflect about better strategies to preserve the rights and excellence of care for newborns and their families. This column will highlight the changes that have occurred in neonatal units, and their impact on neonatal care and families. It is a time for critical reflection on nursing practice. 1. Manuscript text largest and most pervasive public health emergency for more than 100 years. Despite an unprecedented scientific response and heroic pro- The current 2019 coronavirus disease (Covid-19) is the world's fessionalism, there has been a deficient and chaotic response from ∗ Corresponding author. Department of Neonatology, Hospital Sant Joan de Déu, Passeig de Sant Joan de Déu, 2, 08950, Esplugues de Llobregat, Barcelona, Spain. E-mail addresses: maitemontesb@gmail.com (M.T. Montes), nherranz@sjdhospitalbarcelona.org (N. Herranz-Rubia). https://doi.org/10.1016/j.jnn.2020.07.005 Received 13 June 2020; Received in revised form 4 July 2020; Accepted 4 July 2020 1355-1841/ © 2020 Published by Elsevier Ltd on behalf of Neonatal Nurses Association. Please cite this article as: Maria Teresa Montes, et al., Journal of Neonatal Nursing, https://doi.org/10.1016/j.jnn.2020.07.005 M.T. Montes, et al. Journal of Neonatal Nursing xxx (xxxx) xxx–xxx health systems with important restrictions on mobility, and imposed should be accompanied by an effort in the professional workflow isolation. structuring to conduct strict telematic surveillance followed by more Though at first there was great concern about the foetus and new- thorough training of parents. In the case of premature babies, we must borns due to their immature immune system, there is no definitive cautiously assess the impact that these decisions might have on the evidence that SARS-CoV-2 can be transmitted transplacentally outcomes of babies and their families. (Alzamora et al., 2020; Chen et al., 2020; Dong et al., 2020; Egloff et al., 2020; Schwartz, 2020; Yu et al., 2020; Zeng et al., 2020). Data are also 2.2. Perinatal and neonatal care scarce on whether foetal infection can lead to teratogenic effects. For- tunately, most neonates horizontally infected to date have shown mild Initial recommendations to the management regarding the SARS- symptoms and good outcome (Dong et al., 2020; Lu et al., 2020). CoV-2-positive puerperant supported changes to delivery plans by in- Although neonatal units (NUs) have not been the epicentre of the troducing restrictions, both in vaginal deliveries and caesarean sections current health crisis, they have also been forced to adopt contingency on the presence of the other parent at childbirth and postpartum unit, plans with the aim of protecting hospitalised neonates, their families, early skin-to-skin contact, and late-cord clamping (Chen et al., 2020; L. and professionals. NUs have altered the neonatal care framework based Wang et al., 2020). In addition, it was recommended that infants born on promoting neurodevelopment and family-centred care (FCC) to infected mothers as well as newborns with confirmed infection be (Gooding et al., 2011). separated and isolated in an individual room. The peak of the pandemic is subsiding in most countries, but Fortunately, recommendations are being modified on a case-by-case COVID-19 infection is not eradicated and there is uncertainty about basis, and separation is not recommended if the mother is in good new outbreaks. It is time to reflect on better strategies to preserve the clinical condition, providing that precautionary measures can be rights and excellence of care for newborns and their families. guaranteed to avoid contagion including using a face mask and prac- From our large experience as neonatal nurses in Spanish NUs, we ticing hygiene before feeding. Likewise, infected neonates are subject to would like to take this opportunity of using this column to discuss and recommendations that vary from isolated admission without caregivers highlight some of the changes that may have had an impact on neonatal to strategies adapted to their clinical status, but with the accompani- care and families. Though caution is necessary so as not to over- ment of the parents (Chawla et al., 2020; Mimouni et al., 2020). generalise some of the principles and suggestions stated in this manu- Neonates constitute a unique group of particularly vulnerable pa- script, we believe similar circumstances obtain in other countries with tients because they are immersed in a complex process of development similar public health systems and family-centred neonatal care models. and organic maturation, particularly the brain where a sensitive process of synaptogenesis, apoptosis, dendritic growth, and neuronal differ- 2. Contingency plans and their impact entiation is taking place (Rice and Barone, 2000). On this biological basis, the FCC model has been incorporated into perinatal and neonatal Contingency plans due to the covid-19 pandemic have impacted on care based on the ethics of care and scientific evidence. three key areas: 1) the organization and workflow of neonatal units, 2) In this model, free entry of parents in the NU helps continued af- perinatal and neonatal care, including breastfeeding, and 3) commu- fective contact and care empowerment of parents with their child as nication-collaboration with parents. well as shared decision-making with the healthcare team (Craig et al., 2015; O'Brien et al., 2018). The current outbreak has brought about 2.1. Organization and workflow considerable changes in NU policy affecting not only infants with SARS- Cov-2 infection, but also the care offered to other admitted patients (Lu During this crisis, NUs have implemented major changes in their and Shi, 2020; J. Wang et al., 2020). In a desperate attempt to prevent daily workflow, which have entailed a major transformation in the care the spread of the virus, NUs have implemented “visiting hours” and model and work culture of the NU. Spaces and workflows have been have limited the role of the parents in caregiving whether or not they reorganized for patients, whether or not they are affected by Covid-19, were infected with SARS-CoV-2. in order to comply with the recommendations of the technical health Likewise, skin-to-skin contact has suffered restrictions. Skin-to-skin reports. is the simplest and most efficient tool to provide essential sensory input In addition, NUs have been overwhelmed with a shortage of health to the developing neonatal brain, improve breastmilk production, build care workers as staff became infected or transferred to other positions up the bonding, and help parents to play an active role in alleviating the to reinforce hospital areas severely affected by COVID. This has forced baby's pain and diminish their own stress (Anderzen-Carlsson et al., long shifts in order to guarantee the quality of care, which made things 2014; Baley et al., 2015). Furthermore, skin-to-skin care is the back- difficult and unpredictable at first. bone that nurses use to structure FCC, help parents get close to their Many centres have adopted very restrictive policies to care for babies, and increase their confidence about taking care of them. Parents pregnant women who are positive for SARS-CoV-2 in the maternal area, with a child admitted to the intensive care unit are especially vulner- as well as in the NUs, in order to control the spread of the virus and able to restrictions as they have to take on emotional disturbance that protect health professionals. Open access for both parents has been may deeply alter bonding and the relationship established with the limited, and eliminated for other family members, altering the corner- baby. stone of the FCC in which parents are not considered visitors, but rather Scientific evidence, and emotional and ethical considerations, argue the main collaborators and caregivers in their child's care (Gooding for cautious implementation of restrictive policies. The contingency et al., 2011). plans required in a pandemic should remind us that restrictions on the Contingency plans may have also affected hospital-assisted neonatal empowerment of parents in the care of their newborns interfere with home care programmes. Some hospitals have adopted changes in the their neurological development and the psycho-emotional health of the discharge decisions, with positive and negative impact on patients and family. families. Hospital discharge for healthy newborns has been advanced to Although adherence to contingency plans is important, re- lower the risk of the mother and infant becoming infected in hospital, commendations need to be based on evidence-based decision-making while it has been delayed in premature babies ready to be discharged rather than fears. Decisions taken during pandemic outbreaks should home due to mobility restrictions on the health professionals who give have as little impact as possible on this FCC model. In fact, preserving support to these programmes. However, the benefits of hospital-assisted the excellence of care is not at odds with using strict preventive mea- neonatal home care programmes should not be dismissed and decisions sures. In addition to frequent hand-washing, cleaning of the breast should be weighed and considered on a case-by-case basis. Changes before breastfeeding and skin-to-skin contact, and wearing face masks, 2 M.T. Montes, et al. Journal of Neonatal Nursing xxx (xxxx) xxx–xxx the risk to others can be reduced, for example, by testing parents and The isolation of the infant with suspicion or confirmation of SARS- health professionals for SARS-CoV-2 and restricting their access to CoV-2 in special rooms and the use of protective equipment have cre- where their child is placed. In this sense, NUs with individualized areas ated a physical barrier between professionals, the infant, and parents. In may be better equipped to meet the FCC targets. addition, interaction with the infant and the parents has been restricted The impact of contingency plans in the NUs has been even more to reduce the contagion, resulting in physical and emotional distance. transcendent on the FCC than in any other clinical scenarios (Arnaez Moreover, to the direct impact this can have on the quality of baby care, et al., 2020; Lu and Shi, 2020; J. Wang et al., 2020; L. Wang et al., it also hinders effective communication and collaboration with families, 2020). Sharing contingency measures with parents and family organi- contributing to a feeling of low-quality caregiving and increased moral zations by seeking their point of view, strategies and contributions can distress. be relevant to consensually define interventions tailored to the real In this context, it is necessary to set the fear aside and optimize the needs of parents (Williams et al., 2018). quality of the interaction and communication between the nurse and the family. When wearing a gown and mask, nonverbal communication 2.3. Breastfeeding elements take on added importance, including eye contact and the modulation of the tone of voice. The current pandemic has revealed Apart from physiological benefits for infants and mothers, breast- that nurses' communication training and relational skills should be feeding also helps the mother to better face the stress of hospitalization, improved in order to respond to parents’ feelings with empathy and connect emotionally and participate in the care of the baby, and facil- cultural competence (Bry et al., 2016). itate the construction of the maternal role. Even though to date viral While no technology can replace face-to-face communication, tele- load has rarely been isolated in breast milk, international guidelines health can be a valuable complement. Nurses perceive the use of advise that breastfeeding should continue, whether or not the lactating webcam systems to facilitate communication and interaction with parent has SARS-CoV-2 infection, with appropriate precautions parents positively; telehealth also enhances family education through (Davanzo et al., 2020; WHO, 2020). Furthermore, there are many ways schooling of parents and workshops, and neonatal follow-up after dis- to provide mothers their own breast milk if they don't want to take charge (Hoffman et al., 2019). Telemedicine provides the opportunity risks, such as pasteurizing their own milk, or throwing the milk away to isolated parents to visit their child remotely and reduce their anxiety while keeping breastfeeding (with extraction) for 14 days until con- and stress (Epstein et al., 2017). tagion becomes very unlikely. Due to isolation recommendations and restrictions on entry in the Pasteurized donor human milk (milk bank) is a crucial resource for NU, end-of-life caregiving has often involved insufficient empathetic intensive care infants whose mothers are temporarily unable to provide and compassionate care. Therapeutic communication is a determining their own milk. Interruption of feeding with donor human milk, parti- tool to accompany the family and implement palliative care. Once risk cularly in very premature stages, increases the risk of necrotizing en- for other admitted neonates is minimized, both parents should at least terocolitis in these children. Hence it is considered a major health in- be allowed to say face-to-face goodbyes to their child to help the tervention in these patients (de Halleux et al., 2017). grieving process (Kenner et al., 2015). However, in the current situation, most potential donors have re- Finally, affected parents have lost socialization with their partners strictions on mobility, and given the shortage of reserves, the milk bank and peer support. Therefore, more than ever it is necessary to support should be prioritized for preterm infants younger than 30 weeks of them in their day-to-day lives and also offer them specialized psycho- gestational age or weighing < 1500 g at birth whose mother cannot logical support (Williams et al., 2018). Nurses need to work colla- provide her own milk (Furlow, 2020). boratively with social workers and psychologists, since they can play an important role in identifying and supporting families at social risk and 2.4. Communication and collaboration with the families with limited financial resources. Nurses are the key point in the communication and collaboration 3. Moral distress and consequences on health professionals process with the parents and they are in an ideal position to explore their anxieties, fears, and difficulties in order to achieve empowerment Nurses are central players in the provision of quality health care. In and competence in their infant's care (Cleveland, 2008). Parents of this pandemic, factors such as a shortage of medical resources, over- admitted infants are extremely concerned about their child's separation, work with long shifts, restrictions on socialization, and the pain of their caregiving, and the difficulties in sharing emotions with other losing infected colleagues as well as the fear to infect their family family members. members have contributed to increasing stress in nurses. Likewise, they From their autonomous role, nurses face the individualized care of have experienced considerable stress in coping with this pandemic with the high-risk neonate and the family as an inseparable dyad (Griffin, heroic professionalism. In addition to managing the fear of contagion, 2006). With continuous presence and empathetic communication, they have been urged to take on ever-changing responsibilities, ac- nurses progressively establish a collaborative relationship with the cording to technical reports. Some of these emergency measures have parents to enhance parent-infant bonding and promote competency and forced nurses to sacrifice practices closely identified with the huma- empowerment in the infant's care (Reis et al., 2010). These elements are nistic and compassionate profession of nursing. This situation has had a determinants for the cognitive, psycho-emotional, and physical devel- significant emotional cost on nurses which has contributed to in- opment of neonates and ultimately for the health outcomes of the in- creasing their moral distress, when they have been unable to act ac- fant-parent twosome (Craig et al., 2015). cording to their personal and professional values concerning family Stress factors have intensified during the pandemic. Sharing in- care because of limitations beyond their control. In this situation, to formation openly and maintaining effective and empathetic commu- recognize and mitigate moral distress are necessary. Well-designed nication based on respect and mutual trust are fundamental tools that actions that encourage stress reduction, provide psychological support nurses use to cushion parental stress and to facilitate parents’ partici- and promote resilience can help make the day-to-day activities in pation in the care of their newborn (Reis et al., 2010). Restrictions on neonatal units less stressful. Strategies such as identification of the most the presence of parents in the NUs limits the encounters of interaction vulnerable professionals as well as the senior experts, debriefing to- and communication with nurses, while a lack of effective communica- gether about ethics in clinical cases, effective communication within tion and expectations regarding neonatal care inhibits negotiation be- the team, accurate guidelines to be followed, and flexibility in nurse tween the nurse and parents on how to implement the FCC (Corlett and leadership to help nurses carry out their work effectively should help to Twycross, 2006), (Lake et al., 2020). deal with such difficulties and provide moral comfort (Prentice et al., 3 M.T. Montes, et al. Journal of Neonatal Nursing xxx (xxxx) xxx–xxx Table 1 Difficulties and conflicts, and strategies proposed to remedy them. DIFFICULTIES AND CONFLICTS POTENTIAL STRATEGIES AND SOLUTIONS Limiting parents' entry impedes their role as primary caregivers Organization and workflow 24-h entry should not be restricted, providing measures to prevent contagion Entry is allowed only for one progenitor Facilitate stay of both parents even if for short periods Scant support from family associations Facilitate contact with associations by audio-visual means Absence of peer support Contact other parents telematically Difficulties in finding spaces to prevent mother-child separation Scout out imaginative strategies with managers to facilitate individual rooms Unforeseen exceptional situations will appear Consider complex admissions, end-of-life situations, and family difficulties Scant presence of social workers due to mobility restrictions Social workers can carry out their work with telehealth tools While parents await covid test results they are separated from Give preference to parents for testing, to reduce separation time the child Parents do not participate in the joint contingency plans Let parents make proposals and be part of the solution Restrictions on early discharge programs from the neonatal Encourage early discharge accompanied by changes in professional workflow, units with strict telematics surveillance after more thorough training of parents Universal rules for all admitted infants Individualize care and decisions according to the status of the mother and infant Lack of agreement with parents on the delivery plan Perinatal care Listen to parents' wishes and entertain the possibility of fulfilling them, minimizing the risk of contagion Partner accompaniment not allowed Allow accompaniment with preventive measures Skin-to-skin contact and baby's sucking at the breast is not Allow contact with precautions to prevent transmission allowed Lack of communication between the maternity area and Facilitate a communication strategy between the two areas to make parents neonatal unit feel calmer and more reassured Difficulties in parent care empowerment Neonatal care Facilitate extended parental stay and effective communication Restrictions on skin-to-skin care to avoid transmission of the Allow skin-to-skin care with recommended measures to prevent transmission virus of the virus Exaggerated vigilance of parents to ensure compliance with Help parents adhere to contingency plans through training and by explaining isolation measures, but without proper training the rules with empathy Discouraged breastfeeding due to fear of contagion Breast-feeding Encourage breastfeeding based on scientific evidence Own milk discouraged No institution discourages it. Use own pasteurized milk Decrease in milk bank storage Increase donations by means of telephone recruitment, home blood tests and milk collection, assuring supplies for most vulnerable infants Stress because contingency plans don't fit parents' needs Communication Let parents participate in contingency plans Communication difficulties if parents are unable to enter the Make it easier to use audio-visual media and technology to see the child and unit communicate with health workers Loss of nonverbal communication because of masks Use strategies that supplant this lack of nonverbal communication: tone of voice, eye contact, etc. Communication difficulties with minority groups Recognize the difficulty and communicate with cultural competence Fear that parents are the virus transmitters Stereotypes should be avoided and adherence to strict preventive approaches is desirable Stress due to frequent changes in workflow Moral distress of Horizontal leadership and effective communication to achieve flexibility Stress from risk of contagion due to shortage of medical professionals Strictly follow the recommendations of protection and isolation. Demand resources protective equipment Overwork with long shifts Announce when physical and psychological exhaustion comes to facilitate release. Put self-care measures in place Restrictions on socialization Extend social media sources with family and colleagues Pain of losing colleagues or becoming infected and possibly Ask for ongoing psychological support and promote strategies to increase infecting families resilience Absence of psychologists on the teams to help parents and Include psychologists in the neonatal unit teams health care staff 2018). Author contributions M.T. Montes and N. Herranz-Rubia contributed equally to the 4. Challenges from lessons learned manuscript and participated in the conception, writing, and reviewing of the manuscript. The authors included in the NeNe Nursing Group Neonatal care during the covid-19 pandemic has retreated several participated in the writing and reviewing of the manuscript. decades in time and NUs have seen many of their pillars wobble. However, infants and their parents will continue become infected and nurses will need to face difficulties in maintaining the excellence of the Funding FCC. We have a great opportunity to take advantage of the current challenging situation and encourage healthcare providers to reflect on This research did not receive any specific grant from funding valuable strategies to develop well-balanced decisions to overcome the agencies in the public, commercial, or not-for-profit sectors. risk and fear of contagion and preserve the neonatal care framework based on the promotion of neurological development through the FCC (Table 1). In this sense, quantitative and qualitative research focused on Declaration of competing interest understanding the perceptions of nurses as leaders in providing care, as well as the concerns, emotions, and attitudes of families during this None. 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