Most nurses agree that nursing practices should be evidence-based. But making the leap from an established practice to a new, evidence-based practice is always challenging.
To meet the challenges of evaluating and establishing kangaroo care for healthy newborns in our institution, we used the Iowa Model for Evidence-Based Practice, which lays out a logical approach that’s practical for staff nurses. (See Three key terms.)
The Iowa model has three key decision points:
- Is the topic a priority for the organization?
- Is the research sufficient?
- Is the change appropriate for adoption in practice?
Using triggers to improve practice
Following the Iowa model, we identified problem triggers and knowledge triggers to determine whether the topic was a priority for an organization. For the kangaroo-care project, we had two problem-focused triggers: external benchmarking data (that is, data about best practices outside of our facility) and identification of a clinical problem. Our external benchmarking data came from an expert, Dr. Susan Ludington, who described the practice of kangaroo care for healthy newborns in both U.S. and international hospital systems. At our facility, kangaroo care for premature infants in the neonatal intensive care unit was common. But it wasn’t routinely used as an option for healthy newborns. Our clinical problem, identified by staff nurses, was that the newborn radiant warmer blocked access to postpartum patients (mothers and babies). Kangaroo care could replace the warmer.
Our knowledge-focused triggers were changes in the hospital’s philosophy of nursing care, newly published guidelines, and research literature. The hospital’s culture created an expectation that evidence-based practice would be incorporated into the nursing strategic plan, nursing philosophy, registered nurse job descriptions, nursing policies and procedures, and the bylaws of the nursing shared governance councils. Around the time of our kangaroo-care initiative, the American Academy of Pediatrics guidelines for breastfeeding said that healthy newborns should be in direct skin-to-skin contact with their mothers until after their first feeding. Our nurses wanted to practice in accordance with these guidelines.
Decision point 1: Is this topic a priority for the organization?
Without the support of a large number of department members, a new evidence-based practice will fail. Fortunately, the staff nurses convinced colleagues and management of nursing-practice priorities.
Forming a team
To develop, implement, and evaluate the project, we formed a team. Staff nurses explained day-to-day operations and the unit culture and appraised the feasibility of integrating kangaroo care for healthy newborns. The unit practice and research councils selected team members and served as a forum for reviewing the process and disseminating information. The Women’s Health Services’ clinical nurse specialist and an advanced practice nurse, who is our hospital’s specialist on evidence-based practice, provided leadership. Also, a lactation specialist offered expertise on using kangaroo care to promote breastfeeding. As the project evolved, the team solicited more involvement of the medical director of the newborn nursery.
We used several strategies to engage the team and their peers. Viewing Dr. Nils Bergman’s kangaroo-care video, which provides strong evidence of its benefits, generated enthusiasm early in the process. We also distributed an independent study about evidence-based practice. Nurses on the team gained exposure to national experts by attending a kangaroo-care certification program and then served as mentors to more than 300 colleagues in the Women’s Health department.
Reviewing the literature
To translate research into improved clinical practice, we used our nursing research journal club. The basis for our practice change was the Cochrane Review, which summarized the current state of the evidence on kangaroo care. In several sessions of the journal club, staff nurses discussed this review of research and found 30 years of research supporting kangaroo care as a safe, effective nursing intervention for healthy newborns. Other evidence came from benchmark surveys, Internet searches, and local and national conferences. Our staff nurses participated in all these activities.
Decision point 2: Is the research sufficient?
The literature review, Cochrane Review, results from benchmark surveys, and consultations with experts all supported kangaroo care and thus gave the team sufficient research to continue. The next step was to plan the pilot for the change in practice.
Piloting the change in practice
Planning the pilot began with selecting the desired outcomes, one of the most challenging parts of the project. The key to success was to design measurable outcomes, using the language of the hospital’s balanced scorecard, which included:
- quality of care, based on newborn safety
- customer service, based on mothers’ satisfaction
- quality of work life, based on nurses’ satisfaction
- finance, based on minimal cost.
Before trying the kangaroo care with healthy newborns, we developed guidelines for evidence-based practice, using local and national hospital templates. Management was most concerned about newborn safety during kangaroo care, so we stressed this in the guidelines.
We also planned awareness activities before the pilot. To prepare nurses, we used announcements at staff meetings and shared governance councils, newsletter entries, and a wall poster. Each nursing unit had a resource notebook containing the top three research resources and a bibliography.
The team transformed the desired outcomes into questions on a two-page survey. Then nurses and patients in the labor and delivery and postpartum units completed the surveys anonymously. The data summary and collection of narrative responses from the surveys served as baseline data.
As nurses and patients tried kangaroo care, the pilot became a shared process that gathered more stakeholders and champions. Nurses promoted the kangaroo-care option. Here are a few quotes from nurses during the pilot: “Babies really do breastfeed on their own.” “Mothers love it.” “It works with cesarean section moms in the postanesthesia care unit.”
Evaluating the pilot outcomes
The pilot had encouraging outcomes:
- stable newborn vital signs
- minimal separation of baby and mother
- successful breastfeeding
- patient requests for kangaroo care
- nurse satisfaction
- no increase in cost.
The pilot also started to dispel the misconception that radiant warmers provide the most effective newborn thermoregulation. Because the initial newborn bath takes place in the postpartum unit, nurses continue to use the radiant warmer for this portion of care. In the future, we hope to bathe newborns in the labor and delivery/recovery room, so the radiant warmer won’t be necessary.
Using the four balanced scorecard categories, we evaluated the pilot surveys for outcome data.
The last step of the pilot was to determine if the practice guidelines needed any changes. The pilot implementation of the guidelines went smoothly, and they were feasible and effective in the labor and delivery and postpartum areas. Nurses didn’t offer any suggestions or changes to the guidelines after the pilot.
Decision point 3: Is the change appropriate for adoption in practice?
The results of the pilot survey indicated that kangaroo care was a realistic, positive practice change that should be implemented in inpatient and outpatient settings. The staff and families endorsed kangaroo care, and the decision to make the kangaroo-care guidelines official hospital policy was unanimous.
Continuing evaluation of outcomes
The Iowa model steps kept us on track and contributed to our success over 2 years. Now that we’ve implemented kangaroo care, the evaluations of the four outcomes—newborn safety, minimal separation of baby and mother, patient request for kangaroo care, and nurse satisfaction—continue.
To communicate the outcomes and the lessons learned, we’ve created poster presentations, written articles for the hospital-wide and local nursing unit newsletters, and published an article in a peer-reviewed journal. Staff nurses are excited about sharing their experience with this practice change.
Implementing this change in nursing practice also taught us some lessons. We learned that the team needed a bedside nurse who could measure outcomes and navigate the clinical practice environment. And we learned something about flexibility. We didn’t follow the Iowa model flowchart perfectly, and sometimes steps occurred simultaneously. Though the model provides guidance and structure for making a practice change, team members found that a flexible approach served them well.
Evidence-based change
No one said that change was easy—and that certainly applies to a change from an established practice to an evidence-based practice. But following the logical approach of an evidence-based model can make the effort easier. And when the new practice is in place, the benefits to patients, nurses, and the institution make all the work worthwhile.
Selected references
American Academy of Pediatrics. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496-506.
American Nurses Credentialing Center. The Magnet Recognition Program: Recognizing Excellence in Nursing Service, Application Manual, 2005. Silver Spring, Md: American Nurses Credentialing Center; 2005.
Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005.
Mercer JS, Erickson-Owens DA, Graves B, Haley MM. Evidence-based practices for the fetal to newborn transition. J Midwifery Womens Health. 2007;52(3):262-272.
Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub2.
Titler MG, Kleiber C, Steelman V, et al. The Iowa model of evidence-based practice to promote quality care. Crit Care Nurs Clin North Am. 2001:13(4):497-509.
For a complete list of references, see March 2008 references.
Jane Lamp is the women’s health clinical nurse specialist, and Inga M. Zadvinskis is the evidence-based nursing practice specialist at Riverside Methodist Hospital in Columbus, Ohio. The authors would like to thank Jeanette Chambers, PhD, RN, for her assistance with manuscript preparation.
In addition to the authors, team members for the Kangaroo Care Evidence-Based Practice Project were Judy Bowles, RNC; Marlene Burkholder, BSN, RN; Marie Cooper, MBA, BSN, RNC; Maribeth Grywalski, RN; Nancy Hansen, MD; Patricia Rice, BA, IBCLC, LCCE; Sue Snyder, RN; Robin Studlien, RNC; and Christina Titus, BSN, RN.
