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A Nurse-Based Model of Psychosocial Support for Emotionally Distressed Mothers of Infants in the NICU
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Correspondence Lisa S. Segre, PhD, University of Iowa, College of Nursing, 50 Newton Rd., Iowa City, IA 52242. [email protected] Keywords depression screening family-centered care listening visits newborn intensive care unit postpartum depression
Rebecca Chuffo Davila, ARNP, BNP, NNP-BC, FAANP, is a neonatal nurse practitioner in the Division of Neonatology, University of Iowa Stead Family Children’s Hospital, Iowa City, IA. Lisa S. Segre, PhD, is an associate professor in the College of Nursing, University of Iowa, Iowa City, IA.
A Nurse-Based Model of Psychosocial Support for Emotionally Distressed Mothers of Newborns in the NICU
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Rebecca Chuffo Davila and Lisa S. Segre
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ABSTRACT Mothers whose newborns are hospitalized in the NICU are frequently emotionally distressed, particularly early in the hospitalization. The Family-Centered Developmental Care philosophy, widely adopted by NICUs, calls for an expanded focus on the well-being of the entire family. In this article, we describe an innovative, nurse-delivered program for emotionally distressed mothers of newborns in the NICU that includes screening and an empirically supported counseling approach: Listening Visits.
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epression and anxiety symptoms are prevalent among mothers of newborns hospitalized in the NICU. However, emotional distress is often not identified, and even when it is detected, mothers are not always able to access support. In alignment with the philosophy of Family Centered Developmental Care (FCDC; Gooding et al., 2011), which is widely adopted by NICU professionals, nurses are well positioned to identify distress through screening and to provide an empirically supported intervention called Listening Visits (LV) for those in need of such support. We describe how this nurse-based model of psychosocial care was implemented within the context of a program of applied research and suggest how this model might eventually be implemented into routine clinical care within the NICU environment.
Background and Significance Emotional Distress in Mothers of Hospitalized Newborns
The authors report no conflict of interest or relevant financial relationships.
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The hospitalization of a newborn in a NICU is often stressful and may result in clinically significant levels of emotional distress among mothers. Focusing on the immediate postpartum period when a newborn is first hospitalized, two groups of researchers found that elevated anxiety and depression symptoms were prevalent in
mothers (Holditch-Davis et al., 2015; Segre, McCabe, Chuffo-Siewert, & O’Hara, 2014). From their results, a third group of investigators suggested that these elevated depression and anxiety symptoms can be severe. Specifically, they found that early in the newborn hospitalization period, 35% of mothers reported symptoms that met the diagnostic criteria for Acute Distress Disorder (Lefkowitz, Baxt, & Evans, 2010). In addition, they found that 33% of these mothers experienced suicidal thoughts compared with 14% of perinatal women in the general population who report such ideation (Lindahl, Pearson, & Colpe, 2005). Moreover, the depression symptoms can endure. In one longitudinal assessment of mothers whose newborns were hospitalized in the NICU, researchers found that without treatment, at just over 1 year after the birth, 21% (n ¼ 102) still reported clinically significant levels of depression symptoms (Miles, Holditch-Davis, Schwartz, & Scher, 2007). Finally, in studies that included a comparison group of mothers of nonhospitalized, term newborns, researchers found that mothers of hospitalized newborns reported significantly more clinically significant symptoms of anxiety and depression (Brandon et al., 2011; Vanderbilt, Bushley, Young, & Frank, 2009).
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Nurse Support for Mothers of Newborns in the NICU
The hospitalization of a newborn in a NICU is often stressful and may result in clinically significant levels of emotional distress among mothers.
Current NICU Psychosocial Care In the NICU, standard care includes maternal depression screening with as-needed referrals to mental health professionals, usually without follow-up. In suboptimum care, depression symptoms are not assessed, perhaps because emphasis is placed on the hospitalized newborn. Even when clinically significant depression symptoms are identified, barriers such as social stigma and cost (Dennis & Chung-Lee, 2006) prevent most perinatal women from receiving treatment (Marcus, Flynn, Blow, & Barry, 2003). Because mothers are often busy visiting their newborns in the NICU, lack of time may be an additional barrier to seeking care. In two small trials, researchers evaluated interventions for emotionally distressed mothers of hospitalized newborns and reported significant reduction of depression symptoms when treatment was delivered by a psychologist (Jotzo & Poets, 2005) or a care manager (Meyer et al., 1994). Although such interventions are valuable, the social stigma sometimes associated with seeing a mental health professional may prevent some mothers from accessing this form of care. In one model of care, FCDC, the entire family is emphasized, not just the infant (Gooding et al., 2011). The expansion of a nurse’s role in the NICU to include screening for emotional distress and providing support adds a tangible means to implement this philosophy. Many integrated models have been developed for selected health care systems, but the United Kingdom provides a unique example of postpartum services. As part of the United Kingdom’s universal health surveillance, all new mothers receive home visits within the first 10 days after birth from a public health nurse, called a health visitor (Holden, 1996). During this routine care, health visitors attend to the psychological wellbeing of the mother.
The UK Model of Integrated Psychosocial Care In the early 1980s, a British nurse/psychiatrist team developed The Edinburgh Postnatal Depression Screening Scale (EPDS), a 10-item scale used to
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assess depression symptoms (Cox, Holden, & Sagovsky, 1987). Today, the EPDS is used by clinicians and researchers worldwide to screen for depression symptoms in women of childbearing age (Cox, Holden, & Henshaw, 2014). In addition, this nurse/psychiatrist team also developed and validated LV, a first-line depression treatment approach expressly for use by health visitors (Holden, Sagovsky, & Cox, 1989). The LV intervention consists of six 50-minute sessions delivered by a nurse who has completed LV training and has a bachelor’s degree or greater. Key components of LV, which are described fully elsewhere (Chuffo Siewert, Cline, & Segre, 2015), include active listening and collaborative problem solving. These techniques are used to gather a genuine understanding of a woman’s experiences and perspective in the postpartum period. The LV intervention is nondirective, so the focus of each session is decided by the woman herself, not the nurse. In general, a single LV session includes a greeting, debriefing about the previous visit, updates on present issues, discussion of current concerns, a summary, and scheduling the next visit or concluding the visits (Chuffo Siewert et al., 2015). In the United Kingdom, considerable empirical support garnered through several randomized controlled trials (Cooper, Murray, Wilson, & Romaniuk, 2003; Holden et al., 1989; Morrell et al., 2009; Wickberg & Hwang, 1996) prompted the National Institute of Clinical Excellence to recommend LV as an evidence-based treatment for mild to moderate postnatal depression (British Psychological Society, 2007). In a program of research directed by the second author, LV was imported to the Midwestern United States and proved to be a feasible way to deliver a first-line depression treatment approach to low-income mothers who receive home visiting services (Segre, Stasik, O’Hara, & Arndt, 2010). Subsequently, this group of researchers conducted a randomized controlled trial and found that LV significantly reduced depression and improved perceived quality of life compared with home visiting services or routine prenatal services (Segre, Brock, & O’Hara, 2015).
LV in the NICU: Implementation and Evaluation The novel idea to implement LV in the NICU was proposed by the first author, an advanced practice NICU nurse who recognized that the emotional needs of mothers of hospitalized
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newborns are usually not addressed in the NICU setting. Because, to our knowledge, LV had never been implemented in a hospital setting or with mothers of hospitalized newborns, this newly formed research team (first and second authors) conducted a small feasibility trial. In the screening phase of the trial, mothers of hospitalized newborns were invited to participate in a study to assess their emotional experiences in the NICU. Mothers with elevated depression scores were then offered the opportunity to receive LV as participants in the second phase of the trial. The results were promising (Segre, Chuffo-Siewert, Brock, & O’Hara, 2013). First, the successful implementation of LV in the NICU during the trial showed that it was possible for a nurse to deliver LV in a 70-bed, Level IV NICU in an academic medical setting. Second, women were willing to use this form of care: 78% of eligible depressed mothers opted to try the LV intervention. Third, as reported elsewhere (Segre et al., 2013), symptoms of emotional distress improved significantly from before to after LV, as shown by scores from the EPDS (mean score before LV ¼ 14.26 versus after LV ¼ 9.00) and Beck Anxiety Scale (mean score before LV ¼ 16.57 versus after LV ¼ 11.14). Finally, LV recipients were very satisfied with LV provided by a nurse: 91.3% of LV recipients rated the quality of help received as excellent (Segre et al., 2013). A descriptive account of the implementation of LV in the NICU during the feasibility trial, including a clinical case study, is available (Chuffo Siewert et al., 2015).
Proposed Nurse-Based Model of Psychosocial Care for the NICU Q4
In the aforementioned publications, researchers described the implementation and evaluation of LV in the NICU. In this article, we expand on these prior publications with our proposal for a nursebased model of psychosocial care for mothers of newborns in the NICU (depicted in Figure 1). In this model, nurses in the NICU screen mothers for depression and, for those with elevated depression symptoms, offer LV as a first-line treatment option. Although the evidence for components of this approach is available (Chuffo Siewert et al., 2015; Segre et al., 2013), a proposal for how to implement this model into standard clinical care has not been previously described.
Depression Screening During the NICU-based feasibility trial, the EPDS was used to identify depressed postpartum women (Segre et al., 2013). Specifically, within
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a week of newborn admission, all Englishspeaking mothers of newborns hospitalized on the NICU, who were 18 years of age or older, were recruited for a study of maternal emotional experiences. Enrolled participants completed self-report instruments, which included the EPDS, to identify those in need of further emotional support. Those who were eligible for the feasibility trial and interested in receiving LV from a nurse were enrolled into the feasibility trial phase of this study. Mothers with elevated EPDS scores who were not interested in receiving LV or eligible for the trial (i.e., a score of 3 on the suicide item or those who would not be in the NICU long enough to receive a full course of LV) were immediately connected with a social worker in the NICU. In Figure 1, we propose how LV might be implemented as part of routine nursing care in the NICU. The first step would be to identify emotionally distressed women. Nurses in the NICU could incorporate universal depression screening, as was done by nurses who worked in the maternity unit (Segre, Pollack, Brock, Andrew, & O’Hara, 2014). As indicated in Figure 1, if the EPDS score is less than 12, the mother should be reassessed in accordance with the unit’s depression screening protocol. Because the hospitalization of a newborn is stressful early on, we propose that these mothers should be screened every 4 to 6 weeks while their infants are hospitalized in the NICU. Mothers who score between 12 and 19 would be offered two support options: LV provided in the NICU by a nurse who completed LV training or referral to the social work team who would then conduct an assessment and, if needed, refer the mother to mental health professional services. An EPDS score of 20 or greater, which is indicative of depression symptoms in the severe range (McCabe-Beane, Segre, Perkhounkova, Stuart, & O’Hara, 2016), would warrant immediate referral to the social work team to further asses and, if needed, refer the woman to a mental health professional. Women who are actively suicidal as assessed by Item 10 on the EPDS would also be immediately referred to the social work team.
Treatment: LV In the feasibility trial, the first author, a neonatal nurse practitioner (NNP) employed in the NICU, provided six 45- to 60-minute LV sessions to all study participants every 2 to 3 days (Segre et al., 2013). All sessions occurred in a private hospital
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Nurse Support for Mothers of Newborns in the NICU
Figure 1. Proposed nurse-based model of psychosocial care for mothers of infants hospitalized in the NICU.
location chosen by the participant; some were carried out in newborns’ rooms and others in various places within the hospital. During the trial, the NNP LV provider continued to work full time in the NICU as an NNP and provided LV sessions during nonwork hours as part of a research study. However, because no more than two mothers needed to have LV at the same time, it was feasible for the NNP to provide all the LV sessions to trial participants. In addition, after the completion of all LV sessions with each LV participant, the NNP continued to care for the infant and remained in contact with the mother until discharge from the NICU.
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In the feasibility trial, the six sessions were sometimes not sufficient to relieve emotional distress: 39% (9/23) of the women who received LV showed no improvement in EPDS scores (Segre et al., 2013). Because the six LV sessions were concluded approximately 1 month after newborn admission, and a visit with a NICUbased social worker was part of routine care within that timeframe, each trial participant had already met with a social worker at least once. Thus, during the feasibility trial, the assigned social worker was able to speak with women who needed assistance to find additional counseling services.
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In clinical practice, we envision that LV delivered by a part-time nurse employed in the NICU could be available as a first-line treatment for women with mild to moderate emotional distress. LV would be provided in the NICU or private hospital setting by a nurse who has completed LV training. Mothers with severe or acute symptoms or those who opt not to receive LV would be referred to the social work team, who would then engage appropriate specialist services. Similarly, for mothers whose symptoms do not decrease after receipt of LV, the nurse would engage the social work team to connect the mother with specialist services. Thus, as indicated in Figure 1, to have nurses provide LV in the NICU is suggested as a first-line addition to mental health services, not a replacement for social work services. Indeed, in accordance with the model delineated in Figure 1, the nurses would work closely with the social work team. Although the results of the NICU-based feasibility trial of LV were promising, they were nonetheless preliminary. Additional research is required and numerous logistical elements need to be addressed before such a model can actually be implemented. Before delineation of these future directions, we first examine the acceptability of a nurse-delivered model of care.
Nurse-Based Model of Psychosocial Care: Views and Controversy In the United States, psychological treatment is delivered primarily by mental health specialists, including psychiatric nurses, social workers, psychologists, counselors, and psychiatrists. In a significant departure from this traditional mental health care model, we suggest the expansion of the role of the nurse to include depression screening and counseling. In our research to evaluate LV, we assessed the views of nurses and women about this innovative form of care. The results of these studies are reviewed in the sections that follow. Additional concerns about the implementation of LV in the NICU are also described and addressed. Views of nurse-delivered depression screening. In the NICU feasibility trial, most (90.2%) of the 200 mothers who completed questionnaires during the screening phase indicated that they would be willing to complete a depression screening scale given to them by a nurse (Segre, Orengo-Aguayo, & Chuffo Siewert, 2016). A separate survey of 518 clinical nurses indicated similarly positive views: 96.2% indicated that depression screening by
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In the NICU, standard care includes maternal depression screening with as-needed referrals to mental health professionals, usually without follow-up.
nurses is a good idea (Segre, O’Hara, Arndt, & Beck, 2010). Views of nurse-delivered counseling and LV. Among the 200 mothers of newborns hospitalized in the NICU who completed screening questionnaires during the feasibility trial, over half (67%, n ¼ 132) indicated that they would be willing to see a nurse for counseling (Segre et al., 2016). Approximately half of these mothers (47.5%, n ¼ 94) indicated their interest to learn more about LV delivered by a nurse. Among the subset of 49 mothers with elevated EPDS scores, an even greater proportion indicated their interest to learn about LV (65.3%, 32/49). Of these 49 women with elevated depression scores, 32 were eligible to participate in the LV phase of the feasibility trial (e.g., their newborns would be on the NICU long enough for them to receive LV treatment). More than three quarters of these eligible women (78%) agreed to try LV (Segre et al., 2013), which provided one index of acceptability. Finally, among the emotionally distressed mothers who received LV during the NICU-based feasibility trial, results of quantitative and qualitative assessments indicated unanimously favorable views about their experiences with this nurse-delivered supportive approach (Segre et al., 2013; Segre et al., 2016). One participant said, “Just talking to someone who is so caring, not only about my baby but about me too, was very helpful” (Segre et al., 2016, p. 7). Among the 519 clinical nurses who completed a survey to assess their views of a nurse- delivered model of psychosocial support, most (93.7%) strongly agreed or agreed with the statement that nurse-delivered counseling is a good idea, and 62.3% indicated willingness to participate in counseling training (Segre, O’Hara, et al., 2010). We have yet to assess the views of NICU nurses about the nurse-delivered model of psychosocial care; however, during the NICU feasibility trial, the nurses, physicians, and social workers informally indicated that they had come to value this treatment option. Controversy. Informal feedback from health care professionals employed in the NICU has not been all positive. At two national conferences, the first
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author described her experiences with implementation of LV in the NICU. The anonymous evaluations of these presentations were generally positive. However, some conference attendees (approximately <5%) expressed concern that the provision of support in the form of LV is beyond the nurse’s scope of practice. Our responses to this concern are outlined next and summarized in Figure 2. First, the FCDC philosophy emphasizes the importance of caring for the entire family. Second, LV was developed specifically for delivery by nurses, and there is significant empirical support for its efficacy (Cooper et al., 2003; Holden et al., 1989; Morrell et al., 2009; Segre et al., 2015; Segre et al., 2013; Wickberg & Hwang, 1996). Third, nursing students are required to take introductory courses to acquire the therapeutic communication skills that are central to LV, for example, empathy, genuineness, active listening, reflecting, questioning, and clarifying. Fourth, social stigma is often associated with mental health specialists/treatments. However, the NICU nurse often has established a trusting relationship as a primary caregiver and is ideally positioned to provide support free of stigma. Fifth, NICU nurses are physically accessible to mothers who do not want to leave their newborns’ bedsides. Finally, compared with most mental health specialists, NICU nurses draw on considerable medical knowledge that enhances their understanding of mothers’ concerns
about their medically fragile newborns and supports their ability to answer the mothers’ medically related questions.
Future Directions In this LV feasibility trial, we showed that it was possible for a nurse to provide LV in the NICU setting, that LV reduced depression symptoms and improved perceived quality of life, and that women valued this approach. These results are promising but preliminary. First, without a comparison group, the improvement in maternal mood realized in the trial cannot be definitively attributed to LV. Second, given the emphasis on controlling hospital costs, it will also be important to assess economic outcomes to determine how to pay for this service. These outcomes could include costs to implement LV compared with usual care, as well as the effect of LV on outcomes related to costs, including maternal satisfaction, infant length of stay, and rehospitalization in the month after discharge. Third, in the feasibility trial, screening was limited to the identification of elevated depression symptoms. However, mothers with newborns in the NICU have increased risk for depression and anxiety symptoms (Holditch-Davis et al., 2015; Segre, McCabe, et al., 2014). To address these gaps, the next step in this program of research will be to conduct a randomized controlled trial
Listening Visits build on nurses' communication skills.
Nurses can leverage an established trusting relationship to provide support to mothers.
Listening Visits were developed for delivery by nurses and are empirically supported.
Care of mother is central to Family Centered Developmental Care philosophy.
Nurses are accessible, allowing mothers to receive care near the infant.
Rationale for nursedelivered support for mothers of infants hospitalized in the NICU
Nurses are knowledgeable about the medical conditions of hospitalized newborns.
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Figure 2. Rationale for nurse-delivered counseling in the NICU.
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evaluation of LV with depressed or anxious mothers to assess maternal mood and economic outcomes. Before LV can be integrated into routine clinical care in the NICU, screening protocols will need to include assessments of anxiety and depression symptoms. Additionally, numerous administrative issues must also be addressed, including which nurses should provide LV, how to find time for a nurse to provide LV given other clinical duties, how to integrate the nurse into a team of mental health service professionals, how to provide LV training outside the context of a funded trial, and importantly, how to pay for this clinical service. The first author, who serves as a member of the steering committee for the hospital’s NICU breastfeeding task force, observed that similar administrative issues were successfully addressed in the integration of lactation consultants into her NICU setting. For example, just as nurses comfortable and knowledgeable in the provision of breastfeeding help to mothers were needed for the lactation program, one administrative hurdle to implement LV may be the identification of nurses willing to provide specialized mental health care. In our experience with the implementation of LV in the NICU, we have readily identified nurses who are comfortable providing this form of care. With regard to finding time in the nurse’s workday for LV, the lactation consultants work part time as bedside nurses and part time as lactation consultants in the NICU. Potentially, similar arrangements could be made for nurses who provide LV. Although the integration of lactation consultants into routine clinical care in the NICU can serve as a template, many additional issues will need to be addressed before a nurse-delivered model of psychosocial care is implemented in NICU settings.
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We propose a nurse-delivered model of psychosocial care that includes maternal depression screening and Listening Visits as a first-line counseling approach.
the value of LV delivered by a nurse: “I could not have ever imagined that these six visits could have helped me in so many ways.” In conclusion, we posit that a nurse-delivered model of psychosocial care, which includes depression screening and counseling, fills the gap in mentalhealth services for mothers. Future research is required to support the integration of this practice into routine clinical care.
Acknowledgment Funding for the feasibility trial Listening Visits in the Neonatal Intensive Care Unit was provided by the Social Science Funding Program, Vice President for Research Office of the University of Iowa. During the conduct of this study, Dr. Segre was supported by a K-23 Award (MH075964). The authors thank Drs. Rasmussen, Stasik-O’Brien, Williamson, and White-Traut and Mr. Nelson and the College of Nursing editor, Dr. Diana Colgan.
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Conclusion
Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled
The results presented in many published articles highlight the increase in anxiety and depression symptoms in mothers of newborns hospitalized in the NICU. Nevertheless, effective, accessible treatment options are limited. In line with FCDC, we propose a nurse-delivered model of psychosocial care that includes maternal depression screening and LV as a first-line counseling approach. For mothers who experience mild to moderate emotional distress, LV delivered in the NICU by a nurse can provide a first-line treatment approach that is convenient and nonstigmatizing. One LV recipient in the feasibility trial summarized
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Correspondence Lisa S. Segre, PhD, University of Iowa, College of Nursing, 50 Newton Rd., Iowa City, IA 52242. [email protected] Keywords depression screening family-centered care listening visits newborn intensive care unit postpartum depression
Rebecca Chuffo Davila, ARNP, BNP, NNP-BC, FAANP, is a neonatal nurse practitioner in the Division of Neonatology, University of Iowa Stead Family Children’s Hospital, Iowa City, IA. Lisa S. Segre, PhD, is an associate professor in the College of Nursing, University of Iowa, Iowa City, IA.
A Nurse-Based Model of Psychosocial Support for Emotionally Distressed Mothers of Newborns in the NICU
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Rebecca Chuffo Davila and Lisa S. Segre
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ABSTRACT Mothers whose newborns are hospitalized in the NICU are frequently emotionally distressed, particularly early in the hospitalization. The Family-Centered Developmental Care philosophy, widely adopted by NICUs, calls for an expanded focus on the well-being of the entire family. In this article, we describe an innovative, nurse-delivered program for emotionally distressed mothers of newborns in the NICU that includes screening and an empirically supported counseling approach: Listening Visits.
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epression and anxiety symptoms are prevalent among mothers of newborns hospitalized in the NICU. However, emotional distress is often not identified, and even when it is detected, mothers are not always able to access support. In alignment with the philosophy of Family Centered Developmental Care (FCDC; Gooding et al., 2011), which is widely adopted by NICU professionals, nurses are well positioned to identify distress through screening and to provide an empirically supported intervention called Listening Visits (LV) for those in need of such support. We describe how this nurse-based model of psychosocial care was implemented within the context of a program of applied research and suggest how this model might eventually be implemented into routine clinical care within the NICU environment.
Background and Significance Emotional Distress in Mothers of Hospitalized Newborns
The authors report no conflict of interest or relevant financial relationships.
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The hospitalization of a newborn in a NICU is often stressful and may result in clinically significant levels of emotional distress among mothers. Focusing on the immediate postpartum period when a newborn is first hospitalized, two groups of researchers found that elevated anxiety and depression symptoms were prevalent in
mothers (Holditch-Davis et al., 2015; Segre, McCabe, Chuffo-Siewert, & O’Hara, 2014). From their results, a third group of investigators suggested that these elevated depression and anxiety symptoms can be severe. Specifically, they found that early in the newborn hospitalization period, 35% of mothers reported symptoms that met the diagnostic criteria for Acute Distress Disorder (Lefkowitz, Baxt, & Evans, 2010). In addition, they found that 33% of these mothers experienced suicidal thoughts compared with 14% of perinatal women in the general population who report such ideation (Lindahl, Pearson, & Colpe, 2005). Moreover, the depression symptoms can endure. In one longitudinal assessment of mothers whose newborns were hospitalized in the NICU, researchers found that without treatment, at just over 1 year after the birth, 21% (n ¼ 102) still reported clinically significant levels of depression symptoms (Miles, Holditch-Davis, Schwartz, & Scher, 2007). Finally, in studies that included a comparison group of mothers of nonhospitalized, term newborns, researchers found that mothers of hospitalized newborns reported significantly more clinically significant symptoms of anxiety and depression (Brandon et al., 2011; Vanderbilt, Bushley, Young, & Frank, 2009).
ª 2017 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
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Nurse Support for Mothers of Newborns in the NICU
The hospitalization of a newborn in a NICU is often stressful and may result in clinically significant levels of emotional distress among mothers.
Current NICU Psychosocial Care In the NICU, standard care includes maternal depression screening with as-needed referrals to mental health professionals, usually without follow-up. In suboptimum care, depression symptoms are not assessed, perhaps because emphasis is placed on the hospitalized newborn. Even when clinically significant depression symptoms are identified, barriers such as social stigma and cost (Dennis & Chung-Lee, 2006) prevent most perinatal women from receiving treatment (Marcus, Flynn, Blow, & Barry, 2003). Because mothers are often busy visiting their newborns in the NICU, lack of time may be an additional barrier to seeking care. In two small trials, researchers evaluated interventions for emotionally distressed mothers of hospitalized newborns and reported significant reduction of depression symptoms when treatment was delivered by a psychologist (Jotzo & Poets, 2005) or a care manager (Meyer et al., 1994). Although such interventions are valuable, the social stigma sometimes associated with seeing a mental health professional may prevent some mothers from accessing this form of care. In one model of care, FCDC, the entire family is emphasized, not just the infant (Gooding et al., 2011). The expansion of a nurse’s role in the NICU to include screening for emotional distress and providing support adds a tangible means to implement this philosophy. Many integrated models have been developed for selected health care systems, but the United Kingdom provides a unique example of postpartum services. As part of the United Kingdom’s universal health surveillance, all new mothers receive home visits within the first 10 days after birth from a public health nurse, called a health visitor (Holden, 1996). During this routine care, health visitors attend to the psychological wellbeing of the mother.
The UK Model of Integrated Psychosocial Care In the early 1980s, a British nurse/psychiatrist team developed The Edinburgh Postnatal Depression Screening Scale (EPDS), a 10-item scale used to
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assess depression symptoms (Cox, Holden, & Sagovsky, 1987). Today, the EPDS is used by clinicians and researchers worldwide to screen for depression symptoms in women of childbearing age (Cox, Holden, & Henshaw, 2014). In addition, this nurse/psychiatrist team also developed and validated LV, a first-line depression treatment approach expressly for use by health visitors (Holden, Sagovsky, & Cox, 1989). The LV intervention consists of six 50-minute sessions delivered by a nurse who has completed LV training and has a bachelor’s degree or greater. Key components of LV, which are described fully elsewhere (Chuffo Siewert, Cline, & Segre, 2015), include active listening and collaborative problem solving. These techniques are used to gather a genuine understanding of a woman’s experiences and perspective in the postpartum period. The LV intervention is nondirective, so the focus of each session is decided by the woman herself, not the nurse. In general, a single LV session includes a greeting, debriefing about the previous visit, updates on present issues, discussion of current concerns, a summary, and scheduling the next visit or concluding the visits (Chuffo Siewert et al., 2015). In the United Kingdom, considerable empirical support garnered through several randomized controlled trials (Cooper, Murray, Wilson, & Romaniuk, 2003; Holden et al., 1989; Morrell et al., 2009; Wickberg & Hwang, 1996) prompted the National Institute of Clinical Excellence to recommend LV as an evidence-based treatment for mild to moderate postnatal depression (British Psychological Society, 2007). In a program of research directed by the second author, LV was imported to the Midwestern United States and proved to be a feasible way to deliver a first-line depression treatment approach to low-income mothers who receive home visiting services (Segre, Stasik, O’Hara, & Arndt, 2010). Subsequently, this group of researchers conducted a randomized controlled trial and found that LV significantly reduced depression and improved perceived quality of life compared with home visiting services or routine prenatal services (Segre, Brock, & O’Hara, 2015).
LV in the NICU: Implementation and Evaluation The novel idea to implement LV in the NICU was proposed by the first author, an advanced practice NICU nurse who recognized that the emotional needs of mothers of hospitalized
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newborns are usually not addressed in the NICU setting. Because, to our knowledge, LV had never been implemented in a hospital setting or with mothers of hospitalized newborns, this newly formed research team (first and second authors) conducted a small feasibility trial. In the screening phase of the trial, mothers of hospitalized newborns were invited to participate in a study to assess their emotional experiences in the NICU. Mothers with elevated depression scores were then offered the opportunity to receive LV as participants in the second phase of the trial. The results were promising (Segre, Chuffo-Siewert, Brock, & O’Hara, 2013). First, the successful implementation of LV in the NICU during the trial showed that it was possible for a nurse to deliver LV in a 70-bed, Level IV NICU in an academic medical setting. Second, women were willing to use this form of care: 78% of eligible depressed mothers opted to try the LV intervention. Third, as reported elsewhere (Segre et al., 2013), symptoms of emotional distress improved significantly from before to after LV, as shown by scores from the EPDS (mean score before LV ¼ 14.26 versus after LV ¼ 9.00) and Beck Anxiety Scale (mean score before LV ¼ 16.57 versus after LV ¼ 11.14). Finally, LV recipients were very satisfied with LV provided by a nurse: 91.3% of LV recipients rated the quality of help received as excellent (Segre et al., 2013). A descriptive account of the implementation of LV in the NICU during the feasibility trial, including a clinical case study, is available (Chuffo Siewert et al., 2015).
Proposed Nurse-Based Model of Psychosocial Care for the NICU Q4
In the aforementioned publications, researchers described the implementation and evaluation of LV in the NICU. In this article, we expand on these prior publications with our proposal for a nursebased model of psychosocial care for mothers of newborns in the NICU (depicted in Figure 1). In this model, nurses in the NICU screen mothers for depression and, for those with elevated depression symptoms, offer LV as a first-line treatment option. Although the evidence for components of this approach is available (Chuffo Siewert et al., 2015; Segre et al., 2013), a proposal for how to implement this model into standard clinical care has not been previously described.
Depression Screening During the NICU-based feasibility trial, the EPDS was used to identify depressed postpartum women (Segre et al., 2013). Specifically, within
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a week of newborn admission, all Englishspeaking mothers of newborns hospitalized on the NICU, who were 18 years of age or older, were recruited for a study of maternal emotional experiences. Enrolled participants completed self-report instruments, which included the EPDS, to identify those in need of further emotional support. Those who were eligible for the feasibility trial and interested in receiving LV from a nurse were enrolled into the feasibility trial phase of this study. Mothers with elevated EPDS scores who were not interested in receiving LV or eligible for the trial (i.e., a score of 3 on the suicide item or those who would not be in the NICU long enough to receive a full course of LV) were immediately connected with a social worker in the NICU. In Figure 1, we propose how LV might be implemented as part of routine nursing care in the NICU. The first step would be to identify emotionally distressed women. Nurses in the NICU could incorporate universal depression screening, as was done by nurses who worked in the maternity unit (Segre, Pollack, Brock, Andrew, & O’Hara, 2014). As indicated in Figure 1, if the EPDS score is less than 12, the mother should be reassessed in accordance with the unit’s depression screening protocol. Because the hospitalization of a newborn is stressful early on, we propose that these mothers should be screened every 4 to 6 weeks while their infants are hospitalized in the NICU. Mothers who score between 12 and 19 would be offered two support options: LV provided in the NICU by a nurse who completed LV training or referral to the social work team who would then conduct an assessment and, if needed, refer the mother to mental health professional services. An EPDS score of 20 or greater, which is indicative of depression symptoms in the severe range (McCabe-Beane, Segre, Perkhounkova, Stuart, & O’Hara, 2016), would warrant immediate referral to the social work team to further asses and, if needed, refer the woman to a mental health professional. Women who are actively suicidal as assessed by Item 10 on the EPDS would also be immediately referred to the social work team.
Treatment: LV In the feasibility trial, the first author, a neonatal nurse practitioner (NNP) employed in the NICU, provided six 45- to 60-minute LV sessions to all study participants every 2 to 3 days (Segre et al., 2013). All sessions occurred in a private hospital
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Figure 1. Proposed nurse-based model of psychosocial care for mothers of infants hospitalized in the NICU.
location chosen by the participant; some were carried out in newborns’ rooms and others in various places within the hospital. During the trial, the NNP LV provider continued to work full time in the NICU as an NNP and provided LV sessions during nonwork hours as part of a research study. However, because no more than two mothers needed to have LV at the same time, it was feasible for the NNP to provide all the LV sessions to trial participants. In addition, after the completion of all LV sessions with each LV participant, the NNP continued to care for the infant and remained in contact with the mother until discharge from the NICU.
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In the feasibility trial, the six sessions were sometimes not sufficient to relieve emotional distress: 39% (9/23) of the women who received LV showed no improvement in EPDS scores (Segre et al., 2013). Because the six LV sessions were concluded approximately 1 month after newborn admission, and a visit with a NICUbased social worker was part of routine care within that timeframe, each trial participant had already met with a social worker at least once. Thus, during the feasibility trial, the assigned social worker was able to speak with women who needed assistance to find additional counseling services.
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In clinical practice, we envision that LV delivered by a part-time nurse employed in the NICU could be available as a first-line treatment for women with mild to moderate emotional distress. LV would be provided in the NICU or private hospital setting by a nurse who has completed LV training. Mothers with severe or acute symptoms or those who opt not to receive LV would be referred to the social work team, who would then engage appropriate specialist services. Similarly, for mothers whose symptoms do not decrease after receipt of LV, the nurse would engage the social work team to connect the mother with specialist services. Thus, as indicated in Figure 1, to have nurses provide LV in the NICU is suggested as a first-line addition to mental health services, not a replacement for social work services. Indeed, in accordance with the model delineated in Figure 1, the nurses would work closely with the social work team. Although the results of the NICU-based feasibility trial of LV were promising, they were nonetheless preliminary. Additional research is required and numerous logistical elements need to be addressed before such a model can actually be implemented. Before delineation of these future directions, we first examine the acceptability of a nurse-delivered model of care.
Nurse-Based Model of Psychosocial Care: Views and Controversy In the United States, psychological treatment is delivered primarily by mental health specialists, including psychiatric nurses, social workers, psychologists, counselors, and psychiatrists. In a significant departure from this traditional mental health care model, we suggest the expansion of the role of the nurse to include depression screening and counseling. In our research to evaluate LV, we assessed the views of nurses and women about this innovative form of care. The results of these studies are reviewed in the sections that follow. Additional concerns about the implementation of LV in the NICU are also described and addressed. Views of nurse-delivered depression screening. In the NICU feasibility trial, most (90.2%) of the 200 mothers who completed questionnaires during the screening phase indicated that they would be willing to complete a depression screening scale given to them by a nurse (Segre, Orengo-Aguayo, & Chuffo Siewert, 2016). A separate survey of 518 clinical nurses indicated similarly positive views: 96.2% indicated that depression screening by
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In the NICU, standard care includes maternal depression screening with as-needed referrals to mental health professionals, usually without follow-up.
nurses is a good idea (Segre, O’Hara, Arndt, & Beck, 2010). Views of nurse-delivered counseling and LV. Among the 200 mothers of newborns hospitalized in the NICU who completed screening questionnaires during the feasibility trial, over half (67%, n ¼ 132) indicated that they would be willing to see a nurse for counseling (Segre et al., 2016). Approximately half of these mothers (47.5%, n ¼ 94) indicated their interest to learn more about LV delivered by a nurse. Among the subset of 49 mothers with elevated EPDS scores, an even greater proportion indicated their interest to learn about LV (65.3%, 32/49). Of these 49 women with elevated depression scores, 32 were eligible to participate in the LV phase of the feasibility trial (e.g., their newborns would be on the NICU long enough for them to receive LV treatment). More than three quarters of these eligible women (78%) agreed to try LV (Segre et al., 2013), which provided one index of acceptability. Finally, among the emotionally distressed mothers who received LV during the NICU-based feasibility trial, results of quantitative and qualitative assessments indicated unanimously favorable views about their experiences with this nurse-delivered supportive approach (Segre et al., 2013; Segre et al., 2016). One participant said, “Just talking to someone who is so caring, not only about my baby but about me too, was very helpful” (Segre et al., 2016, p. 7). Among the 519 clinical nurses who completed a survey to assess their views of a nurse- delivered model of psychosocial support, most (93.7%) strongly agreed or agreed with the statement that nurse-delivered counseling is a good idea, and 62.3% indicated willingness to participate in counseling training (Segre, O’Hara, et al., 2010). We have yet to assess the views of NICU nurses about the nurse-delivered model of psychosocial care; however, during the NICU feasibility trial, the nurses, physicians, and social workers informally indicated that they had come to value this treatment option. Controversy. Informal feedback from health care professionals employed in the NICU has not been all positive. At two national conferences, the first
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author described her experiences with implementation of LV in the NICU. The anonymous evaluations of these presentations were generally positive. However, some conference attendees (approximately <5%) expressed concern that the provision of support in the form of LV is beyond the nurse’s scope of practice. Our responses to this concern are outlined next and summarized in Figure 2. First, the FCDC philosophy emphasizes the importance of caring for the entire family. Second, LV was developed specifically for delivery by nurses, and there is significant empirical support for its efficacy (Cooper et al., 2003; Holden et al., 1989; Morrell et al., 2009; Segre et al., 2015; Segre et al., 2013; Wickberg & Hwang, 1996). Third, nursing students are required to take introductory courses to acquire the therapeutic communication skills that are central to LV, for example, empathy, genuineness, active listening, reflecting, questioning, and clarifying. Fourth, social stigma is often associated with mental health specialists/treatments. However, the NICU nurse often has established a trusting relationship as a primary caregiver and is ideally positioned to provide support free of stigma. Fifth, NICU nurses are physically accessible to mothers who do not want to leave their newborns’ bedsides. Finally, compared with most mental health specialists, NICU nurses draw on considerable medical knowledge that enhances their understanding of mothers’ concerns
about their medically fragile newborns and supports their ability to answer the mothers’ medically related questions.
Future Directions In this LV feasibility trial, we showed that it was possible for a nurse to provide LV in the NICU setting, that LV reduced depression symptoms and improved perceived quality of life, and that women valued this approach. These results are promising but preliminary. First, without a comparison group, the improvement in maternal mood realized in the trial cannot be definitively attributed to LV. Second, given the emphasis on controlling hospital costs, it will also be important to assess economic outcomes to determine how to pay for this service. These outcomes could include costs to implement LV compared with usual care, as well as the effect of LV on outcomes related to costs, including maternal satisfaction, infant length of stay, and rehospitalization in the month after discharge. Third, in the feasibility trial, screening was limited to the identification of elevated depression symptoms. However, mothers with newborns in the NICU have increased risk for depression and anxiety symptoms (Holditch-Davis et al., 2015; Segre, McCabe, et al., 2014). To address these gaps, the next step in this program of research will be to conduct a randomized controlled trial
Listening Visits build on nurses' communication skills.
Nurses can leverage an established trusting relationship to provide support to mothers.
Listening Visits were developed for delivery by nurses and are empirically supported.
Care of mother is central to Family Centered Developmental Care philosophy.
Nurses are accessible, allowing mothers to receive care near the infant.
Rationale for nursedelivered support for mothers of infants hospitalized in the NICU
Nurses are knowledgeable about the medical conditions of hospitalized newborns.
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Figure 2. Rationale for nurse-delivered counseling in the NICU.
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evaluation of LV with depressed or anxious mothers to assess maternal mood and economic outcomes. Before LV can be integrated into routine clinical care in the NICU, screening protocols will need to include assessments of anxiety and depression symptoms. Additionally, numerous administrative issues must also be addressed, including which nurses should provide LV, how to find time for a nurse to provide LV given other clinical duties, how to integrate the nurse into a team of mental health service professionals, how to provide LV training outside the context of a funded trial, and importantly, how to pay for this clinical service. The first author, who serves as a member of the steering committee for the hospital’s NICU breastfeeding task force, observed that similar administrative issues were successfully addressed in the integration of lactation consultants into her NICU setting. For example, just as nurses comfortable and knowledgeable in the provision of breastfeeding help to mothers were needed for the lactation program, one administrative hurdle to implement LV may be the identification of nurses willing to provide specialized mental health care. In our experience with the implementation of LV in the NICU, we have readily identified nurses who are comfortable providing this form of care. With regard to finding time in the nurse’s workday for LV, the lactation consultants work part time as bedside nurses and part time as lactation consultants in the NICU. Potentially, similar arrangements could be made for nurses who provide LV. Although the integration of lactation consultants into routine clinical care in the NICU can serve as a template, many additional issues will need to be addressed before a nurse-delivered model of psychosocial care is implemented in NICU settings.
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We propose a nurse-delivered model of psychosocial care that includes maternal depression screening and Listening Visits as a first-line counseling approach.
the value of LV delivered by a nurse: “I could not have ever imagined that these six visits could have helped me in so many ways.” In conclusion, we posit that a nurse-delivered model of psychosocial care, which includes depression screening and counseling, fills the gap in mentalhealth services for mothers. Future research is required to support the integration of this practice into routine clinical care.
Acknowledgment Funding for the feasibility trial Listening Visits in the Neonatal Intensive Care Unit was provided by the Social Science Funding Program, Vice President for Research Office of the University of Iowa. During the conduct of this study, Dr. Segre was supported by a K-23 Award (MH075964). The authors thank Drs. Rasmussen, Stasik-O’Brien, Williamson, and White-Traut and Mr. Nelson and the College of Nursing editor, Dr. Diana Colgan.
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The results presented in many published articles highlight the increase in anxiety and depression symptoms in mothers of newborns hospitalized in the NICU. Nevertheless, effective, accessible treatment options are limited. In line with FCDC, we propose a nurse-delivered model of psychosocial care that includes maternal depression screening and LV as a first-line counseling approach. For mothers who experience mild to moderate emotional distress, LV delivered in the NICU by a nurse can provide a first-line treatment approach that is convenient and nonstigmatizing. One LV recipient in the feasibility trial summarized
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