key: cord-0047936-fspjpmsr
authors: nan
title: Council of International Neonatal Nurses (COINN) News page
date: 2020-07-22
journal: J Neonatal Nurs
DOI: 10.1016/j.jnn.2020.05.007
sha: d275d44363f848b0f2362bc37d4574ddb4aa80bb
doc_id: 47936
cord_uid: fspjpmsr

nan

In December 2019 patients in Wuhan, China, began presenting with fever of unknown origin with pneumonia (Lu and Shi, 2020) . The virus rapidly spread to other countries due to the high human-human transmission rate, and on February 11th 2020 the World Health Organisation (WHO) officially named the novel coronavirus, Coronavirus Disease 19 (COVID-19) (World Health Organization (WHO), 2020a; Karimi-Zarchi et al, 2020) . The WHO characterised the outbreak of COVID-19 a pandemic in March 2020 (WHO, 2020a) . As of 13 th May, COVID-19 had been detected in 215 countries, areas or territories with 4,170,424 cases and 287,399 deaths (WHO, 2020b) .

As the number of confirmed cases of COVID-19 increased, the global neonatal community went into preparation. Pregnant woman may be more vulnerable to severe infection (Favre, et al, 2020) and evidence from previous viral outbreaks (SARS-CoV and MERS-CoV) suggests higher risks of adverse maternal and neonatal outcomes in this population (Wong et al, 2004; Alfaraj et al, 2019) . Whether a pregnant woman with COVID-19 could pass the infection to her fetus or baby during pregnancy or delivery was unknown. To date, emerging evidence to support vertical transmission of COVID-19 during pregnancy remains low (Knight et al, 2020) , with no viral detection in amniotic fluid, placenta or cord blood, or breast milk. (Yang et al, 2020) This is a rapidly developing clinical situation however, and more definitive evidence is required around short and long term maternal, fetal and neonatal outcomes (Kimberlin and Stagno, 2020) before we can be certain of the impact.

Concern for our neonatal patients goes beyond vertical transmission. As a high risk population, neonates may acquire COVID-19 through close contact with those infected or carrying the virus. (Wang et al, 2020) Highly trained specialist nurses to care for these infants also remain scare; in the UK only 64% of neonatal units are staffed according to the recommended nurse-patient ratios. (NNAP, 2019) As such, neonatal units around the world began to close their doors to parents and extended family, in an attempt to protect infants and minimise potential sickness in the number of healthcare professionals available to care for them. In the UK, despite national guidance supporting parental access to the neonatal unit (British Association of Perinatal Medicine (BAPM), 2020), huge variation emerged around the country with varying levels of parental restrictions. Guidance also falls in line with social isolation recommendations (Public Health England (PHE), 2020); parents showing symptoms or in contact with others testing positive for COVID-19 must self-isolate for a minimum of 7-14 days. This results in potentially weeks between seeing and touching their baby.

Neonatal nurses around the world experienced a sudden pause in their ability to provide family centred care. Practices known to support parental mental health, attachment, infant development and breastfeeding rates, such as kangaroo care, comfort care, and family integrated care became increasingly challenging (Als et al, 2004; O'Brien et al, 2018; Pineda et al, 2018; Pados and Hess, 2020) . Practices known to increase parental stress, depression and anxiety (and therefore longterm neurodevelopmental outcomes of the infant (Rahkonen et al, 2014) , such as parent-infant separation, inability to participate in infant cares and disruptions to communication with healthcare professionals became more prevalent (Treyvaud et al, 2009; Al Maghaireh et al, 2016; Gallagher et al, 2018) . Neonatal nurses had to quickly adapt to this situation to provide the best care possible to the families whilst ensuring the safety of all babies on the unit, their colleagues and their own families.

Over the next few editions of the JNN, we will present the experiences of neonatal nurses from around the world, and how they have adapted their practices to ensure family centred care remains at the heart of what we do. We will explore issues and innovations from practice educators, staff nurses, managers and academics. We will provide a voice and a community to our international neonatal nursing colleagues to show our solidarity in these unprecedented times of a global pandemic.

Written in March 2020: I am a NICU nurse and, as such, I am not on the front lines of this pandemic (yet). There is a lot of acknowledgement for healthcare workers, especially nurses, and I feel guilty for not being on the front lines. I feel guilt, and relief, and then even more guilt for feeling relief. But I also feel fear. It is always present, always looming. There is not much data on how this virus affects newborns and the virus is constantly evolving. It feels inevitable that we will be faced with it on our unit and in our population. I fear we won't know how to help the babies. I fear we might not even recognize it before it's too late. I fear what this might mean for our most vulnerable patients -the patients born so early and so frail, with no immune system to speak of and already fighting the greatest battle of their lives. I also fear the added trauma my patients will experience by having their earliest days, weeks, and months of life with caregivers whose faces are half covered. I fear what not having the experience of seeing facial expressions or human emotions will do to their development. I fear that they will feel and embody the pervasive anxiety that is felt by every healthcare worker. Stay home. Stop the spread. The babies I take care of fight so hard every day. Do your part in keeping them from having to fight even harder. (Fig. 2) Written later in May 2020: As a NICU nurse in the pandemic, I continue to worry for my patients. I feel less fear, but I still have concerns. The fear has decreased, not because the risk to our immunocompromised patients has decreased, but rather because I recognize that this is the scenario we've trained for during our entire NICU career. Anyone who has ever been in a NICU knows about strict hand hygiene and screening for early signs of illness. We have existed on the frontlines of every illness that could affect our neonatal patients for the past 100+ years.

I am concerned for the increased stress that parents of babies in the NICU feel. Having a child in the NICU is already an extremely stressful situation. If parents are allowed to visit, it is only one at a time. This creates an extremely isolating experience. The stress of the NICU is made even more traumatic in this time of uncertainty. I continue to be concerned for what seeing only half a face in a baby's earliest experience might mean for their development. I see looks of confusion on my patients' faces, but I know that the care I provide and the tone of my I have taken care of an infant with a COVID-19 swab pending. I've spent shifts being mindful of donning PPE in response to my patient. I've heard the mantra of "there is no emergency in a pandemic." This does not feel possible when you see a baby with a decreased heart rate and oxygen saturation, which is why you become as efficient as possible in the donning of PPE. As has every other healthcare professional, I've experienced the effects of carbon dioxide retention. Nobody feels good at the end of a 12-hour shift spent in a face mask, but we step up to the occasion when an emergency arises. This is Nurses' Week and some restrictions are beginning to lift. I just want to encourage everyone to continue to be mindful, compassionate, and conscientious when beginning to reintegrate into the public. Wear the masks when you are out, maintain distance, and keep household members going out to a minimum. Everything we can do to protect each other also protects the most vulnerable patients.

Fortunately, due to natural selection, different immunological characteristics among other assumptions, Sars-Cov-2 affects very few children and those affected seem only to be so in a slight way. Despite this, there have been cases of children with COVID-19 and, above all, neonates born to a mother with suspected or confirmed COVID-19. Spain is made up of 17 autonomous communities (Gobierno de España. Comunidades Autónomas, 2020a). The Community of Madrid and Catalonia are the most affected autonomous communities, especially its two major cities, Madrid and Barcelona. Neonatal care has presented various ways of proceeding, depending on the number of cases, established protocols, human and material resources. In Spanish neonatal nursing we have experienced great confusion in all this process, due to the lack of knowledge about the best management of the disease and the lack of a communication channel, typical of the discipline.

To alleviate this situation, SEEN, the Spanish Society of Neonatal Nursing, has created repositories of the evidence generated on COVID-19 and the management of the child and their family. They transfer said evidence through social networks and the Telegram channel. We have a Telegram group to share doubts and concerns among neonatal nursing. And a reference position regarding care for the suspected or confirmed newborn of COVID-19 (SEEN, 2020a).

One of the topics studied in depth is "Recommendations for the management of the newborn in relation to SARS-CoV-2 infection and breastfeeding" (SEEN, 2020b), a document that presents and details two algorithms that we provide to health professionals for the management of infant feeding. The general recommendations are: the nonseparation of the nursing mother and her child, whenever possible and other action measures exist. Respect for the fundamental rights of the child (UNICEF COMITÉ ESPAÑOL, 2015), and the rights of the hospitalized child (Parlamento Europeo, 1992) , both defenders of the right of the minor not to be separated from their parents and to apply appropriate treatment on an individual basis. We encourage direct breastfeeding in all cases and, if in any particular case it is not possible, promote and facilitate the expression of breast milk and its subsequent administration. Working together with other scientific societies and the government of Spain, a document generated is "Management of pregnant women and new-borns with COVID-19" (Gobierno de España -Ministerio de Sanidad, 2020b), a reference document for health professionals associated with perinatal care in our country.

A first COVID-19 and neonatal nursing meeting was held through the Virtual Session of SEEN with the title of "Neonatal care in the context of COVID-19" in which scientific knowledge and experiences of clinical practice were shared. This meeting was very fruitful to obtain a mapping of COVID-19 neonatal nursing care, transfer material worked on by experts from different autonomous communities and create lines of work appropriate to real needs. The objective of the study is now set in the elaboration of an ecological study that collects epidemiological evidence as well as neonatal care variables. We now seek to maintain a balance between strict COVID-19 isolation and disinfection recommendations and the humanization of care. We must not forget how beneficial the application of Development Centred Care is, a model focused on the performance of interventions that favour the neurodevelopment of the new-born ( Bazo Hernández, 2016) , especially skin-toskin and the strengthening of the maternal-infant bond after childbirth. Well worked, everything is possible. And if there is something that characterizes paediatric nurses, and even more so neonatal nurses, it is the ability to adapt resources to offer quality care to our small patients, it will not be different now.

I arrived for my nightshift and as usual entered the unit through our reception, only to find a huge sign in place explaining how guidance from hospital chiefs stated that parents are no longer allowed on the unit. As parents are usually allowed unlimited access to the unit and their baby, this was a shock for the unit and all families. This decision was only in place for 24 hours but the impact on families was huge. Our visiting times then changed to one parent per baby for a maximum of 2 hours a day and each parent had to come at a separate time to the other parents visiting their babies. Our work as neonatal nurses had changed. As we usually care and support parents almost as much as their babies when they visit, to go to only seeing one for 2 hours a day was vastly different. It was heart breaking picking up the phone to update a parent on their baby's condition and hearing them breakdown with anxiety as they had not been able to see their baby for days. This taught me to aim my care towards empowering parents when they do visit and to make the most of the new Facetime options the senior staff set up on the unit. To use the 2 hours to help that mum to breast feed for the first time, first skin to skin with dad and to really get each parent involved as much as was appropriate with their baby's care was more important than ever.

Parents are still part of the baby's care team and thus should be treated as such even under the new conditions that are in place for everyone's safety. Something we all must try and hold on to during this uncertain time to ensure we still provide the excellent care we love being a part of.

Since the beginning of COVID-19 the routines about how to approach the parents if they are positive and/or have any related symptoms has changed a lot. Sometimes it feels like we have new routines each and every week which builds up frustration because there is not always time to learn the new routines. But we all try our best. For the most part, life at the NICU continues a lot like it did before. Parents are still encouraged to be with their children as much as possible and be a part of the daily routines that we have (rounds, diaper change etc.). That is if the parents have NOT tested positive or to have shown any symptoms correlating with COVID-19. Other visitors such as grandparents or siblings are not allowed at the ward (nor in the hospital).

About kangaroo care: there are no restrictions as long as the parent is tested negative. Today the routine is that if the parent was to be tested positive but does not showcase any symptoms they can still take care of the child but not kiss or perform kangaroo care, and the health care staff need to use face shields when caring for the child with the parents. The child is never seen as infected unless a test is done and comes back positive. We only screen the children if they need surgery (before) or if we have a child that comes from another hospital. This has created a bit of insecurity amongst the staff because we feel that we are not given the chance to fully protect ourselves and also what guarantees us that the parent does not have an active infection and just don't have any symptoms? Or just in an early stage of the infection? Where should we draw the line between what is ethical for the children and their families and our safety? Since we work with the idea of a family centered care it is normal for us that the parents are a part of the daily routine, but now they can travel from their homes to the hospital, be accompanied with whoever they choose (because we don't have any restrictions in Sweden, only recommendations) and then coming back to the hospital to be taking care of the children with us standing only centimetres apart from them. So, there are some concerns on how to approach this situation properly since we want to continue the family centered care but still have our health as a priority as well as not risking bringing home the infection to our loved ones.

I have been distancing myself from everyone except my closest family whom I live with because I don't want to spread the infection to others nor be infected. If I am sick it will affect the whole unit because we already have a lot of staff that are sick (not necessarily in . We try to make ends meet but it is taking a toll on our mental health because a lot of Swedish people don't understand the severity of this infection. We are next to a ward where the sickest people that have been infected are getting treated and we can see the staff with all the protective gear whilst the infected sick people just lay there with all the machines surrounding them. It is scary and it makes me mad that a lot of Swedish people just go along with their lives as if nothing is happening, especially a lot of people my age (I'm 24 y/o) because they don't believe they can get infected. But we can all get infected and it is my fellow colleagues who work at the frontline that get affected the most. And when they can't take it anymore it will probably be our turn to go to the adult units and treat the COVID-19 patients.

It takes a toll on my mental health not knowing if I will get my vacation this summer because I want to spend time with my family as well, but I don't because I need to put the safety of my small patients, my colleagues and the society before my own needs. And we all need to think like that so that we can see the light at the end of the tunnel and hug our loved ones.

I am a NICU nurse since I left nursing school. It was my big and only passion. I work now for about 18 years with babies and families. My main areas of expertise are ethics and palliative care. When COVID-19 was spreading quickly in Europe, I was doing a pediatric palliative care clinical practice in Cardiff. One of the first challenges, was to be returned home safely, when borders where closing, all over the world. I got to Portugal 2 days just before the lockdown. The newspapers and social posts on internet, arriving from China, Italy and Spain, were really scary. Portuguese boards (medical, nursing and even veterinary) asked for health care professionals, from all backgrounds and scenarios, to come and help in human medicine, especially in adult emergency department and intensive care, if needed. They even asked the retired ones to volunteer. And they came. Neonatal nurses knew in advance, one could be mobilized anywhere, anytime. If the situation turned really bad, some would have to go and work in adult department. It sounded very unreal. Some of us went to the pediatric emergency department, when a lot of nurses were home due to quarantine needs. How would we help in adults? The second challenge faced, was the decision to leave my sons (2-and 7-years old) with my husband and fathers in law. I felt heartbroken with all the uncertainty. I experienced strong and mixed feelings. Like never before, I listened the silence shouting and felt time passing in a very painful slow-motion way. In the hospital I work, one building was converted to a COVID-19 area. The other, the maternity, neonatal and pediatric building, was considered the non-COVID-19. NICU would admit babies that where born from mothers that tested positive or babies, during neonatal period, suspected to be or tested positive. Since, labor and delivery unit started testing all women, some, with no symptoms or risk factors, tested positive. Evidence was lacking, but the risk of vertical transmission seemed to be low (hopefully).

Neonatal health care team were daily, adapting, adjusting and reframing institutional guidelines. Would using CPAP increase the risk for professional's transmission as suggested in adult literature? Was it possible to do the test properly to smaller babies, if the swab used is the same size in adults and newborns? Planning was very dynamic and we were all learning from one another, around the globe.

When the time came, NICU nurses, that had previous working experience in adult ICU and had with no risk factors for COVID-19, went to work full time there. NICU also admitted a nurse from ICU that had a chronic condition. The other low-risk nurses, like me, would be the first to take care of COVID-19 babies. First admissions came in Easter time. NICU nurses were committed to promote mother-baby bonding, holding concept and family centered care. Even before the first baby was born, we were all brainstorming. A mobile phone or a tablet was identified as a good option to send video, photo or promote face time with the mother, if possible. Nurses phone called mother's, each shift, to update about baby's situation, lactation advices and other areas of counselling and promote emotional support.

Full protection equipment use was hard. No possibility to eat, drink or use toilets to optimize the deficiency in the number of equipment's available. Even for a couple of hours, makes you feel hot, dehydrated, sometimes dizzy, with fogged glasses and with a sort of shortness of breath. After you remove it bruises and pressure zones in your face can remain for hours or days. All babies that were born during this pandemic time, not only COVID-19, suffered touch and human face interaction deprivation. Parents stayed in the NICU for short periods of time, because they were afraid. Professionals were all wearing masks and gloves. The noxious sensory hyper stimulation seemed to gain preponderance to Kangaroo care, holding or breastfeeding. Difficult balance: health safety or human healthy development? What will be the consequences of this new crazy reality for next generation? What lessons do we have to learn, in order to elevate the quality of nursing care in the near future? This would be, the huge, third challenge. It was really inspired to feel that neonatal and pediatric palliative care were supporting one another in the globe. I felt we were really as one, sharing emotions and difficulties and being inspired to move forward.

COVID-19 has certainly been a force for change in neonatal academia. Like a typhoon it has spun through our relatively ordered world, thrown everything in the air and left students and academics trying to guess where things will settle when this is all over. On the negative side I have seen the impact upon students working clinically, both emotionally and physically. The effects of these stresses vary across individuals but affect all to some degree. I have seen carefully planned teaching sessions and assessments collapse at a moment's notice, affecting students, teachers and the clinical areas desperate for more qualified in speciality neonatal nurses. The sense of loss is unsettling and profound. But there is a flip side to this; I have seen the best of my students as they have stepped up to the challenges in a professional and caring manner which makes me proud of them and of our profession. University colleagues and myself have been on an incredibly steep learning curve as the university moves online to deliver teaching, tutorials and academic assessments; COVID-19 has driven very rapid changes in higher education which I believe could be of real benefit to future neonatal nursing students. These different ways of learning could benefit part-time and distance students and offer flexibility in studying appreciated by those juggling the demands of family life and full-time employment. We should never underestimate the threat of COVID-19. We should never forget the sacrifices made and the lives of loved ones lost, but from this threat comes opportunity for change in neonatal nursing education and the chance to make it better than before. As neonatal nurses we should reflect on this, then lead forward together.

The consequences of the COVID-19 pandemic have been felt far and wide. Never before have we experienced the impact of such a global crisis reaching all areas of the world. In the United Kingdom the impact of isolation and being quarantined to our homes has resulted in many of us adjusting the way we socialise, communicate and work. Whilst our frontline healthcare teams continue with their work and deal with the health crisis, as an educator my support for these teams has been in a different way. As a nurse educator my key area of work is related to educating undergraduate nursing and midwifery students and leading on continual professional courses related to neonatal care. The government guidance to cease face to face contact led to all teaching being changed to online learning. Almost overnight we had to leave our offices, set up online teaching, rearrange face to face exams and find new ways of working. As an academic team we were forced to explore how and if we could continue to run the CPD courses and if so, how could we support the students to reach their end goal of success and academic accreditation.

Some would argue that this crisis has offered an opportunity to revaluate education provision.

Year on year course evaluations demonstrate that students, specifically CPD students, enjoy face to face teaching. One would argue that the discussion that transpires when a room of neonatal nurses from a range of organisations come together is priceless, encouraging shared learning, initiating questioning and prompting change in practice. So how do we continue to nurture this environment whilst working at a distance? For me as an educator zoom has been a lifeline offering me the opportunity to hold meetings, assess neonatal intensive care Viva's and continue to encourage student engagement.

There is no doubt that the COVID-19 crisis will continue for some time demonstrating that not only have we had to evolve but also plan for future education provision. Healthcare teams will continue to require CPD education courses and the neonatal workforce must still aim for 70% of the nursing establishment to be 'qualified in specialty' (UK Dept. of Health, 2009) . It is important now to analyse how we as educators can support clinical teams to achieve this. The future requires all those working in education institutions to seek new ways of offering distance learning that keeps the students engaged, motivated and ensures that CPD education equips healthcare teams with the knowledge they require to offer both safe care and drive change.

We would like to thank all the neonatal nurses who so generously took the time to share their experiences. Our thoughts go out to all the neonatal nurses around the world, and the families that we work with at these challenging times. If you would like to contribute to this series of reflections of neonatal nursing in the COVID-19 global pandemic, please email your videos or reflections to either: Breidge Boyle (JNN Editor) breidge.boyle@qub.ac.uk, Katie Gallagher (UCL IfWH) katie. gallagher@ucl.ac.uk, Alex Mancini (Chelsea & Westminster NHS FT) a. mancini@nhs.net or Julia Petty (UK NNA) j.petty@herts.ac.uk

The Journal of Neonatal Nursing invites you to publish… ''Advancing neonatal nursing care, education and research globally''

The Journal of Neonatal Nursing serves both the UK Neonatal Nurses Association (NNA) and COINN. We need to tell our story through this journal. Please consider submitting your article to the journal. If you would like to contribute to the News pages, contact Julia

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