I have worked in various institutions and with various groups in efforts to improve the care of neonates and ultimately, outcomes for many years. One of the greatest challenges is helping people to see that the little things one does or does not do can have a great impact.
The first example we have of this is the effect of “developmental care.” It took some time for many clinicians to believe that paying attention to light levels and noise could make a difference in brain development. Of course, those aren’t the only things but can certainly have an impact. More recently, efforts to decrease infection fall in the same category. No healthcare worker caring for our vulnerable neonates has any wish to do anything but the best for them. Parents entrust us with their most valuable possession and trust the team to give the very best care so that their baby comes home to them able to enjoy the future they envision. So, if the practitioner doesn’t believe that an exclusively human milk diet is important in infection prevention, this is not discussed as such with the parents and therefore, the mother’s own milk may not be provided. This is just used as an example to communicate how a mental model of something being possible can change the outcome.
In a paper published in 2002, Edwards presents several measures that are identified as important in preventing infection. One of particular interest is the unit culture. While this is very hard to study and relate directly to outcome, it has been observed in several infection reduction quality improvement projects. Edwards lists two conceptual models of unit culture – one of entitlement and one of prevention.1 In the entitlement model, there is a fatalistic view that infections will happen due to the risk level of the neonate, their immature immune system, invasive procedures and so on. In the prevention model, an infection occurrence is seen as a breakdown in ideal care, an opportunity for the clinical team to improve. This must also be accompanied with the notion that it is more about the system than about the individual and that every individual has the best interests of the patient in mind. In fact, the prevention mental model has been shown to result in improved outcomes because, in spite of the high risk of infections, there are many things that can be done in a practical way that decrease this risk.2 In other words, believing that improved care is possible leads to better outcomes, partly because we are always searching for ways to improve.
I recently had the opportunity to participate in a 25 mile bike race. My only goal was to finish the race which I believed to be possible…and it was. What’s more, I wasn’t last!! So, with the next race, I believe I can do better and maybe come in somewhere in the middle of the pack. With each level of improvement, we get encouraged that perhaps more is possible. We begin to look for other ways to improve the outcomes. In many cases, this is further clinical work. But as shown in the two papers mentioned above, it may be as much about culture and a belief system. At least this motivates us to want to continue to improve to provide the very best opportunity for our little patients to live a full life with the best potential.
1. Edwards, WH. Preventing nosocomial bloodstream infection in very low birth weight infants. Seminars in Neonatology. 2002;7:325-333.
2. Suresh, GK & Edwards WH. Central line-associated bloodstream infections in neonatal intensive care: Changing the mental model from inevitability to preventability. American Journal of Perinatology. 2012;29:57-64.
Looking for additional reading from Sandy Beauman’s professional perspective?
View her blog entry, The Prevention of Medication Errors.