Margaret ( Peggy) Settle, PhD, RN, NE-BC
Nurses in the newborn intensive care unit (NICU) are great observers. They carefully notice premature and critically ill infants’ behavioral responses based on the elements of the Synactive Theory of Behavioral Organization and Development (Als, 1982). This Bio-behavioral theory focuses the nurse’s attention on the infant’s five functional internal subsystems and the continuous interaction of each subsystem with the environment. The subsystems include the autonomic, motor, state, attentional/interactive, and self-regulatory subsystems. Nurses learn how to identify the infant’s approach and avoidance behavioral cues of each subsystem during orientation to the NICU. Recognizing when the cues occur during caregiving enables the nurse to support the infant’s approach behaviors and reduce the infant’s vulnerabilities.
The NICU nurse’s recognition of subsystem behaviors is necessary but not sufficient to develop a mutual relationship with their infant patient. The observation of the infant’s pattern of response to each caregiving intervention creates a more comprehensive approach to knowing the patient and describing the infant’s story with colleagues. For example, an infant may be grasping but not able to find something to hold on to and the nurse’s support may include providing a soft cloth for the infant to hold during and after the care time. If the nurse noticed that the infant was desaturating and provided support to the infant by placing their hand on the infant’s trunk, the infant may desaturate less, and the nurse decreases the infant’s vulnerabilities. As the NICU nurse observes the infant’s improved autonomic and motor stability in response to providing the soft cloth and truncal support, the nurse may become more aware of the impact their care had on their infant patient.
At a recent meeting of PhD and DNP nurse leaders at Massachusetts General Hospital, I became re acquainted with Newman’s theory Health as Expanding Consciousness (Newman 1994, HEC). It happened during a discussion that centered on the nurse-patient relationship. As Director of the newborn intensive care unit (NICU), I find this a difficult topic for nurses to discuss when describing the nurse-patient relationship with the infant in their care. I wonder if some NICU nurses don’t see the premature infant’s behavioral pattern during caregiving as an indication of the mutuality that is developing between the nurse and infant. Most nurses working in the NICU can readily describe their relationship with parents but have difficulty articulating their developing relationship with their infant patient.
After the meeting, I reread Health as Expanding Consciousness (Newman, 1994) while I waited for a copy of Transforming Presence, (Newman, 2008) to be delivered to my home. As I read the Nursing Praxis (a chapter in Transforming Presence), I began to understand the way in which nursing praxis transforms the meaning of the nurse-patient relationship in the NICU. As described within the framework of HEC each nurses’ interaction with their patient is unique and different. To recognize what is happening requires the nurse to be fully present and in the moment during each encounter. In becoming fully aware of the other, the nurse begins to recognize the person (i.e. baby) and becomes more sensitive to how they experience the world and manifest their unique expressions through pattern.
Using pattern recognition, nurses uncover meaning, discover information and gain insights. Challenges to health and well becoming (Phillips, 2017) may be recognized and new choices and actions taken that can be transformative for both the patient and nurse.
Linking Theory and Practice
While it is reasonable to discuss links between theory and practice conceptually, how does the NICU nurse establish mutuality, pattern recognition, and transform both the nurse and the patient?
The primary nursing goal for infants in the NICU is energy conservation. However, as with many care practices in acute care settings, the goal of care of often focused on physical and emotional stability, often addressed within the context of a medical practice model and critical to immediate survival. However, the nurse also brings a unique perspective to the care experience guided by disciplinary knowledge. The nurse’s relationship with each baby is unique and an essential component of healing and recovery. Nursing praxis can be achieved when the NICU nurse recognizes or becomes consciously aware of the impact their care has on the whole person pattern including functioning patient’s subsystems.
The infant caregiving experience embodies a dynamic, mutually responsive relationship between the nurse and the patient in the NICU. Using a nursing framework like HEC can help guide the whole person experience between the nurse and patient and increase awareness of the unfolding pattern responses to health and healing. Each action taken by the nurse to identify pattern helps recognize infant’s strengths and supports opportunities for new choices and actions that can be transformative for both the nurse, the patient, and the parents.
As the NICU Nurse Director, I have been at a loss to provide the needed coaching to create a NICU environment where nurses can use disciplinary knowledge to guide and describe how the nurse-patient relationship transforms the care experience.
My goal is to change the practice environment in the NICU. In addition to providing education and dialogue around using nursing frameworks (e.g. HEC), I can also change my approach to changing the care experience. The integration of the Synactive theory with the HEC nursing framework may contribute to the nurse’s expanded consciousness of the developing relationship with their infant patient. Instead of asking the nurse “What more can be done to help the nurse develop awareness of the nurse patient relationship ” I ask “Tell me about your patient’s story ” that shifts the paradigm. “How would you describe the patient’s pattern?” What changes have you noticed over time? How do you describe the change? What meaning do you change? Why do you think your patient is acting that way? What does that mean for your care delivery?”, “How do you think your increasing awareness (consciousness) of pattern is changing your practice?” I wonder will the dialogue I have with the NICU nurses shift as I change my approach? Will the responses to these questions reveal the nurse’s appreciation of both the infant’s behavioral communication and their relationship?
Als, H. (1982) Toward a synactive theory of development: Promise for the assessment of infant individuality. Infant Mental Health Journal.3:229-243.
Newman, M. A. (1994). Health as Expanding Consciousness (2nd ed.) Sudbury, MA: Jones and Bartlett (NLN Press).
Newman, M. A. (2008). Transforming Presence: the difference nursing makes. Philadelphia, PA: F.A. Davis Company.
About Dr. Settle:
I am a PhD prepared Nurse Director in the Newborn Intensive Care Unit (NICU) at Massachusetts General Hospital with over 30 years of nursing experience in a variety of roles (Staff Nurse, Educator, Clinical Nurse Specialist, Nurse Director) in NICUs across Massachusetts. My research focuses on the effects the Newborn Intensive Care Unit environment has on preterm infants and practicing clinicians.