Neonaticide is the leading cause of death in infants younger than 24 hours.1 Since the implementation of Safe Haven laws in all 50 states by 2008, a 66.7% decrease in neonaticide has been seen in the United States.1 The Safe Haven law allows parents to legally surrender their newborn infant to any place deemed a safe facility that corresponds with the state's law. Since its implementation, this initiative has saved 4687 infants' lives and counting.2
Safe Haven infants are babies who are legally surrendered by their parent(s) via in person or through a Safe Haven Baby Box. Safe Haven laws are in place to protect those parents who legally surrender their infant to any healthcare worker or peace officer within a specific amount of hours/days that correlate with each state's law.3,4 Surrendered infants, or Safe Haven babies, are considered high-risk, low-volume.3 These rare events can cause miscommunication and uncertainty, leading to delayed patient care,3 magnifying the need and importance of every staff member to understand their role and act quickly when these events occur. Many facilities lack Safe Haven drills or may not be familiar with Safe Haven laws or policy and protocol needed to care for the surrendered infant.3,5 These quick actions are essential since one study identified that more than half of surrendered infants have medical abnormalities.6 Acting quickly in a Safe Haven scenario can prove beneficial and lifesaving for those special needs infants.
The question for this quality improvement project was in surrendered infants, how do an educational program, a new consecutive policy, and a simulation intervention affect staff knowledge and teamwork compared with the current policy? This research materialized at a level II trauma center in Ohio. Emergency department (ED), special care nursery (SCN), registered nurses (RNs), and pediatric social workers were assessed on their Safe Haven infant, policy, and event knowledge before and after an education and simulation intervention.
CLINICAL SIGNIFICANCE
In 2015, a Safe Haven infant was brought to the level II trauma center. At the time, the staff was unknowledgeable of the policy and protocol associated with these infants and events. What should have been a smooth process was chaotic. Gaps such as decreased communication, decreased knowledge of Safe Haven events and staff roles, uncoordinated care, and lack of teamwork were seen. An expedited process would have been crucial in this event as the newborn's umbilical cord was not clamped. Following this event, no further education, training, or simulations were completed on Safe Haven infants or events. This event, gaps observed, patient populations at risk, and lack of literature gave raw purpose to a new policy, an education intervention, and a simulation intervention for staff, not only for the staff's knowledge but also for future Safe Haven babies and the parent(s) at risk.
Those considered low median income and low educational status are at the highest risk of legally surrendering their infants due to lack of resources. Low-income or low education attainment families have fewer resources available to support new parents or unwanted pregnancies.6 When reviewing the patient population of the county surrounding the level II trauma center, data show 24.3% of the area citizens live under the poverty line. Women, especially, were at a higher risk of living under that poverty line than men.7 Observations were also made regarding education status; 8.9% of the area residents have less than a high school diploma.8 These numbers may not be significant but are consistent with the at-risk evidence-based populations and the possibility for more legally surrendered infants to come.
Since 1999, it was estimated that 4100 infants had been legally abandoned.1 In the past 6 years, Ohio has received 21 legally surrendered infants and the United States has seen a total of 410 legally surrendered infants via Safe Haven Baby Boxes and this number continues to rise.9 To effectively and efficiently care for legally surrendered infants, healthcare staff should possess knowledge of these infants and understand their state's law, policies, and protocols for Safe Haven events and their own roles during these events.
RATIONALE
The researcher used the conceptual framework of King's Change Model for Goal Attainment10 and Lewin's change theory11 to conduct a quasi-experimental study using a pre/posttest design.11 The study used the critical components of King's Change Model of making goals, implementing goals, and evaluating goals to guide the study. The conceptual framework and theory assisted with assessing the cause and effect of an education intervention to increase the knowledge and teamwork of healthcare staff. Goals for the project included increasing staff knowledge of Safe Haven infants and events, increasing staff knowledge of roles during these events, and interprofessional teamwork. The project's interventions included creating a new consecutive Safe Haven policy for the level II trauma center in Ohio, an education intervention, a Safe Haven simulation, and the initiation of a Safe Haven Baby Box at the hospital. The educational intervention included a Qualtrics Likert scale pretest and posttest to evaluate staff knowledge. The framework assumes that the data collected and analyzed would reveal an increase in knowledge of infants, events, roles, and teamwork.
Lewin's change theory framework encompasses an unfreezing phase, a change phase, and a refreezing phase.11 The unfreezing phase includes reviewing previous policies and events, identifying gaps, and discontinuing those current policies and practices. The change phase included a new Safe Haven policy, staff education, data collection and analysis, and a simulation intervention for healthcare staff. Finally, the refreezing phase initiated the new updated policy, biannual evidence-based policy updates, and annual Safe Haven simulations, including the Safe Haven Baby Box.
PURPOSE AND AIM
Objectives
The study's objectives were to increase ED RNs', SCN RNs', and pediatric social workers' knowledge of Safe Haven infants, policy, and events and to assist healthcare staff in understanding their roles during these events at a level II trauma center in Ohio. Another objective was to obtain a Safe Haven Baby Box for the facility.
Aim
This study aimed to create an educational intervention including a new Safe Haven policy, staff education, and a simulation intervention. These interventions will increase healthcare staff knowledge of Safe Haven infants and events and assist healthcare staff in understanding their role during these events.
METHODS
Context
Research was deemed exempt from human subjects research through the institutional review board at the level II trauma center. A quasi-experimental study using a nonequivalent control group design13 assessed knowledge and communication before and after creating a new policy, education, and simulation. The participants of this study included ED RNs, SCN RN staff, and in-hospital pediatric social workers.
Interventions and study of interventions
The study included a new Safe Haven policy, staff education on Safe Haven infants, the new policy and roles during Safe Haven events, and a Safe Haven simulation. The data collection portion of the project incorporated pre- and posttest surveys using a 10-question Likert scale Qualtrics survey to assess knowledge of Safe Haven infants, policy, and events and a Safe Haven simulation including a postsimulation survey and a debrief to assess strengths and gaps.
A consecutive Safe Haven policy was created with assistance from the Perinatal and Neonatal policy workgroup. This policy outlined ED and obstetrical staff roles during a Safe Haven event. It included steps for hospitals with obstetrical services and those without. For those facilities with a Safe Haven Baby Box in place, a second policy specific to the box was created.
A 10-question Likert scale pre/posttest survey was made using Qualtrics online survey generator with a confidence interval to ensure validity (see Table 2). The pre/posttest survey was created using the project objectives (see Supplemental Digital Content Appendix A, available at: http://links.lww.com/JPNN/A32). Project participants completed the Qualtrics survey on knowledge of Safe Haven infants, Safe Haven events, staff roles, simulations, and Safe Haven policy. This survey was open to staff for a period of 2 months, resulting in 31 participants.
Staff education via a 10-minute PowerPoint video presentation was created on Safe Haven infants, the new Safe Haven policy, and staff roles during Safe Haven events. This education was presented on March 15th via the facility's educational portal, Workday. ED, SCN, and social work staff completed the education by April 7th.
The INACSL Standards of Best Practice for Simulation12 guided the researcher to create a Safe Haven simulation to assess knowledge retainment of the policy and education given to staff. On April 29th, a spontaneous relinquishment simulation took place in the ED's waiting room of the level II trauma center, yielding 6 RN participants. An anonymous volunteer brought a baby doll into the waiting room entrance and asked to abandon her "infant" under the Safe Haven law. Three members of the stakeholder team were there to observe the simulation, take notes, and assess strengths and weaknesses. Immediately after the simulation, all participatory staff members met to debrief and take a 5-question survey assessing strengths and gaps (see Supplemental Digital Content Appendix B, available at: http://links.lww.com/JPNN/A33). After completing the education and simulation, participatory staff completed the posttest Qualtrics survey from April 29th-May 27th to complete the 10-question Likert scale. Data analysis began immediately after May 27th, and finalized data analysis was completed on June 10th.
Data collection
Data collection for the pretest survey was completed via a Qualtrics survey using a 10-question Likert sliding scale with a 1-5 score, with 1 meaning "strongly disagrees" to 5 meaning "strongly agrees" (see Supplemental Digital Content Appendix A, available at: http://links.lww.com/JPNN/A32). Thirty-one participants completed this survey; 13/50 (26%) ED RNs, 17/18 (94%) SCN RNs, and 1/1 (100%) pediatric social worker. Staff education started on March 15th via BSMH's online education portal, Workday. ED, SCN, and social worker staff completed the education by April 7th. Following the education, on April 29th, a Safe Haven simulation evaluated 4 ED and 2 SCN staff members' knowledge of the new consecutive policy and roles during a Safe Haven event. Immediately after the simulation, a debrief containing a 4-question survey was presented to the participants to assess strengths and gaps (see Supplemental Digital Content Appendix B, available at: http://links.lww.com/JPNN/A33).
After completing the education and simulation, the researcher published the 10-question Likert sliding scale Qualtrics posttest survey to participants with the same questions used in the pretest survey to assess an increase in knowledge of Safe Haven infants, Safe Haven events, and the new consecutive policy. The posttest survey ran from April 29th to May 27th. Thirty-one participants completed the posttest survey; 13/13 (100%) ED RNs, 17/17 (100%) SCN RNs, and 1/1 (100%) pediatric social worker.
DATA ANALYSIS AND RESULTS
The researcher obtained quantitative data by analyzing pre- and posttest survey data using a paired t test. These data concluded exclusion criteria of those staff members who did not utilize the 1-5 sliding scale, leaving a "0" as the answer to the question. Those answers were viewed as skipped by the researcher, resulting in 21 participants (10 ED RNs, 10 SCN RNs, and 1 social worker) for the pretest survey and 31 participants for the posttest survey (13 ED RNs, 17 SCN RNs, and 1 social worker) (see Table 1).
The pre- and posttest survey questions (see Supplemental Digital Content Appendix A, available at: http://links.lww.com/JPNN/A32) were identical to assess and increase staff knowledge of Safe Haven infants and events. When evaluating the pre- and posttest surveys, there was an increase in the overall Qualtrics survey mean scores. The pretest overall mean score was 2.5 on the 1-5 Likert sliding scale survey, and the posttest survey showed an overall increased mean score of 4.5. Also, an increase in the mean individual question scores indicated increased knowledge. These scores ranged from 1.7 to 4.1 on the pretest survey to 3.9 to 4.7 on the posttest survey. The analysis resulted in P <= .001, showing statistical significance for all questions, excluding question 7, which discussed communication between units and resulted in P = .048, identifying a lower significance (see Table 2). When reviewing individual questions (see Supplemental Digital Content Appendix A, available at: http://links.lww.com/JPNN/A32, and Table 2), there were significant findings to address the objectives of this project. The objective of increasing RN and social worker knowledge of Safe Haven infants and events is met by questions 1, 2, 3, 4, and 5 on the Qualtrics pre- and posttest surveys.
The researcher also obtained qualitative data by assessing knowledge retention and teamwork through a Safe Haven simulation. The simulation resulted in 6 RN participants, 4 ED RNs, and 2 SCN RNs. The simulation observed many strengths, including teamwork, communication, and knowledge of policy and procedures. The gap found was a lack of education given to the registration staff. The registration staff occupy the front desk, are the first person the patients see when they walk into the ED, welcome the patients, and register them into the electronic health record. This gap was quickly resolved by educating them on the policy and providing them with Safe Haven education in Workday's educational portal. After the simulation and simulation debrief, a 4-question Likert scale survey (see Supplemental Digital Content Appendix B, available at: http://links.lww.com/JPNN/A33) was completed by participants to assess strengths and gaps. Participants answered "agree" to "strongly agree" throughout the departments (see Supplemental Digital Content Appendix B, available at: http://links.lww.com/JPNN/A33, and Figure 1). The communication between staff, the delegation of tasks, and smooth transfer of the "infant" to the SCN seen during the simulation met the objective of teamwork. The data from the postsimulation survey represent a met objective of healthcare staff knowledge of the Safe Haven policy, events, and roles during events.
DISCUSSION
The researcher used King's Change Model for Goal Attainment10 and Lewin's change theory11 to conduct a quasi-experimental study using a nonequivalent control group design.11 Once implemented and evaluated, the project goals identified through King's Change Model for Goal Attainment10 showed positive outcomes in increasing staff knowledge of Safe Haven infants, events, and roles during these events (see Table 2 and Figure 1).
The study assessed the increase in knowledge and teamwork after completing a new consecutive Safe Haven policy, education, and Safe Haven simulation. Lewin's change theory suggests that prior knowledge needs to be replaced.10 This project used the unfreezing phase to review old Safe Haven policies and events to assess gaps via a pretest survey of staff knowledge. After gaps were assessed during the unfreezing phase, the changing phase included an educational intervention on a new Safe Haven policy, infants, and events for current and new RN and social worker staff. After receiving education, a Safe Haven simulation was conducted between ED and SCN staff. The researcher then conducted a posttest survey to analyze the results. The educational intervention and simulation revealed increased knowledge, teamwork, and communication from posttest data collection (see Table 2) and postsimulation survey (see Supplemental Digital Content Appendix B, available at: http://links.lww.com/JPNN/A33, and Figure 1). The project experienced the refreezing phase after completing the successful Safe Haven simulation and placed a new Safe Haven policy and retained new knowledge into practice.
Objectives and aim
The literature identifies a lack of staff knowledge on Safe Haven infants, roles during Safe Haven events, and feelings of unpreparedness during Safe Haven events.3,5 This research aligns with the observed low mean overall pretest survey score of 2.5, showing low pre-education and pre-policy knowledge. After policy and education distribution, the overall mean posttest survey scores were 4.5, with a P value of less than .001, concluding with statistical significance of the results and increased staff knowledge. When addressing individual pre- and posttest survey questions, questions 1 to 5 on the Qualtrics pre- and posttest survey assessed knowledge of Safe Haven law, policy, competence, roles, and interprofessional collaboration. All mean pretest scores showed lower scores on the sliding scale (2.1-2.8). After receiving education in all areas, the mean overall posttest scores significantly increased (4.5-4.7), therefore meeting the objectives of increasing staff knowledge of Safe Haven infants, policy, and events and assisting healthcare staff to understand their roles during Safe Haven events.
Simulations assist with the procedural flow, comfortableness of staff, and assessing strengths and gaps.3 Participatory simulation staff completed a Safe Haven simulation showing knowledge of policy and procedure, comfortableness with the flow, and knowledge of interprofessional collaboration. The results from the postsimulation survey showed an understanding of Safe Haven infants, policy and events, and roles during the event. The successful simulation also identified a met objective of increasing staff knowledge of Safe Haven infants, policy, and events and assisting healthcare staff in understanding their roles during Safe Haven events.
Another goal of this quality improvement project was to obtain a Safe Haven Baby Box for the healthcare facility. A parent is able to legally surrender their infant in person to any location deemed as a safe haven by the state's Safe Haven law. This also allows for mothers to obtain healthcare if she chooses. For those parents who may feel embarrassed or anxious about in-person surrendering, the option of a Safe Haven Box was developed, allowing the parent(s) a choice. These boxes provide a safe enclosed area that is temperature controlled and monitored for parents to legally surrender their infants. Once an infant is placed into the box, the door automatically locks for securement and an alarm alerts the facility to the presence of something inside the box, allowing for expedited care of the infant. These boxes also provide brochures on resources for the mother, care for mother after delivery, and an optional medical history form.
A stakeholder team was created involving the researcher, the Chief Operations Office of the Safe Haven Baby Box company, the director of obstetrical services, the director of the ED, manager of the ED, campus police, the director of education, and the director of Mission. The data collected on patient populations at risk, the number of legally surrendered infants in the United States and Ohio, and the financial investment in the project were presented to the administrative board and community benefit committee at the level II trauma center. This box and the project were deemed a community benefit and the $45 500 cost of the Safe Haven Baby Box, Ohio Department of Health fees, and additional construction was granted through the committee and the ministry. Once approved, the Ohio Department of Health approved the placement of the box and the Safe Haven Baby Box company determined the location of the box.
STRENGTHS AND LIMITATIONS
The researcher identifies strengths to this study that readers should consider when determining their healthcare staff's education on Safe Haven infants and events. Many successes included collaboration with facility stakeholders, a smooth Safe Haven policy writing process, implementation of the Safe Haven policy at the facility, creating staff education that was distributed via the facility educational portal, Workday, for current and future staff, and a successful Safe Haven simulation. Strengths were also seen in the statistically significant increase in posttest scores and a successful Safe Haven simulation. Another strength of this project was collaborating with the stakeholder team and the facility's community benefit committee to secure $45 500 for a Safe Haven Baby Box placement. This box was placed on May 27, 2022, and presented to the community on October 24, 2022.
The researcher acknowledges limitations to this study. One weakness observed at the beginning of the project was that ED staff did not know the researcher. Many staff members seemed hesitant to participate in the survey even after many daily unit meetings, face-to-face communications, and e-mails about the project. This barrier resulted in low participation from ED RN staff, resulting in only 13 of 50 (26%) ED RNs completing the pre- and posttest surveys. Another significant limitation to the project was the lack of identifying factors for project participants who completed the survey. Because of the anonymous factors associated with selection, the opportunity to assess individual scores on the pre- and posttest surveys was missed. Therefore, only aggregate data were used during the analysis. The design of the Qualtrics survey was another limitation of the study; the survey asked participants to use a 1-5 sliding Likert scale to answer the 10 pre- and posttest survey questions. The survey generated a "0" for the lowest number available, making it difficult to estimate whether users did not answer the question or whether they chose "0" instead of "1," therefore forfeiting these data in 11 of the pretest participants and one of the posttest participants. Finally, the Safe Haven simulation concluded that the registration staff did not receive the Safe Haven education. This information was crucial as registration staff occupy the front desk; they are the first person the patients see when they walk into the ED, welcome the patients, and register them into the electronic health record. This barrier was quickly fixed by providing registration staff with the Safe Haven education.
CONCLUSION
This quality improvement project has given staff a Safe Haven policy, new knowledge, and appropriate roles and responsibilities during rare, but critical Safe Haven events. The Safe Haven policy has been approved across a 4-state ministry. This policy will be sustained by biannually renewal and by distributing education to new staff members during new hire orientation. Next steps for future study include more research on characteristics of newborns who have been legally surrendered. This research would give healthcare teams a better understanding of patient populations and infants at risk. Next steps for this project include collaboration with the facility's education department to ensure annual Safe Haven simulations occur and the sharing of education and mock simulation ministry-wide.
References