The goal of health care for high-risk infants is to minimize complications and to promote optimal growth and development beyond simple survival. Extensive research has investigated how neonates—including those who are premature, medically unstable, and at high risk for infections—adjust to the environment after abrupt exposure to the extrauterine environment. Several studies have shown the relevance of the physiology of the dermis (Afsar, 2010; Oranges et al., 2015; Visscher et al., 2015) and the physiological adaptations of the skin at birth in this context (Ahn et al., 2013; Kanti et al., 2014).
Soon after birth, neonatal skin, a primary organ that has direct contact with the external environment, adjusts to the transition from the aseptic, alkaline amniotic fluid to a nonsterile environment containing air. The skin integrity of the neonate stabilizes by normal flora colonization within days to weeks (Johnson & Versalovic, 2012; Keyworth et al., 1992) and by the establishment of a proper surface pH through the formation of an acid mantle (Taïeb, 2018). In addition, keratinization, which occurs through a drying and desquamating process after birth, helps to stabilize skin integrity (Chiou & Blume-Peytavi, 2004). A recent study revealed that newborns born prematurely or with lower birth weights tended to show a lesser degree of physiological adaptations of the skin, such as the stabilization of epidermal hydration and the formation of an acid mantle after birth (Ahn et al., 2013). Furthermore, high-risk infants frequently undergo invasive procedures and are exposed to unusual environments, such as an overhead radiant warmer or phototherapy. This may further impair skin integrity, leading in turn to a vicious cycle that aggravates the risk of infections through the skin (Visscher et al., 2015).
Nursing practices for promoting skin integrity should be developed based on a thorough understanding of the adaptations of the skin at birth. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2018) and the National Association of Neonatal Nurses (NANN) published a guideline on neonatal skin care in both term and preterm newborns. The guideline database of the National Institute for Health and Care Excellence (2016) in the United Kingdom describes the management of pressure sores and wounds, as well as practices for specific clinical circumstances. Similarly, the National Pressure Ulcer Advisory Panel (NPUAP) has proposed a guideline for wound care and pressure ulcers that emphasizes risk factors, assessment tools, and interventions for infants in the neonatal intensive care unit (NICU) (Baharestani & Ratliff, 2007).
In Korea, the Korean Association of Neonatal Nurses (KANN, 2015) and the Manual of Neonatal Care of the Korean Society of Neonatology provide guidelines on the use of adhesives or antiseptics, the management of pressure sores and diaper rash, and other practices for neonates, mostly adapted from the AWHONN/NANN guidelines (Pi et al., 2014). However, the information is limited primarily to the management of pressure sores and wounds, rather than assessment of skin conditions or skin physiology. For this reason, some guidelines might not include a comprehensive presentation of epidermal physiology regarding the adaptations of neonatal skin and instead focus on observations such as dryness, erythema, and breakdown. The implications of guidelines might be structurally complicated and not adaptable in terms of issues regarding the need to adjust NICU facilities and staffing in specific units. It is difficult to find practice guidelines that both apply and evaluate evidence-based nursing practices.
The authors' research team therefore performed a nation-wide survey on skin nursing practices in high-risk newborns throughout South Korea (Ahn et al., 2018) and found the majority of nurses had little fundamental understanding of neonatal skin physiology (e.g., the acid mantle or the normal flora of the epidermis) and that nursing practices were limited mostly to routine care (e.g., bathing, diaper rash management, and disinfectant application). The skin care practices of Korean neonatal nurses seem to be performed according to individuals' subjective experiences and discrete judgment. A similar finding was reported in a study of Malaysian nurses' skin knowledge, with 80.5% of nurses having inadequate knowledge of neonatal skin integrity (Mohamed et al., 2014). A substantial gap in skin care for high-risk newborns—in terms of both knowledge on physiological adaptations of the skin and evidence-based practice—exists both nationally and internationally.
Therefore, it is necessary to develop a practice guideline that presents a body of knowledge on the physiological adaptations of the skin, along with evidence-based nursing practices for improving skin integrity. This study had two goals. The first goal was to develop a guideline including up-to-date knowledge on the physiological adaptations of the skin and science-based practice for improving skin integrity. The second goal was to evaluate the effects of education using the guideline on neonatal nurses' skin care knowledge and confidence in caring for high-risk newborns.
Given the twofold goals of this study of developing a skin nursing guideline for high-risk infants and evaluating the effects of using the guideline for training, the study was conducted in two phases: guideline development and evaluation of its effects.
Phase 1: Development of the Skin Nursing Guideline for High-Risk Infants
The target users of the skin care guideline were clinical nurses in neonatal and high-risk infant care units, and the goal was to provide evidence-based skin care guidelines for clinical practice. The guideline was developed in the form of a booklet including a body of knowledge on skin and skin care practices focused on high-risk neonates, such as preterm newborns.
Step 1: Literature Search. Existing data on skin care practice in neonates were researched by investigating both domestic and international guidelines for skin care, as well as by conducting a literature review including textbooks and papers. Information on skin care practice was collected from two major sources on NICU practice: the Guideline for Neonatal Intensive Care Nursing of the KANN (2015), and The Manual of Neonatal Care published by the Korean Society of Neonatology (Pi et al., 2014). In addition, international information was collected from the following sources: (1) the clinical practice guideline database provided by the National Guideline Clearing-house of the United States and the National Institute for Health and Care Excellence of the United Kingdom, (2) the NPUAP white paper, particularly on pressure injury management (Baharestani & Ratliff, 2007), (3) the AWHONN/NANN guideline (AWHONN, 2018), and (4) data on skin nursing provided by the Core Curriculum for Maternal-Newborn Nursing (Mattson & Smith, 2015).
To examine recent articles on skin nursing practice in neonates, studies published within the past 10 years were investigated using both domestic and international search engines, such as PubMed®, Google™ Scholar, and DBpia. Data were collected first by searching for the major concepts of this study and guideline, using the following search terms: term/preterm newborn skin, neonatal skin integrity, and NICU skin care. Data also were collected in relation to the major skin care practices identified from the existing national and international skin nursing practice guidelines by searching for terms such as neonatal bathing, cord care, diaper rash management, positioning, environment management, and skin management. The use of products associated with skin care (e.g., disinfectant, cleanser, adhesives, and dressings) and information on developmental care also were included in the literature search. Data from recent systematic reviews on neonatal skin care were collected by searching Cochrane review papers from the Cochrane Database.
In addition, a fundamental body of knowledge on neonatal skin, including topics such as skin adaptation in neonates and preterm infants after birth, and the structure and functions of the skin (e.g., skin surface pH, normal flora of the skin, and skin hydration) was constructed by referring to international textbooks on pediatrics and dermatology (Eichenfield et al., 2014; Gardner et al., 2015; Lee et al., 2010). The collected body of knowledge related to the promotion of skin integrity and infection control was organized and classified according to its level and range.
Step 2: Process of Integrating the Content. Based on the obtained data on neonatal skin care, a preliminary skin care guideline was developed. The guideline contained two major sections—a section presenting a body of knowledge and a section devoted to nursing practice. In the development phase, images illustrating exemplary management or aspects of management for which a detailed illustration would be suitable were produced by collaborating with an expert illustrator to promote the delivery of accurate information. After several discussions between the illustrator and the research team, along with additional revisions and supplementation, a total of 19 illustrations on high-risk infants' skin care and instructions regarding the use of medical devices and other techniques were produced and included in the guideline. The corresponding content was revised and supplemented after consulting a neonatal nursing professor and a neonatal nursing specialist with more than 20 years of NICU experience regarding its validity and the appropriateness. Following the revision process, the content was presented in a booklet entitled “Practice Guideline for Improving Neonatal Skin Integrity.” The development process of the guideline lasted for 6 months, from January to June 2018.
Phase 2: Evaluation of the Effects of Training Using the Skin Care Guideline
Study Design. The effects of a training session using the skin care guideline on neonatal nurses were evaluated in terms of the nurses' knowledge and nursing confidence in a pretest-posttest design with a comparison control group. Figure 1 outlines the process of the two phases.
Flow chart showing the study process. Note. KANN = Korean Association of Neonatal Nurses; KSN = Korean Society of Neonatology; NGC = Neonatal Guideline Clearinghouse; NICE = National Institute for Health and Care Excellence; NPUAP = National Pressure Ulcer Advisory Panel; AWHONN/NANN = Association of Women's Health, Obstetric and Neonatal Nurses.
Setting and Participants. The participants were nurses who had worked longer than 6 months in the newborn units and the NICUs of three similar-sized hospitals located in metropolitan areas, where newborns with a wide variety of risk levels (from convalescence to critical conditions) were hospitalized. No other selection criteria were applied. Participation in the study was an autonomous choice made by the nurses independently from their official duties. A total of 46 nurses participated in the study from July to August 2018. A total of 23 nurses responded to the survey before the educational session, received the educational intervention, and completed the postsurvey 2 weeks after the educational session; these nurses served as the experimental group. The other 23 nurses who responded to the survey but did not attend the educational session served as the control group.
Human Subject Protection. This study was conducted after receiving approval from the Institutional Review Board (approval number: 151208-1AR) of the study institution. Prior to data collection, permission to conduct research was obtained after providing an explanation regarding the purpose and methods of the study to the chief executive officer of each hospital and the director of the nursing department at each institution. To the neonatal nurses, a full explanation of the study was provided, including an assurance of confidentiality and the autonomous and voluntary nature of their decision to participate or withdraw from the study. Written consent from each participant was obtained prior to the study.
The nurses (n = 23) in the control group, who did not participate in the training session, were provided with the skin care guideline booklet after completing the postsurvey. In addition, the corresponding training also was given to any of the nurses who desired the training, regardless of whether they were study participants, after the postsurvey was completed at each hospital.
Intervention: Skin Care Guideline Education. Training on the skin care guideline was provided to the experimental group. The schedule was arranged with the director of the nursing department at each institution, and all of the nurses were notified in advance prior to participating in the training session, which was conducted using audiovisual materials and the booklet. Following distribution of the Practice Guideline for Improving Neonatal Skin Integrity developed in this study, the training session was conducted as a 30-minute lecture comprising information on the improvement of skin integrity in neonates (15 minutes) and associated nursing practices (15 minutes), using a PowerPoint® presentation based on the content of the Practice Guideline for Improving Neonatal Skin Integrity.
Outcome Measurements.Knowledge about neonatal skin. An instrument for measuring knowledge about skin in neonates was developed to determine nurses' degree of knowledge regarding the improvement of skin integrity in high-risk infants. Based on the content of the Practice Guideline for Improving Neonatal Skin Integrity, a preliminary survey with a total of 64 items was developed. The survey included 32 items measuring general knowledge about skin care in high-risk infants and 32 items measuring practice knowledge. The preliminary items were reviewed by neonatal nursing professors and specialists. A total of 35 items, including 20 items measuring general knowledge and 15 items measuring practice knowledge, were selected after eliminating items with low validity or low mutual exclusivity.
The preliminary survey containing the final selected items was administered to three neonatal nurse specialists, and the content of the survey was confirmed after assessing the validity of the items and the time necessary to complete the survey. The items were formatted as various types of questions, including yes/no questions and short-answer questions; correct answers were scored as 1 point, and incorrect answers were scored as 0 points. The total score was calculated as the sum of the correct answers. The general knowledge score ranged from 0 to 20 points, and the practice knowledge score ranged from 0 to 15 points, for a total knowledge score ranging from 0 to 35 points. Higher total scores indicated a higher degree of knowledge of nurses regarding skin care. The Cronbach's alpha of the instrument was .70.
Confidence in neonatal skin practice. Confidence in neonatal skin nursing was evaluated using a visual analogue scale, on which participants marked their subjective opinion on their degree of confidence in nursing practices related to the improvement of high-risk infants' skin integrity. Responses of not confident at all were scored as 0 points and responses of as confident as possible were scored as 10 points; thus, a higher score indicated a higher subjective degree of confidence in nursing practice. Cronbach's alpha for the instrument was .66.
Data Analysis. Data were analyzed using SPSS® Statistics 23 for Windows. Demographic characteristics were analyzed using descriptive statistics. Homogeneity of the demographic data and variables among the three groups (one experimental group and two control groups), and between the experimental and control groups, was analyzed using analysis of variance, chi-square test, and independent t test. To evaluate the effects of the training session, the collected data were analyzed using the t test.
Phase 1: Development of the Skin Care Guideline
In this study, the Practice Guideline for Improving Neonatal Skin Integrity was developed based on a body of knowledge about epidermal physiology. To enhance its use and availability, the guideline was developed in the form of a booklet with illustrations (Figure 2).
Illustration showing the mechanism of heat loss in newborns.
The developed guideline included two sections on skin integrity knowledge and skin integrity practice. The latter section present methods based on evidence-based practice. The skin integrity knowledge section included information on skin layers and skin barrier function (e.g., skin pH, skin hydration, and normal flora), whereas the skin integrity practice section included practices associated with usual skin care (e.g., bathing, cord care, diaper rash, and positioning), the use of products associated with skin nursing, and specialized nursing (e.g., treatment, environment, and developmental care). Additional information applicable to skin care practice was included in an appendix, with topics covering issues such as insensible water loss and neutral thermal environment; a position change checklist and a skin assessment tool (neonatal tissue viability risk assessment tool) also were included in the guideline (Ashworth & Briggs, 2011).
Phase 2: Validation of the Effectiveness of the Guideline Education
Demographic Characteristics of Participants. Slightly less than half of the participants (48.9%) held a bachelor's degree. The mean (SD) age of participants was 39.2 (9.1) years, and they had 10.9 (6.6) years of clinical experience and 5.7 (6.1) years of experience with neonatal care from low- to high-risk levels. Only four nurses responded that they had received skin care education in the past year. Because the homogeneity test showed no meaningful difference among the three groups (Table 1), data from control group 1 and control group 2 were considered as pre- and postsurvey data from one control group for the following analyses.
Homogenity of Demographic Factors between The Control and Experimental Groups (N = 46)
Effects of Skin Care Guideline Training on Skin Care Knowledge and Skin Nursing Confidence. At baseline, there was no statistically significant difference between the experimental and control groups in knowledge score (20.8 and 20.0, respectively; t = 0.73, p = .468) or confidence score (5.5 and 5.6, respectively; t = 0.11, p = .917). In the posttest for the experimental group, the mean knowledge score increased significantly from 20.0 to 27.2 (t = 7.72, p < .001). The confidence score increased but did not reach statistical significance (from 5.6 to 6.4; t = 1.66, p = .111) (Table 2).
Comparison of Knowledge and Confidence for Skin Care Between The Control and Experimental Groups (N = 46)
In the first phase of this study, a skin care practice guideline for high-risk infants was developed and the effectiveness of education on the guideline in neonatal nurses was evaluated. A strength of this study is that the guideline reflects an up-to-date body of knowledge that was investigated by administering a survey to neonatal nurses regarding their knowledge about skin integrity in the early postnatal period. In particular, this knowledge was reflected in the evidence-based practice section, as having a solid evidence-based foundation was a major goal for this guideline. Moreover, the guideline emphasized topics of practical relevance for nurses, as determined through a nationwide survey on NICU skin care. In particular, the neonatal skin integrity assessment tool (Ashworth & Briggs, 2011) and the position change checklist are expected to be helpful in establishing a systemic skin care system. The neonatal skin integrity assessment tool measures the risk of skin damage based on the clinical features of a newborn (e.g., gestational age, level of activity, and response to discomfort) and the therapeutic environment (e.g., humidity and friction), whereas the position change checklist facilitates changing the position of infants at regular time intervals and provides a way of recording such changes.
Another strength of the guideline is the customized illustrations for neonatal skin care that help nurses easily understand the contents in a contextual way. The illustrations were developed to reflect infants' body proportions and features. On that basis, the learning process was made more intuitive by presenting comparisons between appropriate and inappropriate examples of placing an endotracheal tube or nasal continuous positive airway pressure device, infant positioning, and other practices. In nursing practice education, using visual information is known to be an effective educational method that enhances skin care confidence and competence (Gao et al., 2015). The finely tailored illustrations on skin care practice for high-risk newborns will help neonatal nurses apply their knowledge and skills in actual practice. In addition, the presence of high-quality illustrations is expected to increase use of the guideline.
Correspondingly, in the second phase, this study confirmed that nurses' level of knowledge improved significantly as a consequence of the training session using illustrations. However, there was no significant improvement in skin care confidence, which implies that knowledge improvement from one-time education at the individual level was not connected to improvements in confidence. Nonetheless, the training session on the guideline may have enabled nurses to recognize that previous skin care practices are customary and inexact, and require change at a unit level. In other words, the training session may have temporarily undermined the skin care confidence of individual nurses. In addition, it may take time for nurses to build confidence in the reciprocal cycle from scientific knowledge to clinical practice. This consideration suggests the need for a second survey 3 to 6 months after the educational session. A previous study reported that neonatal nurses were well aware that neonatal skin injuries were extremely common and sometimes serious, but the lack of skin-related education and data impeded efforts to improve their practice (Liversedge et al., 2018). Thus, it is important to lay the foundation for knowledgeable NICU nurses to engage in practice by building a system that regularly provides skin care education to nurses with consistent practice at the unit level.
Limitations and Suggestions
Because the details of clinical practice in the treatment of high-risk infants can vary across institutional systems and specific job roles, a great deal of ongoing effort is needed to standardize practice in detail. As the development and evaluation of the guideline reflected the current state of the art in neonatal care in Korea, some protocols might not be suitable across institutions. However, this limitation may be intrinsic in nature rather than extrinsic to the study itself. For example, immediately after birth, skin-to-skin contact between mother and neonate has been emphasized as a way to establish successful physiological stabilization and transition to breastfeeding (Abdulghani et al., 2018), but differences exist in practice structures and systems across institutions and nations. Differences in practice also exist according to neonates' health condition, underscoring the need for care to be taken when standardizing protocols. Furthermore, additional research is required to provide education about skin integrity-related knowledge and practice guidelines in cooperation with KANN through initiatives such as co-hosted workshops. In addition, a large-scale quality improvement study should investigate skin-related practices and skin integrity enhancement among high-risk infants at health institutions nationwide.
This study was conducted to develop and validate a skin care guideline to be used by neonatal nurses for enhancing the skin integrity of high-risk infants. The significance of the guideline developed in this study is that it takes clinical features into account based on neonatal epidermal physiology. In addition, it reflects the reciprocal loop of evidence-based practice in which scientific nursing knowledge and clinical circumstances are linked in care practices. The guideline was validated as advantageous, as education about the guideline effectively enhanced clinical practitioners' level of skin care knowledge. Therefore, this guideline is a valuable, practical tool for neonatal nurses to use with the goal of enhancing skin integrity in high-risk infants.
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Homogenity of Demographic Factors between The Control and Experimental Groups (N = 46)
|Characteristic||Total||Control Group (n = 23)||Experimental Group (n = 23)||t or χ2 (p)|
|Level of education, n (%)||0.55 (.458)|
| Associate degree||23 (51.1)||10 (45.5)||13 (56.5)|
| Bachelor's degree or higher||22 (48.9)||12 (54.5)||10 (43.5)|
|Skin care education received in past year, n (%)||0.82 (.610)|
| No||39 (90.7)||19 (95.0)||20 (87.0)|
| Yes||4 (9.3)||1 (5.0)||3 (13.0)|
|Neonatal care experience, M (SD), y||5.7 (6.1)||6.3 (6.5)||5.2 (5.7)||−0.59 (.557)|
|Total clinical career, M (SD), y||10.9 (6.6)||9.7 (5.8)||12.1 (7.3)||1.15 (.256)|
Comparison of Knowledge and Confidence for Skin Care Between The Control and Experimental Groups (N = 46)
|Variable||Control Group (n = 23)||Experimental Group (n = 23)||t (p)|
|Knowledge on skin care, M (SD)|
| Baseline||20.8 (4.2)||20.0 (3.4)||0.73 (.468)|
| Posttest||27.2 (3.5)|
|Confidence on skin care, M (SD)|
| Baseline||5.5 (1.9)||5.6 (2.2)||0.11 (.917)|
| Posttest||6.4 (1.8)|