Abstract
This study provides occupational therapists who are interested in implementing the SENSE program (Supporting and Enhancing NICU Sensory Experiences) with an understanding of common barriers, facilitators, costs, and adaptations.
Very preterm infants require care in the neonatal intensive care unit (NICU) for an average of 3 mo after birth (Pineda et al., 2014). In the NICU, high-risk infants are often exposed to invasive medical interventions, contributing to heightened stress and pain, which can have a negative impact on the preterm infant’s development (Smith et al., 2011). Further, early brain development is sensitive to external stimuli (Brown et al., 2009; Pineda et al., 2013), and the NICU is an environment that alters normal sensory experiences. However, there is strong evidence that positive sensory interventions (i.e., skin-to-skin care, massage, music) relate to better parent and infant outcomes (Feldman et al., 2014; Juneau et al., 2015; Krueger, 2010; Pineda, Kellner, Guth, et al., 2023; Procianoy et al., 2010)
Although appropriate early sensory exposures are important for the very preterm infant in the NICU, parent interaction is also critical. The infant’s need for human contact and nurturing has long been understood. Animal studies have identified that even brief periods of maternal separation can result in emotional disturbances and decreased motor activity among offspring (Seay et al., 1962; Seay & Harlow, 1965). Among human preterm infants, early deprivation of caregiver interaction and environmental stimulation has been shown to have lasting effects, such as white matter abnormalities, poor physical growth, developmental delay, and increased emotional and neurocognitive difficulties (Berument et al., 2012; Daunhauer et al., 2007, 2010; Govindan et al., 2010; Tottenham & Sheridan, 2010). Although the vulnerable preterm infant differs from a child who has been institutionalized or deprived of caregiving attention after full-term birth, there are striking similarities with altered temporal structures, in addition to the increased risk of developmental impairment (Anderson & Doyle, 2008; Barre et al., 2011; Govindan et al., 2010). Clinical studies on early parent–infant interactions have demonstrated positive effects of parent interaction on motor and attentional responses of the infant (Brazelton et al., 1975), with infants whose parents are present and engaged in the NICU demonstrating more favorable outcomes (Pineda, Bender, et al., 2018; Reynolds et al., 2013).
There is significant variation in how and when sensory interventions are provided across different NICUs and even within the same unit (Pineda, Roussin, et al., 2018). Differences in the use and interpretation of available evidence, as well as differences in parent education and empowerment in the NICU, are prevalent. Because of the complex environment, there is also significant variability and lack of consistency in the application of positive multisensory interventions, often preventing the most vulnerable infants from benefiting (Pineda et al., 2016). Furthermore, programming in the NICU has largely centered around how to read and respond to infant cues, reduce stressors, and increase parent–infant interaction (Church et al., 2020; Westrup, 2007). Some programs also propose the introduction of positive sensory exposures (White-Traut et al., 1997, 2015). However, before the development of the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, no other programs incorporated all of the available evidence on sensory-based interventions or tailored the type and timing of these sensory exposures on the basis of the infant’s developmental age or maturity.
Utilizing a structured, evidence-based, sensory- supportive program as an implementation strategy can enable positive, parent-delivered, sensory exposures to get to the infant in the NICU each day of hospitalization for a larger, sustained impact (Pineda et al., 2016). The SENSE program was developed in 2017 and defines the specific doses and targeted timing of evidence-based interventions such as massage, auditory exposure, rocking, holding, and skin-to-skin care on the basis of the infant’s postmenstrual age (Pineda et al., 2019). The SENSE parent education materials guide the parents to understand their important role in the NICU, the value in positive sensory exposures to their infant, how to read and respond to their infant’s cues, the application of evidence-based interventions that are appropriate for their infant’s level of maturity, and how to embed such interventions into the daily flow of the NICU to support their infant’s development. The SENSE program is overseen by an identified SENSE administrator, who is usually a neonatal therapist. The SENSE administrator assesses the infant’s tolerance to make any needed adaptations to the sensory exposures, educates the parents, and ensures everyone is aware of the daily, specific sensory needs of the infant in context of the medical environment (Pineda, Kellner, Ibrahim, et al., 2023). The parents conduct the recommended amounts of sensory interventions with their infants with guidance from the SENSE administrator.
The SENSE protocol was rigorously developed. First, an integrative review outlined 88 peer-reviewed manuscripts on sensory-based interventions that were used with preterm infants to improve outcome (Pineda et al., 2016). Then, a multidisciplinary group of 108 health care professionals defined sensory interventions that were implemented across different NICUs (NICU Therapy Lab, 2018). Finally, three multidisciplinary focus groups provided a critical review of the program, and 20 mothers of preterm infants were interviewed about the feasibility of implementing the SENSE program in the NICU (Lisle et al., 2022). The results from all of these were integrated to develop the evidence-based SENSE program (Pineda et al., 2019).
After the development of the SENSE program, research was conducted to assess its feasibility and impact on the parents and infants. A pilot study of 80 preterm mother–infant dyads demonstrated improved parenting confidence and better infant neurobehavior in mother–infant dyads who received the SENSE program (Pineda et al., 2020). Implementation at the study site was explored, with important findings, including the following: Most infants received the SENSE program as defined in a Level 4 NICU; the SENSE program led to differentiation in the amount of positive sensory exposures that infants received; and when education occurred very early in hospitalization, more parent participation in providing positive sensory exposures to their infants across hospitalization was observed (Pineda, Roussin, et al., 2021). In a randomized control trial of 70 preterm infants, those receiving the SENSE program obtained higher scores for lethargy on the NICU Network Neurobehavioral Scale, which remained significant after controlling for social and medical factors. Although it remains unclear why lethargy would be higher among those who received the SENSE program, this finding does parallel research on skin-to-skin care, which identifies better sleep as an outcome (Boundy et al., 2016; Feldman et al., 2002). Among those who received the SENSE program, higher scores for communication on the Ages and Stages Questionnaire at 1 yr corrected age were observed, but this outcome did not reach statistical significance after controlling for social and medical factors (Pineda, Smith, et al., 2021).
The SENSE program was made available to other hospitals in June of 2018, and as of December 2023, more than 450 licenses or user fees had been sold “at cost” to hospitals throughout the United States and abroad. Although there is a high demand for the SENSE program, little is documented about health care professionals’ perceptions of the SENSE program, the scope of SENSE program implementation (including barriers and facilitators) across sites, or the costs and adaptations of SENSE program implementation. Proctor et al.’s (2011) model for dissemination and implementation research allows for the conceptualization and understanding of barriers and facilitators, penetration, adaptations in real-world context, and implementation costs.
This survey-based study sought to improve the scientific knowledge regarding the implementation of the SENSE program among those who have obtained the program. This can aid other health care professionals who seek implementation strategies aimed at improving the early NICU environment.
Method
Participants
This survey-based study was approved by the institutional review board at University of Southern California, with a waiver of written informed consent. Participants included SENSE administrators (those who administer the program in their respective NICUs) across the United States and abroad. Invitations to participate in the SENSE Program Implementation Survey were sent to 211 hospitals that had paid a user fee for the SENSE program before March 11, 2020. Hospitals that paid the user fee after this date were not included in an effort to report on hospitals who may have been attempting to implement before the COVID-19 pandemic. The SENSE administrator was frequently the person who paid the user fee to gain access to the program, but when that was not the case, the person who paid the user fee was asked to identify their site’s SENSE administrator. When there was more than one SENSE administrator at a hospital, all SENSE administrators were asked to complete one survey together. Health care professionals from hospitals and organizations that did not pay the user fee and those who were not SENSE administrators were excluded.
Implementation Science Framework
Proctor et al.’s (2011) model for dissemination and implementation research guided the development of questions on the SENSE Program Implementation Survey to facilitate understanding of organizational practices, barriers, and facilitators to implementation across different sites. Some questions were adapted from the Intervention Rating Profile–15, which is frequently used in implementation research (Witt & Martens, 1983). In addition, the BARRIERS scale was used to assess challenges with implementation, substituting the word SENSE for research (Funk et al., 1991; Kajermo et al., 2010). The BARRIERS scale has been reported to have good internal consistency (Cronbach’s αs = .84–.96; Kajermo et al., 2010), and it is used frequently in implementation science research. In addition to multiple-choice and multiple-select questions, short-answer and paragraph responses enabled respondents to generate qualitative data, such as perceptions related to barriers and facilitators. We also queried with regard to adaptations and costs associated with SENSE program implementation.
SENSE Program Implementation Survey
The survey was developed in Qualtrics with display logic used to engage respondents in appropriate questions related to their responses. For example, if the respondent indicated that they had not implemented the program, additional questions related to implementation were not asked. The initial draft of the survey was reviewed by health care professionals and members of the research team to ensure clarity and reduce redundancy. The survey went through multiple iterations before consensus was achieved on a final version. The survey was piloted with six health care professionals. They were each asked to complete the survey and to share feedback (i.e., confusing wording, additional questions that should be added to the survey, and comments about the length of the survey). The questions highlighted by the pilot group were rewritten or removed, and another iteration of the survey was piloted again with an additional two health care professionals (who voiced no concerns or enhancements of the survey) before the survey was deemed ready for distribution.
Survey questions covered a wide range of topics to aid our understanding of the timing, barriers, and facilitators of SENSE program implementation. Questions probed hospitals regarding the populations being targeted by the program and the use of specific program recommendations (e.g., a SENSE administrator, assessment of infant tolerance, sensory support team, parent education materials). Respondents were given the opportunity to share suggestions for how best to implement the program on the NICU level and parent level. Adaptations to the program were further explored with questions regarding whether the adaptation was planned (proactive) or unplanned (reactive) and whether it was made on the level of the hospital, NICU, or person. We queried about the costs of the program related to increased staffing needs or material needs. Overall opinions of the program were explored, including probes as to how appropriate the program was for the population being served by the respondent from the participating NICU.
Conducting the survey by using Qualtrics allowed responses to be automatically stored in a secure database for analysis. The survey took approximately 1 hr to complete. Not every question was answered by all participants (because of branching logic and because none of the questions were required to be completed). A 4-wk deadline was given for survey completion after the initial e-mail was sent, with a reminder sent after 1, 2, and 3 wk, as well as within 3 d of the survey deadline. Administrators who did not complete the survey within 10 d of the deadline were also contacted by phone to request participation.
Analysis
We used descriptive statistics to report and understand implementation, with analyses conducted with IBM SPSS Statistics (Version 29). Because of the significant amount of data acquired from the survey, we aimed to provide an initial report on implementation descriptively. However, many questions could enable future qualitative analysis. Furthermore, hospital characteristics associated with successful implementation can be better defined after this initial descriptive report.
Results
There were 114 responses (54% response rate) to the SENSE Program Implementation Survey. Ninety-nine (87%) respondents were from the United States, with the most common states represented being Texas, Florida, California, and Wisconsin. Fifteen (13%) respondents were from outside the United States; represented continents included Africa, Asia, Australia, Europe, and South America. Among 53 respondents who identified themselves as the SENSE administrators, 28 (53%) were occupational therapists, 13 (25%) were physical therapists, 6 (11%) were speech-language pathologists, 4 (8%) were nurses, and 2 (4%) identified as “other.”
See Table 1 for descriptive statistics regarding characteristics of the hospitals and NICUs who had participants complete the SENSE Program Implementation Survey, and see Table 2 for questions on the survey that were used to further our understanding of health care professionals’ perceptions, as well as the barriers and facilitators of SENSE program implementation.
Descriptive Statistics of Hospitals Where Participants Who Completed the Survey Were Employed
Note. Data are based on participant answers to survey questions. FTE = full-time equivalent; NICU = neonatal intensive care unit.
Survey Questions and Responses
Note. COVID-19 = coronavirus disease 2019; HIE = hypoxic-ischemic encephalopathy; ISAM = infants of substance-abusing mother; MD = medical doctor; NAS = neonatal abstinence syndrome; NICU = neonatal intensive care unit; PMA = postmenstrual age; ROM = range of motion; SENSE = Supporting and Enhancing NICU Sensory Experiences.
a In the Survey Question column, n = number of responses to question.
When we queried how the SENSE program could be adapted to be more culturally relevant for the respondent’s patient population, suggestions included demonstrating images of alternate swaddling techniques (for Native American populations), including more variations in representation in images throughout the program, and acknowledging that skin-to-skin care is less accepted in certain cultures around the world.
Hospitals were excluded if they obtained the program after COVID-19 pandemic isolation procedures were instituted. However, among the 116 responses to the question “How has the COVID-19 pandemic [affected] rollout or implementation of the SENSE program in your hospital?” 21 (18%) reported that there was no impact. Negative effects of the COVID-19 pandemic included delayed rollout (n = 27; 23%), decreased parental involvement (n = 17; 15%), no volunteer involvement (n = 14; 12%), fewer therapists being available (n = 5; 4%), challenges in educating users and staff (n = 4; 3%), and the program being stopped (n = 2; 4%). Respondents also indicated positive effects, such as lower census, allowing more time for nurses to provide positive sensory exposures (n = 1; 1%); increased parental involvement because of parents having to stay on the unit (n = 1; 1%); and use of the SENSE program to increase communication with parents and compensate for the low parent presence or visitation during this period (n = 2; 2%).
Discussion
The key findings of this study were that the SENSE program was deemed an acceptable intervention in the NICU, with a strong desire among respondents to implement the program. Neonatal therapists were identified as the ones who most often introduced the program and drove its success. Barriers and facilitators to implementation were identified. Among those who had implemented the program, quick timing of implementation (<1 mo) was reported with quick spread of the programming to most of the NICU. Adaptations that facilitated implementation were reported. Minimal extra staff time and cost were incurred with the introduction of the program. This information has been used to optimize the SENSE program and administration materials, with suggestions provided to NICUs to facilitate implementation across sites (Pineda, Kellner, Ibrahim et al., 2023).
Acceptability of programming is an important component of implementation science. The theoretical framework of acceptability defines acceptability as “a multi-faceted construct that reflects the extent to which people delivering or receiving a health care intervention consider it to be appropriate, based on anticipated or experiential cognitive and emotional responses to the intervention” (Sekhon et al., 2017, p. 1). Although this metric is collected from individual stakeholders, often by surveys, its collective metric can be considered in context of readiness for the organization to implement the intervention. Almost all (99%) of the respondents indicated that the SENSE intervention is acceptable for implementation with high-risk infants in the NICU and that the SENSE program is a beneficial intervention for the infant. This is the first study, to our knowledge, to attempt to assess perceptions of the SENSE program by health care professionals who have obtained the program, implemented it, or both. This builds on a growing body of research that evaluates the acceptability of developmental care interventions in the NICU (Feeley et al., 2016; Pierrat et al., 2016; Richter et al., 2022; Zhang et al., 2016).
Identifying staff to administer the program is an important component related to implementation success. Among those who had implemented the program, most (83%) reported that the program was being administered primarily by a neonatal therapist (specifically, a occupational therapist, physical therapist, or speech-language pathologist in the NICU). Although 5 respondents (9%) reported that nurses administered the program, initial focus groups with nurses during the development of the program indicated that administration of such a program fell outside the typical roles and time commitments of nursing staff (Pineda, Roussin, et al., 2018). Neonatal therapists are in an optimal position to administer the program because of their knowledge about infant and family outcomes, their ability to read and respond to behavioral cues, and the overlap with interventions they are already facilitating at the bedside. However, nurses who assume clinical educator or developmental specialist roles may have more dedicated time to administer the SENSE programs. It is unknown, but may be likely, that nurses in those types of roles are the people who completed this survey and who function as SENSE administrators.
Fifty-three percent of the respondents had implemented the SENSE program at the time of the survey. Reasons for not implementing the program included COVID-19 pandemic restrictions, staffing challenges, lack of team buy-in, challenges with staff education, lack of funding, lack of time, need for additional resources (i.e., lux and sound meters, general resources), and changes within the unit (e.g., staff turnover, moving units). Many hospitals that had started the process of implementation had to put things on hold because of staffing shortages and restrictions of parent and volunteer visitation related to the pandemic. This is consistent with other literature that reported less adherence to policies that preserved parental presence, as well as literature that reported reductions in staffing during the COVID-19 pandemic that affected care (Darcy Mahoney et al., 2020).
Among those who had succeeded with implementation, 31% reported quick timing of implementation (<1 mo). However, other comments indicated the need to plan and time the new program implementation carefully and appropriately. Some respondents also reported that it was beneficial to stage small changes before fully ramping up the whole SENSE program. Small progress toward full implementation can prevent feelings of being overwhelmed, which can lead to intervention abandonment (Damschroder et al., 2009). Therefore, small changes leading up to the larger whole appeared to be an important part of SENSE program initiation.
Barriers to SENSE program implementation were identified on both the individual (parent) level and the organizational (NICU or hospital) level. At the individual level, finding ways for the parents to access the educational materials was identified as a common challenge. Lack of overlap between staff and parent presence on the unit was cited as the most common barrier to educating parents about the SENSE program. At the organizational level, getting the whole team involved and resolving staffing or workflow issues were the most common barriers to implementation. Facilitators at the individual level included taking more time with parents and initiating education for families early during hospitalization to encourage visitation and involvement. Facilitators to SENSE program implementation at the organizational level included rolling out implementation in small pieces, focusing on parent education, and getting team buy-in by educating staff across all health care disciplines. Presentations to leadership and management and NICU staff further facilitated program implementation on the hospital or NICU level.
Adaptations of interventions in the real-world context are an important component of implementation. Adaptations can be proactive or reactive, semipermanent or temporary. They can vary in scale and magnitude and affect fidelity while allowing for the evolution of content to address the contextual and cultural needs of new populations and settings (Escoffery et al., 2018). Among 42 respondents who had implemented the SENSE program, 33% indicated that they had adapted the SENSE program. Most commonly, the goals of the adaptations were related to aligning the program with NICU culture. Individual hospitals reported modifications to SENSE program recommendations (i.e., removing blanket holding, not recommending cycled lighting, not using rocking chairs) because of restrictions in what their specific units had available or their unit’s beliefs (as in wanting to promote skin-to-skin care over blanket holding). However, 67% (n = 28) reported using the SENSE program without adaptations. This proportion of adaptations is consistent with other reports, such as that of Escoffery et al. (2018), who found that more than half (62%) of 42 distinct, evidence-based, public-health interventions required adaptations to content, context, cultural modifications, and delivery before implementation within the United States. When asked whether adaptations changed the dosages of the sensory interventions in the program, 44% of the respondents indicated that they did not know. This is a crucial question related to fidelity of the intervention; a better definition of factors that can be adapted (but that do or do not change the dosage of the intervention) is needed.
The cost and resources required, including staffing, are frequently reported factors for the successful implementation of health care interventions (Geerligs et al., 2018). In a systematic review of staff-reported barriers and facilitators to implementation processes, staff workload and lack of time for program implementation were the most commonly cited barriers (Geerligs et al., 2018), which is consistent with our survey results. Support for programs on the organizational level has been identified as an important facilitator to overcome this barrier (Rankin et al., 2015), which was also reported in our survey results. Interventions with greater costs and resources required (in terms of work, time, and stress) can have a negative impact on program acceptability (Pace et al., 2002). Thus, the minimal costs associated with the SENSE program, as reported in the survey results, are likely a driving factor in the high levels of acceptability reported among respondents.
There were limitations to this study. The survey identified the perceptions, rather than the real-world observations, of health care professionals and did not query with regard to parent or volunteer perceptions of the program. The survey was lengthy, and it is unclear whether a smaller number of questions may have increased participation. Although the research team conducted a systematic process for survey question development and pilot testing, the survey is newly developed, and its psychometric properties are not yet formally assessed. The length of the survey, in an attempt to be comprehensive in nature, may have led to fatigue. Furthermore, this study was limited to the first 211 hospitals that obtained the program (before March of 2020), and it may not represent the experiences of the more than 400 hospitals that have now purchased it, or the perceptions after the pandemic restrictions were lifted. Although hospitals were only included if they obtained the SENSE program before COVID-19 isolation, the survey was administered during such restrictions. Notably, although the survey was only sent to hospitals that purchased the program before March 2020, 9 respondents indicated that they obtained the program in 2021. This may reflect the delay that often occurs between the purchase at the hospital level and the implementation on the NICU level, as well as differing interpretations of the word obtain. It may also reflect the nature of this time period during the height of the COVID-19 pandemic, when hospitals were undergoing significant upheaval and structural and policy changes that affected program implementation on many levels. It also highlights the possibility of inaccurate recall, which can be problematic in survey research. Although this study is an initial descriptive report of implementation of the SENSE program, there are many opportunities for further analysis. These include evaluation of the differences among those who implemented the program before and after the COVID-19 pandemic, as well as among hospitals located outside versus in the United States, and identification of hospital characteristics that may relate to differences in implementation strategies as well as success. Further qualitative analysis of open-ended responses could also enhance our understanding of implementation.
Implications for Occupational Therapy Practice
The SENSE program requires someone to administer it, and occupational therapy was noted to be one of the most common disciplines to implement it. Neonatal therapists, including occupational therapists, can use findings from this investigation to understand and inform their own implementation of the SENSE program to optimize the early environment and improve outcomes of high-risk infants and families. NICU practitioners found the SENSE program to be acceptable and feasible to implement. This study has the following implications for occupational therapy practice: ▪ The time to implementation (<1 mo) and spread to most of the infants in the unit (within 6 mo) was quick for most participants. ▪ No additional staff needed to be hired. ▪ There were minimal additional costs, beyond purchasing the SENSE license. ▪ Providing education sessions to other NICU providers (such as nurses and doctors) can increase buy-in and ease transition to using the program. ▪ The program can be adapted to meet the needs of the infant, family, or unit culture and policy.
The information from this article can be used to better understand factors related to initiating the SENSE program to guide occupational therapists and other clinicians in its implementation.
Conclusion
Understanding barriers and facilitators to SENSE program implementation, as well as exploring the adaptations that have been made to the program to help it fit a worldwide audience, has helped inform changes to the program and modifications to the educational tools used to help hospitals implement the program at the organizational and individual levels. This study reports information that can be valuable for hospitals to benchmark against as they seek to roll out the SENSE program, and the findings can aid in local implementation strategies.
Footnotes
Acknowledgments
We thank members of the NICU Therapy Lab, especially Marinthea Richter, Prutha Satpute, Erica Gliga, Kelly Deng, and Brittany Ngo, for their work on developing the survey and analyzing the data. We are also extremely grateful to the clinical providers, who generously donated their time to complete this comprehensive survey.