Strategies, Shifts, NICU Blues


Rank: 183  –Rate: 5.1%   Estimated # of preterm births per 100 live births 

(USA – 12 %, Global Average: 11.1%)

Ecuador, officially the Republic of Ecuador, is a country in northwestern South America, is bordered by Colombia on the north, Peru on the east and south, and the Pacific Ocean on the west. Ecuador also includes the Galápagos Islands in the Pacific, about 1,000 kilometers (621 mi) west of the mainland. The country’s capital and largest city is Quito.

The sovereign state of Ecuador is a middle-income representative democratic republic and a developing country[19] that is highly dependent on commodities, namely petroleum and agricultural products. It is governed as a democratic presidential republic. The country is a founding member of the United NationsOrganization of American StatesMercosurPROSUR and the Non-Aligned Movement.

Ecuador currently ranks 20, in most efficient health care countries, compared to 111 back in the year 2000.  Ecuadorians have a life expectancy of 77.1 years. The infant mortality rate is 13 per 1,000 live births,  a major improvement from approximately 76 in the early 1980s and 140 in 1950. 23% of children under five are chronically malnourished. Population in some rural areas have no access to potable water, and its supply is provided by mean of water tankers. There are 686 malaria cases per 100,000 people. Basic health care, including doctor’s visits, basic surgeries, and basic medications, has been provided free since 2008. However, some public hospitals are in poor condition and often lack necessary supplies to attend the high demand of patients. Private hospitals and clinics are well equipped but still expensive for the majority of the population.

Between 2008 and 2016, new public hospitals have been built, the number of civil servants has increased significantly and salaries have been increased. In 2008, the government introduced universal and compulsory social security coverage. In 2015, corruption remains a problem. Overbilling is recorded in 20% of public establishments and in 80% of private establishments.

Source:Ecuador – Wikipedia


New recommendations from WHO to help improve the health of preterm infants

30 September 2022            


Preterm birth is the leading cause of death in newborns less than 28 days old with more than a million preterm infants dying each year. Those that do survive risk a range of disabilities throughout their lives. Alarmingly, in almost all countries with reliable data, preterm birth rates are increasing.

In order to improve the health outcomes for these newborn babies, the World Health Organization has issued updates for two interventions. One set of recommendations focuses on the use of antenatal corticosteroids. These drugs cross the placenta and enhance the structural maturity of the fetus’ developing lungs, helping to prevent respiratory-related morbidity and mortality in preterm newborns. 

Safe and effective for use in low-income countries

This recommendation (and its nine sub-recommendations) resolves previous confusion about evidence on their use in low-resource settings. Clinical trials in high-resource settings suggested that antenatal corticosteroids were safe and beneficial to newborn outcomes. The Antenatal Corticosteroids Trial in lower-income countries however found a significant increase in the number of perinatal deaths (5 excess deaths per 1000 women exposed to the treatment) and maternal infections. A subsequent trial (WHO ACTION-1) also in lower-income countries found that under the right conditions, antenatal corticosteroids were safe and effective.

New recommendation on tocolytic drugs

Another new WHO recommendation out today, is for the use of tocolytic treatments.  Tocolytic drugs inhibit contractions of the uterus and can be used to delay preterm labour and prolong pregnancy. This has multiple benefits; giving more time for fetal development, and for administering antenatal corticosteroids. It also creates a window of time for women to be transferred to a higher level of care, if necessary. 

“These recommendations provide clear guidance to health professionals on the management of preterm birth and have the potential to improve the health of newborn babies, even in low-resource settings.” Dr Doris Chou, Medical Officer, Department of Sexual and Reproductive Health and Research.

In the 2015 WHO recommendations on interventions to improve preterm birth outcomes, tocolytic treatments (acute and maintenance treatments) were not recommended for women at risk of imminent preterm as there was insufficient evidence demonstrating substantive benefits. A review of the evidence in 2022, however, has recommended in favour of nifedipine for acute and maintenance tocolytic therapy for women with a high likelihood of preterm birth, when certain conditions are met.

In formulating these recommendations, WHO, in addition to considering the clinical evidence also considered aspects of cost-effectiveness, feasibility and resources, equity and whether the intervention was valued by and acceptable to stakeholders including clinicians as well as women and their families.

Useful links- WHO recommendations

Global trends in preterm birth from 1990-2019


In a recent study from China, data from the 2019 Global Burden of Disease study have been analysed to show trends in preterm birth. Deaths and incident cases decreased globally, but on a regional and national level, preterm birth rates also increased.

Preterm birth is a global issue. Almost 15 million infants were born too soon (preterm) in 2014, with a global incidence rate of 10.6%. Despite improvements in medical care, increases in preterm births were also observed in high-income countries, as for example in the USA. Due to the higher risk of infections and other complications, preterm birth is still the leading cause of death in children under five years.

Cao et al. have analysed global trends from 1990 to 2019 regarding the occurrence and death rate in preterm born infants. For this purpose, the researchers used data from the 2019 Global Burden of Disease study. Amongst others, the yearly rate of preterm birth cases and deaths was analysed, together with age-standardised incidence rates (ASIRs: expected disease rate in a certain time period in a reference/standard population) as well as age-standardised mortality rated (ASMRs: weighted average of the age-specific mortality rates per 100 000 persons).

Globally, the good news is that the rate of preterm birth has declined by about five percent (16.06 million in 1990) to 15.22 million in 2019. Also, fewer deaths of preterm newborns could be noted; a reduction of even 48% from 1.27 million (1990) to 0.66 million in 2019.

Interestingly, the findings were also compared according to the socio-demographic index (SDI), which shows the development status of a region and is strongly related to health. It was found that regions with a high SDI show a decrease in incident cases of preterm births by about five percent. Also, the number of deaths of preterm born newborns halved in low-, middle-, middle-high-, and high-SDI regions.

Across all global burden of disease regions, the largest decrease in incident cases and deaths could be noted in East Asia. On a national level, one third of all global incident cases, in absolute numbers, accounted for India (3.10 million) and Pakistan (1.04) in 2019. The most striking increase in preterm birth rates, however, was noted in Niger (182.10%), together with the highest increase in preterm birth related deaths (105.52%). In Greece, the highest increase of age-standardised incident rates could be observed.

Finally, the overall decrease in global incidence and mortality of preterm born children can be explained by improvements in medical care and a better general health status. However, incidence of preterm birth has increased in some countries, also high-income ones. Possible explanations could be higher rates of multiple births, delayed parenthood and other changes in clinical practices. Further research is needed to find the underlying reasons and measures to prevent preterm birth worldwide. 

Paper available at:

Paulina Aguirre – La Tierra Llora

218,265 views  #latina #mujer #musica

Let Them Be Girls, and Not Mothers Before Time


Jenny Benalcazar Mosquera, Coordinator of the delivery room of the Obstetric Gynecology Hospital Isidro Ayora de Loja (Ecuador)

The World Health Organization (WHO) defines adolescence as the period between the ages of 10 and 19 years, a time of life characterised by growth and development. In my country, Ecuador, 12% of girls in this age group have had a child or at least one pregnancy—the highest rate of adolescent pregnancy in South America. According to the statistics published by Ecuador’s National Institute of Statistics and Census (INEC), 49.3 of every 100 live births in the country involve adolescent mothers. These statistics are cause for concern.

Equally worrying is the fact that over the last decade we have seen a 78% increase in births among girls in the 10 to 14 year age group and an 11% increase in motherhood among girls aged between 15 and 19 years. According to the National Sexual and Reproductive Health Plan, Ecuador has the third highest rate of adolescent pregnancy in Latin America and the highest in the Andean region, surpassed only by Nicaragua and the Dominican Republic.

Over the last decade we have seen a 78% increase in births among girls in the 10 to 14 year age group and an 11% increase in motherhood among girls aged between 15 and 19 years.

Sexual and reproductive health rights imply guaranteeing girls and women safe and effective control of their own fertility, enabling them to decide how many children they want and when they have them, facilitating access to contraception and other family planning methods. Access to family planning has improved over the last two decades in Ecuador, but gaps still exist between different social, ethnic, and age groups.

According to research carried out for UNICEF by the Observatory for the Rights of Children, 50% of indigenous adolescents do not complete their basic education, and this figure is higher among girls who become pregnant. Consequently, these adolescent girls are less likely to be integrated into the educational system and improve their living conditions than their non-indigenous peers. From childhood, these children grow up in poverty and inequality and live in a culture of punishment, especially in the provinces of the Ecuadorian Highlands (Chimborazo, Cotopaxi and Imbabura).

Sexual and reproductive health rights imply guaranteeing girls and women safe and effective control of their own fertility, enabling them to decide how many children they want and when they have them, facilitating access to contraception and other family planning methods.

Even though they may know something about contraceptive methods, in most cases they do not use them. However, the main cause of adolescent pregnancy continues to be sexual abuse and violence, which affects 42.7% of adolescents. In more than half of all cases (55%) this sexual violence occurs within the family circle. The national survey of family relations and gender violence against women carried out by the INEC estimated that 60.6% of women in the country have experienced some kind of gender violence (physical, psychological and/or sexual).

Pregnancy in adolescence is associated with serious health effects as well as economic and social repercussions. For example, while the school dropout rate in Ecuador has fallen (and pregnancy is the cause in only 2.8% of cases), the number of pregnancy-related deaths has increased by 2.5% among adolescent girls (aged 10 to 19 years).

Pregnancy in adolescence is associated with serious health effects as well as economic and social repercussions.

The available data are essential to inform decisions on public policy relating to the present adolescent population. After two decades marked by an increase in adolescent fertility, during which profound gender gaps have persisted, the challenge for the state as well as for international and local organizations working in the field of reproductive health is to prioritise strategies aimed at avoiding or postponing motherhood in the adolescent population. Indispensable prerequisites to progress include strengthening the state and the role of public institutions, especially by way of the National Plan for the Eradication of Gender Violence Against Children, Adolescents and Women—a comprehensive plan that addresses the problem of violence—and by implementing the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030).

Among the interventions announced in July 2018, the Intersectoral Strategy for the Prevention of Pregnancy in Girls and Adolescents 2018-2025 is of particular interest. This strategy will involve the cooperation of four ministries: Health, Education, Justice, and Economic and Social Inclusion. The strategy will work towards ensuring universal access among adolescents to sexual and reproductive health information, education and services, with a view to giving young people the freedom to make their own decisions; facilitating access to contraception will also be a priority. The ultimate goal is to achieve the targets for adolescent health defined by the WHO’s Global Strategy.

To reduce adolescent pregnancy rates, Ecuador must successfully tackle major challenges. Early pregnancy is a problem with serious implications for the present and future of girls and adolescents. Beyond that, it is a problem that affects not only young mothers but also the country as a whole because it is a determining factor in the intergenerational cycle of poverty.


Hospital System Saw Fewer Attacks From Patients With New Crisis Strategies

Emergency response teams, de-escalation training likely contributed to dip in violence by Randy Dotinga, Contributing Writer, MedPage Today October 21, 2022

LONG BEACH, Calif. — A Pittsburgh-based hospital system has seen a rapid decrease in violent attacks by mental health patients against staff members, a psychiatric nurse told colleagues here.

From 2020 to 2021, reported violence at Allegheny Health Network facilities fell by 20%, and reported cases of staff being struck by combative patients dropped by 29%, reported Jamie Elyse Malone, MSN, RN, during a presentation at the American Psychiatric Nurses Association annual meeting.

These improvements are likely due to a series of strategies such as emergency response teams, the flagging of violent patients, and crisis intervention training, she noted.

“We’ve seen really positive results from all these different initiatives,” Malone said. “We can’t say there’s causation from the data, but it looks like they really work.”

Any reduction in workplace violence against healthcare workers would make Allegheny Health’s hospital system an outlier. According to a report from earlier this year by the Joint Commission, “U.S. healthcare workers in the private sector are 5 times more likely to experience nonfatal violence-related injury compared to workers in all other private industries combined.”

Violence rates at general hospitals have doubled since 2011, and “overall, nearly three-quarters of all violence-related nonfatal injuries and illnesses in 2018 were incurred by healthcare workers,” the report noted.

While data are sparse, surveys have also suggested that violence against healthcare workers has increased during the COVID-19 pandemic.

A 2018 survey of 990 Allegheny staff members found that only 24% said they reported cases of workplace violence, with 74% reporting that they were instructed to do so. Only 11% said they felt prepared to deal with aggressive/violent behavior. “We realized that we needed to change in order to better protect our team members, patients, and visitors,” Malone said.

Subsequently, the hospital system developed a centralized police force with sworn officers, and spent the next several years developing other strategies to address violence.

Crisis response teams are now in place and led by clinicians with de-escalation training. Depending on availability, the teams can include security/hospital police, behavioral health staff, physicians, and hospital managers. In addition, “crisis response bags” are available that include tools such as “hard” restraints with keys, bite sleeves, spit masks, and towels, Malone added.

However, the protocol only calls for crisis teams to respond in the most severe situations, she noted. “Sometimes somebody might be yelling, they might be acting up a little bit, so you call the whole team to help and it just escalates the situation more,” she explained. “So we have four levels in our crisis response, which helps us get the appropriate response.”

The full crisis teams only respond at the highest two of the four levels when patients actually become physical/violent. “If there’s a threatening act — somebody with an IV pole trying to break a window, somebody’s trying to strangle a nurse — our police and security are trained to get into that room as quickly as possible,” she said.

Debriefing and reporting are important parts of the protocol, Malone noted, and have led to administrative action. “Because you reported that incidences of delirium have gone up, and they’ve caused 50% of our violent offenses in the last month, we’ve set up this whole program to help prevent delirium. That is the way we get staff to actually report — by being transparent with the data and letting them know how that has driven our initiatives and our processes to make things better,” she said.

Over the last 4 years, Allegheny Health has also created councils and committees devoted to preventing workplace violence, added metal detectors to emergency department entrances, conducted simulations, and adopted a violence prediction tool that provides risk notifications.

Patients at risk of being violent are now flagged in the EPIC system, Malone noted. “We wanted to make sure we very clearly but subtly communicated with our staff when a person is likely to become violent.”

Personal panic alarms are now available for staff members, along with specially designed pens and toothbrushes that prevent injury when wielded by a violent patient.

Over 3 years, more than 3,000 staff members were trained in de-escalation techniques, Malone reported, and evidence suggests that “calls for a crisis response appeared to decrease incidents of reported injury from violence.”

What’s next? Malone said she’s working on ways to keep hospital leaders focused on preventing workplace violence instead of letting their attention wander to other projects. “I also would really like to see us do a little bit better with reporting and find out how we can do more projects to continue to prevent violence. One of the big specialty projects that we hope to work on next is alcohol withdrawal. It’s a struggle at our hospitals, and we can do a lot better.”



How the mother’s mood influences her baby’s ability to speak

OCTOBER 07, 2022

Communicating with babies in infant-directed-speech is considered an essential prerequisite for successful language development of the little ones. Researchers at the Max Planck Institute for Human Cognitive and Brain Sciences have now investigated how the mood of mothers in the postpartum period affects their child’s development. They found that even children whose mothers suffer from mild depressive mood that do not yet require medical treatment show early signs of delayed language development. The reason for this could be the way the women talk to the newborns. The findings could help prevent potential deficits early on.

Up to 70 percent of mothers develop postnatal depressive mood, also known as baby blues, after their baby is born. Analyses show that this can also affect the development of the children themselves and their speech. Until now, however, it was unclear exactly how this impairment manifests itself in early language development in infants.

In a study, scientists at the Max Planck Institute for Human Cognitive and Brain Sciences in Leipzig have now investigated how well babies can distinguish speech sounds from one another depending on their mother’s mood. This ability is considered an important prerequisite for the further steps towards a well-developed language. If sounds can be distinguished from one another, individual words can also be distinguished from one another. It became clear that if mothers indicate a more negative mood two months after birth, their children show on average a less mature processing of speech sounds at the age of six months. The infants found it particularly difficult to distinguish between syllable-pitches. Specifically, they showed that the development of their so-called Mismatch Response was delayed than in those whose mothers were in a more positive mood. This Mismatch Response in turn serves as a measure of how well someone can separate sounds from one another. If this development towards a pronounced mismatch reaction is delayed, this is considered an indication of an increased risk of suffering from a speech disorder later in life.

“We suspect that the affected mothers use less infant-directed-speech,” explains Gesa Schaadt, postdoc at MPI CBS, professor of development in childhood and adolescence at FU Berlin and first author of the study, which has now appeared in the journal JAMA Network Open. “They probably use less pitch variation when directing speech to their infants.” This also leads to a more limited perception of different pitches in the children, she said. This perception, in turn, is considered a prerequisite for further language development.

The results show how important it is that parents use infant-directed speech for the further language development of their children. Infant-directed speech that varies greatly in pitch, emphasizes certain parts of words more clearly – and thus focuses the little ones’ attention on what is being said – is considered appropriate for children. Mothers, in turn, who suffer from depressive mood, often use more monotonous, less infant-directed speech. “To ensure the proper development of young children, appropriate support is also needed for mothers who suffer from mild upsets that often do not yet require treatment,” Schaadt says. That doesn’t necessarily have to be organized intervention measures. “Sometimes it just takes the fathers to be more involved.”

The researchers investigated these relationships with the help of 46 mothers who reported different moods after giving birth. Their moods were measured using a standardized questionnaire typically used to diagnose postnatal upset. They also used electroencephalography (EEG), which helps to measure how well babies can distinguish speech sounds from one another. The so-called Mismatch Response is used for this purpose, in which a specific EEG signal shows how well the brain processes and distinguishes between different speech sounds. The researchers recorded this reaction in the babies at the ages of two and six months while they were presented with various syllables such as “ba,” “ga” and “bu.

How the mother’s mood influences her baby’s ability to speak | Max Planck Institute for Human Cognitive and Brain Sciences (

Fortifying Family Foundations:Assistant Professor Ashley Weber’s intervention empowers parents to care for their premature infants

By Evelyn Fleider – July 20, 2021

Imagine you are a new mom or dad whose baby was recently born at fewer than 32 weeks old. Your infant needs weeks-long, round-the-clock support in the hospital, but you do not have the job flexibility that allows you to spend time there, a trusted sitter to care for your other child/children or reliable transportation to get you there. You are overwhelmed, emotional and missing out on critical moments at the hospital, when you could get to know your baby and learn to manage their complex care and needs.

Each year, about 100,000 U.S. women give birth to babies considered very or extremely premature who require long-term stays in a neonatal intensive care unit (NICU) and who are at a high risk of developing chronic conditions. But not all parents get the formal training they need to keep their child healthy, which can cause mental health issues for parents. To address the critical need for an effective, streamlined model of parent-driven care, Ashley Weber, PhD, RN, a practicing NICU nurse and assistant professor at the College, is piloting PREEMIE PROGRESS, a video-based intervention that helps parents understand, monitor and manage their infant’s care while in the NICU.

With the financial backing of a National Institutes of Health (NIH) grant, Weber and the College’s Center for Academic Technologies and Educational Resources (CATER) team designed and built the intervention to deliver education to overwhelmed, high-risk parents with low literacy and education through accessible, platformagnostic videos and optional worksheets. Parents can learn by watching the videos or completing worksheets
while doing laundry or caring for other family members at home. Specifically, PREEMIE PROGRESS provides family management skills including negotiated collaboration, care systems navigation, emotion control, outcome expectancy and more.

“Our mortality rates have significantly gone down over the decades, but long-term complications from prematurity have not changed,” Weber says.
“We need to decrease the stress and sensory stimulation that babies experience throughout their NICU stay. Also, research shows that babies do best when they’re with their parents.”

Although parent education interventions exist, socioeconomic barriers, such as the lack of mandated paid family leave in the U.S., often prevent parents from participating in these opportunities and learning about their baby’s complex care during their NICU stay. The need to return to work shortly after birth or lack of transportation to the NICU are some of the various obstacles that prevent parents from being able to focus on their baby’s health and deliver the majority of care in the NICU.

“If you can spend large amounts of time in the NICU, you get to learn; nurses educate you on the plan of care and you participate in rounds, getting to know your baby,” Weber says.

“I wanted to build an intervention that could help disadvantaged families learn outside of the NICU, so that when they are able to be in the NICU, they maximize that time and spend it caring for their baby as opposed to playing catch-up.”

Currently, Weber and her team are refining PREEMIE PROGRESS through iterative usability and acceptability testing. In October, they will start testing feasibility and acceptability of the refined intervention and study procedures in a pilot randomized controlled trial with 60 families over the course of two years. They anticipate the intervention will decrease parent depression and anxiety, increase infant weight gain and receipt of mother’s milk and reduce neonatal health care utilization. Weber then plans to submit a competitive R01 for additional funding to conduct an even larger trial.

PREEEMIE PROGRESS has been years in the making for Weber, who in 2018 worked with the College of Nursing’s instructional designers, technology specialists, videographers and graphic designers to create the first prototype. She hopes the project will eventually evolve into a collaborative partnership among NICUs in Cincinnati, Columbus and Cleveland to conduct research trials centered on improving family care.

Weber’s long-term goal is to become a leader in designing, disseminating and implementing sustainable family management programs to improve health outcomes in the NICU. Regardless of her success, she recognizes that the best thing she can do for her patients is to advocate for universal paid family leave, better childcare and transportation infrastructures.

“We can come up with all sorts of interventions for reducing parent and infant stress and changing the way providers deliver care in the NICU, but if a mom doesn’t have the money to pay for a babysitter so she can get to the NICU or doesn’t have paid leave and has to go back to work a week or two after birth, the chances of parent engagement in care are extremely low,” Weber says. “I hope that PREEMIE PROGRESS empowers families who are at a disadvantage through no fault of their own. We want to give NICU families skills they can use for a lifetime, but these broader public health policies to support the social determinants of family success are really needed in order to move family research forward in the NICU.”


Late Preterm Infants in the NICU – Tala Talks NICU

NICU Tala Talks

Welcome to Tala Talks NICU! In this video, we talk about late preterm infants (those born between 34 and 37 weeks gestation) and the 8 main reasons a late preterm infant would need admission to the NICU.

Joe’s Legacy: The Family Making A Difference For NICU Babies

#TheProjectTV #NICU #Fundraising  The Project

Three years ago, we introduced you to baby Joe Blackwell. Now, Joe’s legacy lives on with an annual spinathon to raise money for the Royal Hospital For Women’s newborn intensive care unit.


“NICU Blues”:A Novel Term for Common Parental Experiences

Beth Buckingham, Ph.D., HSPP, Grace LeMasters, Ph.D., MSN

Approximately one in ten babies will spend time in a newborn intensive care unit (NICU).  Studies indicate that preterm birth significantly contributes to infant morbidity and mortality. Though mortality rates have been declining for preterm infants, there remains a significant percentage of infants born at the earliest gestational age who die in the NICU. Regardless of gestational age or medical diagnosis, NICU parents often fear their baby’s neonatal death or severe morbidity. There commonly exists some level of acute disorienting parental distress.

A single definition of parental distress in the NICU does not exist.  A novel non-pathological term, “NICU blues,” is proposed to identify common parental experiences specific to the newborn intensive care unit. Giving a name to “NICU blues” for parents provides optimal understanding, relief, and meaning for parents and caregivers moving through a unique NICU journey. Over several years, confidential comments were collected by the principal author from parents with newborns in a Level III family-centered care NICU. These condensed comments, shown in quotes, are many shared voices of pain, including reflecting parental narratives used in developing the term “NICU blues” Parents in the NICU described numerous symptoms of psychological distress not fully meeting specific pathological psychiatric diagnoses in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5). However, the clinical reflection of these vulnerable expressions of NICU parental distress helped us formulate the proposed conceptualized term “NICU blues” to shape those collective narrative stories.

Parental “NICU blues” are defined by the intersection of four factors in figure 1: NICU trauma, baby blues, postpartum mood and anxiety disorders (5), and NICU grief. NICU blues may contain varying levels of these four factors. Both parents are included in this biopsychosocial, transitory, and non-pathological model of predicted cogent symptoms in the NICU. NICU blues normalize feelings of being out of control emotionally and behaviorally with responses and experiences for any parent in the NICU. The concept of NICU blues sets an initiative-taking stage for the healthcare professional to offer adaptive coping responses and interventions within the NICU setting. Parents were suffering from extreme emotional pain, a sense of hopelessness, and despair in response to a potential NICU death or long-term morbidity of their newborn we view as an expected and understandable transitory state of parental functioning. The proposed term “NICU blues” gives voice to the logical collective voices of “feeling like I am crazy and losing my mind.” Hence, we define “NICU blues” as a condition unique to the NICU setting that includes common emotional and behavioral responses to a succession of abnormal parenting events and experiences. These responses include parental guilt, specifically maternal guilt as it relates to pregnancy loss and the baby’s NICU admission, father’s guilt as it relates to not protecting his family from the NICU stay, negative cognition and mood, decreased interest, anger, concentration problems, sleep disturbances, and struggles to experience positive emotions.

NICU blues provides a paradigm for validating parental adaptation experiences within a NICU setting and is viewed similarly to the transitory phenomena of matrescence described by anthropologist Dana Raphael.  Maltrescence is a typical physical, emotional, hormonal, and social process of transitioning into motherhood. In this sense, NICU blues is a typical process of psychosocial adjustment into parenthood occurring within the NICU. The term NICU blues normalizes perceived “out of control and helplessness emotions,” but with awareness and interventions, these emotions can transition to periods of adaptation.

Parents in the NICU need a meaningful relationship with their baby to establish a sense of parenthood, and their baby needs parental contact for optimal physiologic and psychoemotional development. Parents in the NICU often feel an additional layer of angst and guilt with physical separation from their baby. Research documents the interrelationships between NICU parents’ mental health on the functioning of their infants’ physical and psychological development.

Postpartum mothers in the NICU may try to numb the intense emotional pain of “not wanting to deal with the possible mortality of their precious long, imagined baby.” Fathers in the NICU may experience a sense of panic and doom with potential mortality for their partner and his baby, “I’m going to lose my entire family.” Parents often spend infinite initial hours in the NICU without regard for their own needs, “wanting a parent to be with the baby if they die.” This perception, real or imagined, adds to the NICU blues. Often, the father may undertake to stay in the NICU as the mother cannot leave the postpartum floor until physically mobile. The father may or may not be able to express feeling alone and isolated without his partner.

Most research on NICU parents has focused on the high prevalence rates of postpartum mood and anxiety disorders (5) and post-traumatic stress disorder (PTSD). We strongly support the National Perinatal Association (NPA) 2015 recommendations for universal screening and treatment protocols for both parents in the NICU to identify mental health challenges. Studies reveal elevated levels of depression, anxiety, and trauma symptoms shortly after their baby’s birth. Without screening and identification of common parental distress, we will be unable to support the mental health needs of our parents in the NICU as partners in their newborn care. 

We propose a novel term, NICU blues, for consideration by the NICU team within an ongoing supportive relationship with our parents. Identifying and treating complex emotional and mental health needs, such as NICU blues, provides parents in the NICU with additional consideration for robust universal standards of family-centered care. Figure 1 captures the interrelationship of clinical factors, including NICU trauma, baby blues, postpartum mood and anxiety disorders , and NICU grief, to identify a theoretical construct of a transitional, typical, and expected “NICU blues” paradigm.

NICU Trauma:

Considerable evidence exists that both parents in the NICU are at risk for psychological symptoms from traumatic birth events, including acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). We suggest that NICU psychological trauma symptoms may overlap with clinical symptoms in addition to and separate from NICU blues in Figure 1. There exists an intersection of NICU trauma symptoms, including actual or threatened mortality and morbidity for the baby or mother, with symptoms of NICU blues. Parents in the NICU may have the perception and experiences birth trauma events without meeting DSM-5 diagnostic criteria. In this sense, our psychological approach is expanded beyond the narrow psychiatric diagnosis focused solely on ASD or PTSD. In our clinical experience, NICU blues symptoms for parents include attributions of self-blame for their baby’s NICU admission, guilt, fear/horror, feeling detached from self and others, avoidance behaviors from the NICU, decreased parental involvement with their baby, struggles to focus while in the NICU and sleep disturbance.

A parent in the NICU needs a meaningful, loving, and nurturing relationship with their baby. In Ainsworth and colleagues’ classic maternal attachment studies,(10) maternal attachment involves physical and psychological accessibility. Parents of babies in the NICU are largely limited from these crucial parental attachment behaviors. Bonding may be at risk. As mothers may be recovering from a traumatic delivery, fathers may typically be the first visitor to the NICU.

Qualitative research identifies themes for fathers in the NICU. . Fathers may believe they need to be stoic for their family, often hiding feelings of anxiety, fear, helplessness, disconnection, powerlessness, and being out of control. They encompass charting unfamiliar waters, including being the backbone of the family, shouldering heavy responsibilities alone, being torn between his partner and baby in the NICU, and the unexpected journey as an active and possibly only participant.  Parents may question how their involvement and participation in the NICU is important in seeing nurses and others fulfill their caregiving roles.

Trauma during a newborn’s medical stay is now considered an adverse childhood experience (ACE). Toxic stresses or adverse childhood experiences are strongly linked to poor health outcomes. For optimal physiologic and psychoemotional development, a baby may need buffering protection from a lack of parentally connected caregiving. The dearth of physical and emotional closeness between infants and their parents and parental distress can negatively affect the relationship and the infant’s developmental outcomes. Research links possible long-term protective factors for parents who participate in NICU infant care.

Psychosocial education and intervention using the paradigm of the NICU blues are paramount at these initial stages for normalization and validation that these distressing thoughts and feelings are common for most parents in a NICU setting. Unique clinical themes and identification of NICU blues provide parents with alternative schemas for assimilation and adaptation.

Discussion of NICU blues normalizes parents’ turmoil as understandable and predictable within the NICU. Early attunement and co-regulatory caregiving are the foundation for attachment and bonding. We provide a new lens of parenting in the NICU with these caregiving-bonding discussions. In highlighting NICU blues, parents are more apt to discover “what’s lovely about their baby at this moment” apart from the barrage of NICU equipment and stressful environment. Normalization of NICU blues promotes parental discovery of their baby’s physical and emotional nuances.

Parents often need a pause for adaptation from the many successive invasive medical procedures with their babies. With this conversation of NICU blues, parents have reported a much greater understanding of commonly shared universal NICU trauma reactions. With ongoing discussions by the staff of NICU blues, parents gain some psychological distance from their trauma symptoms, reporting greater acceptance, psychological flexibility, and adaptation for continued engagement in the NICU. In our clinical experience, identification of NICU blues sets a family-centered stage for later engagement with parents for other bedside compassionate family-centered interventions and connection between staff and parents in the NICU.

Baby Blues and Postpartum Mood and Anxiety Disorders: Baby blues, also known in the literature as postpartum blues or postnatal blues (with these latter terms excluding the father), is a mild transient disruption of mood occurring several days following delivery. It is imperative for NICU psychologists and medical and nursing staff to help parents make sense and meaning of their initial distress specific to identifiable physical changes, situational stressors, and loss . Parents often express relief in knowing that predictable NICU blues may be additive to or better explained to both parents than the term baby blues in addition to hormonal changes.

Parents in the NCIU report that discussion of possible NICU blues around admission to the NICU gives them a sense of hope and being understood. Our clinical impression is that this initial connection with parents in the NICU gives clarity to an internal disruption not fully understood. Perhaps with this safe therapeutic, nourishing NICU staff-parent connection, parents may be better able to bond with their babies. In our discussion of NICU blues with parents, relationship building for parent-child bonding and meaningful parent-NICU staff communication begins another positive launch for family-centered care.

Baby blues is identified as one potential risk factor for postpartum depression. These authors posit that the risks of developing perinatal mood and anxiety disorder (PMAD) may be lessened or eliminated when identifying NICU blues or baby blues. Early parental psychological identification and intervention by the psychological, medical, and nursing staff is key. Research studies indicate that both parents of babies in the NICU are at risk for postpartum depression and anxiety. There currently does not exist a DSM-5 diagnosis specific to postpartum depression. There is a specifier of “with peripartum onset” with symptom onset during pregnancy or in the four weeks following delivery, with the focus generally on the mother.

PMAD symptoms fail to voice the entire story of NICU parents. Underlying parental NICU distress reveals clinical themes. Using a 4-stage model by Beck, research authors identify maternal loss of control as the underlying problem with a NICU postpartum depressive experience. Beck identified a 4-stage process termed “teetering on the edge” between sanity and insanity with stages of encountering terror, dying of self,  struggling to survive, and regaining control. The author described stages with four identifying themes: incongruity between expectations and the reality of new motherhood, a spiraling downward process, pervasive loss, and making gains. Like Beck’s proposed process of “teetering on the edge of insanity,” parents in the NICU express “a sigh of relief knowing sanity exits and feelings expected within the term NICU blues.” 

A Father’s expectations of ideal fatherhood may, too, be affected by the fears and challenges of parenting a medically fragile baby in the NICU and supporting a mother who is not coping well. (20) Themes of loss fill the NICU room with both parents experiencing the loss of the “perfect” birth to the shocking experiences of seeing their fragile baby for the first time, often with tubes that may affect parental identity and self-esteem. Paternal feelings of helplessness may be incredibly overwhelming.

Parental suffering is often silent. NICU parents may encounter various symptoms, including NICU blues, baby blues, or PMADs. In our clinical experience, parents present with some level of emotional and behavioral NICU distress. They commonly experience an intrusive cognitive disruption to their expected and perceived positive parental role. 

Parents often experience elevated levels of negative self-blaming and misattributions for the baby’s NICU admission exacerbating parental guilt. Dreams of completing a term pregnancy, of expecting a typical delivery complete with physically holding your baby in the delivery room, are abruptly crushed. Multiple losses for any NICU parent are monumental. Parents do not dream of finding themselves as a family in a NICU. As staff present to parents the clinical term NICU blues as a common reaction to their loss of anormal newborn experience, they often feel understood and comforted. In ruling out psychiatric pathology, NICU blues provides an intersecting paradigm of composite reactions, including baby blues and postpartum mood disorder, guilt, sadness, and feelings of parental worthlessness.

NICU Grief:

Parents in the NICU may experience an avalanche of immense losses accompanied by grief associated with those losses. Significant losses for parents may include sudden pregnancy termination, medical complications, loss of anticipated motherhood and fatherhood roles, and loss of hopes and dreams of a highly anticipated future with a healthy full-term baby coming home shortly after delivery.

Symptoms of NICU blues for parents may be further conceptualized within Kubler-Ross’s model of grief and loss. Those stages include shock/denial, anger, bargaining and self-blaming, depression, and acceptance with the recent inclusion of an additional newly defined stage, meaning. Overlap of NICU blues symptoms with stages of Kubler-Ross’s model of grief exists. As Kubler-Ross’s model reflects, these symptoms of grief are experienced in stages without the nuance of diagnostic pathology. Considerations for different cultural, ethnic, and races may also affect expressions of grief and stressors within the NICU setting.

These disorienting grief responses may disrupt parental NICU involvement in baby care bonding behaviors. Parents may further isolate themselves from family and peers, intensifying experiences of NICU blues. This withdrawal from meaningful social support fuels feelings of helplessness and shame with possible stigma adding to their secret “of being different” from other parents leaving the hospital with healthy newborn babies.


Life in the NICU does not make sense. Many parents express negative self-blaming attributions for “causing” their baby’s NICU admission and stay. These parental experiences seem to coincide with feelings and thoughts of NICU blues. We suggest that parental expressions of grief, loss, and shame are strong predictive variables contributing to NICU blues. There is no clear clinical definition for the array of parental psychological distress unique to the NICU. Identifying the NICU blues seeks to add to the understanding of psychological distress as a common contextual response. Thus, parental adaptation to the NICU is viewed as adaptive versus non-adaptive. Awareness of these parental responses by NICU staff and early intervention can ease the experience of NICU blues, foster increased bonding between parent and baby, increase interactions among NICU staff and between staff and parents, and promote an overall more positive parental NICU experience. However, this new paradigm and theoretical concept “NICU blues” for parental distress, needs further empirical qualitative and quantitative evaluation to determine its efficacy and effectiveness for NICU family-centered clinical standards of care.


The Impact of Advanced Practice Registered Nurses’ Shift Length and Fatigue on Patient Safety

Position Statement #3076 – NANNP Council September 2022-  NANN Board of Directors September 2022

The National Association of Neonatal Nurse Practitioners (NANNP) and its members are committed to providing safe, ethical, and professionally accountable care. All healthcare professionals are affected by the challenges associated with role expectations and human performance factors. NANNP recognizes that fatigue, sleep deprivation, and the extended shift lengths or hours that neonatal nurse practitioners (NNPs) often work present potential safety risks for patients, providers, and employers.

As the professional voice of neonatal nurse practitioners, NANNP recommends that, regardless of work setting and patient acuity, NNPs’ maximum shift length in house be 24 hours, that a period of protected sleep time be provided following 16 consecutive hours of working, and that the maximum number of working hours per week be 60 hours. In addition, it is recommended that NNPs, their employers, and institutions collaborate to implement supportive risk-reduction strategies based on current evidence. This is in the best interest of patient safety and NNP health.

 Association Position:  Research addressing sleep deprivation, fatigue, and patient outcomes as related to nurses, and specifically NNPs, is limited. In addition, the uniqueness of the patient population and NNP responsibilities further complicate the delineation of strict scheduling limitations. Based on current evidence, regardless of work setting and patient acuity, (1) NNPs’ maximum in house shift length should be limited to 24 hours, (2) a period of protected sleep time should be provided to NNPs following 16 consecutive hours of working, and (3) the maximum number of working hours per week for NNPs should be 60 hours.

Furthermore, although healthcare providers are susceptible to the negative effects of fatigue and sleep deprivation, NNPs are professionally accountable and, as such, are responsible for minimizing any patient and personal safety risk.

Background and Significance: A number of healthcare organizations, both nursing and other disciplines, have adopted strategies to address concerns related to shift lengths and fatigue as well as the connection with risks to patients and care providers. Although no data exist to support an optimal shift length for the NNP, the safety of extended provider work hours for both the patient and the provider has been questioned in light of concerns raised by healthcare organizations and regulatory bodies (e.g., American Nurses Association [ANA], 2014; Texas Nurse Practitioners, n.d.; New York State Education Department Office of the Professions, 2021). NNPs have workflow patterns analogous to those of medical residents or fellows, flight nurses, and air medical staff (LoSasso, 2011). These healthcare providers are involved in direct patient care but not necessarily during their entire shift. Therefore, it is acceptable to examine published data from both nursing practice and other healthcare disciplines to provide a foundation upon which to form recommendations for shift length for NNPs.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) began limiting shift length and duty hours of residents and fellows, with revisions in 2011 and 2017. The most recent ACGME program revision took effect in 2017 and was based on stronger evidence than the earlier versions. The revision incorporated new language: “clinical and educational work hours” in place of “duty hours.” The limitation of no more than 80 hours per week, averaged over four weeks, was unchanged but clinical hour limits for first-year residents increased from 16 to 24 hours (ACGME, 2011 & 2017). The National Academy of Medicine (NAM), formerly known as the Institute of Medicine (IOM), has published guidelines and recommendations regarding nurses’ roles in the protection of patient safety and improved patient outcomes (IOM, 2004). The Agency for Healthcare Research and Quality (AHRQ) contracted with the IOM to study key aspects of the work environment of nurses as it relates to patient safety. Some of the pertinent issues that have risen to the federal and state policy arenas are extended work hours, fatigue, and mandatory overtime (Page, 2008).

The nursing practice of the certified registered nurse anesthetist (CRNA) has some general similarities to that of the NNP. Professionals in the two groups share the 3 hospital work setting, the need for immediate response time when on call, and long shift lengths. The American Association of Nurse Anesthesiology (AANA) is responsible for protecting and facilitating CRNA professional practice and patient safety. Anesthesia care requires continuous services and at times involves high acuity and intensity of care, which are known contributors to provider fatigue. AANA recommends shift-length guidelines based on variable settings, caseloads, and patient acuity (AANA, 2015). Included in a 2015 AANA document on the topic are considerations regarding minimum required sleep (7–9 hours), effect of circadian rhythm, scheduling in compliance with state and federal statutes and regulations, and the importance of monitoring safety recommendations from relevant organizations such as AANA, AHRQ, Institute for Healthcare Improvement, and NAM.

In the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion “Fatigue and Patient Safety” (2018), a minimum of 5 hours of sleep per night was recommended to help physicians communicate effectively (e.g., during handoffs, to patients). Additional recommendations included training faculty and providers to recognize signs of fatigue and sleep deprivation and the importance of balancing continuity of care and the need for rest.

Another professional organization that has addressed the issues of fatigue and shift length is the American Nurses Association (ANA). In its 2014 position statement on the topic, ANA recommends that registered nurses in all care settings perform no more than 40 hours of professional nursing work (paid or unpaid) in a 7-day period. In addition, employers should limit shifts (including mandatory training and meetings) to a maximum of 12 hours in a 24-hour period, including both on-call hours worked and actual work hours. The ANA document was written for registered nurses and employers but states that it is relevant to other healthcare providers who collaborate to create and sustain a healthy interprofessional work environment. The American Academy of Nursing on Policy described health and safety risks related to shift work, long hours, and worker fatigue in a 2017 position statement.

NANNP conducted neonatal nurse practitioner workforce surveys in 2011, 2014, 2016, and 2020. The most recent data (2020) revealed that most NNPs still work either 24- hour shifts (41%) or 12-hour shifts with day-night rotation (37%), but these numbers decreased from the 2014 data: when 50% of NNPs worked 24-hour shifts and 46% worked 12-hours shifts with day-night rotation. Although the 2020 survey data reflected that NNPs prefer the 24-hour shift, 77% of those responding do not have protected downtime during those 24 hours. The average age of the NNP workforce is unchanged from 2014 data, with more than 50% older than 50 years of age.

The most recent NNP workforce survey also revealed that 63% of respondents worked more than their scheduled hours (up from 33% in the 2014 survey) and that most NNPs have other duties in addition to those related to patient load during their night shifts. These other duties include delivery-room coverage (77%), ER emergencies (47%), Level I consultations (37%), maternal health consultations (36%), and transports (26%). Few NNPs who work night shifts get guaranteed downtime. For those who do, the 4 downtime averaged 3 hours per shift in 2014 (Kaminski et al., 2015). Less downtime was reported in Level IV neonatal intensive care units (NICUs). Forty-seven percent of NNPs report that their practice does not have enough staff. Ninety percent of NNPs spend more than 75% of their clinical practice time in the NICU, and the average work week is 37 hours (this number is higher in Level IV practices) (Snapp et al., 2021).

 The NNP role is a mainstay staffing option for many NICUs. Shift lengths for NNPs vary and are uniquely related to the dynamics of each NICU. Actual time spent providing patient care during prolonged shifts may vary, as do anticipated periods of rest (Snapp & Reyna, 2019). In addition, NNPs may be directed to work beyond their scheduled shift lengths to meet unexpected patient care needs or to satisfy organizational or practice expectations. There is limited data examining mandatory overtime, but it is clear that mandatory overtime presents a higher risk for work-related injury (e.g., needlesticks), illness, and missed shifts (Caruso, 2014). Only 18 of 50 states have legislation against mandatory overtime for registered nurses (WorkforceHub, 2018).

In December 2011, The Joint Commission (TJC) published a Sentinel Event Alert on the connection between healthcare workers’ fatigue and patient safety. It acknowledged research linking extended-duration shifts, fatigue, and impaired performance and safety. TJC suggested evidence-based actions to help mitigate the risks of fatigue resulting from extended work hours (2011), including:

● assessing the organization for fatigue-related risks, especially during patient handoff

● inviting staff input into designing work schedules to minimize potential for fatigue

● implementing a fatigue management plan that includes scientific strategies for fighting fatigue.

● educating staff about sleep hygiene and the effects of fatigue on patient safety

● providing opportunities for staff members to express concern about fatigue and taking actions to   

     address those concerns

● encouraging teamwork as a strategy to support staff who work extended shifts or hours and to

     protect patients from potential harm

● considering fatigue as a potential contributing factor when reviewing adverse events

● assessing the environment provided for sleep breaks to ensure it fully protects sleep.

In 2018, TJC issued an addendum to the 2011 document that adds a new resource, Fatigue and Patient Safety from American College of Obstetricians and Gynecologists (ACOG), and the 2017 ACGME updated program requirements. Some of the updated TJC suggestion actions were assessment of off-shift hours, handoffs, and staffing (2018).

The IOM (now NAM) has published papers on patient and personal safety as they relate to resident duty hours. In Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, the IOM cites prolonged wakefulness, shifts longer than 16 consecutive hours, the variability of shifts, and the volume and acuity of patient load as factors that increase 5 the risk of harm to patients (IOM, 2009). Additionally, prolonged work hours may result in harm to the provider and others. The risks of being involved in a motor vehicle accident after working more than 24 hours were explored by Johnson (2011). Residents who worked more than 24 hours had a 16% higher risk of having a motor vehicle accident post-call.

It is known that sleep deprivation slows reaction time and decreases the ability to concentrate, retain, and learn (Caruso, 2014). Another example is found in a New Jersey law that imposes penalties for reckless driving if the driver is experiencing sleep deprivation (LoSasso, 2011). The Centers for Disease Control and Prevention (CDC) reports that shift work is a cause of drowsy driving and that “being awake for at least 18 hours is the same as someone having a blood alcohol content (BAC) of 0.05%. Being awake for at least 24 hours is equal to having a BAC of 0.10%. This is higher than the legal limit (0.08% BAC) in all states” (CDC National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, 2017).

 Nursing research suggests that shift length affects vigilance and safety. Scott, Rogers, Hwang, & Zhang (2006) and Rogers, Hwang, Scott, Aiken, and Dinges (2004) conducted descriptive self-report studies and found statistically significant increases in errors and near errors when staff nurses worked shifts of 12.5 hours or longer. Caruso (2014) found that risks are 15% higher for evening shifts and 28% higher for night shifts when compared to day shifts. When compared with 8-hour shifts, 10-hour shifts increased the risk by 13% and 12-hour shifts increased the risk by 28%. Risk increased by 17% for the third consecutive night shift and 26% for the fourth. In 2011, Trinkoff et al. found a significant relationship between nurse work schedules and patient mortality. Scott et al. (2007) found a relationship between nurses’ work schedules, sleep duration, and drowsy driving that raised concerns for the safety of the nurses and the public.

Insufficient sleep is the critical link between work and fatigue (Akerstedt et al., 2004). Sleep deprivation, resultant fatigue, and interruptions in circadian rhythm are commonly experienced by nurses performing shift work (Peate, 2007); NNPs commonly do shift work (LoSasso, 2011). Variable working shift patterns have been suggested to affect performance, learning, and memory function (Peate, 2007). Fatigue can be predicted by several additional factors, including high work demands, female sex, the supervisor role, and advanced age (Akerstedt et al., 2004).

Circadian rhythm disruptions, fatigue, and sleep deprivation may affect the NNP’s clinical performance during night and extended shifts, with specific impact on levels of alertness (Lee et al., 2003). Additional fatigue factors include time awake, health factors (i.e., sleep disorders, medications), environmental issues (i.e., light, noise), and workload (Lerman et al., 2012). The potential consequences of altered alertness may include delayed identification or lack of identification of critical markers of clinical deterioration. Effects of fatigue on patient safety include delayed reaction time, delayed processing of information, diminished memory, failure to respond at the appropriate time, impaired efficiency, and inappropriate responses (Dingley, 1996; Caruso, 2014). These alterations in functioning have been summarized as “increased errors of 6 omission and commission” (Lim & Dinges, 2008). Patient safety is threatened when nurses work long and unpredictable hours, especially when the duration of prior awake time increases beyond 17 hours (Berger & Hobbs, 2006). Errors are increased with long shifts; in one study, the number of errors was three times higher with more than 12.5 consecutive hours of nursing practice, and the majority of errors were medication errors (Phillips & Moffett, 2013).

The relevance of these findings should be considered in relation to work hours and executive functioning necessary for the role and responsibilities of NNPs. Reduction in the occurrence of adverse events among patients requires NNPs to recognize important information from a variety of sources, to integrate complex processes and signs into a sensible thought and decision-making process, and to formulate an accurate, appropriate set of actions or reactions. Extended work shifts for nurses in critical-care settings have been associated with decreased levels of alertness and vigilance (Scott, et al., 2006).

In addition to compromising patient safety, sleep deprivation jeopardizes the well-being of providers who work extended hours. Extended workdays can have significant effects on homeostatic balance and circadian rhythm (Johnson, 2011). An increased prevalence of physical and psychiatric disorders—including but not limited to cardiovascular and gastrointestinal disturbances, diminished immunological response, infertility, spontaneous abortions, the birth of premature and low-birth-weight infants, sleep apnea, obesity, miscarriage, mood disorders, and depression—have been reported (Caruso, 2014; National Sleep Foundation, 2008; Peate, 2007). Cognitive difficulties have been cited, as well as long-term consequences of fatigue for nurses (Phillips & Moffett, 2013). Increasing age compounds the physiological and cognitive effects of fatigue (Dean, Scott, & Rogers, 2006). Older individuals are also more likely to experience sleep problems (33% of women aged 18-24 vs. 48% of women aged 55-64; Caruso, 2014).

Research specific to the NNP role in relation to fatigue and shift length is needed. However, a foundation for the following recommendations is provided by current knowledge of the science of sleep deprivation and fatigue, research from nursing and medicine, and outcome data related to shift length and patient safety. It is important to note the discrepancy in the literature regarding the definition of extended hours. The most common definitions of extended hours are shifts longer than 12, 16, or 24 hours.

Recommendations; Existing literature supports the concern that healthcare provider fatigue has a negative impact on both healthcare recipients and providers. NNPs are affected by fatigue the same way other healthcare providers are affected. Therefore, while acknowledging the lack of data clarifying the impact of fatigue on NNPs specifically and recognizing that these professionals are subject to some degree of fatigue-related sequelae, NANNP 7 provides the following recommendations in the areas of education, fatigue management, and system management.


1. NNP program education should include the recognition and management of fatigue regardless of shift length (AANA, 2015). Study areas should include sleep physiology and sleep inertia (grogginess upon awakening), personal and professional performance limitations, and identification of fatigue and fatigue mitigating strategies.

2. NNP employer education should be aimed at recognition of the relationship between extended working hours and fatigue and burnout. The unique critical care working environment, workload, and scheduling of NNPs should be included in this discussion. Education of the entire healthcare team, hospital administration, and private employers is essential to fatigue management. Workload has been identified by NNPs as a key factor in fatigue on the job (Welch-Carre, 2018; Dye, 2017).

3. NNP self and continuing education should address the individual’s responsibility to be adequately rested and fit to deliver optimal patient care. Most employment contracts state that the NNP’s responsibility is to come to work “rested and ready for work.”

 Fatigue Management

4. Fatigue-related risks should be alleviated by research-based strategies. One important aspect of fatigue management is observance of good sleep habits and routines. Sleep-hygiene measures should include monitoring sleep hours on both working and nonworking days and nights (Dean et al., 2006). To avoid chronic sleep deprivation, healthy adults should obtain approximately 8 hours of sleep per day (Dean et al., 2006).

5. Disruption of the circadian rhythm should be reduced by providing the NNP with an opportunity or designated time to sleep in the afternoon before working overnight (Landrigan et al., 2004). Working long, irregular hours, particularly at night, can disrupt the circadian rhythm even when an individual is adequately rested (Rogers, 2019). Additional fatigue mitigation strategies include minimizing shift rotations and optimizing rest time between scheduled shifts.

6. NNPs who are older than 40 years of age should be aware that they are at increased risk of experiencing fatigue and related physiological and cognitive effects that may affect performance (Reid & Dawson, 2001). Because the average NNP age is reported as 51 years old (Snapp et al., 2021), this increased risk is highly relevant to NNPs. For NNPs older than 50, night-shift hours should be optional (NANN, 2018). NNPs who have worked extended shifts for more than 20 years have an increased risk of health problems and illness (Clendon & 8 Walker, 2013) and should have the opportunity to work 8-12-hour shifts at their current position and institution.

7. Opportunities for rest should be incorporated as required by the work environment. Tools for tracking and reporting rest should be utilized. Fatigue can occur anytime in a 24-hour period. Napping is an effective non-pharmacological technique for sustaining alertness (Caldwell, Caldwell, & Schmidt, 2008). Strategic naps of 10–60 minutes have been shown to decrease fatigue and sustain performance (Arora et al., 2006; Rosekind et al., 1995). To maximize the benefit of naps, it is important to provide protected, uninterrupted time so that naps are of adequate length (Caldwell, 2001). The environment must be quiet, secluded (away from the work area), and dimly lit (Phillips & Moffett, 2013). Any on-call communication device should be handed off with sign-out to a colleague during this protected rest time. Personal phones should be put in Do Not Disturb mode.

8. Individuals should be cautious about consuming caffeine, especially 4–7 hours prior to planned sleep time (AANA, 2015). The use of stimulants, most commonly caffeine, is a fatigue management strategy often used by clinicians to temporarily improve alertness. Its effectiveness as a stimulant to temporarily improve alertness varies according to individual tolerance (Dean et al., 2006). Increased consumption of caffeine can interrupt restorative sleep. Various pharmacologic stimulants are available, but information regarding long-term side effects, tolerance, and potential for abuse is very limited (Caldwell, 2001). Behavioral and system counter-fatigue strategies are preferred over drug-based measures.  

9. Education is essential and should cover the dangers of fatigue, the causes of drowsiness on the job, and the importance of sleep and proper sleep hygiene. NNPs should assume personal responsibility to avoid excessive fatigue and use fatigue-mitigating strategies whenever possible. NNPs have a responsibility to recognize and address their fatigue before it becomes a safety concern (Salmon, 2013). Moonlighting (i.e., working a second job) and overtime hours are the responsibility of the employer and employee and need to be tracked and reported. Primary and secondary employers should be informed of any moonlighting hours by the employee.

10. Nutrition and adequate meal breaks are needed, along with respite time, to reduce fatigue (AANA, 2015).

11. Sleep applications for smartphones should be considered to facilitate better sleep practices. Applications can assist with difficulty falling asleep or staying asleep, relaxation, and best awakening time based on sleep-wake cycles (Phillips & Moffett, 2013). However, electronic sleep-tracking tools rely on Internet data tracking, so security risks must be kept in mind. Screen time on electronic devices during rest times is discouraged and use prior to sleep likely decreases ability to fall asleep, further contributing to fatigue (AANA, 2015). 9

System Management

12. Systems or processes should be designed to prevent errors associated with fatigue in the clinical setting. Collaborative efforts should be made among NNPs, their employers (including hospital risk management departments), and institutions to enhance health, safety, and productivity through the development of a fatigue risk management system with periodic review (Lerman et al., 2012). Individual practices and settings should have a written, practice-specific guideline that includes maximum hours worked per week, maximum hours worked per month, maximum number of consecutive shifts, and guidelines and monitoring of moonlighting hours (Blum et al., 2011).

13. Scheduling is vitally important. Optimal scheduling patterns may vary depending on the setting; however, the following recommendations are offered with the goal of providing safe, effective patient care and protecting the wellbeing of NNPs: a. Maximum shift lengths should be 24 hours, in-house, regardless of work setting and patient acuity. b. A relief-call system should be developed to provide coverage for NNPs who feel impaired by fatigue. c. A period of protected sleep time following 16 consecutive hours of working should be provided. d. A work assignment that compromises the availability of sufficient time for sleep and recovery from work should be negotiated or rejected (ANA, 2014). NNPs must be vigilant in pacing their own schedules to avoid fatigue by overscheduling with overtime and moonlighting hours. NNPs must be aware of the consequences of overwork (work hours and patterns) and fatigue-related errors (AANA, 2015). Avoidance of day and night shift swings is important in scheduling of 8–16 hour shifts to avoid drastic changes to sleep patterns. If alternating day/night rotations, consider 1 month on days, then 1 month on nights.

14. Team-based care models (Van Eaton et al., 2005) should be used to manage fatigue. Key aspects of this model include timely and accurate communication of information among team members, appropriate workload distribution, and use of information and documentation systems. Rather than having a single NNP responsible for patient care, team-based models make patient care a shared responsibility. Checks of medications, doses, and procedures should be requested as necessary (ENA, 2013).

15. An inherent value of team-based care is greater conciseness and accuracy in communicating information from one clinician to another, thus ensuring safer hand-offs at the end of shifts. McAllister (2006) proposed that continuity of care is a “process that optimizes our use of people, information, and management strategies.”

16. Employers and institutions should prioritize the education of NNPs and all other caregivers to ensure their understanding of the responsibility to be adequately rested and fit to deliver optimal patient care; the effects of fatigue and sleep deprivation; and strategies to mitigate fatigue and maintain alertness. Employers should conduct regular audits to ensure that scheduling policies are maintained and that meal and rest breaks are taken during work shifts (ANA, 2014). They must promote a work culture that allows the employee to express concern of fatigue (TJC, 2018).

17. Employers should provide fair and sufficient compensation and appropriate staffing to foster a safe and healthful environment (Phillips & Moffett, 2013). Employers are responsible for using scheduling practices that align with research and evidence-based recommendations. Every nurse should be able to decline extra working hours or overtime without being penalized (ANA, 2014). Mandatory overtime or on-call time as a staffing strategy should be eliminated (ANA, 2014).

18. Extended commutes after long shifts should be discouraged or the NNP should be provided with an opportunity to rest prior to leaving the institution (ANA, 2012). Transportation should be offered to fatigued employees who have completed an extended work shift. Blum et al., (2011). recommend transportation after 24-hour shifts, but we suggest it after 16-hours or longer.

19. Employers must provide safe staffing patterns and patient loads consistently for safe patient care and to provide healthy work environments (Snapp et al., 2021; ANA, 2014).

 20. Recruitment and retention of NNPs is dependent on the promotion of healthy work-life balance and on safe staffing patterns and workload. Providing an environment that attracts and retains the NNP workforce is a responsibility of employers and reduces fatigue that is caused by overwork, frequent new hire orientations, and burnout by seasoned NNPs (NANN, 2018).

21. Provider-to-provider handoff is a critical time for error after a long shift. Employers should have standardized electronic health records (EMR) with integrated patient information for the handoff process (Blum et al., 2011).

22. “Home call” should be incorporated into the overall hours worked at each institution and established guidelines for maximum hours worked with a work relief system built in (Blum et al., 2011).

 Future Recommendations

 Future study and research areas identified in this position statement are directly related to NANNP’s mission to provide recommendations for patient safety and promote NNP health and wellness. There is a lack of evidence in the literature to answer critical questions about shift length for NNPs (i.e., 12- versus 24-hour schedules) and fatigue, burnout, and job satisfaction were identified as critical areas of question that were 11 lacking in evidence in the literature. Because the NICU is evolving with increased patient complexity, workload, and NNP responsibilities, research must be conducted to determine whether all healthcare organizations should consider limiting shift length to 12 hours in Level IV units or all practice level nurseries and NICUs by 2030. There is limited evidence regarding patient safety and overall NNP health, so it is recommended that future research grants or areas of study address these questions.


Workplace fatigue remains a critical issue in healthcare and patient safety. NNPs are professionally accountable for ensuring that they are fit to provide patient care, and they should be proactive in minimizing risks to patient and personal safety. NNPs are encouraged to collaborate with colleagues and employers to create responsible staffing patterns and work models that reduce the risk of threats to patient and personal safety caused by fatigue. Employers have a responsibility to limit NNP workloads and schedules to reasonable levels

Source:Impact_of_Advanced_Practice _Shift Length_and_Fatigue_2022.pdf (

The Future Looks Bleak for Surgical Residents Like Me

Looming Medicare cuts will force surgeons to do more with less, undermining trainee succes

by Erfan Faridmoayer, MD September 28, 2022

“But you’re walking away from your dream!”

“Think about all of the years of hard work you have invested.”

“What will you do instead?”

These are common reactions people have when they hear about a surgeon walking away from medicine. It’s hard to imagine a surgeon would ever do such a thing. But the past few years may have changed that commitment to medicine for many.

My peers and I have invested nearly a decade to become surgeons. We’ve spent years in the classroom and hospital rotations, taking various standardized tests, and interviewing for competitive training positions around the country for the privilege of standing in the operating room — a humbling opportunity to serve patients from all walks of life. This is why it’s so disheartening to witness healthcare workers across the country, including residents, walk away from medicine. They are just too frustrated by the challenges of a healthcare system that is crippling surgeons and other doctors from providing effective care.

Now, a looming 8.5% cut in Medicare payments to surgical care threatens to make matters worse.

My Experience in Surgical Training

I went into medicine because I wanted to have a positive impact on people’s lives, and I chose to pursue a career in surgery because I loved the immediacy of improving patients’ health in critical situations.

These are common reactions people have when they hear about a surgeon walking away from medicine. It’s hard to imagine a surgeon would ever do such a thing. But the past few years may have changed that commitment to medicine for many.

My peers and I have invested nearly a decade to become surgeons. We’ve spent years in the classroom and hospital rotations, taking various standardized tests, and interviewing for competitive training positions around the country for the privilege of standing in the operating room — a humbling opportunity to serve patients from all walks of life. This is why it’s so disheartening to witness healthcare workers across the country, including residents, walk away from medicine. They are just too frustrated by the challenges of a healthcare system that is crippling surgeons and other doctors from providing effective care.

Now, a looming 8.5% cut in Medicare payments to surgical care threatens to make matters worse.

My Experience in Surgical Training

I went into medicine because I wanted to have a positive impact on people’s lives, and I chose to pursue a career in surgery because I loved the immediacy of improving patients’ health in critical situations.

I distinctly remember the first time I witnessed a patient wake up from a kidney transplant. The patient, a mother in her sixties, had been on dialysis for years. When I told her that her kidneys were functioning again — that she would no longer need to travel every other day to the hospital for dialysis — her expression was priceless. “I have my life back,” she said, with gratitude for the chance of an improved quality of life. That encounter, and many more, inspired me to become a surgeon.

Medicine is by no means a conventional field. While many of my college classmates are now 5 or 6 years into their careers, my decade-long training after school has just begun. Stepping foot into the hospital as newly minted physicians in 2020 was a rocky start. My co-residents and I began our program just months into the pandemic when elective surgical practice was nearly halted. The vast majority of admissions to the hospital were from complications of COVID-19, impacting our ability to gain the broad knowledge classically acquired in the junior years of surgical training.

On top of this, we’ve continuously faced staffing and equipment and drug shortages, along with pressures from the staggering rise in medical inflation.

The Impact of Looming Medicare Cuts

The challenges that impact patients and their care just keep coming. The latest? The impending sky-high Medicare cuts for the surgical field.

While I’m pleased to see that Congress recently passed legislation aimed at lowering the cost of prescription drugs for seniors, there is much more that needs to be done. It’s alarming to hear that CMS is planning to make significant cuts to Medicare payments for surgical care starting January 1, 2023.

These misguided cuts will force surgeons to do more with less, promising a bleaker future for myself and my peers.

With fewer resources, more senior surgeons will have less time to spend with residents like me. I’ve had amazing role models during my training so far. But these cuts threaten future surgeons’ access to the sound mentorship and necessary resources needed to adequately build the next generation of healthcare providers.

On top of this, these cuts will exacerbate the burnout that surgeons across the country already face, leading more surgeons to close their practices and walk away from medicine toward an early retirement. Put simply, there will be fewer surgeons to care for patients. We will be left with a vicious spiral that jeopardizes the stability of our healthcare system.

I am particularly concerned about the consequences of physician shortages on patients living in underserved areas, where there is already a scarcity of surgeons, anesthesiologists, and operating room staff. I can speak to that by the virtue of my training at the highest volume safety-net hospitals in Brooklyn. Additional cuts to the bedrock — Medicare — on which such systems rely will lead to delays in care, worsening patient outcomes, and eventually, increasing the cost of care with patients walking through our doors with more advanced disease down the road.

Year-after-year proposed cuts by CMS underscore the need for long-term reform to the broader Medicare payment system.

Without congressional action, the cuts to surgical budgets, staffing, and services will hit seniors in my area and many other regions harshly. Now, more than ever, we must support the type of thoughtful, responsible healthcare policies that ensure capable, wide-ranging surgical options for patients and their families across New York and the rest of the country.

Erfan Faridmoayer, MD, is a surgical resident at Downstate Health Sciences University in Brooklyn, New York. He is in his third year of a seven-year program.



Practice of Cuff Blood Pressure Measurements

Cistone, Nicole MSN, RN, RNC-NIC; Erlenwein, Danielle MSN, RN; Bapat, Roopali MD, FAAP; Ryshen, Greg MS, MBA, CSSGB, QIS; Thomas, Leslie MSN, APRN, NNP-BC; Haghnazari, Maria S. MSN, RN; Thomas, Roberta MPT, PT; Foor, Nicholas BS; Fathi, Omid MD Advances in Neonatal Care: August 2022 – Volume 22 – Issue 4 – p 291-299 doi: 10.1097/ANC.0000000000000947



Extreme preterm infants face lengthy hospitalizations and are often subjected to painful stimuli. These stimuli may be related to routine caregiving that may negatively impact long-term developmental outcomes. Frequently obtained cuff blood pressure (BP) measurements are an example of a potentially noxious stimulus to preterm infants that may have a cumulating impact on development.


The primary aim was to explore the frequency of cuff BP measurements obtained in hemodynamically stable extreme preterm infants in the neonatal intensive care unit (NICU). Our secondary aim was to reduce the number of cuff BP measurements obtained in hemodynamically stable extreme preterm infants in the NICU.


Quality improvement methodologies per the Institute for Healthcare Improvement were used combined with a multidisciplinary approach. Participants were infants born less than 27 weeks of gestation and discharged home. The baseline period was 2015 through Q2-2018 and the intervention period was Q3-2018 through Q1-2020. The electronic medical record was used to collect data and Minitab Statistical Software was used for data analysis.


A baseline of 5.0% of eligible patients received the desired number of cuff BP measurements and increased to 63.2% after the intervention period.

Implications for Practice: 

Findings demonstrate that using quality improvement methodology can improve clinical care. Findings suggest the feasibility and safety of reducing the number of cuff BP measurements obtained on hemodynamically stable infants in the NICU.

Implications for Research: 

Future endeavors should aim to reduce the quantity of painful stimuli in the NICU. Long-term developmental outcomes should be correlated in these patients.

Association of Neonatal Pain-Related Stress and Parent Interaction With Internalizing Behaviors Across 1.5, 3.0, 4.5, and 8.0 Years in Children Born Very Preterm

October 21, 2022

Mia A. McLean, PhD1,2Olivia C. Scoten, Bsc, Hons1Cecil M. Y. Chau, Msc1,2; et alAnne Synnes, MDCM, MHSc1,2,3Steven P. Miller, MDCM, MAS4,5Ruth E. Grunau, PhD1,2,3 JAMA Netw Open. 2022;5(10):e2238088. doi:10.1001/jamanetworkopen.2022.38088

Key Points:

Question  Does supportive parenting ameliorate the association between neonatal pain-related stress and child internalizing behaviors in children born very preterm?

Findings  In this cohort study of 186 children born very preterm, internalizing behaviors increased across ages 1.5, 3.0, 4.5, and 8.0 years, and more neonatal pain-related stress was associated with greater internalizing behaviors across ages. At 1.5 years, parenting stress was associated with more internalizing behaviors, whereas at age 3.0 years, a more supportive parenting environment was associated with fewer internalizing behaviors across development.

Meaning  These findings suggest that supportive parenting is associated with reduced child anxiety and depressive behaviors from toddlerhood through school-age in children born very preterm.


Importance  Internalizing (anxiety and/or depressive) behaviors are prevalent in children born very preterm (24-32 weeks’ gestation). Procedural pain-related stress in the neonatal intensive care unit (NICU) is associated with long-term internalizing problems in this population; however, whether positive parenting during toddlerhood attenuates development of internalizing behaviors across childhood is unknown.

Objective  To investigate whether neonatal pain-related stress is associated with trajectories of internalizing behaviors across 1.5, 3.0, 4.5, and 8.0 years, and whether supportive parenting behaviors and lower parenting stress at 1.5 and 3.0 years attenuate this association.

Design, Setting, and Participants  In this prospective longitudinal cohort study, preterm neonates (born at 24-32 weeks’ gestation) were recruited from August 16, 2006, to September 9, 2013, with follow-up visits at ages 1.5, 3.0, 4.5, and 8.0 years. The study was conducted at BC Women’s Hospital, Vancouver, Canada, with recruitment from a level III neonatal intensive care unit and sequential developmental assessments performed in a Neonatal Follow-up Program. Data analysis was performed from August to December 2021.

Main Outcomes and Measures  Parental report of child internalizing behaviors on the Child Behavior Checklist at 1.5, 3.0, 4.5, and 8.0 years.

Results  A total of 234 neonates were recruited, and 186 children (101 boys [54%]) were included in the current study across ages 1.5 (159 children), 3.0 (169 children), 4.5 (162 children), and 8.0 (153 children) years. After accounting for clinical factors associated with prematurity, greater neonatal pain-related stress was associated with more internalizing behaviors across ages (B = 4.95; 95% CI, 0.76 to 9.14). Higher parenting stress at age 1.5 years (B = 0.17; 95% CI, 0.11 to 0.23) and a less supportive parent environment (less sensitivity, structure, nonintrusiveness, nonhostility, and higher parenting stress; B = −5.47; 95% CI, −9.44 to −1.51) at 3.0 years were associated with greater internalizing problems across development to age 8.0 years.

Conclusions and Relevance  In this cohort study of children born very preterm, exposure to repetitive neonatal pain-related stress was associated with persistent internalizing behavior problems across toddlerhood to age 8.0 years. Supportive parenting behaviors during early childhood were associated with better long-term behavioral outcomes, whereas elevated parenting stress was associated with more child anxiety and/or depressive behaviors in this population. These findings reinforce the need to prevent pain in preterm neonates and inform future development of targeted parent-led behavioral interventions.


Neonatal Docosahexaenoic Acid in Preterm Infants and Intelligence at 5 Years

List of authors: Jacqueline F. Gould, Ph.D., Maria Makrides, Ph.D., Robert A. Gibson, Ph.D., Thomas R. Sullivan, Ph.D., Andrew J. McPhee, M.B., B.S., Peter J. Anderson, Ph.D., Karen P. Best, Ph.D., Mary Sharp, M.B., B.S., Jeanie L.Y. Cheong, M.D., Gillian F. Opie, M.B., B.S., Javeed Travadi, D.M., Jana M. Bednarz, G.Dip



Docosahexaenoic acid (DHA) is a component of neural tissue. Because its accretion into the brain is greatest during the final trimester of pregnancy, infants born before 29 weeks’ gestation do not receive the normal supply of DHA. The effect of this deficiency on subsequent cognitive development is not well understood.


We assessed general intelligence at 5 years in children who had been enrolled in a trial of neonatal DHA supplementation to prevent bronchopulmonary dysplasia. In the previous trial, infants born before 29 weeks’ gestation had been randomly assigned in a 1:1 ratio to receive an enteral emulsion that provided 60 mg of DHA per kilogram of body weight per day or a control emulsion from the first 3 days of enteral feeds until 36 weeks of postmenstrual age or discharge home, whichever occurred first. Children from 5 of the 13 centers in the original trial were invited to undergo assessment with the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) at 5 years of corrected age. The primary outcome was the full-scale intelligence quotient (FSIQ) score. Secondary outcomes included the components of WPPSI.


A total of 1273 infants underwent randomization in the original trial; of the 656 surviving children who had undergone randomization at the centers included in this follow-up study, 480 (73%) had an FSIQ score available — 241 in the DHA group and 239 in the control group. After imputation of missing data, the mean (±SD) FSIQ scores were 95.4±17.3 in the DHA group and 91.9±19.1 in the control group (adjusted difference, 3.45; 95% confidence interval, 0.38 to 6.53; P=0.03). The results for secondary outcomes generally did not support that obtained for the primary outcome. Adverse events were similar in the two groups.


In infants born before 29 weeks’ gestation who had been enrolled in a trial to assess the effect of DHA supplementation on bronchopulmonary dysplasia, the use of an enteral DHA emulsion until 36 weeks of postmenstrual age was associated with modestly higher FSIQ scores at 5 years of age than control feeding.

Source:Neonatal Docosahexaenoic Acid in Preterm Infants and Intelligence at 5 Years | NEJM

Animated 🐾Where Does Kitty Go in the Rain?

133,247 views – Apr 7, 2022  #readaloud #storytime #kidsbooksonline

Toadstools and Fairy Dust

🍄We all want to know, where do the animals go…during the rain? 🌧️Do they even like the rain? Come find out and learn a few science facts along the way by joining us for a kid’s book read aloud, “Where does Kitty go in the rain” created by Vooks. Watch even more stories like this on the Vooks app today!

9 reasons why you shouldn’t let a rainy day derail your walk (or run)

No rain, no gain!

Shona Hendley  – MAY 25, 2022 9:30AM

Thanks to La Nina we’ve all be dealing with the effects of wet weather more than we’d like; umbrellas, sodden shoes, and probably cancelling more than a few of your regular ‘mental health walks’ or runs. Shona Hendley explains why the latter should never come at the expense of a bit of harmless precipitation.

For decades, musicians like Gene Kelly, the Ronettes and even Rihanna have been merrily singing and dancing in the rain; while over the past couple of months many Sydneysiders have probably inadvertently and maybe not so happily found themselves walking in it.

No, perhaps not ideal for the unprepared but for those who are equipped with an umbrella or raincoat, there are actually some pretty impressive benefits of walking or running in the rain which may have even the most reluctant soon singing along too.

Dr Vivienne Lewis, a clinical psychologist at the University of Canberra says walking in the rain is actually great for our mental health for “a range of reasons.”

1. It’s a sensory experience

“Human beings need touch. It is an essential need and rain can provide this,” she tells Body+Soul.

“When we walk (or run) in the rain it provides a sensory experience completely different to non-rain. We can feel it on our face and body and this sensory experience can feel lovely on our skin and fresh on our face.”

2. It is freeing and endorphin releasing!

“Have you ever run in the rain and just felt so free? It gets our adrenalin pumping, and this releases stress,” Lewis says.

She also says that when we walk endorphins, the feel-good chemicals are released, and this also makes us feel good.

“In the rain, the release of endorphins can be enhanced especially if we are raising our heart rate to get out of the rain!”

3. It gives us time to think

“A walk in the rain can give us time to think. To be alone with our thoughts. To feel connected to nature. It can clear our head,” explains Lewis.

4. The sound and smell are calming

Because rain is a type of white noise, it can be soothing, meaning you can get your steps up, while taking in natures calming soundtrack at the same time.

Sydneysider and regular rain walker, Leanne Lusher agrees and identifies this as one of her favourite things about walking in the rain.

“I find walking in the rain so refreshing! I love the sounds and smell it creates,” she says.

The distinctive smell that soothes your mind and body even has its own name– Petrichor which was coined in the 1960s by two Australian scientists.

5. There are less people

Lusher says another great benefit to walking in the rain, especially for those who don’t like crowds is that there are usually less people which can make it a more relaxing experience.

“I like that hardly anyone else is out walking as they are hiding from the rain,” she explains.

6. It metaphorically washes the day away

Rain can also be a metaphor for washing the day away or washing our troubles away says Lewis.

“Think of the rain running down your body as a way to release negative emotions. A bit like we might do in the shower after a hard day. It’s that sense of just letting go. Just enjoying what nature has provided. Letting go of all your cares. Allowing yourself to just be in the moment and get soaked.”

7. The air is cleaner

An MIT study published in the journal of Atmospheric Chemistry and Physics showed that the air is actually cleaner during and after heavy rainfall.

Dr Lewis adds that this freshness can make the “smell and touch of fresh water feel exhilarating.”

If the mental health benefits aren’t enough to sell the experience to you, there are also some pretty impressive physical health benefit that may just get it across the line.

8. It’s good for your skin and hair

A 2016 study found that the rain plays a pivotal role in skin health driving humidity which helps freshen and moisturise our skin and hair. Ah, yes please.

9. Walking or running in the cold can burn more fat

And if burning fat is your goal, walking or running in the rain maybe exactly what you need to do.

Japanese scientists have carried out research on the effects of rain on energy metabolism while running in cold weather which showed that “energy demand increases when running in cold conditions.”

In other words, you burn more calories walking or running in the wet and cold than in a dry and warm environment.

So, if you haven’t already, it’s time to invest in a good set of water-resistant shoes, quality raincoat and start walking around those muddy puddles.

Dr Vivienne Lewis is a clinical psychologist at the University of Canberra. She treats people with anxiety and depression.


Taking advantage of the gifts that nature provides within our environment creates opportunities for us to connect, reflect, and reset ourselves in the midst of our daily lives. 

What gifts in nature bring you a sense of joy in life and help you feel present in the world? 

For me, walking in the rain is invigorating, providing a sense of calm tranquility. I love the fresh scent of the earth, the positive ion exchange within the air and calming sounds of the pitter-pattering rain drops. The rain is representative of a new beginning, a simple reset during the day. It reminds me of the joy of being alive and present with the world around me. This Fall season in Seattle, I look forward to basking in the seasonal downpour and crunching leaves as nature transitions into its winter hibernation before the spring re-awakening. 

Wishing you all joyful wonders and rejuvenating adventures in nature’s bounty this Fall season! 

        Dec 30, 2017     Wandering_higher

Coastal towns, national parks, chill vibes, and sick waves! Stayed in Montanita and Ayampe. The people are awesome, the parties are fun, and it’s not overrun with tourists or too Americanized. First time in South America but will be back!

Author: Kathy Papac and Kathryn (Kat) Campos

Kathryn (Kat) Campos: Hello, I am a former 24 week gestation micro-preemie. I lost my twin brother Cruz at birth and encountered open heart surgery with no anesthesia at 3 weeks old weighing 1lb 3oz/0.58kg. I served on the University of Washington Medical Center Advisory Board Neonatal ICU Council from 2013 to 2015. I am passionate about assisting and supporting our Global NICU Community. If your a Preterm Birth/NICU Survivor this blog is dedicated to you, your family, and all members of the NICU Community. Together lets support other Preemie Survivors, Preemies, Preemie families, Preemie Community, Neonatal and related Staff, Providers, Professionals and Facilities. We ALL have stories to share and preemie journeys to help empower! Kathy Papac: Preemie Mom of surviving (Kathryn) and a deceased (Cruz) 24 week gestation twins. Neonatal Womb journeyer, counselor/legal expert with an MA certificate in Spirituality, Health and Medicine from Bastyr University. Passionate Global Community participant. Our goal is to recognize, honor and empower the Neonatal Womb community and shine light upon the presence and potentiality of the preterm birth survivors as vital community participants.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: