Registed Nurses' Association of Ontario

Fellowship Title: Development of an Environmental Lighting Guideline For Use In a Quaternary Level Neonatal Intensive Care Unit

Anne-Marie Hutchinson, RN, BN
The Hospital for Sick Children

The physical environment is an important component of developmental care (Symington & Pinelli, 2006, para. 7). Historically, NICUs have modified their environment in a multitude of ways to mimic the womb for preterm infants. This has included alterations to areas such as sound levels, and lighting. With respect to lighting, many NICUs have moved away from continuously exposing neonates to bright light, as it was recognized by multiple studies, including Rivkees (2000), that this caused increased infant stress (as cited in Morag & Ohlsson, 2016, p. 6). Instead, many units moved toward caring for infants in darkened environments due to its similarity to the womb (Morag & Ohlsson, 2016, p. 7). However, Rivkees (2004) contends that this practice deprives infants of the circadian stimuli ordinarily received during gestation (as cited in Morag & Ohlsson, 2016, p. 7). Current research is illustrating encouraging trends in babies that are cared for with cycled lighting (Morag & Ohlsson, 2016, p. 3). Whilst no single protocol exists, this is generally described as affording 12 hours of dim light (either natural or artificial), and uncovering incubators, followed by 12 hours of darkness. There are recommended illuminance ranges for both of these phases in order to maximize developmental outcomes (as cited in Morag & Ohlsson, 2016, p.7). By exposing infant’s to cycled lighting at a developmentally appropriate time, infants have trends toward improved weight gain, decreased length of stay, incidence of retinopathy of prematurity, and improved sleep periods (Morag & Ohlsson, 2016, p. 3). Several studies, including Rivkees (2003), contend that cycled lighting may afford its health benefits through its “potential to promote circadian rhythms” (as cited in Morag & Ohlsson, 2016, p. 7).

The NICU at SickKids is a 38-bed unit specializing in tertiary and quaternary care of newborns. As a large proportion of patients admitted are preterm, excellence in developmental care is necessitated. However, it was recognized that there was no unit guideline to advise clinicians on the appropriate use of environmental light. Consequently, neonates were being cared for with irregular lighting patterns, which often, unintentionally, failed to consider each infants developmental stage.

The primary goal of my fellowship was to obtain the necessary knowledge and expertise to develop a departmental environmental lighting guideline, generated through the evaluation of quantitative research. This would include the use of cycled lighting. My learning plan included the completion of an extensive literature review, the opportunity to conduct a benchmarking exercise with sites across Canada and the USA, creation of a knowledge translation plan, development of the guideline and involvement in passing it through the appropriate approval processes, and the formation of a conference abstract to disseminate my findings. The completion of these activities was facilitated by my mentor team. This team was comprised of a Neonatal Nurse-Practitioner, NICU Nurse Educator, and an NICU Occupational Therapist. Their expertise and support was paramount to my success in achieving the outlined objectives, and guiding me through this process. By realizing these goals, I developed knowledge and expertise in evidence-based care, knowledge translation, the process of practice change, and information dissemination.

In completing the above-mentioned activities, I also had the opportunity to liaise with experts in multiple fields. This included Nurse Educators, a Knowledge Translation Specialist, and Quality Analysts. By meeting topic experts, I was able to deepen my understanding of the respective areas. I also had the opportunity to attend leadership talks, quality and practice improvement workshops, and develop my presentation skills in an effort to expand my learning and gain additional skills and expertise. These activities afforded enhanced personal knowledge development, and opportunities to sustain my learning post fellowship. I am hopeful that in the future, I will be able to find a suitable venue to submit my conference abstract, and thus disseminate my findings and experience on a larger scale.

As a result of this fellowship, the NICU at SickKids now has an approved environmental lighting guideline. This will result in the provision of appropriate environmental lighting, including cycled lighting, for all neonates in the NICU. Consequently, developmental outcomes will be maximized, and appropriate visual stimulation promoted. Following a comprehensive implementation plan, evaluation will be undertaken to assess the outcomes of this practice change, and compare our results to the results seen in the literature.
Through this fellowship, my colleagues now have a clear guideline detailing appropriate environmental lighting strategies for neonates of varying gestation age. This promotes standardization of the lighting conditions on the unit, thereby reducing the irregular lighting patterns seen previously. In addition, an increased awareness of the current research in this area has been garnered, thus enabling the continued deliverance of high-quality, evidence-based care to our patient population.

Overall, I found the fellowship experience to be extremely valuable and rewarding. It was an incredible learning opportunity that afforded the chance for personal and professional growth. I was able to develop knowledge and skill in numerous areas and value the chance to participate in this program. I look forward to the future activities that will allow me to sustain this learning, and would like to thank RNAO for providing me with this opportunity.
I would also like to thank my mentor team for their tremendous support, guidance, and patience in facilitating my progress through this process. In addition, I would like to thank my leadership team for their encouragement and sponsorship, as well as the SickKids Professional Practice Coordinators for enhancing my learning experiences.