Reflections on T. Berry Brazelton, MD s Influence on Pediatric Nursing

bs_bs_banner Journal of Child and Adolescent Psychiatric Nursing ISSN 1073-6077 Reflections on T. Berry Brazelton, MD s Influence on Pediatric Nursing Ann Coleman Stadtler, DNP, RN, CPNP, Kristie A. Brandt, RN, CNM, NP-C, MSN, DNP, Julie C. Novak, DNSc, RN, CPNP, FAANP, and Michelle A. Beauchesne, DNSC, RN, CPNP, FAANP, FNAP Ann Coleman Stadtler, DNP, RN, CPNP, is Director, Site Development & Training, Brazelton Touchpoints Center, Boston Children s Hospital, Boston, MA; Kristie A. Brandt, RN, CNM, NP-C, MSN, DNP, is Assistant Clinical Professor of Pediatrics, U.C. Davis School of Medicine, Sacramento, CA, and is Director, Parent-Infant & Child Institute, Napa, CA; Julie C. Novak, DNSc, RN, CPNP, FAANP, is Professor and Vice Dean, Practice and Engagement, Joseph and Thelma Crow Endowed Professor, Executive Director, UT Nursing Cynical Enterprise, UTHSCSA, San Antonio, TX; Michelle A. Beauchesne, DNSC, RN, CPNP, FAANP, FNAP, is Director, Doctor of Nursing Practice (DNP) Program, Northeastern University, Boston, MA, USA. Search terms: Family-centered care, pediatric nursing, infant mental health, nursing practice, nursing research, nursing organization, parent groups Author contact: ann.stadtler@childrens.harvard.edu, with a copy to the Editor: kathleen_r_delaney@rush.edu doi: 10.1111/jcap.12057 PURPOSE: The purpose of this article is to provide examples of Dr. Brazelton s important influence on pediatric nursing, and by extension, the work of child psychiatric mental health nurses, the care of children and families, and ultimately, the healthcare delivery system. SOURCES: Dr. Brazelton s professional colleagues, research, professional journals, and books. CONCLUSION: Over the past 40 years, T. Berry Brazelton has had a major impact on the development of pediatric nursing, infant mental health, and the nurse practitioner movement. He has influenced the growth and development of nursing organizations, nursing education, nursing research, nursing practice, and health policy affecting nurses. Introduction T. Berry Brazelton, MD, has had an illustrious career as a developmental pediatrician and advocate for family-centered care of children. The evolution of his work has paralleled the development of the pediatric nurse practitioner (PNP) role (Melnyk, 2000). This article will trace the impact of Dr. Brazelton s work on the nursing profession through a review of his influence on the growth and development of nursing organizations, nursing education, nursing research, nursing practice, and health policy. Impact on Nursing Organizations In 1964, the PNP role was created by nursing professor, Dr. Loretta Ford, and pediatrician, Dr. Henry Silver, at the University of Colorado. Initially, the primary care role was created to fill the void created by a physician shortage and to give community health nurses the education and visibility to meet regional and national community health needs. There were few role models for these new primary care providers (Stadtler, Novak, & Sparrow, 2010). In 1973, there were hundreds of PNPs providing primary care across the United States (Brazelton, 1969, 1992; Brazelton & Sparrow, 2006; Novak, 2006). That same year, Dr. Brazelton developed the Newborn Behavioral Assessment Scale (NBAS), a neurobehavioral assessment scale (Brazelton & Nugent, 2011). Simultaneously in 1973, to meet the continuing educational and professional role needs of PNPs, the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) was formed by a small group of pioneering PNPs (http://www.napnap.org). The current number of NAPNAP members exceeds 7,600 with approximately 11,000 PNPs nationally and 183,000 nurse practitioners in all specialties (http://www.napnap.org; http://www.aanp.org). Over its 40-year history, NAPNAP members have experienced a collaborative relationship with Dr. Brazelton as he was a supporter of this new innovative role and its national organization from the beginning. Dr. Brazelton s focus on infant mental health and family-centered care made him a role model for nurse practitioners. He was honored with the Henry K. Silver award for his national influence on the pediatric nursing profession. Impact on Nursing Education Through the years, PNP educational programs have embraced Dr. Brazelton s teachings, research, methods, his textbooks, and more recently, the Touchpoints Practice 234 Journal of Child and Adolescent Psychiatric Nursing 26 (2013) 234 238

Model (TPM; Stadtler & Hornstein, 2009). By 2012, the number of PNP programs exceeded 117 programs. Dr. Brazelton and his colleagues have served as consultants to many of these PNP educational programs across the country. In a survey of nursing educational programs conducted by Crowley and Magee (2003), 75% of participants noted some exposure to the NBAS, with 25% noting previous in-depth exposure. When asked how this information influenced their approach to practice, 82.4% of respondents stated it had an in-depth influence (Crowley & Magee, 2003). Educators find it useful in conveying the need for provision of sensitive, family-centered care in all settings, primary, or specialty such as psychiatric nursing or acute care. The majority of pediatric nursing textbooks cite the NBAS or Newborn Behavioral Observation (NBO), a clinical adaptation of the NBAS, with many now citing Touchpoints (Nugent, Keefer, Minear, Johnson, & Blanchard, 2007). Several schools of nursing (e.g., Clemson, University of Texas Austin [UT Austin], and Purdue University School of Nursing) are integrating the TPM into their graduate and undergraduate programs (Percy & McIntrye, 2001; Percy, Stadtler, & Sands, 2002). In 1988, Dr. Brazelton s work created a seismic shift in intra-partum and postpartum nursing practice when the four-part To Make a Difference videotape series was distributed by Ross Laboratories to every delivering hospital in the United States and most schools of nursing operating at that time. These videos featured Dr. Brazelton explaining and demonstrating infant behavior, and discussing the impact of care on the family s development. He states that parents are eager to learn about their new babies and that he has named these receptive times Touchpoints (Brazelton, 1987). Across the country, these videos sparked a resurgence of interest within pediatric and maternity nursing to transform care and reach families in new ways with an understanding of both newborn behavior and the powerful relationship that exists between nurses, the families being served, and its impact on the family s future. Dr. Kathryn Barnard, the renowned nurse scientist and author of the Nursing Child Assessment Satellite Training at the University of Washington, has had a profound influence on nursing practice herself and a close professional relationship with Dr. Brazelton, each influences the other s work. Dr. Brazelton and Dr. Barnard were recognized by the Institute of Medicine of the National Academies as joint recipients of the Gustav O. Lienhard award as innovators in the field of child development and parent education (http://www.iom.edu). The TPM: Influence on Practice The Brazelton Touchpoints Center (BTC), Boston Children s Hospital, began in 1995 and provides professional development based on the research and practice of Dr. Brazelton and his multidisciplinary colleagues (Hornstein, O Brien, & Stadtler, 1997). The TPM, a practical preventative method for professionals, provides care to families that support the parent child relationship, the parent provider relationship, the relationships among providers, and ultimately supports the mental and physical health of young children (Stadtler & Hornstein, 2009). When the Touchpoints Project (now called the BTC) began, Dr. Brazelton s hypothesis was that if the Touchpoints Professional Development program was to succeed it would be judged by the way nurses embraced it. He believed that nurses were the group whose philosophy and practice were most closely aligned with his methods. It was piloted with PNPs in Boston working with vulnerable, underserved families. Midway through the training, several of these nurse practitioners reported that they had not realized how close they had been to burnout, causing them to utilize many defenses that often unintentionally obstructed their relationship with the families they were serving. These PNPs concluded that the TPM included strategies enabling them to be reenergized and revived the motivation that led them to a nursing career. Now 18 years later, effects are to be seen on providers, parents, children, and communities (Amy, 2001; Karl, 2004). Nurses have long known that in a relationship there is mutual benefit. Supportive relationships give zest and energy, while negative relationships deplete energy. Following the pilot, the BTC has trained over 100 Touchpoints Teams across the country and in Portugal. The majority have had a nurse (public health, mental health, PNP) on the team and in many cases leading the team (Stadtler et al., 2010). The team s ultimate goal is to support best outcomes for children by supporting healthy functioning families, competent professionals, and strong communities in which the children can thrive. Influence on Practice In a recent landmark review of advanced practice outcomes, it was determined that nurse practitioners provide highquality, cost-effective, evidence-based care (Newhouse et al., 2012). As of 2013, many nurses and nurse practitioners working in primary care settings and specialty practices integrate Dr. Brazelton s work into their practices. Nurse-managed health clinics have been identified as a significant venue for the provision of such care. Of the 200 nurse-managed health clinics currently operating in 37 states, 74% are associated with academic nursing programs to support student learning and provide additional clinic sites to support enrollment growth (Kovner & Walani, 2010). The TPM, with the nurses family-centered partnership focus, is one example of this quality care and has been determined to be more effective in enhancing other models. In 2012, 60 Nurse Family Partnership providers and 60 Air Force Family Journal of Child and Adolescent Psychiatric Nursing 26 (2013) 234 238 235

Advocacy home visiting nurses participated in Touchpoints Professional Development. Both groups reported that the training provided an enhanced understanding of child development and excellent strategies for forming a relationship with families in their home visiting (unpublished evaluation results). TPM has provided a framework for the integration of education, practice, and research in nurse-managed clinics and home visits based on a solid foundation of understanding a holistic approach to care and effective strategies for engaging families in the care of their children. In Napa, California, the Touchpoints approach has been incorporated into the County Health & Human Services Department and the Public Health Division since 1996,and integrated into the community s system of care serving families from pregnancy through the child s fifth year.among many results (Brazelton, O Brien, & Brandt, 1997),the NapaValley s Touchpoints project has led to the development of (a) a community-based Touchpoints training project that won a statewide merit award in 1999;(b) a parent-provider journal for the baby s first year; (c) a nurse home visiting program based on Touchpoints (Brandt & Murphy, 2010); (d) the development of an award-winning Therapeutic Child Care Center conceptualized, constructed, and operated on the Touchpoints approach, and was winner of both state and national awards of excellence; and (e) development of a 15-month specialty training program for professionals in infant-parent mental health that also won both state and national awards. Hospitals are educating nursing staff in Touchpoints as a quality improvement measure. Harris Hospital in Fort Worth, Texas, was named Best Place to Have a Baby by Fort Worth Child Self magazine and listed Harris as one of the Top 10 places in the United States to have a baby. They attribute these awards to the training and mentorship of 98% of their Women/Infant Staff in the Touchpoints Approach. Nurses at the hospital describe the use of Touchpoints and the NBO in prenatal classes, newborn care, car seat checks, neonatal intensive care unit, and parenting classes (http://www.texashealth). Touchpoints and Parent Groups Parent groups are excellent and effective ways to provide care to families. Nurses are leading parent groups focusing on the perinatal period, preschool period, illness, and behavior. Dr. Brazelton s writing and videos are utilized in many of these specialties. At the BTC, two interesting parent/child groups developed are Toilet School (Stadtler & Burke, 1998) and Asthma Groups (Stadtler, Tronick, & Brazelton, 2001). Teen parent groups using Touchpoints were developed by Dr. Melanie Percy, a former nursing professor at UT Austin (Tyler & Horner, 2008b). All are based on the collaboration with parents and children with the goal of supporting their selfesteem and scaffolding problem-solving strategies through the relationship with the professional and other members of the group. School departments in Texas and Montana recommend the Touchpoints as an essential reference in understanding families. Many schools have nurse practitioners and the complexity of care has increased as the level of stress families are exposed to. The majority of child care centers have nurse consultants who utilize the TPM and report that it is invaluable for addressing the many behavioral and relational issues that arise daily in these settings (Stadtler, 1999). Nurses in child care are asked by child care programs to not only give parental support about health issues but also around behavioral and relational issues. Behavioral issues such as sleeping, feeding, discipline, and toileting are embedded in relationship and culture. In 2000, Dr. Brazelton partnered with Dr. Greenspan calling for a model of child care advocacy intending to influence public policy and initiate social change (Brazelton & Greenspan, 2000). Impact on Nursing Research Dr. Brazelton s influence is evident in nursing research, particularly through the continued use of the NBAS and the NBO (Brandt & Murphy, 2010; Olds, 2010). These instruments are appreciated by nurses across the world as a tool for enhancing the connection between the child and family and the provider and family (Brandt, 2007) with studies looking at the effect of observing the newborn with their family on breast-feeding (Karl, 2004). Additionally, several studies analyzed the effect of nurses using the Touchpoints Approach. One study compared public health nurses with Touchpoints training and public health nurses without who made home visits to new families. Positive outcomes for parents and children were reported when visited by a public health nurse using TPM (Brandt & Murphy, 2010). Dr. Brazelton s pioneering work on infant crying is frequently cited as foundational in nursing research (Evanoo, 2007; Wade, Black, & Ward-Smith, 2005) as is his work on infant attachment (Hallas, 2002). More often, Touchpoints and his work on behavioral developmental pediatrics appear in the reference lists of many nursing studies (Hawkins- Walsh, 2001; Lawrence, Magee, & Bernard, 2001). Discussion Dr. Brazelton has also played a critical role in supporting nursing practice. He has provided testimony at the local, state, and national level regarding a variety of child health and professional issues, with unwavering support to the role of nurses. Dr. Brazelton s willingness to serve as a local to global advocate has consistently influenced the care of children and families and the professional practice of pediatric nurses. 236 Journal of Child and Adolescent Psychiatric Nursing 26 (2013) 234 238

Dr. Brazelton has also been a proponent of PNPs with the American Academy of Pediatrics and other medical organizations. He believes that the pediatric nursing role in the neonatal nursery, at the bedside, providing mental health, and in primary care is essential to optimal care of children and families and healthcare system improvements. Dr. Brazelton has been a longtime proponent of nursing and the role of the PNP. The success of this partnership lies in the mutuality of the shared philosophy and belief in the value of family-centered care as the optimal approach to achieving quality health care for children. This article has provided examples of the impact Dr. Brazelton has had upon the nursing profession in many areas from education to practice to policy. Perhaps his greatest impact upon the nursing profession has been his recognition of the key role nurses play on the healthcare teams and the strengths nurses display as the leader of many of those teams. 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