Implementation mapping to develop strategies for skin-to-skin care in the pediatric cardiac intensive care unit: planning for a hybrid trial

Background Skin-to-skin care (SSC) is an evidence-based developmental practice that improves physiological stability, neurodevelopment, and parental well-being in hospitalized neonates. Although feasible and safe for neonates with complex congenital heart disease (cCHD) in the pediatric cardiac intensive care unit (PCICU), SSC remains underused due to knowledge gaps, unclear roles, safety concerns, inconsistent communication, and a lack of peer support. Methods We used implementation mapping to identify determinants of SSC implementation in two United States (U.S.) PCICUs to design a targeted, theory-informed strategy package in preparation for a hybrid type II trial. Semi-structured interviews with clinicians ( n = 25) and parents ( n = 21) were analyzed using the Tailored Implementation for Chronic Diseases (TICD) framework. Determinants were linked to strategies using the Expert Recommendations for Implementing Change (ERIC) taxonomy. A logic model was developed to connect determinants, strategies, mechanisms, and outcomes. Results Key barriers included limited SSC training, unclear responsibilities for initiation, safety concerns, inconsistent communication, and a lack of peer support. Three primary strategies were co-developed with stakeholders: (1) Education with role clarification, (2) Audit and feedback, and (3) Internal peer-to-peer facilitation. The logic model describes mechanisms such as improved knowledge, confidence, and role clarity; reinforcement through feedback; and peer modeling leading to improved adoption, feasibility, and sustainability of SSC. Conclusions This streamlined, end-user informed strategy package addresses the main barriers to SSC implementation in the PCICU and offers a replicable model for linking determinants to strategies in acute care settings.