Introduction
Neonatal Intensive Care Unit (NICU) combines advanced technology and trained health care professionals to provide specialized care for newborn babies who need intensive medical attention are often admitted in NICU. This area provides intermediate continuing care for the babies that are sick and babies needs specialized care before handing it over to the parents. There are technology to monitor nearly every system of a baby’s body including body temperature, heart rate, breathing, oxygen and carbon dioxide levels, and blood pressure.
Some factors that babies admitted to NICU are premature – born before 37 weeks pregnancy or babies have medical condition (heart problems, infection, birth defects) that requires special care in NICU. During the pregnancy the medical professional identifies if the baby is high risk and increases the chances of being admitted to the NICU.
Medical professional running the NICU work together with parents to develop a plan and concept of care for the newborn babies. Programs are also established in other for the parents to cope-up with the problem.
After the birth, parents may expect an instant bond with baby, but for some parents, this doesn’t happen. It may take a few days or even weeks to feel a connection to the baby, and this can create feelings of guilt, stress and disappointment for parents. When parents feel little or no connection with the baby, it may be distant or withdrawn and behave negatively toward the baby. A little worry or anxiety is normal, but too much may affect mother ability to cope with the pregnancy and the baby. Mother can experience anxiety while pregnant (antenatal anxiety) or after the birth of the baby (postnatal anxiety). After the birth, parents may expect an instant bond with baby, but for some parents, this doesn’t happen. It may take a few days or even weeks to feel a connection to the baby, and this can create feelings of guilt, stress and disappointment for parents. When parents feel little or no connection with the baby, it may be distant or withdrawn and behave negatively toward the baby. A little worry or anxiety is normal, but too much may affect mother ability to cope with the pregnancy and the baby. Mother can experience anxiety while pregnant (antenatal anxiety) or after the birth of the baby (postnatal anxiety). After the birth, parents may expect an instant bond with baby, but for some parents, this doesn’t happen. It may take a few days or even weeks to feel a connection to the baby, and this can create feelings of guilt, stress and disappointment for parents. When parents feel little or no connection with the baby, it may be distant or withdrawn and behave negatively toward the baby. A little worry or anxiety is normal, but too much may affect mother ability to cope with the pregnancy and the baby. Mother can experience anxiety while pregnant (antenatal anxiety) or after the birth of the baby (postnatal anxiety). After the birth, parents may expect an instant bond with baby, but for some parents, this doesn’t happen. It may take a few days or even weeks to feel a connection to the baby, and this can create feelings of guilt, stress and disappointment for parents. When parents feel little or no connection with the baby, it may be distant or withdrawn and behave negatively toward the baby. A little worry or anxiety is normal, but too much may affect mother ability to cope with the pregnancy and the baby. Mother can experience anxiety while pregnant (antenatal anxiety) or after the birth of the baby (postnatal anxiety).
After the birth, parents may expect an instant bond with baby, but for some parents, this doesn’t happen. It may take a few days or even weeks to feel a connection to the baby, and this can create feelings of guilt, stress and disappointment for parents. When parents feel little or no connection with the baby, it may be distant or withdrawn and behave negatively toward the baby.
A little worry or anxiety is normal, but too much may affect mother ability to cope with the pregnancy and the baby. Mother can experience anxiety while pregnant (antenatal anxiety) or after the birth of the baby (postnatal anxiety).
Objective of the Study
To be knowledgeable about the function, importance, and nature of Neonatal Intensive Care Unit, and the strategies in reducing the amount of stress to the newborn babies and parents.
The specific objective of this study is to be familiar with the basic strategies and developmental care for NICU patients. Second, to conceptualized the role of the parents to provide after care at home. Lastly, to identify the roles of nurses and parents in other to provide quality care to the newborn babies and close-knit relationship to the babies.
This study will be covering sub-topics in order to integrate the broadness of the subject matters. The sub-topics contain studies from; The Impact of Training Program on Nurses – Knowledge and Performance in Neonatal Intensive Care Unit, Radiographies Evaluation Dose Received by Babies Admitted to NICU, Impact of Preterm Birth on Parental Distress.
Ethical Considerations
The researchers started the sampling after obtaining the ethical code and approval from the administrators of the educational hospital and in coordination with the authorities of the neonatal ward as well as explanations about the research objectives.
Before the study, consent forms were obtained from the participants, and they were noted that they are free to withdraw the study at any time during the study. They were also ensured about the confidentiality of data.
Methods
In this study which structured two tier evaluation for 10 newborn babies parents (babies admitted in NICU), 10 newborn parents (with normal babies) and 8 NICU nurses. Evaluation indicators system frame was initially formed by using literature review, clinical on-spot observation and expert consultation methods. By using specialists meeting method, evaluation indicators system for babies admitted in NICU was verified and established. Evaluation indicators system was performed in NICU of hospital.
Parents of the babies admitted to NICU assessed by systematic point sampling and questionnaires-three stage quasi-experimental. Paper based questionnaire evaluated using descriptive and inferential statistics.
Nurses having at least 6 months experience of working in the NICU and willingness to participate in the study were among the inclusion criteria. The partial completion of the questionnaires was considered as the exclusion criteria. The data gathering tool was a researcher made, self-report questionnaire including three parts. The first part was related to demographic characteristics, and the second and the third parts were made for evaluation of nurses’ knowledge and performance.
The data were collected by a questionnaire for nurses’ knowledge and on the spot performance assessment which its validity and reliability were determined through content validity and internal consistency.
The first part was related to demographic characteristics, and the second and the third parts were made for evaluation of nurses and parents was assessed by 10 multiple-choice questions so that the correct answer was given a score of 1, and if more than one option or a wrong option was selected, it was given a score of 0. Nurses’ performance was also evaluated via 15 multiple-choice questions scored. The options, i.e. “always,” “often,” “sometimes,” and “rarely” were given scores of 4, 3, 2, and 1, respectively. The variation range of the scores for this part was between 15 and 60. The validity of the data collection instrument was calculated using content validity and its reliability was computed through internal consistency and measurement.
Results and Findings
Training Program on Nurses’ Knowledge and Performance in Neonatal Intensive Care Units Sleep is essential for organizing and maturation of the brain in premature infants; it also plays a role in maintaining the natural balance between different nervous centers. Given the role of nurses in neonatal sleep care, this study aimed at assessing the impact of a training program on the nurses’ knowledge and performance in a Neonatal Intensive Care Unit (NICU).
The results indicated that this method of training program could lead to an increase in nurses’ knowledge, but it did not significantly improve their performance. It may be due to a low number of training sessions; therefore, it is recommended to implement long-term training programs in this field.
At present, the highest number of admissions to hospitals in the Neonatal Intensive Care
Units (NICUs) are allocated to premature infants. [1] Premature babies are embryos, which are obligated to have their growth and development outside the uterine, in the critical period that the brain has the most rapid speed of growth compared to any other time of life. [2] Sleep is essential for organizing and maturation of the brain, especially in premature infants, so promoting neonatal sleep is considered as a critical component of providing appropriate developmental care in premature infants hospitalized in NICUs. In addition, sleep promotes neuronal maturation, facilitates learning, reinforces memory, and brain formation. Furthermore, sleep deprivation in healthy infants leads to short-term changes in heart function and duration of subsequent sleep cycle and increases respiratory problems. However, attention to the sleep-wake pattern of premature and term sick infants might prevent stress among them and reduces energy expenditure and physiological instability. Thus, the identification of sleep-wake states in each newborn is necessary for providing better developmental care. [3] Several studies have demonstrated that many factors may cause disorders in sleep-wake states and disrupt neonatal sleep cycle during hospitalization period in NICUs. The most common and the most important factor is multiple manipulations of the newborns by their caregivers while enough sleep will be provided through attention to improvement of sleep time planning, improvement of the environment, and the use of different method of cares inducing sleep promotion. Neonatal sleep care program is a unique and family-centered approach, which reduces environmental stress and promoting overall well being. Moreover, scientific evidence suggests that nurses’ knowledge and improvement of their performance have an important role in sleep health. According to the researcher’s experience, it seems that nurses’ knowledge and performance in the field of sleep health are not sufficient and desirable in NICUs; accordingly, educational interventions may be effective in improving nurses’ performance in the field of sleep health. Therefore, the purpose of this study is to evaluate the effectiveness of training programs in this regard.
In the present study, we assessed the impact of a training program including sleep physiology in newborn infants and the methods of identifying disruptive factors affecting sleep on nurse’s knowledge and performance. The results showed that the mean score of nurses’ knowledge was low before training as it was less than half of the total score. It may be due to no attention to infant’s sleep and its importance in nursing curriculum. Before the intervention, the mean score of nurses’ performance was on the average level. This finding may be due to the self-reporting questionnaire. Moreover, the results showed a significant increase in the mean score of knowledge immediately after the training program in comparison with the score before the training. The results of this study were consistent with previous studies that revealed the mean score of nurses’ knowledge in the fields of developmental care, baby bath, and neonatal intensive care significantly increased after training programs compared with those of before training; [4, 5, 6] other training programs for nurses have been also accompanied by increasing their knowledge. In the present study, the results demonstrated that the mean score of nurses’ knowledge at 1 month after the intervention was less than immediately after it, in fact, training program, if not repeated, may lose its impact on nurses’ awareness over time and is not with favourable outcomes. In this line, other studies have also shown that the impact of the educational nurses’ programs on their knowledge will decrease over time. Therefore, it is necessary to use appropriate educational program with more frequent sessions to sustain their impact. In the present study, findings showed that although nurses’ knowledge had improved after training, their performance regarding neonatal sleep was not significantly different from before the intervention; while in the previous studies, increasing knowledge has been associated with improvement of nurses’ performance. Lack of facilities and equipment in NICUs, inappropriate ratio of number of nurses to patients, and inadequate environmental space in the NICU could be the reasons behind this discrepancy. On the other hand, because the health care system is doctor dominance and adherence to doctor’s orders even in the field of nursing care is obligatory, this may lead to the fact that nurses cannot provide required care for premature infants on the basis of the nursing process and the cares are given based on routine nursing.
Previous studies have also shown that neonatal care is mostly done based on the nursing routines in NICUs and without any regard to infants’ sleep-wake states. [7] For example, in one study, it was revealed that infants were manipulated more than 200 times during a day in the NICU; hence, with frequent manipulations, an infant cannot obviously have calm and favourable sleep-wake conditions. [8] Over time, the impact of training on knowledge and performance is slightly blurred. Therefore, to have sustainable impacts, educational programs should be implemented and repeated with short intervals. The limitation of this study was that the evaluation of nurses’ performance in the field of sleep health was done by a self-report questionnaire, not by checklist and direct researcher observation. The shortage of nurse to patient and performing doctor-centered care by the nurses may be among the other limitations of this study.
Radiographies Evaluation Dose Received by Babies Admitted to NICU. Recently, the concerns have increased about long-term effects of radiation exposure in neonates. Side effects of excessive intake threshold X-ray include cataract and skin injuries; however, its most important complication is the increased risk of hematologic and mass malignancies [9]. The risk, though the poor, gets more with the increased dose of exposure during the life. Since the tissues of children up to 10 times more than adults are sensitive to radiation, the risk is higher in children [9]. Neonates with low birth weight have a risk of the various medical and surgical issues; for this reason, numerous cases of diagnostic radiography may occur for them during a short period. Plain radiographs include frequently thoracic, abdomen and sometimes the spine, which small size of the premature infants makes cause that a major part of their body is placed in the background of radiography; for this cause, they receive a higher effective dose compared to the adult. Today, we know that there are a lot of proliferations and tissue differentiations during fatal growth and early childhood, and the proliferating cells are more prone to cancer induction. In the neonatal intensive care unit (NICU), many neonates are kept in a large room, and this is a cause for that all the adjacent neonates are to be exposed to radiation for each request for a portable radiology image scan [9]. The aim of this study was to evaluate doses received by premature infants hospitalized in NICU of this hospital because of frequent diagnostic radiography during hospitalization.
The result of the study showed that radiation dose received by organs at risk of premature neonates was lower than the international criteria and standards; however, due to a lack of radioactive damage threshold, and for preventing the genetic damages, it is recommended that collimator be limited, and while using radiography of premature neonates, the appropriate filtration, kilo voltage and time be used. In the study, radiation dose received by organs at risk of premature neonates was lower than the international criteria and standards, therefore; also due to the lack of radiation damage threshold, to limit collimator, and the use of the proper filtration, kilo voltage and time during radiography of premature neonates are recommended.
Closeness and separation in neonatal intensive care Skin-to-skin contact, developmental care and other interventions supporting parenting and parental involvement in infant care have been shown to have the potential to enhance neurological and neurobehavioral outcomes of preterm infants. Parental closeness can be lead to improved child outcomes by many mechanisms. One mechanism might be improved sleep, which has been associated with skin-to-skin contact in preterm infants. Second, parent’s participation in pain management may reduce pain in preterm infants and moderate the use of pain medication. Third, infant massage with moderate pressure may increase the concentrations of hormones such as brain growth-promoting factor, IGF-1 and oxytocin, potentially having positive effects on the brain functioning and development. Fourth, the presence of a parent may give the preterm infant learning experiences that he/she might not get otherwise, such as interactive communication. Showed that exposure to parent talk in the NICU was a significantly stronger predictor of preterm infant vocalizations than talk from other adults. These mechanisms might underlie the finding that physical contact enhances early neurobehavioral and psychomotor organization. In addition, interventions supporting parents in their skills to observe and interpret their infant’s behaviour have been associated with improved cognition years later. Such interventions may restore and normalize the parent–infant relationship even after initial separation.
A preterm birth has been associated with poor psychological functioning in mothers and fathers, and in more negative parental interactive behaviours with their infants. Interrupted psychological processes may explain higher prevalence of depression in parents of preterm infants compared with those of full-term infants during pregnancy, a stressful birth, concern for their infant’s well being and NICU experiences. However, it is plausible that separation from the infant is one mechanism that increases the risk of parental depression. Early physical separation from the infant within 24 h of birth is related to an increase in parents’ NICU-related stress. Furthermore, prolonged physical separation between mothers and infants is also known to cause maternal stress, anxiety and depression. Isolation between parents and infants, often attributed to the complex technological support crucial for the infant’s viability, can place immense strain on parents leading to parents feeling less confident and more alienated from their infants and incompetent in the parental role. Whilst poor and restricted staff–parent interaction and communication can exacerbate parents’ sense of isolation from their preterm infants, it has also been suggested that parents’ negative emotions and experiences associated with prematurity or infant illness have led them to withdraw physically and emotionally, thereby handing over the care of their infants to staff. Emerging evidence suggests that care practices supporting physical and emotional closeness between the parent-preterm infants decrease the prevalence of maternal depression similar to levels reported in mothers of full-term infants. Furthermore, psychological well being of the parents of preterm infants has a long-term impact in terms on later child behaviour.
Physical closeness in a neonatal intensive care unit (NICU) ranges from skin-to-skin contact between parent and infant, to parents being in the unit but not in physical contact with their infant Kangaroo care. It’s normally placing the baby unto mother’s chest and help the baby more relax. Emotional closeness describes how parents can experience anything from feelings of strong and consistent love, care, affection and/or connection to emotional disconnection and alienation from their infant. Although ‘physical closeness’ may facilitate ‘emotional closeness’ and vice versa, there may be occasions when parents can be physically close but feel emotionally detached, or even physically remote but still feel emotionally connected. In this paper, we highlight the importance and potential impact of both physical and emotional closeness and the deleterious effects of separation between a preterm infant and the parent during neonatal care.
Parental attachment to the infant, also called psychological bonding, begins and is strengthened throughout pregnancy. After birth, close physical contact with the newborn is crucial for this bond to develop into a secure attachment relationship between parents and their infants. Research has shown that newborn infants have the capacity to exhibit sensory awareness, express emotions and share feelings. These abilities enable infants to engage in very complex early social relationships with their parents, which form the basis for the evolving parent–infant relationship and attachment.
A recent meta-analysis was undertaken to explore mother–infant interactions and relationships within the preterm and full-term populations. The results revealed that, during first 6-month post birth, mothers of preterm infants demonstrated less positive interaction behaviours with their infants than mothers of term infants. However, this review also identified how mothers of preterm infants were as likely to form secure attachments as full-term infants and their mothers at 1 year of infant’s corrected age. Whilst this review focused on the whole preterm population, research targeting infants requiring intensive supervision and surveillance, and hence early and long periods of separation from their parents, identified different results. A qualitative study of attachment revealed that mothers of very low birth-weight infants who experienced prolonged separation displayed more negative attachment behaviours compared with mothers of healthy full-term or preterm infants. It has also been suggested that the lack of physical contact between the mother and infant after birth is associated with later emotional problems in preterm infants. Studies undertaken with fathers and their preterm infants have also identified an association between early contact and feelings of emotional closeness and more positive interactions at discharge. Goulet et al. described how physical closeness and emotional closeness (through vocalizations, visual contact, touch and other sensorimotor interactions) are crucial to the establishment of the parent–infant relationship. Whilst close contact facilitates the development of positive parent–infant relationships, it can also enhance the parent’s confidence and capabilities in providing care for their newborn. Further studies have concluded that maternal sensitivity in mothers with preterm infants is less optimal when compared with full-term controls. Research has identified how mothers of preterm infants may be more controlling, actively engaged and/or intrusive with their infants, perhaps compensating for guilt/shame for not having been the caregiver they wanted to be during hospitalization or for preterm infants’ inactive interaction. These findings emphasize that close physical contact may be important and powerful for the formation of secure and healthy attachment relationships.
Feeding is one of the most prominent care-giving activities in a NICU, in which the transition from tube feeding to breastfeeding is complicated by the degree of prematurity, emotional exhaustion, mother–infant separation, and institutional authority and by a view of breastfeeding as a productive process, thereby preventing mothers’ experiences of breastfeeding as reciprocal and ‘successful’. Early physical closeness and breastfeeding have been described by many mothers as ‘steps towards normality’, nurturing the intimate mother–infant interplay. Skin-to-skin contact has been highlighted as an important intervention to promote breastfeeding, in which oxytocin release is suggested to be an important mediator for the effects of close physical contact on breastfeeding. Moreover, long periods of mother–infant skin-to-skin contact are regarded as an effective way to empower mothers to become familiar with their infants, strengthen their mothering at their own pace and increase feelings of parental competence.
Only a third of the fathers visited on a daily basis and their visits were shorter. Infrequent maternal visits have been identified as a risk factor for later psychological development in preterm infants. However, some parents have fewer means to be with their preterm infant during the hospital stay. Older siblings, long travelling distance to hospital or short parental leave limit the parents’ opportunities to be present at NICU. In such cases, modern technology could be utilized to support parent–infant contact. Web camera connection for parents has been used as a method for ‘virtual visitation’ of a neonatal unit.
To facilitate physical contact between parents and their infants, neonatal unit staffs need to welcome parents’ participation in the care but also guide parents when adapting parental touch into daily care, as touch may induce stress in very ill infants. In a genuinely family-centred culture, institutional powers are limited and the role of the staff is altered from ‘doing’ and supervising to becoming a resource and a facilitator. Hence, when family-centred care is implemented in a professional-centred caring culture, this can highlight issues about control and power or unclear responsibilities, which pose a considerable challenge for the current care culture. Thus, an important aspect of organizational culture centres upon the ways in which staffs are facilitated to build relationships with parents. As parent–infant bonding is a primary goal, successful transition requires education and feedback to the staff as particular demands on staff and care will follow. Different interventions to increase parental involvement and empowerment during the neonatal care have already been performed and reported on: parents have been involved in pain management by holding the preterm infant; parents have been supported in observing and interpreting their infants behaviour; parents have been encouraged to give extended skin-to-skin care. Supporting parents’ abilities to interpret their infant and supporting their empowerment has significantly shortened the length of hospitalization, decreasing separation of the infants from family and home. Although many short- and long-term benefits have been shown after these types of interventions, there is a lack of research on how these interventions change care culture and affect parent–infant closeness during neonatal care.
Large and systematic differences related to cultural and contextual issues in neonatal units, such as parental involvement, implementation of family-centred care and staff practices might influence differences shown in breastfeeding rates, maternal depression, and short- and long-term outcomes of the children. There is a need to evaluate differences in parent–infant closeness/separation between the units and structural, cultural and socio-economic factors affecting the differences. These factors could be evaluated using qualitative and quantitative techniques including ethnography.
The brain of a preterm infant is immature and vulnerable and, therefore, preterm infants are at a risk for abnormal brain development and later developmental problems. However, they also have large brain plasticity and potential for injury compensation. A growing body of evidence in both humans and animals suggests that brain development and later development may be influenced by the quality of care given to preterm infants including physical and emotional closeness and parent empowerment. Mother–infant interaction in early postnatal life, or lack of it in case of separation, can mediate variations in offspring phenotype, including emotional and cognitive development, with long-term health consequences. Environmental factors can influence gene expression through epigenetic mechanisms to provide the ‘plasticity’ necessary to respond to variations in environment. Term infants born to mothers with high levels of depression and anxiety during the third trimester have been shown to display increased DNA methylation in cord blood cells and increased salivary cortisol in response to stress at 3 months of age. Early life separation can alter capacity to regulate responses to stressful events as illustrated in animal studies. Furthermore, animal studies show that prolonged or repeated physical separation between parent and newborn alters brain development, impairs the ongoing bonding/attachment process and has long-lasting effects on, for example, emotional programming. In preterm infants, cortisol levels have been shown to be higher when cared by depressed mothers compared with no depressed mothers, an effect not seen in term infants. In contrast, close physical contact between parent and preterm infant decreases infant’s cortisol levels and pain responses and family-centred care, providing more parent–infant closeness, synchronizes cortisol variation between the preterm infant and mother.
Regulate immune function development neurodevelopmental outcome breast-feeding can enhance preterm infants’ neurodevelopmental outcome, regulate immune function development. The benefits of feeding the premature with their own mothers’ breast milk. It is widely reported and many of the protective influences of breast milk are more pronounced and critical for the premature. According to Lucas [10], preterm infants whose mothers provided breast milk had a substantial advantage in subsequent IQ at age 7.5 to 8 years over those who did not receive mother’s milk, even after adjustment for a wide range of factors that might have confounded this comparison. Apart from nutritional and immunological benefits, human milk has positive effects on cognitive functioning in preterm infants, and it is an important part of Maternal and Child Health (MCH) work in the world to protect, promote, and support breast feeding for newborns. However, in the course of implementation and management for preterm infants’ breastfeeding, there are still many difficulties and disputes, due to inadequate management for breastfeeding in NICUs and the immature development of infants. The rate of breastfeeding for preterm infants is very low, in some reports even zero. Currently, there is neither an objective standard nor a unified method to evaluate the implementation quality for preterm infant breastfeeding in NICUs, and research on the evaluation indicators system for preterm infant feeding is nonexistent. Therefore, development of a preterm infant breastfeeding evaluation indicators system emerged as a topic that needed further exploration. The aim of the study was to develop a breastfeeding indicators system that fits the special conditions and characteristics of premature infants and to explore the factors influencing the quality of breastfeeding provided to premature infants from the elements of hospital, infant, and mother in order to provide support to and a theoretical basis for increasing breastfeeding rates for preterm infants.
Clinical on-spot observation was performed as follows. Breastfeeding is an interactive process between mother and infant. The clinical on-spot was observed, including the preparation, the implementation, and the result of breastfeeding; the related information and data from the NICU and hospital management; the behavioral development of preterm infants; and the mothers’ preparation and skills for breastfeeding. The above were analyzed to initially formulate the important items for evaluation of preterm infant breastfeeding. On the basis of our literature review, a protocol was developed with elements associated with the breastfeeding of preterm infants. According to Avedis Donabedian’s theory of three dimensions of medical care quality, which include structure, process, and outcome, combined with the process workflow of breastfeeding which involves the infant and mother, important items were selected and a framework was formed as the basis for establishing an indicators system. The staff professional knowledge and skills for breastfeeding; The staff perception and attitudes towards premature breastfeeding; The management regulations for premature breastfeeding; Rooming-in facilities; Rooting reflex; Areolar grasp;
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