Kathryn Millar and Professor Catherine Coverston, College of Nursing

The development of immature physiologic systems in preterm infants is compromised as they experience the environment of the neonatal intensive care unit (NICU). Without interventions to recreate an intrauterine environment, the infant experiences delayed development and morbidities including hearing loss, retinopathy, decreased neurodevelopment, and impaired motor function. The purpose of this study was to assess NICU nurses at a public maternity hospital in San Miguel de Tucumán, Argentina in their use and knowledge of developmental therapies for preterm infants. Nurses were observed for two days to understand their current implementation of these therapies. A pre-test was administered to the nurses to assess their knowledge of, practice of, and attitudes towards developmental care. This was followed by a teaching intervention that addressed the development of all body systems at the time of premature birth and the use of specific therapies (lighting control, stimulation, positioning, and the reduction of noise) to facilitate their correct development. In addition, the morbidities associated with the lack of developmental care throughout childhood and the effects on family and society were addressed during the teaching. The nurses were then observed and assisted in their practice of developmental care in the NICU. Interviews were also conducted to identify barriers to administering developmental therapies. Two weeks later a written post-test assessed the impact of the teaching and observation interventions.

The evaluation of the pre- and post-tests showed increased knowledge and understanding of concrete principles that were addressed during the teaching interventions. However, nurses struggled to understand more abstract principles. To date, fourteen of the twenty six pre- and post-test sets have been evaluated. It is expected that the remaining twelve tests will show congruent results with the evaluated tests. Specific topics in which the nurses improved their knowledge were the use of eye covers and incubator covers to prevent stress, the use of containment touch to facilitate the sense of touch and to decrease stress, and in the number of identified signs of stress and pain in the infant. In the pre-tests many thought that hearing was the most developed sense at birth, yet in the post-tests there was an almost anonymous understanding that, at birth, touch is the most developed sense. The nurses have a good understanding of the need for grouping and implementing cares every four hours. The success of the class was shown in the post-tests as many nurses understood that it is important to call the baby by name softly before each care to prepare the baby for stimulation. Many of the nurses identified the musculoskeletal system on the post-tests rather than the central nervous system as the least developed system at birth, even if they put the right answer on the pre-test. This may have been due to an emphasis on positioning and the musculoskeletal system during the class. The abstract principles that were not understood well by the nurses included the implications of developmental cares on childhood development and the importance and content of parent teaching. Nurses had a difficult time recalling specific long-term effects of poor lighting, high levels of noise, and poor positioning. These effects are especially important for the nurses to understand because knowledge of these consequences motivates nurses to implement developmental cares and encourages the nurses to teach the parents of the risk of these problems. In addition, the content of parent teaching identified on the tests lacks detail that is necessary for parents to understand and facilitate development while the infant is hospitalized and at home.

Many observations were made as I spent time in the NICU. Before the teaching intervention was given, it was observed that there were nurses playing radios, open windows letting in a great amount of light, uncovered incubators, alarms sounding very loudly and frequently without being quickly turned off, signs on the walls about good positioning, infants showing specific signs of stress, and nurses successfully grouping cares well. In addition nurses were already using bumpers that facilitated the position of the infants, but not sufficiently. After the teaching intervention was administered, the unit seemed quieter, more containment touch was being used, more head and handmade positioning aids were being used, and the nurses would turn off the radio if I was in the room. However, the snugglies (Fig. 1) that had been brought in and used during the majority of my stay were not being used the week I left.

I became interested to learn why developmental cares were not implemented. By interviewing nurses and making more observations, several barriers were identified that make developmental cares very difficult to implement, especially in a low-income public maternity hospital. First, the majority of the equipment and materials they have in the NICU are of poor quality: alarms go off when they are not supposed to, the monitors do not read the vital signs of the baby correctly, IVs and diapers are too big for babies to be positioned correctly, and monitor electrodes are inaccurate and harm the skin of the baby. These problems cause the need for more monitoring and visualization of the baby by the nurse, thus the incubators of some infants cannot be covered to decrease light and less time can be spent on developmental cares. In addition, there are very few nurses for a highly populated NICU. Therefore, the nurse must spend less time with each baby and some babies are neglected because the sickest babies are cared for first. There is also a hierarchal relationship between the doctors and nurses, which prevents the nurse from protesting doctors’ orders that are contrary to developmental cares. These barriers must be mitigated to successfully care for the premature infants and decrease developmental morbidities.

I spent a lot of time in the NICU in order to teach nurses about cares, help them identify areas that need improvement, and answer any questions they had about these cares. I made posters for the unit and handouts for the nurses that reflected what I taught in the class. I brought snugglies, positioning rolls, and prototypes and material to make eye covers for the babies. Overall, the nurses showed a great deal of improvement in their knowledge and interest in developmental cares. I believe one of the most important findings of this research were the barriers to cares. Without the removal of these barriers, no matter how knowledgeable the nurses are, developmental cares will not be able to be implemented correctly. This has been a very rewarding experience and I am grateful for this opportunity and the knowledge I have gained.