Evidence Digest

Evidence to Guide Clinical Care with PrematureInfants and Parents

Bernadette Mazurek Melnyk, RN, PhD, CPNP/NPP, FAAN, FNAP

The purpose of Evidence Digest, a recurring columnin Worldviews on Evidence-Based Nursing, is to pro-

vide concise summaries of well-designed and/or clinicallyimportant recent studies along with implications for prac-tice, research, administration, and/or health policy. Arti-cles highlighted in this column may include quantitativeand qualitative studies, systematic and integrative reviews,outcomes evaluation studies, as well as consensus state-ments by expert panels. Along with relevant implications,the level of evidence generated by the studies or reportshighlighted in this column (see Figure 1) is included atthe end of each summary so that readers can integrate thestrength of evidence into their health care decisions.

• Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinicalpractice guidelines based on systematic reviews of RCTs

• Level II: Evidence obtained from at least one well-designed RCT • Level III: Evidence obtained from well-designed controlled trials without

randomization • Level IV: Evidence from well-designed case-control and cohort studies • Level V:

studies • Level VI: Evidence from a single descriptive or qualitative study • Level VII: Evidence from the opinion of authorities and/or reports

of expert committees

Modified from Guyatt & Rennie, 2002; Harris et al., 2001.

Evidence from systematic reviews of descriptive and qualitative

Figure 1. Rating system for the hierarchy of evidence(Melnyk & Fineout-Overholt, 2005).

NURSING INTERVENTIONS AND STRESSOF PARENTS OF PREMATURE INFANTS

Turan T., Basbakkal Z. & Ozbek S. (2008). Effect of nurs-ing interventions on stressors of parents of premature in-fants in neonatal intensive care unit. Journal of ClinicalNursing, 17, 2856–2866.

Purpose: The purpose of this study was to determine theeffect of stress-reducing interventions on the stress levels

Copyright ©2009 Sigma Theta Tau International1545-102X1/09

of mothers and fathers of premature infants in the neonatalintensive care unit (NICU).

Design: A RCT with two study groups (i.e., a 30-minuteeducational program delivered to parents about their in-fants and the intensive care unit versus a control groupwho received standard care).

Sample/Setting: The sample was comprised of 40 moth-ers and 36 fathers of premature infants who were 24–37weeks of gestation and hospitalized in a 15-bed NICU thatis part of a university hospital in Turkey. Inclusion crite-ria included no congenital anomaly for the infant and noprevious experience with a NICU for the parents.

Methods: Study participants were randomly assigned toeither a control group or the experimental intervention,which included face-to-face education for approximately30 minutes in the first week, after their infant was admit-ted to the NICU. The parent education included an in-troduction to the NICU, information about the personnelcaring for their infant, technical equipment (e.g., respi-ratory support, nasogastric tubes), information about theappearance of the infant, and the feelings that the parentsmight experience. Following the 30-minute educationalsession, the parents were taken into the NICU and givenadditional information by the researcher, including furthereducation about the infant’s condition and treatments. Theparents in the control group received nothing beyond rou-tine unit procedures. After the infants had been in the unitfor approximately 10 days, they were asked to completethe Parental Stressor Scale (PSS: NICU).

Results: The mean age of the mothers and fathers inthe intervention group was 24.7 years and 28.5 years, re-spectively, and 25.0 and 29.7 years, respectively, for thecontrol group. The mean gestational age for the infantswas 31.05 weeks for the intervention group and 31.45weeks for the control group. There were no differencesbetween the experimental intervention group and the con-trol group on baseline demographic variables for the par-ents or infants, including trait anxiety, mean birth weight,gestational age, mean Apgar scores, and type of delivery.Findings revealed that mothers in the intervention groupreported statistically less stress on the parental role alter-ation as well as sights and sounds subscales of the PSS:NICU than mothers in the control group. There was no

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difference in terms of stress between mothers on the in-fants’ appearance and behaviors subscale of the PSS. Inaddition, there were no statistically significant differenceson reports of stress between the intervention and controlgroup fathers. Overall, fathers had significantly higher to-tal stressor scale scores than mothers. Mothers with infantson a ventilator had higher stress scores. Furthermore, onlymothers in the control group reported more stress whenthey and their infants were younger. Fathers in the controlgroup who had experienced a stressful event in the lastyear had higher PSS scores than fathers who had not.

Commentary with implications for action in clinicalpractice and future research. A major strength of thisinvestigation is that it used a RCT design to test theefficacy of an educational support intervention withparents of preterm infants, which is the strongest de-sign for supporting cause-and-effect relationships aswell as controlling confounding variables. However, animportant limitation of the study is that there was noattention-control intervention to control for the timeand attention that was spent with the intervention groupparents. Therefore, it is difficult to know for sure if itwas truly the content of the intervention that was re-sponsible for the positive effects on the PSS: NICU forthe mothers or the fact that the intervention group re-ceived extra time and attention from the researchers.Another limitation of the trial was that the researchersintroduced the intervention parents to the NICU andspent additional time with them, which could haveintroduced bias into the study. Despite these limita-tions, this is yet another study that supports the pos-itive effects of providing parents of preterm infants inthe NICU with educational information about the envi-ronment and their role in caring for their infants. Thus,evidence is accumulating to support that this type ofeducation should be routinely delivered to parents ofpremature infants early on in the NICU stay as standardof care. It also should be recognized that for parents andinfants who are younger and more acutely ill, furtherintensive interventions may be necessary. Future re-search with these types of interventions should includeattention control groups and manipulation checks toconfirm that the intervention was processed and that it,not just the support of a nurse spending extra time andattention with parents, is responsible for the change inparent outcomes. Additionally, it would be importantto determine the effects of these types of interventionson how parents interact with and care for their infantsin the NICU.

Level of Evidence: II

BEHAVIORAL STRESS AND MODE OF TUBEFEEDING IN PREMATURE INFANTS

Dsilna A., Christensson K., Gustafsson A., Lagercrantz H.& Alfredsson L. (2008). Behavioral stress is affected bythe mode of tube feeding in very low birth weight infants.Clinical Journal of Pain, 24(5), 447–455.

Purpose: The purpose of this study was to compare theeffect of continuous and bolus feeding on behavioral re-sponses of stress in very low birth weight infants duringearly postnatal life.

Design: RCT was conducted with 70 preterm infantswho were randomly assigned to one of three feedingmethods, including: (a) continuous nasogastric feeding,(b) bolus nasogastric feeding every three hours with thenasogastric tube remaining in place, and (c) bolus orogas-tric feeding every three hours with intermittently insertedorogastric feeding tube.

Sample/Setting: The study was conducted in threeNCIUs in Stockholm, Sweden. Infants were 24–29 weeksof age, with a birth weight of less than 1,200 grams.

Methods: After random assignment to one of the threefeeding methods, behavioral responses of the infants werevideo recorded during feeding at 7 and 15 days of post-natal age and at 32 weeks of postmenstrual age. Continu-ous feeding was administered by a syringe infusion pump.Infants received bolus feeding during a period of 15–40 minutes by the nurse in charge of the infant. Du-ration of feeding was adjusted according to the givenvolume. The time periods of video recording were stan-dardized to the first or second meal after noon for bolus-and continuous-fed infants. Procedures surrounding thevideotaping also were standardized in terms of when tem-peratures were taken and diapers changed. The infantswere placed in a right-side position supported by blan-ket rolls. Room lighting was set at semidarkness and theblanket covering the incubator was removed. The infantwas left undisturbed for half an hour before the videorecording commenced. Cameras were placed in the sameposition for all infants and a microphone recorded theinfants’ sounds. Behavioral expressions were coded as oc-curring or not occurring during every 1-minute periodaccording to the Newborn Individualized Care and As-sessment Program (NIDCAP) by two independent coderstrained in NIDCAP. The observers were blind to all clini-cal information, and interrater reliability was assessed anddetermined to be satisfactory. Twenty-four of the codedbehaviors are defined as stress, according to NIDCAP.

Findings: Infants who were bolus fed compared withcontinually fed had significantly higher risk of a behavioralstress response at 15 days of age, as well as 32 weeks ofpostmenstrual age. In addition, they had a significantly

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higher need for behavioral and physiological stabilizationduring feeding.

Commentary with implications for action in clinicalpractice and future research. A major strength of thisstudy is that it was a meticulously conducted RCT—thestrongest experimental design to support the internalvalidity of a study (i.e., the ability to say that it was theintervention that caused a change in outcomes and notother extraneous/confounding variables). Being that, amultitude of adverse outcomes are associated with verylow birth weight, and anything that can be done in theearly postnatal period to diminish stress for these in-fants may have long-term benefits. Prior studies haveshown that bolus feeding may cause delayed gastricemptying, lead to distention, and negatively impact pul-monary functioning and cerebral blood flow velocity.Therefore, strong consideration should be given to con-tinuous feeding in very low birth weight infants versusbolus feeding in early postnatal life. Further research isneeded to determine the more long-term positive im-pact of intermittent versus continuous feeding in verylow birth weight infants.

Level of Evidence: II

PARENTAL STRESS AND SATISFACTIONRELATED TO RESPIRATORY SUPPORT IN

THE NICU

Foster J., Bidewell J., Buckmaster A., Lees S. & Henderson-Smart D. (2007). Parental stress and satisfaction in the non-tertiary special care nursery. Journal of Advanced Nursing,61(5), 522–530.

Purpose: The purpose of this study was to examinethe effects of using headbox oxygen (i.e., warm and hu-midified oxygen delivered through a transparent plastichood surrounding the infant’s head, with an opening forthe neck) and continuous oxygen positive airway pressuretreatments delivered through a nasal prong for respiratorydistress on stress and satisfaction of parents with infantsin a special care nursery, and the relationship betweenparental stress and satisfaction.

Design: RCT with two study groups of infants: (1) agroup who received Hudson nasal prong continuous posi-tive airway pressure (CPAP) respiratory support and (2) agroup who received headbox oxygen.

Sample/Setting: The sample consisted of 42 parents ofinfants receiving headbox oxygen and 51 parents of infantsreceiving CPAP, who were hospitalized in five special carenurseries located in nontertiary hospitals in Australia. Par-ents were excluded if their infant died, or they were lessthan 17 years of age. The mean gestational age of the CPAP

group was 36 weeks and the mean age of the headbox in-fants was 36.5 weeks, with a mean birth weight of 2,911and 2,860 grams, respectively.

Methods: Infants were randomized to either headboxoxygen or nasal prong CPAP respiratory support. Parentsof the infants completed a modified version of the PSS:NICU adapted for infants outside of the NICU.

Findings: Although there was high stress amongst theparents, no significant differences were found on the threesubscales of the PSS: NICU between the two groups. Par-ents of infants with nasal CPAP were more satisfied com-pared with the infants receiving headbox oxygen. Parentstress and satisfaction were not significantly correlated.Parents were most stressed by their infants’ behavior andappearance and parental role alteration.

Commentary with implications for action in clinicalpractice and future research. Findings from this trialindicate that parental stress is not greater for one type ofoxygen delivery system (i.e., CPAP or headbox delivery)over another. Therefore, it is not necessary to favor onetype of oxygen administration over the other when at-tempting to minimize parental stress. However, parentalstress of infants admitted to special care nurseries ishigh, and interventions to reduce stress are needed toenhance coping in parents of these vulnerable infants.Parental satisfaction was greater when their infants werereceiving CPAP than with headbox delivery, with theinvestigators noting that this could be related to theperception that the infants are receiving better techno-logical care. It would have been helpful if interviews hadbeen conducted to determine the explanation for thisfinding. Further research is needed to determine theeffects of these different oxygen delivery systems on in-fant outcomes. Evidence-based interventions supportedby research that have been found to decrease parentalstress in the NICU should be routinely implemented inclinical practice.

Level of Evidence: II

DECREASING MATERNAL ANXIETYAND STRESS FOLLOWING NICUHOSPITALIZATION WITH COPE

Melnyk B.M., Crean H.F., Feinstein N.F. & Fairbanks E.(2008). Maternal anxiety and depression after a prematureinfant’s discharge from the neonatal intensive care unit.Explanatory effects of the creating opportunities for parentempowerment program. Nursing Research, 57(6), 383–394.

Purpose: The purpose of this study was to test a the-oretical model examining the process through which the

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Creating Opportunities for Parent Empowerment (COPE)Program, an educational–behavioral intervention for par-ents of premature infants, influences mothers’ anxiety anddepression 2 months after discharge from the NICU.

Design: Secondary data analysis.Sample/Setting: Study participants were 246 mothers of

low birth weight premature infants who had participatedin a RCT to test the efficacy of the COPE program versus anattention control program on parent and infant outcomes,both during and following a NICU hospitalization.

Methods: In the RCT, COPE mothers received a se-ries of four educational sessions delivered through writtenmaterials and audio tapes at selected times during theirinfant’s NICU stay and approximately 1 week after hos-pital discharge. The educational information prepared themothers for their infants’ physical and behavioral charac-teristics along with how they could best parent their infantsin the NICU and enhance their development. COPE alsoincluded workbook activities that assisted the parents inimplementing concepts that were provided in the educa-tional information. Mothers completed valid and reliablemeasures of parental beliefs regarding their infant and theirrole, anxiety, and depression. In addition, they were ratedinteracting with their infants in the NICU, with a maternal–infant interaction scale completed by observers who wereblind to study group.

Structural equation modeling was used to test thetheory-based conceptual model to explain the processthrough which the COPE intervention program impactedmothers’ anxiety and depression 2 months following thedischarge of their infants from the NICU.

Findings: Participation in the COPE program wasboth directly and indirectly related to mothers’ decreasedposthospital depression and anxiety 2 months after hospi-talization. Mothers who received the COPE program com-pared with those who received the attention control pro-gram had stronger beliefs about what to expect in theirpremature infants and how to parent them, which in turnresulted in less maternal stress, depression, and anxietyin the NICU as well as more positive mother–infant in-

teractions. Fewer depressive and anxiety symptoms in theNICU led to less depression and anxiety in the mothers 2months following their infants’ discharge from the NICU.

Commentary with implications for action in clinicalpractice and future research. Findings from this studysupport that providing mothers with educational infor-mation about what to expect in their premature infantsand how they can parent them to achieve the best out-comes with the COPE program not only reduces theirstress, anxiety, and depressive symptoms during hospi-talization, but also results in less depression and anxiety2 months after hospitalization. This is a very impor-tant finding in that it is well supported in the literaturethat there is a multitude of adverse effects of depressedand anxious mothers on children, including delays indevelopment as well as mental health and behavioraldisorders. This study adds to the science in the area byexplaining the processes through which COPE workedto impact maternal outcomes, which is important inenhancing clinician use of efficacious interventions inclinical practice. Future experimental studies shouldroutinely include an analysis of the process throughwhich interventions impact outcomes.

Level of Evidence: VI

ReferencesGuyatt G. & Rennie D. (2002). Users’ guides to the medical

literature. Washington, DC: American Medical Associa-tion Press.

Harris R.P., Hefland M., Woolf S.H., Lohr K.N., MulrowC.D., Teutsch S.M. & Atkins D. (2001). Current meth-ods of the U.S. Preventive Services Task Force: A reviewof the process. American Journal of Preventive Medicine,20(Suppl.), 21–35.

Melnyk B.M. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare: A guide tobest practice. Philadelphia: Lippincott, Williams &Wilkins.

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